Frontal meningioma and bipolar disorder: Etiopathogenic link or co-morbidity? A case report

Abstract

IntroductionFrontal meningiomas are benign brain tumours known for their late onset. They may be presented by only psychiatric symptoms. Thus, the diagnosis at early stages can be missed or overlooked until the tumour causes neurological deficit.Case reportWe report the case of a 61-year-old man, receiving a treatment and a follow-up for bipolar disorder for 11 years. He has history of 3 major depressive episodes, 2 suicide attempts and a manic episode. The symptoms were initially well controlled by medication. Since 6 months, the patient started to experience atypical symptoms: he had presented disinhibited and aggressive behaviour, psychomotor instability, pyromania and self-neglect. The patient did not respond to treatment despite repeated adjustments. A frontal syndrome was suspected. Cerebral CT scan revealed an unexpected mass measuring 6.8 cm × 5.6 cm at the right frontal area, suggestive of a giant meningioma (Fig 1).ConclusionsGenerally, once diagnosed, psychiatric disorders are rarely revised. Consequently, “silent” tumours such as frontal meningiomas can be overlooked. Neuroimaging should be considered in case of new-onset psychiatric symptoms, atypical or change in clinical presentation.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Presenting Psychiatric and Neurological Symptoms and Signs of Brain Tumors before Diagnosis: A Systematic Review

“…In such cases, psychiatric symptoms may be the first and only clue. However, the diagnosis of the underlying organic brain disorder is complicated by the relative rare incidence of brain tumors, the fact that the brain is relatively silent as regard to pain [26] and that certain types of slowly growing tumors are commonly found at sites likely to cause mental changes early, such as meningiomas involving the frontal lobes [27,28] or gliomas involving the anterior midline structures [29], while neurological signs may appear later.…”

“…Although any psychiatric symptom or constellation of symptoms can occur, a number of factors such as rate of growth, location, tumor type and intracranial pressure may affect the clinical presentation in patients with brain tumors. A rapidly growing tumor will more likely cause symptoms, while slow-growing tumors, such as first grades of meningioma, allow for more adaptive changes of the brain, and therefore, are more likely to be "neurologically silent" and may present only with psychiatric symptoms without or with retarded appearance of neurological signs, as in some of our included cases [27,28,35]. However, we only observed marginally significant differences in tumor types between cases in which focal neurological symptoms appeared along with rather than after psychiatric symptoms and did not observe increased frequency of meningiomas in the second group.…”

“…For instance, meningiomas are most commonly found in the frontal region of the brain but are slower growing than gliomas. Therefore, patients with meningiomas in the frontal region may be more likely to present with psychiatric symptoms and generalized neurological symptoms [27,28,[41][42][43][44], while tumors that cause multiple lesions are more likely to cause more serious focal symptoms than single tumors [45][46][47][48][49]. Finally, the raised intracranial pressure from the tumor may increase appearance of psychiatric symptoms [50].…”

Diagnosing Late-Onset Psychosis in a Medically Complex Patient: A Diagnostic Challenge

“…The large calcification in the patient's frontal lobe, suspected to be a meningioma but requiring further imaging, is another major organic cause to consider. Meningiomas are the most common primary tumors of the brain and frontal meningiomas are known for their late onset, presenting only with psychiatric symptoms [4,5]. Mania, psychosis, and visual hallucinations are the most common manifestations and are mostly associated with right-sided lesions [6,7].…”