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Hydrocephalus has no single presentation shared by every patient. The age of the person, the cause and the speed of change affect what clinicians see. An infant's head may enlarge, while an older child or adult may develop headache, vomiting, visual change or difficulty staying alert. Gradual walking, cognitive or urinary changes can prompt a different assessment in an older adult. These features also occur for other reasons.1

Infant assessment

Head growth is useful clinical information, interpreted over time alongside examination and imaging. Head size alone does not diagnose hydrocephalus. An infant's skull can expand, but that does not mean harmful pressure is impossible. Feeding, alertness, development and the child's overall condition also belong in the assessment. Prenatal imaging may first identify a concern; a suspected condition still needs age-appropriate specialist evaluation.2

What scans can and cannot answer

Ultrasound is useful in some infant assessments; CT and MRI provide different information according to context. Clinicians examine ventricular size and fluid pathways, possible causes and earlier images alongside the history. Enlarged ventricles can accompany active CSF disturbance, longstanding changes or brain-tissue loss. Ex-vacuo enlargement describes expansion related to tissue loss and should not simply be relabeled as hydrocephalus needing diversion. A scan report is not a substitute for the combined assessment.34

NPH testing is a particular pathway

In suspected iNPH, clinicians consider gait, cognition, bladder symptoms, imaging and competing explanations. All three classic symptom domains need not be present. Imaging features such as DESH may contribute, and selected patients undergo CSF drainage or infusion testing. A negative tap test does not independently exclude possible treatment response. The interpretation depends on the broader assessment. Lumbar puncture is not a routine test for every form of hydrocephalus; its suitability and safety must be determined in the actual clinical situation.5

Prepare a useful history

It helps to describe when changes started and whether they are progressing, and to bring prior treatment and imaging records to the clinician. Ask what cause is suspected, whether ventricular enlargement represents an active problem, and what further assessment would change the decision. These questions are a conversation aid, not a score that determines diagnosis.

Someone with severe or rapidly worsening neurological symptoms, a seizure or reduced responsiveness needs local emergency assessment. New concerns after shunt or ETV treatment should be raised promptly with the treating team. Neither a reassuring item on a symptom list nor an online explanation can rule out a serious problem.6

References

  1. NHS. Hydrocephalus: Symptoms. Source ↩
  2. US National Library of Medicine. MedlinePlus Medical Encyclopedia: Hydrocephalus. Source ↩
  3. NHS. Hydrocephalus: Diagnosis. Source ↩
  4. AANS Neurosurgical Members. Adult-onset Hydrocephalus. 15 July 2024. Source ↩
  5. Nakajima M et al. Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus (Third Edition). Neurol Med Chir. 2021;61:63–97. doi:10.2176/nmc.st.2020-0292. Source ↩
  6. NHS. Hydrocephalus: Complications. Source ↩