Fluoxetine modulates motor performance and cerebral activation of patients recovering from stroke

Citalopram Improves Dexterity in Chronic Stroke Patients

Background. A majority of stroke patients have persisting motor deficits despite ongoing physiotherapy. Therefore, additional treatment options are desirable. Objective. We investigated if the serotonin reuptake inhibitor, citalopram, would improve motor functions in chronic stroke patients. Methods. In all, 8 patients >6 months after their stroke participated in a double-blind, placebo-controlled, single-dose crossover experiment. The order (first drug then placebo or vice versa) was randomized. Sessions were separated by at least 2 weeks. Motor function was assessed by nine-hole peg test, and measurements of hand grip-strength before drug intake, 2 hours after drug intake, and after 1 hour of training aimed at improving the function of the paretic hand. Results. Compared with placebo, citalopram intake significantly improved performance of the nine-hole peg test for the paretic hand but not for the unaffected hand. Hand grip-strength remained unchanged. Conclusions. A single dose of citalopram can enhance dexterity in chronic stroke patients. This pilot study justifies a test of efficacy of citalopram in a larger group of stroke patients.

Neurorehabilitation with new functional electrical stimulation for hemiparetic upper extremity in stroke patients

In recent years, our understanding of motor learning, neuroplasticity, and functional recovery after the occurrence of brain lesion has grown significantly. New findings in basic neuroscience have stimulated research in motor rehabilitation. Repeated motor practice and motor activity in a real-world environment have been identified in several prospective studies as favorable for motor recovery in stroke patients. Electrical stimulation can be applied in a variety of ways to the hemiparetic upper extremity following stroke. In this paper, an overview of current research into clinical and therapeutic applications of functional electrical stimulation (FES) is presented. In particular, electromyography (EMG)-initiated electrical muscle stimulation--but not electrical muscle stimulation alone--improves the motor function of the hemiparetic arm and hand. Triggered electrical stimulation is reported to be more effective than untriggered electrical stimulation in facilitating upper extremity motor recovery following stroke. Power-assisted FES induces greater muscle contraction by electrical stimulation in proportion to the voluntary integrated EMG signal picked up, which is regulated by a closed-loop control system. Power-assisted FES and motor point block for antagonist muscles have been applied with good results as a new hybrid FES therapy in an outpatient rehabilitation clinic for patients with stroke. Furthermore, a daily home program therapy with power-assisted FES using new equipment has been able to effectively improve wrist and finger extension and shoulder flexion. Proprioceptive sensory feedback might play an important role in power-assisted FES therapy. Although many physiotherapeutic modalities have been established, conclusive proof of their benefit and physiological models of their effects on neuronal structures and processes are still missing. A multichannel near-infrared spectroscopy study to noninvasively and dynamically measure hemoglobin levels in the brain during functional activity has shown that cerebral blood flow in the sensory-motor cortex on the injured side is higher during a power-assisted FES session than during simple active movement or simple electrical stimulation. Nevertheless, evidence-based strategies for motor rehabilitation are more easily available, particularly for patients with hemiparesis.

Cortical connectivity after subcortical stroke assessed with functional magnetic resonance imaging

OBJECTIVE

This study aimed at identifying the impact of subcortical stroke on the interaction of cortical motor areas within and across hemispheres during the generation of voluntary hand movements.

METHODS

Twelve subacute stroke patients with a subcortical ischemic lesion and 12 age-matched control subjects were scanned using 3-Tesla functional magnetic resonance imaging. Subjects performed visually paced hand movements with their left, right, or both hands. Changes of effective connectivity among a bilateral network of core motor regions comprising M1, lateral premotor cortex, and the supplementary motor area (SMA) were assessed using dynamic causal modeling.

RESULTS

The data showed significant disturbances in the effective connectivity of motor areas in the patients group: Independently from hand movements, the intrinsic neural coupling between ipsilesional SMA and M1, and the interhemispheric coupling of both SMAs was significantly reduced. Furthermore, movements of the stroke-affected hand showed additional inhibitory influences from contralesional to ipsilesional M1 that correlated with the degree of motor impairment. For bimanual movements, interhemispheric communication between ipsilesional SMA and contralesional M1 was significantly reduced, which also correlated with impaired bimanual performance.

INTERPRETATION

The motor deficit of patients with a single subcortical lesion is associated with pathological interhemispheric interactions among key motor areas. The data suggest that a dysfunction between ipsilesional and contralesional M1, and between ipsilesional SMA and contralesional M1 underlies hand motor disability after stroke. Assessing effective connectivity by means of functional magnetic resonance imaging and dynamic causal modeling might be used in the future for the evaluation of interventions promoting recovery of function.

Epidemiology and treatment of post-stroke depression

Mood depression is a common and serious complication after stroke. According to epidemiological studies, nearly 30% of stroke patients develop depression, either in the early or in the late stages after stroke. Although depression may affect functional recovery and quality of life after stroke, such condition is often ignored. In fact, only a minority of patients is diagnosed and even fewer are treated in the common clinical practice. Moreover, the real benefits of antidepressant (AD) therapy in post-stroke depression have not been fully clarified. In fact, controlled studies on the effectiveness of ADs in post stroke depression (PSD) are relatively few. Today, data available suggest that ADs may be generally effective in improving mood, but guidelines for the optimal treatment and its length are still lacking.

Paroxetine-induced modulation of cortical activity supporting language representations of action

INTRODUCTION

Previous studies have shown that paroxetine, a selective serotonin reuptake inhibitor, affects brain motor pathway activity in healthy subjects using simple motor tasks. In this study, we explored the effects of paroxetine on the activity of cortical areas implicated in higher-order representations of goal-directed movements, i.e., action-related language processing.

MATERIALS AND METHODS

A double-blind, crossover, randomized paradigm was used to compare two 1-month treatment phases with either paroxetine (20 mg per day) or placebo. A functional magnetic resonance imaging experiment on 12 healthy subjects, conducted at the end of each treatment phase, comprised a single list of verbs and three tasks that consisted in repeating the verbs aloud, generating verbs depicting actions aloud, and mentally simulating the corresponding actions. The effects of the drug, i.e., paroxetine-placebo>0 (hyperactivation) and placebo-paroxetine >0 (hypoactivation) were assessed on the basis of the activation-rest contrast for each task.

RESULTS AND DISCUSSION

For both verb generation and mental simulation of action which both engaged higher-order representations of action, we observed hypoactivation in the left-sided prefrontal and right-sided medial premotor cortex. By contrast, we observed hyperactivation in the right-sided Brodmann's area 6 for the less demanding verb repetition task.

CONCLUSION

Chronic treatment with paroxetine may modulate the cerebral activities elicited by action-related language tasks depending on the cognitive components involved in such tasks.

The stroke rehabilitation paradigm

The matrix of stroke rehabilitation is evolving as we look outside the box of traditional therapy type, timing, and intensity of rehabilitation techniques. For inpatient wards, the goal of medical stability and prompt resolution of complications to maximize participation in therapy remains paramount. In the current medical model, we focus on teaching compensatory strategies and rarely on restorative approaches because of time and financial limitations. Researchers aim to identify new technologic and molecular approaches to improve functional outcomes and more accurately predict disability. This article examines different concepts surrounding the comprehensive rehabilitation paradigm of stroke survivors.

Brain stimulation in poststroke rehabilitation

Brain stimulation techniques provide a powerful means to modulate the function of specific neural structures, and show potential for future applications in the rehabilitation of stroke patients. Recent studies have started to translate to the bedside the body of data gathered over the last few years on mechanisms underlying brain plasticity and stroke recovery. Both noninvasive and invasive brain stimulation techniques, such as repetitive transcranial magnetic stimulation, transcranial direct current stimulation and direct cortical stimulation with epidural electrodes, have recently been tested in small studies with stroke patients. The results to date are very promising. Nonetheless, we are still at an early stage in the field and further evidence is needed to assess the clinical impact of this new approach. In this review, we provide readers with a basic introduction to the field, summarize preliminary studies and discuss future directions.

Magnetic resonance-compatible robotic and mechatronics systems for image-guided interventions and rehabilitation: a review study

The continuous technological progress of magnetic resonance imaging (MRI), as well as its widespread clinical use as a highly sensitive tool in diagnostics and advanced brain research, has brought a high demand for the development of magnetic resonance (MR)-compatible robotic/mechatronic systems. Revolutionary robots guided by real-time three-dimensional (3-D)-MRI allow reliable and precise minimally invasive interventions with relatively short recovery times. Dedicated robotic interfaces used in conjunction with fMRI allow neuroscientists to investigate the brain mechanisms of manipulation and motor learning, as well as to improve rehabilitation therapies. This paper gives an overview of the motivation, advantages, technical challenges, and existing prototypes for MR-compatible robotic/mechatronic devices.

Correlated change in upper limb function and motor cortex activation after verum and sham acupuncture in patients with chronic stroke

BACKGROUND

Acupuncture may improve motor function in patients with chronic hemiparetic stroke, yet the neural mechanisms underlying such an effect are unknown. As part of a sham-controlled, randomized clinical trial testing the efficacy of a 10-week acupuncture protocol in patients with chronic hemiparetic stroke, we examined the relationship between changes in function of the affected upper limb and brain activation using functional magnetic resonance imaging (fMRI).

METHODS

Seven (7) chronic hemiparetic stroke patients underwent fMRI and testing of function of the affected upper limb (spasticity and range-of-motion) before and after a 10-week period of verum (N=4) or sham (N=3) acupuncture. The correlation between changes in function of the affected upper limb and brain activation after treatment was tested across patients.

RESULTS

We found a significant positive correlation between changes in function of the affected upper limb (spasticity and range of motion) and activation in a region of the ipsilesional motor cortex. Patients treated with verum acupuncture showed a trend toward a greater maximum activation change in this motor cortical area as compared to those treated with sham acupuncture.

CONCLUSIONS

Acupuncture may improve function of the affected upper limb in chronic hemiparetic stroke patients by increasing activity in the ipsilesional motor cortex.

Serotonin 5HT1A receptor availability and pathological crying after stroke

OBJECTIVES

Post-stroke depression and pathological crying (PC) implicate an imbalance of serotonergic neurotransmission. We claim that PC follows serotonin depletion that raises the binding potential (p(B)) of the 5-HT(1A) receptor antagonist [carbonyl-(11)C]WAY-100635, which is reversible by selective serotonin re-uptake inhibitor (SSRI) treatment.

MATERIALS AND METHODS

We PET scanned patients with acute stroke and PC and age-matched control subjects. Maps of receptor availability were generated from the images of eight cortical regions and raphe nuclei.

RESULTS

The maps showed highest binding in limbic areas and raphe nuclei, while binding in basal ganglia and cerebellum was negligible. Baseline binding potentials of patients were lower than that of control subjects (3.7 +/- 0.6 vs 4.2 +/- 0.2). Treatment with SSRI markedly reduced free receptor sites, whereas placebo administration led to a global increase.

DISCUSSION

The study is the first suggestion of changes of serotonergic neurotransmission in the early phase of stroke and the modulation of these changes with SSRI treatment.

Interhemispheric asymmetry of primary hand representation and recovery after stroke: A MEG study

In patients affected by monohemispheric stroke in the middle cerebral artery territory, who do not regain a normal neurological function, a positive contribution to the clinical recovery seems to be made by the involvement of primary hand representation areas in the affected hemisphere (AH), excessively asymmetric to its homologous in the unaffected hemisphere (UH). We investigated primary sensory hand areas in 41 chronic patients who had improved their clinical status without reaching complete recovery. The location and strength of the first cerebral sources activated by a contralateral galvanic median nerve stimulation (M20 and M30) were evaluated in both hemispheres, together with their interhemispheric differences. The source displacement in the AH with respect to the UH was positively correlated with clinical recovery (Spearman's rho=0.584, p=0.003). The excessive interhemispheric asymmetry - as defined on the basis of reference ranges in the healthy population - could be interpreted as the involvement of neuronal pools in the AH outside the hand 'omega zone' of the Rolandic sulcus, revealing the presence of plasticity phenomena. The present data provide support to a positive role of cerebral plasticity phenomena, partially contributing to post-stroke recovery in patients unable to achieve normal neurological function.

Crossed cortico-spinal motor control after capsular stroke

While it is widely accepted that multiple nonprimary motor areas such as the dorsal premotor cortex contribute to recovery from stroke, the contribution of the ipsilesional and contralesional primary motor cortex (M1) is controversial. It has been suggested that re-instating 'near normal' activation patterns is a good strategy for recovery of function [Baron et al., (2004) Cerebrovasc. Dis., 18, 260-267; Ward & Cohen, (2004) Arch. Neurol., 61, 1844-1848]. The present study addressed this aspect of stroke recovery by combining transcranial magnetic stimulation (TMS) and magnetoencephalography (MEG) in a cross-sectional design on nine patients with well-recovered motor function 17.6 +/- 5.5 months (mean +/- SD) after subcortical stroke. While TMS was applied to probe the integrity of the cortico-spinal tract (CST) at rest, MEG was used to test for recruitment of CST pathways during a motor challenge [cortico-muscular coherence (CMC) in a precision grip task]. With both techniques, crossed cortico-spinal connectivity could be demonstrated. A significant correlation (r = 0.85) of CMC magnitude and recovered muscle strength underlined the functional relevance of crossed CST integrity for successful recovery. In conclusion, at the descriptive level, crossed CST connectivity is a common finding in well-recovered patients with capsular stroke. This renders it likely that maintaining or regaining use of crossed CST fibers is one way to achieve effective recovery.

Predicting functional gains in a stroke trial

BACKGROUND AND PURPOSE

A number of therapies in development for patients with central nervous system injury aim to reduce disability by improving function of surviving brain elements rather than by salvaging tissue. The current study tested the hypothesis that, after adjusting for a number of clinical assessments, a measure of brain function at baseline would improve prediction of behavioral gains after treatment.

METHODS

Twenty-four patients with chronic stroke underwent baseline clinical and functional MRI assessments, received 6 weeks of rehabilitation therapy with or without investigational motor cortex stimulation, and then had repeat assessments. Thirteen baseline clinical/radiological measures were evaluated for ability to predict subsequent trial-related gains.

RESULTS

Across all patients, bivariate analyses found that greater trial-related functional gains were predicted by (1) smaller infarct volume, (2) greater baseline clinical status, and (3) lower degree of activation in stroke-affected motor cortex on baseline functional MRI. When these 3 variables were further assessed using multivariate linear regression modeling, only lower motor cortex activation and greater clinical status at baseline remained significant predictors. Note that lower baseline motor cortex activation was also associated with larger increases in motor cortex activation after treatment.

CONCLUSIONS

Lower motor cortex activity at baseline predicted greater behavioral gains after therapy, even after controlling for a number of clinical assessments. The boosts in cortical activity that paralleled behavioral gains suggest that in some patients, low baseline cortical activity represents underuse of surviving cortical resources. A measure of brain function might be important for optimal clinical decision-making in the context of a restorative intervention.

CNS-active drugs in aging population at high risk of cerebrovascular events: evidence from preclinical and clinical studies

The recovery process following cerebral insults such as stroke is affected by aging and pharmacotherapy. The use of medication including CNS-active drugs has increased in the elderly during recent years. However, surprisingly little is known about how safe they are with respect to severity of sensorimotor and cognitive impairments or recovery of function following possible cerebrovascular accidents. This review examines the experimental and clinical literature, primarily from 1995 onwards, concerning medication in relation to cerebrovascular events and functional recovery. Special attention is directed to polypharmacy and to new CNS-active drugs, which the elderly are already taking or are prescribed to treat emerging, stroke-induced psychiatric symptoms. The neurobiological mechanisms affected by these drugs are discussed.

Relationship Between Interhemispheric Inhibition and Motor Cortex Excitability in Subacute Stroke Patients

Background. Studies of stroke patients using functional imaging and transcranial magnetic stimulation (TMS) of the primary motor cortex (M1) demonstrated increased recruitment and abnormally decreased short interval cortical inhibition (SICI) of the M1 contralateral to the lesioned hemisphere (contralesional M1) within the first month after infarction of the M1 or its corticospinal projections. Objective. The authors sought to identify mechanisms underlying decreased SICI of the contralesional M1. Methods. In patients within 6 weeks of their first ever infarction of the M1 or its corticospinal projections, SICI in the M1 of the lesioned and nonlesioned hemisphere was studied using paired-pulse TMS. Interhemispheric inhibition (IHI) was measured by applying TMS to the M1 of the lesioned hemisphere and a second pulse to the homotopic M1 of the nonlesioned hemisphere and vice versa with the patient at rest. The results were compared to M1 stimulation of age-matched healthy controls. Results. SICI was decreased in the M1 of lesioned and nonlesioned hemispheres regardless of cortical or subcortical infarct location. IHI was abnormally decreased from the M1 of the lesioned on nonlesioned hemisphere. In contrast, IHI was normal from the M1 of the nonlesioned on the lesioned hemisphere. Abnormal IHI and SICI were correlated in patients with cortical but not with subcortical lesions. Conclusions. In subacute stroke patients, abnormally decreased SICI of a contralesional M1 can only partially be explained by loss of IHI from the lesioned on nonlesioned hemisphere. As decreased SICI of the contralesional M1 did not result in excessive IHI from the nonlesioned on lesioned hemisphere with subsequent suppression of ipsilesional M1 excitability and all patients showed excellent recovery of motor function, decreased SICI of the contralesional M1 may represent an adaptive process supporting recovery.

Effects of fluoxetine on ischemic cells and expressions in BDNF and some antioxidants in the gerbil hippocampal CA1 region induced by transient ischemia

Fluoxetine, a selective serotonin reuptake inhibitor, alters several physiological processes, for example, elevating intracellular cAMP level, in the hippocampus. We examined the effect of fluoxetine on ischemia-induced neuronal death, the expression of brain-derived neurotrophic factor (BDNF) and changes in some antioxidative enzymes in the hippocampal CA1 region induced by transient ischemia. In addition, we also studied the effect of fluoxetine on locomotor activity in gerbils after ischemia/reperfusion. Animals were administered with various doses of fluoxetine (10, 20, and 40 mg/kg, i.p.) once daily for 3 days before the ischemic surgery. The treatment of 10 mg/kg and 20 mg/kg fluoxetine did not show significant neuroprotective effects on CA1 pyramidal cells 4 days after ischemia/reperfusion, while the treatment with 40 mg/kg fluoxetine in ischemic animals showed about 77% neuronal survival rate compared to the control group. The treatment of 40 mg/kg fluoxetine in ischemic animals enhanced significantly BDNF, catalase (CAT), glutathione peroxidase (GPX), and superoxide dismutase-1 (SOD1) immunoreactivity in the CA1 region compared to those in the saline-treated group 4 days after ischemia/reperfusion. In addition, the treatment of fluoxetine (10, 20, 40 mg/kg) significantly inhibited post-ischemic hyperactivity. In brief, treatment with fluoxetine protects neuronal damage after transient ischemia, and the neuroprotective effect of fluoxetine in an ischemic animal model may be related with the up-regulation of BDNF, CAT, GPX, and SOD1 expression.

fMRI-vs-MEG evaluation of post-stroke interhemispheric asymmetries in primary sensorimotor hand areas

Growing evidence emphasizes a positive role of brain ipsilesional (IL) reorganization in stroke patients with partial recovery. Ten patients affected by a monohemispheric stroke in the middle cerebral artery territory underwent functional magnetic resonance (fMRI) and magnetoencephalography (MEG) evaluation of the primary sensory (S1) activation via the same paradigm (median nerve galvanic stimulation). Four patients did not present S1 fMRI activation [Rossini, P.M., Altamura, C., Ferretti, A., Vernieri, F., Zappasodi, F., Caulo, M., Pizzella, V., Del Gratta, C., Romani, G.L., Tecchio, F., 2004. Does cerebrovascular disease affect the coupling between neuronal activity and local haemodynamics? Brain 127, 99-110], although inclusion criteria required bilateral identifiable MEG responses. Mean Euclidean distance between fMRI and MEG S1 activation Talairach coordinates was 10.1+/-2.9 mm, with a 3D intra-class correlation (ICC) coefficient of 0.986. Interhemispheric asymmetries, evaluated by an MEG procedure independent of Talairach transformation, were outside or at the boundaries of reference ranges in 6 patients. In 3 of them, the IL activation presented medial or lateral shift with respect to the omega-shaped post-rolandic area while in the other 3, IL areas were outside the peri-rolandic region. In conclusion, despite dissociated intensity, the MEG and fMRI activations displayed good spatial consistency in stroke patients, thus confirming excessive interhemispheric asymmetries as a suitable indicator of unusual recruitments in the ipsilesional hemisphere, within or outside the peri-rolandic region.

Prognostic Value of fMRI in Recovery of Hand Function in Subcortical Stroke Patients

The first objective of the study was to determine whether functional magnetic resonance imaging (fMRI) signal was correlated with motor performance at different stages of poststroke recovery. The second objective was to assess the existence of prognostic factors for recovery in early functional MR images. Eight right-handed patients with pure motor deficit secondary to a first lacunar infarct localized on the pyramidal tract were included. This study concerned moderately impaired patients and recovery of handgrip strength and finger-tapping speed. The fMRI task was a calibrated flexion-extension movement. Ten healthy subjects served as a control group. The intensity of the activation in the "classical" motor network (ipsilesional S1M1, ipsilesional ventral premotor cortex [BA 6], contralesional cerebellum) 20 days after stroke was indicative of the performance (positive correlation). The cluster in M1 was posterior and circumscribed to BA 4p. No area was associated with bad performance (negative correlation). No correlation was found 4 and 12 months after stroke. Prognosis factors were evidenced. The higher early the activation in the ipsilesional M1 (BA 4p), S1, and insula, the better the recovery 1 year after stroke. Although the lesions partly deefferented the primary motor cortex, patients who activated the posterior primary motor cortex early had a better recovery of hand function. This suggests that there is benefit in increasing ipsilesional M1 activity shortly after stroke as a rehabilitative approach in mildly impaired patients.

Functional Imaging of Intervention Effects in Stroke Motor Rehabilitation

OBJECTIVE

To assess intervention-specific effects on cortical reorganization after stroke as shown by available functional neuroimaging studies.

DATA SOURCES

We searched Medline for clinical trials that contained the terms stroke, reorganization, and recovery, as well as either positron-emission tomography and PET, near-infrared spectroscopy and NIRS, single-photon emission tomography and SPECT, or functional magnetic resonance imaging and functional MRI; we reviewed primary and secondary references.

STUDY SELECTION

Articles that reported neuroimaging findings as a result of a specific treatment involving more than 1 subject were included.

DATA EXTRACTION

We included clinical trials that contained the terms stroke, reorganization, and recovery, as well as functional neuroimaging data findings as a result of a specific treatment involving more than 1 subject.

DATA SYNTHESIS

Included studies differed clearly from one another with regard to patient characteristics, intervention protocol, and outcome measures. Most studies used functional magnetic resonance imaging and a motor paradigm. Studies were limited in size.

CONCLUSIONS

Despite the methodologic differences, several common features can be identified based on the reviewed studies. Clinical improvements occurred even late after injury, after subjects were deemed to have reached a recovery plateau. This clinical improvement was accompanied by cortical reorganization that depended on the type of intervention as well as other factors. This review also suggests direction for future research studies.

Imaging motor recovery after stroke

Most patients show improvement in the weeks or months after a stroke. Recovery is incomplete, however, leaving most with significant impairment and disability. Because the brain does not grow back to an appreciable extent, this recovery occurs on the basis of change in function of surviving tissues. Brain mapping studies have characterized a number of processes and principles relevant to recovery from stroke in humans. The findings have potential application to improving therapeutics that aim to restore function after stroke.

Methylphenidate modulates cerebral post-stroke reorganization

OBJECTIVE

We hypothesized that a single dose of methylphenidate (MP) would modulate cerebral motor activation and behavior in patients having suffered a subcortical stroke.

METHODS

Eight men with a single stroke on the corticospinal tract resulting in a pure motor hemiparesia were included in a randomized, cross-over, double-blind, placebo-controlled study. Patients were first evaluated 17 days after stroke onset by validated neurological scales, motor tests and fMRI (flexion/extension of the digits) after 20 mg MP or placebo. Seven days later, the patients underwent the same protocol and received the drug they had not taken at the first evaluation. Each patient was his own control.

RESULTS

Placebo intake did not change performance. MP compared to placebo elicited a significant improvement in motor performance of the affected hand at the finger tapping test. MP induced: (1) a hyperactivation of the ipsilesional primary sensorimotor cortex including the motor hand and face areas and of the contralesional premotor cortex; (2) a hypoactivation of the ipsilesional anterior cingulum. Hyperactivation in the face motor area correlated positively with the improvement in performance.

CONCLUSION

We demonstrated that the reorganized network may efficiently be targeted by the drug and that the effect of MP might partly rely on an improvement in attention/effort through cingulum modulation.

Applications of fMRI in translational medicine and clinical practice

Functional MRI (fMRI) has had a major impact in cognitive neuroscience. fMRI now has a small but growing role in clinical neuroimaging, with initial applications to neurosurgical planning. Current clinical research has emphasized novel concepts for clinicians, such as the role of plasticity in recovery and the maintenance of brain functions in a broad range of diseases. There is a wider potential for clinical fMRI in applications ranging from presymptomatic diagnosis, through drug development and individualization of therapies, to understanding functional brain disorders. Realization of this potential will require changes in the way clinical neuroimaging services are planned and delivered.

Design and analysis of fMRI studies with neurologically impaired patients

Functional neuroimaging can be used to characterize two types of abnormality in patients with neurological deficits: abnormal functional segregation and abnormal functional integration. In this paper we consider the factors that influence the experimental design, analysis, and interpretation of such studies. With respect to experimental design, we emphasize that: 1) task selection is constrained to tasks the patient is able to perform correctly, and 2) the most sensitive designs entail presenting stimuli of the same type close together. In terms of data preprocessing, prior to statistical analysis, we note that structural pathology may call for constraints on nonlinear transformations, used by spatial normalization, to prevent distortion of intact tissue. This means that one may have to increase spatial smoothing to reduce the impact of inaccurate normalization. Important issues in statistical modeling concern the first level of analysis (estimation of activation within subject), which has to distinguish correct from incorrect responses. At the second level (between subjects), inference should be based on between-subjects variance. Provided that these and other constraints are met, deficits in functional segregation are indicated when activation in one or a set of regions is higher or lower in patients relative to control subjects. In contrast, deficits in functional integration are implied when the influence of one brain region on another is stronger or weaker in patients relative to control subjects.

Preventing depression after stroke

Mental health prevention research is an emerging and intriguing field. Preventing mental disorders is attractive as successful prevention, as it could potentially avert both emotional suffering and illness related morbidity and mortality. Several studies have looked at preventing post-stroke depression, a common complication of stroke. In this review article, we will first provide a conceptual overview of mental health prevention research. Then, we will discuss recent research supporting the prevention of depression after stroke and the likely positive effect successful prevention may have on non-psychiatric outcomes.

Antiplatelet activity during coadministration of the selective serotonin reuptake inhibitor paroxetine and aspirin in male smokers: a randomized, placebo-controlled, double-blind trial

Depression is associated with an increased incidence of vascular events and develops after stroke and myocardial infarction. Beside potential clinical outcome benefits of selective serotonin reuptake inhibitors for vascular diseases, bleeding events were reported. We investigated whether paroxetine and aspirin synergistically inhibit platelet function. Paroxetine (20 mg/d) was administered over 18 days to 20 men in a randomized, placebo-controlled, crossover design. Aspirin (100 mg/d) was coadministered within the last 4 study days. Platelet function was assessed by the platelet function analyzer and by flow cytometry. Paroxetine prolonged epinephrine-dependent predictive index within 14 days (P<.02). Aspirin enhanced the predictive index (P<.004 vs baseline and P>.05 between periods). A trend toward decreased thrombin receptor-activating peptide-induced CD62P expression after paroxetine was further enhanced by aspirin treatment (P>.05 between periods). The combination of paroxetine and aspirin did not further inhibit platelet plug formation under high shear stress in male smokers.

MR compatible force sensing system for real-time monitoring of wrist moments during fMRI testing

Functional magnetic resonance imaging (fMRI) of brain function is used in neurorehabilitation to gain insight into the mechanisms of neural recovery following neurological injuries such as stroke. The behavioral paradigms involving the use of force motor tasks utilized in the scanner often lack the ability to control details of motor performance. They are often limited by subjectiveness, lack of repeatability, and complexity that may exclude evaluation of patients with poor function. In this paper we describe a novel MR compatible wrist device that is capable of measuring isometric forces generated at the hand and joint moments along wrist flexion-extension and wrist ulnar-radial deviation axes. Joint moments measured by the system can be visually displayed to the individual and used during target matching block or event related paradigms. Through a small set of pilot testing both inside and outside the MR environment, we have found that the force tracking tasks and performance in the scanner are reproducible, and that high quality force and moment recordings can be made during fMRI studies without compromising the fMRI images. Furthermore, the device recordings are extremely sensitive making it possible for individuals with poor hand and wrist function to be tested.

Metacognition in stroke: bedside assessment and relation to location, size, and stroke severity

BACKGROUND

Frontal syndromes are poorly represented on stroke scales, yet may constitute an important component of the neurologic deficit impacting treatment and rehabilitation efforts.

AIMS

To validate an assessment of a frontal network syndrome score (FNSS) in stroke and to ascertain the relationship of the FNSS to lesion location, volume, and severity in young people with stroke.

METHODS

Accrual through a cognitive stroke registry of young, alert, nonaphasic, nonencephalopathic, nonsubstance abuse prone people who were tested with the 16 domain FNSS within 4 weeks of their stroke. Lesion location was determined by the Cerefy 3-dimensional, digital, coxial brain atlas identifying 6 regions of cerebral interest. Lesion severity was assessed by the National Institute of Health Stroke Score and infarct volume was measured in cubic centimeters.

RESULTS

From a sample of 456 cases in the registry after exclusions of encephalopathy, depression, and aphasia, cases with frontal network syndrome encompassed 132 of 341 persons (39%). Of these patients (n=80) with mean age 45.7 years [confidence interval (CI): 43.4, 48.1], educational level 13.1 years (CI:12.5, 13.6), mean National Institute of Health Stroke Score of 3.3 (CI: 2.6, 4.0), and mean lesion volume 30.3 mL (CI: 13.7, 46.9), had full testing with the FNSS battery yielding sensitivity (93%), specificity (74%), positive predictive value (79%), negative predictive value (90%), and a good interrater reliability (kappa=0.89, P=0.001). Construct validity testing with 15 frontal neuropsychologic tests revealed good to excellent significant Pearson r values in 14 of 15 of the tests. There was no correlation (Pearson's) for lesion volume (r=0.07, P=0.52) but significant correlation with stroke severity (r=0.23, P=0.03). Analysis of variance testing of the FNSS revealed significant differences for all 6 domains without intergroup significant differences for frontal network syndrome domains in the stroke group.

CONCLUSIONS

The FNSS is a valid, practical measure of frontal syndromes in stroke. Frontal syndromes are common in young people with stroke and may be present no matter where the lesion, are not dependent on size of stroke and have a low correlation with stroke severity.

Pharmacological modulation of plasticity in the human motor cortex

Ischemic cerebral stroke is the leading cause of long-term disability among adults in industrialized countries. One fundamental but still not sufficiently solved question is how to improve disability after stroke. Here, evidence will be reviewed on how pharmacological treatment modulates plasticity and learning in the intact human motor cortex. It will be argued that these data may be useful for advancing the concepts of pharmacotherapy for recovery after stroke.

Functional MRI, drugs, and poststroke recovery

Stroke is the first cause of disability in industrialized countries. Thus, understanding the mechanisms of poststroke recovery appears to be crucial in improving motor performance and reducing disability in stroke patients. Strategies through which brain restores lost functions after ischemic lesions are numerous. The mechanisms underlying poststroke recovery, known as cerebral plasticity, are so far hypothetical. However, functional magnetic resonance imaging (fMRI) studies recently have provided new insights in to stroke recovery. This article sketches out the mechanisms that are thought to underly recovery and focuses on fMRI experimental studies that have investigated the influence of a number of drugs on functional recovery. Functional MRI is a valuable tool in understanding functional recovery and may help to disclose new therapeutical approaches.

The functional anatomy of cerebral reorganisation after focal brain injury

Stroke is a major cause of disability in all age groups. Although the value of specific rehabilitative therapies is now acknowledged, the mechanisms of impairment and recovery are not well understood. There is growing interest in the role that central nervous system reorganisation might play in the recovery process, and in particular whether this reorganisation can be manipulated to provide clinical benefits for patients. The careful use of non-invasive techniques such as functional magnetic resonance imaging and transcranial magnetic stimulation allows the study of the working human brain, and studies in humans suggest that functionally relevant adaptive changes occur in cerebral networks following stroke. An understanding of how these changes influence the recovery process will facilitate the development of novel therapeutic techniques that are based on neurobiological principles and will allow the delivery of specific therapies to appropriately targeted patients suffering from stroke.

L’imagerie par résonance magnétique cérébrale fonctionnelle en pratique clinique

In the last decade, functional MRI (fMRI) has become one of the most widely used functional imaging technique in neurosciences. However, its clinical applications remain limited. Despite methodological and practical issues, fMRI data has been validated by different techniques (magnetoencephalography, Wada test, electrical and magnetic stimulations, and surgical resections). In neurosurgical practice, fMRI can identify eloquent areas involved in motor and language functions, and may evaluate characteristics of postoperative neurological deficit including its occurrence, clinical presentation and duration. This may help to inform patients and to prepare postoperative care. fMRI may also identify epileptic foci. In neurological practice, fMRI may help to determine prognosis of recovery after stroke, appropriate medication, and rehabilitation. fMRI may help to identify patients at risk of developing Alzheimer disease. Finally, cerebrovascular reactivity imaging is an interesting approach that might provide new radiological insights of vascular function.

Functional neuroimaging studies of cognitive recovery after acquired brain damage in adults

The first two decades of cognitive neuroimaging research have provided a constant increase of the knowledge about the neural organization of cognitive processes. Many cognitive functions (e.g.working memory) can now be associated with particular neural structures, and ongoing research promises to clarify this picture further, providing a new mapping between cognitive and neural function. The main goal of this paper is to outline conceptual issues that are particularly important in the context of imaging changes in neural function through recovery process. This review focuses primarily on studies made in stroke and traumatic brain injury patients, but most of the issues raised here are also relevant to studies using other acquired brain damages. Finally, we summarize a set of methodological issues related to functional neuroimaging that are relevant for the study of neural plasticity and recovery after rehabilitation.

Neurorepair versus neuroprotection in stroke

Stroke is the second to third leading cause of death and the main cause of severe, long-term disability in adults. However, treatment is almost reduced to fibrinolysis, a therapy useful in a low percentage of patients. Given that the immediate treatment for stroke is often unfeasible in the clinical setting, the need for new therapy strategies is imperative. After stroke, the remaining impairment in functions essential for routine activities, such as movement programming and execution, sensorimotor integration, language and other cognitive functions have a deep and life-long impact on the quality of life. An interesting point is that a slow but consistent recovery can be observed in the clinical practice over a period of weeks and months. Whereas the recovery in the first few days likely results from edema resolution and/or from reperfusion of the ischemic penumbra, a large part of the recovery afterwards is due mainly to brain plasticity, by which some regions of the brain assume the functions previously performed by the damaged areas. Neurogenesis and angiogenesis are other possible mechanisms of recovery after stroke. An understanding of the mechanisms underlying functional recovery may shed light on strategies for neurorepair, an alternative with a wide therapeutic window when compared with neuroprotective strategies.

Rehabilitation of the Older Adult with Stroke

Stroke is an increasing public health concern throughout the world as the leading cause of long-term disability. It is well known that there exist differences related to epidemiology, pathophysiology, comorbidity, and functional outcome of stroke patients with advanced age compared with the young. Factors that have been suggested to influence this disparity include age-related complications, availability of resources, lack of aggressive management, and possible diminished capacity for neuroplasticity. This article reviews the current medical and rehabilitative aspects of stroke and the possible disparities related to advanced age.

Pharmacologic management of ischemic stroke: relevance to stem cell therapy

Pharmacologic management of the acute phase of the ischemic stroke includes treating the physical and medical conditions that can worsen cerebral injury; administering intravenous thrombolytic therapy (recombinant tissue plasminogen activator) in those who meet current guidelines; instituting prophylactic measures to prevent medical complications; and initiating passive rehabilitation measures. New approaches under investigation include intra-arterial thrombolytic therapy; endovascular embolectomy and clot disruption; and neuroprotective treatments to preserve surviving ischemic tissue. One neuroprotective agent given within 6 h after stroke onset, NXY059, recently met the primary outcome measure in a phase III clinical trial. Pharmacologic management of the subacute and chronic phases involves treatment of risk factors for recurrent stroke and other forms of cardiovascular disease, including hypercholesterolemia, hypertension, and diabetes mellitus. In this phase, antiplatelet therapy can be initiated or continued; smoking, obesity and alcohol intake can be managed; and active rehabilitation can begin through physical, occupational, and speech therapy. A few medications to augment rehabilitation have shown promising results in small clinical trials, but none have been tested in large phase III trials or approved by the US or European regulatory agencies. Thus, there are no pharmacologic measures available to enhance central nervous system restorative processes after acute stroke, and implantation of stem cells provides one promising approach, not only for cell replacement but also for the provision of therapeutic molecules.

Stroke recovery and its imaging

Functional imaging of stroke recovery is a unique source of information that might be useful in the development of restorative treatments. Several features of brain function change spontaneously after stroke. Current studies define many of the most common events. Key challenges for the future are to develop standardized approaches to help address certain questions, determine the psychometric qualities of these measures, and define the clinical usefulness of these methods.

Atomoxetine Enhances a Short-Term Model of Plasticity in Humans

OBJECTIVE

To evaluate the role of 2 noradrenergic drugs in modulating use-dependent plasticity in humans.

DESIGN

Double-blind, randomized, and placebo-controlled crossover design.

SETTING

A laboratory in a hospital.

PARTICIPANTS

A convenience sample of 10 healthy subjects.

INTERVENTION

An established paradigm that measures motor memory as a short-term model of use-dependent plasticity. Subjects attended 3 sessions, separated by at least 1 week to allow drug washout. Subjects received atomoxetine (Strattera), venlafaxine (Effexor), or placebo.

MAIN OUTCOME MEASURE

Increase in the proportion of movements into the training target zone (TTZ), an indicator of enhanced plasticity.

RESULTS

Atomoxetine, but not venlafaxine, significantly increased movements into the TTZ.

CONCLUSIONS

These results support a role for norepinephrine in enhancing cortical plasticity and suggest potential benefits in using these drugs for improving motor recovery after stroke.

Role of functional imaging in neurological disorders

Neuroimaging in recent years has greatly contributed to our understanding of a wide range of aspects related to central neurological diseases. These include the classification and localization of disease, such as in headache; the understanding of pathology, such as in Parkinson's disease (PD); the mechanisms of reorganization, such as in stroke and multiple sclerosis (MS); and the subclinical progress of disease, such as in amyotrophic lateral sclerosis (ALS). Apart from presurgical mapping, however, the clinical applications so far are limited. Nevertheless, functional imaging does enable the formulation of neurobiological hypotheses that can be tested clinically, and thus is well suited for testing classic clinical hypotheses about how the brain works. Understanding the mechanisms and sites of pathology, such as has been achieved in cluster headaches, facilitates the development of new therapeutic strategies.

Clinical applicability of functional MRI

Functional MRI (fMRI) has become the most widely used modality for examining human brain function in basic and clinical neuroscience. As compared to the application of fMRI in basic neuroscience research, clinical fMRI presents unique challenges. A growing body of literature supports the feasibility of clinical fMRI, with the best-studied applications being localization of motor cortex and lateralization of language. While it may be tempting to assume that fMRI will supercede prior approaches, it may turn out that fMRI will be used to complement more difficult or invasive methods rather than replace them entirely. This article focuses on fMRI studies in patients and patient populations. Specific considerations for such applications include pathophysiological effects on functional physiology, brain-behavior correlations in the presence of cognitive or sensorimotor deficits, and test-retest reliability for longitudinal studies.

Multimodal imaging of brain reorganization in motor areas of the contralesional hemisphere of well recovered patients after capsular stroke

Clinical recovery after stroke can be significant and has been attributed to plastic reorganization and recruitment of novel areas previously not engaged in a given task. As equivocal results have been reported in studies using single imaging or electrophysiological methods, here we applied an integrative multimodal approach to a group of well-recovered chronic stroke patients (n = 11; aged 50-81 years) with left capsular lesions. Focal activation during recovered hand movements was assessed with EEG spectral analysis and H2(15)O-PET with EMG monitoring, cortico-cortical connectivity with EEG coherence analysis (cortico-cortical coherence) and corticospinal connectivity with transcranial magnetic stimulation (TMS). As seen from comparisons with age-matched controls, our patients showed enhanced recruitment of the lateral premotor cortex of the lesioned hemisphere [Brodmann area (BA) 6], lateral premotor and to a lesser extent primary sensorimotor and parietal cortex of the contralesional hemisphere (CON-H; BA 4 and superior parietal lobule) and left cerebellum (patients versus controls, Z > 3.09). EEG coherence analysis showed that after stroke cortico-cortical connections were reduced in the stroke hemisphere but relatively increased in the CON-H (ANOVA, contrast analysis, P < 0.05), suggesting a shift of functional connectivity towards the CON-H. Nevertheless, fast conducting corticospinal transmission originated exclusively from the lesioned hemisphere. No direct ipsilateral motor evoked potentials (MEPs) could be elicited with TMS over the contralesional primary motor cortex (iM1) in stroke patients. We conclude that (i) effective recovery is based on enhanced utilization of ipsi- and contralesional resources, (ii) basic corticospinal commands arise from the lesioned hemisphere without recruitment of ('latent') uncrossed corticospinal tract fibres and (iii) increased contralesional activity probably facilitates control of recovered motor function by operating at a higher-order processing level, similar to but not identical with the extended network concerned with complex movements in healthy subjects.

Challenges of Neuroprotection and Neurorestoration in Ischemic Stroke Treatment

Currently, the most important therapeutic approaches in the acute phase of ischemic stroke are focused on the restoration of regional cerebral blood flow, early admission to a stroke unit and the attempt to block, using neuroprotective drugs, the biochemical and metabolic changes involved in the 'ischemic cascade'. Treatment with rt-PA in the acute phase, although very effective, is still limited to a small number of patients and positive preclinical results of neuroprotective treatment have not, as yet, been endorsed in clinical trials. The remarkable lack of concordance between the positive results in experimental models and the negative results obtained in clinical trials has led to a change in attitude in the conduct of preclinical studies as well as to a modification of the design of clinical trials, with special attention being paid to patient selection criteria and clinical evaluation. Some neuroprotective drugs, such as citicoline, have shown some efficacy in subgroups of patients with cerebral infarction, even with a therapeutic window of up to 24 h, which would suggest a possible neurorestorative effect. Different degrees of functional recovery, weeks or months after the ischemic event, are currently observed in clinical practice and have been related to endogenous self-repair mechanisms. The growing understanding of the mechanisms involved in the phenomena of brain plasticity and their modulation, together with the possibility of restoring functional deficits by encouraging endogenous neurogenesis or by cell therapy, open up new directions in the treatment of stroke patients.

Pharmacological treatment of ischemic stroke

Current pharmacological strategies for acute ischemic stroke largely mirror those employed in acute coronary syndromes. However, important differences in the effectiveness and versatility of the principal agents have emerged between these 2 clinical settings. In general, the level of success achieved with drugs in acute coronary syndromes has not carried over to the same extent when the same drug types are used in stroke. The principal reason is that reperfusion or anticoagulant therapies in the setting of brain infarction run a significant risk of hemorrhagic transformation that has no direct equivalent in myocardial infarction. Consequently, a significant challenge in acute stroke therapeutics is the ability to select patients for drugs where only a narrow therapeutic margin exists and to identify methods that can minimize hemorrhage risk. Other brain-specific vascular factors also pertain in explaining differences in outcome of drugs generally regarded as having a broad cardiovascular remit. The relatively limited efficacy of antiplatelets in stroke might relate to the composition and heterogeneity of the cerebrovascular lesion, while the poor outcome associated with acute anti-hypertensive use is partly due to loss of cerebrovascular autoregulation. Finally, downstream consequences of arterial occlusion within the brain such as excitotoxicity and plasticity are organ specific and, as such, deserve their own pharmacological approaches. In this review, we describe the general mechanism of each drug class used in ischemic stroke and then report on the clinical experience and application for each.

Modulation of behavior and cortical motor activity in healthy subjects by a chronic administration of a serotonin enhancer

SSRIs are postulated to modulate motor behavior. A single dose of selective serotoninergic reuptake inhibitors (SSRIs) like fluoxetine, paroxetine, or fluvoxamine, has been shown to improve motor performance and efficiency of information processing for simple sensorimotor tasks in healthy subjects. At a cortical level, a single dose of SSRI was shown to induce a hyperactivation of the primary sensorimotor cortex (S1M1) involved in the movement (Loubinoux, I., Boulanouar, K., Ranjeva, J. P., Carel, C., Berry, I., Rascol, O., Celsis, P., and Chollet, F., 1999. Cerebral functional magnetic resonance imaging activation modulated by a single dose of the monoamine neurotransmission enhancers fluoxetine and fenozolone during hand sensorimotor tasks. J. Cereb. Blood Flow Metab. 19 1365--1375, Loubinoux, I., Pariente, J., Boulanouar, K., Carel, C., Manelfe, C., Rascol, O., Celsis, P., and Chollet, F., 2002. A Single Dose of Serotonin Neurotransmission Agonist Paroxetine Enhances Motor Output. A double-blind, placebo-controlled, fMRI study in healthy subjects. NeuroImage 15 26--36). Since SSRIs are usually given for several weeks, we assessed the behavioral and cerebral effects of a one-month chronic administration of paroxetine on a larger group. In a double-blind, placebo controlled and crossover study, 19 subjects received daily 20 mg paroxetine or placebo, respectively, over a period of 30 days separated by a wash-out period of 3 months. After each period, the subjects underwent an fMRI (active or passive movement, dexterity task, sensory discrimination task) and a behavioral evaluation. Concurrently, a TMS (transcranial magnetic stimulation) study was conducted (Gerdelat-Mas, A., Loubinoux, I., Tombari, D., Rascol, O., Chollet, F., Simonetta-Moreau, M., 2005. Chronic administration of selective serotonin re-uptake inhibitor (SSRI) paroxetine modulates human motor cortex excitability in healthy subjects. NeuroImage 27,314--322).

RESULTS

On the one hand, paroxetine improved motor performances at the finger tapping test (P=0.02) without affecting choice reaction time, strength and dexterity significantly. Subjects were also faster in processing the spatial incongruency between a stimulus and the motor response (P=0.04). In order to differentiate behavioral components, a principal component analysis was performed on all motor tests, and several characteristics were differentiated: strength, speed, skill, attention, and motor response coding. Paroxetine would improve the efficiency of motor response coding (MANOVA on the factors; factor 3, P=0.01). On the other hand, the chronic administration induced a significant hypoactivation of S1M1 whatever the task: motor or sensory, simple or complex (random effect analysis, P<0.05). The hypoactivation correlated with the improvement of performances at the finger tapping test (P<0.05) suggesting more efficiency in cerebral motor processing.

CONCLUSIONS

Our results showed a clear modulation of sensory and motor cerebral activation after a chronic paroxetine administration. An improvement in both behavior and cerebral efficiency was suggested. It could be hypothesized that monoamines, by an unspecific effect, may tune the response of pyramidal neurons to optimize performances.

Stroke Research in the Modern Era: Images versus Dogmas

Recovery of function following ischaemic stroke is a fascinating clinical observation. It comprises several modes, e.g. spectacular recovery in a matter of hours or days and gradual recovery over months or even years. That a non-functioning neural system can regain its function, even partially so, is challenging because of the obvious therapeutic implications. Until the mid-70s, however, dogmas largely prevailed which underpinned the then nihilistic approach to stroke patients. Proving these dogmas wrong has been a major achievement of modern stroke research. Thanks particularly to physiological imaging, key observations from the basic neurosciences have translated into the clinical realm in ways immediately understandable to the clinician, allowing the emergence of pathophysiology-based management.

Chronic administration of selective serotonin reuptake inhibitor (SSRI) paroxetine modulates human motor cortex excitability in healthy subjects

The aim of the study was to investigate the effect of chronic administration of paroxetine (selective serotonin reuptake inhibitor: SSRI) on motor cortex excitability in healthy subjects by means of transcranial magnetic stimulation (TMS), functional magnetic resonance imaging (fMRI) and behavioral motor tests. In a randomized, double-blind, crossover study, twenty-one right-handed subjects received 20 mg daily of either paroxetine or a placebo over a period of 30 days separated by a period of 3 months wash-out. The TMS study is presented here correlated with some results of the motor behavior study (finger tapping test) and the fMRI study (primary sensorimotor cortex (S1M1) volume of activation). TMS was used to test motor threshold (MT), motor evoked potential recruitment curve (RC), cortical silent period (CSP) and paired-pulse intracortical inhibition and facilitation (ICI, ICF). Chronic administration of paroxetine did not modulate ICI or CSP but induced a significant enhancement of mean ICF (ANOVA P=0.04), which significantly correlated with increase of speed in a finger tapping test (P=0.02). This suggests a modulation of cortical interneuronal excitatory pathways without changes in the excitability of cortical inhibitory GABAergic interneurons. A decrease of RC (ANOVA P=0.05) was also observed after 30 days intake of paroxetine in comparison with placebo and was associated with changes of fMRI activation intensity (left S1M1 hypoactivation, ), without changes of S1M1 activation volume. Finally, the different modulation of RC and ICF after chronic administration of paroxetine compared to single dose (opposite effects) emphasizes the different pharmacological action of the drug at cortical level depending on its acute or long-term administration.

Management of Depression After Stroke

Background and Purpose— Although depression may affect recovery and outcome after stroke, it is often overlooked or inadequately managed, and there is uncertainty regarding the benefits of antidepressant therapy in this setting. We aimed to assess the effectiveness of antidepressants for the treatment and prevention of depression after stroke.

Methods— We undertook a systematic review using Cochrane methods of randomized placebo-controlled trials of antidepressants for the treatment or prevention of depressive illness and “abnormal mood” after stroke. Treatment effects on physical and other outcomes were also examined.

Results— Outcome data were available for 7 treatment trials including 615 patients and 9 prevention trials including 479 patients. Because of the considerable variation in research design, trial quality, and method of reporting across studies, we did not pool all the outcome data. In the treatment trials, antidepressants reduced mood symptoms but had no clear effect on producing a remission of diagnosable depressive illness. There was no definitive evidence that antidepressants prevent depression or improve recovery after stroke.

Conclusions— There is insufficient randomized evidence to support the routine use of antidepressants for the prevention of depression or to improve recovery from stroke. Although antidepressants may improve mood in stroke patients with depression, it is unclear how clinically significant such modest effects are in patients other than those with major depression. There is a pressing need for further research to better define the role of antidepressants in stroke management.