Cerebrospinal fluid shunting for idiopathic normal pressure hydrocephalus: a comprehensive meta‑analysis with trial sequential analysis of randomized controlled trials

Idiopathic normal pressure hydrocephalus (iNPH) is a potentially reversible neurocognitive disorder causing severe functional decline in the elderly. Cerebrospinal fluid (CSF) shunting aims to relieve ventricular stress and restore perfusion; however, high-quality placebo-controlled evidence has historically been limited.

This PRISMA-compliant systematic review and meta-analysis (PROSPERO: CRD420261372290) evaluated adults aged 60 years or older with iNPH. We included randomized controlled trials (RCTs) comparing immediate active CSF shunting against placebo or no shunting. The primary outcome was the change in gait speed using standardized timed assessments. Data were pooled using a restricted maximum-likelihood random-effects model, supplemented by Trial Sequential Analysis (TSA) and GRADE assessment to control for random error.