Revised: 24 May 2021

Accepted: 24 May 2021

DOI: 10.1002/brb3.2245

ORIGINAL RESEARCH

Schizophrenia, bipolar disorder, or intracranial aneurysm? A
case report
Yifan Shi1

Yezhou Tang1

Zhiguo Wu2

Jun Chen1

Jia Huang1

Yiru Fang1,3,4

1

Division of Mood Disorder, Clinical Research
Center, Shanghai Mental Health Center,
Shanghai Jiao Tong University School of
Medicine, Shanghai, China

2

Department of Psychiatry and
Neuropsychology, Shanghai Deji Hospital,
Qingdao University, Shanghai, China

Abstract
Background: Mental disorders are a common finding among patients with unruptured
intracranial aneurysms.
Case: The current case concerns a young man with an anterior communicating artery
aneurysm who was misdiagnosed with schizophrenia and bipolar disorder due to his

3

CAS Center for Excellence in Brain Science
and Intelligence Technology, Shanghai, China

significant psychosis and mood episodes. Having undergone surgery on the unruptured

4

intracranial aneurysm, the patient’s psychiatric symptoms disappeared, and he main-

Shanghai Key Laboratory of Psychotic
Disorders, Shanghai, China
Correspondence
Yiru Fang, Division of Mood Disorder, Clinical
Research Center, Shanghai Mental Health
Center, Shanghai Jiao Tong University School of
Medicine, Shanghai 200030, China.
Email: [email-masked]

1

tained a stable mood during the 3-year postoperative period.
Discussion: The case is indicative of the need to consider the possibility of organic brain
lesions in patients with first episodes of psychiatric presentations.
KEYWORDS

bipolar disorder, intracranial aneurysm, schizophrenia, subarachnoid hemorrhage

CASE PRESENTATION

However, after 1 year of treatment with medication, neither the
paranoia nor the headaches had improved. Moreover, the patient had

Mr. Z is a right-handed, 28-year-old young male. His symptoms were

begun to believe that he was also being monitored by his neighbors

first manifested at the age of 17, when he complained of headache that

and strangers. In addition, he now presented with an elated mood,

felt like lava spreading out within his head. He reported this to his par-

increased energy and activity, flight of fancy, and elevated distractibil-

ents. In addition, he also began to experience paranoia, manifest in the

ity almost every day for a period of 1 month, which resulted in failed

proposition that one of his teachers was monitoring him. This manifes-

relationships with his schoolmates. Two months later, he experienced

tation was assumed to be related to the combined pressures of school

an episode wherein he demonstrated a period of uninterrupted anxi-

life and homework. Specifically, the patient regarded the telephone as

ety and irritability, accompanied by feelings of worthlessness, loss of

a monitoring device controlled by a particular teacher. In addition, his

pleasure, and a diminished ability to think. He also complained repeat-

constant suspicion that he was under criminal investigation placed him

edly about the swollen pains in his head. The diagnosis was revised

in a perpetual state of fear. Overall, his sense of persecution caused him

as bipolar disorder (based on ICD-10 criteria) by another psychia-

to feel stressed and unhappy at school. These feelings were expressed

trist, after which a combination therapy of sodium valproate (up to

as hostility toward his teacher and a refusal to attend school. His par-

1000 mg/day) and olanzapine (up to 10 mg/day) was commenced. The

ents felt that his behavior was abnormal and took him to a psychi-

mirtazapine therapy was discontinued, while the dosage of quetiap-

atric clinic where he received a diagnosis of schizophrenia (based on

ine was reduced to 100 mg/day. His psychiatric symptoms disappeared

ICD-10 criteria) and was subsequently treated with mirtazapine (up to

and his emotional stability and headache severity gradually improved

90 mg/day) and quetiapine (up to 300 mg/day).

after 6 months with the new therapeutic regimen. However, the patient

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2021 The Authors. Brain and Behavior published by Wiley Periodicals LLC
Brain Behav. 2021;1–4.

wileyonlinelibrary.com/journal/brb3

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SHI ET AL .

FIGURE 1

Computed tomography angiography revealed an anterior communicating aneurysm with a subarachnoid hemorrhage

continued to experience difficulties with his thoughts and memories.

subtraction angiography and Guglielmi detachable coil embolization,

Moreover, he developed an unusual strong interest in pornography and

which were successful.

easily became extremely excited when talking with his female class-

After the operation, the patient’s symptoms, previously ascribed to

mates. Believing himself to be cured, the patient discontinued his med-

schizophrenia and bipolar disorder, did not reemerge during the course

ication when he was 19, without consulting his psychiatrist. Due to his

of a 3-year follow-up without the use of mood stabilizers and antipsy-

poor performance in the National Higher Education Entrance Exami-

chotics. His mood stability, energy levels, cognitive status, and other

nation, he was obliged to attend a junior college instead of a university.

symptoms returned to normal, and he no longer complained about his

Subsequently, he struggled to complete his studies at junior college and

headache. He exhibited good interpersonal skills and a capability for

became an office worker. He continued to suffer from repeated, albeit

employment in an office job.

less severe mood swings and paranoia following a renewed onset of
minor headache. Moreover, he did not have any period of emotional
stability for more than 3 months. Consequently, he found it challeng-

2

DISCUSSION

ing to complete tasks and maintain relatively harmonious relationships
with others.

Intracranial aneurysms are estimated to have a prevalence of 3.2%

Eight years after the initial onset of his delusions and 7 years after

of the adult population worldwide, with peak onset between 40 and

the first episode of detectable mood disorder, he attended an emer-

60 years of age. Intracranial aneurysms are acquired lesions that are

gency department at age 25, having experienced a sudden onset of

caused by degenerative changes in vessel walls. Some increase in

severe headache and nausea.

size over a period of hours, days, weeks, or several years, and even-

The physical examination performed upon admission found the

tually either rupture or undergo stabilization and hardening. Most

patient to possess a painful demeanor. He was clearly conscious, with

intracranial aneurysms are asymptomatic prior to rupture, although

stable vital signs, and regular and coordinated limb movement. Both

some patients may present with symptoms such as headache, tran-

pupils were equal and reactive. His deep tendon reflexes were 2+

sient ischemic attack, cranial neuropathies, double or blurred vision,

and equal on both sides without pathological reflexes. Cerebrospinal

and seizures (Thompson et al., 2015).

fluid examination revealed a red blood cell count of 3200 × 106

The early detection of unruptured intracranial aneurysms contin-

cells/L and a white blood cell count of 240 × 106 cells/L. Pandy’s test

ues to present a challenge due to their nonspecific physical and psy-

indicated a positive result, while liver function, renal function, and

chological symptoms. As such, patients with unruptured intracranial

serum electrolyte test were all normal. Cerebrospinal fluid culture

aneurysms are occasionally misdiagnosed with psychogenic disorders.

was sterile after 5 days of incubation. However, computed tomogra-

Prior to the aneurysm rupturing, the patient in the current case pre-

phy angiography of the head revealed a 2.1 mm × 4.8 mm aneurysm

sented with sporadic, endurable headaches, no visual irregularities, and

in the anterior communicating artery with a subarachnoid hemorrhage

no pyramidal dysfunction. However, the patient had experienced dis-

(Figure 1).

cernable mood swings and feelings of paranoia. The combined admin-

The clinical diagnosis of subarachnoid hemorrhage as a conse-

istration of mood stabilizers and atypical antipsychotic drugs caused

quence of an anterior communicating aneurysm was made based on

both the headaches and psychological symptoms to improve. The psy-

the patient’s clinical presentation, laboratory tests, and the imag-

chiatrists’ focus on the psychiatric symptoms exhibited by patient Z

ing examination. Following consultation with several neurosurgeons

caused the progress of the physical manifestations to be overlooked.

who were on duty that day, the patient underwent emergency digital

Consequently, neither the psychiatrist nor the patient requested any

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SHI ET AL .

imaging examination. Had they done so, the root cause of the symp-

The specific clinical manifestations of patient Z also emphasize the

toms would become clear. However, the patient’s underlying illness

importance of individualized diagnosis. Current research indicates

remained undiagnosed.

that normative models can effectively reveal heterogeneous biology

A review of the treatment process suggests that several stages in

at an individual level (Marquand et al., 2019). Healthy individuals

the treatment process should be reviewed. First, the patient initially

usually do not deviate significantly from the normative model. Patients

presented with headaches for which there was no clear cause. Rather

with schizophrenia typically demonstrate significant reductions in

than assuming that the headaches were a symptom of a psychiatric ill-

gray matter in their frontal lobes, cerebellum, and temporal cortex.

ness, it would have been preferable to have conducted cranial imaging

Conversely, patients with bipolar disorder present with differences

evaluation at this early stage in order to rule out any organic abnor-

that are primarily confined to cerebellar regions (Wolfers et al., 2018).

malities. Second, throughout the course of the disease, the patient’s

In summary, the psychiatric symptoms caused by anterior commu-

mental symptoms and headaches always occurred concurrently. The

nicating artery aneurysms could present in a manner akin to those

psychiatrist treated the patient with valproate, which is reported to be

caused by either schizophrenia or bipolar disorder. This case highlights

effective in preventing migraines, with the dosage being in the range

the need for an elaborate differential diagnostic process, such as brain

of 500–1500 mg/day (Pringsheim et al., 2010). Therefore, even if the

imaging, in cases where headaches are among the initial symptoms.

patient’s headache reduced after using the drug, it was not possible
to conclude that the improvement of the bipolar disorder symptoms

ACKNOWLEDGEMENTS

was the cause of the headache relief. Third, the patient presented

This work was supported by the National Key R&D Program of

an inadequate response to effective doses of mood stabilizers and

China (2016YFC1307100); the National Natural Science Foundation

second-generation antipsychotics. He also showed confabulation,

of China (81930033, 91232719, 81771465); the Shanghai Mental

changes in personality, and impairment in memory, learning, attention,

Health Centre Clinical Research Center Special Project for Big Data

and executive functions, all of which are consistent with the neurobe-

Analysis (grant numbers CRC2018DSJ01-1); the Sanming Project of

havioral disturbances associated with intracranial aneurysms (Bottger

Medicine in Shenzhen City (SZSM201612006); the National Key Tech-

et al., 1998). Consequently, the diagnoses of schizophrenia and bipolar

nologies R&D Program of China (2012BAI01B04); and also supported

disorder should have been questioned.

by the Innovative Research Team of High-level Local Universities in

How the intracranial aneurysm caused mania, paranoia, and other

Shanghai.

psychiatric symptoms in this patient remains unclear. It is possible
that the intracranial mass effect and ischemic changes caused by

CONFLICT OF INTEREST

the intracranial aneurysm, in addition to the inflammatory response

The authors declare that there is no conflict of interest.

related to the formation, growth, and rupture of the intracranial
aneurysm might have possibly led to Mr. Z’s mood instability and other
psychiatric presentations.
This study has certain limitations. For example, the patient’s

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the
corresponding author upon reasonable request.

intracranial aneurysm, mental symptoms, and psychiatric symptoms
may have recovered spontaneously. However, it is difficult to draw any
absolute conclusion due to the lack of detailed imaging data. Although
no such case has previously been reported, this paper suggests that
this possibility should be considered.
Misdiagnosis of functional mental disorders may result in the failure
to recognize and treat neurosurgical disorders in a timely manner.
Several critical issues must be addressed in order to avert similar
misdiagnoses, the first of which is that the somatic and psychological
symptoms of patients must be accorded equivalent credence. Second,
possibility of organic encephalopathy for first-onset cases must be
heeded. Third, careful assessment must be made of both the course of
illnesses and patients’ responses to routine treatment. Furthermore,
Madhusoodanan et al. have recommended neuroimaging for patients
who present with one of several clinical conditions, to wit: new-onset
psychosis, new-onset mood/memory symptoms, the occurrence of
new or atypical psychiatric symptoms, and anorexia without body
dysmorphic symptoms (Madhusoodanan et al., 2007). Adopting these
measures may help to ensure that the possibility of intracranial organic
lesions can be excluded as a cause of symptoms prior to the diagnosis
of a mental disorder.

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SHI ET AL .

How to cite this article: Shi, Y., Tang, Y., Wu, Z., Chen, J., Huang,
J., & Fang, Y. (2021). Schizophrenia, bipolar disorder or
intracranial aneurysm? A case report. Brain and Behavior. 1–4.
https://doi.org/10.1002/brb3.2245