NPH with Codman shunt

76 yr old female with NPH and 8 month old Codman shunt.  Surgeon has reprogramed shunt x1 after CAT scan revealed subdural bleed.  6 mos later NPH gait has returned with balance problems, tremors, and noises that went away for 5 mos.  Physician with not see my mother for 45 days and will not order another CAT scan to check for
CSF build up or more bleeding.  He states he cannot adjust the shunt any more.  I have done some research and
do not believe that - but have not told mom that.  Will another neuro see my mother and how best to approach that?Thanks.

[Christopher R Newey, DO]

Thanks for using the forum. I am happy to address your questions, and my answer will be based on the information you provided here. Please make sure you recognize that this forum is for educational purposes only, and it does not substitute for a formal office visit with a doctor.

Without the ability to examine and obtain a history, I can not tell you what the exact cause of the symptoms is. However I will try to provide you with some useful information.

I cannot comment on whether another neurosurgeon should or could see your mother. This will need to be decided with input from your mother. It is always best to follow up with the surgeon who performed the procedure. He/she may wish to wait for shunt adjustments given the recent subdural bleed, which is likely associated with the speed of the initial CSF drainage.

About the normal pressure hydrocephalus (NPH), what were your mother’s first presenting symptoms and how was it diagnosed? NPH classically has a characteristic gait and may progress to have impairment of mental function and perhaps urinary incontinence. Once a shunt is inserted, it can be programmed to drain more or less fluid based on the clinical examination. It is not always necessary to repeat head imaging to decide on changing the shunt settings.  NPH is usually diagnosed by combination of neuroimaging (CT or MRI) and lumbar puncture/drain. Clinically though, when other symptoms are present such as a tremor, esp. if unilateral, you do need to consider other diagnoses, such as Parkinson’s disease or parkinson’s plus diseases. The gait associated with NPH can be similar to the stooped posture of Parkinson’s.

Since I do not have the ability to examine your mother or review her records, it would be best for you to discuss your concerns with your mother’s neurosurgeon. The gait disturbance with NPH will fluctuate until an appropriate setting is established on the shunt. It will be the surgeon’s decision on how fast the CSF can be safely drained. Your mother may benefit from a referral to a neurologist to ensure that another process is not occurring, but I would discuss the shunt more thoroughly with your mother’s primary surgeon.

Thank you for this opportunity to answer your questions, I hope you find the information I have provided useful, good luck.