A STROKE OF BAD LUCK: NEW-ONSET MANIA IN ELDERLY PATIENT FOLLOWING UNDETECTED STROKE, A CASE REPORT

Introduction The phenomenon of developing depression after a stroke is fairly common in the literature (29%) but developing mania after a stroke is rare reportedly to be 1-2% of stroke survivors (Starkstein). One of the earliest descriptions of mania after stroke was described in 1989 of the right hemisphere (Starkstein). In 2011, a systematic review looking at 32 studies identified 49 cases describing symptoms of mania post-stroke. At initial presentation, 92% of these patients presented with elevated mood, 71% with increased rate of speech, 69% with insomnia and 63% with agitation (Santos). Mania is more common after strokes of the right hemisphere than the left hemisphere (Santos). There are a few cases in the literature reporting mania after left side infarct but nothing since 2019 (Jampla, Semiz, Fenn). In our case, we describe a case of 65 year old female with mania after left sided stroke. Methods We report a case of a 65 year-old female with a history of major depressive disorder, generalized anxiety disorder, NSTEMI, chronic diastolic heart failure, and non-ischemic cardiomyopathy who was hospitalized for altered mental status and bilateral leg swelling. This patient presented with a two week history of behavioral activation, significant personality changes, emotional lability, fluctuating between states of extreme euphoria and tearfulness, grandiosity, and impulsive intrusiveness, speaking to strangers and hospital staff in inappropriately affectionate terms. She demonstrated a decrease need for sleep, and was noted to be easily irritated and hypersexual with others. She did not have a history of bipolar disorder. Prior to this hospitalization, she had been recently discharged from the cardiac care unit (CCU) after a five-day admission for chest pain, dyspnea, pneumonia, and NSTEMI. Neurology was consulted while patient was hospitalized and recommended imaging of the head for work-up of physiological causes of AMS. Computed tomagraphy (CT) and magnetic resonance imaging (MRI) scans conducted during her hospitalization were remarkable for small, remote, left parietal and left inferior temporal infarcts; the patient nor the patient's family were aware of a previous history of cerebrovascular accident (CVA). Further workup by medical team was unremarkable for organic cause of altered mental status, and patient was subsequently transferred to the inpatient psychiatric facility. Over the course of her hospitalization, the patient was treated and stabilized on divalproex, olanzapine, and temazepam, with steady improvement in her manic symptoms. Patient was discharged after a 3 week-stay on the inpatient psychiatric unit and followed up with outpatient services, where improvement in her manic symptoms continued to be noted. Though her manic behavior improved, she developed depressive symptoms following her hospitalization, a feature often characteristic following manic episodes. She continues to be seen on an outpatient basis and was referred to the geriatric partial hospitalization program for further treatment. Results Please see below for the discussion in conclusions Conclusions It is common practice to screen patients for depression after acute stroke due to the increased prevalence of the disease. This case illustrates the need for implementing mania screening in patients post stroke especially if there is involvement of the dominant hemisphere. This patient with no prior history of bipolar disorder presented with an acute presentation of mania followed by a course of depression after sustaining a stroke. Due to the rarity of the postroke mania, we suggest further studies to consider creating an accessible reporting tool for clinicians to record possible cases of mania after a stroke. This will be important diagnostically to appropriately treat patients in contrast to attributing the presentation to other diagnosis such as delirium or neurocognitive disorders. This research was funded by: Not applicaple