Participant(s)
The patient was a 44-year-old female. She had been a known case of MDD (for 7 years), hypothyroidism, and hyperlipidemia. She had been taking several courses of different anti-depressant medications. However, the treatment was accompanied with poor compliance. She had quit taking her medications for a year prior to her first admission.
Process
First admission
She was admitted to neurosurgery ward with seizure and right lower extremity weakness. Gadolinium-enhanced brain magnetic resonance imaging (MRI) revealed a right fronto-parietal epidural brain abscess with slight mass effect over right motor cortex. According to her claim, it happened when she accidentally hit her head to a cabinet door. Physical examination revealed a crust over a scalp wound near vertex, muscle force of 4 from 5 in her left upper extremity, and no fever. The normal behavior of the patient herself and her family did not raise any suspicion for an underlying psychiatric condition. She received anticonvulsants and antibiotics for 8 consecutive weeks afterward. She was discharged with complete recovery from neurological problems. She was requested to attend for a follow-up visit within the following month with a new gadolinium-enhanced MRI.
Follow-up visit
A month later, we received a notification from MRI department that this patient could not undergo MRI due to an intracranial metallic object. Accordingly, a skull X-ray and contrast-enhanced spiral computed tomography (CT) scan was requested which revealed, respectively, a metallic object near the vertex (Fig. 1a) and a left para-midline entry without injury to any major vessel in the coronal view (Fig. 1b).
The patient was admitted urgently for further work-up and extraction of the foreign body. This time, the abnormalities in the reactions such as patient’s persistent crying and contradiction in her husband’s answers hinted for an underlying psychiatric illness.
Second admission
Patient was admitted in neurosurgery unit. During the pre-operative work-up, an emergency psychiatrist consultation was requested. According to the psychiatric evaluation, in spite of having a “rich” history of psychiatric problems, she was not treated in a well fashion, i.e., she did not take proper medications. She also had a suicidal attempt 2 years ago (drug poisoning). However, then, she had refused to be admitted to the psychiatry hospital for a thorough evaluation and treatment.
Patient’s neurologic exam was unremarkable, except for a dimple-like fistula at the site of needle entry over left parietal scalp. In addition, her hospital anxiety and depression scale (HADS) scores approved severe anxiety (score 17) and severe depression (score 19).
Surgical intervention
After placing the patient’s head on a horseshoe head rest, general anesthesia was induced. Then, a lazy S-shaped skin incision was made above vertex with the entry site in the middle. The needle was grasped and gently removed (Fig. 1c, d) without the need for any craniotomy.
Psychiatric evaluation and treatment
After surgery, patient was transferred to the psychiatry department for further evaluation. She was admitted in psychiatric department for 3 weeks. During her admission there, she had consultation sessions twice per week. Despite some incoherency in her statements, psychologic assessment revealed that she committed the suicide attempt due to loneliness and family and financial problems.
The patient did not state any sign of psychosis such as delusion, hallucination, or over-valued ideas while she was observed. In addition, she had no history of drug abuse. The most prominent symptoms in the patient were obvious isolation and apathy.
Meanwhile, she received 50 mg per day of sertraline and 20 mg perphenazine every night as well as 8 ECT sessions. The patient was discharged from the hospital after 3 weeks as she did not have any suicide idea and her symptoms were controlled. The patient was prescribed to continue the mentioned medications and requested to do a follow-up in 1 month.