Post-Stroke Psychosis Presenting with Auditory Hallucinations: A Case Report in an Elderly Patient

Abstract

Background: Auditory hallucinations are typically associated with schizophrenia spectrum disorders but can occur secondary to cerebrovascular events, sensory deprivation, or neurodegenerative processes. Post-stroke psychosis (PSP) is an underrecognized neuropsychiatric complication, affecting approximately 5% of stroke survivors. Lesions involving temporoparietal or subcortical structures, in conjunction with dopaminergic dysregulation and sensory impairment, may precipitate hallucinations and delusions, particularly in older adults. Aims: To report a case of late-onset auditory hallucinations following stroke in an elderly patient, and to underscore the diagnostic challenges and therapeutic considerations when psychosis arises in the context of cerebrovascular disease. Case Description: An 83-year-old female with a history of cerebrovascular accident, seizure disorder, hearing loss, multiple medical comorbidities and no prior psychiatric history presented with new-onset auditory hallucinations and persecutory delusions. She reported hearing threatening voices and believed her neighbors conspired against her. Neuroimaging revealed acute lacunar infarcts in the bilateral centrum semiovale and left parietal cortex with chronic microvascular ischemic changes. Laboratory findings and cognitive testing were within normal limits. She was initiated on low-dose olanzapine with symptomatic improvement and later readmitted for recurrence following medication discontinuation. Repeat MRI was unchanged. Given the temporal association with cerebrovascular injury and the absence of prior psychiatric history, a diagnosis of post-stroke psychosis was made. Reintroduction of olanzapine resulted in stabilization, and the patient returned to baseline functioning. Conclusion: This case emphasizes the importance of considering cerebrovascular etiologies in late-onset psychosis, particularly in elderly patients with vascular risk factors and sensory impairment. Early recognition, integrated neuropsychiatric evaluation, and judicious low-dose antipsychotic therapy can lead to favorable outcomes while minimizing treatment-related risk. Future research should further delineate biological mechanisms, looking at vascular injury, sensory loss, and its association with late-life psychosis and/or auditory hallucinations.