
Post-stroke mania is a rare occurrence, and little is known about the natural history of the disease. However, it is a recognised neuropsychiatric syndrome that needs to be rapidly identified and treated to prevent morbidity and mortality. Post-stroke mania is characterised by a prominent and persistent disturbance in mood, with elevated, expansive, or irritable mood. The disturbance is the direct physiological consequence of a stroke and is not accounted for by another mental disorder. It is important to do a proper mental assessment of post-stroke patients to identify any prevailing mood disorder, particularly mania, to prevent disease progression and limit its later onset.
Characteristics | Values |
---|---|
How common is post-stroke mania? | Post-stroke mania is rare, with an estimated prevalence of between <1% and 1.6% among stroke patients. |
What are the symptoms of post-stroke mania? | Manic symptoms include abnormally elevated arousal, affect, and energy levels, irritable mood, hyperactivity, pressured speech, flight of ideas, grandiosity, decreased sleep, distractibility, and lack of judgement. |
What are the risk factors? | Risk factors include being male, having cardiovascular risk factors, and having right frontal lobe lesions affecting the orbitofrontal circuit. |
What treatments are available? | Treatments include second-generation antipsychotics or anticonvulsant mood stabilizers such as valproic acid, lithium, benzodiazepines, diazepam, olanzapine, and sodium valproate. |
What You'll Learn
Post-stroke mania is rare
Post-stroke mania (PSM) is a rare occurrence, with little known about the natural history of the disease. It is estimated that the prevalence of PSM is between <1% and 1.6% among stroke patients. This estimation is limited by small sample sizes, sparse literature, and likely underrecognition of the disorder.
PSM typically presents in older males with cardiovascular risk factors and right frontal lobe lesions affecting the orbitofrontal circuit (OFC). The OFC plays a central role in mood regulation and social behaviour, particularly in social inhibition. However, atypical presentations are possible, as our understanding of the disease is still incomplete.
The onset of bipolar disorder (BD) secondary to a stroke event is a rare clinical entity. It has been associated with specific regions of the brain, such as subcortical atrophy or chronic vascular burden. The precise locations and cerebral circuits involved in the expression of BD after a stroke are yet to be determined.
The term "secondary mania" was introduced by Krauthammer and Klerman in 1978 to describe the onset of symptoms that meet the diagnostic criteria for mania produced by neurological, metabolic, or toxic disorders. Secondary mania is characterised by elevated or irritable mood, hyperactivity, pressured speech, flight of ideas, grandiosity, decreased sleep, distractibility, and lack of judgment.
The immediate assessment of any prevailing mood disorder, particularly mania in post-stroke patients, is necessary to prevent disease progression and limit its later onset, reducing the morbidity of life.
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It is associated with right-sided lesions
Mania following a stroke is an unusual occurrence, with a frequency of less than 1%. It is more common in male patients with cardiovascular risk factors and right frontal lobe lesions affecting the orbitofrontal circuit. This circuit is a complex network that plays a central role in mood regulation and social behaviour, particularly in social inhibition.
The majority of studies reporting secondary mania and bipolar disorder after stroke allocate the responsible lesions to the right hemisphere. However, there are also reports of mania following left-sided lesions. In a case study of a 68-year-old male patient, a right putaminal hemorrhage resulted in hypoperfusion in the right temporal and frontal regions, as well as hyperperfusion in the left hemisphere. Another case study of a 65-year-old male patient with bipolar disorder secondary to multiple subcortical biparietal lacunar infarctions, a lacunar infarction in the left putamen, and an ischemic lesion at the cerebral trunk evolving the right median portion, exhibited both mania and depression.
The right hemisphere is thought to be more closely associated with mania, while the left hemisphere is associated with positive emotions and approach motivation, which can generate a manic state.
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It can be caused by cardioembolic multifocal right hemispheric stroke
Strokes are the most common cause of disability in the United States and are associated with depressive symptoms. However, post-stroke mania (PSM) is a rare occurrence, and little is known about its natural history. PSM typically affects older males with cardiovascular risk factors and right frontal lobe lesions affecting the orbitofrontal circuit (OFC).
In a published case, a 53-year-old male with no personal or family history of medical or psychiatric disease presented to the emergency department with a single 20-minute episode of right upper and lower extremity numbness, along with slurred speech. These symptoms resolved spontaneously before presentation. The patient had taken a 13-hour flight approximately six days prior. Examinations and tests revealed no abnormalities. However, a diffusion-weighted magnetic resonance image of the brain showed a small focus of restricted diffusion in the left parietal lobe and multiple frontal subcortical and cortical lesions in different stages of resolution, consistent with embolic phenomena.
The patient was admitted for evaluation of a suspected stroke and was started on therapeutic anticoagulation. Cardiology was consulted, and a PFO closure device was deployed under conscious sedation within a week of hospital discharge.
A month later, the patient returned to the emergency department, exhibiting increasingly bizarre behaviour, including threatening homicide. A mental status exam revealed rapid and pressured speech, tangential thought process, grandiosity, intrusiveness, and disordered impulse control. Repeat MRI imaging revealed stable lesions. The patient was admitted to psychiatry with a diagnosis of PSM.
On the psychiatric unit, the patient accepted admission and pharmacologic treatment. Treatment with valproate was offered, and the patient's symptoms improved over the next week of inpatient treatment.
PSM is a rare post-stroke neuropsychiatric syndrome that requires rapid identification and treatment to prevent morbidity and mortality. While the pathogenesis and optimal treatments for PSM are not yet fully understood, it is associated with right frontal lobe lesions affecting the OFC. Atypical presentations are possible, as our understanding of PSM is still evolving.
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It can be treated with second-generation antipsychotics or anticonvulsant mood stabilizers
Post-stroke mania (PSM) is a rare occurrence, and there is a lack of understanding of the natural history of the disease. PSM is an infrequent but acknowledged post-stroke neuropsychiatric syndrome that needs to be rapidly identified and treated to prevent morbidity and mortality. While there are no expert guidelines or consensus on the most effective way to treat patients with PSM, published case series suggest approaches ranging from inpatient monitoring without pharmacotherapy to a wide range of treatments with second-generation antipsychotics or anticonvulsant mood stabilizers.
Second-generation antipsychotics have proven to be effective in treating acute mania in bipolar disorder. These medications cause fewer side effects than first-generation antipsychotics, do not appear to induce depressive episodes, and may have some antidepressant effect. However, it is important to note that older adult patients under antipsychotic regimens with a high or intermediate risk of metabolic side effects may face a higher incidence of major cardiovascular events, particularly stroke.
Anticonvulsant mood stabilizers are used to treat both epileptic and non-epileptic disorders such as bipolar disorder. Lithium is considered the gold standard mood stabilizer for bipolar disorder, but valproic acid can be more effective in patients who do not respond to lithium and has a more rapid anti-manic effect. Other mood stabilizers include newer anticonvulsants such as carbamazepine and lamotrigine.
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It can be diagnosed using the DSM-V criteria
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria, poststroke mania can be diagnosed if the following features are present:
- A prominent and persistent disturbance in mood that is characterised by an elevated, expansive, or irritable mood.
- Evidence from the patient's history, physical examination, or laboratory findings that indicates the disturbance is the direct physiological consequence of a stroke.
- The disturbance cannot be explained by another mental disorder.
- The disturbance does not occur exclusively during a period of delirium.
- The symptoms cause clinically significant distress or impairment in important areas of functioning, such as social or occupational domains.
The DSM-V criteria for mania/hypomania require a distinct period of abnormally and persistently elevated, expansive, or irritable mood, along with abnormally and persistently increased goal-directed activity or energy. These symptoms must be present most of the day, nearly every day, for at least four consecutive days. During this period of mood disturbance and increased energy, the patient must exhibit at least three (or four if the mood is only irritable) of the following symptoms:
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience of racing thoughts
- Distractibility (i.e., attention easily drawn to unimportant stimuli)
- Increase in goal-directed activity or psychomotor agitation
- Excessive involvement in pleasurable activities with a high potential for painful consequences
It is important to note that the symptoms should represent a noticeable change from the patient's usual behaviour and should be present to a significant degree. Additionally, the disturbance in mood and functioning should be observable by others.
The DSM-V criteria for mania/hypomania aim to improve diagnostic accuracy and treatment outcomes. However, the impact of these criteria on prevalence and treatment outcomes is still unclear and requires further investigation.
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Frequently asked questions
Post-stroke mania (PSM) is a rare condition where a person experiences mania after a stroke. Mania is characterised by an abnormally elevated arousal, affect and energy level.
Symptoms of post-stroke mania include elevated or irritable mood, hyperactivity, pressured speech, flight of ideas, grandiosity, decreased sleep, distractibility, lack of judgement, irritability, motor excitement, and reduced need for sleep.
Post-stroke mania is typically treated with antipsychotics or anticonvulsant mood stabilisers.