306 - Off-Label Use of Naltrexone for Hypersexuality Following Thalamic Stroke

Case Diagnosis: Treatment of hypersexuality post-thalamic stroke

Case Description: We present a 57-year-old male with an acute right thalamic stroke involving the anteromedial thalamus, parasagittal midbrain, and posterior limb of the internal capsule. He presented with left hemiplegia, expressive aphasia, and dysphagia.  Once stable, the patient was transferred to inpatient rehabilitation. During his rehabilitation course, he exhibited hypersexual behaviors including inappropriate verbal comments toward female staff and one incident of unwanted physical contact, necessitating staff modifications. Notably, he had no prior psychiatric history.

Discussions: Hypersexuality is a rare but recognized neurobehavioral complication following stroke, with prior reports linking it particularly to thalamic involvement. The underlying pathophysiology remains poorly understood but is thought to involve disruption of thalamic connections with limbic and frontal circuits that regulate impulse control. Pharmacologic strategies described in the literature include selective serotonin reuptake inhibitors (SSRIs) and donepezil. Naltrexone, an opioid receptor antagonist traditionally used in addiction medicine, has also been investigated as a potential therapy for compulsive sexual behavior disorder. In this case, while sertraline was initiated, the addition of naltrexone 50 mg daily was associated with a reduction in hypersexual behaviors, highlighting its potential role as an off-label management option in select patients.

Conclusions: This case highlights the potential role of naltrexone in managing post-stroke hypersexuality, particularly in patients without prior psychiatric history. Recognition and treatment of hypersexual behaviors are essential for maintaining patient and staff safety, optimizing rehabilitation participation, and preserving therapeutic relationships. Further study is warranted to explore the role of naltrexone as a pharmacologic option for post-stroke hypersexuality.