Postoperative Delayed Paradoxical Depression After Uncomplicated Unruptured Intracranial Aneurysm Surgery

Garzón-Muvdi, Tomás; Yang, Wuyang; Luksik, Andrew S.; Ruiz‐Valls, Alejandro; Tamargo, Rafael J.; Caplan, Justin M.

doi:10.1016/j.wneu.2016.11.101

Cited by 5 publications

(5 citation statements)

References 28 publications

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“…Some of the differentials considered in this case were multiple sclerosis, Wernicke’s encephalopathy, tumor or metastatic disease, and spinocerebellar ataxia. The realization of the presence of an untreatable AVM reduces the patient’s quality of life, and this finding has been linked to depression and anxiety [ 14 - 16 ]. It can be beneficial to refer patients to psychiatrists or therapists at the time of diagnosis or even after treatment to provide them support and assist them to build coping skills.…”

Section: Discussionmentioning

confidence: 99%

A Rare Case of a Large, Deceitfully Quiet Brainstem Arteriovenous Malformation Presenting Only as Dizziness

Rao¹,

Giron²

2020

Cureus

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Dizziness is one of the most frequent complaints encountered in the medical practice affecting 15%-20% of adults yearly, and can be challenging to assess. Most patients use dizziness as a non-specific term, and thus suffer prejudice from the physicians’ end and can be disregarded frequently. Dizziness can be a symptom of various diseases, some with sinister pathologies. We present a case of garden-variety vertigo that unfurled to be not-so-simple, emphasizing the importance of a thorough history and physical examination again even in the era of technology. A 32-year-old male patient with no past medical history presented with dizziness, later clarified as gradually progressive vertigo for two years, with unstable gait, dysarthria, and occasional diplopia. Physical examination found sustained nystagmus that changed direction with horizontal gaze, vertical nystagmus with upward gaze, dysarthria, and a wide-based ataxic gait. CT head without contrast revealed indeterminate hypodense areas in the left midbrain, pons, and cerebellar hemisphere. MRI brain identified a 2.8 x 3.4 x 4.2 cm Spetzler-Martin grade IV brainstem arteriovenous malformation (AVM) involving the left midbrain, pons, and cerebellum. Feeders were mostly from the posterior circulation, with three intranidal aneurysms, all draining into the deep venous system. The AVM was deemed inoperable, and the patient was treated with onyx embolization for two/three feeding vessel aneurysms. After treatment, the symptoms persisted, and the patient was diagnosed with major depressive disorder (MDD) six months after diagnosis, and was admitted a year later with suicidal ideation and substance use disorder. Brain AVMs are rare clinical entities that present in 0.1% of the population, mostly presenting as intracranial bleeds. When they do rarely present with isolated focal neurologic deficits, it has been attributed to a vascular steal phenomenon, hemorrhage, or a mass effect. The isolated findings of vertigo and dysarthria are highly non-specific; with such presentation, clinicians should consider etiologies under the realm of vertigo of central origin. An untreatable AVM reduces patients’ quality of life and has been linked to depression and anxiety, and thus patients may benefit from psychosocial therapy. Although preventing intracranial hemorrhage (ICH) is the primary concern with brain AVMs, the rest of the patient’s profile should not be forgotten.

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Section: Discussionmentioning

confidence: 99%

A Rare Case of a Large, Deceitfully Quiet Brainstem Arteriovenous Malformation Presenting Only as Dizziness

Rao¹,

Giron²

2020

Cureus

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“…Endovascular coiling and surgical clipping of intracranial aneurysms have different risks and benefits so that individual treatment suggestions based on multidisciplinary board decisions have to be made considering both the clinical condition and comorbidities of the patient and morphological properties of the aneurysm [4,20]. Besides immediate focal neurologic deficits associated with intracranial aneurysms and its therapy, both neurocognitive deficits and affective disorders have been described as potential sequelae [2,3,6,[21][22][23][24]. For middle cerebral artery aneurysms, it was shown that both clipping and coiling are methods with relatively low rates of mortality and morbidity with similar percentages of favourable clinical outcome [20].…”

Section: Discussionmentioning

confidence: 99%

“…However, some studies have indicated that patients undergoing surgery are more likely to suffer from impaired cognition and from neuropsychiatric symptoms such as anxiety and depression [5]. A recent study identified postoperative delayed paradoxical depression following surgical repair of unruptured intracranial aneurysms in around 10% of patients, which may be comparable to mild posttraumatic stress disorder and resulted in a reduced rate of patients fully returning to their activities of daily life [6]. There are previous reports hinting towards atrophy of parts of the limbic system, namely the hippocampus in patients after surgical aneurysm repair [7][8][9][10].…”

Section: Introductionmentioning

confidence: 99%

Hippocampus subfield volumetry after microsurgical or endovascular treatment of intracranial aneurysms—an explorative study

et al. 2019

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Background: To study hippocampus subfield volumes in patients after microsurgical clipping (MC) and/or endovascular coiling (EC) of intracranial aneurysms. Methods: Hippocampus subfield volumetry was performed using FreeSurfer v6.0 in 51 patients (35 females, mean age 54.9 ± 11.9 years, range 24-78 years). Visual inspection of image and segmentation quality was performed prior to statistical analyses. Multiple regression analysis, controlled for age, sex, and side of treatment, was used to assess the impact of prior MC and history of subarachnoid haemorrhage (SAH) on hippocampus subfield volumes (cornu ammonis (CA)-2/3, CA-4, subiculum). Partial correlation analyses were used to assess effect of multiple treatments on hippocampus subfield volumes. Results: Prior MC was significantly associated with lower hippocampal subfield volumes in MC patients for right and left CA-2/3 (β =-22.32 [-40.18,-4.45]; p = 0.016 and β =-20.03 [-39.38,-0.68]; p = 0.043) and right CA-4 (β =-17.00 [-33.86, 0.12]; p = 0.048). History of SAH was not significantly associated with hippocampal subfield volumes. We observed a higher disease burden in the MC cohort. The number of aneurysms correlated with right-sided hippocampal subfield volumes while the number of treatment interventions did not. Conclusion: In this explorative study, we found that history of MC was significantly associated with lower volumes in distinct hippocampal subfields, which may be a consequence of a more extensive treatment. This could indicate specific atrophy of CA-2/3 after MC and should motivate hippocampal subfield assessment in larger cohorts.

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“…There is also no single opinion on how to regard these surgical interventions as a diagnostic intervention or a mistake. The diagnosis of an intracranial aneurysm leads to psychological problems, including anxiety, stress, and depression 28, 29 . In some cases, after a radiological diagnosis is established, patients limit themselves in physical activity, work, hobbies, sex, etc.…”

Section: Unjusti Ed Surgical Interventionsmentioning

confidence: 99%

Diagnosis and management of false-positive intracranial aneurysms: a systematic review and illustrative cases.

Konovalov,

Gadzhiagaev,

Artemyev

et al. 2024

Preprint

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Purpose: To systematically review existing data on a false-positive diagnosis of an intracranial aneurysms and associated risks. Methods: A literature search in two databases (PubMed and Web of Science) using keywords "mimicking an intracranial aneurysm", "presenting as an intracranial aneurysm", "false positive intracranial aneurysms," and "neurosurgery” was conducted. We also presented two illustrative cases of patients operated on due to false diagnosis. Results: A total of 243 papers were found in the initial search in two databases. Sixteenpapers (including 20 patients) were included in the final analysis. There were 10 women and 10 men. The most common location of false-positive aneurysms was the bifurcation of the middle cerebral artery. In the posterior circulation, false-positive aneurysms were identified either on the basilar artery, or at the vertebro-basilar junction. Artery occlusion with vascular stump formation was the most common cause of false intracranial aneurysm diagnosis (55.0%). Most often, this variant was detected at the MCA bifurcation (63.6%). Other causes included infundibular widening, fenestration, arterial dissection, contrast extravasation, venous varix. Conclusion: Surgical interventions for false-positive aneurysms are an underestimated problem in vascular neurosurgery. Despite extremely rare published clinical observations, the actual frequency of erroneous surgical interventions for false-positive aneurysms is unknown.

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Postoperative Delayed Paradoxical Depression After Uncomplicated Unruptured Intracranial Aneurysm Surgery

Cited by 5 publications

References 28 publications

A Rare Case of a Large, Deceitfully Quiet Brainstem Arteriovenous Malformation Presenting Only as Dizziness

A Rare Case of a Large, Deceitfully Quiet Brainstem Arteriovenous Malformation Presenting Only as Dizziness

Hippocampus subfield volumetry after microsurgical or endovascular treatment of intracranial aneurysms—an explorative study

Diagnosis and management of false-positive intracranial aneurysms: a systematic review and illustrative cases.

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