5-Minute Clinical Consult

Hydrocephalus, Normal Pressure

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  • Normal pressure hydrocephalus (NPH) is a clinical triad of gait instability, incontinence, and dementia (mnemonic: wet, wobbly, wacky). Originally described by Hakim and Adams in 1965, it occurs rarely, but is potentially treatable.
  • 2 forms of the disorder: Idiopathic and secondary (to traumatic brain injury, infection, mass lesions or aqueductal stenosis)
  • Absence of papilledema on clinical exam and normal CSF pressures at lumbar puncture

Geriatric Considerations
Idiopathic NPH primarily affects persons >60; extremely rare before 40.


  • No formal epidemiologic data exist regarding NPH because of the lack of consensus-derived diagnostic criteria. The natural history of untreated NPH has not been studied.
  • Idiopathic (iNPH) form primarily affects elderly; at least >40 years of age.
  • Secondary form can occur at any age.
  • Male = Female

  • 3.3/100,000 age 50–59 to 181.7/100,000 age 70–79 for iNPH (1)
  • Estimated to be a contributing factor in ∼6% of all cases of dementia (2)

Etiology and Pathophysiology

  • This is a communicating hydrocephalus, a disorder of decreased CSF absorption (not overproduction). In iNPH, the leading theory suggests that poor venous compliance impairs the subarachnoid granulations’ ability to maintain baseline removal of CSF. In secondary NPH, scarring is likely.
  • The result is a pressure gradient between the subarachnoid space and ventricular system.
  • CSF production decreases in the face of an increased pressure set-point (but still in excess of the amount of CSF absorbed).
  • Elevated pressure distends ventricles and compresses the brain parenchyma.
  • As a result of compression, ischemic changes occur in the parenchymal vasculature with subsequent tissue damage and loss.
  • Some believe that the idiopathic form is a result of persistently insufficient removal of CSF by immature subarachnoid granulations from childhood.
  • Secondary NPH may result from:
    • Subarachnoid hemorrhage
    • Head trauma
    • Resolved acute meningitis
    • Chronic meningitis (tuberculosis, syphilis)
    • Paget disease of the skull

Risk Factors

  • Idiopathic risk is unknown (case reports suggest a possible genetic link, but unsubstantiated).
  • Secondary form is due to head trauma, subarachnoid hemorrhage, meningitis, or encephalitis.

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