Acta Neurochirurgica

, Volume 149, Issue 10, pp 983–990

Continuous intraventricular pressure monitoring for diagnosis of normal-pressure hydrocephalus

  • W. K. Pfisterer
  • F. Aboul-Enein
  • E. Gebhart
  • M. Graf
  • M. Aichholzer
  • M. Mühlbauer
Clinical Article


Objectives. Normal-pressure hydrocephalus (NPH) syndrome is treatable by implantation of a cerebrospinal fluid (CSF) shunt. However, diagnosis of NPH by clinical and radiological findings alone is unreliable, and co-existing structural dementia can contribute to low success rates after shunt implantation. The aim of our study was to investigate whether long-term results after shunt implantation in NPH improve when surgical candidates are selected by continuous intraventricular pressure monitoring (CIPM).

Patients and methods. Ninety-two consecutive patients who were admitted with suspected NPH received CIPM for 48 h including an intraventricular steady-state infusion test to determine the resistance outflow. With positive CIPM, shunt implantation was performed and the patients were prospectively followed up for 1 to 10 years (median 6.5 years).

Results. CIPM was negative in 37 patients. Fifty-five patients had a positive CIPM and received CSF shunt. 96.1% of them improved from gait disturbance, 77.1% from cognitive impairment and 75.7% from urinary dysfunction. Clinical improvement remained during long-term follow-up in all but 3 patients who showed a decline at 4, 5 and 7 years, respectively. CIPM-related complications (ventriculitis) occurred in only one patient.

Conclusion. CIPM is a safe and valuable tool to establish a reliable diagnosis of NPH and to identify promising surgical candidates.

Keywords: Normal pressure hydrocephalus; continuous intraventricular pressure monitoring; intraventricular steady-state infusion; ventriculoatrial shunt. 



Continuous intraventricular pressure monitoring


cerebrospinal fluid


computed tomography


intracranial pressure


idiopathic/primary normal-pressure hydrocephalus syndrome


magnetic resonance imaging


normal-pressure hydrocephalus


pressure volume index


symptomatic/secondary normal-pressure hydrocephalus syndrome


ventricular fluid pressure


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. Adams, RD, Fisher, CM, Hakim, S, Ojemann, RG, Sweet, WH 1965Symptomatic occult hydrocephalus with “normal” cerebrospinal-fluid pressure. A treatable syndromeN Engl J Med273117126PubMedCrossRefGoogle Scholar
  2. Ahlberg, J, Norlen, L, Blomstrand, C, Wikkelso, C 1988Outcome of shunt operation on urinary incontinence in normal-pressure hydrocephalus predicted by lumbar punctureJ Neurol Neurosurg Psychiatry1105108Google Scholar
  3. Albeck, MJ, Borgesen, SE, Gjerris, F, Schmidt, JF, Sorensen, PS 1991Intracranial pressure and cerebrospinal fluid outflow conductance in healthy subjectsJ Neurosurg4597600Google Scholar
  4. Benzel, EC, Pelletier, AL, Levy, PG 1990Communicating hydrocephalus in adults: prediction of outcome after ventricular shunting proceduresNeurosurgery4655660CrossRefGoogle Scholar
  5. Black, PM 1980Idiopathic normal-pressure hydrocephalus. Results of shunting in 62 patientsJ Neurosurg3371377Google Scholar
  6. Black, PM, Ojemann, RG, Tzouras, A 1985CSF shunts for dementia, incontinence, and gait disturbanceClin Neurosurg32632651PubMedGoogle Scholar
  7. Boon, AJ, Tans, JT, Delwel, EJ, Egeler-Peerdeman, SM, Hanlo, PW, Wurzer, HA, Avezaat, CJ, de Jong, DA, Gooskens, RH, Hermans, J 1997Dutch normal-pressure hydrocephalus study: prediction of outcome after shunting by resistance to outflow of cerebrospinal fluidJ Neurosurg5687693Google Scholar
  8. Boon, AJ, Tans, JT, Delwel, EJ, Egeler-Peerdeman, SM, Hanlo, PW, Wurzer, JA, Hermans, J 1997Dutch normal-pressure hydrocephalus study: baseline characteristics with emphasis on clinical findingsEur J Neurol43947CrossRefGoogle Scholar
  9. Borgesen, SE 1984Conductance to outflow of CSF in normal-pressure hydrocephalusActa Neurochir (Wien)1–2145CrossRefGoogle Scholar
  10. Borgesen, SE, Gjerris, F 1982The predictive value of conductance to outflow of CSF in normal-pressure hydrocephalusBrain16586CrossRefGoogle Scholar
  11. Borgesen, SE, Gjerris, F, Sorensen, SC 1979Intracranial pressure and conductance to outflow of cerebrospinal fluid in normal-pressure hydrocephalusJ Neurosurg4489493Google Scholar
  12. Chen, IH, Huang, CI, Liu, HC, Chen, KK 1994Effectiveness of shunting in patients with normal-pressure hydrocephalus predicted by temporary, controlled-resistance, continuous lumbar drainage: a pilot studyJ Neurol Neurosurg Psychiatry1114301432Google Scholar
  13. Crockard, HA, Hanlon, K, Duda, EE, Mullan, JF 1977Hydrocephalus as a cause of dementia: evaluation by computerised tomography and intracranial pressure monitoringJ Neurol Neurosurg Psychiatry8736740Google Scholar
  14. Czosnyka, M, Smielewski, P, Piechnik, S, Schmidt, EA, Al Rawi, PG, Kirkpatrick, PJ, Pickard, JD 1999Hemodynamic characterization of intracranial pressure plateau waves in head-injury patientsJ Neurosurg11119Google Scholar
  15. Delwel, EJ, de Jong, DA, Avezaat, CJ 2005The prognostic value of clinical characteristics and parameters of cerebrospinal fluid hydrodynamics in shunting for idiopathic normal-pressure hydrocephalusActa Neurochir (Wien)1010371043CrossRefGoogle Scholar
  16. Eide, PK 2003Quantitative analysis of continuous intracranial pressure recordings in symptomatic patients with extracranial shuntsJ Neurol Neurosurg Psychiatry2231237CrossRefGoogle Scholar
  17. Fisher, CM 1982Hydrocephalus as a cause of disturbances of gait in the elderlyNeurology1213581363Google Scholar
  18. Gaab, MR 1979Measuring intracranial pressure. Methods and results in diagnosis, monitoring and therapy evaluation. IISchwest Rev71921Google Scholar
  19. Gaab, MR 1979Measuring of intracranial pressure. Methods and results in diagnosis, monitoring and therapy evaluationSchwest Rev61618Google Scholar
  20. Gaab, MR 1984Intracranial pressure recording. Principles, techniques, results and possibilitiesFortschr Med38957962Google Scholar
  21. Gjerris, F, Borgesen, SE, Hoppe, E, Boesen, F, Nordenbo, AM 1982The conductance to outflow of CSF in adults with high-pressure hydrocephalusActa Neurochir (Wien)1–25967CrossRefGoogle Scholar
  22. Graff-Radford, NR, Godersky, JC, Jones, MP 1989Variables predicting surgical outcome in symptomatic hydrocephalus in the elderlyNeurology1216011604Google Scholar
  23. Greenberg, JO, Shenkin, HA, Adam, R 1977Idiopathic normal-pressure hydrocephalus – a report of 73 patientsJ Neurol Neurosurg Psychiatry4336341Google Scholar
  24. Gyldensted, C 1977Measurements of the normal ventricular system and hemispheric sulci of 100 adults with computed tomographyNeuroradiology4183192CrossRefGoogle Scholar
  25. Haan, J, Thomeer, RT 1988Predictive value of temporary external lumbar drainage in normal-pressure hydrocephalusNeurosurgery2388391CrossRefGoogle Scholar
  26. Hakim, S, Adams, RD 1965The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamicsJ Neurol Sci4307327CrossRefGoogle Scholar
  27. Hanlo, PW, Cinalli, G, Vandertop, WP, Faber, JA, Bogeskov, L, Borgesen, SE, Boschert, J, Chumas, P, Eder, H, Pople, IK, Serlo, W, Vitzthum, E 2003Treatment of hydrocephalus determined by the European Orbis Sigma Valve II survey: a multicenter prospective 5-year shunt survival study in children and adults in whom a flow-regulating shunt was usedJ Neurosurg15257Google Scholar
  28. Hughes, CP, Siegel, BA, Coxe, WS, Gado, MH, Grubb, RL, Coleman, RE, Berg, L 1978Adult idiopathic communicating hydrocephalus with and without shuntingJ Neurol Neurosurg Psychiatry11961971Google Scholar
  29. Jack, CR,Jr, Mokri, B, Laws, ER,Jr, Houser, OW, Baker, HL,Jr, Petersen, RC 1987MR findings in normal-pressure hydrocephalus: significance and comparison with other forms of dementiaJ Comput Assist Tomogr6923931CrossRefGoogle Scholar
  30. Katzman, R, Hussey, F 1970A simple constant-infusion manometric test for measurement of CSF absorption. I. Rationale and methodNeurology6534544Google Scholar
  31. Kertesz, A, Black, SE, Tokar, G, Benke, T, Carr, T, Nicholson, L 1988Periventricular and subcortical hyperintensities on magnetic resonance imaging. ‘Rims, caps, and unidentified bright objects’Arch Neurol4404408Google Scholar
  32. Kosteljanetz, M 1986CSF dynamics and pressure-volume relationships in communicating hydrocephalusJ Neurosurg14552Google Scholar
  33. Krauss, JK, Droste, DW, Bohus, M, Regel, JP, Scheremet, R, Riemann, D, Seeger, W 1995The relation of intracranial pressure B-waves to different sleep stages in patients with suspected normal-pressure hydrocephalusActa Neurochir (Wien)3–4195203CrossRefGoogle Scholar
  34. Krauss, JK, Droste, DW, Vach, W, Regel, JP, Orszagh, M, Borremans, JJ, Tietz, A, Seeger, W 1996Cerebrospinal fluid shunting in idiopathic normal-pressure hydrocephalus of the elderly: effect of periventricular and deep white matter lesionsNeurosurgery2292299CrossRefGoogle Scholar
  35. Larsson, A, Wikkelso, C, Bilting, M, Stephensen, H 1991Clinical parameters in 74 consecutive patients shunt operated for normal-pressure hydrocephalusActa Neurol Scand6475482Google Scholar
  36. Lundberg, N 1960Continuous recording and control of ventricular fluid pressure in neurosurgical practiceActa Psychiatr Scand361193Google Scholar
  37. Magnaes, B 1978Communicating hydrocephalus in adults. Diagnostic tests and results of treatment with medium pressure shuntsNeurology5478484Google Scholar
  38. McCullough, DC, Fox, JL 1974Negative intracranial pressure hydrocephalus in adults with shunts and its relationship to the production of subdural hematomaJ Neurosurg3372375Google Scholar
  39. Meese, W, Kluge, W, Grumme, T, Hopfenmuller, W 1980CT evaluation of the CSF spaces of healthy personsNeuroradiology3131136CrossRefGoogle Scholar
  40. Meier, U, Kunzel, B, Zeilinger, FS, Riederer, A, Kintzel, D 1997Diagnosis of normal-pressure hydrocephalus. A calculation model for determining intracranial pressure-dependent resistance and complianceNervenarzt6496502CrossRefGoogle Scholar
  41. Pappada, G, Poletti, C, Guazzoni, A, Sani, R, Colli, M 1986Normal pressure hydrocephalus: relationship among clinical picture, CT scan and intracranial pressure monitoringJ Neurosurg Sci3115121Google Scholar
  42. Petersen, RC, Mokri, B, Laws, ER,Jr 1985Surgical treatment of idiopathic hydrocephalus in elderly patientsNeurology3307311Google Scholar
  43. Pickard, JD, Teasdale, G, Matheson, M, Lindsay, K, Galbraith, S, Wyper, D, Mac Pherson, P,  et al. 1980

    Intraventricular pressure waves – the best predictive test for shunting in normal-pressure hydrocephalus

    Shulman, KMarmarou, AMiller, JD eds. Intracranial pressure IVSpringerBerlin Heidelberg New York498500
    Google Scholar
  44. Raftopoulos, C, Chaskis, C, Delecluse, F, Cantraine, F, Bidaut, L, Brotchi, J 1992Morphological quantitative analysis of intracranial pressure waves in normal-pressure hydrocephalusNeurol Res5389396Google Scholar
  45. Raftopoulos, C, Deleval, J, Chaskis, C, Leonard, A, Cantraine, F, Desmyttere, F, Clarysse, S, Brotchi, J 1994Cognitive recovery in idiopathic normal-pressure hydrocephalus: a prospective studyNeurosurgery3397404CrossRefGoogle Scholar
  46. Sahuquillo, J, Rubio, E, Codina, A, Molins, A, Guitart, JM, Poca, MA, Chasampi, A 1991Reappraisal of the intracranial pressure and cerebrospinal fluid dynamics in patients with the so-called “normal-pressure hydrocephalus” syndromeActa Neurochir (Wien)1–25061CrossRefGoogle Scholar
  47. Sand, T, Bovim, G, Grimse, R, Myhr, G, Helde, G, Cappelen, J 1994Idiopathic normal-pressure hydrocephalus: the CSF tap-test may predict the clinical response to shuntingActa Neurol Scand5311316Google Scholar
  48. Savolainen, S, Hurskainen, H, Paljarvi, L, Alafuzoff, I, Vapalahti, M 2002Five-year outcome of normal-pressure hydrocephalus with or without a shunt: predictive value of the clinical signs, neuropsychological evaluation and infusion testActa Neurochir (Wien)6515523CrossRefGoogle Scholar
  49. Stephensen, H, Andersson, N, Eklund, A, Malm, J, Tisell, M, Wikkelso, C 2005Objective B wave analysis in 55 patients with non-communicating and communicating hydrocephalusJ Neurol Neurosurg Psychiatry7965970CrossRefGoogle Scholar
  50. Symon, L, Dorsch, NW 1975Use of long-term intracranial pressure measurement to assess hydrocephalic patients prior to shunt surgeryJ Neurosurg3258273Google Scholar
  51. Symon, L, Hinzpeter, T 1977The enigma of normal-pressure hydrocephalus: tests to select patients for surgery and to predict shunt functionClin Neurosurg24285315PubMedGoogle Scholar
  52. Tans, JT, Poortvliet, DC 1984Comparison of ventricular steady-state infusion with bolus infusion and pressure recording for differentiating between arrested and non-arrested hydrocephalusActa Neurochir (Wien)1–21529CrossRefGoogle Scholar
  53. Vanneste, J, Augustijn, P, Dirven, C, Tan, WF, Goedhart, ZD 1992Shunting normal-pressure hydrocephalus: do the benefits outweigh the risks? A multicenter study and literature reviewNeurology15459Google Scholar
  54. Vanneste, JA 2000Diagnosis and management of normal-pressure hydrocephalusJ Neurol1514CrossRefGoogle Scholar
  55. Vassilouthis, J 1984The syndrome of normal-pressure hydrocephalusJ Neurosurg3501509Google Scholar
  56. Wiebers, DO, Dale, AJD, Kokmen, E, Swanson, JW 1998Ment Funct33552Google Scholar
  57. Wikkelso, C, Andersson, H, Blomstrand, C, Lindqvist, G 1982The clinical effect of lumbar puncture in normal-pressure hydrocephalusJ Neurol Neurosurg Psychiatry16469Google Scholar
  58. Wikkelso, C, Andersson, H, Blomstrand, C, Lindqvist, G, Svendsen, P 1986Normal pressure hydrocephalus. Predictive value of the cerebrospinal fluid tap-testActa Neurol Scand6566573Google Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • W. K. Pfisterer
    • 1
  • F. Aboul-Enein
    • 2
  • E. Gebhart
    • 1
  • M. Graf
    • 2
  • M. Aichholzer
    • 1
  • M. Mühlbauer
    • 1
  1. 1.Department of NeurosurgeryDonauspital SMZ-OstViennaAustria
  2. 2.Department of NeurologyDonauspital SMZ-OstViennaAustria

Personalised recommendations