Dear Editor,
Subdural hygromas, collections of cerebrospinal-like fluid in the subdural space, are rare complications of traumatic brain injury (TBI) and can manifest with diverse neurological and psychiatric symptoms.[1] Secondary mania is a neuropsychiatric syndrome resulting from structural, metabolic, or infectious processes affecting the brain. Unlike primary idiopathic mania, secondary mania has distinct etiologies, including TBI, infections, and structural brain lesions. Subdural hygromas can cause varied symptoms depending on their location.[2]
A 35-year-old woman from a rural background presented with a 10-day history of excessive talkativeness, irritability, reduced need for sleep, and grandiose delusions. The symptoms significantly impaired her daily functioning and social interactions. She reported increased psychomotor activity, inappropriate joviality, and extravagant claims of wealth. The psychiatric symptoms followed a head injury sustained 3 weeks earlier when she fell from a bike, resulting in a scalp wound requiring sutures. No history of loss of consciousness, seizures, vomiting, or neurological deficits was reported at the time of injury. Her psychiatric and medical history was unremarkable, and there was no family history of mental health disorders. General examination was normal. Neurological evaluation revealed no motor, sensory, or coordination deficits. The rest of the systemic examination was unremarkable. On mental status examination, the patient had increased Psychomotor activity with pressured speech. Her mood was abnormally elevated with irritable affect, flight of ideas, and grandiose delusions. Impaired abstract thinking and judgment were present. Lobar function tests were largely intact, with minor deficits in frontal executive tasks. Routine Laboratory investigations, including thyroid function tests, were normal. Neuroimaging with MRI revealed bilateral subdural hygromas in the frontal convexities with increased subarachnoid space and vertical tortuosity around the optic nerve. EEG findings were within normal limits. Using the ICD 11, the diagnosis of “Secondary Mood Syndrome with Manic Symptoms” was established, with TBI as the underlying cause. She was hospitalized for further management. She was treated with Tab. Lithium (900 mg/day) to stabilize mood and Tab. Lorazepam (2 mg/day) for sedation and anxiety for a shorter duration. Lithium was considered in view of mood stabilizing and neuroprotective effects.[3]
Regular follow-up, family education, and supportive psychotherapy sessions addressed functional impairments. Over 3 weeks, the patient’s behavior, mood, and sleep patterns improved. The Young Mania Rating Scale (YMRS) score decreased from 26 to 12, and her Mini-Mental State Examination (MMSE) score improved from 24 to 27. Neurological symptoms associated with subdural hygromas were monitored, and no progression was noted on repeat imaging.
Secondary mania is a rare but important consequence of TBI, especially when involving the frontal or baso-temporal regions. In this case, bilateral subdural hygromas were the likely etiology, supported by neuroimaging findings.[4] The patient’s presentation includes classic manic symptoms such as over talkativeness, grandiosity, hyperactivity, and reduced need for sleep. Structural damage to the orbitofrontal and baso-temporal regions has been implicated in secondary mania as these areas have roles in mood regulation. TBI-related brain injuries often involve a combination of primary effects (e.g., contusions, hematomas) and secondary effects (e.g., inflammation, hygromas). Conditions like primary bipolar disorder, delirium, and infectious or toxic encephalopathy were differentials. The lack of psychiatric history, presence of an identifiable organic cause, and preserved cognitive orientation favors the diagnosis of secondary mania.[5]
Authors’ contributions
Literature review and initial drafting: MN, MS; Editing the article: SS, SP.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
Thankful to the patient and her family members.
Funding Statement
Nil.
REFERENCES
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