Department of  Neurosurgery
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Normal Pressure Hydrocephalus 


Normal pressure hydrocephalus (NPH) is a neurological disorder that affects elderly patients. Some estimates suggest that over 700,000 Americans may have NPH, the majority of whom become debilitated by dementia and are often placed in care homes. NPH is characterized by abnormal buildup of fluid in the brain, which progressively causes dementia and other neurologic symptoms including gait difficulties and urinary incontinence. The diagnosis of NPH remains challenging and requires an expert multidisciplinary team. However, NPH is surgically treatable if diagnosed and treated in a timely fashion.


There are three major symptoms of NPH. Having any one of the three symptoms, especially in an elderly patient (over the age of 60), raises the suspicion of NPH and requires further assessment not only to diagnose NPH, but also to ensure it is not a herald to other diseases such as Alzheimer’s disease, frontotemporal dementia, progressive supranuclear palsy, and Parkinson’s disease. Classic NPH symptoms include:

  • Dementia: cognitive decline/progressive mental impairment
  • Gait disturbances: difficulty with walking or balance
  • Urinary incontinence

Initial Investigations

  • Careful assessment of gait and cognition, ideally by an expert neurologist/neurosurgeon
  • CT or MRI the brain to show the enlarged fluid spaces in the brain

The Washington University Multidisciplinary NPH Program

Given the difficulty in diagnosing NPH, as it is a disease of the elderly who are already at risk for many other forms of dementia and gait disturbances, it is imperative to have a collaborative group of expert care providers to make the correct diagnosis, recommend the appropriate treatment and to care for these patients long-term. The NPH Center at the Washington University School of Medicine and Barnes-Jewish Hospital is a consortium of experts dedicated to the assessment and treatment of patients with NPH. The team includes the chairman, Dr. Greg Zipfel (neurosurgeon); co-chair, Dr. Mwiza Ushe (neurologist); Dr. Manu Goyal (neuroradiologist); Dr. Joshua Dowling (neurosurgeon); Dr. David Limbrick (neurosurgeon, research advisor); Dr. Albert Isaacs (neurosurgery resident, research coordinator); and a dedicated team of nurse practitioners and allied health personnel from physiotherapy, occupational therapy and psychology. Typically, patients with suspected NPH are initially assessed by Dr. Ushe. They will then undergo an advanced brain MRI scan designed specifically to evaluate NPH by Dr. Goyal. Further evaluation will also include an assessment of whether symptoms improve after removing of excess cerebrospinal fluid (CSF), that will be coordinated by our physical therapists, occupational therapists, psychologists, neurologists and neuroradiologists.  

All of this data will be used to determine whether NPH is likely to be the cause of the patient’s symptoms. If so, Dr. Zipfel and Dr. Dowling will provide further evaluation to determine whether a shunt can be safely placed to treat the NPH. A unique aspect of our multidisciplinary process is that we work together to expedite the evaluation and treatment of potential NPH patients, and to continue to monitor the success of your treatment over time.

For more information, please contact Gretchen Blow by email.