Normal Pressure Hydrocephalus

Sometimes, changes in your balance, gait (how you walk), thinking or urination aren't just because you're getting older. They could be signs of a condition called normal pressure hydrocephalus (NPH). NPH is a problem in the brain that can look like Parkinson’s or Alzheimer’s disease, but it has a different cause.

At Banner Health, we understand how confusing and frustrating these symptoms can be. These changes may worry you but with proper diagnosis and care, there is hope.

What is normal pressure hydrocephalus? 

NPH is a condition that happens when too much fluid builds up in the brain. 

Your brain and spinal cord are covered by a clear fluid called cerebrospinal fluid (CSF). This fluid cushions your brain, helps remove waste and keeps the pressure inside your skull steady. Usually, your body continuously makes CSF which bathes the brain and the spine and later absorbs it back into the bloodstream.

In NPH, the way fluid moves in the brain changes. CSF builds up instead of flowing out properly. This causes the brain’s fluid spaces, called ventricles, to get bigger very slowly. Even if the pressure inside the head seems normal, the enlarged ventricles can stretch and press on nearby brain tissue. This pressure can make it hard to walk, think and control your bladder.

Because these symptoms appear gradually, NPH is often confused with Alzheimer’s disease, Parkinson’s disease or just getting older. The good thing is that symptoms of this brain condition, like walking difficulties may get better with treatment allowing you to prevent falls and hopefully maintain the ability to walk independently for a longer amount of time. 

However, timely intervention and treatment are important. The longer you wait to receive treatment, the less likely it is to help. 

How NPH differs from other types of hydrocephalus

Normal pressure hydrocephalus is one form of communicating hydrocephalus. This means that CSF can still move between the brain’s spaces but isn’t absorbed properly.

Other types of hydrocephalus, like obstructive or non-communicating hydrocephalus, happen when a blockage stops fluid from flowing through the brain. These types often occur in babies and children and can cause high pressure inside the skull.

Unlike other forms of hydrocephalus, NPH develops slowly over time and can sometimes be reversed with treatment.

What causes normal pressure hydrocephalus?

Fluid buildup that causes normal pressure hydrocephalus can happen for different reasons. Experts recognize two types based on the cause:

Idiopathic (primary) NPH

This problem may happen spontaneously without a clear cause. It is most common in older people over 60. This may happen because the brain changes as we get older, but a clear cause has not been identified.

Acquired (secondary) NPH

This form happens after an event or condition affects the brain’s ability to manage CSF. Possible causes include:

• Head injury or concussion
• Bleeding in the brain from trauma, stroke or aneurysm
• Infections like meningitis or encephalitis
• Brain surgery or tumors that alter CSF flow

Sometimes, symptoms of secondary NPH show up months or even years later because scar tissue or blockage slows the reabsorption of CSF fluid into the blood stream.

Key symptoms to watch for

Symptoms of NPH often develop over an extended period of time. These symptoms usually include three main problems, called the classic triad or Hakim’s triad. About 50% to 75% of people with NPH have all three symptoms at the same time. 

1. Walking difficulties (gait disturbances):

• Imbalance
• Difficulty taking steps or feeling as if your feet are stuck to the ground
• Short, shuffling steps or trouble turning
• Not picking up feet when walking
• Unsteadiness or frequent falls

2. Memory or thinking changes (cognitive changes):

• Slowed thinking or reduced attention span
• Forgetfulness or confusion
• Trouble planning or completing familiar tasks
• Reduced motivation

3. Bladder control problems: 

• Increased urinary frequency
• Accidental leakage (incontinence)
• Difficulty reaching the bathroom in time (urgency)

Walking problems are usually one of the first signs. If you or someone you care about has trouble walking, forgetting things or bladder problems, see a neurologist or a Banner Health specialist. Getting help early can lead to better results. 

How is NPH diagnosed?

Because NPH symptoms overlap with other conditions, diagnosis requires careful testing. 

Common tests include:

• Physical and neurological exams: These exams look for visible signs or symptoms of a condition. They test your walking, strength, reflexes and sensation in your arms and legs.
• Magnetic resonance imaging (MRI) scans: Creates detailed pictures of the brain to show whether the ventricles are enlarged or if CSF is built up. Special MRI scans can also evaluate the flow the spinal fluid within the brain which may be increased in people with NPH.
• Computer tomography (CT) scans: Helps identify structural changes or blockages in CSF pathways.
• Lumbar puncture (spinal tap): Measures CSF pressure and may remove a small amount of fluid. Specialists may check how well you walk or think before and after fluid is removed. If walking temporarily improves after the test, it can indicate that shunt surgery may help with walking.
• Extralumbar drain (ELD): A small portion of people who do not have a positive response to the lumbar puncture may respond to longer term drainage through an extralumbar drain. With ELD, a small flexible tube is placed in the lower spine to drain spinal fluid over multiple days. to see if you have improvements in your walking and other symptoms.  While in the hospital, daily evaluations may be made to identify improvements in walking and other symptoms. If successful, shunt surgery may be recommended to help with walking.

Treatments for normal pressure hydrocephalus

Treatment focuses on restoring the natural flow of CSF and relieving pressure on the brain. The most common and effective treatment is surgery. 

NPH is progressive and will worsen over time with or without treatment. However, treatment can help to prevent falls and allow for independent walking.

Shunt system placement

A device called a shunt is the most common treatment. A shunt is a small, flexible tube that helps drain excess cerebrospinal fluid from the brain’s ventricles to another part of the body, usually the belly, where the fluid can be absorbed. The shunt system has a valve that controls how much fluid flows out, so there is not too much or too little. 

Shunt surgery often improves walking and balance but is less likely to help with thinking and bladder control. Every shunt has a valve that can be adjusted to help with imbalance-related symptoms over time as the disease progresses. Regular follow-up visits help monitor shunt function and adjust the valve as needed.

Endoscopy third ventriculostomy (ETV)

Sometimes, surgeons do a special operation called an endoscopic third ventriculostomy (ETV). In this operation, they make a tiny opening in the floor of the brain’s third ventricle. This helps the fluid in the brain flow more freely without the need for a shunt.

Your care team will determine which treatment is best based on your age, health and how much your symptoms improve after testing. 

Rehabilitation and supportive therapies

After surgery, many people benefit from rehab programs to rebuild strength and confidence. These may include:

• Physical therapy to improve balance, gait and coordination and eventually determine what devices are needed to help make walking as safe as possible as the disease progresses
• Occupational therapy Cognitive exercises to strengthen memory and attention

Learn more about diagnosis and treatment. 

Living with normal pressure hydrocephalus

With early diagnosis and proper care, many people with NPH regain mobility and independence and feel more confident when walking. Regular check-ups are important to make sure the shunt system is working and to watch for any changes in symptoms.

If you start having trouble walking, remembering things or bladder issues return, talk to your care team right away.  Adjustments to the valve can often help with problems if they get worse. 

Living well with NPH means taking care of your health. Exercising regularly may help improve your confidence in walking. Having support from family and friends can also help you feel better and recover more easily.

Hope through the treatment

Banner Health provides advanced, patient-centered care for people with NPH and other types of hydrocephalus. Using the best technology and coordinated care, we focus on what matters most: improving your quality of life. Our goal is to help you or your loved one become more independent and feel at peace. 

If you or someone you care about is having trouble walking, increased memory loss or loss of bladder control, don’t think it’s just due to getting older. Make an appointment with a specialist at Banner Health neurosciences.