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Official reprint from UpToDate® www.uptodate.com

©2021 UpToDate®

Approach to the evaluation of a patient with

possible normal pressure hydrocephalus
(NPH)

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MRI: magnetic resonance imaging; DESH: disproportionately

enlarged subarachnoid space hydrocephalus; OP: opening
pressure; ICP: intracranial pressure; CSF: cerebrospinal fluid.

* Signs and symptoms of increased ICP, such as headaches,

nausea/vomiting, papilledema, and visual loss, are not
consistent with NPH and suggest an alternative diagnosis and
need for additional evaluation beyond the scope of this
algorithm.

¶ Examples include cervical or lumbar spondylosis, vestibular

dysfunction, osteoarthritis, deconditioning, visual impairment,
peripheral neuropathy, and medication side effects.

Δ Typical neuroimaging findings for NPH include:

Absent or modest cortical and hippocampal atrophy
Disproportionately enlarged subarachnoid space
hydrocephalus (DESH)
Refer to UpToDate topic review on NPH for further additional
details and imaging examples.

◊ Focally entrapped fluid in sulci, which is seen in DESH, should

not be confused with cortical atrophy and ex vacuo
hydrocephalus.

§ High-volume lumbar puncture is generally sufficient, although

some clinicians and centers prefer lumbar drain trial. CSF
should be analyzed for cell count, differential, total protein, and
glucose. Refer to UpToDate topic reviews for additional details.

¥ Unfavorable prognostic factors for response to shunting

include early appearance of cognitive impairment in relation to
other symptoms, moderate to severe dementia, dementia
present for >2 years, gait disorder absent or appearing after
onset of dementia, alcoholism, marked white matter disease,
and diffuse sulcal enlargement (cortical atrophy) and/or
hippocampal atrophy.

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Graphic 117418 Version 2.0

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