Normal Pressure Hydrocephalus(Hakim-Adams Syndrome)is a dilation of the ventricles without an increase of intracranial pressure.It corresponds to he classic triade of are gait disturbance, memory/cognitive problems,and urinary incontinence. Manic and depressive symptoms can be related to hydrocephalus occlusus even in the absence of neurological symptoms.These symptoms disappear after neurosurgery or pharmacological treatment.
CaseA 26 year old-male,from Cabo Verde,is interviewed in the Emergency Department in June 2011 presenting disturbance of general behaviour.He is being aggressive and presents flight of ideas.The diagnosis: “Hypomanic state” treated with lorazepam 6 mg/day and Olanzapine 5 mg/day. August 2011, the patient is reevaluated because of his behaviour:soliloquies,laughs,expansive mood, abnormal irritability, easily excited to enthusiasm and irritable humor. He also presents psychomotor agitation associated to delusion of persecution.He has not been taking his medication. No other neurological symptoms are detected.
In Hospital he receives Risperidone 6 mg/day, Clorazepate Dipotassium45mg/day and Lormetazepam 2 mg /day disappearing most of the symptoms.
A MRI was done, presenting triventricular hydrocephalus with absence of intraparenchymal damage.After monitoring the intracranial pressure, Neurosurgery decides not to perform surgery.
In the case of not responding to Risperidone, studies have been published that Aripiprazole (atypical antipsychotic with a unique partial agonistic effect at D2receptors)is effective and safe in the treatment of manic episode. Some publications about the reduction of D2receptors demonstrated that the binding of striatal was reduced in NPH.
Sometimes imaging tests are needed in patients with behavioural disturbance as manic symptoms in order to avoid misdiagnosis and it is crucial for the correct medical and chirurgical treatment.
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