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Severe Transient Suicidality Due to Hemispheric Hyperperfusion After Successful Acute Stroke Thrombolysis
Vijay K. Sharma, M.D., RVT; Leonard L.L. Yeo, M.R.C.P.; Roger C. Ho, M.R.C.Psych.; Rahul Rathakrishnan, M.R.C.P.
The Journal of Neuropsychiatry and Clinical Neurosciences 2013;25:E33-E34. doi:10.1176/appi.neuropsych.12100245
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Contributorship statement: Conception and acquisition of data: Leonard Yeo, Rahul Rathkrishnan, Roger Ho, Vijay K Sharma; interpretation of data and drafting the article: Leonard Yeo, Rahul Rathkrishnan; critical revision: Roger Ho, Vijay K Sharma; final approval of the version: Vijay K. Sharma, Rahul Rathkrishnan, Roger Ho, Leonard Yeo.

Division of Neurology, National University Hospital, Singapore
Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Division of Psychological Medicine, National University Hospital, Singapore

Correspondence: Dr. Vijay K Sharma; e-mail: vijay_kumar_sharma@nuhs.edu.sg

Copyright © 2013 by the American Psychiatric Association

Extract

To the Editor: Intravenously administered tissue plasminogen activator (IV-tPA) remains the only approved drug therapy for achieving arterial recanalization in acute ischemic stroke. Timely administration of IV-tPA often results in rapid recanalization and rapid clinical recovery. However, rapid recanalization of an occluded intracranial artery rarely can lead to cerebral hyperperfusion syndrome, with variable presentations. We present a case that showed an excellent early recovery after IV-tPA for severe acute ischemic stroke. However, the patient developed severe suicidal ideation on Day 3. We present clinical and various imaging studies to elucidate the underlying pathophysiological mechanisms.

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FIGURE 1. Brain CT of Patient With Suicidal Ideation After Successful Acute Stroke Thrombolysis

Pre-thrombolysis brain CT angiography shows occluded right middle cerebral artery [A] that recanalized completely on Day 2 [B]. Significantly elevated cerebral blood flow (CBF) and volume (CBV) are evident in right frontal region (region 3 and 5; reference 4 and 6 on left hemisphere) on CT perfusion (CTP) performed on Day 3. Day-6 CTP shows normalization of various cerebral perfusion parameters. Corresponding raw electroencephalography (EEG) data and spectral brain mapping on Days 3 and 6 are shown. EEG performed on Day 3 shows considerable right fronto-temporal slowing, seen as red/yellow areas on spectral brain mapping. EEG and spectral maps show normalization of cerebral activity on Day 6.

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References

Bolli  R;  Marbán  E:  Molecular and cellular mechanisms of myocardial stunning.  Physiol Rev 1999; 79:609–634
[PubMed]
 
Alexandrov  AV;  Hall  CE;  Labiche  LA  et al:  Ischemic stunning of the brain: early recanalization without immediate clinical improvement in acute ischemic stroke.  Stroke 2004; 35:449–452
[CrossRef] | [PubMed]
 
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