Intracerebral Hemorrhage With Superimposed Psychiatric Illness: Navigating the Evaluation of Altered Mental Status

TL;DR

A 70-year-old woman with psychiatric illness and altered mental status was found to have a brain hemorrhage, highlighting the diagnostic challenges when psychiatric and neurological conditions overlap.

Contribution

The paper presents a case emphasizing the importance of interdisciplinary collaboration and diagnostic tools in managing complex AMS cases with psychiatric comorbidities.

Findings

A psychiatric patient with altered mental status was found to have an intracerebral hemorrhage and lithium toxicity.

Interdisciplinary evaluation and serial neuroimaging helped distinguish between psychiatric and neurological causes of AMS.

Gradual improvement followed medication adjustments and antiepileptic therapy.

Abstract

Evaluating altered mental status (AMS) in patients with psychiatric illness presents a major diagnostic challenge, particularly when acute neurologic pathology such as intracerebral hemorrhage (ICH) is present. This report describes a 70-year-old woman with schizophrenia and bipolar disorder on haloperidol, lithium, and clonazepam who presented with confusion, rigidity, and agitation. Workup revealed a supratherapeutic lithium level and a right temporo-occipital intraparenchymal hemorrhage. The differential included lithium toxicity, catatonia, seizure, and hemorrhagic progression.

Multidisciplinary evaluation with neurology, psychiatry, and neurosurgery, along with EEG and serial imaging, identified right temporal epileptiform activity and stable hemorrhage. Gradual improvement followed medication adjustments and antiepileptic therapy.

This case underscores the diagnostic complexity of AMS in patients with coexisting psychiatric and neurologic disease. Overlapping symptoms can obscure acute intracerebral pathology, emphasizing the need for interdisciplinary collaboration, serial neuroimaging, and prompt EEG when indicated.

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