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Normal pressure hydrocephalus is a condition characterized by urinary incontinence, gait disturbance and dementia. As the name suggests, there is an excess of cerebrospinal fluid (CSF) in the brain cavities and there is enlargement of the brain cavities (ventricles). Complaints related to increased pressure in the head such as headache, nausea and vomiting, which we encounter in other types of hydrocephalus, are rarely seen.


What causes normal pressure hydrocephalus?

Normal pressure hydrocephalus may develop after intracerebral hemorrhages, hemorrhages under the cerebral cortex, head blows, brain surgeries and infections. However, it can occur for no reason due to the aging of the brain.


Who is it seen in?

Normal pressure hydrocephalus is usually seen in the elderly, especially in people over 60 years of age. It occurs in equal proportions in men and women. Sometimes this diagnosis can be made in patients of all ages. In one study, 1.3 out of 2.2 million people had normal pressure hydrocephalus in four out of 982 people over the age of 65. The annual incidence in Germany is estimated at 1.8 per 100,000.


What are the symptoms?

In patients with normal pressure hydrocephalus, complaints usually begin insidiously. They do not work properly by affecting the brain, especially the legs, urinary control centers and balance system. Therefore, gait and balance disorders, frequent urination or urinary incontinence occur. Gait impairment can range from shuffling with small steps (as in Parkinson's disease) to not being able to walk at all. The gait disturbance may be accompanied by imbalance. Stair climbing becomes difficult. There may be frequent falls due to gait disturbance. At the same time, patients may also experience forgetfulness, especially recent memory disorders, and reluctance in daily work. Patients often forget the recent past while remembering past events. Complaints such as frequent urination can reach as much as urinary incontinence. Rarely, fecal incontinence can be added to urinary incontinence or urinary control disorders.



Imaging methods, clinical examination and some tests are needed to diagnose normal pressure hydrocephalus. First of all, it is necessary to detect enlarged brain spaces in radiological examinations such as computed tomography (CT) or magnetic resonance imaging (MRI). There may be some loss of brain tissue. All patients should undergo MRI to determine whether there is a narrowing or obstruction in the CSF pathways.

After diagnosing hydrocephalus on CT and MRI, lumbar puncture (emptying the CSF by entering the waist with a needle and measuring the pressure) is performed in order to understand that it is at normal pressure and whether it will benefit from surgical treatment. Since the CSF pressure was found within normal limits, this disease was named normal pressure hydrocephalus. If the patient benefits from CSF evacuation, this procedure can be repeated. If it is found to be beneficial, the surgery is planned considering that it will also benefit from the surgery.



In the treatment of normal pressure hydrocephalus, shunt surgeries are most commonly performed. Endoscopic third ventriculostomy was also performed in some patients. The highest success rate in shunt surgeries is 70-80%. Endoscopic third ventriculostomy should be performed mostly in patients with obstruction or stenosis in the CSF pathways. Many tests are performed to predict which patients will benefit from treatment. However, none of them was 100% successful.

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