Psychotic symptoms in normal pressure hydrocephalus

Area of Science:

• Neurology
• Psychiatry

Background:

• Normal Pressure Hydrocephalus (NPH) is characterized by cerebrospinal fluid accumulation due to aqueductal stenosis, typically presenting with cognitive impairment, gait disturbance, and urinary incontinence.
• Atypical presentations of NPH, particularly those involving predominant psychotic symptoms, are rare but documented, suggesting potential secondary development of thought and perceptual disorders due to brain damage.

Observation:

• A 30-year-old female presented with acute psychosis, including delusions of persecution and agitation, with subtle neurological signs like bradykinesia and mild cognitive deficits.
• Neuroimaging revealed significant ventricular dilatation consistent with idiopathic aqueductal stenosis, the underlying cause of NPH in this patient.

Findings:

• The patient's psychotic symptoms significantly improved with second-generation antipsychotics, despite a conservative management approach for NPH.
• This case suggests that frontal lobe dysfunction, implicated in hydrocephalic psychosis, may contribute to delusions in NPH.

Implications:

• The case underscores the importance of investigating underlying organic causes, such as NPH, in patients presenting with unexplained psychosis, especially when accompanied by subtle neurological signs and mild cognitive impairment.
• Conservative treatment of the primary NPH cause, combined with second-generation antipsychotics, can effectively manage hydrocephalic psychosis, as demonstrated by the patient's positive response.