Diagnosis of frontal meningioma presenting with psychiatric symptoms.

The frontal lobes of the brain are notoriously "silent": Benign tumors such as meningiomas that compress the frontal lobes from the outside may not produce any symptoms other than progressive change of personality and intellect until they are large. We present two cases with symptoms suggestive of depressive episodes, which on further investigations showed space occupying lesions suggestive of frontal meningiomas.

INTRODUCTION

Brain tumors, either primary or metastatic, typically cause development of focal neurologic deficits such as hemiparesis, sensory deficit and aphasia. Functional imaging studies have repeatedly reported abnormalities in the neural activation patterns in depressive conditions. These abnormalities provide compelling evidence that specialized frontal brain structures such as orbitofrontal cortex and medial prefrontal cortex underlie various cognitive and emotional functions with an implication in mood control, such as regulation of responses to aversive emotional experiences and interpretation of social and emotional cues. Disturbance in the function of these areas can lead to mood disorders.[1] The frontal lobes of the brain are notoriously “silent”: Benign tumors such as meningiomas that compress the frontal lobes from the outside may not produce any symptoms other than progressive change of personality and intellect until they are large. Patients with such tumors are often referred first to psychiatrists, and the correct diagnosis may emerge only when the tumor has grown large and has begun to displace the brain.[2]

CASE REPORTS

Case report 1

A 52-year-old male patient came to psychiatry outpatient department (OPD) with a 1-month history of depressive symptoms. The condition was characterized by sadness of mood, fatigue, hopelessness, withdrawal from social activities and sleep disturbance. He met the International Classification of Diseases-10 (ICD-10) criteria for a major depressive episode (depressive episode without psychotic features, ICD-10: F32.0). His history regarding psychiatric and other medical conditions were unremarkable. The general physical, as well as neurological examination, showed no neurological deficit. He was prescribed tablet escitalopram 10 mg/day and asked for follow-up in psychiatry OPD. Even after 1-month, patient's depression did not improve and he complained of headache. His wife also complained that he forgets things easily but patient showed relative lack of insight to these complaints. Patient was advised contrast-enhanced computed tomography (CECT) head and it showed an extraxial dural based well defined circumscribed lobulated mass involving bilateral frontal regions, which showed intense homogenous enhancement suggestive of frontal meningioma [Figure 1]. The case was referred to Department of Neurosurgery for further management.

Figure 1

Contrast-enhanced computed tomography head case 1

Case report 2

A 43-year-old married male patient came to psychiatry OPD at Rajindra Hospital, Patiala for consultation. For the last 2 months, patient had complaints of remaining sad for most of the day. He also started talking less than usual and would remain quiet. This was accompanied by decreased sleep and appetite. Patient visited a private psychiatrist and was diagnosed as a case of moderate depressive disorder without psychotic features (F-32.1 as per ICD-10). He was prescribed tablet desvenlafaxine 50 mg/day. Patient's condition did not improve, and he came to RH, Patiala for consultation. Patient also had complaints of forgetfulness and headache now along with previous depressive symptoms. There was no history of head trauma or any focal neurological deficit. There was no family history of any psychiatric illness. The general physical, as well as neurological examination, showed no abnormality. On mental status examination, his affect was depressed with impairment in recent memory. Patient was advised CECT head which showed a large extra-axial hyperdense mass measuring approx. 7 cm × 6.3 cm in right frontal region. The lesion showed heterogeneous enhancement with areas of necrosis in it suggestive of right frontal meningioma with malignant transformation [Figure 2]. The case was referred to Department of Neurosurgery for further management.

Figure 2

Contrast-enhanced computed tomography head case 2

DISCUSSION

Both cases represented depressive episodes due to a frontal lobe tumor without accompanying neurologic deficits. In case report 1, CECT head shows meningioma affecting bilateral frontal lobes arising near sphenoidal sinus which is a common site of origin of meningioma. In case report 2, CECT head shows meningioma with malignant transformation affecting right frontal region. Intracranial tumors, notably frontal meningiomas, may present with psychological symptoms resembling depression, anxiety states, hypomania, and schizophrenia.[2]

Psychiatric symptoms may be the only initial manifestations of meningiomas of the brain in a significant number of cases (21%) occurring in the fifth decade of life.[3] Hence, when a middle aged person with no past history of psychiatric disorder, develops a slowly progressive psychological change, a frontal meningioma should be considered. Headache, papilledema, and focal neurological signs may develop only when the tumor has reached an advanced stage.[2]

Hunter et al. have reported cases of excitement and hallucinosis seen in association with a basal frontal lesion, and psychotic syndromes like hypomania and schizophrenia with tumor encroaching on the third ventricle and adjacent structures.[4] The association between slow growing frontal lobe tumors, anosmia, and personality change is one of the most celebrated in behavioral neurology.[5]

CONCLUSION

Cases such as ours emphasize the necessity for psychiatrists to remember that psychological symptoms may be a mode of presentation of organic disease of the brain. Symptoms like headache, recent memory loss and relative lack of insight should warn about organic disease like frontal meningioma and thus brain imaging should be considered.