What Is Normal Pressure Hydrocephalus (NPH)?
Normal pressure hydrocephalus, or NPH, is a type of hydrocephalus in which the brain’s fluid-filled cavities (ventricles) enlarge as a result of impaired circulation and absorption of the cerebrospinal fluid.
Seen particularly in older age, NPH may present with walking and balance problems, cognitive slowing and difficulties with bladder control. Because these symptoms can be mistaken for ageing or for other neurological diseases, the diagnostic process is important.
What Are the Symptoms of Normal Pressure Hydrocephalus?
Classically, three main groups of symptoms stand out in NPH:
1. Walking and Balance Problems
In most patients, one of the most noticeable symptoms is slowing of gait, shorter steps, impaired balance or difficulty initiating walking. In some patients the risk of falling may also increase.
2. Forgetfulness and Slowed Thinking
Forgetfulness, reduced attention, slowness in daily activities and reduced speed of thinking may be seen. For this reason NPH can at times be confused with Alzheimer’s disease or other types of dementia.
3. Problems with Bladder Control
Frequent urination, a sudden urge to urinate or, at a later stage, urinary incontinence may occur.
These three symptoms do not have to be present at the same time. Evaluation for NPH may be considered particularly in patients with a marked walking disorder accompanied by cognitive or urinary complaints.
How Is NPH Diagnosed?
The diagnosis is not made by looking at a brain MRI alone. The patient’s complaints, the neurological examination and the brain imaging findings are evaluated together.
MRI may show enlarged ventricles and certain imaging features consistent with NPH. In suitable patients, a “tap test”, in which a set amount of cerebrospinal fluid is drained by lumbar puncture, can help the diagnostic evaluation. In some patients, methods such as longer-duration CSF drainage may also be used.
How Is Normal Pressure Hydrocephalus Treated?
In patients whose NPH diagnosis and suitability for surgery have been evaluated, one of the main treatment options is diverting the cerebrospinal fluid to another part of the body with a shunt system. One of the most commonly used methods is the ventriculoperitoneal (VP) shunt.
However, enlarged ventricles on MRI are not in themselves sufficient grounds for surgery. Whether shunt treatment is needed is decided by evaluating the patient’s clinical findings, the imaging results and, when necessary, the information obtained from CSF drainage tests together.
What Is the Difference Between NPH and Alzheimer’s Disease?
Forgetfulness and cognitive problems can be seen in both conditions. In NPH, however, walking difficulty is often an important clinical finding, and problems with bladder control may also be part of the picture.
For this reason, it is important that newly developing walking difficulty and cognitive changes, particularly in older age, are not simply put down to “ageing” or “dementia”.
Frequently Asked Questions
Can normal pressure hydrocephalus be treated?
In suitable patients, shunt treatment can bring about an improvement in symptoms. However, the response to treatment varies from patient to patient.
Is a shunt placed in every NPH patient?
No. The decision for surgery is made after a detailed clinical and radiological evaluation.
Does NPH cause only forgetfulness?
No. Walking and balance problems and problems with bladder control are also important symptoms.
Are NPH and Alzheimer’s the same disease?
No. Although some symptoms are similar, they are different diseases. When necessary, neurological and neurosurgical evaluation is carried out for the differential diagnosis.
If the ventricles are enlarged on MRI, is NPH diagnosed?
No. Imaging findings alone are not sufficient. Clinical findings and, when necessary, additional diagnostic tests should be evaluated together.
Conclusion
Normal pressure hydrocephalus is a condition that can present, particularly in older age, with walking difficulty, cognitive slowing and urinary problems, and that can be treated in suitable patients. Attributing the symptoms to ageing can delay the diagnosis.
It is therefore important that people with newly developing walking difficulty accompanied by forgetfulness or bladder-control problems are evaluated for NPH.
For detailed information on the types, diagnosis and treatment options of hydrocephalus, see the Hydrocephalus page.
References
- Hamilton MG, Williams MA, Edwards S, et al. Guidelines for Diagnosis and Management of Idiopathic Normal Pressure Hydrocephalus. Neurosurgical Clinics of North America. 2025.
- Moghekar AR. Clinical Features and Diagnosis of Normal Pressure Hydrocephalus. Continuum. 2025.
- Panciani PP, et al. Idiopathic normal pressure hydrocephalus: a systematic review and a streamlined six-step algorithm. 2025.
- Tipton PW, Elder BD, Cogswell PM, Graff-Radford N. Normal pressure hydrocephalus, or Hakim syndrome: review and update. Neurologia i Neurochirurgia Polska. 2024.