Journal Article Annotations
2019, 2nd Quarter
Annotations by Nicholas Konton MD and Franklin King MD
July 2019
Findings:
Delirium is a common accompaniment of acute stroke. Hypoactive and mixed subtypes were found to be the most common subtypes in this relatively large sample, with the hyperactive subtype a distant third. While vision disorders, WBC count, and anticoagulation were found to predict a hypoactive delirium, atrial fibrillation and comorbidity index a mixed type, and urine bacteremia and diabetes mellitus a hyperactive type, an unemphasized finding is that all subtypes were significantly predicted by MoCA scores averaging about 20 and the presence of spatial neglect.
Strengths and limitations:
Within a neglected research domain, this study is most notable for its relatively large sample size. Attention to stroke focality is conspicuously absent and a worthy topic for future work, as is commentary on the common factors predicting all subtypes of post-stroke delirium.
Relevance to Consultation-Liaison Psychiatrists:
Post-stroke delirium is a challenging entity to diagnose and to determine the termination of (i.e., when delirium gives way to a temporary “new baseline”). This study draws attention to this important subject. The common finding of spatial neglect is a predictive factor in all subtypes is interesting, given the longstanding lore about “permanent delirium” (actually weeks-months observation) resulting from right parietal strokes (attributable mainly to a single case series by Marcel Mesulam).
Type of study:
Prospective cohort study
Findings:
Hippocampal tail (and, to a lesser extent, body) volume is decreased in patients with postictal psychosis and intericatal psychosis relative to epilepsy control patients without psychosis. The two psychosis-of-epilepsy groups were not significantly different in this regard.
Strengths and limitations:
Rigorous volumetric methods and differentiation of the two main psychosis-of-epilepsy groups buttress the significance of these results. The low (but in comparison to prior studies, not so low) n’s of the study, particularly with the post-ictal and interictal psychosis groups (both in the 20’s) are a somewhat unavoidable weakness.
Relevance to Consultation-Liaison Psychiatrists:
The psychoses of epilepsy are diagnostic entities prone to generate “turf” issues between psychiatry and neurology services. Better appreciation of why and how epilepsy is not merely defined by ictal semiology and frequency can only help bring greater clarity to this situation.
Type of study:
Prospective cohort study
Findings:
Aside from unspecified “agitation,” psychosis was found to be the most common psychiatric presenting symptom of anti-NMDA encephalitis. These symptoms may be indistinguishable from schizophrenia. Nearly ¼ of patients in this group exposed to neuroleptics developed neuroleptic malignant syndrome (often the reason for assumption of care by a non-psychiatric service, as opposed to suspicion of encephalitis).
Strengths and limitations:
As a review of case reports and case series, a phenomenological analysis of psychiatric presentations is made possible. At the same time, all of the limitations of case-based publications, augmented by their being combined, come into play.
Relevance to Consultation-Liaison Psychiatrists:
Despite there being a glut of papers on this topic, this one provides one-stop-shopping on the topic. This report is the product of an annual commission by the American Neuropsychiatric Association which consistently produces rather definitive reviews of important, and often murky, topics in neuropsychiatry and behavioral neurology.
Type of study:
Review