Can agitation be a feature of stroke?

Can Agitation Be a Feature of Stroke?

Yes, agitation is a recognized neurological manifestation of acute stroke and should be actively identified and managed as it can indicate underlying complications requiring immediate treatment.

Agitation as a Direct Stroke Manifestation

Agitation occurs as a direct clinical feature of stroke, particularly in specific anatomical patterns:

• Right hemisphere infarctions, especially in the right middle cerebral artery (RMCA) territory, can present with agitated confusional states as the primary manifestation, sometimes without obvious localizing neurologic signs 1.

• In hemorrhagic stroke, agitation has significantly higher prevalence compared to ischemic stroke (P<0.001), along with dilated pupils, lower Glasgow Coma Scale scores, and seizures 2.

• Thalamic hemorrhagic strokes can produce agitation as a prominent behavioral symptom, often requiring specific management strategies 3.

• The initial presentation may mimic metabolic encephalopathy, making stroke diagnosis challenging when prominent motor or sensory signs are absent 1.

Agitation as a Secondary Complication

Beyond being a direct manifestation, agitation frequently signals treatable underlying complications that require urgent evaluation:

Critical Underlying Causes to Address First

The American Heart Association guidelines emphasize that before treating agitation symptomatically, clinicians must identify and treat reversible causes 4:

• Hypoxia - Check oxygen saturation immediately
• Increased intracranial pressure - Assess for signs of herniation
• Seizures - Rule out ongoing or subclinical seizure activity
• Hypoglycemia - Check blood glucose
• Pain - Assess for headache or other discomfort
• Full bladder - Often overlooked but easily correctable
• Fever - Associated with increased morbidity and mortality after stroke 4

Management Approach

Non-Pharmacological First-Line Measures

Initial management should focus on treating underlying causes and environmental modifications 4, 5:

• Ensure adequate oxygenation and treat hypoxia
• Address pain, headache, nausea, and vomiting
• Check for urinary retention
• Treat fever with antipyretic agents 4
• Implement orientation strategies and environmental modifications 5

Pharmacological Management When Necessary

When agitation persists despite addressing underlying causes, the treatment approach differs based on stroke severity and thrombolytic eligibility 4, 5:

For patients NOT eligible for thrombolysis:

• Mild to moderate agitation: Lorazepam 1-2 mg IV/IM 5
• Moderate to severe agitation: Haloperidol 5-10 mg IV/IM 5
• Agitation with hypertension: Labetalol 10-20 mg IV over 1-2 minutes may address both issues 4, 5

For patients eligible for thrombolysis:

• Blood pressure must be maintained <185/110 mmHg before initiating thrombolysis 4, 5
• Use minimal sedation to avoid masking neurological deterioration 5
• Labetalol can be used cautiously if blood pressure control is needed 4

Special Considerations for Specific Stroke Types

Subarachnoid hemorrhage with agitation:

• Beta-blockers (particularly metoprolol) may be more effective than traditional antipsychotics or benzodiazepines for managing post-hemorrhagic agitation 6
• Antipsychotics and benzodiazepines are often insufficiently effective in hemorrhagic stroke-related agitation 6

Thalamic stroke with hemiballismus and agitation:

• Olanzapine may be superior to haloperidol for combined movement disorder and agitation 3

Critical Pitfalls to Avoid

• Do not dismiss stroke as a diagnosis in agitated, confused patients without obvious lateralizing signs - right hemisphere strokes commonly present this way 1

• Avoid excessive sedation that masks neurological symptoms or impedes serial neurological assessments, particularly in thrombolysis candidates 5

• Do not use benzodiazepines routinely during stroke recovery as they may have deleterious effects on neural plasticity and recovery mechanisms 4

• Monitor blood pressure carefully when using any sedative medication, especially in patients being considered for or receiving thrombolytic therapy 4, 5

Prognostic Implications

Agitation after stroke is associated with important clinical outcomes:

• Agitation/aggression occurs in approximately 18.5% of stroke patients at 3 months and is independently associated with poorer quality of life, particularly affecting personality changes and social role functioning 7

• The presence of agitation is more common in hemorrhagic stroke and correlates with greater stroke severity 2

• Effective management of agitation is essential for rehabilitation participation and recovery 7