Post-stroke psychosis: how long should we treat?

Jealousy's stroke: Othello syndrome following a percheron artery infarct

INTRODUCTION

Othello syndrome is a psychosis with delusions of infidelity, where the patient harbors a persistent, unfounded belief - a "delusion" - that their partner is being unfaithful. This condition can manifest in certain psychiatric conditions and neurological disorders, such as neurodegenerative diseases, as parkinson's disease treatment side effects, or occasionally after a stroke.

CASE

We report a rare case of a 50-year-old woman, with no previous psychiatric history, who developed a delusion of infidelity, leading to verbal and physical aggressions with bladed weapons, days after experiencing a bi-thalamic infarct due to the occlusion of the Percheron artery.

DISCUSSION

Psychosis is the third most common psychiatric symptom post-stroke, with delusional disorders being the most prevalent type. Within this category, delusional jealousy is the second most common subtype, following persecutory delusions. Although no specific brain lesions are exclusively responsible for jealousy delusions, lesions in various regions, particularly in the right hemisphere, have been implicated. Thalamic strokes disrupt the frontal-subcortical-thalamic circuitry, crucial for executive functions, and the dorsomedial nuclei, leading to alterations in limbic circuitry and emotional regulation. These damages can result in significant impairments in impulse control and judgment, manifesting as behavioral disorders due to a flawed interpretation of a partner's actions as infidelity. In this case, our patient experienced a bi-thalamic infarct predominantly on the right side.

CONCLUSION

Othello syndrome represents a challenging post-stroke complication, highlighting the intricate relationship between neurological damage and psychiatric manifestations. Recognizing and promptly addressing this syndrome is crucial, given its potential for dangerous outcomes.

Poststroke psychosis: a case report

Background

Stroke is currently the second leading cause of death in the elderly population. Neuropsychiatric complications following stroke are common, can be overlooked, and are associated with low quality of life, increase in the burden of caregiving and impaired functional status.

Methods

We report a case of poststroke psychosis in a woman without prior psychiatric history. In addition, a brief, nonsystematic review of the pertinent literature was performed.

Results

Psychosis can present in almost 5% of stroke survivors. Many patients with poststroke psychosis have no previous psychiatric history and the most common lesion locations include the right frontal, temporal and parietal lobes, the white matter connecting those areas, as well as the right caudate nucleus. Compared to other stroke survivors, patients with poststroke psychosis are more likely to depend on assistance in their everyday lives, can have more difficulty coping with the sequelae of stroke, and have an increased 10-year mortality risk. Guidelines for diagnosing and managing poststroke psychosis are needed.

Conclusion

Psychosis is a possible complication of stroke and is associated with impairment and increased mortality. Guidelines for diagnosing and managing poststroke psychosis are currently lacking. To assure evidence-based care, further research is needed.

Psychiatric sequelae of stroke affecting the non-dominant cerebral hemisphere

There are a plethora of cognitive sequelae in addition to neglect and extinction that arise with unilateral right hemispheric stroke (RHS). Cognitive deficits following non-dominant (right) hemisphere stroke are common with unilateral neglect and extinction being the most recognized examples. The severity of RHS is usually underestimated by the National Institutes of Health Stroke Scale (NIHSS), which in terms of lateralized right hemisphere cognitive deficits, tests only for visual inattention/extinction. They account for 2 out of 42 total possible points. Additional neuropsychiatric sequelae include but are not limited to deficiencies in affective prosody comprehension and production (aprosodias), understanding and expressing facial emotions, empathy, recognition of familiar faces, anxiety, mania, apathy, and psychosis. These sequelae have a profound impact on patients' quality of life; affecting communication, interpersonal relationships, and the ability to fulfill social roles. They also pose additional challenges to recovery. There is presently a gap in the literature regarding a cohesive overview of the significant cognitive sequelae following RHS. This paper serves as a narrative survey of the current understanding of the subject, with particular emphasis on neuropsychiatric poststroke syndromes not predominantly associated with left hemisphere lesions (LHL), bilateral lesions, hemiplegia, or paralysis. A more comprehensive understanding of the neuropsychological consequences of RHS extending beyond the typical associations of unilateral neglect and extinction may have important implications for clinical practice, including the ways in which clinicians approach diagnostics, treatment, and rehabilitation.

Comparative safety of antipsychotic medications in elderly stroke survivors: A nationwide claim data and stroke registry linkage cohort study

BACKGROUND

Antipsychotics remain the first choice of treatment for post-stroke psychosis, despite an increased risk of mortality reported in elderly patients. We aimed to compare the mortality risk among antipsychotics in elderly patients with stroke using the stroke registry for external adjustment.

METHODS

We conducted a retrospective cohort study to identify patients aged above 65 years who were admitted for stroke in the National Health Insurance Database (NHID) from 2002 to 2014. The first date of antipsychotic use after the stroke hospitalization was defined as the index date. Covariates including diseases, medications and external information on smoking, BMI, stroke severity and disability, that were unavailable in the NHID were obtained from the linked Multicenter Stroke Registry (MSR) and used for propensity score calibration (PSC). The main outcome was one-year all-cause mortality.

RESULTS

Stroke patients in the NHID prescribed with haloperidol, quetiapine and risperidone numbered 22,235, 28,702 and 8 663, respectively. In the PSC-adjusted analyses, haloperidol [adjusted hazard ratio (aHR) = 1.22; 95% CI 1.18-1.27] and risperidone (aHR = 1.31; 95% CI 1.24-1.38) users had a higher mortality risk than quetiapine users. When the dosage was higher than 0.5 defined daily dose (DDD), haloperidol and risperidone users had a significant mortality risk as compared with those taking a lower dose.

CONCLUSIONS

In post-stroke elderly patients, quetiapine would pose less mortality risk than risperidone and haloperidol at doses higher than 0.5 DDD. When haloperidol or risperidone is indicated, starting with a lower dose is suggested to avoid excess risk.

Identification of pleiotropic genes between risk factors of stroke by multivariate metaCCA analysis

Genome-wide association studies (GWASs) have identified more than 20 genetic loci as risk predictors associated with stroke. However, these studies were generally performed for single-trait and failed to consider the pleiotropic effects of these risk genes among the multiple risk factors for stroke. In this study, we applied a novel metaCCA method followed by gene-based VEGAS2 analysis to identify the risk genes for stroke that may overlap between seven correlated risk factors (including atrial fibrillation, hypertension, coronary artery disease, heart failure, diabetes, body mass index, and total cholesterol level) by integrating seven corresponding GWAS data. We detected 20 potential pleiotropic genes that may be associated with multiple risk factors of stroke. Furthermore, using gene-to-trait pathway analysis, we suggested six potential risk genes (FUT8, GMIP, PLA2G6, PDE3A, SMARCA4, SKAPT) that may affect ischemic or hemorrhage stroke through multiple intermediate factors such as MAPK family. These findings provide novel insight into the genetic determinants contributing to the concurrent development of biological conditions that may influence stroke susceptibility, and also indicate some potential therapeutic targets that can be further studied for the prevention of cerebrovascular disease.

Chronic Post-stroke Psychosis with Left Cortical and Bilateral Inferior Cerebellar Involvement

Post-stroke psychosis is the presence of delusions and/or hallucinations that result from an infarct in the cerebrovascular network. Involvement of a predominantly right-sided cortical pathology has been described in triggering the psychosis. In identified cases, patients often have little to no prior psychiatric history. We report a case of a 70-year-old female with chronic post-stroke psychosis consisting of auditory hallucinations and persecutory delusions. Our patient serves as a unique case in not only contributing to the limited number of documentations overall, but also in highlighting a presentation with infarction of the left parietal-temporal-occipital cortex and bilateral inferior cerebellum.

Organic psychosis: The pathobiology and treatment of delusions

Organic or secondary psychosis can be seen in diverse conditions such as toxic/metabolic disorders, neurodegenerative disease, and stroke. Poststroke psychosis is a rare phenomenon, but its study has significantly contributed to the understanding of delusion formation. The evidence from case studies of patients with focal strokes shows that delusions develop following unilateral damage of the right hemisphere. The majority of patients with right hemisphere stroke do not develop delusions however, and advanced neuroimaging analysis has elucidated why this symptom develops in only a small proportion. Lesions of the right lateral prefrontal cortex or lesions with connectivity to this area correlate with delusional beliefs in this subgroup. Studies of patients with primary psychosis, for example schizophrenia, or under the influence of the psychotogenic drug ketamine, also show abnormal function of this area in relation to the severity of their abnormal beliefs. The conclusion of these studies is that the right lateral prefrontal cortex is 1 hub in a neural network which includes the basal ganglia and limbic system and receives inputs from midbrain dopamine neurones. In patients with schizophrenia, or at risk of psychosis, dopamine is dysregulated and evidence suggests that faulty dopamine signaling is the precursor of delusion formation. It is therefore likely that the mechanism of delusion formation is the same in both primary and secondary psychosis. This is consistent with the mainstay of treatment of both conditions being antipsychotic medication. However, antipsychotic medication in people with cerebrovascular disease should be avoided if at all possible. This is because epidemiological studies have found that antipsychotic use is associated with an increased risk of stroke and will thus compound the possibility of a further cerebrovascular accident.