Exploring the concept and management of post ictal psychosis through a clinical case and review

Introduction Postictal Psychosis of Epilepsy (PIPE), part of the group collectively known as Psychosis of Epilepsy, is characterized by an onset of confusion or psychotic symptoms within one week of apparent normal mental function. PIPE has been argued to be underdiagnosed in the clinical population, perhaps due to a failure to recognize the temporal relation between the seizure and the psychotic episode. Objectives To explore the concept and management of post ictal psychosis. Methods We present a clinical case and a review of the literature concerning post ictal psychosis. Results We report the case of a 36 year old woman with focal refractory epilepsy after a likely episode of limbic encephalitis in 2015. Cognitive and psychiatric sequelae in the form of depressive symptoms, in treatment with neurology and psychiatry since 2021. One previous episode of psychotic symptoms during seizures. Worsening of seizure frequency since march of 2022 with apparent normalization (absence of seizures after dose reduction of eslicarbamazepine and introduction oflamotrigine) for about four days before being hospitalized in the neurology unit due tobehavioral abnormalities. During psychiatric exploration, the patient showed signs of partial clouding of consciousness with manierisms, ecopraxias and ecolalias; verbigerance in the form of the neurologist’s name and bizarre movements like looking behind suggestive of sensoroperceptive disturbances. The symptomatology resolved itself during the following week after treatment with diazepam. Finally, a narrative review concerning the case was also performed; with particular emphasis on antipsychotic drugs with low risk of lowering seizure threshold (such as risperidone or aripiprazole) as the recommended treatment. Conclusions Our findings point to the relevance of Postictal Psychosis of Epilepsy as a clinical entity. Further studies on pathogenic mechanisms and therapeutic management are required. Disclosure of Interest None Declared

Introduction: Postictal Psychosis of Epilepsy (PIPE), part of the group collectively known as Psychosis of Epilepsy, is characterized by an onset of confusion or psychotic symptoms within one week of apparent normal mental function.PIPE has been argued to be underdiagnosed in the clinical population, perhaps due to a failure to recognize the temporal relation between the seizure and the psychotic episode.Objectives: To explore the concept and management of post ictal psychosis.Methods: We present a clinical case and a review of the literature concerning post ictal psychosis.Results: We report the case of a 36 year old woman with focal refractory epilepsy after a likely episode of limbic encephalitis in 2015.Cognitive and psychiatric sequelae in the form of depressive symptoms, in treatment with neurology and psychiatry since 2021.One previous episode of psychotic symptoms during seizures.Worsening of seizure frequency since march of 2022 with apparent normalization (absence of seizures after dose reduction of eslicarbamazepine and introduction oflamotrigine) for about four days before being hospitalized in the neurology unit due tobehavioral abnormalities.During psychiatric exploration, the patient showed signs of partial clouding of consciousness with manierisms, ecopraxias and ecolalias; verbigerance in the form of the neurologist's name and bizarre movements like looking behind suggestive of sensoroperceptive disturbances.The symptomatology resolved itself during the following week after treatment with diazepam.Finally, a narrative review concerning the case was also performed; with particular emphasis on antipsychotic drugs with low risk of lowering seizure threshold (such as risperidone or aripiprazole) as the recommended treatment.Conclusions: Our findings point to the relevance of Postictal Psychosis of Epilepsy as a clinical entity.Further studies on pathogenic mechanisms and therapeutic management are required.

EPV0264
Neuropsychiatric symptoms in Posterior Cerebral Artery Stroke: Avoiding misdiagnosis Introduction: Posterior Cerebral Artery (PCA) strokes cause the restriction of blood flow to multiple areas of the brain including the occipital lobe, the thalamus, the inferomedial temporal lobe, the upper part of the brainstem and the midbrain.This results in a panoply of possible symptomatology (including psychiatric manifestations) that increases the difficulty in diagnosis.Objectives: We aimed to present and discuss atypical presentations of cerebrovascular disease that often results in misdiagnosis in an emergency context.Methods: A non-systematic review of the topic was conducted, and a case report is presented.
Results: An 86-year-old male patient, previously autonomous and cognitively intact, presents with periods of confusion and incoherent speech, visual hallucinations, incongruity of affect with pathological laughter, insomnia and increased aggressive behaviour, which began suddenly and worsened in the period of a week.The symptoms motivated several recurrences to the emergency department and numerous diagnostic exams performed, including CT scans and an EEG.Neurological examination showed no focal neurological deficits.The patient was admitted to a psychiatric ward for further diagnostics work-up.Due to increasingly altered status of consciousness, an MRI was performed, which found ischemic left occipital lesions compatible with PCA stroke.The patient was afterwards transferred to a neurology ward for continuing medical care.
Conclusions: This case exemplifies how atypical symptoms such as visual hallucinations and changes in behaviour can be the only clues to diagnosing a PCA infarction, particularly in the absence of other focal neurological deficits.PCA strokes most commonly present with homonymous hemianopia, unilateral limb weakness, gait ataxia and vertigo.However, several other studies and case reports have found that this is not always the case and a minutious approach should be preferred in patients with a sudden onset of sensory and perceptual alterations and oscillating state of consciousness and disorientation, especially when discussing elderly people.Often these patients are admitted in psychiatric wards which may hinder the appropriate care they must receive.The increasing prevalence of cannabis use in the world requires awareness of cannabis-related disorders such as cannabinoid hyperemesis syndrome (CHS).CHS is characterized by cyclic episodes of nausea, vomiting and abdominal pain, affecting chronic cannabis users, who usually recur to hot showers to relief the symptoms.The pathophysiology underlying this syndrome is still unclear.Despite the well-established anti-emetic properties of cannabis, there is increasing evidence of its paradoxical effects on the gastrointestinal tract and central nervous system.Objectives: The authors pretend to inform the readers about the rare Cannabinoid Hyperemesis Syndrome (CHS).Methods: The authors describe a case of a 22 years old patient with chronic cannabis use, cyclic and intractable nausea and vomiting, to bring to the attention that this condition exists and is underdiagnosed.

Disclosure of
Results: CHS should be strongly considered in the differential diagnosis of persistent vomiting in patients who reports relief with hot showers.In the acute setting, supportive care with intravenous fluids, dopamine antagonists, topical capsaicin cream, and avoidance of narcotic medications has shown some benefit.However, cannabis cessation appears to be the best treatment.Conclusions: CHS prevalence will continue to rise in parallel with increasing worldwide cannabis use and potency.So, health professionals must be aware of this syndrome, its diagnosis, and treatment, to provide better care and avoid overlooking CHS.Further research is required to elicit the exact mechanism and additional therapies for this condition.

Disclosure of Interest: None Declared
Interest: None Declared EPV0265 Cannabinoid Hyperemesis Syndrome -A Case Report of an uncommon condition B. Peixoto*, M. Bicho, M. Cruz, M. Mendonça and V. Ustares Introduction: