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Acta Neurochir (2013) 155:75–76DOI 10.1007/s00701-012-1532-9 Vestibular schwannoma presenting with psychosis Received: 8 October 2012 / Accepted: 12 October 2012 / Published online: 14 November 2012 nursing on a secure psychiatric unit. Electroencephalographic We describe an unusual case of vestibular schwannoma (EEG) examination did not reveal any epileptiform activity.
presenting with psychotic symptoms, which resolved with The lesion was removed via a retrosigmoid approach. A remnant of the tumour was left at the internal auditory A 22-year-old right-handed female presented with a 1- meatus. Histological examination demonstrated a WHO day history of abnormal behaviour. She was disorientated, grade I vestibular schwannoma. She had complete sensori- confused and claimed that the people around her were an neural hearing loss in the left ear.
illusion. Over the preceding month she had become intro- Following surgery the patient made a steady recovery.
verted, slept longer hours and stopped going out. She no- Her visual and auditory symptoms receded and she stopped ticed decreased hearing in the left ear and had been treated risperidone 6 weeks postoperatively. At outpatient review at for ear wax. On the day of presentation she reported that she 3 months she was entirely well and had applied to restart an saw unusual shapes that made her feel like she was in undergraduate course of study. Postoperative imaging ‘another world’. She shouted ‘I want God’ repeatedly and revealed encephalomalacia in the left middle cerebellar pe- then just ‘god’. At times she was unresponsive with rapid duncle, consistent with prior compression (Fig. ).
eye movements. She became calmer following sedation and This patient’s presentation is unusual for vestibular explained that her imagination frightened her and that chant- schwannoma, which commonly presents with hearing and balance loss. Peduncular hallucinosis (PH) is a syndrome There was no history of drug or alcohol abuse, and no that combines hallucinations (‘sensory perception in the previous medical or family history of note.
absence of external stimuli’) with brainstem symptoms. First Imaging showed a large tumour in the left cerebellopon- described by L’hermitte in 1922 it is associated with tine angle with associated obstructive hydrocephalus intrinsic brainstem lesions, subarachnoid haemorrhage and (Fig. ). She was commenced on dexamethasone and un- surgical trauma in the posterior fossa However there is derwent insertion of a ventriculoperitoneal shunt.
no description of a vestibular schwannoma that presented The patient’s psychosis was treated with risperidone. Further with PH and resolved with resection. It was postulated that review revealed auditory and visual hallucinations. She de- our patient’s auditory hallucinations were linked to hearing scribed ringing in the left ear interspersed with voices saying loss and tinnitus in the left ear, following a ‘disinhibition’ ‘I hate you’. She was unable to describe her visual hallucina- model ]. It is not clear that this is the case, however.
tions other than reporting they were on the ceiling. Her psy- Psychosis was not related solely to auditory symptoms, and chosis and agitation worsened, which required intensive her symptoms persisted for weeks following resection of thelesion and complete loss of hearing on the left side.
The psychosis of PH consists of visual hallucinations, associated with hypersomnolence and oculomotor distur- Department of Neurosurgery, National Hospital for bance. Causative lesions are usually located in the rostral brainstem but are also found in the thalamus and basal ganglia It is unusual for extrinsic brainstem compres- London WC1N 3BG, UKe-mail: [email protected] Fig. 1 a T2-weighted MRIshowing a left cerebellopontineangle space-occupying lesion(arrow). b T2-weighted post- operative MRI that showsencephalomalacia (arrow) inthe left middle cerebellarpeduncle Transient PH has been described secondary to extrinisic compression of the brainstem by a cystic craniopharyng-ioma []. In this case the symptoms also resolved with relief 1. David AS (1999) Auditory hallucinations: phenomenology, neuro- of the compression. Posterior compression of the brainstem psychology and neuroimaging update. Acta Psychiatr Scand 99 by medulloblastoma has also been shown to cause halluci- 2. Demetriades AK, Bhangoo RS (2009) Peduncular hallucinosis and nosis that resolved with excision Large posterior fossa cerebellar cognitive affective syndrome: Letter to the editor. Acta meningiomas have been associated with psychotic symp- toms, which resolved within days of excision ]. The 3. Dunn DW, Weisberg LA, Nadell J (1983) Peduncular hallucinations pathophysiological mechanism is unclear. There are numer- caused by brainstem compression. Neurology 33(10):1360–1361 4. Maiuri F, Iaconetta G, Sardo L, Buonamassa S (2002) Peduncular ous publications describing lesions around the limbic sys- hallucinations associated with large posterior fossa meningiomas.
tem that present with psychotic symptoms []. The role of the cerebellum in cognitive and emotional activity is less 5. Manford M, Andermann F (1998) Complex visual hallucinations.
documented, but may be implicated via influence on dopa- 6. Miyazawa T, Ito M, Yasumoto Y (2009) Peduncular hallucinosis following microvascular decompression for trigeminal neuralgia Our report confirms the possibility that compression of without direct brainstem injury: case report. Acta Neurochir the brainstem by an extra-axial posterior fossa tumour can present with psychosis. Psychiatric symptoms resolved with 7. Nadvi SS, van Dellen JR (1994) Transient peduncular hallucina- tions secondary to brain stem compression by a medulloblastoma.
8. Ouma JR (2004) Psychotic manifestations in brain tumour patients: 2 case reports from South Africa. Afr Health Sci 4(3):189–193 9. Pollak L, Klein C, Rabey JM, Schiffer J (1996) Posterior fossa Contributors RM and NK jointly conceived and wrote this report.
lesions associated with neuropsychiatric symptomatology. Int JNeurosci 87(3–4):119–126 10. Reeves RRR, Torres RAR (2003) Exacerbation of psychosis by misinterpretation of physical symptoms. South Med J 96(7):702–704

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