(Kiosk 3) Brainstorming Solutions to Encephalopathy and Agitated Catatonia in the Setting of Recurrent Glioblastoma Multiforme Resection

Case Diagnosis: Agitated catatonia and encephalopathy secondary to Glioblastoma Multiforme (GBM) resection

Case Description or Program Description: A 63-year-old woman who underwent resection of recurrent right temporal lobe GBM developed postoperative encephalopathy and agitation. The patient was treated initially with antipsychotics, which appeared to worsen her agitation; only Lorazepam trials proved effective. Upon admission to inpatient rehabilitation, her Bush-Francis Rating Scale was 22, suggesting agitated catatonia. Her hyperorality and hypersexuality also suggested a partial Kluver-Bucy syndrome presentation in the setting of temporal lobe dysfunction affecting the amygdala. Oral lorazepam and escitalopram were started with strong clinical improvement. Unfortunately, enteral access was later compromised due to delirium, poor oral medication compliance, and COVID-19 pneumonia and sepsis. The patient was started on IV diazepam and valproic acid (VPA) instead with limited clinical effect. Later in her hospital course, she was able to tolerate oral medications, and her original lorazepam and escitalopram were restarted. VPA was also continued, and Memantine was started for suspected benzodiazepine-refractory catatonia worsened by sepsis.

Setting: Acute inpatient rehabilitation center

Assessment/Results: The patient’s symptoms improved on this regimen, but repeat neuroimaging revealed GBM recurrence. She was discharged to home hospice care.

Discussion (relevance): Catatonia is a neuropsychiatric disorder characterized by abnormal movements and behaviors, typically in the setting of an underlying neurological insult, such as brain tumor resections as in our case. The pathophysiology is poorly understood but possibly related to frontal lobe dysfunction and depletion of dopamine and GABA neurotransmitters. The specific constellation of symptoms of excitement, stereotypy, impulsivity, and perseveration is consistent with agitated catatonia.

Conclusions: Multiple etiologies can cause persistent encephalopathy and agitated catatonia, including GBM recurrence and resection. Treatment with benzodiazepines, specifically lorazepam, and alternative agents such as VPA and memantine have been effective in reducing agitation and improving therapy participation.