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Coexisting Alzheimer's disease (AD) pathology may contribute to this variability. This systematic review and meta\u2010analysis investigated whether pre\u2010shunt AD co\u2010pathology influences post\u2010shunt outcomes across distinct clinical domains and follow\u2010up durations. Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta\u2010Analyses) guidelines, PubMed, Embase, Scopus, and Web of Science were searched for studies assessing the impact of pre\u2010shunt AD co\u2010pathology on post\u2010shunt outcomes in iNPH. Studies were included in the meta\u2010analysis if they stratified patients by pre\u2010shunt AD status (iNPH\u2010AD vs. iNPH\u2010nAD) and reported at least one post\u2010shunt outcome compared between groups. Random\u2010effects meta\u2010analyses pooled standardized mean differences across short\u2010 (&lt;12\u2009months) and long\u2010term (\u226512\u2009months) follow\u2010up. Sixteen studies (n\u2009=\u20091825 patients) were included in the systematic review, with nine (n\u2009=\u2009428) eligible for meta\u2010analysis. Pre\u2010shunt AD co\u2010pathology prevalence ranged from 23.9% to 67.6%, and post\u2010shunt follow\u2010up duration ranged from 3 to 60\u2009months. No short\u2010term group differences were observed for cognitive outcomes; however, a significant long\u2010term group effect indicated poorer cognitive recovery in the iNPH\u2010AD group. Gait measures showed short\u2010term group differences favoring the iNPH\u2010nAD group, with no group effects at long\u2010term follow\u2010up, whereas urinary outcomes showed no group differences at any follow\u2010up. AD pathology is not a contraindication to shunting; rather, AD biomarker assessment should be incorporated into the pre\u2010shunt workup, as it can enhance outcome prediction and support tailored postoperative management. \u00a9 2026 International Parkinson and Movement Disorder Society.<\/jats:p>","DOI":"10.1002\/mds.70333","type":"journal-article","created":{"date-parts":[[2026,5,4]],"date-time":"2026-05-04T07:06:26Z","timestamp":1777878386000},"page":"2254-2266","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Impact of Alzheimer's Disease Co\u2010Pathology on Shunt Outcomes in Idiopathic Normal Pressure Hydrocephalus: A Systematic Review and Meta\u2010Analysis"],"prefix":"10.1002","volume":"41","author":[{"given":"Ameya","family":"Patwardhan","sequence":"first","affiliation":[{"name":"Division of Geriatric Medicine, Department of Medicine, Schulich School of Medicine and Dentistry Western University  London 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