以躁狂為突出表現的腦梗塞
腦梗塞常表現為各種神經功能缺失癥狀，而以首發躁狂等精神癥狀為突出表現的腦梗塞臨床少見。
這種情形未受到重視，容易造成誤診。
躁狂表現為興奮躁動，情緒高漲、譫妄、甚至有攻擊行為，撕衣及言語猥瑣等。
急性起病起初表現為興奮、欣快、易激惹及暴怒，迅速進展到躁狂狀態。
腦部的病變可出現各種精神癥狀，是由於病變區缺失神經結構後神經系統所產生的功能障礙，尤其是邊緣葉、邊緣系統病變。邊緣系統主要包括海馬旁回、海馬結構和杏仁體等一些皮質下結構，這些結構與額葉、顳葉皮質等交互聯繫，對內臟功能有巨大影響，並廣泛參與各種精神活動。
躁狂這一組精神癥狀是由於腦缺血後局部產生的一系列病理生理變化所導致的。
機制是腦缺血後，腦組織單胺類遞質（參與各種生理活動，包括精神活動）含量異常增高，不但直接導致細胞受損、腦代謝、循環功能障礙，還通過興奮性氨基酸、氧自由基介導多種神經毒性作用，而且降低缺血後神經營養因子（海馬含高濃度）的分泌，促使細胞凋亡。這樣，在缺血的刺激下與精神癥狀有關的腦細胞處於興奮狀態，便產生相應的精神癥狀。
因此，對於一個腦血管病患者，尤其存在腦血管病高危因素的中老年人，在注意神經功能缺失癥狀的同時，更應該重視突發的精神癥狀這一危險信號。
重視突發的精神癥狀在腦血管病發展中的意義，才能減少誤診。
【永軍朗讀】
A 61 year-old man with a history of stroke and alcohol use disorder presented with grandiosity, impulsivity and decreased sleep.
Three months before this presentation, after 3.5 years of sobriety, the patient began to drink 1 pint of vodka per day.
The next month, during a period in which the patient reportedly felt reckless and out of control, he borrowed his wife"s car and drove for the first time since surrendering his license.
He lost control of the car and crashed into a bar and sustaining spinal fractures that necessitated the use of a cane.
One month before presentation, the patient reportedly had increased energy irritability, euphoric mood and a decreased need for sleep.
He was spending impulsively.
Three days before presentation, the patient travel to Boston to check into several hotels, gambled, shopped extravagantly and invited strangers for a steak dinner.
He contacted his son for money.
Although patient threatened to assault his son, his son brought him to the emergency department.
The evaluation was notable for an expansive affect, emotional lability and impaired memory.
This patient"s mood reflected a manic episode.
The differential diagnosis at a manic episode begins with determining whether it is the primary psychiatric disorder or a secondary disorder related to substance use or a general medical condition.
Emotional lability, personality changes, psychosis and mania are all possible psychiatric manifestations of stroke.
