Prediction of intracerebral hemorrhage survival

The Pilot Stroke Data Bank obtained information on 94 patients with intracerebral hemorrhage. These data were used to identify factors predictive of 30-day outcome from among 85 demographic, historical, clinical, and laboratory variables generally available to clinicians on the day of admission. The 9 univariate factors statistically associated with outcome were Glasgow Coma Scale score, systolic blood pressure, pulse pressure, horizontal and vertical gaze palsies, severity of weakness, presence of brainstem-cerebellar deficits, interval stroke course, and parenchymal hemorrhage size. Beginning with these factors, a step-down variable selection procedure was used to derive a logistic regression model, containing only Glasgow Coma Scale score, pulse pressure, and hemorrhage size, that could be used to categorize correctly 92% of the patients as alive or dead at 30 days after onset.

Differential mood changes following basal ganglia vs thalamic lesions

Patients with computed tomographic scan-verified unilateral lesions in the basal ganglia or thalamus were examined for the presence of poststroke mood disorders. Patients with left-sided basal ganglia lesions (mainly in the head of the caudate nucleus) showed a significantly higher frequency and severity of depression, as compared with patients with right-sided basal ganglia or thalamic (left- or right-sided) lesions. Results suggest that damage to biogenic amine pathways and/or frontocaudate projections may play an important role in the modulation of mood.

The Stroke Data Bank: design, methods, and baseline characteristics

The National Institute of Neurological and Communicative Disorders and Stroke initiated the Stroke Data Bank, which is a multicenter project to prospectively collect data on the clinical course and sequelae of stroke. Additional objectives were to provide information that would enable a standard diagnostic clinical evaluation, to identify prognostic factors, and to provide planning data for future studies. A brief description of the structure and methods precede the baseline characterization of 1,805 patients enrolled in the Stroke Data Bank between July 1983 and June 1986. Two thirds of these patients were admitted within 24 hours after stroke onset. Medical history, neurologic history, and hospitalization summaries are presented separately for the following stroke subtypes: infarction, unknown cause; embolism from cardiac source; infarction due to atherosclerosis; lacune; parenchymatous or intracerebral hemorrhage; subarachnoid hemorrhage; and other. The utility and limitations of these data are discussed.

Depressive disorders following posterior circulation as compared with middle cerebral artery infarcts

Patients with cerebrovascular lesions in the posterior circulation territory (PC) were compared with patients having middle cerebral artery territory (MCA) strokes for the presence of mood disorders. Both groups showed a similar profile of clinical symptoms of depression during the acute evaluation in hospital. Patients with posterior circulation lesions involving the brainstem and/or cerebellum demonstrated a significantly lower frequency of depression than patients with MCA lesions or patients with posterior circulation lesions involving the left cerebral hemisphere. Moreover, depression following brainstem and/or cellebellar infarcts was of significantly shorter duration than depression following MCA lesions. These differences in the frequency and duration of depression following brainstem/cerebellar as compared with MCA lesions were not explained by differences in lesion volume, physical impairment, cognitive deficits or quality of social support. They suggest that PC and MCA induced depression may have different aetiologies.

Comparison of patients with and without poststroke major depression matched for size and location of lesion

Patients who developed major depression within two years following stroke (n = 13) were compared with patients who did not become depressed in the same period (n = 13) but who did have a similar size and location of lesion as in the depressed group. Although the depressed patients were not significantly different from the nondepressed patients in background characteristics, history of depressive disorder, neurological impairment, or social functioning, the depressed group had greater cognitive impairment as measured by Mini-Mental State score. In addition, the depressed group had significantly larger lateral and third ventricular to brain ratios than nondepressed patients on computed tomographic scan analysis. The results suggest that poststroke depression itself may produce an intellectual impairment; subcortical atrophy, which likely preceded the stroke lesion, may produce a vulnerability for depression following stroke.

Comparison of mania and depression after brain injury: causal factors

Patients who developed secondary mania after brain injury (N = 17) had a significantly greater frequency of injury to right hemisphere areas connected with the limbic system than poststroke patients with major depression (N = 31), who had injury primarily in the left frontal cortex and basal ganglia. For patients without mood disturbance after brain injury (N = 28), the location of the lesion was not significant. Secondary mania patients also had a significantly greater frequency of family history of affective disorder than did the other two groups. These results suggest that an interaction between injury to certain areas of the right hemisphere and genetic factors or other neuropathological conditions produces secondary mania.

The sensitivity and specificity of the Center for Epidemiologic Studies Depression Scale in screening for post-stroke depression

The present study examines the sensitivity and specificity of the Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for post-stroke depression. Eighty stroke patients were evaluated by a research nurse over a two-year period using the CES-D and also by a trained psychiatrist using a standardized interview for affective, cognitive, physical and social functioning. CES-D scores correlated significantly with DSM-III diagnoses of depression in-hospital and at three months, six months, and one year follow-up but not at two years follow-up, reflecting the natural course of these depressions, as well as the predictive validity of the CES-D. Furthermore, at a cut-off point of 16, the CES-D was found to have a specificity of 90 percent, a sensitivity of 86 percent and a positive predictive value of 80 percent and thus may be a potentially useful screening instrument for post-stroke depression.

A two year longitudinal study of poststroke mood disorders: prognostic factors related to one and two year outcome

In a prospective study of mood disorders in 103 stroke patients, we examined the predictive value of affective, cognitive, social and neurologic variables obtained in-hospital and at six months poststroke in terms of outcome as determined by the same measures at one and two years follow-up. The following factors were found to have prognostic significance: 1) Lesion Location: proximity of the lesion on CT scan to the frontal pole in patients with left anterior infarcts showed a strong positive relationship with severity of depression at one year but not at two years poststroke. 2) Affective Status: depression (in-hospital and at 6 months) strongly predicted depression at one year but not at two years poststroke. Additionally, in-hospital depression significantly correlated with physical impairment at two years, while depression at six months bore a moderate relationship to physical impairment at one year. 3) Physical Impairment: impairment in activities of daily living in-hospital bore a modest relationship to depression at one year while such impairment at six months correlated strongly with depression at both one and two years. These findings may reflect the natural course of major depression which remits between one and two years poststroke. Although stroke lesion location is the strongest predictor of subsequent depression, there appears to be a reciprocal relationship between physical impairment and depression (i.e., depression predicts impairment and impairment predicts depression). Since poststroke depressions are amenable to therapeutic intervention, these prognostic factors may have implications for the treatment and rehabilitation of stroke patients.

Periodic courses of human 1-34 parathyroid peptide alternating with calcitriol paradoxically reduce bone remodelling in spinal osteoporosis

In an attempt to achieve an anabolic response in both axial and peripheral bone, we treated twelve patients with osteoporosis using human 1-34 parathyroid peptide given discontinuously. The peptide was given as seven daily subcutaneous injections followed by 21 days' treatment with 0.25 mg calcitriol orally. This regime was repeated cyclically for at least sixteen cycles, of which the first four were at a lower dose of hPTH 1-34 than used subsequently. The results of treatment were monitored by kinetic, densitometric, histomorphometric and biochemical studies performed before and during treatment. Two patients developed hPTH 1-34 binding in their plasma during treatment: this was presumed to be due to the development of antibodies. The remainder, instead of increasing their indices of bone turnover as judged by iliac bone histomorphometry, were found to have consistent reductions in trabecular resorption surfaces. The other indices of bone formation and resorption measured showed no change or comparable reductions. The small increases seen in total body calcium were consistent with 'in-filling' of deleted basic multicellular units (BMUs). Because there is no evidence that calcitriol alone causes comparable reductions in activation of bone remodelling in osteoporosis, interruption of treatment with hPTH 1-34 after 7 days may have led to a failure of the activation mechanism to proceed to the resorption stage, with a consequent overall reduction in remodelling activity. This type of treatment regime, with its calcitonin-like effect, might be effective in reducing net bone loss due to imbalance between bone formation and resorption at the BMU level, particularly in patients with increased numbers of BMUs ('high turnover' osteoporosis).(ABSTRACT TRUNCATED AT 250 WORDS)

Two-year longitudinal study of poststroke mood disorders: diagnosis and outcome at one and two years

As part of a prospective study of mood disorders in stroke patients, interviews were obtained from 37 patients at 1 year and 48 patients at 2 years follow-up. In-hospital evaluations for these 65 follow-up patients found that 9 patients (14%) had symptom clusters of major depression, 12 patients (18%) had symptom clusters of dysthymic or minor depression, and 44 patients (68%) did not meet the DSM III diagnostic criteria for depression. Although overall prevalence of depression did not change significantly over time, the prognosis for individual patients, depending on diagnostic group, was different. All of the follow-up patients with major depression in-hospital were improved by 2 years, with a significant reduction in their mean depression scores and improvement in their activities of daily living, whereas only 30% of follow-up patients with dysthymic depression improved by this time. There was no significant improvement in their mean depression scores or mean activities of daily living score. Of the patients followed up who were not depressed in-hospital, 34% had developed major or minor depression by 2 years, and their mean depression scores were significantly increased. These data suggest that the prevalence of depression among the follow-up patients remains high (between 30 and 40%) for the first 2 years after stroke, but that untreated poststroke major depression has a natural course of about 1-2 years, with associated improvement in activity of daily living scores, whereas the prognosis for poststroke dysthymic depression is frequently unfavorable and often persists for greater than 2 years.

Comparison of cortical and subcortical lesions in the production of poststroke mood disorders

Patients with single stroke lesions, verified by computerized tomography, involving either cortical tissue or restricted entirely to subcortical structures were examined for mood disorders. Those with left anterior lesions, either cortical or subcortical, had significantly greater frequency and severity of depression than patients with any other lesion location. A strong correlation between the severity of depression and proximity of the lesion to the frontal pole was observed for both left cortical and subcortical groups. Right hemisphere lesions did not show the same correlation with depression but were associated with a significantly higher incidence of undue cheerfulness. These findings demonstrate the importance of the location of subcortical lesions in poststroke mood disorders and suggest that anterior subcortical structures may play an important but lateralized role in the production or regulation of mood.

Two-year longitudinal study of post-stroke mood disorders: dynamic changes in correlates of depression at one and two years

As part of a prospective study of 103 stroke patients, we have analyzed the relation between depression and associated variables at 3 months, 6 months, 1 year, and 2 years after stroke. At all intervals up to and including 1 year poststroke, patients with left hemisphere strokes showed a strong relation between severity of depression and distance of the lesion on computed tomography scan from the frontal pole. At 2 years poststroke, this relation was no longer significant. The correlation between depression and impairment in activities of daily living peaked at 6 months and thereafter fell but remained significant at 1 and 2 years poststroke. The correlation between depression and cognitive impairment and between depression and social functioning fluctuated--with most correlations at 1 and 2 years follow-up nonsignificant. Although the conclusions that can be drawn from this study are limited by the fact that less than half of the original patients were followed up at each time, these declining correlations between depression and associated variables at 1 and 2 years follow-up may reflect the natural course of major depression which spontaneously remits between 1 and 2 years after stroke. The persisting significant association of impairment in activities of daily living with depression may reflect the effect of severe depression in sustaining and possibly retarding recovery from physical impairment.

Interobserver reliability in the interpretation of computed tomographic scans of stroke patients

Interobserver reliability in interpretation of computed tomographic images was studied by six senior neurologists who independently evaluated on a standardized Stroke Data Bank form the brain lesions of 17 patients. The results analyzed with kappa statistics yielded moderate to substantial agreement on most items of interest including the stroke pathology and anatomy. In general, the levels of agreement were as high as previously reported for the diagnosis of the mechanism of the stroke, and much higher than on many stroke history items and items of neurologic examination. Excellent agreement was obtained for the detection of infarcts and intracerebral hemorrhage, and substantial agreement was obtained on whether the computed tomographic images were normal or indicative of small deep infarcts, superficial and deep infarcts, and aneurysms. The level of agreement on anatomy of the lesions was best for the frontal, parietal, and temporal lobes, putamen, cerebellum, and subarachnoid space. Implications for clinical research and diagnosis are discussed.

Clinical and DST response to bilateral sinusoidal but not to unilateral brief-pulse ECT

Five patients with depressive illness who were DST nonsuppressors and who did not respond to unilateral nondominant brief-pulse ECT are described. When given a subsequent course of bilateral sinusoidal ECT, all five demonstrated marked clinical improvement associated with normalization of their DSTs.

Two-year longitudinal study of post-stroke mood disorders: comparison of acute-onset with delayed-onset depression

Patients who developed post-stroke depression 3 to 24 months after hospital discharge (N = 21) were compared with patients who developed depression during hospitalization (N = 26) and patients who never developed depression over 24 months of follow-up (N = 15). During the acute hospitalization and at follow-up, the three groups were not significantly different in their demographic characteristics, neurological impairment, intellectual impairment, or quality of social support. The acute depression group, however, showed an increased correlation between impairment and depression from hospitalization to follow-up. Findings suggest that impairment does not produce depression, but, once depression occurs, it may interact with impairment to influence post-stroke recovery.

Interobserver agreement in the diagnosis of stroke type

Interobserver agreement is essential to the reliability of clinical data from cooperative studies and provides the foundation for applying research results to clinical practice. In the Stroke Data Bank, a large cooperative study of stroke, we sought to establish the reliability of a key aspect of stroke diagnosis: the mechanism of stroke. Seventeen patients were evaluated by six neurologists. Interobserver agreement was measured when diagnosis was based on patient history and neurologic examination only, as well as when it was based on results of a completed workup, including a computed tomographic scan. Initial clinical impressions, based solely on history and one neurologic examination, were fairly reliable in establishing the mechanism of stroke (ie, distinguishing among infarcts, subarachnoid hemorrhages, and parenchymatous hemorrhages). Classification into one of nine stroke subtypes was substantially reliable when diagnoses were based on a completed workup. Compared with previous findings for the same physicians and patients, the diagnosis of stroke type was generally more reliable than individual signs and symptoms. These results suggest that multicentered studies can rely on the independent diagnostic choices of several physicians when common definitions are employed and data from a completed workup are available. Furthermore, reliability may be less for individual measurements such as signs or symptoms than for more-complex judgments such as diagnoses.

Procedural validity of an abbreviated version of the SADS/RDC diagnostic process

Formal diagnostic systems such as the Research Diagnostic Criteria (RDC) and standardized diagnostic interviews such as the Schedule for Affective Disorders and Schizophrenia (SADS) have enhanced clinical psychiatric research over the past decade. Because of the cost and time factors, however, they are not routinely used in most clinical settings. The availability of reliable alternatives compatible with clinical practice would encourage more psychiatrists to engage in clinical research. This study describes the nature and procedural validity of two such alternatives based on the RDC. Acceptably accurate, less costly research diagnostic processes can be incorporated into clinically oriented short-term acute inpatient units.

Phenomenology of temporal lobe dysfunction: a link to atypical psychosis--a series of cases

This report is a phenomenological study of 20 cases of temporal lobe disorders manifested as complex partial seizures. The major behavioral symptoms observed were episodic affective disturbances, episodic cognitive disturbances, and "spells," with normal functioning between episodes. The remarkable similarity of this phenomenology to what has been described as atypical or episodic psychosis provides a possible theoretical link to the etiology of atypical psychosis. These cases also establish atypical psychosis as an entity clearly different from the other major psychoses.

Depression influences intellectual impairment in stroke patients

Patients with ischaemic lesions of the left cerebral hemisphere were examined for depression and intellectual impairment: in non-depressed patients, the severity of impairment was related to both lesion volume and location, as assessed by CT scan analysis. Cognitive impairment in patients with major depression was greater than predicted by lesion volume alone, and when patients were matched for severity of impairment, depressed patients had smaller lesion volumes than the non-depressed. After six months, non-depressed patients had significantly less cognitive impairment than depressed patients who showed no improvement. Both depression and lesion volume were significantly and independently related to cognitive impairment. These findings suggest that post-stroke depression can produce a true dementia in its own right, and that treatment of post-stroke depression might benefit cognitive function.

Response of depressed patients to sequential unilateral nondominant brief-pulse and bilateral sinusoidal ECT

Of 37 endogenously depressed patients given a course of unilateral nondominant brief-pulse ECT, 20 responded well and received no further treatment; 17 showed minimal clinical improvement but improved significantly after a subsequent course of bilateral sinusoidal ECT. These findings suggest that there may be subgroups of depressed patients who respond differentially to unilateral and bilateral ECT, to high- and low-energy stimuli, or to combinations thereof. Seizure duration did not appear to be a crucial variable in the efficacy of ECT; among the unilateral nonresponders, seizures of equal duration induced by unilateral stimulation were not as therapeutically effective as those induced by bilateral ECT. Response to the first three ECTs appeared to be the only predictor of unilateral responsiveness.

Screening for depression in stroke patients: the reliability and validity of the Center for Epidemiologic Studies Depression Scale

This study examined the inter-observer reliability and validity of the Center for Epidemiologic Studies Depression Scale (CES-D) as a measure of depressive symptomatology in stroke patients, and its utility as a screening tool for depression in this population. The CES-D Scale is a brief questionnaire originally designed for use in community surveys. Twenty-seven non-aphasic patients enrolled in the Stroke Data Bank at the University of Maryland were interviewed by a research nurse using the CES-D. On the same day, each patient was independently evaluated by a research assistant using a psychiatric battery for depression and measures of cognitive, physical, and social functioning. Forty-one percent (11/27) of the patients were depressed according to clinical criteria for major or minor depression. With a cutpoint corresponding to the upper (most severe) 20% in community surveys, the CES-D Scale picked up 73% (8/11) of the depressed patients. In this sample no nondepressed patient scored over 16 on the CES-D (no false positives). The CES-D Scale scores correlated significantly with the other depression measures (r = .57 to r = .82, p less than .002) and did not correlate with the measures of cognitive, physical, or social functioning. Based on 24 patients who received a CES-D Scale score from both the nurse and the research assistant, inter-rater reliability was high (r = .76, p less than .001). Thus, the CES-D was found to be reliable and valid as a screening tool for assessing depression in stroke patients.

Mood disorders in left-handed stroke patients

Thirty left-handed patients hospitalized for stroke were examined for mood disorders. Patients with left hemisphere lesions and nondominant hand impairments had significantly higher depression scores and more depressive diagnoses than patients with right hemisphere lesions and dominant hand impairments. Major depression was strongly associated with left anterior brain injury, and depression severity was significantly correlated with proximity of the lesion on CAT scan to the left frontal pole. These findings are almost identical to previously reported results from right-handed patients and suggest that cerebral lateralization of poststroke mood disorders may be independent of cerebral motor dominance and language dominance.

Colocutaneous fistula as late complication of total hip replacement in rheumatoid arthritis

Images

Bilateral sinusoidal ECT following poor response to five unilateral brief-pulse ECTs

Of 31 depressed patients, 12 failed to respond to five unilateral brief-pulse ECTs. Eight of the 12 responded fully to bilateral sinusoidal ECT. In some patients, therapeutic outcome may be a function of the type of stimulus used.

Social functioning assessment in stroke patients

The influence of depression, intellectual function, and physical impairment on patient reports of social functioning was assessed by comparing responses obtained from 30 stroke patients with those obtained from an outside informant who knew the patient well. There was relatively good agreement between patient and other for both the overall score on the Social Functioning Examination (SFE) and individual items related to specific aspects of social functioning. Differences between scores obtained from a patient and outside informant were not significantly related to either depression, moderate degrees of intellectual impairment, relative closeness of patient and informant or to degree of physical impairment. These data suggest that valid SF assessments can be made either by a stroke patient who is capable of being interviewed or by a familiar outside informant. In addition, the prognostic utility of the SFE was examined by interviewing 50 patients during the acute stroke period and following them over six months. Social functioning in-hospital scores were not found significantly related to 6-month scores for either depression, intellectual impairment, or physical impairment, but depression and in-hospital impairment significantly predicted social functioning at 6-month follow-up. These data suggest that the most impaired stroke patients are the most likely to undergo social deterioration during the post-stroke period and may require the greatest amount of social intervention. Whether treatment of these variables significantly affects 6-month outcome remains an intriguing question for further study.

Interobserver variability in the assessment of neurologic history and examination in the Stroke Data Bank

Interobserver reliability in obtaining neurologic histories and examinations was investigated among neurologists collaborating in the Stroke Data Bank (SDB). Seventeen in-hospital stroke patients were examined by six neurologists experienced in stroke over the course of three days. Patients were examined twice a day for two successive days, with each patient seen by four different neurologists. Data were recorded on SDB forms, according to definitions and procedures established for the SDB. Percent agreement and kappa coefficients were calculated to assess the levels of agreement for each item. Important differences in levels of agreement were found among items on both neurologic history and examination. Agreement among neurologists was higher for neurologic examination than for history. Patterns of agreement for items with low prevalence or with numerous unknown ratings are discussed. Improvement in interobserver agreement due to data editing for intra-observer consistency was shown.

A two-year longitudinal study of poststroke mood disorders. In-hospital prognostic factors associated with six-month outcome

In a prospective study of mood disorders in stroke patients, variables obtained during the acute hospitalization were examined for their relationship to outcome at either 3- or 6-month follow-up. Distance of the lesion on computerized axial tomography scan from the frontal pole in patients with left anterior infarcts was significantly associated with severity of depression at 3 and 6 months poststroke. In addition, intellectual and functional physical impairment in-hospital were significantly correlated with severity of depression and social functioning scores at 3 and 6 months poststroke. Thus, patients who develop depression during the first 6 months poststroke may be responding to the severity of their impairment whereas the patients who develop depressions during the acute poststroke period may have a neuroanatomical and neurophysiological basis for their depression. Although other explanations might be proposed, the dynamic nature of the relationship between depression and associated variables during the first 6 months poststroke indicates that etiology of poststroke depression may be different depending upon the time of onset of the depression after brain injury.

The dexamethasone suppression test and mood following stroke

Dexamethasone suppression tests (DSTs) were given to 65 acute and chronic stroke patients. For patients who had had a stroke less than 1 year earlier, nonsuppression on the DST was significantly associated with the presence of poststroke depression. The authors, who used the DSM-III symptom criteria for major depression, found that DST sensitivity was 67% but specificity was only 70%. False positive tests in the stroke patients seemed related to large lesion volume. The DST, although of limited clinical utility in this population because of false positive tests, may help define more homogeneous subtypes of poststroke depression for research.

Sensorimotor neuropathy with sulphasalazine

A case of mixed sensorimotor neuropathy associated with sulphasalazine therapy is reported. This is believed to be unique.

Computer-aided assessment of transient ischemic attacks. A clinical evaluation

We developed and evaluated a computer-based system to assist with the difficult problem of assessing the conditions of patients with transient ischemic attacks (TIAs). The program used criteria to classify a patient's illness localize the neurologic deficit, screen for 46 causative or mimicking disorders, recommend additional tests, and suggest management steps. We evaluated this program in 103 patients with TIAs. The TIA program's localization and classification of patients generally agreed with those made by stroke specialists at our institution, demonstrating that computer programs can reproduce the decision criteria of stroke specialists. With revisions, the TIA program or similar systems could be useful for objective disease classification in clinical trials or epidemiologic studies. In contrast, the TIA program's treatment recommendations were often found to differ significantly from the actual treatments administered by non-stroke specialists.

Volitional disability and physician attitudes toward noncompliance

We develop the concept of a volitional disability as an aid in understanding those patients who behave in ways that are harmful to themselves in spite of their desire to do otherwise. Using this concept enables us to describe their behavior as intentional but 'involuntary'. We demonstrate the clinical reality of such behavior by giving clinical examples of the behavior of those with phobic, compulsive, and addictive disorders. We then attempt to show how some kinds of self-harming behavior of noncompliant patients are similar to phobic and compulsive behavior. We propose use of the concept of volitional disability to make it easier for physicians to work with these noncompliant patients and thus to improve their ability to provide better care for them.

Impediments to Alcohol Education

Two major forces mitigate against alcoholism education within the medical school curriculum. One relates to the structure and organization of academic medicine with its emphasis on disease states and pathophysiology; sophisticated and technologically complex diagnostic and treatment modalities; and an acute illness, cure-oriented focus rather than a chronic illness, adaptational approach to illness. The second constellation of factors relates to the alcoholism field's failure to identify with other issues in medical education that similarly challenge the Flexnerian curriculum; the lack of a conceptual basis for defining the physician-alcoholism specialist in relation to other medical disciplines; the clinical treatment field's competing craft and professional orientations; and the absence of a scientific vocabulary suited to the existing biopsychosocial paradigms. It is suggested that these impediments could be overcome if the alcoholism field defined the model for managing chronic illness that is implicit in alcoholism treatment.

The pilot Stroke Data Bank: definition, design, and data

Four university centers collaborated to contribute 1158 patients with acute episodes of cerebrovascular disease to the pilot Stroke Data Bank, initiated by NINCDS in 1978. During the pilot project a standard set of data collection forms were developed and used at each of the collaborating centers. Data on clinical course, laboratory findings, therapy and outcome were gathered prospectively throughout the patient's hospitalization and at specified follow-up intervals. Using operational definitions of stroke sub-types, consecutive cases were systematically allocated to specific categories of brain and vascular pathology. The definitions were based on clinical criteria as well as on laboratory data, including computerized tomography (CT), and angiography findings. This paper describes the pilot Stroke Data Bank and presents the distribution of cases by diagnostic and demographic categories. It represents one of the largest series of prospectively collected stroke cases studied by CT (90% of the cases) and angiography (42%). Based upon the methods and processes of this pilot study, a main phase of the Stroke Data Bank has been established to address a number of questions pertaining to stroke classification, evolution, diagnosis, and prognosis.

A two-year longitudinal study of post-stroke mood disorders: dynamic changes in associated variables over the first six months of follow-up

We are prospectively studying a group of 103 stroke patients over the first 2 years after infarction to determine the variables which are associated with the development of depression. At both 3 and 6 months post-stroke, patients with left hemisphere infarcts showed a strong relationship between severity of depression and distance of the lesion on CT scan from the frontal pole. The strength of this association was unchanged from the immediate post-infarction period. In contrast, the correlation between degree of functional physical impairment and severity of depression steadily increased over the 6 month follow-up. The correlation between severity of depression and Mini-Mental score or between depression and social functioning score dropped between in-hospital and 3 months but then increased significantly between 3 and 6 months post-stroke. Age did not correlate with depression beyond the acute post-stroke period. Whether the increasing strength of the relationships between impairment and depression over the first 6 months post-stroke indicates that continued depression led to delayed recovery or whether continued severe impairments led to depression is not known, however, this issue will be addressed in further data evaluation from this prospective study.

A two year longitudinal study of mood disorders following stroke. Prevalence and duration at six months follow-up

We are conducting a two year longitudinal study of mood disorders in a group of 103 stroke patients. During the first six month period following the stroke the prevalence of symptoms of major depression increased from 23 per cent to 34 per cent while the frequency of symptoms of dysthymic depression increased from 20 per cent to 26 per cent. In addition, 10 of 13 patients who had major depressive symptoms during the initial evaluation continued to have these symptoms at six months follow-up and 4 of 9 patients who had minor depression in hospital developed major depression, while 5 of 9 continued to have minor depressive symptoms. Thus, the duration of depression following stroke is more than six months and the prevalence of major depressive symptoms increases steadily for the first half year after a cerebral hemorrhage or ischemic lesion.

Mood disorders in stroke patients. Importance of location of lesion

In a selected group of right-handed patients with single stroke lesions of either the right (n = 14) or left (n = 22) hemisphere and no predisposing factors for psychiatric disorder, we found that the severity of depression was significantly increased in patients with left anterior lesions as opposed to any other lesion location. In addition, the severity of depression correlated significantly with proximity of the lesion on CT scan to the frontal pole in the left anterior group. The right hemisphere lesion group showed the reverse trend: patients with right posterior lesions were more depressed than patients with right anterior lesions, who were unduly cheerful and apathetic. These findings suggest that intrahemispheric lesion location is in some way related to mood disorder in stroke patients and that there is a graded effect of lesion location on severity of mood change. The neuroanatomy of the biogenic amine-containing pathways in the cerebral cortex might explain this graded effect and provide a neurochemical basis for the mood change.

Nortriptyline treatment of post-stroke depression: a double-blind study

The efficacy of nortriptyline in the treatment of post-stroke depression was assessed by a double-blind study in thirty-four patients. Half of the patients had major depression. There was a significantly greater improvement in depression in patients treated with nortriptyline than in a similar group of placebo-treated patients. Depression was measured by the Hamilton depression scale, Zung depression scale, present state examination, and an overall depression scale. Successfully treated patients had serum nortriptyline levels in the therapeutic range. Post-stroke depressions are common, severe, and longstanding, and the demonstrated efficacy of nortriptyline provides an important addition to the treatments available for stroke patients.

A two-year longitudinal study of post-stroke mood disorders: findings during the initial evaluation

A consecutive series of 103 stroke patients capable of undergoing a psychiatric interview were evaluated for mood disorders. Nearly 50% of patients studied in the acute stroke period had clinically significant depressions and one fourth had symptom clusters found in major depressive disorders. We confirmed our previous findings that lesion location is most important in determining frequency and severity of depression. In addition, we have identified other variables including functional physical impairment, intellectual impairment, quality of social support, and age which contribute to or modify depression. Post-stroke depressive disorders are multifactorial in their determination and expression and include both neurophysiological-neurochemical mechanisms and psychological factors in their etiology.

Mood change following bilateral hemisphere brain injury

Fifteen patients with bilateral hemisphere brain injury secondary to thromboembolic stroke or trauma were evaluated for depression, cognitive impairment, and functional physical impairment. Analysis of CT scans and standardized mood scales revealed that patients with left anterior brain injury were significantly more depressed than patients without such injury. Depression severity was directly and significantly correlated with left lesion proximity to the frontal pole. Left lesion age, lesion temporal sequence, right lesion location, cognitive impairment, and functional physical impairment did not significantly correlate with depression. Depressive symptomatology previously shown to be associated with single left frontal lobe lesions appeared to dominate post-brain injury psychopathology regardless of location or temporal sequence of other brain lesions.

Reliability, validity, and clinical utility of the social functioning exam in the assessment of stroke patients

Social functioning is an important variable in the rehabilitation of stroke patients. We have designed a 28 item semi-structured interview to measure social functioning and have used this instrument in 103 stroke patients in whom we were investigating the occurrence of mood disorders. The social functioning exam was demonstrated to have high interrater and test-retest reliability as well as good agreement with social functioning as measured by other instruments or clinical assessment. The utility of the measurement of social functioning in the assessment of post-stroke mood disorders was demonstrated by the significant correlation between severity of depression and the degree of dysfunction in social functioning six months after the acute stroke, as well as the significant difference in mean social functioning scores between non-depressed and depressed groups.

Post-stroke depressive disorders: a follow-up study of 103 patients

One hundred three patients attending a stroke clinic were evaluated for post-stroke depressive disorders using repeated quantitative assessment of psychopathology during a 12 month period. Almost one-third of these patients were depressed at the time of the initial assessment and two-thirds of these depressed patients who were re-evaluated remained depressed for 7 to 8 months. The prevalence and severity of depressive disorders was significantly elevated in those patients who were between 6 months and 2 years post-stroke. Demographic variables however did not distinguish depressed and non-depressed patients, nor did type of neurological symptoms, degree of impairment in activities of daily living or global cognitive impairment. However, patients with left hemisphere brain injury were significantly more depressed than patients with right hemisphere or brain stem infarctions. Based on this work and previous studies, we have suggested a profile for patients who are at high risk for developing post stroke depressive disorders: patients with left hemisphere frontal lobe infarctions who are within 2 years of the stroke. In spite of the fact that these depressions were clinically significant, none of the patients were presently receiving treatment. Effective treatment methods for these patients need to be developed.