"Mania": An unusual presentation of craniopharyngioma.

Sir,

Craniopharyngioma usually presents with of increased intracranial pressure, such as headache and vomiting, or with visual worsening.[12] 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].

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

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.[45] 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.

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.