A juvenile homicide associated with a left-sided cerebral arteriovenous malformation

Brain lesions are known to affect cognition, emotions, and behavior, and have been implicated in cases of violence, particularly when involving neural circuits responsible for impulse control, emotional regulation, and judgment. While tumors, traumatic brain injuries, vascular abnormalities, and other types of brain lesions have been associated with psychiatric and behavioral disturbances, cerebral arteriovenous malformations (AVMs) have rarely been linked to psychosis and not with homicidal violence. We present the case of a 14-year-old boy with a large inoperable left parieto-occipital arteriovenous malformation extending into the temporal lobe who developed progressive neuropsychiatric symptoms culminating in psychosis and an explosive and fatal knife attack on neighbors. His developmental course was remarkable for early speech delay, attention deficit hyperactivity disorder (ADHD), oppositional behaviors, emotional dysregulation, severe headaches, and eventual psychotic decompensation characterized by paranoid delusions, disorganized thinking, and behavioral disinhibition. Prior to the homicidal event, neuroimaging showed progression of his AVM with cerebral edema, and John developed a Psychotic Disorder due to a Medical Condition (AVM). After arrest, he was found incompetent to stand trial and eventually placed in a state psychiatric facility. In contrast, his twin brother, raised in the same environment, was developmentally typical and psychiatrically healthy. How brain lesions can contribute to violent acts is a complex topic given the multifactorial origins of aggression. This case report, using a developmental approach, illustrates the connection between focal brain pathology, a cerebral AVM, and homicidal violence in a teenage boy. Treatment approaches, rehabilitation efforts, and legal implications are considered.