2026 ECNP Congress

PS04-4117

Secondary affective disorder associated with cerebral cavernomatosis: a case report

Başak Güldür — E.E. Kılıçaslan, M. Kılınç · Psychiatry, Izmir Katip Çelebi University Atatürk Training and Research Hospital, Izmir, Türkiye

2026 ECNP Congress

Introduction

Secondary mood disorders may occur as a consequence of structural brain abnormalities affecting limbic and frontotemporal networks. Cerebral cavernous malformations are vascular lesions predominantly presenting with seizures, focal neurological deficits, or haemorrhage. Nevertheless, affective and psychotic manifestations related to these lesions, particularly following haemorrhagic transformation, are often overlooked. We aimed to describe a case of secondary mania precipitated by a haemorrhagic cavernoma of the right anterior temporal lobe, and to highlight the diagnostic and therapeutic implications for neuropsychiatric practice.

Case Presentation

A 44-year-old woman presented with a ten-day history of decreased need for sleep, pressured speech, paranoid ideation, and psychomotor agitation.Her history included a depressive episode with psychotic features and a suicide attempt eight years previously, followed by a prolonged symptom free period; family psychiatric history was non-contributory and there was no history of substance misuse. Two years prior, she sustained a cerebral haemorrhage and was commenced on levetiracetam 500 mg/day for post-haemorrhagic epilepsy. Eight months before admission, fluoxetine and aripiprazole were prescribed for anxiety and irritability but discontinued after one month due to extrapyramidal symptoms. Progressive behavioural disturbance, insomnia, grandiose and paranoid ideation, and increased psychomotor activity developed in the weeks preceding admission following interpersonal conflicts.Mental status examination revealed elevated and irritable mood, accelerated speech, tangential and perseverative thought content, disorganised associations, and marked hostility (Young Mania Rating Scale [YMRS] score: 28). Routine laboratory investigations, including thyroid function, vitamin B12, and urine toxicology, were unremarkable, as was unenhanced cranial computed tomography. Cranial magnetic resonance imaging (MRI) demonstrated multiple cavernous malformations consistent with cavernomatosis, including a 2.5 cm haemorrhagic lesion in the right anterior temporal lobe; electroencephalography (EEG) was normal. Levetiracetam, an antiepileptic agent associated with neuropsychiatric adverse effects including irritability and mood dysregulation, was gradually tapered and replaced with sodium valproate 1000 mg/day. Olanzapine was initiated at 10 mg/day and reduced to 5 mg/day. After 14 days, the patient was discharged under a working diagnosis of organic manic episode with substantial clinical improvement (YMRS score: 9).

Written informed consent for anonymised publication was obtained from the patient.

Discussion and Conclusions

A remarkable relationship has been reported in the literature between right hemisphere and temporal lobe involvement and mania [1,2,3]. Previous reports suggest that psychosis and mood changes in cavernomas can be triggered especially after haemorrhagic transformation [4]. Cavernous malformations located in the temporal lobe, particularly when haemorrhagic, may disrupt limbic circuits involved in emotional regulation and behavioural control. This case suggests that systematic neurological assessment and neuroimaging may be valuable in patients with new-onset or atypical psychiatric presentations, particularly when a relevant neurological history is present. Collaboration between psychiatry, neurology, and neurosurgical disciplines is particularly valuable in such cases, because optimal management may require simultaneous attention to mood symptoms, seizure risk, and lesion-related complications.

References

  1. Satzer, D., Bond, D.J., 2016. Mania secondary to focal brain lesions: implications for understanding the functional neuroanatomy of bipolar disorder. Bipolar Disord. 18 (3), 205-220.
  2. Sokolski, K.N., Denson, T.F., 2003. Exacerbation of mania secondary to right temporal lobe astrocytoma in a bipolar patient previously stabilized on valproate. Cogn. Behav. Neurol. 16 (4), 234-238.
  3. Yetimalar, Y., Iyidogan, E., Basoglu, M., 2007. Secondary mania after pontin cavernous angioma. J. Neuropsychiatry Clin. Neurosci. 19 (3), 344-345.
  4. Majarwitz, D., Dvalishvili, M., Pastis, I., 2022. Levetiracetam-induced psychosis in the setting of intracranial cavernomas. Case Rep. Psychiatry 2022, 9114118.