(PO-066) "I am always hungry": A Case of Obesity, Hyperphagia, Somnolence, and Amotivation in the Setting of a Bleeding Cavernoma Treated with Stereotactic Radiosurgery
Hypothalamic obesity is a syndrome of hyperphagia and weight gain arising from impaired hypothalamic regulation of body weight and energy expenditure. This syndrome is most commonly associated with pituitary tumors but can also be caused by hypothalamic dysfunction from surgery, trauma, infiltrative disorders, congenital malformations and genetic mutations. Our case examines a particular cause of hypothalamic obesity and the associated syndromic psychological and behavioral changes that can often accompany hyperphagia with weight gain.
The patient is a 38-year-old female who was diagnosed with a hemorrhagic left basal ganglia cavernoma three years ago after initially presenting with seizures. Resistance of the seizures to medication and the location of the cavernoma led to treatment after several months with stereotactic radiosurgery. Changes post-surgery included significant weight gain (BMI increased from 22 to 40), cognitive decline with recurrent hemorrhages, post-radiation edema, hypothyroidism, and hydrocephalus managed with a VP shunt. The patient was admitted for progressive increase in fatigue and weakness for 1 week noticed by her caregiver.
Pertinent features on history were poor motivation, fatigue, weakness and increased appetite. Family reported she requires significant encouragement to perform ADLs, needs strict monitoring to limit food intake, and expresses hopelessness about her condition.
On exam, she was a morbidly obese woman, with poor attention, memory and recall. She was oriented to place and person only.
Work up yielded a negative EEG for seizures. MRI showed a stable hemorrhagic mass in the left inferior thalamus with decreased surrounding vasogenic edema and stable mild obstructive hydrocephalus. TSH was elevated with low T4.
Hypothalamic obesity was first defined as hyperphagia and weight gain in the setting of suprasellar tumors and their surgical excision. This syndrome occurs with many causes of hypothalamic impairment and can manifest clinically as psychosocial disorders, hyperphagia, sleep disturbance, decreased energy expenditure, hyperinsulinemia and hypopituitarism (Van Iersel L 2019). Behavioral, social, emotional and neurocognitive dysfunction may include impulsivity, aggression, anger, inattention, depression and anxiety, and symptoms may be aroused when food access is restricted. Hormonal regulation of appetite, satiety, sleep, wakefulness, autonomic tone, metabolic rate, and pituitary function by hypothalamic nuclei can all be disrupted. The choice of surgical versus radiological intervention against bleeding cerebral cavernomas must balance accessibility and efficacy against the risk of hypothalamic-pituitary axis disruption (Shih YH 2005).
This case highlights the importance of recognition of the psychological and behavioral manifestations that can often present with the neurocognitive and endocrinological disruptions of hypothalamic obesity.
Shih YH: Management of supratentorial cavernous malformations: craniotomy versus gammaknife radiosurgery. Clinical neurology and neurosurgery 2005; 107(2):108-12.
Van Iersel L: Pathophysiology and individualized treatment of hypothalamic obesity following craniopharyngioma and other suprasellar tumors: a systematic review. Endocrine reviews 2019; 40(1):193-235.
Recognize the psychological and behavioral disturbances associated with hypothalamic obesity.