Medscape is available in 5 Language Editions – Choose your Edition here.


Normal Pressure Hydrocephalus Clinical Presentation

  • Author: Michael J Schneck, MD, MBA; Chief Editor: Selim R Benbadis, MD  more...
Updated: Jul 12, 2016


Patients present with a gradually progressive disorder. As noted above, the classic triad consists of abnormal gait, urinary incontinence, and dementia. The gait disturbance is typically the earliest feature noted and considered to be the most responsive to treatment. The primary feature is thought to resemble an apraxia of gait. True weakness or ataxia is typically not observed.

The gait of NPH is characterized as bradykinetic, broad based, magnetic, and shuffling. The urinary symptoms of NPH can present as urinary frequency, urgency, or frank incontinence. While incontinence can result from gait disturbance and dementia, in a study by Sakakibara and colleagues, 95% of patients had urodynamic parameters consistent with detrusor overactivity.[7]

The dementia of NPH is characterized by prominent memory loss and bradyphrenia. Frontal and subcortical deficits are particularly pronounced. Such deficits include forgetfulness, decreased attention, inertia, and bradyphrenia. The presence of cortical signs such as aphasia or agnosia should raise suspicion for an alternate pathology such as Alzheimer disease or vascular dementia. However, comorbid pathology is not uncommon with advancing age. In one study, more than 60% of patients with iNPH had cerebrovascular disease.[8] In another similar study, more than 75% had Alzheimer disease pathology at the time of shunt surgery.[9]

Patients commonly present with a gait disorder and dementia. On neurologic examination, pyramidal tract findings may be present in addition to the above findings.



Normal pressure hydrocephalus may occur due to a variety of secondary causes but may be idiopathic in approximately 50% of patients. Secondary causes of NPH include head injury, subarachnoid hemorrhage, meningitis, and CNS tumor. Another potential cause could be previously compensated congenital hydrocephalus.[10]

Contributor Information and Disclosures

Michael J Schneck, MD, MBA Vice Chair and Professor, Departments of Neurology and Neurosurgery, Loyola University, Chicago Stritch School of Medicine; Associate Director, Stroke Program, Director, Neurology Intensive Care Program, Medical Director, Neurosciences ICU, Loyola University Medical Center

Michael J Schneck, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Society of Neuroimaging, Stroke Council of the American Heart Association, Neurocritical Care Society

Disclosure: Received honoraria from Boehringer-Ingelheim for speaking and teaching; Received honoraria from Sanofi/BMS for speaking and teaching; Received honoraria from Pfizer for speaking and teaching; Received honoraria from UCB Pharma for speaking and teaching; Received consulting fee from Talecris for other; Received grant/research funds from NMT Medical for independent contractor; Received grant/research funds from NIH for independent contractor; Received grant/research funds from Sanofi for independe.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Nestor Galvez-Jimenez, MD, MSc, MHA The Pauline M Braathen Endowed Chair in Neurology, Chairman, Department of Neurology, Program Director, Movement Disorders, Department of Neurology, Division of Medicine, Cleveland Clinic Florida

Nestor Galvez-Jimenez, MD, MSc, MHA is a member of the following medical societies: American Academy of Neurology, American College of Physicians, International Parkinson and Movement Disorder Society

Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cyberonics; Eisai; Lundbeck; Sunovion; UCB; Upsher-Smith<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cyberonics; Eisai; Glaxo Smith Kline; Lundbeck; Sunovion; UCB<br/>Received research grant from: Cyberonics; Lundbeck; Sepracor; Sunovion; UCB; Upsher-Smith.

Additional Contributors

Arif I Dalvi, MD Director, Movement Disorders Center, NorthShore University Health System; Clinical Associate Professor of Neurology, University of Chicago Pritzker Medical School

Arif I Dalvi, MD is a member of the following medical societies: International Parkinson and Movement Disorder Society, European Neurological Society

Disclosure: Nothing to disclose.

Ashvini P Premkumar, MD Associate Director, Movement Disorders Center, NorthShore University HealthSystem, Clinical Instructor of Neurology, University of Chicago Pritzker Medical School

Ashvini P Premkumar, MD is a member of the following medical societies: American Academy of Neurology, International Parkinson and Movement Disorder Society

Disclosure: Nothing to disclose.

  1. Aimard G, Vighetto A, Gabet JY, Bret P, Henry E. [Acetazolamide: an alternative to shunting in normal pressure hydrocephalus? Preliminary results]. Rev Neurol (Paris). 1990. 146(6-7):437-9. [Medline].

  2. Hakim S, Adams RD. The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamics. J Neurol Sci. 1965 Jul-Aug. 2(4):307-27. [Medline].

  3. Brean A, Eide PK. Prevalence of probable idiopathic normal pressure hydrocephalus in a Norwegian population. Acta Neurol Scand. 2008 Jul. 118(1):48-53. [Medline].

  4. Hiraoka K, Meguro K, Mori E. Prevalence of idiopathic normal-pressure hydrocephalus in the elderly population of a Japanese rural community. Neurol Med Chir (Tokyo). 2008 May. 48(5):197-99; discussion 199-200. [Medline].

  5. Tanaka N, Yamaguchi S, Ishikawa H, Ishii H, Meguro K. Prevalence of possible idiopathic normal-pressure hydrocephalus in Japan: the Osaki-Tajiri project. Neuroepidemiology. 2009. 32(3):171-5. [Medline].

  6. Marmarou A, Young HF, Aygok GA. Estimated incidence of normal pressure hydrocephalus and shunt outcome in patients residing in assisted-living and extended-care facilities. Neurosurg Focus. 2007 Apr 15. 22(4):E1. [Medline].

  7. Sakakibara R, Uchiyama T, Kanda T, Uchida Y, Kishi M, Hattori T. [Urinary dysfunction in idiopathic normal pressure hydrocephalus]. Brain Nerve. 2008 Mar. 60(3):233-9. [Medline].

  8. Bech-Azeddine R, Hogh P, Juhler M, Gjerris F, Waldemar G. Idiopathic normal-pressure hydrocephalus: clinical comorbidity correlated with cerebral biopsy findings and outcome of cerebrospinal fluid shunting. J Neurol Neurosurg Psychiatry. 2007 Feb. 78(2):157-61. [Medline].

  9. Golomb J, Wisoff J, Miller DC, et al. Alzheimer's disease comorbidity in normal pressure hydrocephalus: prevalence and shunt response. J Neurol Neurosurg Psychiatry. 2000 Jun. 68(6):778-81. [Medline].

  10. Graff-Radford NR, Godersky JC. Symptomatic congenital hydrocephalus in the elderly simulating normal pressure hydrocephalus. Neurology. 1989 Dec. 39(12):1596-600. [Medline].

  11. Sasaki M, Honda S, Yuasa T, Iwamura A, Shibata E, Ohba H. Narrow CSF space at high convexity and high midline areas in idiopathic normal pressure hydrocephalus detected by axial and coronal MRI. Neuroradiology. 2008 Feb. 50(2):117-22. [Medline].

  12. Gyldensted C. Measurements of the normal ventricular system and hemispheric sulci of 100 adults with computed tomography. Neuroradiology. 1977 Dec 31. 14(4):183-92. [Medline].

  13. Singer OC, Melber J, Hattingen E, Jurcoane A, Keil F, Neumann-Haefelin T, et al. MR volumetric changes after diagnostic CSF removal in normal pressure hydrocephalus. J Neurol. 2012 May 17. [Medline].

  14. Williams MA, Razumovsky AY, Hanley DF. Comparison of Pcsf monitoring and controlled CSF drainage diagnose normal pressure hydrocephalus. Acta Neurochir Suppl. 1998. 71:328-30. [Medline].

  15. Governale LS, Fein N, Logsdon J, Black PM. Techniques and complications of external lumbar drainage for normal pressure hydrocephalus. Neurosurgery. 2008 Oct. 63(4 Suppl 2):379-84; discussion 384. [Medline].

  16. Marmarou A, Young HF, Aygok GA, et al. Diagnosis and management of idiopathic normal-pressure hydrocephalus: a prospective study in 151 patients. J Neurosurg. 2005 Jun. 102(6):987-97. [Medline].

  17. Murai R, Hashiguchi F, Kusuyama A, et al. Percutaneous stenting for malignant biliary stenosis. Surg Endosc. 1991. 5(3):140-2. [Medline].

  18. Walchenbach R, Geiger E, Thomeer RT, Vanneste JA. The value of temporary external lumbar CSF drainage in predicting the outcome of shunting on normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry. 2002 Apr. 72(4):503-6. [Medline].

  19. Burnett MG, Sonnad SS, Stein SC. Screening tests for normal-pressure hydrocephalus: sensitivity, specificity, and cost. J Neurosurg. 2006 Dec. 105(6):823-9. [Medline].

  20. Stein SC, Burnett MG, Sonnad SS. Shunts in normal-pressure hydrocephalus: do we place too many or too few?. J Neurosurg. 2006 Dec. 105(6):815-22. [Medline].

  21. Hebb AO, Cusimano MD. Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome. Neurosurgery. 2001 Nov. 49(5):1166-84; discussion 1184-6. [Medline].

  22. Vanneste J, Augustijn P, Davies GA, Dirven C, Tan WF. Normal-pressure hydrocephalus. Is cisternography still useful in selecting patients for a shunt?. Arch Neurol. 1992 Apr. 49(4):366-70. [Medline].

  23. Rangel-Castilla L, Barber S, Zhang YJ. The role of endoscopic third ventriculostomy in the treatment of communicating hydrocephalus. World Neurosurg. 2012 Mar. 77(3-4):555-60. [Medline].

  24. Vanneste J, Augustijn P, Dirven C, Tan WF, Goedhart ZD. Shunting normal-pressure hydrocephalus: do the benefits outweigh the risks? A multicenter study and literature review. Neurology. 1992 Jan. 42(1):54-9. [Medline].

  25. Boon AJ, Tans JT, Delwel EJ, et al. Dutch Normal-Pressure Hydrocephalus Study: the role of cerebrovascular disease. J Neurosurg. 1999 Feb. 90(2):221-6. [Medline].

  26. Hamilton R, Patel S, Lee EB, Jackson EM, Lopinto J, Arnold SE. Lack of shunt response in suspected idiopathic normal pressure hydrocephalus with Alzheimer disease pathology. Ann Neurol. 2010 Oct. 68(4):535-40. [Medline].

  27. Pujari S, Kharkar S, Metellus P, Shuck J, Williams MA, Rigamonti D. Normal pressure hydrocephalus: long-term outcome after shunt surgery. J Neurol Neurosurg Psychiatry. 2008 Nov. 79(11):1282-6. [Medline].

  28. Hertel F, Zuchner M, Decker C, Schill S, Bosniak I, Bettag M. The Miethke dual switch valve: experience in 169 adult patients with different kinds of hydrocephalus: an open field study. Minim Invasive Neurosurg. 2008 Jun. 51(3):147-53. [Medline].

  29. Brooks M. CSF Protein a Diagnostic Marker for Idiopathic NPH? Medscape Medical News. July 05, 2013. Available at Accessed: July 16, 2013.

  30. Nishida N, Nagata N, Toda H, Ishikawa M, Urade Y, Iwasaki K. L-PGDS could be a surrogate marker of frontal lobe dysfunction in idiopathic NPH [abstract 1014]. Available at Accessed: July 16, 2013.

  31. Tisell M, Hellstrom P, Ahl-Borjesson G, Barrows G, Blomsterwall E, Tullberg M. Long-term outcome in 109 adult patients operated on for hydrocephalus. Br J Neurosurg. 2006 Aug. 20(4):214-21. [Medline].

  32. Tsakanikas D, Relkin N. Normal pressure hydrocephalus. Semin Neurol. 2007 Feb. 27(1):58-65. [Medline].

  33. Walter C, Hertel F, Naumann E, Morsdorf M. Alteration of cerebral perfusion in patients with idiopathic normal pressure hydrocephalus measured by 3D perfusion weighted magnetic resonance imaging. J Neurol. 2005 Dec. 252(12):1465-71. [Medline].

  34. Wikkelso C, Andersson H, Blomstrand C, Lindqvist G, Svendsen P. Normal pressure hydrocephalus. Predictive value of the cerebrospinal fluid tap-test. Acta Neurol Scand. 1986 Jun. 73(6):566-73. [Medline].

T2-weighted MRI showing dilatation of ventricles out of proportion to sulcal atrophy in a patient with normal pressure hydrocephalus. The arrow points to transependymal flow.
CT head scan of a patient with normal pressure hydrocephalus showing dilated ventricles. The arrow points to a rounded frontal horn.
This image shows ventriculomegaly, which is typical in hydrocephalus ex vacuo.
This image shows cortical atrophy, which is the defining feature of hydrocephalus ex vacuo.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.