When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Normal pressure hydrocephalus

Last reviewed: 9 Nov 2023
Last updated: 13 Oct 2022



History and exam

Key diagnostic factors

  • levodopa-unresponsive gait apraxia
More key diagnostic factors

Other diagnostic factors

  • cognitive impairment
  • urinary frequency, urgency, or incontinence
  • fecal incontinence
Other diagnostic factors

Risk factors

  • age >65 years
  • vascular disease
  • diabetes mellitus
More risk factors

Diagnostic investigations

1st investigations to order

  • CT head (without contrast) or MRI head
  • levodopa challenge
More 1st investigations to order

Investigations to consider

  • lumbar puncture
  • lumbar puncture with large-volume cerebrospinal fluid (CSF) tap
  • prolonged external lumbar drainage
  • cerebrospinal fluid (CSF) infusion procedure
  • continuous intracranial pressure monitoring
More investigations to consider

Treatment algorithm


suitable for surgery

not suitable for surgery



Richard Adam Grünewald, MA, DPhil, FRCP
Richard Adam Grünewald

Consultant Neurologist

Honorary Clinical Senior Lecturer

Sheffield Teaching Hospitals NHS Foundation Trust




RAG has chaired a NICE guideline development group on neurological conditions, including recognition of movement disorders associated with normal pressure hydrocephalus. RAG received standard remuneration for chairing a NICE guideline development group. RAG is the author of a paper cited in this topic.


Dr Richard Grünewald would like to gratefully acknowledge Mr Jeremy Rowe, a previous contributor to this topic.

Peer reviewers

Robin Wilson, MD, PhD

Associate Director

Adult Hydrocephalus Center

Sandra and Malcolm Berman Brain & Spine Institute

Sinai Hospital




RW declares that she has no competing interests.

  • Normal pressure hydrocephalus images
  • Differentials

    • Parkinson disease
    • Parkinson-plus syndromes
    • Cerebrovascular parkinsonism
    More Differentials
  • Guidelines

    • Practice guideline: idiopathic normal pressure hydrocephalus: response to shunting and predictors of response
    • Guidelines for the diagnosis and management of idiopathic normal-pressure hydrocephalus
    More Guidelines
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer