Date of Award

January 2018

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

Amit Mahajan


It is very difficult to counsel patients who are suspected to have idiopathic normal pressure hydrocephalus (iNPH) due to the variability in diagnostic criteria and clinical presentations, as well as the difficulty in evaluating prognosis. This two part study was conducted in order to identify ways to improve the counseling of patients with iNPH. A qualitative analysis of patient experience with iNPH and shunting was initially performed. This was followed by an imaging analysis to identify predictors of outcome after shunt surgery.

A cohort of patients with iNPH who were shunted at a single institution were identified retrospectively and interviewed to explore patient experience. Interview transcripts were analyzed using the principles of grounded theory, which yielded seven overarching themes. From these themes, it was concluded that patients: suffer from a long preoperative course, desire improvement in functional independence, are not affected by the inability to provide a prognosis associated with shunt surgery, are confounded by comorbid conditions, and receive heavy influence from family members and caregivers. These conclusions can be incorporated by physicians to improve patient counseling.

Features on the brain imaging of the same cohort of patients were reviewed retrospectively and compared with patient-reported subjective binary outcomes obtained from the patient interviews. A few imaging features were found to be possible predictors of outcome after shunting. The presence of focally dilated sulci may be a predictor of gait improvement, and a larger Evans' index, larger third ventricular diameter, and larger callosal height, may all be predictors of cognitive improvement. However, there is significant discordance in the literature regarding the predictive value of imaging features. The utility of imaging parameters in patient counseling remains limited until more consistent results can be produced.


This is an Open Access Thesis.

Open Access

This Article is Open Access