AAN 2026 | Diagnosing normal pressure hydrocephalus
Alfonso Fasano, MD, PhD, FAAN, University of Toronto, Toronto, Canada, provides an overview of normal pressure hydrocephalus (NPH), a frequently underdiagnosed condition characterized by gait disturbance, cognitive decline, and urinary dysfunction. He underscores the importance of early clinical recognition to enable timely intervention and improve patient outcomes before irreversible brain damage occurs. This interview took place at the 78th American Academy of Neurology (AAN) Annual Meeting in Chicago, IL.
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Transcript
NPH stands for normal pressure hydrocephalus, and it’s a mysterious disease to some extent. It’s quite common, poorly understood, and it is characterized radiologically by the buildup of CSF in the brain. So we see these large ventricles, we see entrapment of the CSF in the sulci or the lateral fissures, something called DESH. So these are very specific radiological signs that can raise the suspicion of NPH...
NPH stands for normal pressure hydrocephalus, and it’s a mysterious disease to some extent. It’s quite common, poorly understood, and it is characterized radiologically by the buildup of CSF in the brain. So we see these large ventricles, we see entrapment of the CSF in the sulci or the lateral fissures, something called DESH. So these are very specific radiological signs that can raise the suspicion of NPH. But at the end of the day, NPH is a clinical syndrome. So it needs to be diagnosed on clinical grounds. And the characteristics of these patients is for sure the most important is the gait imbalance disorder. These people have short steps, wide base gait, with a relatively preservation of the upper body. They may have start hesitation, freezing, turning. They might fall. They might have festination. These are all characteristic gait features that are not necessarily seen just in NPH. These are also seen in Parkinson’s. So gait and balance are the key features of these patients. But over time, these patients can also develop urinary urgency and a type of cognitive decline that is more of the executive problem. Some people might call it a subcortical type of dementia. So that’s the so-called triad, gait and balance, so motor problems, urinary problems, and cognitive problems. A common misunderstanding, though, is that people need to have this whole array of problems to be diagnosed. And in reality, we focus for the most part on gait and balance problems, so we don’t have to wait until the other problems arise. And actually, that’s important to emphasize because some people with NPH get to be diagnosed and treated when it’s too late. And over time, we know that this buildup of fluid causes an irreversible damage to the brain, either through lesioning the white matter or causing ischemia or even triggering neurodegeneration. So that’s a debated area of the field. But it seems like having NPH increases the chance to have neurodegenerative processes like Alzheimer’s disease. So obviously it’s up to debate whether treating NPH earlier can also prevent these people from having this further deterioration. So diagnosing people early enough is key because we also know from the data that the earlier the intervention, the better the outcome from a motor and cognitive standpoint.
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Disclosures
Dr. Fasano has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Abbott. Dr. Fasano has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Abbvie. Dr. Fasano has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ipsen. Dr. Fasano has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Medtronic. Dr. Fasano has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Boston Scientific. Dr. Fasano has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Abbott. Dr. Fasano has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Medtronic. Dr. Fasano has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Ceregate. Dr. Fasano has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for Inbrain Neuroelectronics. Dr. Fasano has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Syneos Health. Dr. Fasano has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for Annovis. Dr. Fasano has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for CADTH. Dr. Fasano has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for International Parkinson and Movement Disorders Society. The institution of Dr. Fasano has received research support from Boston Scientific. The institution of Dr. Fasano has received research support from Medtronic. The institution of Dr. Fasano has received research support from Abbvie. The institution of Dr. Fasano has received research support from Canadian Institutes of Health Research (CIHR). The institution of Dr. Fasano has received research support from Michael J Fox Foundation. The institution of Dr. Fasano has received research support from Bluerock Therapeutics. Dr. Fasano has received publishing royalties from a publication relating to health care. Dr. Fasano has a non-compensated relationship as a Medical Advisory Committee with CenteR for Advancing Neurological Innovation to Application (CRANIA) that is relevant to AAN interests or activities. Dr. Fasano has a non-compensated relationship as a Medical Advisory Committee with HopeNET that is relevant to AAN interests or activities. Dr. Fasano has a non-compensated relationship as a Medical Advisory Committee with International Essential Tremor Foundation that is relevant to AAN interests or activities. Dr. Fasano has a non-compensated relationship as a Member with Tremor Research Group that is relevant to AAN interests or activities. Dr. Fasano has a non-compensated relationship as a Co-Chair with Tremor Study Group of the IPMDS that is relevant to AAN interests or activities. Dr. Fasano has a non-compensated relationship as a Vice-Chair with NPH Study Group of the IPMDS that is relevant to AAN interests or activities. Dr. Fasano has a non-compensated relationship as a Vice-Chair with Industry Committee of the IPMDS that is relevant to AAN interests or activities.
