Ischemic stroke in a young patient associated with psychosis

Introduction: Neuropsychiatric manifestations may be associated with stroke patients. In the acute phase, agitation, euphoria and aberrant motor behavior may be present. In the chronic phase, insomnia, hypersomnia and inappropriate behavior. Post-stroke psychosis is a rare complication with few cases described in the literature. Objectives: To report a case of ischemic stroke in a young patient associated with behavioral change. Methodology: This is a descriptive observational study based on the analysis of the patient's medical record and literature review. Results: A 15-year-old boy was admitted to the clinic, accompanied by his mother, due to suicidal ideation, auditory and visual hallucinations. He reported that auditory hallucinations tell him to commit suicide or to kill someone. Cranial CT scan showed hypodense lesion in the upper portion of the right cerebellar hemisphere. Patient was taking biperiden, clonazepam, sertraline, acyclovir and dexamethasone. One month after treatment, the patient returned to the neurology outpatient clinic with suspicion of herpetic encephalitis reaggravation, due to the return of symptoms of visual and auditory hallucinations, headache, aggressiveness and insomnia. Cerebrospinal fluid without alterations, no growth in culture and negative cytological findings for neoplastic or inflammatory cells. Cranial MRI showed an area with signal similar to CSF located in the posterosuperior aspect of the right cerebellar hemisphere suggesting encephalomalacia. Based on the imaging findings, cerebellar ischemic stroke was diagnosed. Patient was discharged as soon as symptoms of hallucinations and suicidal ideation ceased. Acetylsalicylic acid + atorvastatin + valproic acid + amitriptyline + quetiapine + sertraline was prescribed. On outpatient return, the patient denied new episodes of auditory hallucinations, reporting only anxiety when around other people. Transthoracic echocardiogram without changes and carotid Doppler ultrasound without evidence of significant stenosis in internal carotid arteries. Patient is still in outpatient follow-up to monitor symptoms. Conclusion: This is a rare case of a young patient with ischemic stroke with behavioral change that made the diagnosis difficult. For this case, imaging examination was essential for diagnostic elucidation and appropriate treatment.