Case of organic mania associated with stroke and open heart surgery

Abstract

ORGANIC MANIA HAS been reported to have multiple causes. Although post-stroke depression is well recognized, post-stroke mania has rarely been reported. There have been few cases in the literature reporting mania secondary to cerebrovascular lesions, one of which followed a lesion in the non-dominant hemisphere. A 27-year-old, right-handed woman presented with symptoms of elevated mood, grandiosity, sleeplessness, and disinhibition with a history of stroke 1 year previously. She had undergone surgery because of mitral valve stenosis 6 months previously. She had no other disease and no family history of psychiatric disorders. At admission, neurological examination was normal except for a mild weakness on the left side. Poststroke magnetic resonance imaging findings of the patient after 6 months were as follows. The lesion was seen on the right insular and frontal cortex. The patient scored 52 out of 60 on the Young Mania Rating Scale. We started treatment with olanzapine (30 mg/day) and valproate (1000 mg/day). Her symptoms significantly improved after three months. The patient provided informed consent to publish this paper. Krauthammer and Klerman described and gave a list of organic causes of mania, such as drugs, infection, epilepsy, cerebral neoplasm and metabolic disturbances. However, mania is a rare complication of stroke with an incidence of <1%. Robinson and colleagues conducted a series of studies with 27 patients with organic mania due to stroke, traumatic injury, or brain tumors. The authors emphasized that mania following brain injury (especially stroke) is associated with a positive family history of mood disorders and lesions involving the right limbic area or subcortical atrophy by increased ventricle-to-brain-size ratio. There have been some cases of mania after heart surgery that may be related to valve replacements or factors complicating surgery, such as macroembolism, microembolism and cerebral hypoperfusion. Although organic mania is generally reported in the elderly, it is also possible in younger patients, like this case.