A Case of Right Cerebellopontine-Angle Lesion: Psychotic Symptoms and Magnetic Resonance Imaging Findings
Here, we report psychotic symptoms together with a right cerebellopontine-angle lesion. A37-year-old female patient presented with a trigeminal Schwannoma occupying the right cerebellopontine angle. Her psychotic symptoms included auditory hallucinations and delusions of persecution. T1- and T2-weighted images on magnetic resonance imaging (MRI) revealed hyperintense and hypointense areas in the right cerebellopontine angle, respectively. The clinical and neuroimaging reviews in this case suggest that sudden onset of psychotic symptoms at a mature age may be associated with a right cerebellopontine-angle lesion and that MRI should be used to evaluate possible organic bases in patients that present with psychosis.
Previous studies have hypothesized that psychiatric symptoms could be major symptoms of cerebellopontine-angle (CPA) lesions,1 specifically in patients with acoustic neuromas in the CPA.2–4 One report described how a focal temporal-lobe tumor expanded to the CPA and caused postoperativepsychotic symptoms.5 However, in cases where psychotic patients show few or no neurological symptoms, magnetic resonance imaging (MRI) can be an extremely useful tool for evaluating organic lesions; this is often overlooked by psychiatrists. In this paper we reported an adult patient who suddenly developed psychotic symptoms that were associated with a right CPA lesion found on MRI.
A 37-year-old, right-handed woman visited a psychiatrist after she had experienced persecutory delusions and auditory hallucinations for a month. No specific problems were revealed in the physical examination at admission. During the persecutory delusion she felt that she was being stalked and had recently been wiretapped. She also heard a man’s voice that talked about her behavior, including menstruation and toilet habits. She thought that he had installed closed-circuit television around her house to watch her and followed her on the subway. These symptoms became worse, and she felt that he had invaded her privacy. She was unable to go to the bathroom or eat. When her mother visited her apartment 2 days before admission to the hospital, the windows were covered with newspapers, and the house was full of waste. She described the things that were disturbing her to her mother. She also talked to herself, asking “Why did you follow me to install the cameras?” while crying and smiling.
The patient was the younger of 2 daughters. She had a normal birth and no history of seizures. She was calm, focused, and got along well with other children. After graduating from high school, she worked at a company for 5 years. She entered music college and maintained good grades. She had moved out of her parents’ house 3 years before, when they pressured her to get married. There was no family or personal history of neuropsychiatric disorders. Her premorbid personality was well tempered and introverted.
Brain MRI (Figure 1) revealed a tumor occupying the right CPA. The tumor was clinically diagnosed as a trigeminal Schwannoma. Examination by a neurosurgeon revealed few neurological problems. She exhibited auditory hallucinations, delusions of reference and persecution, and talked to herself while simultaneously crying and smiling. Mental status examination revealed alert consciousness on admission to a university hospital. She was cooperative during the interview and maintained good eye contact. She was oriented with regard to place and person. She did not show impaired memory function and answered questions with normal tone and speed. She did not show impaired cognitive functions. Although her thoughts were somewhat persecutory and included hallucinations, her thought process was relatively coherent. She was mildly anxious and her affect was blunted and appropriate. Her impulse control was moderate. Brain electroencephalogram (EEG) and a toxicology screen were performed to evaluate other organic causes, but there were no abnormal findings. Her MRI showed a small enhanced mass lesion in the right CPA region; T1-weighted images revealed a hyperintense signal (Figure 1A and B), and T2-weighted images revealed a hypointense signal (Figure 1C) within the foci. The imaging findings strongly suggested the possibility of acoustic Schwannoma. She was treated with a low dose of risperidone (1 mg daily), and her psychotic symptoms gradually and completely resolved over the next month. She is presently well and continues with antipsychotic drug maintenance.
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