Karl Bechter

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Acta Clin Croat,  Vol. 50,  (Suppl) No. 2,  2011 35Acta Clin Croat (Suppl. 2) 2011; 4th international epilepsy symposium in Pula – how to start seizure treatmentMAIN THEME:COGNITIVE PSYCHIATRY, PERSONALITY CHANGESON A POSSIBLE CAUSAL RELATIONSHIP BETWEEN ARACHNOID CYSTS AND PERSONALITY DISORDERSKarl BechterClinic for Psychiatry and Psychotherapy II, Ulm University, Department Psychotherapeutic Medicine and Psychosomatics, Bezirkskrankenhaus Günzburga Ulm University, Dept Psychiatry II, 89312 Günzburgb Ulm University, Dept Neurosurgery, 89312 GünzburgPresent view on the causal relationship between arachnoid cysts and neuropsychiatric syndromesPrevalence of arachnoid cysts (AC) is high in psy-chiatric patients (about doubled compared to normal controls), suggesting a possible causal relationship between AC and certain psychiatric disorders. Neu-rosurgery of AC is recommended when focal neuro-logical symptoms or signs of increased intracranial pressure are present.Th e question whether arachnoid cysts, most preva-lent in frontotemporal area and fossa posterior, should be treated by neurosurgery is often diffi  cult to an-swer. For example, it remained questionable, whether symptoms of headaches or epileptic seizures really im-prove, though in some patients did. Th ere is no ques-tion, that in so-called symptomatic arachnoid cysts (that is in cases showing focal neurological symptoms or signs of increased intracranial pressure) AC should be treated and are usually successfully treated [1]: 2/3 of such cases were symptomfree after neurosurgery, the overall improvement correlated with cyst volume reduction. In cases of childhood psychiatric disorders, all cases with attention defi cit hyperactivity disorder (ADHD) associated with temporal ACs, no surgical treatment was recommended [2]. On the other hand [3], when treating a number of patients (n=55, age 16 – 70 years) presenting supratentorial cysts (temporal 43, frontal 11, parietal 1), a considerable number of patients reported relief from symptoms (29), or re-duced complaints (20), few were unchanged (3), but few worsened (3). Again, more volume reduction correlated with better improvement. Th e symptoms before neurosurgery were headache (48), dizziness- nausea (9) and epilepsy (8). In parallel, cognition was tested before and after neurosurgery by various tests: overall, the group of persons treated by neurosurgery improved whereas not the control group (speed high-er, less errors) and improvement correlated with more cyst volume reduction.Regarding treatment of arachnoid cysts in patients with pure psychiatric syndromes the question is how-ever unclear, and present treatment recommendations do not include neurosurgery of such psychiatric syn-dromes [1]. Nevertheless it was shown, that psychi-atric patients with severe psychiatric disorders may indeed improve with AC neurosurgery: Clavell et al [4] reported 2 cases (67 years old male and 69 years old female) in whom dementia was associated with frontal or posterior fossa AC. After AC neurosurgery both cases improved. Heidrich et al [5] reported a 52 year old female, suff ering from instable mood and pseudologia fantastica and having acted as a fi resetter, however neurosurgery of posterior fossa AC showed a questionable result. Russo et al [6] reported a case of a 43 year old male with occipital headache and nausea associated with AC in the posterior fossa, which im-proved spontaneously, improvement correlating with Acta Clin Croat (Suppl. 2) 2011; 4th international epilepsy symposium in Pula – how to start seizure treatment36 Acta Clin Croat,  Vol. 50,  (Suppl) No. 2,  2011volume reduction of the AC after 2 months - Kuhnley et al [7] reported a pure psychiatric presentation in a 23 year old male who developed over 18 months a progressive loss of mental functions ending up in a schizophreniform disorder, which completely remit-ted after neurosurgery of a left temporal AC. Licina et al [8] reported a chronic remitting-relapsing case of depression and stupor, at the timepoint of report suf-fering over nearly 20 years at age 45 years, the phases of stupor beeing associated with variant cyst sizes of a left frontotemporal AC. Th is case was not proposed to neurosurgery instead treated by psychopharmaca with limited success. Pure psychiatric syndromes in AC suff erersTh e question of a possible causal relationship be-tween ACs in psychiatric syndromes appears to be more diffi  cult to answer in cases with pure psychiat-ric syndromes not presenting focal neurological sign, epilepsy or severe headache. It has been found, that in a large sample (n=13 297) of patients investigated by brain imaging in a large university hospital (Würz-burg) the prevalence of arachnoid cysts was 3,2 ‰ (n=43) [10]): the share of psychiatric patients in the whole sample was 8%, but in the AC suff erers 19%. So the prevelance of arachnoid cysts in psychiatric patients was considerably increased. When looking at the cyst size and age it was shown that apparently the cyst size in a subgroup was increasing with age [11].Own recent studiesChance observations of psychiatric cases suff ering from AC detected by routine brain imaging (CCT or MRI) initiated by the clinical in-depth evaluation of the single cases: specifi c course characteristics or comorbid symptoms, suggested a possible causal re-lationship between AC and the psychiatric disorder in some individual cases. But to diff erentiate non-pathogenic vs. possible pathogenic ACs was diffi  cult. Assessment of brain imaging and psychological test-ing was repeated before and after AC neurosurgery. In two cases of slow onset personality disorder, both persons suff ering from so-called asymptomatic AC according to the present recommendations, we even-tually performed AC neurosurgery beyond established rules [9]. Pre-post neurosurgery comparison and long-term course suggested that in both cases the ACs were pathogenic regarding psychiatric symptoms. So, our cases were re-diagnosed as having suff ered from ‘mi-nor’ organic personality disorders before AC neuro-surgery. OutlookIn a preliminary evaluation of individual AC suf-ferers, it appears usually diff ucult to decide whether or not neurosurgery of an AC should be recommended in patients with pure psychiatric syndromes (without neurological symptoms). Neverthelesss, some pure psychiatric syndromes apparently can be caused by arachnoid cysts. Criteria to recommend or not neu-rosurgery in the single case remain however open. On the other hand, when refusing neurosurgery as a treatment option, one may miss a chance for consider-able and rapid improvement if not full remission of severe psychiatric syndromes. More studies including long term observations and careful psychological test-ing before and after neurosurgery are required. Th e established rules for AC neurosurgery should be re-considered in therapy resistant psychiatric disorders observed in AC suff erers, though a non-causal asso-ciation of ACs with personality disorder can hardly be excluded before neurosurgery. Th e risks of AC-neuro-surgery in the individual case have to be balanced to expected benefi ts, a diffi  cult undertaken.References1. Kandenwein, J.A., H.P. Richter, and W. Borm, Surgical therapy of symptomatic arachnoid cysts - an outcome analy-sis. Acta Neurochir (Wien), 2004. 146(12): p. 1317-22; dis-cussion 1322.2. Millichap, J.G., Temporal lobe arachnoid cyst-attention defi cit disorder syndrome: role of the electroencephalogram in diagnosis. Neurology, 1997. 48(5): p. 1435-9.3. Raeder, M.B., C.A. Helland, K. Hugdahl, and K. Wester, Arachnoid cysts cause cognitive defi cits that im-prove after surgery. Neurology, 2005. 64(1): p. 160-2.4. Clavel, M., F.G. Taborga, and I. Onzain, Arachnoid cysts as a cause of dementia in the elderly. Acta Neurochir (Wien), 1985. 78(1-2): p. 28-32.5. Heidrich, A., A. Schmidtke, K.P. Lesch, E. Hofmann, and T. Becker, Cerebellar arachnoid cyst in a fi resetter: the weight of organic lesions in arson. J Psychiatry Neurosci, 1996. 21(3): p. 202-6.6. Russo, N., M. Domenicucci, M.R. Beccaglia, and A. San-toro, Spontaneous reduction of intracranial arachnoid cysts: a complete review. Br J Neurosurg, 2008. 22(5): p. 626-9.Acta Clin Croat,  Vol. 50,  (Suppl) No. 2,  2011 37Acta Clin Croat (Suppl. 2) 2011; 4th international epilepsy symposium in Pula – how to start seizure treatment7. Kuhnley, E.J., D.H. White, and A.L. Granoff, Psychiat-ric presentation of an arachnoid cyst. J Clin Psychiatry, 1981. 42(4): p. 167-8.8. Licina, M., S. Vitorovic, and I. Velikonja, Frontotempo-ral arachnoid cyst connected to relapsing stupor. J Neuropsy-chiatry Clin Neurosci, 2004. 16(1): p. 120.9. Bechter, K., R. Wittek, K. Seitz, and G. Antoniadis, Personality disorders improved after arachnoid cyst neuro-surgery, then rediagnosed as ‘minor’ organic personality dis-orders. Psychiatry Res, 2010. 184(3): p. 196-200.10. Becker, T., M. Lanczik, E. Hofmann, T. Müller, M. Warmuth-Metz, J. Fritze, and B. Schuknecht, Er-höhte Prävalenz von Arachnoidalzysten bei psychiatrischen Patienten: Eine retrospective CT- und MR-Untersuchung. . Klin Neuroradiol, 1991(1): p. 154-160.11. Becker, T., M. Wagner, E. Hofmann, M. Warmuth-Metz, and M. Nadjmi, Do arachnoid cysts grow? A retro-spective CT volumetric study. Neuroradiology, 1991. 33(4): p. 341-5.

Cognitive Psychiatry, Personality Changes on a Possible Causal Relationship Between Arachnoid Cysts and Personality Disorders

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