Poststroke psychosis: a systematic review

Abstract

A preregistered systematic review of poststroke psychosis examining clinical characteristics, prevalence, diagnostic procedures, lesion location, treatments, risk factors and outcome. Neuropsychiatric outcomes following stroke are common and severely impact quality of life. No previous reviews have focused on poststroke psychosis despite clear clinical need. CINAHL, MEDLINE and PsychINFO were searched for studies on poststroke psychosis published between 1975 and 2016. Reviewers independently selected studies for inclusion, extracted data and rated study quality. Out of 2442 references, 76 met inclusion criteria. Average age for poststroke psychosis was 66.6 years with slightly more males than females affected. Delayed onset was common. Neurological presentation was typical for stroke, but a significant minority had otherwise ‘silent strokes’. The most common psychosis was delusional disorder, followed by schizophrenia-like psychosis and mood disorder with psychotic features. Estimated delusion prevalence was 4.67% (95% CI 2.30% to 7.79%) and hallucinations 5.05% (95% CI 1.84% to 9.65%). Twelve-year incidence was 6.7%. No systematic treatment studies were found. Case studies frequently report symptom remission after antipsychotics, but serious concerns about under-representation of poor outcome remain. Lesions were typically right hemisphere, particularly frontal, temporal and parietal regions, and the right caudate nucleus. In general, poststroke psychosis was associated with poor functional outcomes and high mortality. Poor methodological quality of studies was a significant limitation. Psychosis considerably adds to illness burden of stroke. Delayed onset suggests a window for early intervention. Studies on the safety and efficacy of antipsychotics in this population are urgently needed.

Organic psychosis: The pathobiology and treatment of delusions

“…If an embolus or atheroma causing ischemia occludes 1 cerebral artery or a tributary thereof, a unilateral, circumscribed lesion may develop which helps pinpoint the neural substrate of ensuing symptoms. The development of delusions after a stroke is a relatively rare phenomenon (<5%) so much so that it has mainly been reported as individual cases. Nevertheless, the evidence which has accumulated from these detailed case descriptions shows that delusions mainly arise following right cerebral hemisphere damage.…”

“…[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.…”

Posterior Circulation Stroke –presenting as Psychotic disorder

“…The average time between the onset of psychotic symptoms and stroke was variable in different studies. 2 Focusing specifically on delusional ideation (DI) following stroke, Kumral and Oztürk reported mostly an acute onset of DI within two days of stroke, unlike our patient. The prevalence of other symptoms which can be observed along with delusions like agitation, aggression, emotionalism, anxiety reactions and depression were noted inconsistently.…”

“…A recent systematic review did not identify any case or case series involving posterior circulation infarcts. 2 We will briefly discuss a case of posterior circulation stroke, which initially presented as a psychotic disorder. Written informed consent has been taken before publishing the data.…”

“…5 Considering the high prevalence of stroke in the population, post-stroke psychosis should be studied systematically. 2…”