Cerebral Malignancy Presenting with Post Stroke Depression

Abstract

The following case report highlights about a Glioblastoma presenting with features of post stroke depression. The neuropsychological findings though initially was normal but on subsequent follow up showed gross abnormalities. The imaging studies revealed the tumor, involving the right parietal and temporal lobes with midline shift and high vascularity. The patient exhibited rapid downhill course and died within 4 weeks of initial presentation.

Subtle neuropsychiatric symptoms of glioblastoma multiforme misdiagnosed as depression

“…The emergence of psychiatric symptoms may be the initial, and often insidious, sign of an evolving GBM. In several of the cases summarised here, it was the psychiatric symptoms that prompted clinical presentation 3 10 13 14 16 17 20–23 26–28 30 31. Psychiatric manifestations related to GBM in the cases retrieved here have been reported in adults whose ages spanned 24–65 years; most (62%) of the afflicted persons were middle-aged.…”

“…Depression was the primary psychiatric symptom manifestation of the underlying GBM in 62% (16/26) of retrieved cases 3 10 13 14 16–18 20–23 25 28 30 32 33. Other mood disturbances reported among GBM patients included pseudobulbar affect-like states,24 manic-like states27 31 and anxiety,3 12 13 17 34 some of the latter of which co-occurred in depressed patients.…”

“…Due to the effects of increased intracranial pressure, brain neoplasm classically presents with generalised symptoms, that is, headache, vomiting and seizure 3 10–18. Fast-growing tumours, particularly within the frontal lobe and corpus callosum3 19 can produce cognitive changes3 10 12 16 20 21 and/or neurological signs12 13 17 18 22–29 but these may not be appreciable until the tumour becomes quite large. Subtle and atypical neuropsychiatric symptoms may predominate early in the course of tumour growth/expansion.…”

“…Other mood disturbances reported among GBM patients included pseudobulbar affect-like states,24 manic-like states27 31 and anxiety,3 12 13 17 34 some of the latter of which co-occurred in depressed patients. Mood disorders were associated with tumours involving the frontal lobes,10 12–14 22–25 34 temporal lobes14 16 17 20 30 and limbic structures 17 31. Patients manifested psychotic symptoms in 35% (9/26) of cases 11 15 22 25–28 30 32.…”

“…In only a few cases was it possible to establish some support for a causal association when symptoms resolved following after tumour resection 10 13 24 30. In other cases, the evolution of new or unusual psychiatric symptoms3 11 13 16 21 26 28 30 32 33; poor response to treatment in a person who had previously responded favourably to psychiatric treatment14 25; or the emergence of new cognitive and neurological symptoms11 12 15 17 18 20 23 29 34 provided clues to the presence of the tumour. For example, in one well described case,3 a patient with a 4-year history of mood disturbance had a series of multiple brain images undertaken during the course of her psychiatric illness.…”