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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 



CT scan of the brain should be requested via ICE in all patients with suspected NPH. Please state clearly your concerns (including details of the patient's symptoms and signs) and that you wish to exclude NPH as a cause. 

Imaging may be ambiguous (3) but it is often diagnostic. However, there is not necessarily a good correlation with the imaging findings and clinical severity.

If imaging is suggestive of NPH then they should be referred as detailed in the Referral section below’.


Referral to Neurosurgery - consider

Patients with clinical suspicion of NPH and supporting imaging findings should be referred 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 not suspected on imaging, 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 |