What is the best management approach for a patient with a history of delusional disorder, now admitted with a Cerebrovascular Accident (CVA)?

Management of CVA in a Patient with History of Delusional Disorder

For a patient with delusional disorder now admitted with CVA, prioritize acute stroke management first, then address neuropsychiatric complications with low-dose antipsychotics if psychotic symptoms emerge or worsen post-stroke. 1

Immediate Acute Stroke Management

Initial Assessment and Imaging

• Perform urgent brain CT without delay to determine stroke type (ischemic vs. hemorrhagic) and guide immediate treatment decisions 2
• Follow with MRI/MRA if clinically stable to better characterize the lesion, assess for small infarcts, and evaluate vascular anatomy 2, 1
• Brain imaging takes priority over psychiatric considerations in the acute setting 2

Stroke-Specific Treatment

• For ischemic stroke progression, consider DOACs (rivaroxaban or dabigatran) over standard anticoagulation (LMWH, UFH, warfarin) as they show better outcomes with reduced thrombus recurrence 1
• Withhold any immune checkpoint inhibitors if the patient is receiving cancer therapy, as these can worsen neurological symptoms 1
• Conduct comprehensive neurological examination to assess severity and monitor for progression 1

Management of Neuropsychiatric Complications

Monitoring for Post-Stroke Psychosis

Post-stroke psychotic symptoms are uncommon but well-documented, particularly with right hemisphere lesions 3, 4. Two distinct presentations exist:

• Early-onset (days to weeks): Continuous psychotic behavior soon after CVA, often in patients with chronic diseases or brain atrophy 3
• Delayed-onset (months to years): Episodic psychotic symptoms emerging remotely from the stroke event 4

Screening and Assessment

• Screen all stroke patients for depression and anxiety in the postacute period using validated screening tools, as mood disorders affect 25-75% of stroke patients 2
• Administer cognitive screening tools to identify cognitive impairment, which commonly coexists with neuropsychiatric symptoms 2
• Monitor specifically for emergence or worsening of delusional symptoms, particularly if the stroke involves the right hemisphere, basal ganglia, or caudate nucleus 5, 3, 6

Pharmacological Management of Psychotic Symptoms

If delusional symptoms emerge or worsen post-stroke, use low-dose risperidone as first-line treatment 5. However, critical safety considerations apply:

Antipsychotic Use - Major Warnings

• Antipsychotics carry a BLACK BOX WARNING for increased mortality in elderly patients with dementia-related psychosis (1.6-1.7 times increased death risk) 7
• Cerebrovascular adverse events (stroke, TIA) occur at significantly higher rates in elderly patients treated with risperidone compared to placebo 7
• Risperidone is NOT FDA-approved for dementia-related psychosis 7

When Antipsychotics Are Necessary

Despite these warnings, antipsychotics may be required when:

• Psychotic symptoms are severe, distressing, or pose safety risks 5
• The patient has a pre-existing delusional disorder requiring ongoing treatment 6

Use the lowest effective dose for the shortest duration 7. Case reports demonstrate effectiveness of low-dose risperidone (specific dosing not detailed but described as "small dose") in controlling post-stroke delusional ideas 5.

Alternative Considerations

• For depression with or without psychotic features, SSRIs are reasonable as they can treat both mood disorders and may help with neuropsychiatric symptoms 2
• SSRIs (particularly sertraline) have shown effectiveness in post-stroke OCD and may benefit other post-stroke psychiatric symptoms 8
• Continuation of pre-existing SSRI therapy for mood disorders is beneficial and should not be discontinued after stroke 2

Cognitive Rehabilitation

Implement cognitive retraining for identified deficits 2, 1:

• Training for attention deficits (Grade A recommendation) 2
• Visual-spatial rehabilitation for visual neglect after right CVA (Grade B recommendation) 2
• Compensatory strategies for mild short-term memory deficits (Grade B recommendation) 2
• Formal problem-solving strategies for executive dysfunction (Grade C recommendation) 2

Management of Mood Disorders

For moderate to severe post-stroke depression, use evidence-based treatments including psychotherapy and pharmacotherapy 2:

• Cognitive behavioral therapy (CBT) improves mood, increases depression remission odds, and enhances quality of life in patients with vascular cognitive impairment 2
• SSRIs are first-line pharmacotherapy for post-stroke depression and agitation 2
• Physical activity reduces depressive symptoms in patients with mild cognitive impairment 2

Vascular Risk Factor Management

Aggressively control vascular risk factors to prevent stroke progression and recurrence 1:

• **Target intensive blood pressure control (SBP <120 mmHg)** in patients over 50 with BP >130 to reduce mortality and cognitive impairment risk 2
• Screen for and manage diabetes mellitus with regular fasting glucose assessment 1
• Address hypercholesterolemia 1

Rehabilitation and Functional Recovery

Early Mobilization Caution

• Avoid very early, high-intensity mobilization within 24 hours of stroke, as this increases risk of poor outcomes at 3 months and mortality at 14 days in ICH patients 2
• Standard rehabilitation should begin after the acute phase stabilizes 2

Multidisciplinary Approach

• Involve physiotherapy, occupational therapy, and speech-language therapy based on specific deficit patterns 2, 1
• Address swallowing dysfunction if present, as this is common post-stroke 2
• Plan for behavioral experiments to address fear and avoidance of activities affected by stroke deficits 2

Common Pitfalls to Avoid

1. Do not assume psychiatric symptoms are solely due to pre-existing delusional disorder - they may represent new post-stroke psychosis requiring different management 3, 6, 4

2. Do not use antipsychotics casually in elderly stroke patients given the significant mortality and cerebrovascular event risks 7

3. Do not overlook depression screening - it is frequently underdiagnosed by non-psychiatric physicians and undertreated despite affecting up to 75% of stroke patients 2

4. Do not delay cognitive screening - early identification of cognitive impairment allows for timely rehabilitation interventions 2

5. Do not forget to prepare patients for potential relapse of both stroke symptoms and psychiatric symptoms, with clear criteria for when to seek further treatment 2