Objective:

To present a case of a cerebral cavernous malformation (CM) near the caudate nucleus in a patient with acute behavioral changes. 

Background:

Lesions in the caudate nucleus are known to cause changes in behavior such as abulia and disinhibition among other psychiatric symptoms. Basal ganglia CMs are rare, accounting for about 13.3 % of overall CMs with 21.4 % of these located in the caudate nucleus. Microhemorrhages or microthrombi can result in acute neurologic manifestations of a clinically silent CM. However, acute behavioral changes due to a CM hemorrhage have been extremely rare. To our knowledge, only two cases in literature reported caudate CM hemorrhages resulting in psychiatric manifestations where patients were noted to have obsessive compulsive disorder manifesting acutely in the setting of bleed.

Design/Methods:

N/A

Results:

A 77-year-old male presented with acute behavioral changes over 1 week where patient became agitated, confused, and restless with sleep disturbance, incoherent speech, and poor memory. On evaluation, the patient was highly aggressive and refused examination. CT Head showed an 8mm focus of hyperdensity in the right basal ganglia abutting the caudate nucleus suggestive of a small CM. Inpatient workup for toxic metabolic causes of encephalopathy was unremarkable. MRI Brain with and without contrast showed susceptibility artifact within the area with faint T1 hyperintensity and T2 hypointensity, suggesting a CM with subacute hemorrhage. Post contrast imaging also revealed a developmental venous anomaly within the area draining into the right sphenoparietal sinus. The patient’s behavioral changes improved throughout his hospital stay. In the absence of other explanatory factors, the patient’s acute change in behavior was likely related to subacute hemorrhage within the CM affecting his caudate nucleus. 

Conclusions:

This case suggests that caudate nucleus CM with imaging findings suggestive of subacute hemorrhage can present with variable acute psychiatric manifestations.