Normal Pressure Hydrocephalus (NPH)
1. What is NPH?
Normal Pressure Hydrocephalus (NPH) is a neurological condition in which cerebrospinal fluid (CSF) accumulates in the brain ventricles, causing them to enlarge.
Although the ventricles enlarge, the CSF pressure measured during lumbar puncture is usually normal, which is why it is called “normal pressure.”
The enlarged ventricles compress surrounding brain tissue, especially areas responsible for walking, bladder control, and cognition.
It usually occurs in older adults (over 60 years).
2. Causes of NPH
NPH can be:
A. Idiopathic NPH (most common)
No clear cause.
B. Secondary NPH
Occurs after conditions such as:
- Subarachnoid hemorrhage
- Head injury
- Brain infection (meningitis)
- Brain surgery
- Tumors
3. Classic Clinical Triad (Hakim’s Triad)
NPH is characterized by three major symptoms:
- Gait disturbance (most common first symptom)
- Slow walking
- Wide-based gait
- Difficulty starting walking
- “Magnetic gait” (feet appear stuck to floor)
- Urinary incontinence
- Urgency
- Frequency
- Loss of bladder control
- Cognitive impairment
- Memory problems
- Poor attention
- Confusion
- Dementia-like symptoms
4. Diagnosis of NPH
1. Clinical assessment
Doctor evaluates:
- Gait disturbance
- Memory impairment
- Urinary symptoms
- Neurological examination
2. Brain Imaging
CT Scan or MRI
Findings:
- Enlarged ventricles (ventriculomegaly)
- No severe brain atrophy
3. Lumbar Puncture (CSF Tap Test)
- 30–50 ml CSF removed
- Observe improvement in gait or cognition
If symptoms improve → strong evidence for NPH
4. CSF Pressure Measurement
Opening pressure usually normal or slightly elevated.
5. Extended Lumbar Drainage
CSF drained over 2–3 days to see improvement.
5. Treatment of NPH
Main Treatment: Surgical
Ventriculoperitoneal (VP) Shunt
A shunt system is inserted to drain excess CSF from:
Brain ventricles → abdominal cavity
Parts:
- Ventricular catheter
- Valve
- Distal catheter
This reduces ventricular size and relieves symptoms.
Alternative Surgery
- Ventriculoatrial shunt
- Endoscopic third ventriculostomy (less common for NPH)
6. Medical Management
There is no effective medication to cure NPH.
Management focuses on:
- Treating underlying cause (if secondary)
- Managing complications
- Monitoring shunt function
Medications sometimes used for symptoms:
- Bladder control drugs
- Cognitive support drugs
7. Nursing Management
A. Preoperative Nursing Care
- Assess gait, cognition, urinary control
- Monitor neurological status
- Prepare patient for CT/MRI and lumbar puncture
- Provide psychological support
B. Postoperative Nursing Care (after shunt surgery)
1. Neurological monitoring
- Level of consciousness
- Pupillary reaction
- Motor function
2. Monitor for shunt complications
- Infection
- Obstruction
- Over-drainage
Signs:
- Headache
- Vomiting
- Fever
- Altered consciousness
3. Wound care
- Inspect surgical site
- Prevent infection
4. Mobility support
- Assist walking
- Prevent falls
5. Bladder care
- Monitor urinary incontinence
- Skin care
6. Patient education
Teach patient and family:
- Signs of shunt malfunction
- Importance of follow-up
- Infection symptoms
8. Complications of NPH or Shunt
- Shunt infection
- Shunt blockage
- Subdural hematoma
- Seizures
- Overdrainage syndrome
9. Prognosis
- Gait disturbance improves most after treatment
- Urinary symptoms moderately improve
- Cognitive impairment improves less
Early diagnosis → better outcomes
✅ Summary
| Feature | NPH |
|---|---|
| Main problem | CSF accumulation with normal pressure |
| Classic triad | Gait disturbance + Urinary incontinence + Dementia |
| Diagnosis | CT/MRI + Lumbar tap test |
| Main treatment | Ventriculoperitoneal shunt |
| Nursing role | Neurological monitoring, infection prevention, rehabilitation |