DG is a 50–year–old female with no significant past medical history who presented to the emergency department (ED) two weeks after a near–syncopal episode. She complained of “flu–like” symptoms and ED physicians noted her to be “hyper.” A non–contrast CT head was negative for acute intracranial abnormalities and patient was discharged home with a prescription for alprazolam and instructions to follow up with her primary care physician. Several days later, the patient again presents to the ED, now noting increased stress and anxiety related to the anniversary of her mother’s death ten years prior. The patient is admitted to the general medicine floor service. The admitting resident remarks that the patient’s speech is hyperverbal and tangential, and she is a poor historian. There are no abnormalities noted on physical exam or routine lab work. Psychiatry is consulted and recommends outpatient follow up, the patient is discharged. Two days later, the patient again presents to the ED, now with the family noting increased agitation and possible hallucinations. Both psychiatry and neurology are consulted, and an MRI brain is performed. The MRI notes acute stroke in the head of the caudate nucleus.
Psychotic symptoms (delusions, hallucinations, disorganized thought processes) are exceedingly rare presenting symptoms of cerebrovascular accidents (CVAs). Several case reports have been published that demonstrate varying degrees of psychosis related to acute or chronic CVAs in the caudate or putamen. While the type of symptoms with which the patients present differ, the common connecting thread is the age of presentation, all over the age of 40, outside the typical age–of–onset for schizophrenia.
Hospitalists must include cerebrovascular accidents in their work–up for psychosis, especially in those patients who fall outside the usual age–range for onset of mental illness.