Withdrawn Catatonia Mimicking a Cerebrovascular Accident: A Story of Diagnosis

Case Diagnosis: Acute withdrawn catatonia secondary to high dose risperidone in the setting of incidental left temporal lobe infarction.

Case Description or Program Description: 54-year-old female with history of left hemiparesis due to chronic cerebrovascular accidents (CVA) presenting after being found altered and unresponsive. Initial CT head demonstrated acute/subacute infarct of posterior left temporal lobe and remote infarcts of right frontal/parietal lobes. Further imaging revealed extensive bilateral pulmonary emboli. Psychiatry team consulted after patient became acutely suicidal/agitated and revealed history of bipolar disorder with documented prescription of risperidone. Patient started on risperidone 5mg nightly. After initiation of risperidone, there was concern for new stroke but further workup was unremarkable. Due to worsening left sided hemiparesis, cognitive decline, ataxia and aphasia, patient was sent to an inpatient rehabilitation (IPR) facility.

Setting: Stroke unit, IPR facility

Assessment/Results: Patient demonstrated characteristic posturing, slowed motor/speech initiation, staring spells, and apathy with lack of emotional expression at IPR. Patient was nonadherent to prescribed risperidone at home. Due to concerns of withdrawn catatonia, patient was weaned off risperidone. With discontinuation of risperidone, patient had noted improvements in motor/speech initiation, cognitive ability, expression, interaction, and motor strength which was noted across all therapy teams.

Discussion (relevance): Catatonia is a well-documented side effect of antipsychotics. Many of its characteristic effects can be mistaken for acute symptoms of CVA. Despite imaging findings, our patient exhibited no new symptoms until after initiation of risperidone. However, all deficits were wrongfully attributed to acute CVA. With discontinuation of risperidone, patient improved to previous known baseline functioning.

Conclusions: Given the proclivity of side effects for antipsychotic medications, clinicians need to be cognizant of symptoms following initiation of medication. Several characteristics of catatonia mimic symptoms of pathologies including CVAs. Understanding of these symptoms can guide differentiation of thorough workup versus prompt treatment. Furthermore, this may eliminate unnecessary workup and improve preservation of function in select patients.