LETTERS
Auditory Hallucinations Secondary to a Right Frontal Meningioma
To the Editor: A wide spectrum of psychiatric symptoms including cognitive and behavioral symptoms can present after brain tumors.1 Clinical presentation is not always entirely consistent with the expected symptomatology normally associated with the underlying anatomical lesions.1–3 Right-sided frontal meningiomas may be associated with psychiatric symptoms more frequently than those on the left.4 Furthermore, a range of psychotic symptoms can occur secondary to frontal lobe tumors in some patients.1–4 However, case descriptions of persisting auditory hallucinations without other ongoing psychiatric symptoms after a right frontal meningioma, appear to be more rarely reported. Case Report A woman in her mid-60s, with no history of previous psychiatric problems, presented to hospital with a history of progressively worsening lethargy, headaches, and left leg weakness. MR brain revealed a solitary meningioma measuring 59 3 54 3 41 mm in the right frontal lobe, causing mid line shift and compression of the frontal horn of the right lateral ventricle, minimal
surrounding edema and no associated infarct. The meningioma was neurosurgically removed. Postoperative scan at 9 months revealed no reoccurrence of the meningioma. The patient subsequently presented with auditory hallucinations and irritability, without any symptoms of depression or anxiety. Although her irritability later subsided, the hallucinations never went into remission, despite antipsychotic medication. The hallucinations entailed receiving messages via the television, telling her she is being controlled by persons in the neighborhood, poisoned, or hearing voices of deceased persons. A relative frequently observed her verbally responding to hallucinations. MiniMental State Examination (MMSE)5 was 26, representing impairments of attention and visiospatial functions, mirroring the remainder of the bedside cognitive assessment. At 12 months post-surgery, attention had improved with very little obvious cognitive impairment evident on bedside testing. Psychiatric symptoms are associated with frontal tumors, with personality change and mood disorders more commonly observed.2–4 Persisting auditory hallucinations secondary to a brain tumor, if present, generally tend to be simple rather than complex, and more often visual than auditory.1 The case reported here is potentially unique in regard to the chronic
J Neuropsychiatry Clin Neurosci 26:3, Summer 2014
nature of auditory hallucinations in the absence of other franc psychotic, behavioral or cognitive symptoms with onset after resection of a right frontal meningioma. The authors report no financial relationships with commercial interests. Rudi Coetzer, D.Clin.Psy. North Wales Brain Injury Service, Betsi Cadwaladr University Health Board NHS Wales, Colwyn Bay, United Kingdom Send correspondence to Dr. Coetzer; e-mail: Rudi.Coetzer@wales. nhs.uk References 1. Price TRP, Goetz KL, Lovell MR: Brain tumors, in Clinical Manual of Neuropsychiatry. Edited by Yudofsky SC, Hales RE. USA, American Psychiatric Press, 2011, pp 235–263 2. Avery TL: Seven cases of frontal tumour with psychiatric presentation. Br J Psychiatry 1971; 119:19–23 3. Hunter R, Blackwood W, Bull J: Three cases of frontal meningiomas presenting psychiatrically. BMJ 1968; 3:9–16 4. Lampl Y, Barak Y, Achiron A, et al: Intracranial meningiomas: correlation of peritumoral edema and psychiatric disturbances. Psychiatry Res 1995; 58:177–180 5. Folstein MF, Folstein SE, McHugh PR: “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189–198
http://neuro.psychiatryonline.org
E15
Auditory Hallucinations Secondary to a Right Frontal Meningioma
To the Editor: A wide spectrum of psychiatric symptoms including cognitive and behavioral symptoms can present after brain tumors.1 Clinical presentation is not always entirely consistent with the expected symptomatology normally associated with the underlying anatomical lesions.1–3 Right-sided frontal meningiomas may be associated with psychiatric symptoms more frequently than those on the left.4 Furthermore, a range of psychotic symptoms can occur secondary to frontal lobe tumors in some patients.1–4 However, case descriptions of persisting auditory hallucinations without other ongoing psychiatric symptoms after a right frontal meningioma, appear to be more rarely reported. Case Report A woman in her mid-60s, with no history of previous psychiatric problems, presented to hospital with a history of progressively worsening lethargy, headaches, and left leg weakness. MR brain revealed a solitary meningioma measuring 59 3 54 3 41 mm in the right frontal lobe, causing mid line shift and compression of the frontal horn of the right lateral ventricle, minimal
surrounding edema and no associated infarct. The meningioma was neurosurgically removed. Postoperative scan at 9 months revealed no reoccurrence of the meningioma. The patient subsequently presented with auditory hallucinations and irritability, without any symptoms of depression or anxiety. Although her irritability later subsided, the hallucinations never went into remission, despite antipsychotic medication. The hallucinations entailed receiving messages via the television, telling her she is being controlled by persons in the neighborhood, poisoned, or hearing voices of deceased persons. A relative frequently observed her verbally responding to hallucinations. MiniMental State Examination (MMSE)5 was 26, representing impairments of attention and visiospatial functions, mirroring the remainder of the bedside cognitive assessment. At 12 months post-surgery, attention had improved with very little obvious cognitive impairment evident on bedside testing. Psychiatric symptoms are associated with frontal tumors, with personality change and mood disorders more commonly observed.2–4 Persisting auditory hallucinations secondary to a brain tumor, if present, generally tend to be simple rather than complex, and more often visual than auditory.1 The case reported here is potentially unique in regard to the chronic
J Neuropsychiatry Clin Neurosci 26:3, Summer 2014
nature of auditory hallucinations in the absence of other franc psychotic, behavioral or cognitive symptoms with onset after resection of a right frontal meningioma. The authors report no financial relationships with commercial interests. Rudi Coetzer, D.Clin.Psy. North Wales Brain Injury Service, Betsi Cadwaladr University Health Board NHS Wales, Colwyn Bay, United Kingdom Send correspondence to Dr. Coetzer; e-mail: Rudi.Coetzer@wales. nhs.uk References 1. Price TRP, Goetz KL, Lovell MR: Brain tumors, in Clinical Manual of Neuropsychiatry. Edited by Yudofsky SC, Hales RE. USA, American Psychiatric Press, 2011, pp 235–263 2. Avery TL: Seven cases of frontal tumour with psychiatric presentation. Br J Psychiatry 1971; 119:19–23 3. Hunter R, Blackwood W, Bull J: Three cases of frontal meningiomas presenting psychiatrically. BMJ 1968; 3:9–16 4. Lampl Y, Barak Y, Achiron A, et al: Intracranial meningiomas: correlation of peritumoral edema and psychiatric disturbances. Psychiatry Res 1995; 58:177–180 5. Folstein MF, Folstein SE, McHugh PR: “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189–198
http://neuro.psychiatryonline.org
E15
