In South Africa, normal pressure hydrocephalus is managed by neurologists. Hydrocephalus is an abnormal accumulation of cerebrospinal fluid (CSF) inside the brain's ventricular system, raising intracranial pressure or distorting brain tissue when CSF production exceeds absorption or when flow is obstructed. Roughly 1 in 770 newborns is affected globally, and an estimated 700,000 American adults live with idiopathic normal pressure hydrocephalus, the most common adult form.
Hydrocephalus (ICD-10: G91 in adults, Q03 in congenital, G91.2 idiopathic normal pressure) is a heterogeneous group of disorders defined by progressive ventricular enlargement secondary to imbalance between cerebrospinal fluid production at the choroid plexus (about 500 mL/day in adults) and absorption at the arachnoid villi and lymphatic pathways. The Rekate classification divides hydrocephalus by the site of CSF flow obstruction: foramen of Monro, aqueduct of Sylvius, fourth ventricle outflow, basal cisterns, or arachnoid villi. The historic dichotomy of communicating versus non-communicating (obstructive) hydrocephalus remains useful clinically; obstructive hydrocephalus causes acute deterioration and requires urgent CSF diversion, while communicating hydrocephalus, including idiopathic normal pressure hydrocephalus, develops gradually with the classic triad of gait apraxia, cognitive impairment, and urinary incontinence (Hakim's triad). Etiologies include congenital aqueductal stenosis, Chiari malformations, neural tube defects, intraventricular hemorrhage of prematurity, post-meningitic adhesions, tumors blocking CSF pathways, subarachnoid hemorrhage, and idiopathic processes.
The key symptoms of Normal pressure hydrocephalus are: Rapidly enlarging head with abnormal head-circumference crossing two percentile lines in an infant under 18 months, often with widely separated cranial sutures and a tense bulging anterior fontanelle., Persistent downward deviation of both eyes (the 'setting-sun' sign) caused by pressure on the dorsal midbrain in infants and young children with obstructive hydrocephalus., Morning headache that improves on standing, often with projectile vomiting and progressively worsens over weeks in children and adults with raised intracranial pressure., Magnetic, broad-based, shuffling gait with reduced step height and difficulty initiating walking — the most common and earliest symptom of idiopathic normal pressure hydrocephalus in 90% of patients., Subcortical cognitive impairment with bradyphrenia, executive dysfunction, apathy, and impaired attention in adult-onset hydrocephalus, distinguishable from cortical dementia by relatively preserved memory storage., Urinary urgency progressing to frank incontinence in 60-80% of patients with iNPH, often preceded by detrusor overactivity demonstrable on urodynamic study., Papilledema on fundoscopy with blurring of disc margins, venous engorgement, and eventually optic atrophy and vision loss when intracranial pressure has been elevated for weeks..
Diagnosis combines clinical examination, neuroimaging, and selected CSF testing. In infants, serial head-circumference measurement on World Health Organization growth charts identifies the rapidly enlarging head; cranial ultrasound through the open fontanelle is the first-line imaging study and detects ventricular dilation and intraventricular hemorrhage without sedation. In older children and adults, MRI brain with thin-cut sagittal sequences through the aqueduct is the diagnostic standard — it confirms ventricular enlargement, identifies obstruction (tumor, aqueductal stenosis), assesses CSF flow with phase-contrast cine sequences, and rules out hydrocephalus ex vacuo by demonstrating disproportionate ventricular size relative to cortical atrophy. The Evans index (ratio of frontal horn width to maximum biparietal diameter) above 0.30 supports ventriculomegaly; a callosal angle below 90° on coronal MRI distinguishes iNPH from atrophic ventriculomegaly with 93% specificity. CT brain is faster and useful for shunt-malfunction assessment and acute presentations but exposes children to radiation. In suspected iNPH, a high-volume lumbar tap test (drainage of 40-50 mL of CSF) with timed gait and cognitive testing before and after carries sensitivity of about 60% and specificity above 80% for predicting shunt response; extended lumbar drainage over 72 hours raises sensitivity to 90%. Intracranial-pressure monitoring or CSF infusion studies are reserved for ambiguous cases at high-volume centers. Funduscopy for papilledema, visual-evoked potentials, and neuropsychological assessment complete the workup.
Outlook varies sharply by etiology, age, and treatment access. Children with non-syndromic aqueductal stenosis treated with ETV or shunt have 5-year survival above 95% and normal or near-normal cognition in 60-75% when surgery occurs before significant cortical thinning. Premature infants with post-hemorrhagic hydrocephalus have a less favorable course — 30-50% reach adulthood with developmental delay, and shunt revision rates exceed 40% within five years. Adult iNPH treated with programmable VP shunting improves gait in 60-80% at 12 months in selected responders, with stable benefit at 3 years in roughly half. Untreated obstructive hydrocephalus carries a mortality of 50-70% within two years of presentation in low-resource settings. Shunt-related complications dominate long-term outcomes: about 40% of patients need at least one revision in five years, infection occurs in 5-10% of operations, and over-drainage produces chronic subdural collections in 5-15%. Tumor-related hydrocephalus follows the prognosis of the underlying neoplasm.
Pediatric or adult neurosurgery is mandatory once hydrocephalus is suspected on imaging — the decision between VP shunt, ETV, ETV plus choroid plexus cauterization, and observation depends on age, etiology, ventricular anatomy, and ETV Success Score. Neurology, neuropsychology, and rehabilitation evaluate and document the cognitive, gait, and continence deficits before and after surgery. Ophthalmology monitors papilledema and protects vision while CSF diversion is planned.
Find specialists →Postoperative hospital stay 2-5 days for uncomplicated shunt and 1-3 days for ETV. Headache and incision tenderness fade over 1-2 weeks. Gait improvement in iNPH is often noticeable within days and continues for 3-6 months. Cognitive and continence gains plateau at 6-12 months. Children resume schooling within 2 weeks. Annual follow-up imaging and valve checks continue lifelong.
Low-impact aerobic exercise (walking, stationary cycling, swimming in supervised pools) is encouraged within 4-6 weeks of uncomplicated shunt or ETV. Resistance training resumes at 6-8 weeks. Avoid contact sports (rugby, boxing, martial arts) and activities with high deceleration (downhill skiing, diving from height) in shunted patients. In iNPH, structured gait rehabilitation begins within days of CSF tap or shunt insertion and continues for at least 12 weeks.
Choose a neurosurgeon at a high-volume center performing at least 50 shunt or ETV procedures per year, ideally affiliated with the Hydrocephalus Clinical Research Network or an equivalent national registry. For iNPH, an neurosurgery program with a structured outpatient pathway (clinical screening, tap test, extended drainage, programmable-valve shunt) outperforms ad hoc referrals. Pediatric cases benefit from a multidisciplinary clinic combining neurosurgery, neonatology, and developmental pediatrics.
Medically reviewed by AIHealz Medical Editorial Board · May 13, 2026
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