Am
J Psychiatry
Colloid
135:3,
Cyst
BY FREDERICK
March
of the
1978
Third
CLINICAL
Ventricle
M. BURKLE,
JR.,
M.D.,
Presenting M.P.H.,
as Psychiatric
AND
ZBIGNIEW
AND
RESEARCH
REPORTS
Disorder
J. LIPOWSKI,
M.D.
Psychiatric symptoms occur in about 70% of patients with brain tumor (I). Because a mental disorder may dominate the clinical picture, diagnostic errors may occur, especially when the presenting symptoms suggest a functional psychiatric disorder (2-5). Diagnosis is even more difficult when the patient is a psychologically sophisticated mental health worker offeming his or her own diagnostic and psychodynamic interpretation of the symptoms. The psychiatric consultant may be inclined to accept the sick colleague’s explanation and fail to carry out a detailed mental status examination and to recommend proper investigations. The following case is reported to remind readers of such potentially disastrous diagnostic pitfalls and to underscore the value of computerized axial tomognaphy for the diagnosis of cerebral disease.
three objects after three minutes. The consultant felt that the patient was severely depressed but not suicidal. He doubted that her illness was organic but recommended con-
nia,
to stop
working,
Case
long
interview
the
Report
tinued medical workup Three days later the psychiatric consultant. problems were depression
having
worked
too
stated
that
her
that
Her
mother
amitriptyline,
25 mg t.i.d.
had
died
and she said that cancer because she said that to get well
and
slowed
‘
‘
ninth). The Neurologists
patient completed concluded that
the
serial sevens patient was
without depressed
error. but
her
kind
when
yawned
down,
undergone ment both
personality
were impaired. schizophrenia
father
of
she was
a baby. about
and
hysteria.”
10 years
old,
Throughout
every
withdrawn,
two
slightly
change.
were
state
was
also
the
minutes.
amused
by
done
considered
CSF.
ingly.
the
to
blood
and
X ray
increase
and judg-
suggestive Hysterical
the
were
unexpected
patient
of
herself
recommended
urinalysis,
brain scan were was abnormal-it
of
intracranial
T3
all normal. indicated
pressure
hydrocephalus. by the radiologist, the
due
to
A CT scan, showed a large
spherical
mass
needed a routine neurological workup. Psychiatric consultation was requested to arrange for a transfer to the psychiatry ward. When first seen by the psychiatric consultant. who knew her personally. the patient seemed changed. Normally vivacious, outgoing, and energetic, she was then a picture of apathy. She spoke slowly, smiled faintly and incongruously, responded with short sentences or monosyllables, and stared
lateral colloid
ventricles, cyst rather
impassively
teddy bear, and said that she wanted a baby. She was disoriented for time and had retrograde and anterograde amnesia. Ten days after the operation she was transferred to the psychiatric ward for rehabilitation. She gradually showed an increase in affect, cried easily but appropriately, was some-
into
space.
She
was
fully
oriented,
ing hallucinations, and was not obviously only cognitive abnormality was her failure
denied
delusional. to name
hay-
The any of
When this work was done, Dr. Bunkle was a resident in psychiatry, Dartmouth-Hitchcock Medical Center, Hanover, N.H. 03755, where Dr. Lipowski is Director, Psychiatric Consultation Service. Dr.
Lipowski
is also
Professor
School.
Dr. Bunkle
Address
reprint requests
is currently
of
Psychiatry,
in private
Dartmouth
practice.
Maui,
to Dr. Lipowski.
0002-953X/78/0003-0373$0.35
Medical
Hawaii.
The
patient
procedure one week
which than
underwent
with
ventricle
were dilated. a tumor.
and
It was
disinhibited
excision
verbally,
getfulness.
She
interpreted
it as
to tell her what gery
she
© 1978 American
was
great
ofcontrol,
had happend
considered
Psychiatric
shunting
for about a week. and clung to her
and continued
expressed loss
to be a
noncommunicating hydrocephalus Four days later she underwent of a colloid cyst of the third yen-
tricle. After the surgery she was lethargic She complained of fatigue. lay motionless
what
obstructing
thought
a ventriculoperitoneal
to relieve her after admission.
craniotomy
third
uptake,
Surprisa slowly
possibly
a tumor or an early-acquired which was recommended occupying
but
findings.
chemistries,
isotope
skull
progressive
and
tests
due
Hemogram,
EEG.
memory
features syndrome.
plausible that she might have develas a reaction to her father’s mental
Neuropsychobogical never
Her recent
She displayed and organic brain
illness.
.
with
‘
had
the questions. and affectively flat rather than depressed. She talked without spontaneity. She was oriented but stated that when she was brought to the hospital she did not know in which town she was. She thought her husband had brought her to the hospital for a rest. Consultants were baffled but agreed that the patient had
her
to a
her father
Asked what she easily while walkuse of the term.
some
‘ ‘
to have
patient
ported
referred
‘over-identified’ of cancer
suggested it. It seemed oped pseudodementia
neurology service, and she was hospitalized. Neurological examination including ophthalmoscopy, was normal except for poor recall (only one of three objects after three minutes) and mild temporal disorientation (the patient could not tell the day of the week and said that it was ‘early December’ when asked for the date on December
that
her own illness could also be due to tended to identify with her mother. She she needed to have a vacation in Califor-
dissociative
psychiatrist
to sleep
‘
a friend and re-
this
started
on the fact
represented
up to 17
of memory
then
she
hours a day, and her husband asked for advice from who was a psychiatrist. Because of her sleepiness lapses
She
and
and was paranoid. ‘ she said that he fell this was inappropriate
symptoms
She appeared The patient. a 24-year-old married psychiatric social worker, presented symptoms of increasing depression, sleepiness, loss of interest and energy, decreased ability to concentrate. and memory lapses. Her depression had developed gradually over several months, but she continued to work full-time until about five days before hospitalization when she became withdrawn, lay on her bed for hours staring at the ceiling or sleeping, spoke slowly. ate little, and neglected personal hygiene. The family doctor prescribed
hard
Alzheimer’s disease meant by ‘ ‘paranoid’ ing; she denied that
She
and prescribed imipramine. patient was interviewed by a senior She stated then that her main and fatigue. which she blamed on
and
to her.
recovered;
Association
to complain
concern
about
repeatedly
Three the
her
of foramnesia,
asked
months
surgical
people
after results
sunwere 373
CLINICAL
AND
RESEARCH
thought
to be excellent.
activity
in right
wise.
The
patient
temporal
returned
Am
REPORTS
Her
EEG
leads
but
showed was
to full-time
occasional
unremarkable
social
theta other-
work.
Discussion Colloid cysts of the third ventricle arise from the pamaphysis, ependyma, or choroid plexus. They vary in size from one to three cm in diameter, are lined with epithelium, and contain fluid or gelatinous matemial (6). A colloid cyst is attached to the choroid plexuses of the lateral ventricles and is invariably placed at the foramina of Monmo, the obstruction of which causes hydrocephalus. Sudden death may result from acute blockage of the foramina and a sharp rise of pressure in the lateral ventricles with consequent brain hemniation and compression of the brain stem (7). Clinical features of the cyst are typically variable and related to how complete and sudden the hydrocephalus is. Hydrocephalus may be acute and fatal, intermittent, or chronic. Sudden death preceded by violent headache had occurred in about 20% ofthe cases reviewed by Cairns and Mosberg (7). If the obstruction is gradual, dementia results. Most commonly, hydrocephalus is chronic and progressive and punctuated by acute rises of intracranial pressure, manifested by severe headache, amblyopia, loss of consciousness or falling attacks without loss of consciousness, episodes ofdelimium, vertigo, or hallucinations of smell and taste (7). Akinetic mutism may occur. Spontaneous remissions of symptoms, lasting from weeks to ten years, add to diagnostic difficulties. Our patient had neither headaches nor papilledema. Some patients, like ours, display hypersomnia and may be misdiagnosed as having narcolepsy. Endocrine disturbances due to compression of the hypothalamus may occur. Mental symptoms may be the only presenting abnonmality, as in our patient. They include one or more of the following: disorders of vigilance and consciousness, impairment of intellect and memory, and, less often, hallucinations. Antemogmade amnesia is particularly common (8). Immediate memory is intact, as is typical of Korsakoff’s syndrome. but the ability to retain new material is impaired. The symptoms may come on gradually and tend to clear up completely during remission or after removal of the cyst. The patient is forgetful, slow, inattentive, and apathetic. Disorientation may appear. Episodes of delirium tend to occur when intracranial pressure rises acutely and thus accompany and follow severe headaches. Depression and emotional lability are encountered in some cases. Cognitive impairment may take several months
374
J Psychiatry
135:3,
March
1978
to clear up after successful surgery. Lesions in the region of the floor and walls of the third ventricle are known to cause an amnestic syndrome (8-10). Pathology usually involves the mammillary bodies on the medial dorsal thalamic nuclei or both. Craniopharyngiomas, pituitary adenomas, colbid cysts, and other tumors invading or compressing the floor and walls of the third ventricle may cause amnestic syndrome Increased intracranial pressure if present, may account for intellectual impairment but does not seem to be responsible for the marked anterograde amnesia in diencephalic lesions. Our patient displayed an amnestic syndrome preand postoperatively. This was overshadowed by a marked personality change, which suggested a functional psychosis. Her own plausible psychodynamic interpretations further confused the doctors. Soniat (4) warned that severe headaches quickly relieved by changing the position of the head and episodes of hypersomnia are common in tumors of the third yentricle and are often mistaken for conversion symptoms. ln this patient’s case a CT scan was vital since her cyst was large and could have led to sudden death if not diagnosed and treated promptly. Psychiatrists should always suspect a focal cerebral lesion in the presence of antemograde amnesia. Brain tumor may occur in anyone at any age and does not spare mental health workers. When suspected, it should prompt full investigation including computerized axial tomogmaphy, if a catastrophe is to be averted. .
,
,
REFERENCES I. Walther-BUel
2.
H:
Die
Psychiatne
Springer. 1951, p 198 Blustein JE: Further observations functional psychiatric disturbances.
den
HirngeschwUlste.
on brain tumors The Psychiatric
Wien.
presenting Journal
as of
the University ofOttawa 1:21-26, 1976 3. Donald AG. Still CN. Pearson JM: Behavioral symptoms with intracranial neoplasm. South Med I 65:1006-1009, 1972 4. Soniat ILL: Psychiatric symptoms associated with intracranial neoplasms. Am I Psychiatry 108:19-22, 1951
S.
Waggoner
changes 1954 6. Walton
7.
RW.
Bagcchi
by psychic IN:
Brain’s
New York, Oxford Cairns H. Mosbeng
Gynecol 8. Crahay des
Obstet
mentaux
Initial
Diseases
of the Press, cyst
A, Iancu dans
masking
of
Am I Psychiatry
University WH: Colloid
92:545-570,
S. Viobon
troubles
BK:
symptoms.
Nervous 1977, ofthe
tumeurs
du
brain
I 10:904-910, System,
8th ed.
p 246 third ventricle.
1951 H, et al: L’analyse les
organic
troisieme
Surg
psychobogique ventnicule.
Acta Psychiatr BeIg 72:316-344, 1972 9. McEntee WI. Biber MP, Perl DP, et al: Diencephalic amnesia: a reappraisal. I Neurol Neunosurg Psychiatry 39:436-441, 1976 10.
Williams M, tricle tumors.
Pennybacken.J: Memory disturbances in third venI Neurol Neurosung Psychiatry 17:115-123, 1954
J Psychiatry
Colloid
135:3,
Cyst
BY FREDERICK
March
of the
1978
Third
CLINICAL
Ventricle
M. BURKLE,
JR.,
M.D.,
Presenting M.P.H.,
as Psychiatric
AND
ZBIGNIEW
AND
RESEARCH
REPORTS
Disorder
J. LIPOWSKI,
M.D.
Psychiatric symptoms occur in about 70% of patients with brain tumor (I). Because a mental disorder may dominate the clinical picture, diagnostic errors may occur, especially when the presenting symptoms suggest a functional psychiatric disorder (2-5). Diagnosis is even more difficult when the patient is a psychologically sophisticated mental health worker offeming his or her own diagnostic and psychodynamic interpretation of the symptoms. The psychiatric consultant may be inclined to accept the sick colleague’s explanation and fail to carry out a detailed mental status examination and to recommend proper investigations. The following case is reported to remind readers of such potentially disastrous diagnostic pitfalls and to underscore the value of computerized axial tomognaphy for the diagnosis of cerebral disease.
three objects after three minutes. The consultant felt that the patient was severely depressed but not suicidal. He doubted that her illness was organic but recommended con-
nia,
to stop
working,
Case
long
interview
the
Report
tinued medical workup Three days later the psychiatric consultant. problems were depression
having
worked
too
stated
that
her
that
Her
mother
amitriptyline,
25 mg t.i.d.
had
died
and she said that cancer because she said that to get well
and
slowed
‘
‘
ninth). The Neurologists
patient completed concluded that
the
serial sevens patient was
without depressed
error. but
her
kind
when
yawned
down,
undergone ment both
personality
were impaired. schizophrenia
father
of
she was
a baby. about
and
hysteria.”
10 years
old,
Throughout
every
withdrawn,
two
slightly
change.
were
state
was
also
the
minutes.
amused
by
done
considered
CSF.
ingly.
the
to
blood
and
X ray
increase
and judg-
suggestive Hysterical
the
were
unexpected
patient
of
herself
recommended
urinalysis,
brain scan were was abnormal-it
of
intracranial
T3
all normal. indicated
pressure
hydrocephalus. by the radiologist, the
due
to
A CT scan, showed a large
spherical
mass
needed a routine neurological workup. Psychiatric consultation was requested to arrange for a transfer to the psychiatry ward. When first seen by the psychiatric consultant. who knew her personally. the patient seemed changed. Normally vivacious, outgoing, and energetic, she was then a picture of apathy. She spoke slowly, smiled faintly and incongruously, responded with short sentences or monosyllables, and stared
lateral colloid
ventricles, cyst rather
impassively
teddy bear, and said that she wanted a baby. She was disoriented for time and had retrograde and anterograde amnesia. Ten days after the operation she was transferred to the psychiatric ward for rehabilitation. She gradually showed an increase in affect, cried easily but appropriately, was some-
into
space.
She
was
fully
oriented,
ing hallucinations, and was not obviously only cognitive abnormality was her failure
denied
delusional. to name
hay-
The any of
When this work was done, Dr. Bunkle was a resident in psychiatry, Dartmouth-Hitchcock Medical Center, Hanover, N.H. 03755, where Dr. Lipowski is Director, Psychiatric Consultation Service. Dr.
Lipowski
is also
Professor
School.
Dr. Bunkle
Address
reprint requests
is currently
of
Psychiatry,
in private
Dartmouth
practice.
Maui,
to Dr. Lipowski.
0002-953X/78/0003-0373$0.35
Medical
Hawaii.
The
patient
procedure one week
which than
underwent
with
ventricle
were dilated. a tumor.
and
It was
disinhibited
excision
verbally,
getfulness.
She
interpreted
it as
to tell her what gery
she
© 1978 American
was
great
ofcontrol,
had happend
considered
Psychiatric
shunting
for about a week. and clung to her
and continued
expressed loss
to be a
noncommunicating hydrocephalus Four days later she underwent of a colloid cyst of the third yen-
tricle. After the surgery she was lethargic She complained of fatigue. lay motionless
what
obstructing
thought
a ventriculoperitoneal
to relieve her after admission.
craniotomy
third
uptake,
Surprisa slowly
possibly
a tumor or an early-acquired which was recommended occupying
but
findings.
chemistries,
isotope
skull
progressive
and
tests
due
Hemogram,
EEG.
memory
features syndrome.
plausible that she might have develas a reaction to her father’s mental
Neuropsychobogical never
Her recent
She displayed and organic brain
illness.
.
with
‘
had
the questions. and affectively flat rather than depressed. She talked without spontaneity. She was oriented but stated that when she was brought to the hospital she did not know in which town she was. She thought her husband had brought her to the hospital for a rest. Consultants were baffled but agreed that the patient had
her
to a
her father
Asked what she easily while walkuse of the term.
some
‘ ‘
to have
patient
ported
referred
‘over-identified’ of cancer
suggested it. It seemed oped pseudodementia
neurology service, and she was hospitalized. Neurological examination including ophthalmoscopy, was normal except for poor recall (only one of three objects after three minutes) and mild temporal disorientation (the patient could not tell the day of the week and said that it was ‘early December’ when asked for the date on December
that
her own illness could also be due to tended to identify with her mother. She she needed to have a vacation in Califor-
dissociative
psychiatrist
to sleep
‘
a friend and re-
this
started
on the fact
represented
up to 17
of memory
then
she
hours a day, and her husband asked for advice from who was a psychiatrist. Because of her sleepiness lapses
She
and
and was paranoid. ‘ she said that he fell this was inappropriate
symptoms
She appeared The patient. a 24-year-old married psychiatric social worker, presented symptoms of increasing depression, sleepiness, loss of interest and energy, decreased ability to concentrate. and memory lapses. Her depression had developed gradually over several months, but she continued to work full-time until about five days before hospitalization when she became withdrawn, lay on her bed for hours staring at the ceiling or sleeping, spoke slowly. ate little, and neglected personal hygiene. The family doctor prescribed
hard
Alzheimer’s disease meant by ‘ ‘paranoid’ ing; she denied that
She
and prescribed imipramine. patient was interviewed by a senior She stated then that her main and fatigue. which she blamed on
and
to her.
recovered;
Association
to complain
concern
about
repeatedly
Three the
her
of foramnesia,
asked
months
surgical
people
after results
sunwere 373
CLINICAL
AND
RESEARCH
thought
to be excellent.
activity
in right
wise.
The
patient
temporal
returned
Am
REPORTS
Her
EEG
leads
but
showed was
to full-time
occasional
unremarkable
social
theta other-
work.
Discussion Colloid cysts of the third ventricle arise from the pamaphysis, ependyma, or choroid plexus. They vary in size from one to three cm in diameter, are lined with epithelium, and contain fluid or gelatinous matemial (6). A colloid cyst is attached to the choroid plexuses of the lateral ventricles and is invariably placed at the foramina of Monmo, the obstruction of which causes hydrocephalus. Sudden death may result from acute blockage of the foramina and a sharp rise of pressure in the lateral ventricles with consequent brain hemniation and compression of the brain stem (7). Clinical features of the cyst are typically variable and related to how complete and sudden the hydrocephalus is. Hydrocephalus may be acute and fatal, intermittent, or chronic. Sudden death preceded by violent headache had occurred in about 20% ofthe cases reviewed by Cairns and Mosberg (7). If the obstruction is gradual, dementia results. Most commonly, hydrocephalus is chronic and progressive and punctuated by acute rises of intracranial pressure, manifested by severe headache, amblyopia, loss of consciousness or falling attacks without loss of consciousness, episodes ofdelimium, vertigo, or hallucinations of smell and taste (7). Akinetic mutism may occur. Spontaneous remissions of symptoms, lasting from weeks to ten years, add to diagnostic difficulties. Our patient had neither headaches nor papilledema. Some patients, like ours, display hypersomnia and may be misdiagnosed as having narcolepsy. Endocrine disturbances due to compression of the hypothalamus may occur. Mental symptoms may be the only presenting abnonmality, as in our patient. They include one or more of the following: disorders of vigilance and consciousness, impairment of intellect and memory, and, less often, hallucinations. Antemogmade amnesia is particularly common (8). Immediate memory is intact, as is typical of Korsakoff’s syndrome. but the ability to retain new material is impaired. The symptoms may come on gradually and tend to clear up completely during remission or after removal of the cyst. The patient is forgetful, slow, inattentive, and apathetic. Disorientation may appear. Episodes of delirium tend to occur when intracranial pressure rises acutely and thus accompany and follow severe headaches. Depression and emotional lability are encountered in some cases. Cognitive impairment may take several months
374
J Psychiatry
135:3,
March
1978
to clear up after successful surgery. Lesions in the region of the floor and walls of the third ventricle are known to cause an amnestic syndrome (8-10). Pathology usually involves the mammillary bodies on the medial dorsal thalamic nuclei or both. Craniopharyngiomas, pituitary adenomas, colbid cysts, and other tumors invading or compressing the floor and walls of the third ventricle may cause amnestic syndrome Increased intracranial pressure if present, may account for intellectual impairment but does not seem to be responsible for the marked anterograde amnesia in diencephalic lesions. Our patient displayed an amnestic syndrome preand postoperatively. This was overshadowed by a marked personality change, which suggested a functional psychosis. Her own plausible psychodynamic interpretations further confused the doctors. Soniat (4) warned that severe headaches quickly relieved by changing the position of the head and episodes of hypersomnia are common in tumors of the third yentricle and are often mistaken for conversion symptoms. ln this patient’s case a CT scan was vital since her cyst was large and could have led to sudden death if not diagnosed and treated promptly. Psychiatrists should always suspect a focal cerebral lesion in the presence of antemograde amnesia. Brain tumor may occur in anyone at any age and does not spare mental health workers. When suspected, it should prompt full investigation including computerized axial tomogmaphy, if a catastrophe is to be averted. .
,
,
REFERENCES I. Walther-BUel
2.
H:
Die
Psychiatne
Springer. 1951, p 198 Blustein JE: Further observations functional psychiatric disturbances.
den
HirngeschwUlste.
on brain tumors The Psychiatric
Wien.
presenting Journal
as of
the University ofOttawa 1:21-26, 1976 3. Donald AG. Still CN. Pearson JM: Behavioral symptoms with intracranial neoplasm. South Med I 65:1006-1009, 1972 4. Soniat ILL: Psychiatric symptoms associated with intracranial neoplasms. Am I Psychiatry 108:19-22, 1951
S.
Waggoner
changes 1954 6. Walton
7.
RW.
Bagcchi
by psychic IN:
Brain’s
New York, Oxford Cairns H. Mosbeng
Gynecol 8. Crahay des
Obstet
mentaux
Initial
Diseases
of the Press, cyst
A, Iancu dans
masking
of
Am I Psychiatry
University WH: Colloid
92:545-570,
S. Viobon
troubles
BK:
symptoms.
Nervous 1977, ofthe
tumeurs
du
brain
I 10:904-910, System,
8th ed.
p 246 third ventricle.
1951 H, et al: L’analyse les
organic
troisieme
Surg
psychobogique ventnicule.
Acta Psychiatr BeIg 72:316-344, 1972 9. McEntee WI. Biber MP, Perl DP, et al: Diencephalic amnesia: a reappraisal. I Neurol Neunosurg Psychiatry 39:436-441, 1976 10.
Williams M, tricle tumors.
Pennybacken.J: Memory disturbances in third venI Neurol Neurosung Psychiatry 17:115-123, 1954
