Cognitive assessment methods and outcomes following shunt surgery in idiopathic normal pressure hydrocephalus (iNPH): a systematic review and meta-analysis

Clinical Snapshot

Key Findings

• P Value: Not reported in abstract

• Effect Size: Statistically and clinically significant improvement demonstrated

• Primary Outcome: Cognitive improvement following shunt surgery measured by neuropsychological tests

• Nnt Or Sensitivity: Trail Making Test-A, Grooved Pegboard-Dominant, and Trail Making Test-B showed changes exceeding clinically significant improvement thresholds

• Confidence Interval: Not reported in abstract

Clinical Application

Requires standardised cognitive assessment protocols and validated improvement criteria for optimal implementation Relevant to Australian neurosurgical centres managing iNPH patients; supports need for standardised cognitive assessment protocols in line with international best practice Adults with idiopathic normal pressure hydrocephalus being considered for or having undergone shunt surgery

Abstract

INTRODUCTION: Core cognitive deficits in iNPH include slowed information processing, psychomotor slowing and executive dysfunction. However, cognitive outcomes following shunt surgery are not well understood. This review synthesised evidence on cognitive assessment methods and outcomes following shunt surgery in iNPH. METHODS: PubMed, Scopus, PsycINFO and Web of Science were searched for peer-reviewed studies including adults with iNPH who underwent shunt surgery and had within-subject cognitive evaluations pre- and post-operatively. Key data were extracted and study quality was assessed. Random-effects meta-analyses were performed on pooled baseline and post-shunt difference scores for frequently reported cognitive tests with comparable outcome data. RESULTS: Of 1,876 records, 195 met the inclusion criteria, comprising 11,445 patients. Cognitive evaluation methods ranged from subjective reports and NPH grading scales to brief screening tools and comprehensive test batteries. Over 193 distinct tests were reported and 54.4% of studies did not formally assess any core iNPH cognitive deficits. Post-shunt improvement rates, follow-up times and criteria for defining improvement varied widely. Eighty-five studies contributed data to meta-analyses of ten outcomes. Pooled estimates indicated post-shunt cognitive improvement, with Trail Making Test-A, Grooved Pegboard-Dominant and Trail Making Test-B showing changes exceeding thresholds for clinically significant improvement. CONCLUSIONS: Cognitive assessment in iNPH is highly heterogeneous and frequently omits core domains, limiting detection of treatment effects. When domain-relevant cognitive measures are used, shunt surgery is associated with statistically and clinically significant cognitive improvement. These findings highlight the need for standardised iNPH-appropriate cognitive evaluation tools with validated criteria for detecting clinically meaningful change and have direct implications for clinical assessment, interpretation of shunt response and the selection of cognitive endpoints in future interventional studies.

References

1. 1.Healy, L. M., Tooze, J., Quist, D., Varma, P., Carswell, C., Fernández-Méndez, R., Pickard, J. D., Smielewski, P., & Joannides, A. J. (2026). Cognitive assessment methods and outcomes following shunt surgery in idiopathic normal pressure hydrocephalus (iNPH): a systematic review and meta-analysis. Fluids and Barriers of the CNS. https://doi.org/10.1159/000328924