Psychotic manifestations as an initial presentation in a Glioma patient: Two Case Reports & Review of Literature
Psychotic manifestation as an initial presentation of brain tumor is a rare manifestation of the primary disease. A 32 years old male patient presented with auditory and visual hallucinations, delusion of persecutionand profound agitation. The patient was initially suspected as a case of acute psychosis; however on imaging work up, large central space occupying lesion (SOL) in brain was detected. Following surgical removal of the brain tumor, psychotic manifestations disappeared. The pathology revealed high grade Glioma. Similar presentation was observed in a 28 years female who first visited psychiatry department. Imaging revealed SOL in left parietal lobe. Neuropsychiatric manifestations in these patients have great bearing on the quality of life which has now become a major concern in the management of the brain tumors.
Psychotic manifestations are usually not seen in primary brain tumor patients. The patient usually presents with headache, vertigo, projectile vomiting, focal neurological deficits, and seizures. Anxiety, depression, mania, psychosis, cognitive or personality changes may be present as psychotic manifestations. Patients presenting with psychosis not responding to antipsychotic treatment or having focal neurological deficits and papilloedema should be examined thoroughly to rule out space occupying lesion in brain. The main objective of this article is to highlight this type of patients who can be helped if properly diagnosed.
Case Report: 1
A 32 year old male was admitted with 3-month history of auditory and visual hallucinations, delusion of persecution, and loss of recent or remote memories. During the same period patient had also become irritable and with no clouding of consciousness. He complained of headache and vertigo occasionally. Patient having no prior history of psychosis or any narcotic or drugs abuse, or any other medical complaints. Patient received antipsychotic drug for last three days with no response. MRI brain showed moderate hydrocephalus related to foramen of Monero obstruction with mild transependymal CSF seepage. Edema is also seen in the deep right frontal lobe along the ventricular margin. There is compression of the adjacent brain parenchyma. These MRI findings are compatible with central glioma attached to septum pellucidum within the right lateral ventricle, showing extension across the midline with a tomoral component in the body of left lateral ventricle. He had bilateral papillo oedema with out focal neurological deficits. On examination, the patient was disoriented to time and place, had poor attention, poor comprehension, recent and remote memory loss. He underwent a craniotomy and resection of tumor. There was resolution of all his psychotic symptoms soon after the operation.
Case Report: 2
A 28 years old woman visited to psychiatry department for the complaints of headache, vertigo for last seven months. From last 10 days she complaints of heard sounds that someone whispering in her ears. Since last 3 days she having violent out brust with visual hallucination and develop seizures. She was given benzodiazepine with phenytoin. Response to treatment was poor. MRI brain reveled large SOL in left parietal region, findings are compatible with glioma. After removal of tumor all symptoms subside.
Brain tumours are commonly associated with neurological deficits but rarely psychiatric manifestations may be seen. The cause underlying most patients presenting in this manner are functional causes such as manic-depressive psychosis, schizophrenia and substance or drugs abuse of various types. The degree to which organic causes are responsible for psychiatric manifestations is difficult to determine hence accurate diagnosis in these cases can be a diagnostic challenge. Attempts have been made to categorize brain tumors in accordance with the location of the tumor in the brain . Filley and Kelinschmidt-De Mastersreported that tumors in frontal lobe usually cause abulia, depression or personality change and tumors in the temporolimbic areas, mania, panic attacks, amnesia or auditory and visual hallucinations.  Uribedescribe association with schizophrenia-like psychoses to left hemispheric malfunction and affective disorders to right hemispheric malfunction. In areas, such as the intraventricular occipital lobe, corpus callosum only transitory symptoms are produced without localizing signs and tumors can grow considerably.  Binderdescribed a series of three cases of patients with no or minimal neurologic signs or symptoms with brain tumors, they all had tumors in silent areas of the brain.  Burns and Swerdlowdescribed a case presented with alterations in sexual behavior, poor impulse control, and sociopathy in an orbitofrontal tumor.  In some cases, symptoms can respond to antipsychotic treatments, further complicating the diagnosis. Detailed history, brain imaging, information from collateral sources become essential, when brain tumors develop in patients with established psychiatric disorders as psychiatric patients are known to have difficulties in reporting and describing their own symptoms. 
Cognitive decline occurring during the course of brain tumour progression was reported by Taphoorn et al in his study, main objective of clinical management of brain tumor is to remove the tumor, restore neurologic functions and treatment of psychiatric symptoms.  Treatment modalities like surgery/ radiotherapy/ chemotherapy have good result if tumor size is small. A 9 year-old boy on MRI having tumour in the anterior third ventricle associated hydrocephalus and papilledema is presented with psychosis as the initial presentation.  Patient remained free of symptoms after resection of the tumor at one-year follow-up. Even more intriguing has been the reported association of posterior fossa structural abnormalities with neuropsychiatric symptoms . It is hypothesized that in these cases disruption of the cerebellar output to mesiodopaminergic areas, locus coeruleus and raphe nuclei or deafferentation of the thalamolimbic circuits by cerebellar lesions may lead to these behavioural and psychiatric changes. A 55-year-old woman with a six year history of uncontrollable complex partial seizures and severe delusions is reported to have improved following removal of a right frontal lobe mixed oligoastrocytoma or dysembryoplastic neuroepithelial tumour.  The anatomic site which control human behavior and emotions are believed to be the circuits of limbic system which interact with the basal ganglia and disturbances in these systems are primarly responsible for manifestations of psychiatric symptoms. [9, 10] In patients hospitalized for psychotic affective disorder abnormalities have been found in left subgenual cingulate. Schizophrenic disorder was observed in patients suffering from agenesis of septum pellucidum . Y et another study has demonstrated lateral and third ventricular enlargement as well as preferential ab circuits of the limbic system and the interactions with the basal ganglia normalities of medial temporal lobe structures including the amygdala, hippocampus, and the parahippocampal gyrus and neocortical temporal lobe regions in patients with schizophrenia. The positive correlation between structural brain abnormalities and mental illness has been borne out by several studies. These include ventriculomegaly and smaller temporal lobes, frontal
parietal and superior temporal gyrus grey matter. Hippocampal volume reduction has been reported in schizophrenia as well as volume reduction in the parahippocampal and fusiform gyri on the left side in another study on schizophrenics.
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