To compare the efficacy and safety of shunting vs no shunting in idiopathic normal pressure hydrocephalus.

Idiopathic NPH is a clinical syndrome characterised by the triad of gait impairment, cognitive decline and urinary incontinence due to ventricular expansion. With the standard of care being shunting, we aim to assess the efficacy and adverse events of the recent trials evaluating the short-term cognitive and gait velocity improvements.

A Systematic review and meta-analysis was conducted according to PRISMA guidelines. Suitable studies were identified through major databases until September 2025. Pooled odds ratios (ORs) were calculated using random effects models.

Across 4 RCTs, involving 239 participants, CSF shunting showed significant short term benefits across various functional outcomes. It resulted in significant improvement in mobility, as seen with increased gait velocity, MD 0.21[0.12,0.29], I²= 67%. Qualitative gait function, measured by Tinetti scale score, also favoured shunting (MD 1.37[0.01, 2.73], I²= 60%). Cognitive function showed overall improvement (MD 0.97[0.29,1.66] I²=52%) with a highly significant benefit observed with processing speed (Symbol Digit Modalities test score). However, adverse events were significantly higher in the shunting group, 36.8% vs 10.8% in the control group (OR 4.41[2.07, 9.41] I²=88%).

 CSF shunting provides significant short term benefit in iNPH patients, particularly with gait speed and cognitive processing speed. However, it holds a notably increased risk of adverse events. With moderate to high heterogeneity among certain outcomes due to reliance on 4 trials, it warrants a need for trials with a larger sample.