Clinical Case Discussion
Poststroke Psychosis Reduction: A Case Report
Strokes have been shown to result in psychiatric phenomena that can range from mood
disorders to psychosis. Ablative neurosurgeries have been performed with the goal
of reducing the burden of psychiatric symptoms following such cerebrovascular accidents. In this report, we review poststroke
psychiatric manifestations, and then present
the case of a woman with schizophrenia
whose thought disorder improved following a
hemorrhagic stroke. Not only did she require
less medication, but her remaining symptoms
were signiﬁcantly less impairing than they
had previously been. We then compare and
contrast the effects of this stroke with ablative
neurosurgery.
(Journal of Psychiatric Practice 2018;24;194–
198)
KEY WORDS: schizophrenia, stroke, psychosis,
cerebrovascular accident, psychosurgery

Strokes change lives, both for those who directly experience them, as well as for their family and friends. The
World Health Organization deﬁnes a stroke as “rapidly
developing clinical signs of focal (or global) disturbance
of cerebral function, with symptoms 24 hours or longer
or leading to death, with no apparent cause other
than of vascular origin.”1 For most, the poststroke
experience involves great challenges and requires great
tenacity, and, in some cases, mental changes ensue.
Psychiatric phenomena such as poststroke depression,
euphoria, personality changes, and cognitive deterioration are common during the clinical evolution of
patients who have had a stroke.2 Intentionally ablative
lesions have been used to aid in the treatment of
mental illness, and in this report, we compare and
contrast the effects of a stroke in a female patient with
schizophrenia with those of ablative neurosurgery.

POSTSTROKE PSYCHIATRIC SYNDROMES
Mood Disorders
New onset depression is the most common poststroke psychiatric disorder, occurring in 20% to 50%

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Case presentation:
MICHAEL B. CENTORINO, MD
GLENN CATALANO, MD
LAURA C. GRIMSICH, MD
ROULA M. ANTOUN, MHA

of cases2–5 with a mean duration ± SD of 39 ± 32
weeks.3 Poststroke anxiety is signiﬁcantly comorbid
with poststroke depression and has an independent
prevalence of ∼25%.2–4 Poststroke mania is rare,
occurring in fewer than 1% of cases, but it has been
reported to be successfully treated with lithium.2,3
Strokes that affect both parietal and frontal circuits
are associated with anosognosia, a symptom also
commonly seen in psychotic disorders.3
Psychosis
Poststroke psychosis is much rarer than poststroke
depression, often involving precise infarcts to the
caudate nucleus, striatum, or thalamus,2,6 and its
onset may be delayed by years after the stroke
occurs.3,7 Patients with poststroke psychosis have
been found to demonstrate more subcortical atrophy than controls when matched for age, lesion size,
and location.8 It has also been postulated that the
development of poststroke psychosis is more
attributable to the resultant asymmetry of poststroke brain activity, rather than the intrinsic
nature of any speciﬁc, individual lesion.6

STROKES IN SCHIZOPHRENIA
Even when the data are controlled for sex, income,
degree of urbanization, and comorbid medical disorders, studies have found that people with schizophrenia are up to twice as likely to sustain a stroke as
individuals in the general population.9,10 This has
been attributed to antipsychotic medications, poor
CENTORINO, CATALANO, and GRIMSICH: Mental Health
and Behavioral Sciences Service, James A. Haley Veterans
Hospital, and Department of Psychiatry and Behavioral
Neurosciences, University of South Florida, Tampa, FL;
ANTOUN: Mental Health and Behavioral Sciences Service,
James A. Haley Veterans Hospital, Tampa, FL
Copyright © 2018 Wolters Kluwer Health, Inc. All rights
reserved.
Please send correspondence to: Michael B. Centorino, MD,
Mental Health and Behavioral Sciences Service, James A.
Haley Veterans Hospital, 13000 Bruce B. Downs Boulevard
#116A, Tampa, FL 33612 (e-mail: michael.centorino@va.gov).
The authors declare no conﬂicts of interest.
DOI: 10.1097/PRA.0000000000000304

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CLINICAL CASE DISCUSSION
nutrition, increased rates of smoking, and being twice
as likely to either delay seeking, or ﬁnd themselves
unable to obtain, medical care.9 They are also more
likely than controls to be male and to have hypertension, diabetes, and/or hyperlipidemia.10 The disparity in risk for stroke was actually found to be four
times greater for women with schizophrenia, when
they were followed for a 5-year period after hospitalization and compared with women in a control group
who had been hospitalized for an appendectomy.10
There have been multiple reports of poststroke
psychosis.6–8,11–18 However, we have located only 1
report concerning the resolution of a mood disorder
poststroke19 and 1 report of a stroke leading to
improvement in psychosis.20 In the report of psychosis abatement, a 74-year-old woman with schizophrenia showed symptomatic improvement after
sustaining a left putaminal hemorrhage.20 She had
experienced persistent hallucinations and delusions, despite treatment with haloperidol 15 mg/d
and mosapramine 150 mg/d. Following the stroke,
her psychosis resolved, and her medication regimen
was reduced to haloperidol 4.5 mg/d. At one point,
her haloperidol was stopped, and her positive
symptoms recurred. Subsequently, she continued
on haloperidol 1.5 mg/d, without psychosis; at followup 26 months later, still on haloperidol 1.5 mg/d, the
patient continued to be free of psychotic symptoms.
Here we present the case of a 61-year-old woman
diagnosed with schizophrenia, who experienced
a bilateral hemorrhagic stroke, resulting in a
reduction of psychotic symptoms.

CASE DESCRIPTION
The patient, a 61-year-old woman, had been followed chronically by the intensive case management service of an urban teaching hospital for
management of her schizophrenia. She was originally diagnosed at age 33, and had been on
medication since age 36. She had attained clinical
stability with olanzapine 10 mg in the morning and
20 mg at bedtime, trazodone 100 mg at bedtime,
benztropine 1 mg twice a day, and ﬂuphenazine
decanoate 25 mg IM every 2 weeks, in conjunction
with case management. Although adherent to
treatment, the patient continued to report frequent
auditory hallucinations and rather prominent and
often bizarre delusional thought content. Her
aberrant thoughts would include notions such as

Journal of Psychiatric Practice Vol. 24, No. 3

“I’m an Indian and of a rare tribe,” or that she had
“suffered a heart attack at age 5,” because she “did
the work of 27 men working in the mines in Egypt.”
There were no signs of thought broadcasting,
although there had been some remote evidence of
thought insertion. Before the patient was on the
current medication regimen, there were reports of
occasionally increased thought disorganization, but
within the past 10 years, her speech was consistently ﬂuid and organized, and without evidence
of thought blocking or overt disorganization.
One evening, the patient was found collapsed and
unconscious on the ﬂoor of her room in her assisted
living facility, with resultant cranial trauma. She
was brought to the emergency room, intubated, and
deemed not to be a surgical candidate, based on the
extensive damage already accrued. She was found
on initial computed tomography (CT) scan to have
“bilateral frontal hemorrhages with surrounding
vasogenic edema, mass effect on the frontal horns of
the lateral ventricles, and 7 mm right to left midline
shift at the level of the anterior falx and 4 mm right
to left midline shift at the level of the septum pellucidum” (Fig. 1). A “small left tentorial subdural
hematoma” was also noted. Six weeks later,
follow-up magnetic resonance imaging with diffusion-weighted imaging revealed an “evolving
hemorrhage in the right frontal lobe, with residual
hematoma,” “bilateral frontal and anterior temporal encephalomalacia,” and “scattered foci … of
hyperintensity in the periventricular and subcortical white matter.” There was no tonsilar
herniation. The only earlier imaging available for
the patient was a CT scan without contrast performed 24 years earlier, which revealed “bifrontal
posttraumatic encephalomalacia; otherwise, unremarkable.” Results of laboratory work at the time of
the stroke included a variety of mild dyscrasias,
most notably hypokalemia of 3.1 mEq/L, an elevated white blood cell count between 11.6 and
12.49×109/L, elevated platelet count of 687×109/L,
and mild anemia with a hemoglobin of 11.3 g/dL.
Following the stroke, the patient had experienced
physical motor impairment, but she was able to
engage in physical therapy and largely regained her
walking ability over time. Mentally, she was “jovial
and engaging” and, when asked about the auditory
hallucinations that had been present for decades,
she “smiled and replied ‘not anymore.’ ” Along with
a notable decrease in the bizarreness, frequency,

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195

CLINICAL CASE DISCUSSION
FIGURE 1. Poststroke computed tomography of the brain.

offered at her assisted living facility. She no longer
required ﬂuphenazine decanoate but was maintained
on olanzapine 10 mg in the morning and 20 mg at
bedtime, trazodone 50 mg at bedtime, lorazepam
0.5 mg/d as needed for anxiety, donepezil 5 mg at
bedtime, and benztropine 1 mg twice a day.

DISCUSSION

and intensity of her auditory hallucinations, the
delusions that had previously been a consistent
feature of the patient’s presentation faded to rarity.
She did not exhibit signs of mania. There was no
evidence of seizures. She also denied any ongoing
thought broadcasting or thought insertion. Her
speech remained ﬂuid, and there was no evidence of
thought blocking or response to internal stimuli.
The patient denied any deleterious disturbance in
her mood, and she started ordering beauty products
for the ﬁrst time since she had been followed by case
management. The uncontrolled psychosis that had
previously continued despite the patient’s medication regimen was no longer present, even though
she was being maintained on fewer medications.
At follow-up 1 year later, the patient reported
occasional auditory hallucinations that continued to
be “much reduced” in frequency, compared with her
prestroke baseline, consisting mainly of “a radio
playing songs.” She continued to be quite functional,
walking avidly and engaging in many of the activities

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The 61-year-old woman whose case is presented here
achieved a signiﬁcant amelioration of psychotic
symptoms following a hemorrhagic stroke. Initially,
she reported a complete absence of psychosis while
continuing on her chronic medication regimen; on
later follow-up, when she was no longer receiving
ﬂuphenazine decanoate, the patient reported infrequent nonverbal auditory hallucinations. Of perhaps
more importance was the change in the patient’s
negative symptoms, as she began engaging in activities that she had long given up and displaying her
personality with reduced interference from her illness.
There appears to be some notable overlap
between the rare beneﬁcial effects of the stroke
described here and the outcomes of ablative neurosurgical procedures. As opposed to the haphazard
lesions resulting from stroke, surgery has been used
to place lesions with strategic intent. Ablative psychosurgery in psychiatry began with prefrontal
leucotomy, a nonstandardized, nonguided, and
extensive procedure, targeting substantive swaths
of anterior, frontal cerebral white matter. Chieﬂy
used before the advent of effective medication, the
primary positive outcome from this procedure was
hospital discharge, at a rate of 18% to 23% compared with 10% among controls.21 Approximately
half of those who underwent this surgery developed
convulsive seizures, which resolved in 50% of the
patients after 5 to 10 years. In 92% of patients,
signiﬁcant changes in personality and/or deﬁcits in
learning and planning were observed.21
There are 4 contemporary, ablative neurosurgical
options for psychiatric dysfunction,22 which are typically indicated for use in individuals with major
depressive disorder (MDD) or obsessive compulsive
disorder (OCD). In subcaudate tractotomy, the substantia innominata is disrupted bilaterally, in an
effort to disconnect the orbitofrontal cortex from
subcortical structures. This procedure has produced
signiﬁcant improvement in 68% of patients with
MDD and 50% of patients with OCD. There are some

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CLINICAL CASE DISCUSSION
reports of personality changes, including transient
disinhibition.22 In one sample of 4 patients with
schizophrenia who had the subcaudate tractotomy
surgery, 2 experienced no change, and 2 showed
improvement, albeit with signiﬁcant residual symptoms of psychosis.23
The most common psychosurgery today is anterior cingulotomy, targeting Brodmann areas 24 and
32. With stereotactic (magnetic resonance imaging)
guidance, improvement has been reported in 60% of
patients with MDD, 40% with bipolar disorder, and
between 27% and 54% of those with OCD. The
procedure has not been noted to generate signiﬁcant, long-term changes in personality.22 No
reports concerning the efﬁcacy of this procedure in
patients with schizophrenia were found.
Limbic leukotomy involves the combination of
subcaudate tractotomy and anterior cingulotomy,22
historically guided by intraoperative stimulation
and the monitoring of autonomic responses. This
procedure has yielded an 89% rate of improvement
in symptoms of OCD, and a 78% improvement rate
in symptoms of MDD, but it also generates chronic
lethargy in 12% of patients. One study24 of its use in
7 patients with schizophrenia found improvement in
6 of the 7 patients. Following the procedure, lower
doses of medications were required, and the patients
also experienced a reduction in the frequency and
intensity of their psychotic symptoms.
Anterior capsulotomy targets the anterior limb of
the internal capsule, in an effort to disrupt the
connections between the prefrontal cortex and
subcortical nuclei. Improvement between 50% and
70% in those with OCD and of 48% in patients
with MDD has been documented. Of the patients
who had this procedure, 29% experienced, 17% poor
memory, 10% weight gain, and 8% “slovenliness.”22
A 74% response rate from the overall symptoms of
schizophrenia has also been reported, with an 82%
rate of improvement in aggressive behavior, a 71%
response rate for hallucinations, and a 70% rate of
amelioration for delusions.25
Intriguingly, the outcomes in the case reported
here are consistent with the reported outcomes in
individuals with schizophrenia treated with anterior capsulotomy, with a similar improvement in
hallucinations and delusions. Furthermore, the
patient’s stroke was bilateral, as are the psychosurgeries that yield effective results. Unfortunately,
the information available on the impact of other

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currently used psychosurgeries in patients with
schizophrenia is insufﬁcient for comparison.
With regard to the case described here, the earlier
imaging study done in this patient was likely of
substantially lower quality than the more recent
studies, given that it was done more than 20 years
earlier. Nevertheless, that CT scan found bifrontal
encephalomalacia, which contrasts with the more
recent poststroke report, which reﬂected more
extensive areas of encephalomalacia, not to mention
edema and resultant mass effect. It is possible that
the patient’s stroke resulted from cranial trauma, but
amyloid angiopathy could also have contributed,
given the patient’s age and the lobar nature of the
hemorrhage. Although this is speculative, it appears
likely that this stroke disrupted the connections
between the patient’s forebrain, and her aberrant
dopaminergic midbrain, resulting in a reduction in
hallucinations, and consequently, a diminution in
delusional prominence, with sufﬁcient recovery having occurred at 1-year follow-up to result in the
reappearance of mild auditory hallucinations.
Given the scant information concerning the use of
stereotactic psychosurgery in individuals with
schizophrenia, and the fact that refractory psychosis is currently typically treated with cumbersome and potentially lethal clozapine, further
exploration of psychosurgery for psychosis may be
worth pursuing, despite this area being muddied by
past efforts. Another intriguing ﬁnding is the overlap between psychosis and the intrusive thoughts of
OCD, which may suggest the possibility of similar
anatomic origins and surgical outcomes. The ethics
of performing untested, irreversible surgery in this
vulnerable population would surely prove problematic, but if cases are chosen selectively from
those unresponsive to current treatment, and sufﬁcient informed consent is given, such studies may
be fruitful. We were only able to locate 1 other report
regarding poststroke psychotic improvement.20 Thus,
although ours is an isolated case, anatomic clues
provided by it and other reports yield information
that may hopefully lead to an increased understanding in the future of the psychotic disorders that
affect so many people.

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