- Department of Neurology, Center for Neurorehabilitation and Paraplegiology, REHAB Basel,
- Department of Psychiatry, Clinic for Psychiatry, Psychotherapy and Psychosomatics, SHG-Kliniken Sonnenberg, Saarbrücken, Germany,
- Department of Neurosurgery, University Hospital Basel, Baselland, Switzerland.
Correspondence Address:
Christian Saleh, M.D. (Neurologist), Department of Neurology, Center for Neurorehabilitation and Paraplegiology, REHAB Basel, Basel, Baselland, Switzerland.
DOI:10.25259/SNI_754_2021
Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Christian Saleh1, Ulrich Seidl2, Gregor Hutter3, Margret Hund-Georgiadis1. The need for neuroimaging in first manifestations of psychiatric symptoms. 06-Sep-2021;12:441
How to cite this URL: Christian Saleh1, Ulrich Seidl2, Gregor Hutter3, Margret Hund-Georgiadis1. The need for neuroimaging in first manifestations of psychiatric symptoms. 06-Sep-2021;12:441. Available from: https://surgicalneurologyint.com/surgicalint-articles/the-need-for-neuroimaging-in-first-manifestations-of-psychiatric-symptoms/
Abstract
Background: Brain imaging in psychiatry, especially by first-episode psychiatric symptoms, is unfortunately not a standard procedure in psychiatric clinics and is recommended only if indicated by history or if associated with neurological findings. As a result, the most serious diagnoses can be delayed or missed.
Case Description: We describe a patient who presented with psychiatric symptoms admitted initially to a psychiatric clinic. Thanks to routine imaging the diagnosis of a brain tumor could be made with prompt transfer to neurosurgery.
Conclusion: Brain imaging should be a mandatory procedure upon admission to a psychiatric clinic also in patients who present with exclusive psychiatric symptoms.
Keywords: Brain tumor, Diagnostic work-up, Imaging, Neurology, Neurosurgery, Psychiatry
INTRODUCTION
Structural brain imaging in psychiatry even with first onset psychiatric symptoms remains controversial. Psychiatric diagnostic work-up varies between clinics, and brain imaging is not always part of the standard procedure. One reason for this could be that psychiatric diseases, in contrast to neurological disorders, usually cause no structural brain changes visible on standard imaging.[
CASE REPORT
We saw a 22-year-old man who had been complaining of dreamlike states for 6 months, associated with philosophical questions about the sense of existence. He described these derealization states as frightening, and as being accompanied by avolition, a depressed mood, and concentration deficits. The patient was admitted to a psychiatric hospital, and a mild-to-moderate depression in the context of an adolescent crisis was suspected. A pharmacological treatment with lorazepam 0.5 mg twice daily and bupropion initially 150 mg titrated up to 300 mg was initiated. The patient improved under the pharmacological treatment. On admission, no apparent focal neurological deficit was detected. As part of a further clinical diagnostic work-up, a routine magnetic resonance imaging (MRI) of the head was performed, which revealed a partially contrast enhancing space-occupying compressive lesion at the roof of the fourth ventricle, with a nodular hypervascular component [
Figure 1:
(a-d) Gadolinium-enhanced, T1-weighted MRI (a: axial, left panel; b: mid-sagittal, right panel) shows a cerebellar, partially nodular lesion at the roof of the 4th ventricle with consecutive tonsillar herniation (arrow) and beginning compression of the medulla oblongata. Postoperative MRI confirms (c: axial, d: sagittal) complete resection of the benign tumor and decompression of the foramen magnum.
DISCUSSION
Our case and other published reports[
CONCLUSION
As brain tumors can manifest only with psychiatric symptomatology, it is advisable performing imaging in patients also with a predominant or exclusive psychiatric presentation.[
Authors’ contributions
C. Saleh: Clinical examination, wrote the first draft, and revised critically the final draft. U. Seidl: Drafted the manuscript and revised critically the final draft. G. Hutter: Performed surgery, drafted the manuscript, and revised critically the final draft. M. Hund-Georgiadis: Clinical examination, drafted the manuscript, and revised critically the final draft.
Data availability statement
All data analyzed for this case report are included in this article and its supplementary material files. Further enquiries can be directed to the corresponding author.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Authors’ contributions
C. Saleh: Clinical examination, wrote the first draft, and revised critically the final draft. U. Seidl: Drafted the manuscript and revised critically the final draft. G. Hutter: Performed surgery, drafted the manuscript, and revised critically the final draft. M. Hund-Georgiadis: Clinical examination, drafted the manuscript, and revised critically the final draft.
Data availability statement
All data analyzed for this case report are included in this article and its supplementary material files. Further enquiries can be directed to the corresponding author.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. 2. Andrea S, Papirny M, Raedler T. Brain imaging in adolescents and young adults with first-episode psychosis: A retrospective cohort study. J Clin Psychiatry. 2019. 80: m12665 3. Caruso R, Piro A. Why in the age of CT scans and MRIs is a brain tumour mistaken for a psychiatric illness?. BMJ Case Rep. 2017. 2017: bcr2017220131 4. Khandanpour N, Hoggard N, Connolly DJ. The role of MRI and CT of the brain in first episodes of psychosis. Clin Radiol. 2013. 68: 245-50 5. Madhusoodanan S, Ting MB, Farah T, Ugur U. Psychiatric aspects of brain tumors: A review. World J Psychiatry. 2015. 5: 273-85 6. McClellan RL, Eisenberg RL, Giyanani VL. Routine CT screening of psychiatry inpatients. Radiology. 1988. 169: 99-100
Dr. Miguel A. Faria
Posted September 6, 2021, 11:03 am
This case is very interesting, and the fact that the patient presented with unusual mental symptomatology that improved on medications was somewhat of a red herring. Nevertheless a neuropsychiatric illness, such as a temporal lobe disorder, should have been a possibility from the beginning, and both an MRI and an EEG evaluation would not have been out of order.
This article is also a bit controversial in concluding that basically all psychiatric patients should have neuroimaging studies, given the fact that as the authors admitted, only a few cases would be positive. I wonder how psychiatrists feel about this clinically, and whether government entities paying for these studies, will approve of these procedures, fiscally.