Frontotemporal Arachnoid Cyst Connected to Relapsing Stupor
Case Report
SIR: A 45-year-old married woman was admitted to our hospital for the first time in January 1983. At first, she was depressed, hypo mimic, and she didn't speak. Since she had symptoms of major depression, we started the therapy with maprotiline and thioridazine. Her condition deteriorated, she began refusing food and liquid. We started with an i.v. treatment with maprotiline, but her condition still worsened along with the EPS (tremor, rigor). After that, she had three ECTs. She became febrile and dehydrated. There were no signs of improvement. We assumed that stupor was organic in origin, so we referred her to the CT scan, which revealed an arachnoid cyst 5cm by 7cm in the region of the left frontotemporal lobe. She was sent to Neurosurgery Clinic of Ljubljana, where the patient underwent an operation. Her condition improved immediately without any medication.
The second admission was in 1986. She was in stupor again. The CT scan revealed arachnoid cyst in the same region as the first time. The cyst sized 3cm in diameter. The neurosurgeon decided for non-surgical procedure, since she already had an aqueduct by-pass done. Psychiatric therapy proceeded with the selection of sulpiride, which she was taking orally.
In the following years, the same clinical picture appeared whenever she faced any minor stress life events (her sons wedding, conflicts with neighbors and similar). The successful therapy proved to be sulpiride, carbamazepine and lorazepam. After 1995, she became very religious, but no delusions were noticed.
She was last admitted to our hospital in March of 2001. She had been denying food intake and liquids three days prior to admission; she was depressed and had auditory hallucinations and paranoid delusions. Her medication consisted of sulpiride, carbamazepine, lorazepam, tianeptine and finally olanzapine and doxepine. The neurological examination revealed no specific pathology. The CT scan showed again large frontotemporal cyst with the tip of catheter seen along with enlarged ventricles in close vicinity of limbic structures. She was to go to the neurosurgeon, but abruptly, although CPR was performed, died because of massive pulmonary embolism.
In the past 20 years, we accidentally discovered 4 patients with arachnoid cysts. The literature describes catatonic symptoms in 14-year old boy with anorexia nervosa1 and mental disturbances are connected to arachnoid cysts in children.2 Case studies reported on differential diagnosis of schizophrenia in patients with bilateral temporal cysts.3,4,5
We treated our patient for twenty years. There are no reports in available medical literature of such long treatment. We would like to emphasize the connection between cyst and symptoms, which, in our case, were always depression, which gradually developed to stupor.
1 Wolanczyk T, Komender J, Brozowska A: Catatonic syndrome preceded by symptoms of anorexia nervosa in a 14-year-old boy with arachoid cyst. Eur Child Adolesc Psychiatry. 1997 Sep; 6(3):166–169Google Scholar
2 Sommer IE, Smit LM. Congenital supratentorial arachnoidal and giant cyst in children: a clinic study with arguments for conservative approach. Childs Nerv Syst. 1997 Jan; 13(1):8–12Google Scholar
3 Shiraishi H et al. Differential diagnosis of schizophrenic symptoms complicated with brain anomalies including bilateral temporal arachnoid cysts by eye mark recorder and PET: a case study. Seishin Shinkeigaku Zasshi. 1999; 101(4):350–367Google Scholar
4 Krzyzowski J et al. A case of schizophrenia-like psychosis in a patient with arachnoid cyst. Neurol Neurochir Pol. 1998 Mar-Apr; 32(2):433–440Google Scholar
5 Gontard von A, Moeller. Psychiatrische und neuropsychologische Symptome bei Kindern mit Arachoidalzysten—eine Kasuistik. Z. Kinder-Jugendpsychiat. 1991; 19:30–37Google Scholar
