Clinical Features and Diagnosis of Normal Pressure Hydrocephalus

OBJECTIVE: This article serves as a practical guide for the assessment of patients with suspected idiopathic normal pressure hydrocephalus (NPH). LATEST DEVELOPMENTS: Significant advancements in neuroimaging, biomarker identification, and neurosurgical techniques have considerably improved the diagnostic accuracy and outcomes of treatment for idiopathic NPH. The full triad of gait disturbance, cognitive impairment, and urinary incontinence is not present in all patients and is not a prerequisite to pursuing treatment. Comorbid cervical stenosis is common and may also require surgical intervention. ESSENTIAL POINTS: NPH remains a challenging clinical entity with significant overlap in presentation with other neurodegenerative disorders such as Alzheimer disease, vascular dementia, and parkinsonian syndromes, especially progressive supranuclear palsy and dementia with Lewy bodies. Gait tends to be affected first and more severely than other domains in patients with idiopathic NPH. The CSF tap test is a key diagnostic tool where both objective and subjective improvements in symptoms help identify patients likely to have a good outcome after shunt surgery.