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REMEDY : BNSSG referral pathways & Joint Formulary

Normal Pressure Hydrocephalus - Draft

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Normal pressure hydrocephalus (NPH) happens when too much fluid builds up in a person’s brain without increasing pressure in their brain tissue. People who have NPH are usually aged over 60. (1)

The importance of this diagnosis lies in the fact that it is a potentially reversible cause of dementia, accounting for up to 6% of dementias (2).

Symptoms that should raise suspicion about NPH include:

  • Cognitive decline -  usually progresses more quickly than other causes of dementia.
  • Gait abnormality - shuffling or 'magnetic' gait
  • Urinary incontinence 

Brain maging  (?CT or MRI) should be undertaken in all patients with suspected NPH - imaging can be ambiguous (3) and may raise suspicion of NPH but is not diagnostic. 

Treatment can be medical or surgical.



Patients with suspected NPH (either based on symptoms or imaging) should be referred.

Can a patient have NPH with a normal MRI/CT? Should GP await result of MRI scan and only refer if abnormal? If GP has high suspicion of NPH should they refer prior to getting a scan result to avoid delay?

Should radiology reports advise onward referral to neurosurgery if appropriate?

Referral to Neurosurgery  

If a patient has suspected NPH clinically or radiologically then refer to neurosurgery (for consideration of VP shunt) via eRS (Neurosurgery -Adult Hydrocephalus - RAS)

If there is doubt about appropriateness of surgical intervention then consider requesting neurology advice and guidance. (is this appropriate?)

Referral to Dementia Service

Patients should only be referred to the Dementia Wellbeing Service if NPH is absent or if no neurosurgical or neurology-led intervention is appropriate and there is a comorbid neurodegenerative disease.



(1) Alzheimers Society - Normal Pressure Hydrocephalus

(2) - Normal Pressure Hydrocephalus

(3) Normal pressure hydrocephalus | Radiology Reference Article |