Annals of Indian Psychiatry

LETTER TO EDITOR
Year
: 2020  |  Volume : 4  |  Issue : 2  |  Page : 236--237

Acute psychosis as a manifestation of cerebrovascular accident


Sai Kiran Pasupula, Saka Meghana, Sravanthi Meesala, Suresh Kumar Kota 
 Department of Psychiatry, Katuri Medical College and Hospital, Guntur, Andhra Pradesh, India

Correspondence Address:
Ass Prof. Sai Kiran Pasupula
Department of Psychiatry, Katuri Medical College and Hospital, Guntur-522 014 Andhra Pradesh
India




How to cite this article:
Pasupula SK, Meghana S, Meesala S, Kota SK. Acute psychosis as a manifestation of cerebrovascular accident.Ann Indian Psychiatry 2020;4:236-237


How to cite this URL:
Pasupula SK, Meghana S, Meesala S, Kota SK. Acute psychosis as a manifestation of cerebrovascular accident. Ann Indian Psychiatry [serial online] 2020 [cited 2021 Feb 26 ];4:236-237
Available from: https://www.anip.co.in/text.asp?2020/4/2/236/301431


Full Text



Sir,

Cerebrovascular accident (CVA), commonly termed as cerebral stroke, is the fifth largest cause of mortality.[1] Stroke is associated with many comorbidities, and psychotic features are one among the commonly related disturbances.[2] The relationship between stroke and psychosis is bidirectional,[3] and there is a high suspicion of cerebral insult when there is a sudden-onset of psychotic features with rapid progression.[4] Earlier literature on CVA and psychosis mainly dealt with poststroke psychosis, and very few case reports are documented regarding stroke with concurrent psychosis and the current study focused on this association.

A 60-year-old married woman, a homemaker, was brought by her family members to the psychiatry outpatient department with chief complaints of irritability, not recognizing family members, abusing family members, self-smiling, self-muttering with no obvious reason, hearing of voices, and decreased sleep for the past 20 days. The patient was initially taken to a local faith healer and subsequently brought to the hospital for treatment. There was no history of similar complaints in the past. Neurological examination revealed a slight weakness in the left lower limb. Assessment of mental status revealed perceptual disturbance of second-person auditory hallucinations, and thought content revealed delusion of persecution. Higher mental status assessment revealed impairment of immediate and recent memory with intact remote memory. Magnetic resonance imaging (MRI) of the brain showed an acute infarct in the right capsuloganglionic region, right caudate nucleus, and right frontal lobe.[Figure 1]. We referred the patient to a neurologist who started her on antiplatelet medication. Psychotic disturbances were controlled with quetiapine 100 mg. Her hallucinations steadily declined and her sleep has improved. She responded to medication and was discharged after 10 days of hospital stay.{Figure 1}

Among all the psychiatric disturbances associated with stroke, psychosis is an infrequent complication.[5] Organic psychosis is commonly found among the geriatric population, and acute onset of hallucinations and delusions in elderly patients with no history of previous psychiatric disorders should prompt a thorough investigation for neurological causes of psychotic symptoms.[6] In the current report, the age of the patient is 60 years which supports the earlier statement. The MRI brain showed decreased blood supply to the cerebral regions, which supports that the prevalence of psychotic features is more common among individuals with an episode of ischemic stroke rather than hemorrhagic stroke.[7] The current location of the lesion was on the right hemisphere of the brain which is concurrent with Cummings,[8] who described that stroke with right hemisphere lesions was more commonly associated with delusions or hallucinations. CVA is associated with delusions and hallucinations when the location of the infarct is at the subcortical region, and our patient had lacunar infarcts in the right thalamus, with a decreased blood supply to the caudate nucleus and the prefrontal region. The incidence of psychotic features is more when there is lacunar lesion at the caudate nucleus, and also, the chance of psychosis is high when the stroke is associated with prefrontal hypometabolism.[9],[10]

There is a need to rule out organicity, especially among the geriatric population, when there is a sudden onset of psychotic features with rapid progression.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Arauz A, Marquez-Romero JM, Barboza MA, Serrano F, Artigas C, Murillo-Bonilla LM, et al. Mexican-National Institute of Neurology and Neurosurgery-Stroke Registry: Results of a 25-year hospital-based study. Front Neurol 2018;9:207.
2Kim JS. Post-stroke mood and emotional disturbances: Pharmacological therapy based on mechanisms. J Stroke 2016;18:244-55.
3Hesdorffer DC. Comorbidity between neurological illness and psychiatric disorders. CNS Spectr 2016;21:230-8.
4Kanner AM, Ribot R, Mazarati A. Bidirectional relations among common psychiatric and neurologic comorbidities and epilepsy: Do they have an impact on the course of the seizure disorder? Epilepsia Open 2018;3:210-9.
5Stangeland H, Orgeta V, Bell V. Poststroke psychosis: A systematic review. J Neurol Neurosurg Psychiatry 2018;89:879-85.
6Brendel RW, Stern TA. Psychotic symptoms in the elderly. Prim Care Companion J Clin Psychiatry 2005;7:238-41.
7Perna R, Temple J. Rehabilitation outcomes: Ischemic versus hemorrhagic strokes. Behav Neurol 2015;2015:891651.
8Cummings JL. Neuropsychiatric manifestations of right hemisphere lesions. Brain Lang 1997;57:22-37.
9McMurtray A, Tseng B, Diaz N, Chung J, Mehta B, Saito E. Acute psychosis associated with subcortical stroke: Comparison between basal ganglia and mid-brain lesions. Case Rep Neurol Med 2014;2014:428425.
10McMurtray AM, Sultzer DL, Monserratt L, Yeo T, Mendez MF. Content-specific delusions from right caudate lacunar stroke: Association with prefrontal hypometabolism. J Neuropsychiatry Clin Neurosci 2008;20:62-7.