Psychosis preceding Hakim’s triad: A rare case of idiopathic normal pressure hydrocephalus responsive to cerebrospinal fluid tapping

Abstract

Normal pressure hydrocephalus (NPH) is a reversible cause of dementia, classically presenting with Hakim’s triad of gait disturbance, cognitive impairment, and urinary incontinence. Psychiatric symptoms are often secondary; they tend to be mild neurosis and usually follow the classical triad. We report a 58-year-old male who initially presented with severe psychosis characterized by auditory hallucinations, delusions, and thought broadcast, followed later by gait imbalance, memory disturbances, and urinary urgency. MRI brain revealed ventriculomegaly (Evans index 0.44), and a normal cerebrospinal fluid (CSF) analysis confirmed idiopathic NPH. Following high-volume CSF tapping, there was marked improvement in neuropsychiatric symptoms, with Positive and Negative Syndrome Scale scores reducing from 48 to 20 within a week. This case highlights that psychosis can be an early and predominant manifestation of NPH and that timely CSF diversion procedures can result in both neurological and psychiatric recovery.