As society advances and medical care continues to improve, human life expectancy continues to increase. With the development of an aging society, diseases associated with the elderly such as Alzheimer’s disease, Parkinson’s disease and idiopathic normal pressure hydrocephalus (iNPH) are increasingly becoming a real problem for the medical community to address. The typical person with iNPH presents with a triad of gait instability, dementia, and urinary incontinence, most often in the elderly, with enlargement of the ventricular system. Studies have shown that iNPH is a disorder independent of Alzheimer’s disease and Parkinson’s disease, but there are many similarities in the clinical presentation of the three disorders, and all three may coexist in a single patient. Therefore, determining the diagnosis of iNPH is not an easy task. In addition, although the clinical manifestations of people with iNPH can be improved by bypass surgery, not all patients with this disease have a satisfactory outcome, and the presence of post-bypass complications negatively affects the patient’s outcome. In order to standardize the research related to iNPH, the Japanese Society of Neurosurgery published the Japanese version of iNPH guidelines in 2004 [3], and the International Guidelines (IG) were published in 2005. 2008, based on the Japanese version of the guidelines, the Japanese Society of Neurosurgery published the English version of the iNPH The Japanese Guidelines (JG) were published in 2008. The promulgation of these guidelines has become an important basis for research on iNPH and has promoted the development of corresponding guidelines and standardization of basic and clinical research in various countries. 1. The current situation of iNPH in China China is the most populous country in the world, and has also entered the aging society long ago. According to the statistical report of the National Population and Family Planning Commission, by the end of 2009, 12.5% of the total population was over 60 years old in China. “During the 12th Five-Year Plan period, China’s total population will be nearly 1.4 billion, and the number of elderly people over 60 will increase from 4.8 million in the 11th Five-Year Plan to 8 million in the 12th Five-Year Plan. In 2015, the total number of elderly people will exceed 200 million. Although the incidence of iNPH cannot be determined yet, the actual number of patients in China far exceeds the number of clinical consultations, based on the assumption that 5% of the population in the United States may have dementia (including patients with hydrocephalus). On the other hand, the awareness and attention to hydrocephalus in China is still far from adequate. There is neither a professional academic committee nor regular thematic academic exchanges. Even in the clinical units, hydrocephalus is not given as a separate disease to focus on research and independent professional division of labor, and the diagnosis and treatment of hydrocephalus is considered to be low-tech, simple and easy, and usually carried out by young physicians. In contrast, foreign research on hydrocephalus is very deep and involves a wide range of topics. In recent years, with the increase of foreign exchange, the domestic counterparts realized that due to the limitation of awareness and insufficient attention, although the number of patients with hydrocephalus treated by neurosurgeons in China is huge, it still belongs to the rough diagnosis and treatment level, and to change this state, a leap in awareness is needed first. For this reason, in November 2010, the editorial board of Chinese Journal of Neurosurgery and Beijing Wang Zhonglian Medical Foundation organized the “National Symposium on Standardized Application of Shunt for Hydrocephalus” in Guilin, where the diagnosis and treatment of hydrocephalus were carefully discussed, and a special issue on hydrocephalus research was published in 2011. However, among the 43 papers selected for the compilation of the symposium, only 2 were related to iNPH; in the special issue on hydrocephalus research, there was only 1 article on iNPH. It can be seen that the standardized research of iNPH in China is still in the initial stage, and it is imperative to pay more attention and give more active standardized research, refer to the relevant international literature and guidelines, and formulate the guidelines for the diagnosis and treatment of iNPH in accordance with our national conditions. The diagnosis and diagnostic criteria of iNPH in IG and JG are different due to the different time of publication and the difference in understanding, and the diagnosis in IG is divided into Probable, Possible and Unlikely. In terms of the criteria for Unlikely iNPH (absence of ventricular enlargement, presence of signs of increased ICP, absence of any of the manifestations and symptoms of iNPH that can be explained by other etiologies), the diagnosis does not fit the definition of iNPH and therefore the category is slightly redundant. In addition, the diagnostic criteria for IG are too detailed and inconvenient to grasp, and the patient’s age >40 years and lumbar puncture ICP pressure range of 70-245 mmH2O can easily cause confusion in clinical practice. From the clinical practical point of view, the author believes that the diagnostic classification and criteria of Possible, Probable and Definite proposed by JG are more simplified and practical. Among the preoperative diagnostic methods, the CSF drainage test (Tap test) in IG releases 40-50 ml of cerebrospinal fluid each time, and the predictive value is considered to be greater when the drainage is >300 ml outside the lumbar pool, which is the preferred method. However, the chances of complications and adverse effects are high when the drainage volume is too much and too large. 30 ml of CSF per release is recommended as the preferred Tap method in JG, which is recommended to be relatively safe and has wide operability. In China, there is no study report of a large number of cases, and the author uses the Tap method with 30 ml of CSF per release recommended in the JG in clinical practice. The cortical subarachnoid changes are of more interest in the imaging diagnosis of iNPH. 2010 Japanese scholar Hashimoto et al. reported the results of a prospective study on the role of MRI in the diagnosis of iNPH with the participation of 26 centers in Japan. The final enrollment of 100 patients concluded that the sign of disproportionately enlarged subarachnoidspace hydrocephalus (DESH) on MRI, characterized by narrowing of the cerebral convexity and medial subarachnoid space and widening of the lateral fissure subarachnoid space, is of great value in the diagnosis of iNPH. This sign, which is more exact on coronal images of MRI. The vast majority of units in China, however, use cross-sectional and sagittal imaging of MRI as a routine. It is recommended that coronal imaging of MRI be included in the diagnosis and treatment of iNPH as a routine item and as a key observation. 3.1 Indications for surgery So far, there is no standardized protocol for the surgical treatment of iNPH, and the IG suggests that theoretically all patients with probable and possible iNPH are suitable for surgical treatment, but the patient’s systemic status must be taken into account and the risk-to-benefit ratio must be evaluated. In JG, surgery is considered only for those with probable iNPH. It is thus clear that preoperative determination of the diagnosis and screening of patients effective for bypass are crucial in determining the surgical treatment of iNPH in order to ensure the effectiveness of surgical treatment. It should also be noted that any surgery has the potential for complications, especially in elderly patients who are at greater risk for accidents, and that not every patient diagnosed with iNPH is suitable for surgical treatment; the patient’s status, information from all tests, and the technical equipment and experience of the operator’s unit must be integrated to determine whether to operate or not. 3.2 Surgical modality and choice of shunt The surgical treatment of iNPH is still dominated by shunt surgery, with ventriculo-peritoneal shunt (V-P shunt) and ventriculo-atrial shunt (V-A shunt) being the most commonly used treatments. To date, there are no prospective or retrospective studies to compare which procedure is better, V-P or V-A, based mainly on the individualized status of the patient and the experience and habits of the operator. For those who are not suitable for ventricular shunt, a lumbar pool-abdominal shunt (L-P shunt) can be used. In recent years, the continuous development of endoscopic equipment and techniques has also expanded the spectrum of diseases treated by this technique. Although some scholars have reported that the use of third ventriculostomy for iNPH can achieve efficacy, both IG and JG have concluded that the efficacy and safety of this procedure for iNPH lack sufficient evidence and further study summaries are needed to confirm it. As for the choice of shunt, although prospective study results are still lacking, retrospective results suggest that the efficacy of using an adjustable pressure shunt for iNPH may be better because the set pressure can be adjusted according to the patient’s status after surgery outside the body to address the problem of under- or over-shunting. In bypass surgery for iNPH, both IG and JG believe that adjustable pressure shunts should be preferred. As for whether to use an anti-siphon device, it is stated in the JG that although the use of this device can reduce the incidence of postoperative subdural effusion, it cannot be completely avoided, and shunt underflow may occur, so it is not recommended for routine use. Due to the imbalance of economic development, it is not realistic to widely adopt adjustable pressure shunts for iNPH treatment in China, but considering the actual efficacy and the need for patients to set pressure adjustment according to individualized intracranial status after surgery, the author advocates that adjustable pressure shunts are preferred for iNPH patients. 3.3 Complications Postoperative complications are one of the main factors affecting the efficacy of postoperative hydrocephalus shunts and are a realistic topic that plagues clinicians. The literature reports a wide variation in the incidence of complications after iNPH shunts, ranging from 0 to 91.7%. Statistical comparisons between these complication rates are not possible due to differences in the duration of follow-up, choice of shunt system, surgical approach, age of publication, and type of complication. The main types of complications include postoperative infection, shunt occlusion, intracranial hemorrhage, excessive shunts (including postural headache, subdural effusion, and subdural hematoma), inadequate shunts, and shunt displacement with protrusion outside the body. To reduce the incidence of complications, neurosurgical colleagues have been conducting summaries and studies. These include the site of ventricular puncture and placement, the method and site of retention of the ventral end of the shunt, the choice of shunt system, and the application of antimicrobial tubes. Comprehensive literature reports and combined with the author’s experience, several aspects should be emphasized when performing shunt surgery as follows: (1) strict aseptic concept: not only emphasize asepsis when disinfecting and spreading towels, but also pay more attention to all aspects during the procedure, including covering the sites that do not need to be exposed with a patch, unpacking the shunt system after the skull drilling and subcutaneous tunneling are completed to reduce the time of exposure, changing gloves before touching the shunt and cleaning talcum powder, and touching the shunt with instruments as much as possible to reduce the possibility of contamination; (2) layering of incisions with tight sutures: whether the incision is made on the head, abdomen, or subcutaneous tunnel walk, it should be layered with tight sutures; some scholars suggest the use of absorbable sutures within the skin, whether it can reduce the corresponding infection, clinical summary is still needed; Eymann R and Kiefer M introduced the use of subcutaneous sutures after, skin layer (3) Cranial hole closure: In order to reduce infection and local bleeding caused by cerebrospinal fluid leakage at the cranial borehole, the author used gelatin sponge to fill the bone hole during shunt surgery and then gave closure with otocerebral glue to avoid cerebrospinal fluid (4) disposal of the ventral end of the shunt: in practice, the selection of the incision and the placement site of the ventral end of the shunt are diverse. The traditional view is that placing the shunt in the hepatic compartment can avoid large omental adhesions; in recent years, many scholars believe that placing it in the pelvis can also avoid the aforementioned adhesions and can avoid the large trauma caused by exposing the hepatic compartment. The author prospectively studied the dynamic position of the ventral end of the shunt in 40 patients with hydrocephalus who underwent V-P shunt with a small subxiphoid incision, and the results showed that the ventral end of the shunt entered the pelvis in 87.5% of cases within 3 days and 97.5% within 7 days after surgery. It was concluded that this method is simple, practical, reduces surgical trauma and shortens operative time, and that the majority of the ventral end of the shunt descends into the pelvic cavity at 1 d postoperatively without special fixation and treatment. At the same time, in order to avoid complications of organ penetration caused by the excessive length of the abdominal end, the author cut off the excessive length of the V-P shunt and placed the abdominal end of the shunt in the plane of the anterior superior iliac crest. 4, efficacy assessment The assessment of efficacy should take into account the following six factors (1) patient selection; (2) choice of procedure; (3) duration of postoperative follow-up (short-term efficacy or long-term efficacy); (4) shunt-related complications (such as subdural effusion and postoperative management of those who are ineffective); (5) clinical prognostic assessment scales used; (6) psychological assessment. There is no standardized assessment method regarding the time point, quantitative assessment method and imaging follow-up for the assessment of postoperative outcome of iNPH, and thus there is a great variability in the results of postoperative outcome. Most believe that short-term postoperative follow-up should be performed within 3 to 6 months after surgery, and that the main factor affecting outcome is the risk associated with bypass surgery, while long-term outcome should be performed ≥1 year after surgery, and that the main factor affecting outcome is mainly the patient’s own combined or underlying cardiovascular and cerebrovascular disease and other disorders. In assessing postoperative outcomes, most scholars advocate quantitative assessment of changes in the iNPH triad, of which changes in gait are the most obvious indicators. 3m folding method (Up & Go) and the Mini-mental state examination (MMSE), recommended in JG, are reference methods for assessing changes in gait and cognitive function and are clinically The MMSE is a reference method for assessing changes in gait and cognitive function and is clinically feasible. The Activity of daily living (ADL) scale and the modified Rankin scale are used to assess overall functioning. Although adjustable shunts are advocated for iNPH, the effect of magnetic fields on the shunt pump limits the use of postoperative MRI follow-up to observe changes in the ventricular system and periventricular exudate. comparison of changes in the Evans index on CT scans is a valid quantifier. Although comparisons of third ventricular width and anterior-posterior and left-right midbrain width (the site where the midbrain and pontine brain meet) have also been reported, statistically significant differences are lacking. In addition, there is a lack of accepted quantitative methods for observing changes in periventricular exudate. As the largest country in the world in terms of population, the actual number of patients with iNPH is also the largest in the world. iNPH is a “minor problem”, but there is a large “market” for it. To shorten the gap with international counterparts and promote the rapid development of basic and clinical research on iNPH, we should focus on the following aspects: (1) to establish a professional committee as soon as possible and hold regular academic exchanges; (2) to develop a feasibility study plan and seek special funding from the health department: to summarize the initial experience in China and refer to the latest international progress, to develop a feasibility study that meets the national conditions as soon as possible (3) Develop an expert consensus on the diagnosis and treatment of iNPH to standardize clinical diagnosis and treatment, and on this basis, establish guidelines for the diagnosis and treatment of iNPH in China; (4) Participate actively in international hydrocephalus conferences to showcase our research achievements in the international academic arena and participate actively in international related research. Hydrocephalus 2012 will be held in Kyoto, Japan in October 2012, which is also the fourth international conference on hydrocephalus and cerebrospinal fluid disorders, and we expect more research reports from China to be exchanged at this conference.