What is the role of surgery in the treatment of normal pressure hydrocephalus (NPH)?

Updated: Oct 19, 2018
  • Author: Michael J Schneck, MD, MBA; Chief Editor: Selim R Benbadis, MD  more...
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Surgical CSF shunting remains the main treatment modality for NPH. Prior to embarking upon surgical therapy, knowing which patients may benefit from surgery is necessary. Detailed testing is performed before and after CSF drainage (eg, baseline neuropsychological evaluation, timed walking test, large-volume lumbar puncture, external lumbar drainage, CSF infusion testing).

Ideal candidates for shunt surgery would show imaging evidence of ventriculomegaly, as indicated by a frontal horn ratio exceeding 0.50 on imaging studies, along with one or more of the following criteria:

  • Presence of a clearly identified etiology

  • Predominant gait difficulties with mild or absent cognitive impairment

  • Substantial improvement after CSF withdrawal (CSF tap test or lumbar drainage)

  • Normal-sized or occluded sylvian fissures and cortical sulci on CT scan or MRI

  • Absent or moderate white-matter lesions on MRI

An alternative technique to shunt surgery is endoscopic third ventriculostomy.

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