Mega cisterna magna is considered to be a type of Dandy-Walker complex (Notaridis et al., 2006). Mega cisterna magna is characterized by compressive atrophy of the vermis associated with cystic enlargement of the cisterna magna, and free communication across the foramen of Luschka and Magendie with the fourth ventricle and subarachnoid space. It has been linked with psychiatric manifestations including mania, catatonia, psychosis and obsessive-compulsive disorder (OCD). The authors present a case of mega cisterna magna associated with psychosis and look for possible explanations linking the two by reviewing the literature.
The patient is a 26-year-old African-American single male with a past psychiatric history of three episodes of unspecified psychosis but no significant past medical history and was brought to the hospital by emergency medical services for bizarre behavior. He arrived to the emergency department with catatonic symptoms and intermittent violent outbursts. Urine toxicology was negative. He was admitted to the inpatient unit for stabilization, where he arrived mute and akinetic. He exhibited catatonic symptoms and refused to eat for the first three days of his inpatient stay. His catatonic symptoms resolved with the administration of benzodiazepines; however, he went on to have episodes of violence, including biting staff members and jumping over a high barrier. There was brief improvement in his psychotic symptoms after he received antipsychotic medication that was given as needed for agitation. He refused to take any medication secondary to poor insight into his illness. He did not believe that he had psychiatric illness, did not acknowledge any behavior change, and did not believe that it was necessary for him to take medication. He had paranoid delusions of being persecuted by police officers and what he referred to as “the system.” He scored 95 on the Positive and Negative Syndrome Scale. He denied any auditory or visual hallucinations. He denied any history of illicit substance use, and a thorough history obtained from his family did not reveal any concomitant illicit substance use. Further history revealed that the patient had episodes of psychosis lasting months with multiple hospitalizations since the age of 13 followed by complete recovery and return to his baseline level of functioning. These episodes often involved defiant behavior toward police officers.
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CT of the head showed left posterior fossa mega cisterna magna. MRI of the brain without contrast was done for confirmation and showed fluid space posterior to the left cerebellar hemisphere. Neurology and neurosurgery were consulted. The patient did not have any motor or sensory deficits. He did not report dizziness, changes in vision, or headaches. Neurosurgery recommended periodic follow-up but not surgical intervention. During the course of three weeks in the hospital, his behavioral symptoms of physical aggression and anger outburst resolved. By the end of his hospitalization, he continued to express paranoid delusions, lacked insight into his illness, and refused to take antipsychotic medication despite extensive psychoeducation. He was guarded with constricted affect. He was calm and isolative. He had poor self-care. He had poor impulse control and judgment but denied suicidal or homicidal ideation. He was not considered a safety risk. He was court ordered for long-term psychiatric facility for further stabilization.
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