{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,29]],"date-time":"2026-01-29T23:14:43Z","timestamp":1769728483914,"version":"3.49.0"},"reference-count":32,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"4","license":[{"start":{"date-parts":[[2025,7,28]],"date-time":"2025-07-28T00:00:00Z","timestamp":1753660800000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Cosmet Laser Ther"],"published-print":{"date-parts":[[2025,7,28]]},"abstract":"\n BACKGROUND<\/jats:title>\n Idiopathic normal pressure hydrocephalus (iNPH) typically manifests with the classic Hakim-Adams triad of gait disturbance, cognitive impairment, and urinary incontinence. While akinetic mutism represents a rare and severe neurological presentation characterized by profound reduction in voluntary movement and speech, its association with iNPH remains underrecognized in clinical practice. This case illustrates both the diagnostic challenges and remarkable therapeutic potential when encountering this unusual manifestation of iNPH.<\/jats:p>\n <\/jats:sec>\n \n OBSERVATIONS<\/jats:title>\n A previously healthy 52-year-old female developed progressive gait instability, urinary incontinence, and cognitive decline over 6 months, followed by 3 months of akinetic mutism. Examination demonstrated characteristic features of iNPH including paratonic rigidity, magnetic gait, and frontal release signs. Neuroimaging revealed moderate ventriculomegaly with an Evans index of 0.38 and hyperdynamic CSF flow dynamics (peak velocity 7.4 cm\/sec, stroke volume 95 \u00b5L). The patient exhibited dramatic clinical improvement within 1 week of ventriculoperitoneal shunt placement, with complete resolution of akinetic mutism and significant recovery of other symptoms sustained at the 6-month follow-up.<\/jats:p>\n <\/jats:sec>\n \n LESSONS<\/jats:title>\n This case underscores that akinetic mutism, while uncommon, may represent a severe but treatable manifestation of iNPH. The rapid reversal of akinetic mutism following CSF diversion highlights the importance of considering iNPH even in atypical presentations. Quantitative CSF flow analysis emerges as a valuable diagnostic tool in such challenging cases, while the striking clinical response reinforces the potential for complete functional recovery with timely intervention.<\/jats:p>\n \n https:\/\/thejns.org\/doi\/10.3171\/CASE25257<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/case25257","type":"journal-article","created":{"date-parts":[[2025,7,28]],"date-time":"2025-07-28T06:32:29Z","timestamp":1753684349000},"source":"Crossref","is-referenced-by-count":0,"title":["Beyond the triad: akinetic mutism in idiopathic normal pressure hydrocephalus, with response to shunt placement. Illustrative case"],"prefix":"10.3171","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6745-5697","authenticated-orcid":true,"given":"Moustafa A.","family":"Mansour","sequence":"first","affiliation":[{"name":"Neurosurgery Department, Nasser Institute for Research and Treatment, Cairo, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ahmed","family":"Refaat","sequence":"additional","affiliation":[{"name":"Neurosurgery Department, Nasser Institute for Research and Treatment, Cairo, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ahmed M.","family":"Kamer-Eldawla","sequence":"additional","affiliation":[{"name":"Neurosurgery Department, Nasser Institute for Research and Treatment, Cairo, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-5063-3619","authenticated-orcid":true,"given":"Michael","family":"Zohney","sequence":"additional","affiliation":[{"name":"Neurosurgery Department, Nasser Institute for Research and Treatment, Cairo, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohamed","family":"El-Batanony","sequence":"additional","affiliation":[{"name":"Neurosurgery Department, Nasser Institute for Research and Treatment, Cairo, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohammad M.","family":"Selim","sequence":"additional","affiliation":[{"name":"Neurosurgery Department, Nasser Institute for Research and Treatment, Cairo, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ahmed M.","family":"Elshaer","sequence":"additional","affiliation":[{"name":"Neurosurgery Department, Nasser Institute for Research and Treatment, Cairo, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hamdi Nabawi","family":"Mostafa","sequence":"additional","affiliation":[{"name":"Neurosurgery Department, Nasser Institute for Research and Treatment, Cairo, Egypt"},{"name":"Department of Neurosurgery, Faculty of Medicine, Misr University for Science and Technology, Giza, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"3","key":"bib1","series-title":"Neurosurgery","first-page":"S2","article-title":"Diagnosing idiopathic normal-pressure hydrocephalus","volume":"57","author":"Relkin","year":"2005","unstructured":"Relkin NMarmarou AKlinge PBergsneider MBlack PM.Diagnosing idiopathic normal-pressure hydrocephalus. Neurosurgery. 2005;57(3suppl):S2-S16."},{"issue":"11","key":"bib2","series-title":"Neurol Med Chir (Tokyo)","first-page":"775","article-title":"Guidelines for management of idiopathic normal pressure hydrocephalus: second edition","volume":"52","author":"Mori","year":"2012","unstructured":"Mori EIshikawa MKato TGuidelines for management of idiopathic normal pressure hydrocephalus: second edition. Neurol Med Chir (Tokyo). 2nd ed. 2012;52(11):775-809."},{"issue":"1","key":"bib3","series-title":"Eur J Neurol","first-page":"39","article-title":"Dutch normal pressure hydrocephalus study: baseline characteristics with emphasis on clinical findings","volume":"4","author":"Boon","year":"1997","unstructured":"Boon AJTans JTDelwel EJDutch normal pressure hydrocephalus study: baseline characteristics with emphasis on clinical findings. Eur J Neurol. 1997;4(1):39-47."},{"issue":"1","key":"bib4","series-title":"Mov Disord","first-page":"53","article-title":"Movement disorders in adult hydrocephalus","volume":"12","author":"Krauss","year":"1997","unstructured":"Krauss JKRegel JPDroste DWOrszagh MBorremans JJVach W.Movement disorders in adult hydrocephalus. Mov Disord. 1997;12(1):53-60."},{"issue":"8","key":"bib5","series-title":"Eur Radiol","first-page":"4454","article-title":"Cerebrospinal fluid dynamics in idiopathic normal pressure hydrocephalus on four-dimensional flow imaging","volume":"30","author":"Yamada","year":"2020","unstructured":"Yamada SIshikawa MIto HCerebrospinal fluid dynamics in idiopathic normal pressure hydrocephalus on four-dimensional flow imaging. Eur Radiol. 2020;30(8):4454-4465."},{"issue":"1","key":"bib6","series-title":"J Neurosurg","first-page":"161","article-title":"Akinetic mutism and magnetic resonance imaging in obstructive hydrocephalus. Case illustration","volume":"88","author":"Abekura","year":"1998","unstructured":"Abekura M.Akinetic mutism and magnetic resonance imaging in obstructive hydrocephalus. Case illustration. J Neurosurg. 1998;88(1):161."},{"issue":"2 Dementia","key":"bib7","series-title":"Continuum (Minneap Minn)","first-page":"579","article-title":"Diagnosis and treatment of idiopathic normal pressure hydrocephalus","volume":"22","author":"Williams","year":"2016","unstructured":"Williams MAMalm J.Diagnosis and treatment of idiopathic normal pressure hydrocephalus. Continuum (Minneap Minn). 2016;22(2 Dementia):579-599."},{"key":"bib8","series-title":"Neurosci Biobehav Rev","first-page":"270","article-title":"On the pathophysiology and treatment of akinetic mutism","volume":"112","author":"Arnts","year":"2020","unstructured":"Arnts Hvan Erp WSLavrijsen JCMvan Gaal SGroenewegen HJvan den Munckhof P.On the pathophysiology and treatment of akinetic mutism. 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Front Neurol. 2023;14:1184713."},{"issue":"3","key":"bib16","series-title":"Neurosurgery","first-page":"S1","article-title":"Development of guidelines for idiopathic normal-pressure hydrocephalus: introduction","volume":"57","author":"Marmarou","year":"2005","unstructured":"Marmarou ABergsneider MRelkin NKlinge PBlack PM.Development of guidelines for idiopathic normal-pressure hydrocephalus: introduction. Neurosurgery. 2005;57(3suppl):S1-S3."},{"issue":"3","key":"bib1","series-title":"Neurosurgery","first-page":"S2","article-title":"Diagnosing idiopathic normal-pressure hydrocephalus","volume":"57","author":"Relkin","year":"2005","unstructured":"Relkin NMarmarou AKlinge PBergsneider MBlack PM.Diagnosing idiopathic normal-pressure hydrocephalus. 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Eur J Neurol. 1997;4(1):39-47."},{"issue":"1","key":"bib4","series-title":"Mov Disord","first-page":"53","article-title":"Movement disorders in adult hydrocephalus","volume":"12","author":"Krauss","year":"1997","unstructured":"Krauss JKRegel JPDroste DWOrszagh MBorremans JJVach W.Movement disorders in adult hydrocephalus. Mov Disord. 1997;12(1):53-60."},{"issue":"8","key":"bib5","series-title":"Eur Radiol","first-page":"4454","article-title":"Cerebrospinal fluid dynamics in idiopathic normal pressure hydrocephalus on four-dimensional flow imaging","volume":"30","author":"Yamada","year":"2020","unstructured":"Yamada SIshikawa MIto HCerebrospinal fluid dynamics in idiopathic normal pressure hydrocephalus on four-dimensional flow imaging. Eur Radiol. 2020;30(8):4454-4465."},{"issue":"1","key":"bib6","series-title":"J Neurosurg","first-page":"161","article-title":"Akinetic mutism and magnetic resonance imaging in obstructive hydrocephalus. 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Neurosci Biobehav Rev. 2020;112:270-278."},{"issue":"7","key":"bib9","series-title":"Neurologia (Engl Ed)","first-page":"449","article-title":"Current concepts on the pathophysiology of idiopathic chronic adult hydrocephalus: are we facing another neurodegenerative disease?","volume":"33","author":"Mart\u00edn-L\u00e1ez","year":"2018","unstructured":"Mart\u00edn-L\u00e1ez RValle-San Rom\u00e1n NRodr\u00edguez-Rodr\u00edguez EMMarco-de Lucas EBerciano Blanco JAV\u00e1zquez-Barquero A.Current concepts on the pathophysiology of idiopathic chronic adult hydrocephalus: are we facing another neurodegenerative disease? Neurologia (Engl Ed). 2018;33(7):449-458."},{"key":"bib10","series-title":"BMC Med","first-page":"142","article-title":"Venous hemodynamics in neurological disorders: an analytical review with hydrodynamic analysis","volume":"11","author":"Beggs","year":"2013","unstructured":"Beggs CB.Venous hemodynamics in neurological disorders: an analytical review with hydrodynamic analysis. BMC Med. 2013;11:142."},{"issue":"5","key":"bib11","series-title":"Neurosurgery","first-page":"701","article-title":"Significance of periventricular hemodynamics in normal pressure hydrocephalus","volume":"30","author":"Kimura","year":"1992","unstructured":"Kimura MTanaka AYoshinaga S.Significance of periventricular hemodynamics in normal pressure hydrocephalus. Neurosurgery. 1992;30(5):701-705."},{"key":"bib12","series-title":"Cerebrospinal Fluid Res","first-page":"10","article-title":"Multiplicity of cerebrospinal fluid functions: new challenges in health and disease","volume":"5","author":"Johanson","year":"2008","unstructured":"Johanson CEDuncan JAIIIKlinge PMBrinker TStopa EGSilverberg GD.Multiplicity of cerebrospinal fluid functions: new challenges in health and disease. Cerebrospinal Fluid Res. 2008;5:10."},{"issue":"1","key":"bib13","series-title":"J Neurosurg","first-page":"152","article-title":"Relief of akinetic mutism from obstructive hydrocephalus using bromocriptine and ephedrine. Case report","volume":"76","author":"Anderson","year":"1992","unstructured":"Anderson B.Relief of akinetic mutism from obstructive hydrocephalus using bromocriptine and ephedrine. Case report. J Neurosurg. 1992;76(1):152-155."},{"issue":"9","key":"bib14","series-title":"Neurol Med Chir (Tokyo)","first-page":"419","article-title":"Akinetic mutism responsive to bromocriptine following subdural hematoma evacuation in a patient with hydrocephalus","volume":"47","author":"Kim","year":"2007","unstructured":"Kim MSRhee JJLee SJKwon SJLee CH.Akinetic mutism responsive to bromocriptine following subdural hematoma evacuation in a patient with hydrocephalus. Neurol Med Chir (Tokyo). 2007;47(9):419-423."},{"key":"bib15","series-title":"Front Neurol","first-page":"1184713","article-title":"Case report: levodopa-responsive parkinsonism with akinetic mutism after ventriculo-peritoneal shunt","volume":"14","author":"Zhang","year":"2023","unstructured":"Zhang YLi PZhang JCase report: levodopa-responsive parkinsonism with akinetic mutism after ventriculo-peritoneal shunt. 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