Emotional Lability After Stroke

I was seeing L back in the office for the first time since he had suffered a stroke. Now age 55, he had suffered with complications of diabetes mellitus since the age of seven. Despite the development of retinopathy, neuropathy and renal failure leading to a kidney transplant, he had remained upbeat, motivated to take care of his health and most importantly he always found joy in life. Today he was clearly different.

The stroke had caused a large bleed in the right side of his brain. His wife had called 911 after he had fallen from sudden left sided weakness. Initially she thought he was hypoglycemic, but his glucose was fine. Soon after arriving in the emergency room, he became obtunded and required intubation and placement on a ventilator. Miraculously, he started to steadily improve over the next 72 hours and was extubated. He quickly regained strength and was able to walk. He improved so quickly that he decided (with my support) not to go to a rehabilitation hospital, but rather to go home and receive home physical therapy.

So here he was before me with tears in his eyes and I did not know how to understand them. We had walked from the waiting room to my office together and his gait was amazingly normal. We had chatted while walking and he had appeared his old self. Once he sat down, his eyes had swelled with tears. I let him regain his composure and he finally explained.

Since returning home from having the stroke, he had started having vivid recollections of childhood events. Several were triggering crying spells. One event, however, was dominating his thoughts as if it had happened the day before:

“I am four years old and helping my mom and dad decorate the Christmas tree. I dropped a light bulb and somehow it sparked. Within a few seconds, there was a fire and the tree and all the presents underneath it were in flames. My dad put out the fire, but all the presents were destroyed. I had ruined everybody’s Christmas. I was heartbroken. My mom and dad tried to reassure me that it was not my fault and that they were not angry with me. I couldn’t stop crying for days. But now here I am over 50 years later and I can’t stop crying over this event that all of sudden seems like it occurred yesterday.”

It was clear that somehow the stroke had activated this painful memory and made him have uncontrolled crying. He denied feeling depressed. We talked more that day and later that afternoon I scoured the literature looking to find out if there were descriptions of this happening after a stroke. Sure enough, there were several reports of post-stroke pathological crying attributed to “stroke-induced partial destruction of the serotonergic raphe nuclei in the brainstem or their ascending projections to the hemispheres.” However, I could not find an explanation as to why he was having such a vivid recollection of a distant memory, as most stroke patients indeed have memory difficulties.

I called him about a week later and discussed with him what I had found. He related that he was getting better gradually and was no longer crying quite as much. He felt even better as we discussed emotionality being common after a stroke. Now we are working on getting him back to work. I am sure he will succeed.