Resident Physician, PGY-III University of New Mexico Albuquerque, New Mexico, United States
Case Diagnosis: Left middle cerebral artery infarction
Case Description: A 77 year-old male with a history of morbid obesity, atrial fibrillation, heart failure and hypertension was transported to the emergency department via emergency medical services after an unwitnessed fall. NIH score on admission was 29. A computed tomography angiography of the head and neck revealed a left middle cerebral artery occlusion. The patient received alteplase and underwent mechanical thrombectomy. The patient was noted as having right hemiplegia, expressive aphasia, and hypoactive delirium. Due to the patient's history of diastolic heart failure and prolonged QTc, the medical team felt uncomfortable administering amantadine or modafinil. The patient was started on low dose aripiprazole for cognitive enhancement.
Discussions: Neurostimulant administration after acute neurological injury such as stroke can improve cognition and lead to more interaction and participation in acute rehabilitation therapy sessions. Conversely, antipsychotics have been well documented in the literature as hindering motor function recovery. Most antipsychotics are dopamine receptor antagonists. Aripiprazole, an atypical third-generation antipsychotic, is unique in that it exhibits functional selectivity and partial agonism for dopamine receptors, similar to common neurostimulants such as amantadine and modafinil. Current research has demonstrated aripiprazole's neuroprotective effects in mouse models. Additionally, aripiprazole has been shown to improve functional recovery in mice. Furthermore, aripiprazole may be preferred over traditional mood stabilizers in patients with a prior psychiatric illness.
Conclusions: Patients with hypoactive delirium after stroke may benefit from neurostimulants. Properly managing the cognitive state can optimize rehabilitation programs by increasing participation in therapy sessions, minimizing fall risk, improving communication among rehabilitation team members and the patient, and possibly decreasing length of stay. Unlike most antipsychotics, aripiprazole has partial dopamine receptor agonist activity, and may be an additional option for patients who require neurostimulation. Future research studies should determine the safety and efficacy of aripiprazole in the stroke population.