The Role of Neuropsychiatry in Meningioma Care: A New Perspective

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The Role of Neuropsychiatry in Meningioma Care
A New Perspective

• David Silbersweig M.D.
• Chairman, Department of Psychiatry
• Chairman, Institute for the Neurosciences
• Brigham and Womens Hospital
• Stanley Cobb Professor of Psychiatry
• Harvard Medical School

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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
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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
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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
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Case Presentation
I celebrated that the tumor caused depression
was gone
Newsweek, 2007
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• 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

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What is Neuropsychiatry?
Neuropsychiatrists seek to understand symptoms in
domains

• Cognition
• Emotion
• Behavior
• Perception
• Experience

In terms of Localized brain dysfunction
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What is Neuropsychiatry?
Knowledge base drawn from variety of related
fields

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

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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

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Frontal and Subcortical Neuropsychiatric Circuits
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Frontal and Subcortical Neuropsychiatric
Circuits
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Neuropsychiatry of Meningioma

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

J.R.Coll.Surg.Edinb., 2001
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• Possible Symptoms
• Mood Disturbance (depression, mania)
• Impaired language production
• Difficulty understanding language
• Difficulty with the emotionality of language
• Hallucinations (auditory)
• Delusions
• Weakness
• Face or arm most common
• Numbness
• (Laterality dependent)

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Neuropsychiatry of Meningioma

• Example 2 Meningiomas at the olfactory groove

R S Physician, 2006
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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

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Neuropsychiatry of Meningioma

• Example 3 Midline (Parasagittal Meningioma)

Mod Pathol., 2002
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Possible Symptoms

• Leg Weakness
• Leg Numbness
• State of Indifference (Apathy)
• Urinary Incontinence
• Slowed Movements
• Mood Disturbances
• Personality change

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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/depres
  sion, if needed

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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-scientist
  s, at the interface of traditional academic
  medical fields

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• Questions?

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• Thank You