To shunt or not to shunt, that is the (NPH) question? The first large randomized trial of shunting for normal pressure hydrocephalus (NPH) just dropped in NEJM, and there was clear benefit for walking, and it favored the group receiving shunts. Spoiler alert: Walking improved, however thinking (cognition) and bladder function did not. Key Points: - NPH is a condition usually presenting in older adults where fluid builds up in the brain and it associated w/ trouble walking, memory and thinking challenges as well as bladder incontinence. - Shunting significantly improved walking speed and balance compared w/ placebo. - No meaningful change in cognition or bladder control observed at 3 months. - Risks included subdural bleeding and headaches, underscoring the need for careful follow up. My take: NPH has always been a tricky area for clinicians when trying to decidr 'to shunt or not to shunt.' Here are 5 points that resonated w/ me: 1- Shunting in well selected persons can restore some walking ability in NPH. 2- Thinking did not improve at 3 months. 3- Incontinence showed no clear benefit. 4- Risks to always discuss w/ people considering shunts should include bleeding and headaches (as not uncommon). 5- Walking gains may possibly reduce falls and boost independence, however we must be careful as sometimes improved walking w/o improved balance, can actually trigger falls. nejm.org/doi/full/10.1056/NE… @FixelInstitute @ParkinsonDotOrg @alzassociation @SfNtweets @SfNtweets @NEJM