Gait and graphology changes after ventriculoperitoneal shunting for idiopathic normal pressure hydrocephalus: an exploratory pilot study.

BACKGROUND

Idiopathic normal pressure hydrocephalus (iNPH) is a potentially reversible neurological syndrome characterized by gait impairment, cognitive decline, and urinary dysfunction. While gait improvement after ventriculoperitoneal shunting (VPS) is well established, postoperative changes in handwriting-related graphomotor function remain poorly investigated. This exploratory pilot study aimed to evaluate whether a multidimensional motor-oriented assessment, including clinical gait scores, instrumental gait analysis, and handwriting-related graphomotor features, may capture postoperative responsiveness after shunting.

METHODS

This single-centre observational pilot study included 14 patients with iNPH who underwent standardized preoperative work-up, including neuroimaging and lumbar infusion testing, followed by ventriculoperitoneal shunting (VPS) placement and longitudinal postoperative reassessment. Clinical evaluation included the Tinetti Performance-Oriented Mobility Assessment and neuropsychological scales such as MMSE, FAB, and MoCA. Instrumented gait analysis assessed spatiotemporal parameters. An exploratory graphological evaluation examined organization, graphomotor movement, cohesion, pressure, dimensions, and alignment on the line. To summarize overall handwriting change, a directional composite score of favourable graphological features was developed. Paired baseline/postoperative comparisons were analysed using non-parametric tests.

RESULTS

The most robust postoperative effect was observed in gait-related functional performance. Median Tinetti score improved significantly from 15.0 at baseline to 24.5 at the first postoperative evaluation (p = 0.0088) and remained improved at last follow-up (22.5; p = 0.0137). Instrumental gait parameters showed favourable trends, with reduced gait duration and increased walking velocity, although without statistical significance. No consistent significant changes emerged in neuropsychological scales. Individual graphological domains were mostly stable, but the composite analysis suggested an overall favourable postoperative shift, reaching significance at last follow-up (p = 0.041) and in the exploratory best-postoperative sensitivity analysis (p = 0.025).

CONCLUSIONS

In this exploratory pilot cohort, ventriculoperitoneal shunting for idiopathic normal pressure hydrocephalus was associated with significant improvement in gait-related functional performance and a possible favourable shift in graphomotor features. These preliminary findings suggest that graphomotor assessment may represent a feasible adjunctive exploratory measure of postoperative motor recovery in iNPH. Larger prospective, controlled, and blinded studies are required before graphological parameters can be considered validated outcome measures.