Letters to Editor
“Mania”: An unusual presentation of craniopharyngioma Sir, Craniopharyngioma usually presents with of increased intracranial pressure, such as headache and vomiting, or with visual worsening.[1,2] We present a 13‑year‑old female who came to us with symptoms suggestive of hyperactivity, excessive talkativeness, echolalia, increased speed of talking, overfamiliarity with unknown persons, smelling objects and wandering behavior, over cheerfulness, persistent irritability, overdemanding, singing, dancing, increased appetite, and decreased sleep. She was diagnosed to have first episode mania and was started on sodium valproate and olanzapine. However there was no improvement in the clinical condition of the patient even after 3 weeks of medication. In view of nonimprovement, she was further investigated with computed tomography (CT) head. CT head showed large sellar suprasellar lesion with calcification and obstructive hydrocephalus [Figure 1]. Her anterior pituitary hormonal profile was normal. Her visual acuity and fields were normal. Patient initially underwent right‑sided medium pressure ventriculoperitoneal shunt. This was followed by right pterional craniotomy and gross total excision of the tumor. Postoperatively, patient recovered well, and had no fresh neurological deficits. Her manic symptoms improved significantly. Histopathology revealed features suggestive of adamantinomatous craniopharyngioma. At 6 months follow‑up, she did not have any manic symptoms, and she was not on any medications. Follow‑up magnetic resonance imaging did not show any residual tumor [Figure 1]. Mood disorders or anxiety disorders are rare presentations of childhood craniopharyngioma.[3] Majority of patients with craniopharyngioma who present with behavioral disturbances are adults. The case described is that of 13‑year‑old female who on initial presentation met criteria for mania. She did not have any symptoms of raised intracranial pressure, or visual disturbances, and hence was treated on the lines of a mood disorder. Mania is a very rare presentation of craniopharyngioma, and to the best of our knowledge, until now only two cases have been described in literature.[4,5] The possibility of manic symptoms is speculated to be due to hypothalamo‑pituitary disturbances because of the compression of the hypothalamus and pituitary stalk. Other possibility of explaining the affective symptoms could be the involvement of the right temporal lobe in this condition, when the tumor has parasellar extension.
a
b
c
d
Figure 1: Preoperative axial noncontrast computed tomography scan (a and b) shows sellar suprasellar lesion with areas of calcification and hydrocephalous. Postoperative T2-weighted image axial (c) and coronal (d) images show gross total tumor decompression with normal ventricles
Majid Mohammed Abdul, Paritosh Pandey, Avinash V. Waghmare1, Mayur V. Kaku
Departments of Neurosurgery and 1Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India E‑mail: [email protected] REFERENCES 1.
Sklar CA. Craniopharyngioma: Endocrine abnormalities at presentation. Pediatr Neurosurg 1994;21 Suppl 1:18‑20. 2. Mitan LA. An unusual presentation of craniopharyngioma. J Adolesc Health 1999;24:274‑6. 3. Pierre‑Kahn A, Recassens C, Pinto G, Thalassinos C, Chokron S, Soubervielle JC, et al. Social and psycho‑intellectual outcome following radical removal of craniopharyngiomas in childhood. A prospective series. Childs Nerv Syst 2005;21:817‑24. 4. Sweet RA Case of craniopharyngioma in late life. J Neuropsychiatry Clin Neurosci 1990;2:464‑5. 5. Prusty GK, Subramanya, Hemalatha V, Narayanan HS. Craniopharyngioma presenting as ‘mania’ – Case report. Indian J Psychiatry 1982; 24:305‑6. Access this article online Quick Response Code
Craniopharyngioma can rarely manifest as mania and the treatment of the underlying condition may leads to total remission of the psychiatric symptoms. Keeping this in view, it is necessary to have detailed neurological assessment in psychiatric patients, and imaging in the patients who do not have remission on medication. 308
Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.140669
Indian Journal of Psychiatry 56(3), Jul‑Sep 2014
Copyright of Indian Journal of Psychiatry is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
“Mania”: An unusual presentation of craniopharyngioma Sir, Craniopharyngioma usually presents with of increased intracranial pressure, such as headache and vomiting, or with visual worsening.[1,2] We present a 13‑year‑old female who came to us with symptoms suggestive of hyperactivity, excessive talkativeness, echolalia, increased speed of talking, overfamiliarity with unknown persons, smelling objects and wandering behavior, over cheerfulness, persistent irritability, overdemanding, singing, dancing, increased appetite, and decreased sleep. She was diagnosed to have first episode mania and was started on sodium valproate and olanzapine. However there was no improvement in the clinical condition of the patient even after 3 weeks of medication. In view of nonimprovement, she was further investigated with computed tomography (CT) head. CT head showed large sellar suprasellar lesion with calcification and obstructive hydrocephalus [Figure 1]. Her anterior pituitary hormonal profile was normal. Her visual acuity and fields were normal. Patient initially underwent right‑sided medium pressure ventriculoperitoneal shunt. This was followed by right pterional craniotomy and gross total excision of the tumor. Postoperatively, patient recovered well, and had no fresh neurological deficits. Her manic symptoms improved significantly. Histopathology revealed features suggestive of adamantinomatous craniopharyngioma. At 6 months follow‑up, she did not have any manic symptoms, and she was not on any medications. Follow‑up magnetic resonance imaging did not show any residual tumor [Figure 1]. Mood disorders or anxiety disorders are rare presentations of childhood craniopharyngioma.[3] Majority of patients with craniopharyngioma who present with behavioral disturbances are adults. The case described is that of 13‑year‑old female who on initial presentation met criteria for mania. She did not have any symptoms of raised intracranial pressure, or visual disturbances, and hence was treated on the lines of a mood disorder. Mania is a very rare presentation of craniopharyngioma, and to the best of our knowledge, until now only two cases have been described in literature.[4,5] The possibility of manic symptoms is speculated to be due to hypothalamo‑pituitary disturbances because of the compression of the hypothalamus and pituitary stalk. Other possibility of explaining the affective symptoms could be the involvement of the right temporal lobe in this condition, when the tumor has parasellar extension.
a
b
c
d
Figure 1: Preoperative axial noncontrast computed tomography scan (a and b) shows sellar suprasellar lesion with areas of calcification and hydrocephalous. Postoperative T2-weighted image axial (c) and coronal (d) images show gross total tumor decompression with normal ventricles
Majid Mohammed Abdul, Paritosh Pandey, Avinash V. Waghmare1, Mayur V. Kaku
Departments of Neurosurgery and 1Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India E‑mail: [email protected] REFERENCES 1.
Sklar CA. Craniopharyngioma: Endocrine abnormalities at presentation. Pediatr Neurosurg 1994;21 Suppl 1:18‑20. 2. Mitan LA. An unusual presentation of craniopharyngioma. J Adolesc Health 1999;24:274‑6. 3. Pierre‑Kahn A, Recassens C, Pinto G, Thalassinos C, Chokron S, Soubervielle JC, et al. Social and psycho‑intellectual outcome following radical removal of craniopharyngiomas in childhood. A prospective series. Childs Nerv Syst 2005;21:817‑24. 4. Sweet RA Case of craniopharyngioma in late life. J Neuropsychiatry Clin Neurosci 1990;2:464‑5. 5. Prusty GK, Subramanya, Hemalatha V, Narayanan HS. Craniopharyngioma presenting as ‘mania’ – Case report. Indian J Psychiatry 1982; 24:305‑6. Access this article online Quick Response Code
Craniopharyngioma can rarely manifest as mania and the treatment of the underlying condition may leads to total remission of the psychiatric symptoms. Keeping this in view, it is necessary to have detailed neurological assessment in psychiatric patients, and imaging in the patients who do not have remission on medication. 308
Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.140669
Indian Journal of Psychiatry 56(3), Jul‑Sep 2014
Copyright of Indian Journal of Psychiatry is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
