Conversion Disorder after Surgery in a Brain Tumour Patient

Abstract

We describe a case of conversion disorder in a young lady who had just been operated on for a glioma. CASE REPORTA 31-year-old lady presented two years ago with seizures manifesting as jerking of her right arm and leg. Neurological examination revealed no focal deficits. Brain imaging revealed the presence of a small lesion in her left mesial posterior frontal lobe, just anterior to the motor strip ( Figure 1). The appearance was compatible with a low grade glioma. There was no perilesional edema, enhancement, or mass effect. She was treated with anti-epileptic medications with good control of her seizures. The brain tumour was managed conservatively with regular clinical and imaging follow-up.The patient remained well and asymptomatic, but her most recent magnetic resonance imaging (MRI) showed an increase in the size of the tumour (Figure 2). Awake craniotomy with cortical mapping for tumour excision was recommended and performed. Mapping over the motor cortex was positive, in that the right leg became weak when that area of cortex was stimulated. Corticotomy was made anterior to the motor cortex and aggressive subtotal resection of the tumour was achieved leaving behind a small cuff posteriorly, adjacent to the motor strip. As is our usual protocol, the patient was sedated after the mapping was performed, precluding continuous testing during tumour resection.Immediately post-operatively, the patient could not move her right leg. Motor examination was 5/5 for all limbs except for the right lower extremity which was 0/5 in all muscle groups. There was no sensory deficit. The patient had hyperreflexia bilaterally but no Babinski. She was noted to have a positive Hoover's sign, with palpable downward force of the right leg while raising the unaffected left limb. The patient's pattern of leg weakness exhibited some inconsistencies: despite a motor strength of 0/5, she was able to bear weight on her right leg and walk with support within two days. In addition, throughout the patient's hospital stay, she showed little concern about and seemed to be indifferent to her condition.Various investigations were carried out. Computed tomogram four hours after surgery and MRI 40 hours post-operatively both revealed the resection cavity in the left posterior frontal area anterior to the precentral gyrus, and a small amount of residual tumour between the surgical site and the motor strip (Figure 3). There was no hemorrhage, increase in the perilesional edema, or mass effect. Neurophysiologic studies such as nerve conduction velocity, electromyography, and motor evoked potentials done two weeks after surgery confirmed no organic brain pathology. BRIEF COMMUNICATIONSSteroids were started but there was no improvement in the patient's leg weakness. Our considerations during this time were supplementary motor cortex syndrome versus conversion disorder. Upon probing further into the patient's history, it was found that she is married with a three-year-old son. She is a high school graduate and is unemployed. She has no previous med...

Postoperative Conversion Disorder in Elderly Oral Cancer Patient

“…The risk factors for this disease include female sex, lower educational level, physical or sexual abuse, emotional trauma, pre-existing psychopathology, and a history of serious medical illness 2) . Furthermore, Khu et al noted that the etiology for conversion disorder was unclear, but suggested that it was caused by severe stress, emotional conflict, or an associated psychiatric disorder 5) . Nakagawa et al speculated that conversion disorder developed due to lack of communication and excessive stress 8) .…”

Decision Making, Bias, and Low Grade Glioma

“…Surgical resection of WHO I gliomas such as pilocytic astrocytoma, is clearly beneficial, however the value of removal of more infiltrative gliomas is not so clear and remains the subject of controversy 5,6 . Early resection may cause neurological impairment [5][6][7] , when symptoms can often be controlled with medications until tumor progression is documented. Physicians' and surgeons' opinions on management range from early surgical resection to observation until surgery (and adjuvant treatment) becomes necessary.…”