Psychotic Symptoms and Idiopathic Adult Hydrocephalism: Case Report Psychotic Symptoms and Idiopathic Adult

Hydrocephalus consists of a clinical entity characterized by accumulation of fluid in the cerebral ventricles and in the subarachnoid space. Idiopathic normal pressure hydrocephalus (NPHP) is a neurological syndrome usually characterized by a clinical triad: gait apraxia, dementia and urinary incontinence, associated with ventriculomegaly (radiologically detected by cranial tomography and / or magnetic resonance imaging) and normal cerebrospinal fluid. However, the absence of one or more of these symptoms does not rule out the diagnostic hypothesis of hydrocephalus, as observed in the case in which the patient presented only urinary incontinence and auditory hallucinations. Hydrocephalus is primarily a manifestation of some underlying morbid state, such as tumors, infections, or intracranial hemorrhages. The fact that auditory hallucination is not an initial symptom and does not form part of the diagnostic clinical triad, demonstrates the importance of anamnesis and the correct documentation of the case when it is associated with the patient’s age, absence of trauma or absence of any other cause of hydrocephalus. The objective of this study was to describe a clinical case of a young patient presenting with psychotic symptoms and hydrocephalus and, more specifically, to promote the discussion of idiopathic normal pressure hydrocephalus in adults. It was possible to conclude that the follow-up of the case, from the initial approach to the implemented therapy, was, in general, consistent sicular murmurs without adventitious sounds. Abdomen: atypical, hydroaeuric noises present, tympanic, painless to superficial or deep palpation. Extremities: without edema, free calves, symmetri-cal and palpable pulses. Neurological examination: Glasgow Coma

can produce hallucinations [1]. The diagnosis of psychotic disorder due to a general medical condition is defined by specifying the predominant symptoms. When the diagnosis is used, the medical condition should be included along with the predominant pattern of symptoms (eg, psychotic disorder due to a brain tumor with delusions). [1] The disorder does not occur exclusively while the patient is in delirium or dementia and the symptoms are not well explained by another mental disorder. Hydrocephalus, in turn, consists of a clinical entity characterized by accumulation of fluid in the cerebral ventricles and the subarachnoid space. This accumulation can occur due to an imbalance between synthesis and resorption or by some obstruction that prevents its circulation and drainage. [1] Cerebrospinal fluid, acts as a protector of the central nervous system (CNS) by reducing the impact on the brain and spinal cord, and carries essential nutrients to the CNS, maintaining the intra-cranial pressure (ICP) [2].
Taking into account the possible causes of hydrocephalus, it can be classified as obstructive, non-obstructive hydrocephalus and idiopathic normal pressure [3]. The obstructive occurs when there is an obstacle to the circulation of the spinal fluid, commonly due to stenosis of the Sylvius aqueduct. In non-obstructive hydrocephalus, the spinal fluid circulates freely, however, reabsorption is mostly impaired by intra-cranial bleeding. Finally, idiopathic normal pressure hydrocephalus has no specific cause.
spinal fluid is retained in the cerebral ventricles, dilating them and causing compression of the brain structures [3]. Idiopathic normal pressure hydrocephalus (HPNI) is a neurological syndrome usually characterized by a clinical triad (gait apraxia, dementia and urinary incontinence), associated with ventriculomegaly (radiologically detected by cranial tomography and / or resonance) and normal cerebrospinal fluid [2].
The literature reports a limited number of epidemiological studies on idiopathic normal pressure hydrocephalus. The reported incidence varies from 1.8 cases per 100,000 inhabitants to 2.2 cases per 1,000,000 inhabitants. It is estimated that 1.6% to 5.4% of patients with dementia are caused by PNyRP [3]. Hydrocephalus is a morbidity of extreme importance for neurosurgery and for the whole medical society, due mainly to the great range of diseases to which it can associate, the number of surgical procedures within the total volume of the specialty and the virtual sequels to which the hydrocephalus occurs primarily as a manifestation of some underlying morbid state, such as tumors, infections or intracranial haemorrhages, for example [3]. Most of these diseases typically affect the extremes of age, children and the elderly, not being common in young adults. This fact justifies this work and makes it important to describe this clinical condition in a young patient who developed psychotic symptoms concomitantly with hydrocephalus diagnosed by nuclear magnetic resonance of the skull, without obvious cause. Thus, the objective of this study was to describe a clinical case of a young patient presenting with psychotic symptoms and hydrocephalus and, more specifically, to promote the discussion of idiopathic normal pressure hydrocephalus in adults.

Case Report
Female patient, 26 years old, born in Vassouras-RJ, divorced, protestant, brown, completed high school and is a professional maid.
She denied allergies, smoking, alcoholism and use of medications.
She had no comorbidities, no family history of neurodegenerative, neurological or psychiatric disorders. She began sporadicly 03 years ago, a condition of auditory hallucinations, without distinction of the spoken content. She also denied any other kind of false sensory perception, claiming to remain vigilant and alert. After a few months presenting the hallucinations, she noticed an increase in voiding volume, even presenting diurnal urinary incontinence. She denied nocturnal enuresis, progressing to incapacitating holocronial headache associated with an alleged complex partial convulsive crisis (she said to be "aerial" and "deglutting", but conscious). In the post-ictal period, there was a significant worsening of the headache.    It is in good general condition, lucid and oriented in time and space, being able to walk, stained, hydrated, acyanotic, anicteric, afebrile and hemodynamically stable. Featuring a ventriculoperi-toneal shunt valve in the skull. Cardiovascular system: regular heart rhythm in two times, normofonetic sounds, without blows or extrassistoles. Respiratory apparatus: universally audible ve-sicular murmurs without adventitious sounds. Abdomen: atypical, hydroaeuric noises present, tympanic, painless to superficial or deep palpation. Extremities: without edema, free calves, symmetrical and palpable pulses. Neurological examination: Glasgow Coma Scale: 15/15, isofio-reactive pupils, with no evident changes.

Discussion
Normal pressure hydrocephalus (PNH) can be divided into two categories: secondary and idiopathic. Secondary PNH occurs following underlying neurological events, such as subarachnoid hemorrhage (HSA) and intraventricular hemorrhage caused by tumors or ruptures of aneurysms and meningitis. In contrast, idiopathic PHN usually occurs between the sixth and eighth decades of life and does not yet have its pathophysiological mechanisms completely defined [4] Taking into account what is present in the current literature on the topic1, it is perceived that the case reported in this work is an atypical presentation of idiopathic normal pressure hydrocephalus, since the patient started the symptomatic condition with only 24 years old, differently from the usual age group reported in the literature In addition to this, the primary manifestation with psychotic symptoms stands out. Although most of the published works on the subject do not mention the description of psychiatric symptoms in patients with hydrocephalus, these have become more common in recent years [5]. Depression, anxiety and psychotic syndromes are mainly reported. Patients with PNH may develop symptoms with frontal predominance, such as personality changes, anxiety, depression, psychotic syndromes, obsessive compulsive disorder, Othello syndrome, theft and mania [5].
The HPNI-related guidelines provide specific criteria for the clinical diagnosis of the disease, and may, from these criteria (history, neuroimaging, clinic and physiological tests of the patient) classify the diagnosis as probable, possible and unlikely [6]. To be classified as probable, patient history must include: insidious involvement, origin after age 40, minimal duration of 3 to 6 months, no evidence of antecedents such as head trauma, intracerebral hemorrhage, meningitis or other known condition of hydrocephalus neurological / psychiatric condition that is sufficient to explain the presence of the symptoms. In the classification as NPH possible, the patient may present onset of recent or indeterminate, at any age after childhood, duration of less than three months or indeterminate, followed by events such as head trauma, remote history of intracerebral hemorrhage, childhood meningitis or in adolescence or other conditions. It is also permissible for PNH to coexist with another neurological, psychiatric or general condition, but which, in the evaluation of the clinician, is not entirely attributed to these conditions and is not progressive or clearly progressive [7]. In addition, a neuroimaging presenting an increase in the ventricles  [8]. In elucidating the history of the case, the clinician should pay particular attention to how the symptoms (acute and subacute), their temporal (static, progressive) and their severity (mild, moderate, severe) have started. Emphasis should be given especially to symptoms involving gait, balance, cognition and urinary incontinence. The family occurrence of PNH is rarely observed (in contrast to congenital hydrocephalus). However, it is recommended that elements of family history be obtained, with emphasis on neurodegenerative diseases such as Parkinson's disease, Alzheimer's disease and Huntington's disease, as well as other neurological and psychiatric conditions that have a hereditary character [8].
Despite the importance of clinical evaluation for the diagnosis of PNH, the degree of certainty provided only by clinical diagnosis related to the patient's improvement after the implantation of a cerebrospinal fluid system varies from less than 50% to 60% [9].
Therefore, since such surgery is an invasive procedure that can lead to complications, especially in elderly patients, such as those with PNH, it is necessary to use additional tests (lumbar puncture, infusion test, external lumbar drainage, and evaluation of the volume of cerebrospinal fluid in the aqueduct of the midbrain).
These tests have the purpose of confirming the diagnosis, identify which patients have a greater chance of improvement after the surgical intervention and more accurately predict the probability of this improvement [10] Analyzing the above and confronting the clinical and diagnostic follow-up of the patient whose case was reported in this study, we realized that this is a possible HPNI diagnosis, considering that it does not have all the criteria to fit as a probable HPNI. It reinforces the fact that the patient started the symptoms before the age of 40, had symptoms of urinary incontinence and had no gait disturbances. It is also noted that not all tests (mainly supplementary tests) were performed. In spite of this, the diagnosis was aptly closed considering only history, clinical examination and neuroimaging.
In a previously published study [9], the authors reported that 50% to 60% of patients who improve their symptoms with PVD are diagnosed with PNH. This fact reaffirms the need for additional tests before the patient is submitted to neurosurgery, taking into account all the present risks [9]. It was clear in the case in question that physicians did not use these tests, perhaps because they did not evaluate the need for them, since the clinic and neuroimaging already subsidized the diagnosis. However, even with the clinical improvement of the patient after the DVP, it is worth mentioning that the additional tests are essential with respect to the therapeutics and the prognosis. The adequate choice of therapy against a patient with PNH is primarily intended to restore the functional capacity of the patient. Therefore, the decision about when a surgical intervention should be performed necessarily depends on the use of tools that predict post-surgical outcome.
In addition to the supplementary tests discussed above, there are other indicators (favorable and unfavorable) that can be used.
Favorable indicators of post-surgical improvement include the early onset of walking disorder and onset of symptoms in less than 6 months. Unfavorable indicators include absence of gait disturbance or onset after dementia onset, early onset of dementia, moderate to severe dementia, presence of dementia for more than two years, diffuse atrophy, and significant impairment of the white matter in the examination of magnetic resonance imaging [11]. As in any other disease, the choice of therapy should always be based on the risks and benefits, and in these cases, complementary tests become important tools to support this choice. Even considering the clinical improvement of the patient, the decision not to request complementary tests is questionable or questionable, since they help in the choice of therapy. Probably, in the case reported this happened because it is an atypical case, in a young patient, without comorbidities or still, for not being able to perform them. on the ventricular walls during pulsed systolic waves [11].
Other examples of derivation that are rarely used include ventricular-atrial shunt and DLP. The rate of significant complications (severe intraoperative hemorrhage, subdural hematomas, neurological deficits, epilepsy, cardiac arrhythmias, hypothalamic dysfunction, cystic fistulas, infections) occurs in approximately 6% of patients after surgery [12]. The implantation of a derivation for cerebrospinal fluid drainage are varied and what will guide the choice will be, mainly, the professional experience. The results regarding the postoperative responses are similar and the complication rates are also similar, being the choice, therefore, at the discretion of the neurosurgeon. In the patient of the case, a choice was made for ventricular-peritoneal shunting. As for the postoperative period, the patient had a good response. However, two months after the procedure, he presented a subdural hematoma that had to be drained surgically, since he did not respond to conservative treatment. One day after the approach, the subdural hematoma had to be reopened, with no other complications. When the diagnosis is made early and the appropriate therapy is also implanted early, the results are very favorable, the prognosis is good, and patients return normally to their activities.

Conclusion
It can be concluded that PNH is a potentially treatable condition characterized by gait disorders, cognitive alteration and urinary incontinence, and should be included in the differential diagnosis even in young patients, despite its prevalence in the elderly, The patient in the case reported presented a reality test without compromising and obtained cure of her auditory hallucinations with the treatment of the underlying disease. This fact allowed to conclude that this symptom occurred exclusively in the presence of hydrocephalus and was not related to the diagnosis of psychotic disorder due to PNH. It was, therefore, psychotic symptoms related to a general medical condition. It can also be affirmed that the followup of the case (from initial approach to implemented therapy) was, in general, consistent with what the literature describes. Failure to perform complementary tests, although desirable, did not prevent the success of the treatment and the clinical improvement of the patient.