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In a child with a shunt: vomiting, headache, drowsiness or irritability may mean the shunt has blocked. Go to hospital today. Shunt blockage can raise pressure rapidly and is an emergency at any hour. In adults, seek urgent care for severe headache with vomiting and drowsiness.

Home  /  Treatments  /  Neurosurgery  /  Hydrocephalus

Hydrocephalus

Fluid produced continuously inside the brain cannot drain away, and pressure builds. In babies the head enlarges; in adults the skull cannot expand, so the pressure affects the brain directly.

One form of this condition in older adults is frequently mistaken for dementia and is genuinely treatable. Recognising it is one of the more rewarding things in neurosurgery.

Clinically reviewed by Dr. Annie Varughese, Consultant Neurosurgeon Clinical oversight Dr. Annie Varughese, MD, FACC Last reviewed August 2026 Editorial and medical review policy
In older adults
Often mistaken for dementia
And frequently reversible
Classic triad
Walking, memory, bladder
Gait disturbance usually comes first
Two operations
Shunt or endoscopy
Endoscopy avoids any implant
Time in India
3 to 4 weeks
Longer where assessment is needed first
On this page
  1. What it is
  2. Symptoms and warning signs
  3. How it is diagnosed
  4. Treatment options
  5. How the choice is made
  6. How urgent is your case
  7. What to send us
  8. Questions patients ask
The condition

What hydrocephalus is

Cerebrospinal fluid is produced continuously within cavities in the brain, circulates around the brain and spinal cord, and is absorbed back into the bloodstream. Hydrocephalus occurs when that circulation is obstructed or absorption fails, and fluid accumulates.

In infants, whose skull bones have not yet fused, the head enlarges and the fontanelle bulges. Common causes are bleeding in premature babies, infection, spina bifida and congenital narrowing of the channel between the fluid cavities.

In adults the skull cannot expand, so accumulating fluid raises pressure and causes headache, vomiting, visual disturbance and drowsiness. Causes include tumours obstructing flow, bleeding, and infection — tuberculous meningitis is an important cause in the regions our patients travel from and frequently produces hydrocephalus.

Normal pressure hydrocephalus is different and deserves particular attention. It occurs in older adults, and the pressure measured is not high. It produces a characteristic triad — a shuffling, magnetic gait as though the feet are stuck to the floor, memory and thinking difficulties, and urinary urgency or incontinence. It is regularly diagnosed as Alzheimer's disease or simple ageing, and unlike either it can improve markedly with treatment.

Symptoms

Symptoms and warning signs

Common symptoms
  • In babies: enlarging head, bulging fontanelle, downward-fixed gaze, irritability, poor feeding
  • In children and adults: headache worse in the morning, vomiting, drowsiness
  • Blurred or double vision
  • Difficulty walking, with a shuffling magnetic gait
  • Memory and concentration difficulty, slowed thinking
  • Urinary urgency or incontinence
  • In a child with a shunt: recurrence of any previous symptoms
Warning signs of an emergency
  • Vomiting, headache or drowsiness in anyone with a shunt
  • A baby with a rapidly enlarging head or bulging fontanelle
  • Reduced consciousness
  • Downward-fixed gaze in an infant
  • Fever with headache and neck stiffness
  • New seizure with headache and vomiting

A walking difficulty with memory loss in an older adult may be treatable

Normal pressure hydrocephalus produces gait disturbance, cognitive decline and urinary incontinence in older people, and it is regularly attributed to dementia or to ageing. It is not common, but it is one of the few causes of cognitive decline that can improve substantially with treatment. The gait usually deteriorates before the memory, which is a useful distinguishing feature — in Alzheimer's disease the reverse is typical. If an older relative has developed a shuffling, unsteady walk alongside memory problems, a brain scan is worth requesting.

Diagnosis

How it is diagnosed

Imaging shows the enlarged cavities; the harder question is whether draining fluid will help.

Initial tests

  • CT or MRI of the brain — shows enlarged ventricles and often the cause of obstruction
  • Ultrasound through the fontanelle — in infants, before the skull has fused
  • Head circumference measurement over time — in babies, plotted on a growth chart
  • Examination of the optic discs — swelling indicates raised pressure

The deciding tests

  • Lumbar puncture with removal of fluid — in suspected normal pressure hydrocephalus, temporary improvement in gait after removing fluid predicts benefit from a shunt
  • Extended lumbar drainage — a more sensitive version of the same test over several days
  • Formal gait assessment before and after fluid removal — timed walking, ideally filmed
  • MRI flow studies — assess whether fluid movement is obstructed and where

Film the walking, before and after

For suspected normal pressure hydrocephalus, a short video of the patient walking a fixed distance and turning around is the most useful single item you can provide. If a lumbar puncture removing fluid has been done, a video before and a few hours afterwards is genuinely diagnostic. Send it with the scan report and a description of the memory and bladder symptoms and when each began.

Options

Treatment options

Which operation depends on why the fluid cannot drain.

Option one

Ventriculoperitoneal shunt

A thin tube drains fluid from inside the brain, under the skin, into the abdomen where it is absorbed. A valve controls the flow, and programmable valves can be adjusted afterwards without further surgery. It is reliable and works for essentially all types of hydrocephalus, but it is an implant and implants can block, become infected, or need revision.

Usually appropriate whenCommunicating hydrocephalus, normal pressure hydrocephalus, and cases where endoscopic treatment is unsuitable.
Option two

Endoscopic third ventriculostomy

An endoscope makes an opening in the floor of one of the fluid cavities so that fluid bypasses the obstruction and drains internally. There is no implant at all, and therefore no shunt to block or become infected. It works only where the problem is a physical obstruction and the absorption mechanism is intact.

Usually appropriate whenObstructive hydrocephalus — for example from narrowing of the aqueduct or a tumour blocking flow — in a suitable patient.
Option three

Treating the cause

Removing a tumour obstructing fluid flow, treating tuberculous or bacterial meningitis, or managing bleeding. In some cases treating the cause resolves the hydrocephalus without any diversion procedure, though a temporary drain may be needed while treatment takes effect.

Usually appropriate whenWhere an identifiable and treatable obstruction or infection is responsible.
Option four

Shunt revision

Shunts block, disconnect, become infected or, in children, become too short as they grow. Revision is common over a lifetime and is not a failure of the original operation. Any patient with a shunt and new symptoms should be assessed for blockage urgently.

Usually appropriate whenRecurrence of symptoms in a patient with an existing shunt.
The decision

How the choice is made

Obstructive or communicating

An anatomical obstruction may be bypassed endoscopically without an implant. Failure of absorption requires a shunt.

Age and cause

Endoscopic treatment succeeds less reliably in very young infants and after certain infections. This affects the recommendation.

For normal pressure hydrocephalus, response to fluid removal

Improvement in gait after a lumbar puncture or drain is the best predictor that a shunt will help.

Where endoscopic treatment is feasible, we will recommend it — it avoids a lifetime of implant-related complications, even though it is the smaller procedure.

Urgency

How urgent is your case

Usually safe to plan travel
  • Stable symptoms, alert
  • Assessment complete, planning surgery
  • Existing shunt working, planning revision electively
  • Normal pressure hydrocephalus under assessment
Needs local assessment before travel
  • Any shunt patient with vomiting, headache or drowsiness
  • A baby with a rapidly enlarging head
  • Reduced consciousness
  • Fever with headache and neck stiffness
  • Rapidly worsening vision

We will tell you which column you are in

Shunt blockage raises pressure quickly and is an emergency wherever you are. Any patient with a shunt and new symptoms needs assessment the same day.

Next step

What to send us

Photographs taken on your phone are fine. Reports in Arabic, Russian or Bengali are fine — we translate them ourselves.

Most useful

  • CT or MRI of the brain, report and images
  • A video of walking, if gait is affected
  • Head circumference measurements over time in a baby
  • Details of any previous shunt and when it was placed

Also helpful

  • Lumbar puncture results, including any improvement afterwards
  • Details of when gait, memory and bladder symptoms each began
  • Any history of meningitis, tuberculosis or head injury
  • Previous operation notes if a shunt exists
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Questions

Questions patients ask

It is worth checking. Normal pressure hydrocephalus causes a triad of walking difficulty, cognitive decline and urinary incontinence in older adults, and it is regularly mistaken for dementia. A brain scan showing enlarged ventricles, followed by a test of whether removing fluid improves the walking, establishes it. Where it does, a shunt can produce marked improvement.

Endoscopic third ventriculostomy avoids any implant, which means nothing to block, become infected, or need revision over a lifetime. But it only works where the problem is a physical obstruction with intact absorption. Where it is feasible it is usually preferable; where it is not, a shunt is the reliable answer.

Recurrence of the symptoms the shunt was placed to treat — headache, vomiting, drowsiness, irritability in a child, or deterioration in walking or thinking in an adult. Treat it as urgent and go to hospital the same day. Shunt blockage can raise pressure rapidly, and delay is dangerous.

In most cases yes, and revisions are likely over the years — as a child grows, and because shunts eventually block or malfunction. This is expected rather than a sign of failure. Where endoscopic treatment is possible instead, it avoids that lifetime of maintenance, which is a substantial advantage.

Yes, and it is an important cause in the countries our patients travel from. Tuberculous meningitis inflames the membranes around the brain and blocks fluid circulation, frequently producing hydrocephalus. Treating the tuberculosis is essential alongside diverting the fluid, and both are needed.

Gait usually improves most and often earliest, sometimes strikingly. Urinary symptoms frequently improve. Cognitive improvement is more variable and generally less complete, particularly where symptoms have been present for a long time. Earlier treatment gives better results, which is why recognising it matters.

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Send the brain scan and, where walking is affected, a short video of the patient walking and turning. That video is often the most useful thing we receive.

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