Hindawi Publishing Corporation Case Reports in Neurological Medicine Volume 2014, Article ID 428425, 6 pages http://dx.doi.org/10.1155/2014/428425

Case Report Acute Associated with Subcortical Stroke: Comparison between Basal Ganglia and Mid-Brain Lesions

Aaron McMurtray,1,2,3 Ben Tseng,2 Natalie Diaz,1,2,3 Julia Chung,4,5,6 Bijal Mehta,1,2,3 and Erin Saito1

1 Division, Los Angeles Biomedical Research Institute, Torrance, CA 90502, USA 2 Neurology Department, Building N-25, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA 3 Neurology Department, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA 90095, USA 4 Division, Los Angeles Biomedical Research Institute, Torrance, CA 90502, USA 5 Department of Psychiatry, Harbor-UCLA Medical Center, Torrance, CA 90509, USA 6 Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA 90095, USA

Correspondence should be addressed to Aaron McMurtray; [email protected]

Received 27 June 2014; Revised 19 August 2014; Accepted 8 September 2014; Published 18 September 2014

Academic Editor: Peter Berlit

Copyright © 2014 Aaron McMurtray et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Acute onset of psychosis in an older or elderly individual without history of previous psychiatric disorders should prompt a thorough workup for neurologic causes of psychiatric symptoms. This report compares and contrasts clinical features of new onset of psychotic symptoms between two patients, one with an acute basal ganglia hemorrhagic stroke and another with an acute mid- brain ischemic stroke. Delusions and due to basal ganglia lesions are theorized to develop as a result of frontal lobe dysfunction causing impairment of reality checking pathways in the brain, while visual hallucinations due to mid-brain lesions are theorized to develop due to dysregulation of inhibitory control of the ponto-geniculate-occipital system. Psychotic symptoms occurring due to stroke demonstrate varied clinical characteristics that depend on the location of the stroke within the brain. Treatment with medications may provide symptomatic relief.

1. Introduction damage to connections between the prefrontal cortices and subcortical structures causing impairment of reality monitor- Acute onset of hallucinations and delusions in older and ing functions [2, 3], direct insult to primary visual cortices elderly patients with no known history of previous psychiatric (Anton’ssyndrome) causing misinterpretation of signals from disorders should prompt a thorough investigation for sec- undamaged visual association cortex areas [1, 4], and loss of ondary or neurologic causes of psychotic symptoms. Previous inhibitory control of ponto-geniculate-occipital connections reports describe acute onset of psychosis resulting from acute leading to visual hallucinations that have been described as stroke or other structural lesions affecting several different similar in nature to rapid eye movement (REM) sleep (pedun- brain areas, including the prefrontal and occipital cortices, cular hallucinosis) [2]. Consequently, we hypothesized that and subcortical locations such as the basal ganglia, thalamus, newonsetpsychosisduetoacquiredbrainlesionsmaydisplay mid-brain, and [1, 2]. different clinical characteristics depending on the location Several different mechanisms are postulated to explain of the responsible lesion and the underlying brain structures acute development of psychotic symptoms due to acquired and mechanisms involved. brain lesions, including direct injury to the frontal lobes In this report we compare two cases of new onset or disruption of normal frontal lobe functioning through acute psychosis resulting from subcortical strokes located in 2 Case Reports in Neurological Medicine different brain regions, the basal ganglia, and the mid-brain. friend with new onset of dizziness and unsteadiness when The cases discussed in this report underwent brain imaging walking that had developed suddenly approximately one studies, general physical and neurological examinations, rou- month earlier. She also reported new onset of double vision tine blood tests, and other studies related to workup of stroke. and an occipital headache both of which had developed In both cases the psychotic symptoms developed acutely were acutely three days prior to presentation and visual and not the result of coexistent delirium and responded well to auditory hallucinations that developed one day prior to treatment with antipsychotic medications. presentation. On presentation to the emergency room, the patient was 2. Case Presentation 1: Left Basal Ganglia obtunded but able to be aroused and she could answer ques- tions and follow simple commands when aroused. The patient Hemorrhagic Stroke was noted to be grabbing at unseen objects by the nursing staff. The patient was alert and oriented to self, location, and A fifty-nine-year old right-handed male with no known date. Cranial nerve examination showed fixed dilated pupils past medical history was brought in by emergency medical bilaterally that were not reactive to light, bilateral exotropia of services to the emergency room after acute onset at home of the eyes at rest, and complete paresis of ocular movements. right sided weakness and visual and auditory hallucinations The corneal and gag reflexes were present. The patient had that started approximately eight hours prior to arrival. The purposeful movement in all extremities but was noted to patient was alert and oriented to self, location, and date. have more spontaneous movement of the left side limbs Examination revealed a right lower facial droop and right than the right side. Sensation for light touch and pin-prick hemiparesis with associated pronator drift. Sensation for light were normal in the upper and lower extremities bilaterally. touch and pin-prick was normal in the upper and lower Deep tendon reflexes were also normal and symmetrical extremities bilaterally. Deep tendon reflexes were brisk on the throughout. right side compared to the left side. The patient’s visual hallucinations were formed and The patient reported content specific delusions that the consisted of seeing a deceased uncle. The patient’s audi- right side of his body was “rotting,” that he had a tooth that tory hallucinations consisted of intermittently hearing the was decaying in the right side of his mouth and that the nurses deceased uncle’s voice saying indistinct words and sentences. had injured the right side of his body when transporting him. The patient demonstrated preserved insight: she was aware Despite repeated reassurance by his treating physicians that that the hallucinations were not real and that her uncle was none of these were true, he continued to display these fixed deceased and therefore could not be present and talk to her. false beliefs. His visual hallucinations consisted of seeing The patient received a single dose of haloperidol in the emer- colors and lights and hearing voices telling him that the gency room due to agitation, which temporarily resolved the rightsideofhisbodywas“dead.”Hewastreatedwithlow auditory and visual hallucinations for the remainder of that dose risperidone and his hallucinations steadily decreased in night. The patient’shallucinations were initially worse at night frequency over the course of the next two weeks. butthengraduallydecreasedonscheduledhaloperidol. Initial laboratory assessment showed a normal serum The initial laboratory assessment for this patient showed chemistry panel, normal complete blood cell count, normal a normal serum chemistry panel, normal complete blood urinalysis, and negative urine toxicology screen for illicit cell count, normal urinalysis, and negative urine toxicology substances. Serum HIV testing was negative and a thyroid screen for illicit substances. stimulating hormone level was within normal limits. A 1.5 Tesla magnetic resonance imaging of the brain A 1.5 Tesla magnetic resonance imaging scan of the without contrast showed areas of restricted diffusion on DWI brain without contrast showed a 3.8 cm by 2.2 cm intra- sequences located bilaterally in the thalami, left cerebral parenchymal hematoma located in the left basal ganglia peduncle, the mid-brain, and right external capsule consis- with adjacent edema likely affecting the corona radiate and tent with acute infarcts. Additional small, scattered white possibly extending to the optic radiations. There was no matter hyperintensities were present in the periventricular midline shift. Gray-white differentiation was preserved and regions bilaterally on the FLAIR sequence, consistent with the ventricles, sulci, and cisterns were normal. Additionally, small vessel vascular disease. The ventricles, cisterns, and no extra-axial fluid collections or significant atrophy was sulci were normal in appearance and there was no significant present, and there was no evidence of acute or subacute atrophy. There were no intra-axial or extra-axial fluid collec- ischemic change. Small periventricular hyperintensities were tions, no mass, and no midline shift (Figure 2). present in the white matter on a fluid attenuated inversion recovery (FLAIR) sequence, consistent with chronic small 4. Discussion vessel vascular disease (Figure 1). Psychosis is a relatively rare complication after stroke, with 3. Case Presentation 2: Peduncular one large cohort study reporting a cumulative incidence of Hallucinosis due to Ischemic Stroke psychoticdisordersofjust6.7%inthetwelveyearsafterfirst stroke [5]. Psychosis in patients with basal ganglia lesions is A fifty-two-year old right-handed female with past medical theorized to result from decreased reality testing or reality history significant for type two , hypertension, and monitoring and typically manifests as a combination of hyperlipidemia was brought to the emergency room by a content specific delusions (usually with a paranoid quality) Case Reports in Neurological Medicine 3

(a) (b)

(c) (d)

(e) (f)

Figure 1: Brain magnetic resonance imaging showing a left intracranial hemorrhage. (a) Axial T1 weighted image, (b) axial T2 weighted image, (c) sagittal T1 weighted image, (d) axial gradient echo (GRE) image, (e) axial diffusion weighted image, (f) adjusted diffusion coefficient (ADC) image. and sometimes visual or auditory hallucinations, although Delusions and hallucinations caused by lesions in the these are reported less frequently [2, 3, 6]. The first case basal ganglia are thought to occur due to disruption of normal presented in this report was typical of patients who develop self-corrective functions that prevent development to odd delusions and hallucinations due to basal ganglia lesions. The beliefsaswellasimpairmentofthesenseoffamiliaritywhich patient primarily reported fixed false beliefs related to his new may contribute to development of paranoid ideation [3]. physical impairment on the right side of the body, including Normal frontal lobe functioning depends on five frontal- a paranoid component as evidenced by his belief that the subcortical circuits that when damaged can alter normal hospital nurses had injured him. These false beliefs were behavior and contribute to development of neuropsychi- content specific and he did not exhibit delusional thinking in atric symptoms [8]. Previous reports have demonstrated other areas. His visual hallucinations were unformed and his that lacunar infarction in the basal ganglia is sufficient to auditory hallucinations also primarily were related to the new causeprefrontallobehypometabolismonpositronemission physical impairment on the right side of his body, suggesting tomography (PET) imaging, suggesting decreased or altered a content specific quality to the auditory hallucinations as frontal lobe functioning as a direct result of the lacunar stroke well. Interestingly, the patient’s lateralized nihilistic somatic [2, 9, 10]. The patients also were noted to have chronic white delusions (that his right side was rotting and a tooth in matter small vessel ischemic disease which could further the right side of his mouth was decaying), accompanied by be a disruption in the frontal subcortical pathways further auditory hallucinations telling him that the right side of his facilitating the behavioral sequelae mentioned. body was dead, may be consistent with Cotard syndrome In the case presented in this report, the left basal ganglia (delire des negations), which has been reported in primary lesion was quite extensive, likely causing disruption not psychiatricdisordersaswellasneurologicdisorderssuchas only of the frontal subcortical circuits mentioned above but dementia, traumatic brain injury, and [7]. additional subcortical structures such as the external capsule, 4 Case Reports in Neurological Medicine

(a) (b)

(c) (d)

(e) (f)

Figure 2: Brain magnetic resonance imaging showing acute infarcts in the thalami, left , and mid-brain. (a) Axial T1 weighted image, (b) axial T2 weighted image, (c) sagittal T1 weighted image, (d) axial gradient echo (GRE) image, (e) axial diffusion weighted image, (f) adjusted diffusion coefficient (ADC) image.

thalamus, and posterior limb of the internal capsule. This the structural analysis [2]. The pervious case report used the lesion was much larger for instance than the right caudate PET imaging to determine that a unilateral lesion affecting lacunar stroke lesion previously reported to cause content this system can produce bilateral alterations of prefrontal specific delusions [2]. Additionally, the basal ganglia lesion functioning, which is theorized to be necessary for generation described in this report affected the dominant hemisphere, of delusions and other psychotic symptoms [2]. However, while the previous case report involving the caudate lacunar it is not currently known and has not previously been stroke involved the nondominant hemisphere [2]. Taking reported if unilateral prefrontal dysfunction or lesions would these two case reports together, it appears that unilateral basal be sufficient to produce psychotic symptoms. Additional ganglia lesions in either the dominant or nondominant hemi- research utilizing advanced neuroimaging techniques such sphere are sufficient to produce delusions2 [ ].Thisissup- as diffusion tensor imaging to visual disruption in specific ported by the previous case report which included functional brain pathways and connections would be useful for further neuroimaging data obtained from brain fluorodeoxyglucose identifying and defining implicated pathways involved in the positron emission tomography (PET) imaging in addition to generation of acquired psychotic phenomena. Case Reports in Neurological Medicine 5

Peduncular hallucinosis, in contrast, was first described cerebellar tumors, and metastases), subarachnoid hemor- in the early 1920s by Jean Lhermitte [1, 4]. The patho- rhage, and even cases of iatrogenic injury from surgery [14, physiology of peduncular hallucinosis was then elicited 17–20]. through autopsy studies and the term “Peduncular Hal- Taken together these cases support the idea that psychosis lucinosis” was coined in reference to cerebral peduncles is a clinical syndrome that can arise from alteration of being the predominant anatomic structures thought to be several distinct underlying brain structures and mechanisms involved [1, 4]. Peduncular hallucinosis is described as and that clinical differences in the quality of the psychotic having a dream like quality, including vivid and colorful symptoms may reflect the particular underlying systems visual images [1, 4]. The images reported to be seen by involved. Specifically, content specific delusions with para- patients with this disorder that can be scenic or bizarre noid ideation likely suggest a process disrupting normal are almost always formed and consist of complex objects frontal lobe reality monitoring and checking systems, while or people [1, 4]. Lilliputian hallucinations of either animals formed hallucinations with preserved insight and related to or people have been reported as well [1, 4]. Usually there changes in the sleep cycle may suggest a release phenomenon is preserved insight and the hallucinations are considered with decreased suppression of spontaneous visual cortex to be egosyntonic [1, 4]. Additionally there is a high per- functioning by brainstem and structures. Since centage of hypnagogic hallucinations that predominantly both types of hallucinations responded well to antipsychotic occur in the evening when falling asleep and are thought medications, there is the possibility of a shared common to be related to a derangement of mid-brain and brainstem pathway or structure necessary for psychosis to develop that mechanisms that contribute to control of the sleep-wake cycle responds to antidopaminergic medications. [1]. The case presented in this report displayed hallucinations Conflict of Interests typical to those reported to occur with mid-brain and thalamic injuries. Specifically, the patient had formed hal- The authors declare that there is no conflict of interests lucinations with preserved insight that were worse at night, regarding the publication of this paper. consistent with a hypnogogic component. However, there were no bizarre or Lilliputian qualities to the hallucinations, which have also been described to occur with peduncular References hallucinosis. [1] F. R. Talih, “A Probable case of peduncular hallucinosis sec- A previous report by Benke in 2006 described auditory ondary to a cerebral peduncular lesion successfully treated with hallucinations in addition to visual hallucinations in a series an atypical antipsychotic,” InnovationsinClinicalNeuroscience, of five cases [11]. All of the patients described by Benke vol. 10, no. 5-6, pp. 28–31, 2013. reported visual and auditory hallucinations, with three of [2]A.M.McMurtray,D.L.Sultzer,L.Monserratt,T.Yeo,and the five patients also reporting tactile hallucinations as M. F. Mendez, “Content-specific delusions from right caudate well [11]. 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Stern, “Visual hallucinations: made by animals or inanimate objects such as trains, both differential diagnosis and treatment,” Primary Care Companion of which were reported in some of the patients described to the Journal of Clinical Psychiatry,vol.11,no.1,pp.26–32,2009. by Benke [11]. It is not clear from the literature if involve- [5] O. P. Almeida and J. Xiao, “Mortality associated with incident ment of certain brain structures predisposes to auditory mental health disorder after stroke,” The Australian and New hallucinations of voices, animals, or inanimate objects; or Zealand Journal of Psychiatry,vol.41,no.3,pp.274–281,2007. perhaps if personal experience and life-experience related [6]D.L.Sultzer,C.V.Brown,M.A.Mandelkernetal.,“Delusional factors play a role in the types of auditory hallucinations thoughts and regional frontal/temporal cortex metabolism in Alzheimer’s disease,” The American Journal of Psychiatry,vol. experienced. 160, no. 2, pp. 341–349, 2003. 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