Normal Pressure Hydrocephalus (NPH)

Normal pressure hydrocephalus (NPH) happens when cerebrospinal fluid, or CSF, collects in the ventricles of the brain. CSF normally cushions and protects the brain and spinal cord, but too much fluid can enlarge the ventricles and interfere with nearby brain tissue. Unlike some other forms of hydrocephalus, NPH may occur without a major increase in pressure during a single measurement, which can make diagnosis more complex.

NPH is important to identify because some people improve with timely treatment. Symptoms can develop gradually and may be mistaken for aging, stroke, Parkinson’s disease or dementia. A careful evaluation by Baptist Health Brain & Spine Care specialists can help determine whether NPH may be contributing to a person’s changes in walking, thinking or bladder control.

NPH is generally described in two main ways: idiopathic and secondary.

Idiopathic NPH means there is no clear cause. This is the most common form in older adults and often develops slowly over time.

Secondary NPH happens after another condition or event affects CSF flow or absorption. Possible causes include bleeding around the brain, infection, head injury, brain surgery or other neurologic problems. People with secondary NPH may need evaluation for the underlying cause as well as the fluid buildup.

The classic symptoms of NPH are often described as a triad. Not everyone has all three symptoms at first, and the severity can vary.

Common symptoms include:

• Difficulty walking, often with short, slow or shuffling steps
• Trouble starting to walk or feeling as if the feet are stuck to the floor
• Balance problems or frequent falls
• Urinary urgency, frequency or loss of bladder control
• Slower thinking, memory changes or trouble concentrating
• Less interest in usual activities or changes in mood

Walking problems are often the earliest and most noticeable symptom. Because these symptoms overlap with other neurologic conditions, diagnosis usually requires a combination of imaging, physical assessment and response to CSF drainage testing.

NPH occurs when CSF does not flow or absorb normally, leading to enlarged ventricles. In idiopathic NPH, the exact reason this happens is not always known. In secondary NPH, fluid buildup may follow another brain-related event or condition.

Risk factors and associated conditions may include:

• Older age, especially age 60 and older
• Prior bleeding in or around the brain
• Meningitis or other central nervous system infections
• Head injury
• Brain surgery
• Tumors or other conditions that affect CSF pathways

Because NPH can resemble other conditions, specialists may also evaluate for stroke, movement disorders, memory disorders and other causes of walking or cognitive changes.

Diagnosing NPH starts with a detailed medical history, neurologic exam and review of symptoms. Your care team may ask when walking changes began, whether bladder symptoms or memory changes are present, and how symptoms have changed over time.

Testing may include brain imaging, such as MRI or CT, to look for enlarged ventricles and rule out other causes. Specialists may also use gait testing, cognitive screening and a lumbar puncture to remove a small amount of CSF and see whether symptoms improve. In some cases, extended CSF drainage testing is used to better understand whether shunt surgery may help.

Baptist Health Brain & Spine Care brings together neurologists, neurosurgeons, imaging specialists and rehabilitation experts to evaluate complex conditions such as NPH and related hydrocephalus.

Treatment depends on the person’s symptoms, overall health, imaging results and response to CSF drainage testing. The main treatment for NPH is usually surgery to divert extra CSF away from the brain so the body can absorb it elsewhere.

A ventriculoperitoneal shunt, or VP shunt, is the most common approach. During this procedure, a neurosurgeon places a thin tube into a ventricle of the brain and connects it to tubing that drains fluid to the abdomen. Some shunts are programmable, allowing the care team to adjust drainage settings without another surgery.

For select patients, other procedures or additional monitoring may be considered. Treatment planning may also include physical therapy, fall-prevention strategies and support for bladder or cognitive symptoms. Baptist Health Brain & Spine Care specialists tailor treatment to each patient’s goals, risks and expected benefit.

Untreated NPH may lead to worsening walking problems, falls, loss of independence, bladder control issues and progressive cognitive changes. Early recognition can help patients and families understand whether treatment may improve function.

Shunt surgery can be effective for carefully selected patients, but it also has possible risks. These may include infection, bleeding, shunt blockage, overdrainage or underdrainage of CSF, and the need for shunt adjustment or revision. Your care team will explain what symptoms require urgent medical attention after surgery and how follow-up visits help monitor shunt function.

Many cases of idiopathic NPH cannot be prevented because the cause is not known. However, timely care for brain injury, infection or bleeding around the brain may help reduce the risk of secondary complications.

People who notice new or worsening problems with walking, balance, bladder control or memory should seek medical evaluation rather than assuming the changes are part of aging. A prompt assessment can help identify treatable causes, including NPH, stroke or other neurologic conditions.

If you or a loved one has symptoms that may suggest NPH, start by writing down the changes you have noticed, when they began and how they affect daily life. Bring a list of medications, prior neurologic diagnoses, brain imaging results and questions for your appointment.

To schedule a visit with a Baptist Health Brain & Spine Care provider, fill out an appointment request form or call 833-596-3876.