r e v c o l o m b p s i q u i a t . 2 0 2 0;4 9(3):194–198

www.elsevier.es/rcp

Case Report

Neuropsychiatric symptoms as the only acute
manifestation of a stroke in the left hemisphere.
Case report
Oscar Mauricio Castaño Ramírez, Carlos Andrés Gómez Bedoya,
Laura María García Henao ∗ , Juan Castro Navarro
Departamento de Salud Mental y Comportamiento Humano, Universidad de Caldas, Manizales, Caldas, Colombia

a r t i c l e

i n f o

a b s t r a c t

Article history:

We report the case of a 60-year-old female patient with a history of hypertension and dyslipi-

Received 12 August 2018

demia, who suddenly presented with a clinical picture of emotional lability, disorientation,

Accepted 17 February 2019

complex visual hallucinations and persecutory delusions. There were no associated neu-

Available online 23 May 2019

rological findings in her initial physical examination. At a local hospital she was initially
diagnosed with late-onset bipolar disorder and a manic episode with psychotic features,

Keywords:

then referred to the mental health unit, where nuclear magnetic resonance (NMR) imag-

Stroke

ing of the brain revealed an acute ischemic stroke in the territory of the left posterior

Diagnostic Errors

cerebral artery (PCA) with haemorrhagic reperfusion to the occipital cortex. Complete and

Posterior Cerebral Artery Infarct

spontaneous resolution of her clinical condition was achieved after approximately 15 days.

Mental Disorders

© 2019 Published by Elsevier España, S.L.U. on behalf of Asociación Colombiana de
Psiquiatrı́a.

Alteraciones neuropsiquiátricas como única manifestación de accidente
cerebrovascular en hemisferio izquierdo. Reporte de caso
r e s u m e n
Palabras clave:

Se presenta el reporte de caso de una mujer de 60 años de edad con antecedente de hiperten-

Accidente cerebrovascular

sión arterial y dislipidemia, quien presenta cuadro clínico de inicio súbito consistente en

Errores diagnósticos

labilidad emocional, desorientación alopsíquica global, alucinaciones visuales complejas

Infarto de la arteria cerebral

e ideación delirante de tipo persecutorio, sin hallazgos neurológicos asociados en el exa-

posterior

men físico inicial. Se enfocó en hospital local como un trastorno bipolar de inicio tardío

Trastornos mentales

con episodio actual maníaco con características psicóticas y es remitida a unidad de salud
mental. Posteriormente hallazgos de resonancia magnética nuclear (RMN) cerebral revelaron una lesión correspondiente a ataque cerebrovascular (ACV) isquémico agudo en
territorio de la arteria cerebral posterior (ACP) izquierda con reperfusión hemorrágica a nivel

∗

Corresponding author.
E-mail address: lauragarciah20@gmail.com (L.M. García Henao).
https://doi.org/10.1016/j.rcp.2019.02.001
0034-7450/© 2019 Published by Elsevier España, S.L.U. on behalf of Asociación Colombiana de Psiquiatrı́a.

r e v c o l o m b p s i q u i a t . 2 0 2 0;4 9(3):194–198

195

de corteza occipital. Se alcanzó una resolución espontánea completa de su cuadro clínico
en un curso aproximado de 15 días.
© 2019 Publicado por Elsevier España, S.L.U. en nombre de Asociación Colombiana de
Psiquiatrı́a.

Introduction
Although a “mimics” chart is that presented with the typical clinical features of a diagnosis, it actually corresponds
to another aetiology. Stroke’s more frequent mimics include
seizures, migraine headaches, fainting, and metabolic disorders. By contrast, a chameleon clinical chart consists of those
charts in which demonstrations are not typically expected,
generally leading to diagnostic errors.1 Stroke is among the
clinical conditions most frequently diagnosed as another; up
to 20% of these errors occur in emergency rooms (ER), where
the pressure of time windows for appropriate intervention
represents great stress on the physician.2 This error rate
can range between 4%3 and 64%,4 depending on the clinical
population studied. Approximately 9% of the strokes are subdiagnosed during their initial stages, especially when there
are mild, non-specific, or transitory neurological manifestations (ranging from 24% to 60%5 ). This characteristically occurs
with motor or sensory disorders, aphasia, and hemianopia.6
However, other less common clinical manifestations which
lead to misdiagnosis in the ER have been described.5 One
study found that altered mental state was the most common chameleon,7 including manifestations such as psychosis,
memory alterations, behavioral changes, mood alterations,
and confusion.7,8 This type of presentation often guides the
physician toward a non-neurological (psychiatric) cause for the
clinical chart.9 These findings are consistent with another
study, which found that up to a 6% of patients attended
for alteration in their mental status in fact had an ischemic
stroke.10
In this panorama of mimics and chameleons, lesion location is important. A stroke in the posterior cerebral artery
(PCA) represents 20-25% of ischemic strokes.11 In its clinical
profile, visual field defects are more frequent, while speech
and limb weakness disorders are less frequent.12 Pure alexia
(alexia without dysgraphia) is probably the most characteristic
sign of unilateral stroke of the left PCA.13 Other manifestations
include unilateral, bilateral, or cross sensory weakness or loss,
instability or ataxia, dysarthria, and dysphagia.14 It has been
found that stroke chameleons are more likely to occur when
the PCA is compromised.15,16 This situation can generate atypical symptoms such as vertigo, nausea, vomiting, headache,
or dizziness.4,7,14 In addition, the National Institute of Health
Stroke Scale (NIHSS), often used to detect signs of stroke in the
ER, is focused on dominant and neurological deficits of the
above-mentioned circulation.8 All of these factors make the
stroke in the PCA being the most commonly sub-diagnosed
variety of these conditions.4,17
Acute neuropsychiatric manifestations as initial presentations of stroke have been poorly reported in the literature.
There is frequent reference to their mediate and late

consequences on behavior and mood. These manifestations have mainly been described when the right cerebral
hemisphere is involved,18,19 with depression being the most
common symptom, with a prevalence of 9% to 37%,20,21 followed by generalized anxiety disorder, with 24%. Emotional
lability is among the least prevalent manifestations, while
pathological laughter and crying, constitute the most commonly described clinical chart.19 Its prevalence in different
studies varies between 8-32% in the 3 to 12 months following a stroke, with symptoms subsiding in a maximum of
6 months.22 Secondary mania presents a prevalence of less
than 2%. Nearly the half of the patients tend to present this
chart in the early days of the stroke, and the other 50%
between 1 and 24 months later.22 It has been found that most
lesions causing mania involve, directly or indirectly, the limbic system, as practically all of these lesions are located in
the right hemisphere, mainly on the right orbit frontal cortex and thalamus.18 Psychotic symptoms are reported with an
approximate incidence of 0.4% to 3.1%, with a higher prevalence at the right temporo-parieto-occipital union.18 Finally,
global alterations in behavior and mood (non psychiatric disorders of personality), due to scarce reports thereof, have an
unknown prevalence.22
It is worth highlighting that, among the causes of the
misdiagnosis in the ER, it has also been found that the
sensitivity of diagnostic images is overestimated. One study
reported that almost one third of patients diagnosed with nondisabling stroke lacked proof of acute ischemic lesions in their
initial image (computed tomography [CT] or magnetic resonance imaging [MRI]), which were later encountered on their
MRIs.23

Clinical Case
This involves a 60-year-old woman who is a widow, housekeeper, and has basic primary schooling. As important
background information, she reported only hypertension and
dyslipidemia. She presents a clinical chart with sudden onset,
consisting of overall allopsychic disorientation (with time,
people, places, and spaces), emotional lability, uncontrollable
crying followed by unrestrained laughter, persecutory delusions, complex visual hallucinations, and hetero-aggressive
behavior. She then presented attention problems and occasionally incoherent speech, and finally she was taken to the
emergency room of the local hospital 5 days after the onset of
said manifestations. There, management began with 5 drops
of haloperidol every 12 hours, with little effect in recovery and
a presumptive diagnosis of late onset bipolar disorder with
manic episodes and psychotic features. She was referred to
the San Juan de Dios Psychiatric Clinic in the city of Manizales
on February 25th , 2017.

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Figure 1 – Contrast nuclear magnetic resonance imaging.

When she was admitted to the mental health unit, she
was alert, with global disorientation, a neglected appearance,
extremely friendly attitude, presence of motor symptoms of
anxiety, and a mixed anxious and elevated mood. Speech characterized by circumstantiality and tangential pararesponses,
with increased time for latency question-answering, without
delusional ideation verbalization, or indicators of hallucinations. Higher mental functions were clinically assessed
and found that they were compromised with poor judgment
and marked distractibility, without immediate memory alterations, but with failures in recent memory, and with apparent
amnesia of the events reason of consultation, and poor insight.
Neuropsychology standardized tests were not used during
the initial assessment or follow up. Physical examination
did not find any significant alteration, especially regarding the neurological aspect: no conscious state alteration,
Glasgow 15/15, normal muscle tone, preserved sensitivity.
No neck stiffness and without meningeal signs, symmetric
osteotendinous reflexes + + / + + + + , preserved and symmetric strength, without pathological reflexes, negative Babinski,
negative Oppenheimer, negative Gordon, negative frontal
release reflexes (glabellar, snout, sucking, grasping, palmomentonian). This findings staid negative for the remain of the
hospitalization.
A contrast MRI of brain was requested, due to atypical manifestations on the clinical chart, especially the
age of presentation without a previous history of mental health problems (Figure). It showed microangiopathic
leukoencephalopathy, and an image suggestive of ischemic
stroke in the area of the left PCA, with hemorrhagic reperfusion in the occipital cortex measuring 31 × 38 mm (lateral and
anteroposterior diameter) and a possible old ischemic region
in the territory of the Middle Cerebral Artery (MCA). In addition, lab tests were requested for vitamin B12 levels, HIV 1 and
2 antibodies, glucose, creatinine serum, ureic nitrogen, potassium, sodium, AST liver enzymes, ALT, folic acid, VDRL, test for
prothrombin time (PT) or international normalized ratio (INR),

partial thromboplastin time (PTT). All results were within the
normal laboratory range. An altered lipid profile was found,
with cholesterol levels at 244 mg/dl, triglycerides at 229 mg/dl,
low density lipoproteins (LDL) at 140.1 mg/dl, and high density
lipoproteins (HDL) at 58.1 mg/dl.
In consequence, the case was considered to be a clinical
chart of acute neuropsychiatry symptomatology secondary
to stroke, an urgent neurology consultation was requested,
but was not authorized by her insurer (EPS) during hospitalization. Followed treatment only with haloperidol 10 mg/day
(5 drops of VO every 12 h) and psychotherapeutic interventions of reinsurance and psycho-education. During her time
in the mental health unit, her neuropsychiatric chart manifestations evolved favorably. Two days after her admission, on
February 27th , there was an increase in the support base as
a single abnormality on the neurological exam, and persistence of time disorientation as the only alteration, on mental
examination. Resolution of her clinical chart is progressively
achieved, without the need for additional pharmacological
interventions, up to its full resolution in about 15 days, with
a gradual decrease in haloperidol followed by its complete
removal, she was therefore discharged from the hospital with
an order for a neurology and psychiatric outpatient consultation. At the time of the drafting of this case report, the patient
was in general, appropriate conditions, without psychiatric
consequences or evident neurological focalization.

Discussion
The clinical diagnosis of stroke is complex, especially when its
manifestations are atypical. In this case, the patient only presented, late in the course of her symptoms, instability denoted
by the increase in the support base as a single neurological
phenomenon, which favored an initial misdiagnosis of bipolar disorder, given pathological laughter and crying, psychotic
symptoms, elevated mood and motor restlessness.

r e v c o l o m b p s i q u i a t . 2 0 2 0;4 9(3):194–198

There is a high frequency of psychiatric symptoms in
almost all diseases affecting the central nervous system.
Psychiatric symptoms typically occur parallel to classical neurological symptoms, and they can deteriorate one’s quality
of life even more drastically.24 However, psychiatric symptoms may also be the only acute manifestation of stroke, as
occurred in this case. In few existing reports, it has been found
that the above mentioned manifestations are mainly present
when the right hemisphere is affected.18,19 This patient’s left
hemisphere was affected. This may be a clinical presentation yet undescribed, which would be especially important,
as neuropsychiatric manifestations have been more scantly
reported and studied, probably as they go unnoticed in clinical practice,22 thus compromising patients’ diagnosis, early
treatment, and prognosis.
It is worth highlighting that patients with a stroke only
affecting the PCA have significantly less risk of long-term disability and mortality, in comparison to those who have a stroke
in PCA together with another outside that territory.25 In this
case, it is clear that, despite the late diagnosis and management, the patient had an appropriate clinical recovery, which
is consistent with the aforementioned findings.

Conclusions
We agree with other authors that there is a need to recognize
the difficulties implied in stroke diagnosis, and to carry out
studies about misdiagnosis, so as to identify related factors
which lead to this errors and thus to contribute to the improvement of clinical reasoning when facing similar situations.4,8,15
This especially applies to delays in treatment that they may
represent, which may worsen patient prognosis and possibility for long-term improvement. It is possible that some
indicators of atypical presentations should be included on
scales which focus on stroke in emergency rooms. It is fundamental to keep in mind that mental pathologies which occur
with sudden onsets and at infrequent ages should guide us to
non-psychiatric pathologies, even in the absence of neurological phenomenology.

Ethical responsibilities
The authors declare that they do not have conflicts of interests, that experiments were not carried out on human beings
or animals, that in this article, there is not any patient or
family data present, and that, through the respective consultation, informed consent was obtained for the composition of
this case report, a document that is in the power of the main
author.

Conflicts of interests
The authors declare that they do not have conflicts of interests, that experiments were not carried out on human beings
or animals, that in this article, there is not any patient or
family data present, and that, through the respective consultation, informed consent was obtained for the composition of

197

this case report, a document that is in the power of the main
author.

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