CARTA AOS EDITORES
Poststroke manic symptoms: an unusual neuropsychiatric condition
Sintomas maniformes pós-AVC: uma condição neuropsiquiátrica infreqüente
Dear Editor,
Recently, we have published a case report describing a patient with history of maniac behavior that started three weeks after a right medial frontal lobe stroke that was successfully managed with valproic acid.1
Our Department of Psychiatry has evaluated a second case with poststroke hypomania symptoms.
A 57-year-old Caucasian man, married, salesman, with a 15-year history of hypertension and diabetes was admitted to our ward with occasional episodes (six per month) of irritability, emotional labiality, reduced sleep need, rapid speech and thoughts. Each episode lasted for two days approximately. These symptoms had begun after a severe case of stroke affecting his right temporal-parietal lobe with unspecific lesions in the white matter in both hemispheres eights months before the admission. Magnetic resonance scan was carried out soon after the stroke and showed an area at the right temporal-parietal lobe compatible with stroke and few chronic ischemic lesions widespread throughout the white matter (Figure 1).
Although he did not fulfilled clinical criteria for manic episode according to DSM-IV-TR, his Young Mania Rating Scale (YMRS) classification was 21 (range 0-20) during one of the episodes. No previous history of any psychiatric disorder, including mood or substance use disorders, could be evidenced.
A neurological examination was performed whereas he scored 28 out of 30 in the Folstein Mini-Mental State Examination. No cognitive deficits were observed.
Laboratory work-up, including complete blood count, creatine kinase level, electrolytes, renal, liver and thyroid function tests, serology for syphilis and HIV were unrevealing.
Valproic acid (750 mg/day) was initiated with good improvement of his symptoms (YMRS scoring 10 during mood episodes; serum level of valproic acid was 79.0 µg/ml).
Discussion: Some papers discuss a probable correlation between mania episodes after right hemisphere lesions, mainly in right orbitofrontal and basotemporal cortices, the dorsomedial thalamic nucleus and the head of the caudate nucleus.1-3
In our patients, both presented symptoms of mania after a stroke that affected the right portion of the brain. Despite the two cases, classic poststroke mania syndrome is not frequently observed, and the major hypothesis for this is that it takes more than one area with a dysfunction to make this occur. Also, an increase in serotonin receptor binding on the right hemisphere, caused by stroke event, may explain why mania episodes are always related to injuries on the right lobe of the brain.1,3
It has also been discussed a connection between the white matter hyperintensities (WMH) lesions in poststroke mania cases, including our cases. These could be a result from vascular cerebral tissue insults and there is also accumulated evidence supporting a role of WMH in the pathophysiology of adult-onset bipolar disorder.4
There are some drugs used for the treatment of this condition, like olanzapine, lithium, carbamazepine and valproic acid. In both our cases, the last one had the most successful result. Perhaps, mood stabilizing anticonvulsants may be the agents of choice in the treatment of secondary mania, besides the propensity for seizures in the poststroke period.1-3
Felipe Filardi da Rocha
Psychiatric Service, School of Medicine,
Universidade Federal de Minas Gerais (UFMG),
Belo Horizonte (MG), Brazil
Department of Pharmacology,
Universidade Federal de Minas Gerais (UFMG),
Belo Horizonte (MG), Brazil
Juliana Garcia Carneiro, Patrícia de Araújo Pereira
Department of Pharmacology,
Universidade Federal de Minas Gerais (UFMG),
Belo Horizonte (MG), Brazil
Humberto Correa
Mental Health Department, School of Medicine,
Universidade Federal de Minas Gerais (UFMG),
Belo Horizonte (MG), Brazil
Antonio Lúcio Teixeira
Department of Internal Medicine, School of Medicine,
Universidade Federal de Minas Gerais (UFMG),
Belo Horizonte (MG), Brazil
Financial support: None
Conflict of interests: None
- 1. da Rocha FF, Correa H, Teixeira AL. A successful outcome with valproic acid in a case of mania secondary to stroke of the right frontal lobe. Prog Neuropsychopharmacol Biol Psychiatry. 2008;32(2):587-8.
- 2. Wijeratne C, Malhi GS. Vascular mania: an old concept in danger of sclerosing? A clinical overview. Acta Psychiatr Scand Suppl. 2007;434:35-40.
- 3. Chemerinski E, Levine SR. Neuropsychiatric disorders following vascular brain injury. Mt Sinai J Med. 2006;73(7):1006-14.
- 4. Zanetti MV, Cordeiro Q, Busatto GF.Late onset bipolar disorder associated with white matter hyperintensities: a pathophysiological hypothesis. Prog Neuropsychopharmacol Biol Psychiatry. 2007;31(2):551-6.
Publication Dates
-
Publication in this collection
23 June 2008 -
Date of issue
June 2008
