*Aims and objectives:* A pre-registered systematic review of post-stroke psychosis examining clinical characteristics, prevalence, diagnostic procedures, lesion location, treatments, risk factors, and outcome.
Background: Neuropsychiatric outcomes following stroke are common and severely impact quality of life. No previous reviews have focused on post-stroke psychosis despite clear clinical need.
*Methods:* CINAHL, MEDLINE and PsychINFO were searched for studies on post-stroke psychosis published between 1975 and 2016. Reviewers independently selected studies for inclusion, extracted data, and rated study quality.
*Results:* Out of 2442 references, 76 met inclusion criteria. Average age for post-stroke psychosis was 66.6 years with slightly more males than females affected. Delayed onset was common. Neurological presentation was typical for stroke but a significant minority had otherwise ‘silent strokes’. The most common psychosis was delusional disorder, followed by schizophrenia-like psychosis and mood disorder with psychotic features. Estimated delusion prevalence was 4.67% (95% CIs 2.30 – 7.79), and hallucinations 5.05% (95% CIs 1.84 – 9.65). 12 year incidence was 6.7%. No systematic treatment studies were found. Case studies frequently report symptom remission after antipsychotics but serious concerns about under-representation of poor outcome remain. Lesions were typically right-hemisphere, particularly frontal, temporal and parietal regions, and the right caudate nucleus. In general, post-stroke psychosis was associated with poor functional outcomes and high mortality. Poor methodological quality of studies was a significant limitation.
*Conclusion:* Psychosis considerably adds to illness burden of stroke. Delayed onset suggests a window for early intervention. Studies on the safety and efficacy of antipsychotics in this population are urgently needed.
