Acta Neurochirurgica

, Volume 112, Issue 1–2, pp 50–61 | Cite as

Reappraisal of the intracranial pressure and cerebrospinal fluid dynamics in patients with the so-called “Normal pressure hydrocephalus” syndrome

  • J. Sahuquillo
  • E. Rubio
  • A. Codina
  • A. Molins
  • J. M. Guitart
  • M. A. Poca
  • A. Chasampi
Clinical Articles


Fifty-four shunt-responsive patients were selected from a prospective protocol directed to study patients with suspected normal pressure hydrocephalus (NPH). Patients with gait disturbances, dementia, non-responsive L-Dopa Parkinsonism, urinary or faecal incontinence and an Evans ratio greater or equal to 0.30 on the CT scan were included in the study.

As a part of their work-up all patients underwent intracranial pressure monitoring and hydrodynamic studies using Marmarou's bolus test. According to mean intracranial pressure (ICP) and the percentage of high amplitude B-waves, patients were subdivided in the following categories: 1) Active hydrocephalus (mean ICP above 15 mmHg), which is in fact no tone normal pressure hydrocephalus; 2) Compensated unstable hydrocephalus, when mean ICP was below 15 mmHg and B-waves were present in more than 25% of the total recording time and 3) Compensated stable hydrocephalus when ICP was lower or equal to 15 mmHg and beta waves were present in less than 25% of the total recording time.

The majority of the patients in this study (70%) presented continuous high or intermittently raised ICP (active or unstable compensated hydrocephalus group). Mean resistance to outflow of CSF (Rout) was 38.8 mm Hg/ml/min in active hydrocephalus and 23.5 mm Hg/ml/min in the compensated group (Students t-test, p < 0.05). Higher resistance to outflow was found in patients with obliterated cortical sulci and obliterated Sylvian cisterns in the CT scan.

No statistically significant correlation was found when plotting the percentage of beta waves against pressure volume index (PVI), compliance or Rout. An exponential correlation was found when plotting beta waves against the sum of conductance to outflow and compliance calculated by PVI method (r=0.79).

Patients with the so-called normal pressure hydrocephalus syndrome have different ICP and CSF dynamic profiles. Additional studies taking into consideration these differences are necessary before defining the sensitivity, specificity and predictive value of ICP monitoring and CSF studies in selecting appropriate candidates for shunting.


Normal pressure hydrocephalus intracranial pressure B-waves cerebrospinal fluid dynamics compliance hydrodynamics 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Adams RD, Fisher CM, Hakim S, Ojemann RG, Sweet WH (1965) Symptomatic occult hydrocephalus with “normal” cerebrospinal fluid pressure. N Engl J Med 273: 117–126PubMedGoogle Scholar
  2. 2.
    Anderson M (1986) Normal pressure hydrocephalus. Br Med J 293: 837–838Google Scholar
  3. 3.
    Bering EA Jr, Sato O (1963) Hydrocephalus: Changes in formation and absorption of cerebrospinal fluid within the cerebral ventricles. J Neurosurg 20: 1050–1063PubMedGoogle Scholar
  4. 4.
    Black PM (1982) Normal-pressure hydrocephalus. Current understanding of diagnostic tests and shunting. Postgr Med 71: 57–67Google Scholar
  5. 5.
    Blessed G, Tomlinson BE, Roth M (1968) The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects. Br J Psychiat 114: 797–811Google Scholar
  6. 6.
    Børgesen SE (1984) Conductance to outflow of CSF in Normal Pressure Hydrocephalus. Acta Neurochir (Wien) 71: 1–45Google Scholar
  7. 7.
    Børgesen SE, Gjerris F, Sorensen SC (1979) Intracranial pressure and conductance to outflow of cerebrospinal fluid in normal-pressure hydrocephalus. J Neurosurg 50: 489–493PubMedGoogle Scholar
  8. 8.
    Børgesen SE, Gjerris F (1987) Relationships between intracranial pressure, ventricular size, and resistance to CSF outflow. J Neurosurg 67: 535–539PubMedGoogle Scholar
  9. 9.
    Børgesen SE, Gjerris F, Sorensen SC (1978) The resistance to cerebrospinal fluid absorption in humans. A method of evaluation by lumbo-ventricular perfusion, with particular reference to normal pressure hydrocephalus. Acta Neurol Scand 57: 88–96PubMedGoogle Scholar
  10. 10.
    Børgesen SE, Gjerris F, Sorensen SC (1979) Cerebrospinal fluid conductance and compliance of the craniospinal space in normal-pressure hydrocephalus. J Neurosurg 51: 521–525PubMedGoogle Scholar
  11. 11.
    Braham J, Sarova-Pinhas I, Front D, Goldhammer Y (1971) A simple CSF manometric test for adult hydrocephalus associated with dementia. A comparison with radioisotope encephalography. Europ Neurol 5: 294–302PubMedGoogle Scholar
  12. 12.
    Cardoso ER, Reddy K, Bose D (1988) Effect of subarachnoid haemorrhage on intracranial pulse waves in cats. J Neurosurg 69: 712–718PubMedGoogle Scholar
  13. 13.
    Chawla JC, Hulme A, Cooper R (1974) Intracranial pressure in patients with dementia and communicating hydrocephalus. J Neurosurg 40: 376–380PubMedGoogle Scholar
  14. 14.
    Clough CG (1987) A case of normal pressure hydrocephalus presenting as levodopa responsive parkinsonism (letter). J Neurol Neurosurg Psychiatry 50: 234–244PubMedGoogle Scholar
  15. 15.
    Di Rocco C, Maira G, Rossi GF, Vignati A (1976) Cerebrospinal fluid pressure studies in normal pressure hydrocephalus and cerebral atrophy. Eur Neurol 14: 119–128PubMedGoogle Scholar
  16. 16.
    Di Rocco C, McLone DG, Shimoji T, Raimondi AJ (1975) Continuous intraventricular cerebrospinal fluid pressure recording in hydrocephalic children during wakefulness and sleep. J Neurosurg 42: 683–689PubMedGoogle Scholar
  17. 17.
    Diez-Lobato R (1989) Utilidad del estudio de la dinámica del liquido cefalorraquídeo en el paciente hidrocefálico. Neur 1: 3–10Google Scholar
  18. 18.
    Fillenbaum G (1985) Screening the elderly. A brief instrumental activities of daily living measure. J Am Geriatr Soc 33: 698–706PubMedGoogle Scholar
  19. 19.
    Fisher CM (1982) Hydrocephalus as a cause of disturbances of gait in the elderly. Neurology 32: 1358–1363PubMedGoogle Scholar
  20. 20.
    Folstein MF, Folstein SE, McHugh PR (1975) “Mini-Mental State”. J Psychiatr Res 12: 189–198PubMedGoogle Scholar
  21. 21.
    Foltz E, Ward AA (1956) Communicating hydrocephalus from subarachnoid bleeding. J Neurosurg 6: 546–566Google Scholar
  22. 22.
    George AE, de Leon MJ, Kalnin A, Rosner L, Goodgold A, Chase N (1986) Leukoencephalopathy in normal and pathologic aging: 2. MRI of brain lucencies. AJNR 7: 567–570PubMedGoogle Scholar
  23. 23.
    Geschwind N (1968) The mechanism of normal pressure hydrocephalus. J Neurol Sci 7: 481–493PubMedGoogle Scholar
  24. 24.
    Goto K, Ishii N, Fukusawa H (1981) Diffuse white matter disease in the geriatric population: A clinical neuropathological study. Neuroradiology 141: 687–695Google Scholar
  25. 25.
    Graff-Radford NR, Godersky JC (1986) Normal-pressure hydrocephalus. Onset of gait abnormality before dementia predicts good surgical outcome. Arch Neurol 43: 940–942PubMedGoogle Scholar
  26. 26.
    Gray WJ, Rosner MJ (1987) Pressure-volume index as a function of cerebral perfusion pressure. Part 1: the effects of cerebral perfusion pressure changes and anesthesia. J Neurosurg 67: 369–376PubMedGoogle Scholar
  27. 27.
    Gücer G, Viernstein L, Walker AE (1979) Continuous intracranial pressure recording in adult hydrocephalus. Surg Neurol 13: 323–328Google Scholar
  28. 28.
    Hachinski VC, Merskey H (1987) Leuko-Araiosis. Arch Neurol 44: 21–23PubMedGoogle Scholar
  29. 29.
    Hakim S (1964) Algunas observaciones sobre la presión del L.C.R. Sindrome hidrocefalico en el adulto con “presión normal” del L.C.R. Thesis, Facultad de Medicina, Universidad Javierana, Bogota, ColombiaGoogle Scholar
  30. 30.
    Hakim S, Adams RD (1965) The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. J Neurol Sci 2: 307–327PubMedGoogle Scholar
  31. 31.
    Hartman A, Alberti E (1977) Differentiation of communicating hydrocephalus and presenile dementia by continuous recording of cerebrospinal fluid pressure. J Neurol Neurosurg Psychiatry 40: 630–640PubMedGoogle Scholar
  32. 32.
    Hochwald GM, Lux WE Jr, Sahar A, Ransohoff J (1972) Experimental hydrocephalus. Changes in cerebrospinal fluid dynamics as a function of time. Arch Neurol 26: 120–129PubMedGoogle Scholar
  33. 33.
    Hoff J, Barber R (1974) Transcerebral mantle pressure in normal pressure hydrocephalus. Arch Neurol 31: 101–105PubMedGoogle Scholar
  34. 34.
    Jacobs L, Conti D, Kinkel WR, Manning EJ (1976) “Normalpressure” hydrocephalus. Relationship of clinical and radiographic findings to improvement following shunt surgery. JAMA 235: 510–512PubMedGoogle Scholar
  35. 35.
    Janny P, Flori B, Georget AM, Veyre A (1975) La résistance a l'écoulement du liquide céphalo-rachidien dans l'hydrocéphalie a pression normale (Paris). Rev Neurol 131: 211–217PubMedGoogle Scholar
  36. 36.
    Katzman R (1977) In: Wells CHE (ed) Dementia. F. A. Davis Company, Philadelphia, pp 69–92Google Scholar
  37. 37.
    Katzman R, Hussey F (1970) A simple constant-infusion manometric test for measurement of CSF absorption. I. rationale and method. Neurology 20: 534–544PubMedGoogle Scholar
  38. 38.
    Kosteljanetz M (1986) CSF dynamics and pressure-volume relationships in communicating hydrocephalus. J Neurosurg 64: 45–52PubMedGoogle Scholar
  39. 39.
    Kosteljanetz M (1987) Intracranial pressure: Cerebrospinal fluid dynamics and pressure-volume relations. Acta Neurol Scand 75 [Suppl] 111: 1–23PubMedGoogle Scholar
  40. 40.
    Kosteljanetz M, Ingstrup HM (1985) Normal pressure hydrocephalus: Correlation between CT and measurements of cerebrospinal fluid dynamics. Acta Neurochir (Wien) 77: 8–13Google Scholar
  41. 41.
    Kushner M, Younkin D, Weinberger J, Hurtig H, Goldberg H, Reivich M (1984) Cerebral hemodynamics in the diagnosis of normal pressure hydrocephalus. Neurology (Cleveland) 34: 96–99Google Scholar
  42. 42.
    Lamas E, Lobato RD (1979) Intraventricular pressure and CSF dynamics in chronic adult hydrocephalus. Surg Neurol 12: 287–295PubMedGoogle Scholar
  43. 43.
    Magnaes B (1988) Communicating hydrocephalus in adults. Diagnostic tests and results of treatment with medium pressure shunts. Neurology 30: 478–484Google Scholar
  44. 44.
    Marmarou A, Shulman K, LaMorgese J (1975) Compartmental analysis of compliance and outflow resistance of the cerebrospinal fluid system. J Neurosurg 43: 523–534PubMedGoogle Scholar
  45. 45.
    Marmarou A, Shulman K, Rosende RM (1989) A nonlinear analysis of the cerebrospinal fluid system and intracranial pressure dynamics. J Neurosurg 77: 8–13Google Scholar
  46. 46.
    McHugh PR (1964) Occult hydrocephalus. Q J Med 33: 297–308PubMedGoogle Scholar
  47. 47.
    McLone DG, Naidich TP (1985) In: (The Congress of Neurological Surgeons, ed.) Clinical neurosurgery 32. Williams and Wilkins, Baltimore, pp 527–539Google Scholar
  48. 48.
    Mulrow CD, Feussner JR, Williams BC, Vokaty KA (1987) The value of clinical findings in the detection of normal pressure hydrocephalus. J Gerontol 42: 277–279PubMedGoogle Scholar
  49. 49.
    Nornes H, Rootwelt K, Sjaastad O (1973) Normal pressure hydrocephalus. Long-term intracranial pressure recording. Europ Neurol 9: 261–274PubMedGoogle Scholar
  50. 50.
    Ojemann RG, Fisher CM, Adams RD, Sweet WH, New PFJ (1969) Further experience with the syndrome of “normal” pressure hydrocephalus. J Neurosurg 31: 279–294PubMedGoogle Scholar
  51. 51.
    Pfeiffer E (1975) A short portable mental status questionaire for the assessment of organic brain deficit in elderly patients. J Am Geriat Soc 23: 433–441PubMedGoogle Scholar
  52. 52.
    Pickard JD (1984) In: Warlow Ch, Warlow J (eds) Dilemmas in the management of the neurological patient. Churchill Livingstone, Edinbourgh, pp 207–214Google Scholar
  53. 53.
    Rezek DL, Morris JC, Fulling KH, Gado MH (1987) Periventricular white matter lucencies in senile dementia of the Alzheimer type and in normal aging. Neurology 37: 1365–1368PubMedGoogle Scholar
  54. 54.
    Rosner MJ (1987) In: Wood JH (ed) Cerebral blood flow. Physiological and clinical aspects. McGraw-Hill Company, New York, pp 425–448Google Scholar
  55. 55.
    Shapiro K, Marmarou A, Shulman K (1980) Characterization of clinical CSF dynamics and neural axis compliance using the pressure-volume index: I. The normal pressure-volume index. Ann Neurol 7: 508–514PubMedGoogle Scholar
  56. 56.
    Siegel BA, Johnson EW (1974) Measurement of intrathecal I 131-albumin transport to plasma. Neurology 501–503Google Scholar
  57. 57.
    Sorensen S, Jansen EC, Gjerris F (1986) Motor disturbances in normal-pressure hydrocephalus. Special reference to stance and gait. Arch Neurol 43: 34–38PubMedGoogle Scholar
  58. 58.
    Steingart A, Hachinski VC, Lau C, Fox AJ, Diaz F, Cape R, Lee D, Inzitari D, Merskey H (1987) Cognitive and neurologic findings in subjects with diffuse white matter lucencies on computed tomographic Scan (Leuko-Araiosis). Arch Neurol 44: 32–35PubMedGoogle Scholar
  59. 59.
    Symon L, Hinzpeter T (1975) The enigma of normal pressure hydrocephalus: Tests to select patients for surgery and predic shunt function. Williams and Wilkins, pp 285–315Google Scholar
  60. 60.
    Vassilouthis J (1984) The syndrome of normal-pressure hydrocephalus. J Neurosurg 61: 501–509PubMedGoogle Scholar
  61. 61.
    Vassilouthis J, Richardson AE (1979) Ventricular dilatation and communicating hydrocephalus following spontaneous subarachnoid hemorrhage. J Neurosurg 51: 341–351PubMedGoogle Scholar
  62. 62.
    Wikkelsö C, Andersson H, Blomstrand C, Lindqvist G, Svendsen P (1986) Normal pressure hydrocephalus. Predictive value of the cerebrospinal fluid tap-test. Acta Neurol Scand 73: 566–573PubMedGoogle Scholar
  63. 63.
    Yarnitsky D, Honigman S, Hemli JA, Bental E (1987) Normalpressure hydrocephalus associated with spinal cord tumour. Acta Neurol Scand 76: 302–305PubMedGoogle Scholar

Copyright information

© Springer-Verlag 1991

Authors and Affiliations

  • J. Sahuquillo
    • 1
  • E. Rubio
    • 1
  • A. Codina
    • 2
  • A. Molins
    • 2
  • J. M. Guitart
    • 1
  • M. A. Poca
    • 1
  • A. Chasampi
    • 1
  1. 1.Neurosurgical DepartmentVall d'Hebron HospitalBarcelonaSpain
  2. 2.Neurological DepartmentVall d'Hebron HospitalBarcelonaSpain

Personalised recommendations