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Elderly patients are more likely to have physical comorbidity and unrecognized medical disorders associated with behavioral disturbances.1 Unruptured intracranial aneurysms occur in up to 6% of the general population, and unusual presenting symptoms may include headache, cranial nerve compression or mass effects.2 We report a case of psychosis and bipolar depression associated with an unruptured intracranial aneurysm.
"Mr. M," a 65-year-old right-handed Caucasian man with no previous psychiatric history, was seen for an acute manic episode with psychotic symptoms in the emergency room. He had 2 months of paranoia in the context of "my house was bugged by Iraqi satellites." He also had elated mood, flight of ideas, pressured speech, and slept only 3 hours a day. Three weeks prior to ER visit, patient was depressed, unable to concentrate, losing weight, and not taking care of his dog. Patient also complained of mild unilateral headache. His medical history was significant for obesity, hypertension, coronary artery disease, and a grapefruit size ventral hernia.
A thorough neurological examination revealed no abnormalities. On the initial Mini-Mental State Examination (MMSE),3 he scored 19 out of 30. On day 2, Mr. M scored 29 out of 30 on the MMSE. On the Neurobehavioral Cognitive Status Examination,4 Mr. M’s pattern of scores was consistent with those suffering from mild to moderate presenile dementia. Laboratory studies for dementia and delirium were both unremarkable. CT scan revealed mild cortical atrophy, and a 15 mm diameter aneurysm at the right basilar artery compressing against the pons. Previous CT performed a year ago did not reveal such findings. Given the poor prognosis and significant risk, Mr. M refused invasive operation for the intracranial aneurysm.
An association between erotomanic delusional syndrome and intracranial aneurysm has been reported previously.5 To our knowledge, this is the first documented case of association between intracranial aneurysm and paranoia with subsequent bipolar depression. It is still unclear how intracranial aneurysm causes depression, mania, and paranoia in Mr. M’s case. It is likely that ischemic changes, calcification in the wall of the aneurysm and compression of adjacent brain tissue led to the current neuropsychiatric presentation, which included a form of psychosis, bipolar depression, dementia, and delirium. In summary, our case highlights the importance of searching for unrecognized medical conditions that could be solely or partially responsible for new-onset neuropsychiatric symptoms in elderly patients.
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