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We read with interest the recent paper by Benabarre et al1 of the first reported case of endoscopic third ventriculostomy followed by severe psychiatric complications.
In our department, we also had a patient who developed severe psychiatric symptoms after an endoscopic third ventriculostomy (ETV).
A 45 year old woman with an aqueductal stenosis underwent an EVT because of progressive gait and visual disturbances. In November 1997 she underwent an ETV through a right side precoronal burr hole using a rigid neuroendoscope. The third ventricular floor was perforated with a 4 French Fogarty catheter, the perforation being enlarged with the inflatable balloon. No problems were encountered during the procedure, although we noted an incomplete septum pellucidum. After ETV her gait and visual disturbances gradually resolved. However, after the procedure the patient was nervous and agonised, and she complained of a crepitating sound in her head and behaved aggressively towards her spouse. Because her complaints and behaviour worsened a psychiatric evaluation was performed. Psychotic depression was diagnosed and three weeks after the EVT she was admitted to the department of psychiatry. For several months she was treated with antipsychotic and antidepressant drugs and her psychotic depression partially resolved. She is still being treated for mild depression. Postoperative magnetic resonance imaging six weeks, three months, and one year after the EVT showed no normalisation of the ventricular system, but no other abnormalities were seen.
Signs and symptoms were abrupt and probably organic because of the apparently strong relation between the procedure and the start of the psychotic depressive episode. Previously, the patient had no psychiatric complaints and had undergone other invasive procedures under general anaesthesia and admittance to the hospital. It is not clear how this psychotic depression after EVT can be explained. Sometimes when ETV is performed, injury of the fornix is seen. The fornix constitutes the sole efferent system from the hippocampus and both are involved in the limbic system. The limbic system has an important role in mood and emotional behaviour. We hypothesize that in this patient a combination of incomplete septum pellucidum and an injury of the fornix may have caused an organic personality syndrome after EVT. We agree with Benabarre et al that clinicians should be aware of and take into account this potential serious complication of EVT in this so called minimally invasive procedure.
We are satisfied with the clinical interest generated by our case report where we explained the first case of endoscopic third ventriculostomy followed by severe psychiatric complications.
Van Aalst et al have reported a patient who developed severe psychiatric symptoms after an endoscopic third ventriculostomy. Their patient underwent an endoscopic third ventriculostomy through a right sided precoronal burr hole using a rigid neuroendoscope. In our case the patient underwent surgery under general anaesthesia and a 6.5 mm rigid neuroendoscope (Gaab Endoscope, Storz, Tutlingen, Germany) was inserted through a right sided precoronal burr hole in the frontal horn of the right lateral ventricle, following the technique described by Vries1 and Viñas et al.2 Fenestration of the floor of the third ventricle to the basal cisterns was performed with bipolar coagulation and enlarged with a 3 French Fogarty catheter. The surgical technique was similar in both cases.
Both patients behaved aggressively but ours developed a severe complication consisting of an organic personality disorder characterised by impulsiveness, physical heteroaggressiveness, binge eating, hypersomnia, and impaired memory and frontal executive functions. In our discussion we postulated that a frontal lobe lesion may explain some of the symptoms presented such as the uncontrolled impulses, the aggressive behaviour, and even the binge eating. However, a longitudinal neuropsychological evaluation showed a severe deficit in immediate memory and difficulties in planning and consolidation of newly learned information, which may be best related to damage in the frontal-basal structures of the brain: the fornix and its connection to the hippocampus and the mamillary bodies. Postoperative magnetic resonance images confirmed the clinical hypothesis.
We do not totally agree with the diagnosis postulated by Aalst et al. Is true that signs and symptoms were abrupt and probably organic because of the apparently strong relation between the procedure and the start of the psychotic depressive episode. However, we think that an organic personality syndrome cannot be conceptually diagnosed after EVT because the correct Diagnostic and statistical manual of mental disorders category may be a mental disorder not otherwise specified due to a general medical condition.3 This residual category should be used for situations in which it has been established that the disturbance is caused by the direct physiological effects of a general medical condition but where the criteria are not met for a specific mental disorder due to a general medical condition (such as dissociative symptoms due to complex partial seizures). The diagnosis of an organic personality syndrome requires that the patient suffer a persistent personality disturbance that is a change from the person’s previous characteristic personality pattern. Eight specific types are described: labile type, disinhibited type, aggressive type, apathetic type, paranoid type, other type, combined type, and unspecified type. We think that the patient described by Van Aalst et al did not meet all of these diagnostic criteria.
We think it would be very interesting to know more of the clinical aspects of the patient. For example, had this patient suffered from other depressed states during her life? The patient’s problem may have been a severe recurrence of a depressive disorder.
We agree that these clinical cases should help clinicians to take these potential complications of endoscopic third ventriculostomy into account before indicating this so called minimally invasive procedure.
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