Acta Neurochirurgica (2026) 168:80
This retrospective cohort study from Tel-Aviv Medical Center evaluates predictors of clinical benefit following shunt placement in idiopathic normal pressure hydrocephalus (iNPH). Among 167 patients undergoing high-volume lumbar puncture, 62 (37%) were LP responders and 38 proceeded to shunting; 21 of 38 (55%) experienced favorable outcomes at one year, with gait disturbance the commonest presenting symptom.
Key associations with LP responsiveness and positive one‑year shunt outcome included lower CSF total tau, lower CSF protein, younger age at symptom onset, pronounced immediate gait improvement after CSF drainage, and the presence of a disproportionately enlarged subarachnoid-space hydrocephalus (DESH) imaging pattern. The authors recommend a multimodal approach combining clinical response, imaging, and fluid biomarkers to refine patient selection for shunting.
Aim Identify clinical, imaging, and CSF biomarkers linked to LP responsiveness and 1-year shunt outcomes in suspected idiopathic normal pressure hydrocephalus (iNPH).
Cohort & pathway 183 evaluated (2020–2022); 167 underwent high-volume LP (≥30 mL removed); LP responders were referred for shunting and outcomes assessed at 1 year.
LP response rate 62/167 (37%) improved after CSF drainage and were referred; 38/62 (61%) ultimately received a shunt (others mainly declined surgery).
Clinical predictors (LP response) Gait disturbance was the most common initial symptom (68%) and was more frequent in LP responders, while cognitive symptoms were more common as the first symptom among non-responders.
CSF biomarkers (LP response) LP responders had lower CSF total tau (t-tau) and protein than non-responders.
Imaging predictor (LP response) DESH pattern was more common in LP responders (73% vs 46%).
Shunt effectiveness Among shunted patients, 21/38 (55%) had a favorable clinical outcome at 1 year.
Outcome predictors (post-shunt) Favorable 1-year outcomes were associated with more frequent DESH and a trend toward lower t-tau.
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