Case Report - Biomedical Research (2025) Volume 36, Issue 1

Suspected Very Late-Onset Schizophrenia-Like Psychosis Clinically Diagnosed as Cerebral Amyloid Angiopathy by Susceptibility-Weighted MRI Sequencing: A Case Report

Background: Very late-onset schizophrenia-like psychosis (VLOSLP) is a psychiatric disorder characterized by the onset of schizophrenia-like symptoms, including hallucinations and delusions, after 60 years old. VLOSLP diagnosis requires ruling out various organic causes, including neurodegenerative diseases such as dementia with Lewy bodies and cerebrovascular disorders, which may present with similar psychotic features. Herein, we report a case in which susceptibility-sensitive Magnetic Resonance Imaging (MRI) sequences, including T2*- and susceptibility-weighted MRI sequences, enabled the clinical diagnosis of Cerebral Amyloid Angiopathy (CAA) in a patient suspected of VLOSLP. Case-Presentation: The patient was a woman in her 80’s who exhibited memory impairments and visual hallucinations, such as perceiving inanimate objects as people and clothes in motion. Neurological examination revealed mild cognitive impairment and gait instability, with no other abnormalities. Neuropsychological testing indicated attention and visuospatial function deficits. Dopamine transporter single-photon emission computed tomography yielded findings inconsistent with dementia with Lewy bodies, and the relatively mild cognitive impairment indicated VLOSLP. T1- and T2-weighted brain MRI revealed no abnormalities; however, multiple cerebral microbleeds and superficial siderosis suggestive of CAA were detected on T2*-weighted imaging. To prevent the recurrence of cerebrovascular events, antihypertensive therapy was optimized, and anticoagulant medication was discontinued. The patient’s symptoms persisted with some non-adherence to medication and pharmacological treatment with yokukansan and galantamine. Nevertheless, supportive care and environmental modifications led to gradual improvements post-discharge. Conclusion: Unlike VLOSLP, CAA requires careful management to prevent recurrent cerebrovascular events, and nonpharmacological interventions are generally prioritized over pharmacotherapy in addressing associated psychiatric symptoms. This case underscores the importance of susceptibility-weighted MRI sequences in the clinical diagnosis of CAA in patients suspected of VLOSLP.

Author(s):

Kentaro Uchida, Hideo Kurozumi, Jumpei Maruta, Koki Inoue

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