Düşünen Adam The Journal of Psychiatry and Neurological Sciences, Volume 29, Number 1, March 2016 Tactile hallucination and delusion following acute stroke: a case report
Type of Spiritual Experience
Irbesartan is an angiotensin receptor blocker (ARB) medicine widely used to treat high blood pressure (hypertension).
A description of the experience
Dusunen Adam The Journal of Psychiatry and Neurological Sciences 2016;29:79-84
Address reprint requests to / Yazışma adresi:
Buca Seyfi Demirsoy State Hospital,
Departrment of Psychiatry, Ozmen Caddesi,
No: 145, Buca Merkez/Izmir, Turkey
Phone / Telefon: +90-232-444-3508
E-mail address / Elektronik posta adresi:
Date of receipt / Geliş tarihi:
February 24, 2015 / 24 Şubat 2015
Date of the first revision letter /
İlk düzeltme öneri tarihi:
April 10, 2015 / 10 Nisan 2015
Date of acceptance / Kabul tarihi:
June 28, 2015 / 28 Haziran 2015
Nowadays, after cardiac diseases and cancer, stroke is the third largest cause for mortality. Despite a reduction of its incidence and mortality thanks to risk control over the last years, stroke is still one of the most important reasons for death (1). After stroke, a
number of psychiatric conditions can be seen, such as depression, most of all, but also anxiety disorders, behavioral disorders, apathy, mania, and psychosis (2-4). Compared to other psychiatric presentations, mania and psychosis occur more rarely (4,5) (Table 1).
Psychiatric complications developing after stroke affect not only the patient’s social life negatively, but impact on their entire quality of life and the rehabilitation process (6,7). The relation between a cerebrovascular event and secondary psychosis was first described by Westphal in 1879. A 42-year-old male patient, developing left hemiplegia and left homonymous hemianopsia before his death, reported the sight of bright colors and hallucinations of a sword hanging above his head that might come down at any moment. Westphal described the aspect of the patient in that moment as “fixing his eyes on the ceiling as if he was seeing something
scary”. At autopsy, brain atrophy and an involvement of the posterior section of the right hemisphere were observed (8).
Physical and psychiatric symptoms developing after stroke show correlations with the affected brain regions (9,10). Anatomically, it has been established that stroke lesions in the temporoparietal/temporoparietooccipital 80 section, and particularly in the right rather than the left hemisphere, have a higher probability to lead to the development of secondary psychosis (11-13). In addition, psychosis cases with effects from the deep subcortical structures can be found in the literature (14-16). After stroke, a number of psychiatric disorders can develop, but psychosis is relatively rarely seen (9,16). Case reports about the development of psychosis
after stroke are quite rare in the literature, and data about psychotic disorders related to stroke are limited (17).Aim of this report is to present a case of acutely developing tactile hallucinations, interpreted as delusional, after an infarction of the right middle cerebral
artery (MCA) border region, and to discuss psychiatric presentations that may occur in relation to stroke in the
light of information from the relevant literature.
H.O., a 61-year-old right-handed man, was
admitted to the emergency room with complaints of
forgetfulness and unusual behavior. After examination,
the patient was admitted with a diagnosis of acute
right MCA infarction. The patient provided written
informed consent during his inpatient treatment.
Around 3 months earlier, the patient had suffered a
transitory episode of dysmnesia while talking to his
daughter on the phone, not remembering who she
was. He described a moment of short-term confusion
experienced the day before presenting to the hospital,
while praying in the mosque: “I was praying in the
mosque, and everyone was prostrating, but I was
standing up; I was confused…”
It was learned that the following morning he had
started to search for someone who had pushed him by
his neck, trying to make him fall down, later pushing
him on the stairwell in his own house. As the patient
said: “That morning, it was as if someone put his hands
on the back of my neck. I grabbed with my hand, as if I
was holding his finger. I asked my wife ‘is there
anyone?’” His family reported that the patient had
opened the door of his house and was searching for
someone on the staircase, angrily shouting “Someone
pushed me from the bed to the ground”.
The patient was known to have suffered from
hypertension for 10 years; he was regularly using
irbesartan 300mg/day and hydrochlorothiazide
12.5mg/day. No other disease was found, and the
patient used neither alcohol nor any other psychoactive
The patient was examined psychiatrically and
neurologically. In the psychiatric examination, he
appeared appropriate for his age, with sufficient selfcare and anxious affect. He showed full cooperation
and orientation, speed and amount of speaking were
normal, associations were linear and goal-directed.
During the patient interview, occasional blocks in his
speech were observed. Other than the acute tactile
hallucination during the seizure and the subsequent
delusional state, no further active psychotic signs were
found in the patient. Abstract thinking was preserved
and reasoning in the test complete.
In the neurological examination, the patient’s eyes
were spontaneously open and aligned to the center
Table 1: Neuropsychiatric presentations accompanying stroke (4,5)
Syndrome Prevalence Clinical signs
Depression 35% Depressive mood, reduced appetite, weight loss, insomnia, anergy, anhedonia, social withdrawal
Anxiety Disorder 25% Increased anxiety, unease, physical signs like palpitation, sweating, difficulties to concentrate or to fall asleep
Mania Rare Raised mood, reduced need to sleep, flight of ideas, increased speed and amount of speaking, grandiosity
Psychosis Rare Hallucinations and delusions
Apathy 20% Indifference and negligence (independent from depression)
Pathologic affect 20% Inappropriate laughing and crying attacks
Catastrophic reaction 20% Anxiety attacks developing in states of physical and cognitive inadequacy, crying, aggressive behavior,
swearing, rejection and compensatory self-praise
Anosognosia 24% Denial of post-stroke deficits without concern
Akinci E, Oncu F, Topcular B
Düşünen Adam The Journal of Psychiatry and Neurological Sciences, Volume 29, Number 1, March 2016
line. Other than a frust paresis in the right upper
extremity, there were no motor deficits. Plantar
responses were bilaterally flexor.
The patient’s laboratory tests (hemogram,
biochemical tests and sedimentation) were normal.
In the diffusion brain MRI, a cortico-subcortical
diffusion restriction at the level of the temporooccipital
lobe in the upper section was observed, showing partly
continuity towards the parietal lobe, consistent with
acute infarction. The result was consistent with a
border zone infarction (Figure 1).
Bilateral carotid and vertebral artery Doppler USG
examination found multiple millimeter-thick local
parietal fibrocalcific plaque formations in the carotid and
its branches, which did not cause hemodynamic changes.
With a diagnosis of acute ischemic cerebrovascular
disease, the patient was started on antiaggregant and
anticoagulant therapy. The antihypertensive treatment
for the patient’s hypertension was continued. During
monitoring, vital signs and clinical state appeared stable.
At discharge, the patient’s self-care was assessed as
good, his affect adequate, cooperation and orientation
complete, association goal-directed, perception normal.
The patient showed residual signs of an acute psychotic
presentation developed secondarily to an ischemic
attack; he still stated that the state experienced during
the attack was real. Other than that, no active psychotic
signs were found. Abstract thinking and test reasoning
were evaluated as complete. Insight was partly present.
While after stroke a number of neuropsychiatric
disorders can be seen, especially depression, reports
about acute psychotic attacks are quite rare in the
While the risk of developing psychosis is higher in
temporoparietooccipital lesions, secondary psychosis
has also been reported with focal lesions in other brain
regions. Depending on the localization of these lesions,
differences in the psychotic presentation can be
observed (9,11,18) (Table 2). Kumral et al. (19) did a
study with 15 patients, reporting that the great majority
of persecutory and jealousy-type delusions developing
after stroke were related to the right posterior
In right hemisphere lesions, secondary psychosis is
more likely to develop than in hemisphere lesions. This
has been identified as a risk factor for secondary
psychosis (13,25,26). Some sources, however, state
that both right and left hemisphere lesions can result in
psychotic symptoms (27,28).
Generally, a strong correlation is found between the
lateralization of the lesion and the related
neuropsychiatric clinical presentations. Cases of mania
and alexithymia almost always have right hemisphere
lesions. Anxiety, sexual behavior disorder, dissociative
state and palinopsia cases are reported to show isolated
right hemisphere or bilateral rather than isolated left
Figure 1: Cranial MRI consistent with border zone infarction
82 Düşünen Adam The Journal of Psychiatry and Neurological Sciences, Volume 29, Number 1, March 2016
Tactile hallucination and delusion following acute stroke: a case report
hemisphere lesions. Visual hallucinations and
psychosis cases have been reported equally for both
hemispheres (18). Cutting (25) proposed the hypothesis
that there are similarities between right hemisphere
lesions and psychosis, and that schizophrenia might
primarily be a right-brain dysfunction. However, some
researchers assert that in schizophrenia, a dysfunction
is evident in the left hemisphere or in both, rather than
on the right side (29,30).
Rabins et al. (26) report temporoparietal lesions in
five cases with post-stroke atypical psychosis,
accompanied by subcortical atrophy. Subcortical
atrophy and right hemisphere lesions have been
reported as risk factors for psychosis. Some sources
have claimed that only the anatomical localization of
the lesion alone may not be sufficient to explain the
psychosis and that lesion-related seizures might
increase the probability for the development of
psychosis. Levine and Finklestein (32) reported that in
seven out of eight cases with right temporoparietal
stroke or traumatic injury psychosis occurred together
with a seizure. As a hypothesis, it may be thought that
the lesion region causes continuous electrical activity,
thus constituting the organic substrate for the
psychotic phenomenon (16). The association between
post-lesion seizure and acute psychosis is important
for the diagnosis and the therapeutic process of the
It is still not precisely known how focal lesions in
which regions constitute what kind of psychotic
presentations. In our case, it can be assumed that an
ischemic lesion in the right MCA border irrigation area
involving the right temporoparietooccipital region
triggered the patient’s acute psychotic presentation.
The inadequacy of today’s approaches to
psychiatric diagnostic systems shows that we still need
a better understanding of the pathophysiology of
psychiatric diseases. A broader collaboration between
neurology and psychiatry may point a way towards an
understanding of a number of neuropsychopathologies
still waiting for an explanation (33). In conclusion;
1. After a stroke, a number of psychiatric
presentations can develop, first of all depression.
Depending on localization, different clinical
presentations can be seen.
2. Psychotic symptoms are rarely seen after stroke.
The likelihood of psychotic symptoms is higher with
right hemisphere temporoparietooccipital lesions.
However, with other localizations, especially in deep
subcortical structures, psychosis can also be seen.
3. A good understanding of the psychiatric signs
accompanying focal brain lesions can provide
important hints for an understanding of the organic
reasons for psychiatric diseases.
4. After stroke, seizures can be seen and related
neuropsychiatric presentations can occur. This
condition may affect diagnosis and treatment process
of the disease.
Table 2: Cases of cerebrovascular lesions and accompanying psychotic presentations
Author Psychotic Presentations Localization of Lesion
Kumral and Ozturk, 2004 (19) Jealousy or persecutory or somatic delusions Mostly lenticular, thalamic, and medullar lesions in the right
posterior temporoparietooccipital cortex
Nagaratnam and O’Neile, 2000 (20) Tactile hallucinations and bizarre delusions Left temporoparietooccipital ischemic stroke
Beniczky et al., 2002 (21) Complex visual and tactile hallucinations Right temporoparietooccipital ischemic stroke
Narumoto et al., 2005 (22) Persecutory delusions Bilateral caudate ischemic infarction (caput caudatum lesion)
Nye and Arendts, 2002 (23) Episodic olfactory hallucinations Hemorrhagic left uncus lesion
Berthier and Starkstein, 1987 (24) Sporadic auditory and sensory hallucinations
accompanied by complex visual hallucinations
Wide right frontotemporoparietal ischemic infarction
Barboza et al., 2013 (17) Delayed persecutory-type delusion Right frontotemporoparietal lesion
Peroutka et al., 1982 (31) Complex hallucinations and delusions Right temporoparietooccipital lesion
Levine and Finklestein, 1982 (32) Delayed psychosis: Hallucinations and in some
cases delusions and agitation
Right temporoparietooccipital lesion
Akinci E, Oncu F, Topcular B
Düşünen Adam The Journal of Psychiatry and Neurological Sciences, Volume 29, Number 1, March 2016
Conflict of Interest: Authors declared no conflict of Interest.
Financial Disclosure: Authors declared no financial support.
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Contribution Categories Name of Author
Follow up of the case E.A., B.T.
Literature review E.A., F.O., B.T.
Manuscript writing E.A., F.O.
Manuscript review and revisation E.A., F.O., B.T.
84 Düşünen Adam The Journal of Psychiatry and Neurological Sciences, Volume 29, Number 1, March 201