Normal Pressure Hydrocephalus

NPH is a condition that occurs when cerebrospinal fluid (CSF) accumulates in the brain without a significant increase in pressure.  This accumulation may lead to the slow onset and progression of symptoms that may mimic other Neurodegenerative conditions such as Alzheimer’s or Parkinson’s disease.

CSF is produced in the Brain (Ventricles) and surrounds the brain and spinal cord before being reabsorbed into the vascular system. It serves to cushion, protect , provides nutrients to, and remove waste material from the Brain and Spinal Cord.  Normally, the CSF is continuously absorbed from the brain to maintain a constant pressure, however it is commonly believed that in NPH, while CSF production seems to function normally, it (CSF) is not being absorbed properly.  This problem creates a buildup of fluid in the brain which enlarges the brain’s ventricles (cavities), and puts tension on surrounding brain tissue – without a significant increase in pressure.

There are two types of NPH: 

1) Idiopathic NPH accounts for about half the cases and occurs without any known cause,

2) Secondary NPH is associated with an identifiable cause such as a Head injury, Stroke, Hemorrhage, or infection.

Symptoms of Normal Pressure Hydrocephalus (NPH)

There are three primary symptoms of NPH:

1. Gait disturbance is commonly the primary manifestation of NPH as well as the most readily recognizable feature.  Persons with NPH are often “glue-footed”, or have a hard time picking their feet up off the floor leading to shuffling, instability and frequent falls.
2. Cognitive disturbance (Dementia) is the next most common symptom of NPH and often includes slowing of thought, inattentiveness, and apathy, as well as memory problems(forgetfulness).
3. Urinary incontinence can be less common in NPH and may present with feelings of frequency and urgency.

NPH is progressive and symptoms gradually worsen with time.  Not all three symptoms need be present to indicate the presence of NPH. The timing of these symptoms as well as their degree of severity can vary greatly between NPH patients.

Diagnosis of Normal Pressure Hydrocephalus (NPH)

NPH is difficult to diagnose and often goes untreated for extended periods.   Many of  the usual ways of diagnosing this condition are often unreliable. NPH is frequently misdiagnosed as Parkinson’s disease or Alzheimer’s disease because of the symptoms it shares with these diseases (gait disturbances and dementia).  NPH can also present alongside these conditions as well as other medical conditions.  New methods are continually evolving for better diagnosis of this condition and even more importantly can more accurately predict those who may benefit from treatment of this otherwise disabling condition.

Treatment of Normal Pressure Hydrocephalus (NPH)

NPH is usually treated by the insertion of a permanent shunt that diverts CSF from the brain into the abdominal cavity for clearance.  The potential risks of this surgery can include, but are not limited to: infection, seizure, bleeding, and subdural hematoma - therefore it is important to be selective and only place a permanent shunt in those patients who will likely benefit from the procedure. Though not all cases of NPH are completely curable, many can be safely and effectively treated to allow the patient and his/her families to lead a much more enjoyable and productive life.

Florida Hospital’s Normal Pressure Hydrocephalus (NPH) Program

Here at Florida Hospital our primary goal is to identify those patients that will most likely benefit from the placement of a shunt to treat NPH. A secondary goal is to advance the knowledge base in this condition and contribute to the understanding and treatment of NPH. 

Our carefully selected multidisciplinary team thoroughly evaluates each patient to determine whether each patient is unlikely to, possibly will , or probably will benefit from treatment of their condition by placement of a shunt device.  By identifying those most likely to benefit, the potential risks and possible complications of surgery are avoided for those patients who are determined to be least likely to benefit from treatment.   We continually strive to advance the diagnosis and treatment of NPH, as well as provide caring support for patients, friends, and family members.

Florida Hospital NPH Program Multidisciplinary Team

Florida Hospital’s NPH Program was conceived by Dr. Phillip St. Louis, an Orlando Neurosurgeon who has a sincere concern for this disorder.  The program was developed when our team recognized the critical need for a comprehensive multidisciplinary center where scholarly evaluation and treatment, of individuals considered to have NPH was essential. A useful byproduct of this coordinated effort would be the development of new and exciting ways to better understand and treat this disorder.

We are comprised of a team of experienced health care professionals from several areas including:

-Neurosurgery

-Neuroradiology (Imaging)

-Neurology

-Neuropsychology

-Physical Therapy

-Geriatrics

-Neurosurgical Nursing 

-NPH Clinical Program Coordinator

Florida Hospital NPH Program Timeline of Events

Patients with a potential NPH diagnosis are admitted to Florida Hospital(after an initial evaluation), for a three day hospital stay.

Day One

-Initial MRI or CT scan of brain                    

-Initial Neuropsychological assessment

-Initial Physical therapy assessment

-Nursing and geriatrics evaluate and follow patient throughout stay

Day Two

-Physical therapy assessment

-NPH Clinical Care Program Coordinator visitation

Day Three

-Final Neuropsychology assessment

-Final Physical therapy assessment

-Removal of the lumbar drain

-Final MRI or CT scan of brain

On the first day, the patient comes in for initial assessments from our multidisciplinary team.  After these assessments are complete, a lumbar drain is placed.  The lumbar drain is a small tube placed in the back that will continuously drain CSF over  the three days the patient is  in the hospital –this attempts to simulate what a permanent shunt would do, or in other words mimic the NPH treatment.  The patient is continuously reevaluated throughout the stay to determine how he/she is performing as the CSF is being drained.  An improvement in performance on repeated testing would suggest that draining the fluid is helping, and therefore that treating NPH by placing a shunt may be of benefit to the patient.

After the three day stay in the hospital, our multidisciplinary team meets to review the patient’s stay and collectively determine whether the patient is an unlikely, possible, or probable candidate for the placement of a permanent shunt to treat their condition. The recommendations of the committee are then forwarded to the patient / family, and also to their Primary care Physician and Referring Physician(if not one and the same). It is then left up to the patient and his/her family to decide on whether to have a shunt placed or not.  The patient is always encouraged to maintain a close working relationship with his/her primary care physician.

Regardless of whether the patient has a permanent shunt placed or not, the Florida Hospital NPH Program is committed to follow this patient with repeat testing at six months and twelve months ( MRI or CT scan, Neuropsychological evaluation, Physical Therapy assessment, and Neurosurgical evaluation).  The important of this requirement is that it helps us to objectively determine each individual’s long-term outcome, and how this outcome differs between patients who received a shunt and those who did not.

Contact Information

Address: 2501 N. Orange Ave., Suite 111, Orlando, FL 32804

NPH Clinical Program Coordinator: Jesse Passler

Phone: (407) 303-3282 | Fax: (407) 303-2835 | E-Mail: Jesse.Passler@flhosp.org

Additional Information

Educational Resources

1. Florida Hospital NPH Brochure
2. “NPH- The Untold Story” (60 Minutes, 12/2008)
   http://www.youtube.com/watch?v=fm0CZh_X-vM
3. “What is NPH?” (Hydrocephalus Association, 6/27/2008)
   http://www.youtube.com/watch?v=ubDS_SqJQns
4. “Causes of NPH”
   http://www.youtube.com/watch?v=RoiIpP6UkGA
5. “Insertion of a CSF Shunt”
   http://www.youtube.com/watch?v=Qmym2iFVNw8

To learn more about our NPH program, call our NPH Care Coordinator at (407) 303-3282 or contact us online.