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Neurocognitive Disorders, Delirium, and Neuropsychiatry

Session: Poster Session

(100) Suspected Huntington's Disease Complicated by Bilateral Subdural Hematomas Presenting as First-episode Psychosis

Location: Griffin Hall

Trainee Involvement: Yes

Background: A 37-year-old Caucasian woman with no past medical history and a past psychiatric history of major depressive disorder and attention deficit hyperactivity disorder presented to the crisis center via police involuntarily for inability to care for self at home.She was admitted to inpatient psychiatry and subsequently found to have bilateral subdural hematomas. After treatment her psychosis resolved. This case highlights the importance of a thorough history, medical and interdisciplinary workup in cases of first episode psychosis.

Case: A 37-year-old Caucasian woman with no past medical history and a past psychiatric history of major depressive disorder and attention deficit hyperactivity disorder presented to the crisis center via police involuntarily for inability to care for self at home. The patient had a strong family history of Huntington’s Disease although had had no formal testing or diagnosis herself. Initial presentation was notable for psychosis versus cognitive decline as well as choreiform movements in all extremities. She was admitted to inpatient psychiatry and subsequently found to have bilateral subdural hematomas on magnetic resonance imagining (MRI) of her brain. She was transferred to neurosurgery and underwent evacuation via Burr holes as well as middle meningeal artery embolization and afterwards had resolution of her psychiatric symptoms.

Discussion:

Currently, no universally standard guidelines exist regarding a medical workup prior to admission to a psychiatric facility a number of studies highlight key diagnostic tests that proceed in a tiered approach to inform practitioners of potential concurrent medical illness contributing to a psychiatric presentation. Prospective studies of neuroimaging in presentations of first-episode psychosis were shown to be particularly useful for diagnosis in patients with neurological symptoms, older age, or atypical clinical pictures (Coentre, 2016). While psychosis could be a manifestation of Huntington’s disease, presentations of psychosis are more typically seen in advanced disease of patients who were clinically diagnosed with Huntington’s at a younger age, have a lower number of CAG repeats or have a history of depression (Rocha, 2018). Additionally, while a strong family history in this presentation was significant for Huntington’s disease, of which chorea is a hallmark, there have been case reports of chorea and subtle cognitive impairments as side effects of chronic subdural hematoma. Notably, Huntington’s disease also carries an increased risk of chronic subdural hematoma compared to the general population. In case reports of patients with chronic subdural hematomas, a significant improvement in cognitive function following burr hole evacuation was noted.

Conclusion: An interdisciplinary approach to patients with first time or atypical clinical presentations of psychiatric illness is particularly important for treatment and prognosis. Practitioners should be aware of a broad range of differentials that can contribute to a clinical presentation and work through suggested algorithms to ensure key diagnosis are ruled out.

References: Coentre R, Silva-Dos-Santos A, Talina MC. Retrospective study on structural neuroimaging in first-episode psychosis. PeerJ. 2016;4
Rocha NP, Mwangi B, Candano CAG, Sampaio C, Stimming EF, Teixeira AL. The Clinical Picture of Psychosis in Manifest Huntington's Disease: A Comprehensive Analysis of the Enroll-HD Database. Frontiers in Neurology. 2018;9