Neuropsychological evaluation of mild head injury.

Sir: I was quite pleased to read the article on behavioural manifestations of third ventricular colloid cysts by Lobosky, Vangilder and Damasio. ' It is with this in mind that I would like to present the following case. A 67-year-old female has a 1 year history of intermittent periods of confusion, manifested by forgetfulness and inability to do her normal activity. For example, she was driving as a passenger with her husband, and it was time for them to get out of the car. She found herself unable to go through the mechanical action of getting out of the car and actually had to be carried out. Once she was out of the car, she had no difficulty walking into the house. In relation to her skills of daily living, she is able to continue to cook, dress and bathe herself, and go to the store and shop. Mental status examination revealed that the patient was disoriented to time and place; she thought that she was in her home. She could not remember her own birthdate. When asked to attend to four objects given to test her recent memory, she could not maintain attention long enough to maintain these words in immediate memory; thus making it impossible to check for recent memory deficit. When asked to perform simple commands, she was able to close her eyes or open her mouth. When asked to show her right or left hand, she was confused and unable to do this consistently and accurately. When asked to put her right index finger on her left ear, she responded with, "Do I have to get up to touch my ear? " She seemed a bit confused at that time, and when asked to point to just her ear, she did this accurately. There was no difficulty with naming simple objects such as a watch, a pair of glasses, or a tie. There was no clear evidence of dysarthria or aphasia. There was an inability of the patient to perform complex motor activities. When asked to go from the sitting position to the lying down position, she could not do this. It was clear that this was not on the basis of impaired strength or coordination. Neurological examinations revealed cranial nerves 2-12 intact. The muscles were of normal tone, bulk and strength. Sensation could not be tested well, owing to poor cooperation, but was intact to pinprick and proprioception. Reflexes were 2+ and symmetric in the upper extremities, 2+ at the knees, 1 + at the ankles, and the toes were downgoing bilaterally. Finger to nose and heel to shin tests were normal. The gait was normal as were heel walk, toe walk, tandem walk. CT scan revealed a colloid cyst of the third ventricle without hydrocephalus. EEG revealed diffuse slowing with frontal intermittent rhythmic delta activity of high voltage. Blood studies revealed normal thyroid, liver function, B-12 and folate, and VDRL. Neurosurgical consultation was obtained with three different neurosurgeons, all of whom declined to pursue an operative course. This case calls to attention behavioural manifestations associated with colloid cyst of the third ventricle without hydrocephalus. In general, it is the impression of my neurosurgical colleagues in the United States that in the absence of hydrocephalus, removal of a colloid cyst is not mandatory. It is my hope that reports of cases such as this will raise the awareness of behavioural manifestations in colloid cysts of third ventricle without hydrocephalus.