Diagnosing Normal Pressure Hydrocephalus

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Adult Hydrocephalus Program

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If your primary-care doctor thinks you might have Normal Pressure Hydrocephalus (NPH), he or she will refer you to a neurologist or neurosurgeon with special training and experience in this condition. This doctor is part of a team of specialists who will conduct an in-depth evaluation. The evaluation is designed specifically to determine if you have NPH.

Day 1: Initial Visit and Testing

During your first visit, the doctor will talk with you about your medical history, and will conduct a thorough physical exam. The doctor will review existing CT or MRI images. If necessary, the doctor may order additional imaging, including a special MRI to look at the volume of cerebrospinal fluid (CSF) and how it flows through your brain.

If the results do not suggest NPH, we will refer you to a neurologist on our team who will evaluate you to determine other explanations for your symptoms.

If the results of this initial evaluation suggest you might have NPH, the team will ask you to perform a series of tests, including gait and balance testing and cognitive testing. The results of these tests are your baseline or starting point.

Gait and Balance Testing:

The team uses gait and balance tests to evaluate how well you are able to walk and whether you have trouble balancing while standing. During these tests our specialists may take a video of you performing simple movements. The team measures and characterizes how well you are able to perform these tests and they record the results.

Cognitive Testing:

The team also tests you on how well you can focus on completing a task, remember simple things and identify familiar objects. During this test you will answer a series of questions and also perform a few tasks involving language, information processing and memory. The team will record these results.

The results of these tests are your baseline or starting point.

Before you leave the clinic, our clinic scheduler will make two appointments for you:

  1. An appointment with Physical Therapy for more in-depth gait and balance testing
  2. An appointment at the NPH clinic for a lumbar puncture (also called a lumbar puncture).

These two appointments will be scheduled for the same day.

Day 2: Testing (Physical Therapy) and Lumbar Puncture (NPH Clinic)

During your Physical Therapy appointment, the therapist will have you perform additional gait and balance tests. These tests will provide your doctor additional information about your ability to walk and balance. The therapist will record the results in your medical record. The therapist will schedule a follow-up appointment for you for the next day.

After you are finished your Physical Therapy appointment, you will return to the NPH clinic for a lumbar puncture.

Lumbar puncture:

A lumbar puncture is a procedure to remove a specific amount of spinal fluid. This procedure can be done in your doctor’s office or in the hospital. Your doctor will sterilize and numb the lower portion of your back (the lumbar region) before carefully inserting a needle into the spinal canal to remove the correct amount of fluid.

Because removing spinal fluid may improve some NPH symptoms, a lumbar puncture helps the doctor properly diagnose your condition. If you have NPH, removing some fluid may relieve some of the pressure on your brain and you may have some improvement in your symptoms.

Before leaving the NPH clinic, our scheduler will make a follow-up appointment for you for the next day after your repeat testing at Physical Therapy.

Day 3: Repeat Testing (Physical Therapy) and Repeat Cognitive Testing (NPH Clinic)

During your second visit to Physical Therapy, the therapist will ask you to repeat the gait and balance tests you performed the previous day before your lumbar puncture. The therapist will record the results of these repeat tests.

After you complete the repeat gait and balance testing, you will return to the NPH clinic to repeat the cognitive testing.

Your doctor will compare the results from all of your testing (before and after your lumbar puncture) to see if the lumbar puncture improved your symptoms.


If your symptoms improved after draining the small amount of fluid during the lumbar puncture, your doctor will talk with you about treatment, which will include inserting a small tube (shunt) in your brain to help drain the fluid.

No improvement:

If the results show no improvement, but the team’s evaluation and the MRI images suggest NPH, the doctor may talk with you about admitting you to the hospital for three to four days for more testing. While you are in the hospital, the doctor will insert a lumbar drain to allow a larger amount of spinal fluid to drain. You will have daily gait and cognitive testing. If your symptoms improve after draining more fluid, the doctor will talk with you about treatment. No improvement after testing in the hospital confirms you do not have NPH. Your doctor will discuss other possible explanations for your symptoms and will suggest a referral to a neurologist for additional evaluations.