Accepted Manuscript Title: Organic mania secondary to left arteriovenous malformation Author: Vijaya Raghavan Dhandapani PII: DOI: Reference: S1876-2018(16)30102-2 http://dx.doi.org/doi:10.1016/j.ajp.2016.05.003 AJP 876 To appear in: Received date: Revised date: Accepted date: 3-3-2016 14-3-2016 14-5-2016 Please cite this article as: Dhandapani, V.R.,Organic mania secondary to left arteriovenous malformation, Asian Journal of Psychiatry (2016), http://dx.doi.org/10.1016/j.ajp.2016.05.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Organic mania secondary to left arteriovenous malformation M an us cr ip t 1. List of authors and affiliations – One author Vijaya Raghavan Dhandapani Consultant Psychiatrist Schizophrenia Research Foundation R/7A, North Main Road, Anna Nagar West Extension, Chennai, Tamil Nadu – 600101 India Phone: +91 9043705687 E-mail: drvijayaraghavand@gmail.com 2. Caption for Fig.1 A MDCT with cerebral angiogram showing 3 x 2.6 cm AVM in the left thalamus and posterior ganglio capsular region with feeding artery from left posterior cerebral artery. My contact details: Vijaya Raghavan Dhandapani Consultant Psychiatrist Schizophrenia Research Foundation R/7A, North Main Road, Anna Nagar West Extension, Chennai, Tamil Nadu – 600101 India Phone: +91 9043705687 E-mail: drvijayaraghavand@gmail.com Ac ce pt e d Sir, The concept of secondary mania was first given by Krauthammer and Klerman in 1978 (Krauthammer and Klerman 1978). Mania usually occurs as a phase of maniac-depressive disorder but it can also occur in association with organic conditions in patients with no history of mood disorders. Organic mania has many secondary causes such as neurologic, toxic and metabolic disorders (Larson and Richelson 1988). In a prospective study by Das et al., it was found that 4.67% of all individuals with mania had a secondary cause (Das and Khanna 1993). However, vascular malformations as a secondary cause for organic mania is not common. Literature review shows only few case reports of right arteriovenous malformations (AVM) causing organic mania (MPsychMed et al. 2011; Mohapatra, Deo, and Rath 2015). Here, a case report of organic mania with left massive AVM is presented. A 24-year old male presented with the complaints of decreased need for sleep, irritability, excessive boastful talking, overfamiliarity, grandiosity and excessive indiscriminate spending for five weeks. Along with this, he also complained of severe headache on and off. No history of similar episodes or any other psychiatric history in past. Family history is nil for psychiatric illnesses. No history of substance use. On examination, his vitals were stable. He was oriented and alert. His neurological examination was within normal limits and there were no deficits in motor and sensory system. On mental status examination, he had pressure of speech and delusion of grandiosity. He was diagnosed to be having mania with psychotic symptoms, according to ICD-10. He was evaluated for his severe headache. A plain computed tomography (CT) brain showed a large strongly enhancing heterogeneous lesion involving the most of the left thalamus. The patient was further investigated by multi detector computed tomography (MDCT) with cerebral angiogram. He was diagnosed to have a 3 x 2.6cm arteriovenous malformation Page 1 of 3 Ac ce pt e d M an us cr ip t (AVM) of the left thalamus and posterior ganglio capsular region with feeding artery from left posterior cerebral artery (Fig.1). His diagnosis was revised to organic mood disorder (left cerebral AVM with secondary mania). He was treated with sodium valproate 1000 mg and risperidone 4 mg. Neurosurgical opinion was obtained and was advised to manage the patient conservatively as AVM was extensive involving major portion of left cerebrum. After the start of medications, his symptoms reduced significantly in three weeks. By the end of 12 weeks, antipsychotic medication, Risperidone, was slowly tapered off and stopped and he was maintained on sodium valproate to prevent relapse. Most of the AVM are congenital in origin but they can present at later age (Stein and Wolpert 1980). Previous case reports detailed right sided AVM causing organic mania which support the role of right hemisphere in secondary mania (Mohapatra, Deo, and Rath 2015; Cummings 1997; Gross and Herridge 1988). Contrary to the previous case reports where mania is associated with right AVM, in this case report, mania is associated with a lift sided AVM. This could be due to due to massive size of left sided AVM that might have a possible effect on right hemisphere. This case report highlights the importance of considering organic causes in patients with mania who presents with odd features like late age of onset, associated headaches, sustained irritability, no substance use and no family and past psychiatric history. Maniac symptoms might be prominent during the presentation and might mask the underlying neurologic or other causes. High degree of suspicion is needed when dealing with mania presenting with atypical clinical features. Prompt identification would lead to early intervention of organic cause and better outcome. REFERENCES Cummings, Jeffrey L. 1997. 'Neuropsychiatric manifestations of right hemisphere lesions', Brain and language, 57: 22-37. Das, A., and R. Khanna. 1993. 'Organic manic syndrome: causative factors, phenomenology and immediate outcome', J Affect Disord, 27: 147-53. Gross, RA, and P Herridge. 1988. 'A maniclike illness associated with right frontal arteriovenous malformation', The Journal of clinical psychiatry, 49: 119-20. Krauthammer, C., and G. L. Klerman. 1978. 'Secondary mania: manic syndromes associated with antecedent physical illness or drugs', Arch Gen Psychiatry, 35: 1333-9. Larson, E. W., and E. Richelson. 1988. 'Organic causes of mania', Mayo Clin Proc, 63: 90612. Mohapatra, Satyakam, Sardar JK Deo, and Neelmadhav Rath. 2015. 'Manic illness associated with right temporo-thalamic arteriovenous malformation: A rare presentation', Australian and New Zealand Journal of Psychiatry: 0004867415580155. MPsychMed, Jesjeet Singh Gill1 MBBS, Subash Kumar Pillai1 MBBS MPsychMed, Koh Hui Ong1 MBBS MPsychMed, and Stephen Jambunathan. 2011. 'Mania secondary to a right arteriovenous malformation'. Stein, Bennett M, and Samuel M Wolpert. 1980. 'Arteriovenous Malformations of the Brain: I: Current Concepts and Treatment', Archives of Neurology, 37: 1-5. Page 2 of 3 Page 3 of 3 d Ac ce pt e us an M cr ip t