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

INTRODUCTIONCore cognitive deficits in iNPH include slowed information processing, psychomotor slowing and executive dysfunction. However, the cognitive benefits of iNPH treatment with shunt surgery are not well understood. This review synthesised evidence on cognitive assessment methods and outcomes following shunt surgery in iNPH. METHODSPubMed, 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 data. RESULTSOf 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. CONCLUSIONSCognitive 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-specific 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. Summary BoxO_ST_ABSWhat is already known on this topicC_ST_ABSCognitive outcomes after shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) have been inconsistently reported, with cognitive improvement reported less reliably than gait outcomes, in the context of highly variable assessment practices across centres. What this study addsThis systematic review of 195 studies (11,445 patients) shows substantial heterogeneity in iNPH cognitive assessment and demonstrates that when tests sensitive to frontal-subcortical dysfunction are used, shunt surgery is associated with statistically and clinically meaningful cognitive improvement. Widely used dementia screening tools, including the MMSE and MoCA, show changes largely within expected practice-effect ranges and do not adequately capture core iNPH cognitive deficits. How this study might affect research, practice or policyThese findings demonstrate the need to standardise cognitive assessment in iNPH using appropriate iNPH-specific tools with validated metrics for determining clinically meaningful improvement. This will enable robust trial endpoints and accurate evaluation of cognitive benefits of shunting in routine clinical practice.