Post-stroke psychosis: how long should we treat?

Abstract

Objective: To describe a rare case of a patient who developed psychotic symptoms after a right stroke that disappeared with antipsychotic treatment, but appears to need low-dose maintenance antipsychotic therapy. Case description: A 65-year-old man presented at the psychiatric emergency service with a history of persistent delusional jealousy, visual illusions and agitation with onset about 1 month after a right posterior cerebral artery ischemic stroke. These symptoms only disappeared with therapeutic dosages of an antipsychotic drug (3 mg/day of risperidone). At 2-year follow-up, he no longer had delusional activity and the antipsychotic treatment was gradually discontinued over the following year. However, 1 week after full cessation, the patient once more became agitated and suspicious and was put back on risperidone at 0.25 mg/day, resulting in rapid clinical remission. One year after the return to low-dose risperidone, the patient's psychopathology is still under control and he is free from psychotic symptoms. Comments: Psychosis is a relatively rare complication after stroke. To our knowledge, no cases of post-stroke psychosis that apparently require continuous low-dose antipsychotic treatment have been reported to date. Our case suggests that low-dose maintenance antipsychotic therapy may be needed for certain patients with post-stroke psychosis, especially for those with risk factors and non-acute onset. Keywords: Psychosis, stroke, antipsychotic treatment. ResumoObjetivo: Descrever o caso raro de um paciente que desenvolveu sintomas psicóticos após um acidente vascular cerebral (AVC) no nível do hemisfério direito que remitiram com tratamento antipsicótico, mas parece precisar de uma terapêutica de manutenção com antipsicótico em baixa dosagem. Descrição de caso: Um homem de 65 anos apresentou-se no serviço de urgência psiquiátrica por um quadro persistente de delírio de ciúmes, ilusões visuais e agitação com início cerca de 1 mês após AVC isquêmico no nível da artéria cerebral posterior direita. Esses sintomas só desapareceram com doses terapêuticas de antipsicótico (risperidona 3 mg/dia). Após 2 anos de seguimento, o paciente não mais apresentava atividade delirante, e o tratamento antipsicótico foi progressivamente descontinuado durante o ano seguinte. No entanto, 1 semana após a suspensão total, o paciente começou a ficar agitado e desconfiado, tendo-se reiniciado a risperidona 0,25 mg/dia, com rápida remissão clínica. O paciente está medicado com esta baixa dose de antipsicótico há um ano, permanecendo psicopatologicamente compensado e sem sintomas psicóticos. Comentários: A psicose é uma complicação relativamente rara após AVC. Segundo nosso conhecimento, não há casos descritos até ao momento de psicose após AVC que, aparentemente, requerem uma dose baixa contínua de antipsicótico. Nosso caso sugere que uma terapêutica de manutenção com antipsicótico em baixa dosagem pode ser necessária para determinados pacientes com psicose após AVC, especialmente para aqueles com fatores de risco e iní...

Organic psychosis: The pathobiology and treatment of delusions

“…For some patients, psychoses are transient and resolves either spontaneously or with the temporary use of antipsychotics and is due to the reduced impact of the lesion by resolution of edema and inflammation. Other patients develop persistent psychotic symptoms and require continual treatment . Here, antipsychotics are the mainstay of pharmacotherapy as there is no evidence that other forms of medication are effective in this condition .…”

“…Nevertheless, the evidence which has accumulated from these detailed case descriptions shows that delusions mainly arise following right cerebral hemisphere damage. For example, of 16 published reports, which included 30 patients, 23 had unilateral right hemisphere lesions [8][9][10][11][12][13][14][15][16][17][18][19] compared to 7 with bilateral or left-sided hemisphere lesions or lesions elsewhere in the brain. [19][20][21][22] Collectively, these case reports also suggest that delusions can arise following right hemisphere damage as a new event without a premorbid history of psychosis and without altered consciousness, as in delirium, or intellectual impairment, as in dementia.…”

“…Psychosis can arise within the first few days following a stroke 13,15,16,20 or there may be a delayed onset of weeks or months. 13,16,18,22 For some patients, psychoses are transient and resolves either spontaneously or with the temporary use of antipsychotics 13,16,17,20,23 and is due to the reduced impact of the lesion by resolution of edema and inflammation. Other patients develop persistent psychotic symptoms and require continual treatment.…”

“…Other patients develop persistent psychotic symptoms and require continual treatment. [16][17][18]27 Here, antipsychotics are the mainstay of pharmacotherapy as there is no evidence that other forms of medication are effective in this condition. 7 Thus, the management of poststroke psychosis is the same as that for the primary psychoses and likely reflects their common etiology.…”

İnme Sonrası Nöropsikiyatrik Sorunlar

“…Treatment suggestions are limited with case reports. There are case reports in the literature reporting that clozapine and valproic acid (Almeida et al 2011) risperidone (Ferreira et al 2017), fluvoxamine and chlorpromazine (Rocha et al 2014), and fluoxetine and risperidone (Duggal 2005) yielded positive results.…”