This report presents the course of diagnostic examinations and treatment of a 20-year-old man with bipolar affective disorder for which an organic basis was demonstrated. Computed tomography of the brain revealed an arachnoid cyst that was surgically treated. The patient underwent both psychiatric and neurosurgical treatment. After two-year follow-up and medicamentous treatment prescribed, the patient was symptom-free requiring no psychopharmacotherapy for the next 5.5 years. His overall life functioning is normal, with no signs of disease.Ovaj prikaz predstavlja tijek dijagnostičkih pregleda i liječenja 20-godišnjeg muškarca koji boluje od bipolarnog afektivnog poremećaja, a za kojega je i prikazana organska podloga same bolesti. Kompjutorska tomografija mozga otkrila je kod bolesnika arahnoidnu cistu koja je kirurški liječena. Bolesnik je podvrgnut i psihijatrijskom i neurokirurškom liječenju. Nakon dvije godine kontinuiranog praćenja stanja bolesnika uz primjenu propisane medikamentne terapije bolesnik više nije pokazivao simptome bipolarnog afektivnog poremećaja i nije bila potrebna daljnja primjena psihofarmaka sljedećih 5,5 godina. Njegova ukupna kvaliteta života je zadovoljavajuća, a bolesnik normalno funkcionira u svakodnevnom životu bez ikakvih znakova bolesti

Branka Vidrih

Dalibor Karlović

Marija Bošnjak Pašić

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Acta Clin Croat,  Vol. 51,  No. 4,  2012 655Acta Clin Croat 2012; 51:655-659 Case ReportARACHNOID CYST AS THE CAUSE OF BIPOLAR AFFECTIVE DISORDER: CASE REPORT Branka Vidrih, Dalibor Karlović and Marija Bošnjak PašićUniversity Department of Psychiatry, Sestre milosrdnice University Hospital Center, Zagreb, CroatiaSUMMARY – This report presents the course of diagnostic examinations and treatment of a 20-year-old man with bipolar affective disorder for which an organic basis was demonstrated. Com-puted tomography of the brain revealed an arachnoid cyst that was surgically treated. The patient underwent both psychiatric and neurosurgical treatment. After two-year follow-up and medica-mentous treatment prescribed, the patient was symptom-free requiring no psychopharmacotherapy for the next 5.5 years. His overall life functioning is normal, with no signs of disease.  Key words: Bipolar affective disorder, organic etiology; Computed tomography of the brain; Diagnosis; TreatmentCorrespondence to: Branka Vidrih, MD, PhD, University Depar-tment of Psychiatry, Sestre milosrdnice University Hospital Cen-ter, Vinogradska c. 29, HR-10000 Zagreb, CroatiaE-mail: branka.vidrih@zg.t-com.hrReceived December 27, 2011, accepted September 3, 2012IntroductionBipolar affective disorder is a category of mood dis-orders of a multifactor genesis. Pathologic mood and related vegetative and psychomotor symptoms make the key clinical features. The change of affect, togeth-er with the change in instinct dynamism, will and opinion, generally lead to a significant and conspicu-ous change of behavior in comparison to the period before the illness1. The manic phase of the disorder, especially when concurring with psychotic symptoms, is often not diagnosed as the affective mood disorder. Bipolar affective disorder is a mood disorder in which depressive phases occur with typical depression symp-toms which are not different from unipolar depression, when only depression occurs. Hypomania or mania is a phase of elevated mood occurring in patients with bipolar affective disorder. Phases of elevated mood are characterized by hyperactivity, higher level of energy, reduced need for sleep, and other symptoms. In ma-nia, the behavior is more conspicuously changed. Per-sons suffering from depression are at a risk of suicide, while in hypomania/mania there is a possibility that the person puts himself in a series of embarrassing situations relating to the person’s finances, job, family relations, reputation, and the like. It is necessary to differentiate between depression and depression oc-curring in bipolar disorder. Although their clinical characteristics are the same, the treatment of bipolar depression differs2,3. Bipolar affective disorder has a greater incidence than schizophrenia. The prevalence ranges from 1% to 3%. This mood disorder appears less frequently than depression and makes up to 10%-20% of all mood disorders. Depression is most frequently diagnosed, while the hypomanic phase relatively often remains undetected. Unfortunately, too often the disorder is undiagnosed and untreated in primary health care (40%), especially in younger and older patients because of comorbidity and age specifics. A large number of patients do not seek any psychiatric help, although the suicide rate with this disorder is very high (15%-20%). In 90% of all cases, there are multiple recurrences, with unsatisfactory improvement in almost half of the total number of patients4-6. The etiological factors of bipolar affective disorder are multiple, including neurochemical, genetic, psy-chosocial and organic factors7. 656 Acta Clin Croat,  Vol. 51,   No. 4,  2012Branka Vidrih et al. Arachnoid cyst as the cause of bipolar affective disorder: case report Concerning the organic basis of bipolar affective disorder, it is well known that the following condi-tions increase the risk of a mental disorder: epilepsy, limbic encephalitis, Huntington’s disease, head trau-ma, brain neoplasm, extracranial neoplasm with dis-tant effects on the central nervous system (particularly pancreatic cancer), cerebrovascular diseases, lesions or malformations, lupus erythematosus and other collag-enoses, endocrine diseases (especially hypothyroidism and hyperthyroidism, Cushing’s syndrome), tropical infective and parasitic diseases (e.g., trypanosomia-sis), and toxic effects of nonpsychotropic medications (propranolol, levodopa, methyldopa, steroids, antihy-pertensives, antimalarials)8-10. For a clinical syndrome to be construed as being caused by one of the above mentioned organic damages there has to be proof of a brain disease, damage or dysfunction, a systemic dis-ease known to concur with one of the mentioned syn-dromes. There also needs to be a time relation between the disease development and the onset of a mental disorder. It is necessary to prove recovery from dis-order after elimination of or recovery from the cause. The absence of an alternative cause of mental disorder also needs to be established (for instance, a burdened family medical history or precipitating stress)11. The organic origin of bipolar affective disorder has been presented by a number of authors in their case reports12-16.The aim of this case report of a patient with arach-noid cyst and organic bipolar affective disorder is to present our experience and approach to the psychotic condition in terms of diagnosis and treatment, as well as patient follow-up. Case Report A young man at the age of 20 was urgently hos-pitalized for acute psychotic condition. A few days before, he had been admitted to the psychiatric ward of a hospital in the town where he did his regular military service, where he was administered high dos-ages of haloperidol (30 mg daily), so that his clinical manifestation, along with the dominant signs of psy-chomotor agitation, elevated mood, racing thoughts, disorganized behavior, elevated instinct dynamisms, also showed pronounced extrapyramidal symptoms. From his medical history, we could learn that he was born as the second of four children in a family with no previous psychiatric disorder or disease history. The pregnancy, early growth and development were nor-mal. He finished his schooling normally, with good results. He was hospitalized during his regular military service term. The family provided heterohistory data on his occasional cannabis consumption over the past three years, so his mental state was seen as symptom-atic for cannabis abuse. However, we also found that he had been showing behavior changes and mood swings in the past few years: for months he had been in bad mood, had no energy, stayed mostly in bed and slept a lot. In subsequent medical history data the patient provided, he rationalized cannabis and alcohol intake, explaining that he did not feel well, that he was sad, depressed, often thinking how life was meaningless, thought of death, and that, after smoking marihuana or drinking alcohol his mental state would be better. About three weeks before he was first admitted, he was at home on a regular free weekend from the military, at which time his behavior was very conspicuous, ex-hibiting rapid talking, hyperactivity, an extremely good mood, he was exhilarated, full of plans, he did not sleep, none of the family members could follow his rac-ing thoughts and behavior, and at that time, the family associated his condition with alcohol intake. During his hospital stay, after detoxification and al-leviating the side effects of haloperidol, he was started on antipsychotic treatment with olanzapine and the mood stabilizer carbamazepine in order to alleviate acute psychotic symptoms. Indicated examinations re-vealed changes in his electroencephalogram (EEG): left frontal temporal dysrhythmic irritation changes. Computed tomography (CT) scan showed an arach-noid cyst located in the middle cranial fossa on the left, stretching cranially along the fissure of Sylvius fron-tally about 7-8 cm, and with a wide basis adhering to the bone and discretely exerting pressure on the frontal part of the left temporal lobe, the frontal lobe and the insular cortex with mild compression and dislocation of the left lateral ventricle medially, and dislocation of the left middle cerebral artery flow, laterolaterally by about 5 cm and with an anteroposterior diameter of 5 cm.  The diagnosis was established on the basis of clini-cal evidence, in compliance with the DSM-IV and ICD-10 classification criteria, as well as psychological examination and organic examination results: EEG and CT brain scan. Acta Clin Croat,  Vol. 51,  No. 4,  2012 657Branka Vidrih et al. Arachnoid cyst as the cause of bipolar affective disorder: case report After reducing the acute psychotic state of a manic character, in agreement with neurosurgeons, we did the indicated surgery, cystoperitoneostomy. The pa-tient was subsequently discharged from the hospital in good physical and mental condition. After his inpa-tient stay was over, the patient received regular follow-ups and took the prescribed treatment. For months he complained of headaches and dizziness, he would rest for most part of the day, lying in bed because it made him feel physically better. Five months later, he fell into depressive state and attempted suicide by overdose drug ingestion. He was readmitted to the hospital, this time for depressive decompensation and a high risk of suicide. Along with his previous treat-ment, because of dominant symptoms of depression, we introduced the antidepressant clomipramine. For four months, the patient underwent inpatient care treatment, during which time he had two very seri-ous suicide attempts: by slashing his cubital veins on both forearms while he was out on a pass and by drug intoxication and hypothermia, when he left the ward on his own will and, heavily intoxicated from alcohol, fell asleep in the snow. Upon agreement of the en-tire medical team and with parental consent, he was discharged in a relatively good mental and physical condition. In the months that followed, he regularly took all his medications as prescribed, he followed the instructions he was given, he functioned increas-ingly better and with better quality. The follow-ups showed no signs of disease relapse; on the contrary, with time his condition improved. So much better, actually, that he started working only three months after being discharged from hospital. In parallel to psychiatric follow-ups, he also received neurosurgi-cal follow-ups, which showed normal postoperative results. The psychiatric medications prescribed were gradually reduced as months went by, and after two years, due to the lack of any signs of psychopathology, they were discontinued. Before psychopharmaco-therapy was discontinued, we ran psychological tests, which revealed a person of solid cognitive abilities and a balanced personality profile. In the meantime, the patient has changed jobs, makes his own living, has had several emotional relationships and an adequate social life for his age. A year ago, the family suffered a trauma of the mother’s sudden death, with which the patient managed to cope without the need for any psychiatric support. His current state is normal; his mental examination results show no signs of pathol-ogy. Five and a half years have elapsed since he last took any medication, and the last clinical follow-up in spring 2010 showed no signs of the disease. DiscussionIn psychiatric clinical practice, we daily encounter patients who show psychotic symptoms, being either recurrent or first episodes of the disease. In case of first hospitalization, clinical evaluation and psycho-logical tests are always run along with a series of other diagnostic procedures such as laboratory tests, EEG and CT brain scan. In this particular case, the pa-tient was hospitalized at our department for the first time, and although we had clear clinical evidence, the symptoms that satisfied the criteria for establish-ing the diagnosis of bipolar affective disorder accord-ing to DSM-IV and ICD-10, medical history data, heterohistory data of his premorbid functioning and cannabis and alcohol abuse, we followed our standard clinical practice. As soon as we got the EEG results, which indicated a possible organic cause, in view of the left frontal temporal dysrhythmic changes, CT brain scan was indicated as soon as possible. After CT scan, it was clear that there possibly was an organic basis of the disorder. As we were dealing with manic decompensation with an abundance of glaring symp-toms, we needed to detoxify the patient first because of pronounced extrapyramidal side effects, and then sta-bilize him by administering appropriate medications. We chose olanzapine and carbamazepine; olanzapine for its design and the patient’s prior hypersensitivity to haloperidol, and carbamazepine because of organic test results, possible epileptic seizures (not only be-cause of the arachnoid cyst, but also the administra-tion of antipsychotics)17,18. From the neurosurgical as-pect, surgery was indicated in order to drain the cyst and thus reduce the intracranial pressure. After re-ducing the acute state and prepping the patient, neu-rosurgery was performed and postoperative recovery was normal. Then came psychiatric and neurosurgical follow-ups, and re-hospitalization due to depressive decompensation. His state was complicated by suicide attempts. However, with administration of appropri-ate psychopharmacotherapy, which included olanzap-658 Acta Clin Croat,  Vol. 51,   No. 4,  2012Branka Vidrih et al. Arachnoid cyst as the cause of bipolar affective disorder: case report ine, carbamazepine and clomipramine, after several months of inpatient care, the patient was discharged in good mental and physical state. On subsequent fol-low-ups, his medications were adjusted to his mental state. After two years, treatment was discontinued. It has now been 5.5 years since the patient took any medications. His mental functioning is normal.We believe that this patient’s bipolar affective disorder, which presented itself in a wide-ranging symptomatology of manic and depressive phases, had an organic basis. We draw this conclusion on the fol-lowing facts: for a clinical syndrome to be considered as being caused by organic damage there should be proof of a brain disease that is known to concur with one of the mentioned syndromes. In our case, the existence of an arachnoid cyst was undoubtedly con-firmed. There also needs to be time relation between the disease development and the onset of mental dis-order. As the arachnoid cyst in our patient was taken to be congenital because there were no data on head trauma or any other brain disease experienced during his life, it is our opinion that the mentioned cyst must have grown over time, which ultimately led to pres-suring certain brain structures and to mental disorder. It was necessary to prove recovery from the disorder after elimination of or recovery from the cause. This criterion was also met because after surgery, although it was followed by a depressive phase, the patient did fully recover both mentally and physically and is able to function in all segments of life. Apart from that, the absence of an alternative cause of mental disorder should also be proven (for instance, a burdened family medical history or precipitating stress). In the detailed data provided by members of the family we found no hereditary cause or a precipitating stress event. In conclusion, based on several years of the pa-tient’s follow-up, we believe that the patient’s mood disorder, the bipolar affective disorder, was of an or-ganic genesis. References1. BALDASSANO CF. Assessment tools for screening and monitoring bipolar disorder. Bipolar    Disord 2005;7:8-15.2. 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Evidence based guidelines for treating bipolar disorder: recommendations from the BAP. J Psychop-harmacol 2003;17:149-73.  8. KUHNLEY EJ, WHITE DH, GRANDOFF AL. Psy-chiatric presentation of an arachnoid cyst. J Clin Psychiatry 1980;42:167-9.  9. SWAYZE VW 2nd, ANDREASEN NC, ALLIGER RJ, EHRHARDT JC, YUH WT. Structural brain abnormali-ties in bipolar affective disorder. Ventricular enlargement and focal signal hyperintensities. Arch Gen Psychiatry 1990;47:1054-9.10. BARKOVICH AJ, CHUANG SH, NORMAN D. Mag-netic resonance of neuronal migration anomalies. AJR Am J Roentgenol 1988;150:179-87.11. MKB-10 Klasifikacija mentalnih poremećaja i poremećaja ponašanja, deseta revizija. Zagreb: Medicinska naklada, 1999. (in Croatian)12. CONNOR SE, NG V, McDONALD C, SCHULZE K, MORGAN K, DAZZAN P, MURRAY RM. A study of hippocampal shape anomaly in schizophrenia and in families multiply affected by schizophrenia or bipolar disorder. Neu-roradiology 2004;46:523-34.13. KATAPATAPU RK. Aripiprazole treatment of psychosis in a child with posterior fossa retrocerebellar arachnoid cyst. J Child Adolesc Psychopharmacol 2009;19:321-5.14. AGZARIAN MJ, CHRYSSIDIS S, DAVIES RP, POZZA CH. Use of routine computed tomography brain scanning of psychiatry patients. Australas Radiol 2006;50:27-8.15. CRNKOVIć D, BULJAN D, KARLOVIć D, KRMEK M. Connection between inflammatory markers, antidepres-sants and depression. Acta Clin Croat 2012;51:25-33.16. VIDRIH B, KARLOVIć D, PASIć MB, UREMOVIć M, MUFIć AK, MATOSIć A. A review of the psychoneu-roimmunologic concepts on the etiology of depressive disor-ders. Acta Clin Croat 2012;51:403-9.17. BAUER MS, MITCHNER L. What is a “mood stabilizer”? An evidence-based response. Am J Psychiatry 2004;161:3-18.18. HENRY C. Antidepressant-induced mania in bipolar patients: identification of risk factors. J Clin Psychiatry 2001;62:249-55.Acta Clin Croat,  Vol. 51,  No. 4,  2012 659Branka Vidrih et al. Arachnoid cyst as the cause of bipolar affective disorder: case report SažetakARAHNOIDNA CISTA KAO UZROK BIPOLARNOG AFEKTIVNOG POREMEćAJA: PRIKAZ SLUČAJAB. Vidrih, D. Karlović i M. Bošnjak PašićOvaj prikaz predstavlja tijek dijagnostičkih pregleda i liječenja 20-godišnjeg muškarca koji boluje od  bipolarnog afek-tivnog poremećaja, a za kojega je i prikazana organska podloga same bolesti. Kompjutorska tomografija mozga otkrila je kod bolesnika arahnoidnu cistu koja je kirurški liječena. Bolesnik je podvrgnut i psihijatrijskom i neurokirurškom liječe-nju. Nakon dvije godine kontinuiranog praćenja stanja bolesnika uz primjenu propisane medikamentne terapije bolesnik više nije pokazivao simptome bipolarnog afektivnog poremećaja i nije bila potrebna daljnja primjena psihofarmaka slije-dećih 5,5 godina. Njegova ukupna kvaliteta života je zadovoljavajuća, a bolesnik normalno funkcionira u svakodnevnom životu bez ikakvih znakova bolesti.Ključne riječi: Bipolarni afektivni poremećaj, organska etiologija; Kompjutorizirana tomografija mozga; Dijagnostika; Lije-čenje

Arahnoidna cista kao uzrok bipolarnog afektivnog poremećaja: prikaz slučaja

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