Authors : Miguel Angel Diaz Diaz; Valentina Salazar Maldonado; Nicolás Alejandro Contreras Diaz; Juan Manuel Alfonso Parada

Volume/Issue : Volume 11 - 2026, Issue 7 - July

Google Scholar : https://tinyurl.com/mwxejkyv

Scribd : https://tinyurl.com/7xmtwzd5

DOI : https://doi.org/10.38124/ijisrt/26jul1760

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Abstract : Post-stroke neuropsychiatric disturbances may manifest as affective, cognitive, behavioral, or psychotic symptoms and may represent a diagnostic challenge, particularly when structural epilepsy coexists with brain lesions involving different vascular territories. We present the case of a 67-year-old man with a history of arterial hypertension, type 2 diabetes mellitus, and obstructive sleep apnea syndrome, who had experienced ischemic strokes in the territories of the right posterior cerebral artery and the left middle cerebral artery approximately one month before admission, with residual nonfluent aphasia and right upper-limb paresis. Fifteen days before admission, he experienced a late-onset focal seizure and was started on lacosamide. He subsequently developed progressive anxiety, depressed mood, psychomotor agitation, cognitive decline, behavioral changes, persecutory delusions, ideas of reference, and visual and auditory hallucinations. During the evaluation, he was conscious, without evident fluctuations in the level of consciousness or clinical findings consistent with delirium. Metabolic and infectious studies did not identify an alternative cause. Brain computed tomography showed right occipital and left frontoparietal encephalomalacia, as well as cerebral small-vessel disease, without evidence of intracranial hemorrhage or a new acute ischemic event. Video-EEG monitoring did not record epileptiform activity or electrographic seizures during the monitoring period. Brain magnetic resonance imaging was requested to rule out additional structural lesions; however, the study could neither be completed nor retrieved because the patient was transferred to another institution. During the observed hospital stay, he remained neurologically stable, without new focal deficits or recurrent seizures. He received symptomatic treatment with olanzapine, lacosamide was continued, and he underwent joint evaluation by the Neurology and Psychiatry services. The exact doses, subsequent pharmacological adjustments, and longitudinal course of the psychiatric symptoms could not be established because institutional follow-up was lost after the transfer. This case highlights the complexity of distinguishing post-stroke psychiatric manifestations from a new cerebrovascular event, delirium, nonconvulsive epileptic activity, postictal states, and primary psychiatric disorders. Integration of the clinical timeline, mental status examination, neuroimaging, and electrophysiological studies is essential to guide diagnosis and establish individualized treatment.

Keywords : Stroke; Post-Stroke Psychosis; Neuropsychiatric Symptoms; Delusions; Hallucinations; Cognitive Decline; Post-Stroke Epilepsy.

References :

1. Zhang S, Xu M, Liu ZJ, Feng J, Ma Y. Neuropsychiatric issues after stroke: clinical significance and therapeutic
2. implications. World J Psychiatry. 2020;10(6):125-138. doi:10.5498/wjp.v10.i6.125.
3. Stangeland H, Orgeta V, Bell V. Poststroke psychosis: a systematic review. J Neurol Neurosurg Psychiatry. 2018;89(8):879-885. doi:10.1136/jnnp-2017-317327.
4. Pottkämper JCM, Hofmeijer J, van Waarde JA, van Putten MJAM. The postictal state—What do we know? Epilepsia. 2020;61(6):1045-1061. doi:10.1111/epi.16519.
5. Ng IKS, Chua JW, Lui YS, Tan LF, Teo DBS. Approach to acute psychosis in older adults. Singapore Med J. 2023;64(6):391-397. doi:10.4103/singaporemedj.SMJ-2022-150.
6. Kim K, Jeon HJ, Myung W, Suh SW, Seong SJ, Hwang JY, et al. Clinical approaches to late-onset psychosis. J Pers Med. 2022;12(3):381. doi:10.3390/jpm12030381.
7. Sutter R, Rüegg S, Kaplan PW. Epidemiology, diagnosis, and management of nonconvulsive status epilepticus: opening Pandora’s box. Neurol Clin Pract. 2012;2(4):275-286. doi:10.1212/CPJ.0b013e318278be75.
8. Saha G, Chakraborty K, Pattojoshi A. Management of psychiatric disorders in patients with stroke and traumatic brain injury. Indian J Psychiatry. 2022;64(Suppl 2):S344-S354. doi:10.4103/indianjpsychiatry.indianjpsychiatry_34_22.
9. Mota Freitas R, Reis Gomes D, Antunes Pedro J, Guerra A. Poststroke psychosis: a case report. Neuropsychiatr. 2023;37(2):101-104. doi:10.1007/s40211-022-00432-1.
10. Nascimento H, Almeida B. Psychotic disorder after left posterior cerebral artery stroke—an atypical event. Actas Esp Psiquiatr. 2024;52(1):60-65.
11. Huang JA, Chen WH, Liao NC, Wu CL, Fu YC, Chen PL. Acute delirium as an initial manifestation of COVID-19 patients with acute ischemic stroke: report on two cases. J Formos Med Assoc. 2022;121(8):1605-1609. doi:10.1016/j.jfma.2022.01.025.
12. Veldsman M, Werden E, Egorova N, Khlif MS, Brodtmann A. Microstructural degeneration and cerebrovascular risk burden underlying executive dysfunction after stroke. Sci Rep. 2020;10:17911. doi:10.1038/s41598-020-75074-w.
13. Rafique SA, Richards JR, Steeves JKE. Altered white matter connectivity associated with visual hallucinations following occipital stroke. Brain Behav. 2018;8(6):e01010. doi:10.1002/brb3.1010.
14. Hassanin A, Ramsamaroo Z, Barry M, Cassidy T. Carotid endarterectomy for symptomatic carotid artery stenosis in a patient who presented with psychosis. BMJ Case Rep. 2022;15(4):e242457. doi:10.1136/bcr-2021-242457.
15. Ahmed S, Ahmed S, Zafar J. Alice in Wonderland syndrome as a rare presentation of cryptogenic stroke: a case report. Cureus. 2025;17(2):e79750. doi:10.7759/cureus.79750.
16. Regala J, Lourenço J, Moniz-Pereira F, Bento A. Postictal psychosis: case report and literature review. Case Rep Psychiatry. 2023;2023:7960227. doi:10.1155/2023/7960227.
17. Hasan TF, Tatum WO. When should we obtain a routine EEG while managing people with epilepsy? Epilepsy Behav Rep. 2021;16:100454. doi:10.1016/j.ebr.2021.100454.
18. Bell V, Tamayo-Agudelo W, Revill G, Okai D, Poole N. Association between stroke and psychosis across four nationally representative psychiatric epidemiological studies. BJPsych Open. 2023;9(3):e71. doi:10.1192/bjo.2023.47.
19. Tampi RR, Young J, Hoq R, Resnick K, Tampi DJ. Psychotic disorders in late life: a narrative review. Ther Adv Psychopharmacol. 2019;9:2045125319882798. doi:10.1177/2045125319882798.
20. Lavu VK, Mohamed RA, Huang R, Potla S, Bhalla S, Al Qabandi Y, et al. Evaluation and treatment of depression in stroke patients: a systematic review. Cureus. 2022;14(8):e28137. doi:10.7759/cureus.28137.