Inefficacy of Antipsychotics in Treatment of Delirium and Agitation in Two Cases of Bickerstaff Brainstem Encephalitis

Alam, Abdulkader; Puri, Neil V.

doi:10.1176/appi.neuropsych.13040078

Cited by 16 publications

(12 citation statements)

References 15 publications

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“…8 Currently, the data on VPA's efficacy in delirium are limited to only two case series comprising a total of eight patients. 9,10 In addition, there are limited data on VPA's usefulness in the management of agitation in patients with dementia, 11 traumatic brain injury (TBI), 12 alcohol withdrawal, and corticosteroidinduced mania. 13 Finally, emerging data support the use of VPA for neuroprotection in acute central nervous system injuries because of its anti-inflammatory, antiapoptotic, and neurotrophic effects.…”

mentioning

confidence: 99%

Adjunctive Valproic Acid in Management-Refractory Hyperactive Delirium: A Case Series and Rationale

Sher¹,

Miller²,

Lolak³

et al. 2015

JNP

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mentioning

confidence: 99%

Adjunctive Valproic Acid in Management-Refractory Hyperactive Delirium: A Case Series and Rationale

Sher¹,

Miller²,

Lolak³

et al. 2015

JNP

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“…Data from a retrospective cohort study suggests that valproate sodium has been associated with reduced agitation and delirium among critically ill adults in the intensive care unit [16]. Several case series also reported improvement in ICU agitation or delirium with the use of valproate sodium [17,18,19]. Valproate has been suggested as an option for the managing delirium in critically ill patients due to its proposed biochemical mechanism, which provides anti-inflammatory and antioxidant effects [16,20].…”

Section: Discussion Of Significancementioning

confidence: 99%

Management of Agitation, Delirium, and Catatonia in Intubated COVID-19 Patients: A Case Series & Rationale for Valproate Sodium Use During Extubation

Schumaker¹,

Gomez²,

Rojasova³

et al. 2021

obm neurobiol

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The complete spectrum of neuropsychiatric effects of SARS-CoV-2 acute respiratory distress syndrome has yet to be fully appreciated, particularly in intubated patients. Manifestations including delirium and catatonia need to be considered in intubated COVID-19 patients. Medications known to exhibit neuroprotective effects, like valproate, can assist in agitation related to sedative withdrawal during extubation. This case series reports on the management of agitation, delirium, and catatonia in COVID-19 patients during and after extubation efforts. We present three cases in which Psychiatry was consulted for agitation in intubated COVID-19 patients. These patients were managed for severe agitation during weaning from extubation as well as for subsequent psychiatric challenges, including catatonia. Patient 1: 26-year-old female with bipolar I with psychotic features who was admitted for acute hypoxic respiratory failure from COVID-19 pneumonia. After an emergency C-section at 31 weeks’ gestation, she was intubated for 9 days and started on valproate 250 mg BID for agitation. She was extubated successfully and discharged home. Patient 2: 42-year-old female with bipolar I and PTSD who was intubated following COVID-19-related acute hypoxic respiratory failure. She received valproate 250mg BID and was extubated successfully. She became catatonic when home quetiapine was resumed and recovered following quetiapine discontinuation and lorazepam. She was discharged on valproic acid and alprazolam. Patient 3: 23-year-old female with bipolar I with psychotic features who was admitted for COVID-19 acute hypoxic respiratory failure and intubated. She received valproate 250 mg BID and was extubated successfully. She became catatonic when risperidone was re-initiated, but recovered following risperidone discontinuation and addition of lorazepam, gabapentin, and duloxetine. Quetiapine was added before discharge. Valproate was effective for managing delirium and agitation during extubation, as evidenced by normalizing Richmond Agitation and Sedation Scale scores. Additionally, valproate aided in managing catatonia post-extubation. This case series reports on the management of agitation in COVID-19 patients during extubation efforts with valproate sodium, due to its ability to manage delirium and catatonia. Valproate is known to exhibit neuroprotective effects, which possibly explains successful management of agitation during the extubation process.

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“…In BBE, mental symptoms and sleep disturbances are common [6]. However, the initial psychiatric presentation with complex visual hallucinations and agitation is extremely rare [7]. These hallucinations correspond to peduncular hallucinosis (PH), a rare form of visual hallucination.…”

Section: Discussionmentioning

confidence: 99%

Peduncular Hallucinosis and Overlapping Antiganglioside Antibody Syndrome

Demas¹,

Costentin²,

Langlois³

et al. 2019

AJPN

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Guillain Barre Syndrome (GBS), Miller Fisher Syndrome (MFS) and Bickerstaff Brainstem Encephalitis (BBE)form part of the same disease spectrum, sharing some clinical signs and auto-immune based mechanisms with antiganglioside antibodies. GBS, the most common cause of subacute flaccid paralysis, is a well-known and extensively described syndrome. MFS is characterized by subacute ophthalmoplegia, ataxia and areflexia. In 1957, Bickerstaff described some patients who, in addition to ataxia and ophthalmoplegia, had abnormal mental status, corresponding to brainstem involvment. Neurological manifestations associated with anti-GQ1b antibodies can occur in isolation or in association. We report the case of a woman with an unusual psychiatric presentation (peduncular hallucinosis) of anti-GQ1b antibody syndrome, with features of these three diseases, and a dramatic improvement with immunoglobulin therapy. Peduncular hallucinosis are a rare form of visual hallucination. They are often described as colourful visions of people and animals, and are usually associated with vascular lesions in the midbrain and thalamus. This provides further evidence of the broad spectrum of neurological diseases associated with antiganglioside antibodies. To the best of our knowledge this is the first description of PH complicating BBE. Clinicians should be aware of the existence of overlapping syndrome with combined central and peripherical neurological system involvement.

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Inefficacy of Antipsychotics in Treatment of Delirium and Agitation in Two Cases of Bickerstaff Brainstem Encephalitis

Cited by 16 publications

References 15 publications

Adjunctive Valproic Acid in Management-Refractory Hyperactive Delirium: A Case Series and Rationale

Adjunctive Valproic Acid in Management-Refractory Hyperactive Delirium: A Case Series and Rationale

Management of Agitation, Delirium, and Catatonia in Intubated COVID-19 Patients: A Case Series & Rationale for Valproate Sodium Use During Extubation

Peduncular Hallucinosis and Overlapping Antiganglioside Antibody Syndrome

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