The Role of Neuropsychiatry in Meningioma Care: A New Perspective

David Silbersweig M.D.Chairman, Department of Psychiatry

Chairman, Institute for the NeurosciencesBrigham and Women’s Hospital

Stanley Cobb Professor of PsychiatryHarvard Medical School

Case Presentation• I present to you a case of woman in her 60s

who had a life long history of depression treated with antidepressants and psychotherapy

• In 2002, her depression significantly worsened prompting her first suicide attempt

• Her psychiatrist requested a neurologic consultation and brain MRI to evaluate for neurologic causes of her mood decompensation Newsweek, 2007

Case Presentation• A small, 1cm meniongioma was detected but

was thought to be asymptomatic and of little initial concern

• Unfortunately, her condition further declined including two additional suicide attempts

• By 2006, she made her fourth suicide attempt and was now additionally experiencing weakness, memory trouble and language disabilities and continued depression

Newsweek, 2007

Case Presentation• There was now repeated concern for neurologic

disease and a repeat MRI was obtained revealing a meningioma that had grown 6 times larger

• Patient had surgery to remove her tumor

• Her neurosurgeon wrote in follow-up: she has gone "from being completely unresponsive to a walking, talking, normal human being again."

Newsweek, 2007

Case Presentation

Newsweek, 2007

“I celebrated that the tumor causeddepression was gone”

Lessons Learned

• Neurologic disease can present with psychiatric symptoms

• Psychiatric symptoms can sometimes be the first manifestation of neurologic disease including meningiomas

• Neuropsychiatry can help provide a complete picture of mind-brain through an integrated understanding of Neurologic and Psychiatric disease

What is Neuropsychiatry?

• Cognition • Emotion• Behavior• Perception • Experience

Neuropsychiatrists seek to understand symptoms in domains

In terms of:Localized brain dysfunction

What is Neuropsychiatry?

• Basic Neuroscience • Human Functional Brain Imaging • Behavioral Neurology• Psychiatry• Cognitive psychology• Neuropsychology• Evolutionary psychology• Ethology

Knowledge base drawn from variety of related fields…

Neuropsychiatry of Meningioma

• Symptoms can be related to– Mass effect

• Tumor, edema

– Seizures– Hydrocephalus– Treatments

• Post-surgical• Medical/pharmacological

– Psychological reactions, stress– Pre-existing conditions

Frontal and Subcortical Neuropsychiatric Circuits

Frontal and Subcortical Neuropsychiatric Circuits

Neuropsychiatry of Meningioma

• Example # 1: Meningiomas at the junction of the frontal, temporal, parietal lobes (sylvian)

J.R.Coll.Surg.Edinb., 2001

Possible Symptoms

1. Mood Disturbance (depression, mania)2. Impaired language production

• Difficulty understanding language• Difficulty with the emotionality of language

3. Hallucinations (auditory)4. Delusions5. Weakness

• Face or arm most common

6. Numbness(Laterality

dependent)

Neuropsychiatry of Meningioma

• Example # 2: Meningiomas at the olfactory groove

R & S Physician, 2006

Possible Symptoms• Changes in Smell

• Visual Disturbances

• Personality Change

• Disinhibited Behavior

• Mood Changes (mania more commonly than depression)

• State of Indifference (Apathy)

• Urinary Incontinence

• Slowed Movements

Neuropsychiatry of Meningioma

• Example # 3: Midline (Parasagittal Meningioma)

Mod Pathol., 2002

Possible Symptoms

• Leg Weakness

• Leg Numbness

• State of Indifference (Apathy)

• Urinary Incontinence

• Slowed Movements

• Mood Disturbances

• Personality change

Treatment Options

• Patient:– Psychopharmacology– Psychotherapy/Cognitive Behavioral Therapy– Neuromodulation (e.g. TMS)– Cognitive Rehabilitation

• Family:– Improve disease understanding and coping– Targeted involvement of family in care of loved one– Evaluation and treatment for

stress/anxiety/depression, if needed

BWH Institute for the Neurosciences

• “One-stop-shopping” for integrated, interdisciplinary care– Comprehensive consultation and diagnostic

evaluations• Neurology, neurosurgery, neuropsychiatry, neuroradiology,

neuropsychology, neuropathology, social work, rehab medicine/occupational therapy

– State-of-the-art, multi-faceted treatment plans• Medical, surgical, psychological, social

– Access to new therapeutic trials

• Unique scientific and educational brain-mind programs, led by world leading physician-scientists, at the interface of traditional academic medical fields

Questions?

Thank You