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Krick S, Koob JL, Latarnik S, Volz LJ, Fink GR, Grefkes C, Rehme AK. Neuroanatomy of post-stroke depression: the association between symptom clusters and lesion location. Brain Commun 2023; 5:fcad275. [PMID: 37908237 PMCID: PMC10613857 DOI: 10.1093/braincomms/fcad275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 08/07/2023] [Accepted: 10/24/2023] [Indexed: 11/02/2023] Open
Abstract
Post-stroke depression affects about 30% of stroke patients and often hampers functional recovery. The diagnosis of depression encompasses heterogeneous symptoms at emotional, motivational, cognitive, behavioural or somatic levels. Evidence indicates that depression is caused by disruption of bio-aminergic fibre tracts between prefrontal and limbic or striatal brain regions comprising different functional networks. Voxel-based lesion-symptom mapping studies reported discrepant findings regarding the association between infarct locations and depression. Inconsistencies may be due to the usage of sum scores, thereby mixing different symptoms of depression. In this cross-sectional study, we used multivariate support vector regression for lesion-symptom mapping to identify regions significantly involved in distinct depressive symptom domains and global depression. MRI lesion data were included from 200 patients with acute first-ever ischaemic stroke (mean 0.9 ± 1.5 days of post-stroke). The Montgomery-Åsberg Depression Rating interview assessed depression severity in five symptom domains encompassing motivational, emotional and cognitive symptoms deficits, anxiety and somatic symptoms and was examined 8.4 days of post-stroke (±4.3). We found that global depression severity, irrespective of individual symptom domains, was primarily linked to right hemispheric lesions in the dorsolateral prefrontal cortex and inferior frontal gyrus. In contrast, when considering distinct symptom domains individually, the analyses yielded much more sensitive results in regions where the correlations with the global depression score yielded no effects. Accordingly, motivational deficits were associated with lesions in orbitofrontal cortex, dorsolateral prefrontal cortex, pre- and post-central gyri and basal ganglia, including putamen and pallidum. Lesions affecting the dorsal thalamus, anterior insula and somatosensory cortex were significantly associated with emotional symptoms such as sadness. Damage to the dorsolateral prefrontal cortex was associated with concentration deficits, cognitive symptoms of guilt and self-reproach. Furthermore, somatic symptoms, including loss of appetite and sleep disturbances, were linked to the insula, parietal operculum and amygdala lesions. Likewise, anxiety was associated with lesions impacting the central operculum, insula and inferior frontal gyrus. Interestingly, symptoms of anxiety were exclusively left hemispheric, whereas the lesion-symptom associations of the other domains were lateralized to the right hemisphere. In conclusion, this large-scale study shows that in acute stroke patients, differential post-stroke depression symptom domains are associated with specific structural correlates. Our findings extend existing concepts on the neural underpinnings of depressive symptoms, indicating that differential lesion patterns lead to distinct depressive symptoms in the first weeks of post-stroke. These findings may facilitate the development of personalized treatments to improve post-stroke rehabilitation.
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Affiliation(s)
- Sebastian Krick
- Department of Neurology, University Hospital Cologne, Cologne 50937, Germany
| | - Janusz L Koob
- Department of Neurology, University Hospital Cologne, Cologne 50937, Germany
| | - Sylvia Latarnik
- Department of Neurology, University Hospital Cologne, Cologne 50937, Germany
| | - Lukas J Volz
- Department of Neurology, University Hospital Cologne, Cologne 50937, Germany
| | - Gereon R Fink
- Department of Neurology, University Hospital Cologne, Cologne 50937, Germany
- Institute of Neuroscience and Medicine, Cognitive Neuroscience (INM-3), Forschungszentrum Jülich, Jülich 52425, Germany
| | - Christian Grefkes
- Department of Neurology, University Hospital Cologne, Cologne 50937, Germany
- Institute of Neuroscience and Medicine, Cognitive Neuroscience (INM-3), Forschungszentrum Jülich, Jülich 52425, Germany
- Department of Neurology, Goethe University Hospital Frankfurt, Frankfurt am Main 60528, Germany
| | - Anne K Rehme
- Department of Neurology, University Hospital Cologne, Cologne 50937, Germany
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Wen L, Yan C, Zheng W, Li Y, Wang Y, Qu M. Metabolic Alterations and Related Biological Functions of Post-Stroke Depression in Ischemic Stroke Patients. Neuropsychiatr Dis Treat 2023; 19:1555-1564. [PMID: 37435550 PMCID: PMC10332415 DOI: 10.2147/ndt.s415141] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/20/2023] [Indexed: 07/13/2023] Open
Abstract
Background Post-stroke depression (PSD) is one of the most common neuropsychiatric complications after stroke. However, the underlying mechanisms of PSD remain ambiguous, and no objective diagnosis tool is available to diagnose PSD. Previous metabolomic studies on PSD included patients with ischemic and hemorrhagic stroke indiscriminately, which is not conducive to elucidating and predicting the occurrence of PSD. The aim of this study is to elucidate the pathogenesis of PSD and provide potential diagnostic markers for PSD in ischemic stroke patients. Methods In total, 51 ischemic stroke patients at 2 weeks were included in this study. Those with depressive symptoms were assigned to the PSD group, while the others were assigned to the non-PSD group. Plasma metabolomics based on liquid chromatography-mass spectrometry (LC-MS) was performed to explore the differential plasma metabolites between the PSD and non-PSD groups. Results Principal component analysis (PCA), partial least squares discriminant analysis (PLS-DA) and orthogonal partial least-squares discriminant analysis (OPLS-DA) showed significant metabolic alterations between PSD patients and non-PSD patients. In total, 41 differential metabolites were screened out, mainly including phosphatidylcholines (PCs), L-carnitine and acyl carnitines, succinic acid, pyruvic acid and L-lactic acid. Metabolite-related pathway analysis revealed that alanine, aspartate and glutamate metabolism, glycerophospholipid metabolism and the citrate cycle (TCA cycle) may contribute to the pathogenesis of PSD. A panel of three signature metabolites [PC(22:5(7Z,10Z,13Z,16Z,19Z)/15:0), LysoPA(18:1(9Z)/0:0) and 1,5-anhydrosorbitol] was determined as potential biomarkers for PSD in ischemic stroke patients. Conclusion These findings are conducive to providing new insights into the pathogenesis of PSD and developing objective diagnostic tools for PSD in ischemic stroke patients.
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Affiliation(s)
- Lulu Wen
- Neurology Department, Xuan Wu Hospital Capital Medical University, Beijing, People’s Republic of China
| | - Chuming Yan
- Neurology Department, Xuan Wu Hospital Capital Medical University, Beijing, People’s Republic of China
| | - Wancheng Zheng
- Neurology Department, Xuan Wu Hospital Capital Medical University, Beijing, People’s Republic of China
| | - Yi Li
- Neurology Department, Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Yuhui Wang
- Neurology Department, Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Miao Qu
- Neurology Department, Xuan Wu Hospital Capital Medical University, Beijing, People’s Republic of China
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Trapp NT, Bruss JE, Manzel K, Grafman J, Tranel D, Boes AD. Large-scale lesion symptom mapping of depression identifies brain regions for risk and resilience. Brain 2023; 146:1672-1685. [PMID: 36181425 PMCID: PMC10319784 DOI: 10.1093/brain/awac361] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 08/15/2022] [Accepted: 09/02/2022] [Indexed: 11/14/2022] Open
Abstract
Understanding neural circuits that support mood is a central goal of affective neuroscience, and improved understanding of the anatomy could inform more targeted interventions in mood disorders. Lesion studies provide a method of inferring the anatomical sites causally related to specific functions, including mood. Here, we performed a large-scale study evaluating the location of acquired, focal brain lesions in relation to symptoms of depression. Five hundred and twenty-six individuals participated in the study across two sites (356 male, average age 52.4 ± 14.5 years). Each subject had a focal brain lesion identified on structural imaging and an assessment of depression using the Beck Depression Inventory-II, both obtained in the chronic period post-lesion (>3 months). Multivariate lesion-symptom mapping was performed to identify lesion sites associated with higher or lower depression symptom burden, which we refer to as 'risk' versus 'resilience' regions. The brain networks and white matter tracts associated with peak regional findings were identified using functional and structural lesion network mapping, respectively. Lesion-symptom mapping identified brain regions significantly associated with both higher and lower depression severity (r = 0.11; P = 0.01). Peak 'risk' regions include the bilateral anterior insula, bilateral dorsolateral prefrontal cortex and left dorsomedial prefrontal cortex. Functional lesion network mapping demonstrated that these 'risk' regions localized to nodes of the salience network. Peak 'resilience' regions include the right orbitofrontal cortex, right medial prefrontal cortex and right inferolateral temporal cortex, nodes of the default mode network. Structural lesion network mapping implicated dorsal prefrontal white matter tracts as 'risk' tracts and ventral prefrontal white matter tracts as 'resilience' tracts, although the structural lesion network mapping findings did not survive correction for multiple comparisons. Taken together, these results demonstrate that lesions to specific nodes of the salience network and default mode network are associated with greater risk versus resiliency for depression symptoms in the setting of focal brain lesions.
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Affiliation(s)
- Nicholas T Trapp
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
- Iowa Neuroscience Institute, University of Iowa, Iowa City, IA, USA
| | - Joel E Bruss
- Department of Neurology, University of Iowa, Iowa City, IA, USA
| | - Kenneth Manzel
- Department of Neurology, University of Iowa, Iowa City, IA, USA
- Department of Psychological and Brain Sciences, University of Iowa, Iowa City, IA, USA
| | - Jordan Grafman
- Shirley Ryan AbilityLab, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Daniel Tranel
- Iowa Neuroscience Institute, University of Iowa, Iowa City, IA, USA
- Department of Neurology, University of Iowa, Iowa City, IA, USA
- Department of Psychological and Brain Sciences, University of Iowa, Iowa City, IA, USA
| | - Aaron D Boes
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
- Iowa Neuroscience Institute, University of Iowa, Iowa City, IA, USA
- Department of Neurology, University of Iowa, Iowa City, IA, USA
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
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Aychman MM, Goldman DL, Kaplan JS. Cannabidiol's neuroprotective properties and potential treatment of traumatic brain injuries. Front Neurol 2023; 14:1087011. [PMID: 36816569 PMCID: PMC9932048 DOI: 10.3389/fneur.2023.1087011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023] Open
Abstract
Cannabidiol (CBD) has numerous pharmacological targets that initiate anti-inflammatory, antioxidative, and antiepileptic properties. These neuroprotective benefits have generated interest in CBD's therapeutic potential against the secondary injury cascade from traumatic brain injury (TBI). There are currently no effective broad treatment strategies for combating the damaging mechanisms that follow the primary injury and lead to lasting neurological consequences or death. However, CBD's effects on different neurotransmitter systems, the blood brain barrier, oxidative stress mechanisms, and the inflammatory response provides mechanistic support for CBD's clinical utility in TBI. This review describes the cascades of damage caused by TBI and CBD's neuroprotective mechanisms to counter them. We also present challenges in the clinical treatment of TBI and discuss important future clinical research directions for integrating CBD in treatment protocols. The mechanistic evidence provided by pre-clinical research shows great potential for CBD as a much-needed improvement in the clinical treatment of TBI. Upcoming clinical trials sponsored by major professional sport leagues are the first attempts to test the efficacy of CBD in head injury treatment protocols and highlight the need for further clinical research.
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Koob JL, Viswanathan S, Mustin M, Mallick I, Krick S, Fink GR, Grefkes C, Rehme AK. To engage or not engage: Early incentive motivation prevents symptoms of chronic post-stroke depression - A longitudinal study. Neuroimage Clin 2023; 37:103360. [PMID: 36889100 PMCID: PMC10009723 DOI: 10.1016/j.nicl.2023.103360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Although post-stroke depression (PSD) is known to disrupt motor rehabilitation after stroke, PSD is often undertreated and its relationship with motor impairment remains poorly understood. METHODS In a longitudinal study design we investigated, which factors at the early post-acute stage may increase the risk for PSD symptoms. We were especially interested in whether interindividual differences in the motivational drive to engage in physically demanding tasks indicate PSD development in patients suffering from motor impairments. Accordingly, we used a monetary incentive grip force task where participants were asked to hold their grip force for high and low rewards at stake to maximize their monetary outcome. Individual grip force was normalized according to the maximal force prior to the experiment. Experimental data, depression, and motor impairment were assessed from 20 stroke patients (12 male; 7.7 ± 6.78 days post-stroke) with mild-to-moderate hand motor impairment and 24 age-matched healthy participants (12 male). RESULTS Both groups showed incentive motivation as indicated by stronger grip force for high versus low reward trials and the overall monetary outcome in the task. In stroke patients, severely impaired patients showed stronger incentive motivation, whereas early PSD symptoms were associated with reduced incentive motivation in the task. Larger lesions in corticostriatal tracts correlated with reduced incentive motivation. Importantly, chronic motivational deficits were preceded by initially reduced incentive motivation and larger corticostriatal lesions in the early stage post-stroke. CONCLUSIONS More severe motor impairment motivates reward-dependent motor engagement, whereas PSD and corticostriatal lesions potentially disturb incentive motivational behavior, thereby increasing the risk of chronic motivational PSD symptoms. Acute interventions should address motivational aspects of behavior to improve motor rehabilitation post-stroke.
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Affiliation(s)
- Janusz L Koob
- Department of Neurology, University Hospital Cologne, 50937 Cologne, Germany.
| | - Shivakumar Viswanathan
- Institute of Neuroscience and Medicine, Cognitive Neuroscience (INM-3), Forschungszentrum Jülich, 52425 Juelich, Germany
| | - Maike Mustin
- Department of Neurology, University Hospital Cologne, 50937 Cologne, Germany
| | - Imon Mallick
- Department of Neurology, University Hospital Cologne, 50937 Cologne, Germany
| | - Sebastian Krick
- Department of Neurology, University Hospital Cologne, 50937 Cologne, Germany
| | - Gereon R Fink
- Department of Neurology, University Hospital Cologne, 50937 Cologne, Germany; Institute of Neuroscience and Medicine, Cognitive Neuroscience (INM-3), Forschungszentrum Jülich, 52425 Juelich, Germany
| | - Christian Grefkes
- Department of Neurology, University Hospital Cologne, 50937 Cologne, Germany; Institute of Neuroscience and Medicine, Cognitive Neuroscience (INM-3), Forschungszentrum Jülich, 52425 Juelich, Germany; Department of Neurology, University Hospital Frankfurt, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany.
| | - Anne K Rehme
- Department of Neurology, University Hospital Cologne, 50937 Cologne, Germany
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Ribeiro de Souza F, Sales M, Rabelo Laporte L, Melo A, Manoel da Silva Ribeiro N. Body structure/function impairments and activity limitations of post-stroke that predict social participation: a systematic review. Top Stroke Rehabil 2022:1-14. [PMID: 35787246 DOI: 10.1080/10749357.2022.2095086] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Stroke is the leading cause of death and disability in Brazil, and its prognostic indicators of social reintegration are not well established yet. OBJECTIVE To identify body structure/function impairments and activity limitations in post-stroke that predict social participation restrictions in the community. METHODS cohort studies were selected, involving adult post-stroke participants, which investigated body structure and function impairments or activity limitations of post-stroke individuals as predictors of social participation in the community. Studies that included individuals with subarachnoid hemorrhage, other neurological disorders and participants in long-term care facilities were excluded. The Newcastle-Ottawa quality assessment scale was applied to assess the methodological quality. The results were synthesized according to the found exposures, considering the used statistical models. RESULTS Eleven articles were included, with a total of 2,412 individuals, 58.4% men, 83.7% ischemic stroke. Seven exposures were assessed across studies, in which 10 studies assessed body structure and function exposures (stroke severity, cognitive, executive, emotional and motor function), and 8 studies assessed activity exposures (daily living activity and walking ability). CONCLUSION There is some evidence that stroke severity, mental and motor deficits, limitations in activities of daily living and the ability to walk after a stroke can predict social participation in the community. PROSPERO registration CRD42020177591.
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Affiliation(s)
| | - Matheus Sales
- Epidemiologia, Universidade Federal da BahiaDivisão de Neurologia e , Salvador, Brazil
| | - Larrie Rabelo Laporte
- Grupo Brasileiro de Metaciência, Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil
| | - Ailton Melo
- Epidemiologia, Universidade Federal da BahiaDivisão de Neurologia e , Salvador, Brazil.,Saúde Mental, Faculdade de Medicina da Bahia, Universidade Federal da BahiaDepartamento de Neurociências e , Salvador, Brasil
| | - Nildo Manoel da Silva Ribeiro
- Epidemiologia, Universidade Federal da BahiaDivisão de Neurologia e , Salvador, Brazil.,Departamento de fisioterapia, Instituto de Ciências da Saúde, Universidade Federal da Bahia, Salvador, Brasil
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Siddiqi SH, Kording KP, Parvizi J, Fox MD. Causal mapping of human brain function. Nat Rev Neurosci 2022; 23:361-375. [PMID: 35444305 PMCID: PMC9387758 DOI: 10.1038/s41583-022-00583-8] [Citation(s) in RCA: 111] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 12/11/2022]
Abstract
Mapping human brain function is a long-standing goal of neuroscience that promises to inform the development of new treatments for brain disorders. Early maps of human brain function were based on locations of brain damage or brain stimulation that caused a functional change. Over time, this approach was largely replaced by technologies such as functional neuroimaging, which identify brain regions in which activity is correlated with behaviours or symptoms. Despite their advantages, these technologies reveal correlations, not causation. This creates challenges for interpreting the data generated from these tools and using them to develop treatments for brain disorders. A return to causal mapping of human brain function based on brain lesions and brain stimulation is underway. New approaches can combine these causal sources of information with modern neuroimaging and electrophysiology techniques to gain new insights into the functions of specific brain areas. In this Review, we provide a definition of causality for translational research, propose a continuum along which to assess the relative strength of causal information from human brain mapping studies and discuss recent advances in causal brain mapping and their relevance for developing treatments.
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Affiliation(s)
- Shan H Siddiqi
- Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Konrad P Kording
- Department of Neuroscience, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Josef Parvizi
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Michael D Fox
- Center for Brain Circuit Therapeutics, Brigham & Women's Hospital, Boston, MA, USA
- Department of Neurology, Harvard Medical School, Boston, MA, USA
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8
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Abstract
Mania, the diagnostic hallmark of bipolar disorder, is an episodic disturbance of mood, sleep, behavior, and perception. Improved understanding of the neurobiology of mania is expected to allow for novel avenues to address current challenges in its diagnosis and treatment. Previous research focusing on the impairment of functional neuronal circuits and brain networks has resulted in heterogenous findings, possibly due to a focus on bipolar disorder and its several phases, rather than on the unique context of mania. Here we present a comprehensive overview of the evidence regarding the functional neuroanatomy of mania. Our interpretation of the best available evidence is consistent with a convergent model of lateralized circuit dysfunction in mania, with hypoactivity of the ventral prefrontal cortex in the right hemisphere, and hyperactivity of the amygdala, basal ganglia, and anterior cingulate cortex in the left hemisphere of the brain. Clarification of dysfunctional neuroanatomic substrates of mania may contribute not only to improve understanding of the neurobiology of bipolar disorder overall, but also highlights potential avenues for new circuit-based therapeutic approaches in the treatment of mania.
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Affiliation(s)
- Gonçalo Cotovio
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
- NOVA Medical School, NMS, Universidade Nova de Lisboa, Lisbon, Portugal
- Departamento de Psiquiatria e Saúde Mental, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Albino J Oliveira-Maia
- Champalimaud Research and Clinical Centre, Champalimaud Foundation, Lisbon, Portugal.
- NOVA Medical School, NMS, Universidade Nova de Lisboa, Lisbon, Portugal.
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Guo J, Wang J, Sun W, Liu X. The advances of post-stroke depression: 2021 update. J Neurol 2021; 269:1236-1249. [PMID: 34052887 DOI: 10.1007/s00415-021-10597-4] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/02/2021] [Accepted: 05/04/2021] [Indexed: 12/13/2022]
Abstract
Post-stroke depression (PSD) is one of common and serious sequelae of stroke. Approximately, one in three stroke survivors suffered from depression after stroke. It heavily affected functional rehabilitation, which leaded to poor quality of life. What is worse, it is strongly associated with high mortality. In this review, we aimed to derive a comprehensive and integrated understanding of PSD according to recently published papers and previous classic articles. Based on the considerable number of studies, we found that within 2 years incidence of PSD has a range from 11 to 41%. Many factors contribute to the occurrence of PSD, including the history of depression, stroke severity, lesion location, and so on. Currently, the diagnosis of PSD is mainly based on the DSM guidelines and combined with various depression scales. Unfortunately, we lack a unified mechanism to explain PSD which mechanisms now involve dysregulation of hypothalamic-pituitary-adrenal (HPA) axis, increased inflammatory factors, decreased levels of monoamines, glutamate-mediated excitotoxicity, and abnormal neurotrophic response. At present, both pharmacotherapy and psychological therapies are employed in treating PSD. Although great advance has been made by researchers, there are still a lot of issues need to be addressed. Especially, the mechanism of PSD is not completely clear.
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Affiliation(s)
- Jianglong Guo
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China
| | - Jinjing Wang
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wen Sun
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China
| | - Xinfeng Liu
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China.
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
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10
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Abstract
Neuropsychiatric disturbances represent a common and uniquely challenging consequence of stroke. These disorders arise at the intersection of lesion-related brain dysfunction and psychological distress related to the event and its aftermath, making it difficult to identify what symptom is a direct physiological consequence of the stroke. Depression, anxiety, fatigue, apathy, emotionalism, and anger are the most common of these syndromes, and posttraumatic stress disorder related to the stroke event has become increasingly recognized as a relevant entity. Mania, obsessive-compulsive disorder, and psychosis are less commonly encountered but potentially highly debilitating conditions that may be underrecognized. Early identification and treatment may mitigate functional impairment and improve quality of life. Evidence-based guidelines from the general population are often relied upon to guide treatment. Further research is needed to understand and tailor treatment of these disorders in the poststroke population.
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Affiliation(s)
- Katlyn Nemani
- Departments of Neurology and Psychiatry, NYU Langone Health, New York, New York
| | - Lindsey Gurin
- Departments of Neurology, Psychiatry, and Rehabilitation Medicine, NYU Langone Health, New York, New York
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11
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Abstract
Stroke causes many forms of disability, including emotional and mood disorders. Depression is the most common of these, affecting approximately one-third of stroke patients. Other disorders like mania, bipolar disorder, anxiety disorder, or apathy may also develop following stroke, although they are less common. The development of mood and emotional disorders is dependent on the severity of brain injury, the side of injury, and hemispheric location. Whereas a left hemispheric stroke often results in depression or a catastrophic reaction with anxiety, injury to the right hemisphere has predominantly been associated with the development of emotional indifference (anosodiaphoria) or euphoria. In this chapter, we discuss the mood disorders associated with hemispheric strokes and the neuropsychological mechanisms that might account for the clinical manifestations of these affective disorders.
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Affiliation(s)
- Michał Harciarek
- Department of Social Sciences, Institute of Psychology, University of Gdansk, Gdansk, Poland.
| | - Aleksandra Mańkowska
- Department of Social Sciences, Institute of Psychology, University of Gdansk, Gdansk, Poland
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12
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Barrows PD, Thomas SA, Van Gordon W. Assessing Self-Reported Mood in Aphasia Following Stroke: Challenges, Innovations and Future Directions. J Stroke Cerebrovasc Dis 2020; 30:105425. [PMID: 33161350 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/13/2020] [Accepted: 10/21/2020] [Indexed: 01/21/2023] Open
Abstract
Assessment of mood is critical in determining rehabilitation outcomes for stroke and other acquired brain injury, yet a common consequence of such injuries is aphasia, where language is impaired. Consequently, the use of language-based measures in this population is often not possible. Following a critical review of the neuropsychological aspects of self-reported mood, this paper evaluates the problems in reporting mood after stroke due to aphasia, and discusses implications for the design of adapted instruments. The paper then appraises the construction and psychometric properties of existing, adapted self-report measures developed to try and address these problems, and evaluates their utility and limitations. This includes a focus on the recently validated tablet-based Dynamic Visual Analog Mood Scales (D-VAMS), which uses innovative non-verbal assessment methods based on facial expression modulated via a slider control on a touchscreen interface. Currently, most studies evaluating recovery interventions simply omit individuals with aphasia because of the difficulty of assessing mood and quality of life in this population. However, adapted scales such as the D-VAMS appear to represent an important step forward in assessing mood in people with language impairments, with the use of interactive modulated imagery having wider applications for nonverbal communication as well as the quantification of subjective phenomena.
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Affiliation(s)
- Paul D Barrows
- University of Nottingham, Medical School, Nottingham, NG7 2UH, UK; Human Sciences Research Centre, University of Derby, Kedleston Road, Derby, DE22 1GB, UK.
| | - Shirley A Thomas
- University of Nottingham, Medical School, Nottingham, NG7 2UH, UK.
| | - William Van Gordon
- Human Sciences Research Centre, University of Derby, Kedleston Road, Derby, DE22 1GB, UK.
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13
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Cotovio G, Talmasov D, Barahona-Corrêa JB, Hsu J, Senova S, Ribeiro R, Soussand L, Velosa A, Silva VCE, Rost N, Wu O, Cohen AL, Oliveira-Maia AJ, Fox MD. Mapping mania symptoms based on focal brain damage. J Clin Invest 2020; 130:5209-5222. [PMID: 32831292 PMCID: PMC7524493 DOI: 10.1172/jci136096] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 06/24/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUNDAlthough mania is characteristic of bipolar disorder, it can also occur following focal brain damage. Such cases may provide unique insight into brain regions responsible for mania symptoms and identify therapeutic targets.METHODSLesion locations associated with mania were identified using a systematic literature search (n = 41) and mapped onto a common brain atlas. The network of brain regions functionally connected to each lesion location was computed using normative human connectome data (resting-state functional MRI, n = 1000) and contrasted with those obtained from lesion locations not associated with mania (n = 79). Reproducibility was assessed using independent cohorts of mania lesions derived from clinical chart review (n = 15) and of control lesions (n = 490). Results were compared with brain stimulation sites previously reported to induce or relieve mania symptoms.RESULTSLesion locations associated with mania were heterogeneous and no single brain region was lesioned in all, or even most, cases. However, these lesion locations showed a unique pattern of functional connectivity to the right orbitofrontal cortex, right inferior temporal gyrus, and right frontal pole. This connectivity profile was reproducible across independent lesion cohorts and aligned with the effects of therapeutic brain stimulation on mania symptoms.CONCLUSIONBrain lesions associated with mania are characterized by a specific pattern of brain connectivity that lends insight into localization of mania symptoms and potential therapeutic targets.FUNDINGFundação para a Ciência e Tecnologia (FCT), Harvard Medical School DuPont-Warren Fellowship, Portuguese national funds from FCT and Fundo Europeu de Desenvolvimento Regional, Child Neurology Foundation Shields Research, Sidney R. Baer, Jr. Foundation, Nancy Lurie Marks Foundation, Mather's Foundation, and the NIH.
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Affiliation(s)
- Gonçalo Cotovio
- Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
- NOVA Medical School | Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Daniel Talmasov
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, New York University School of Medicine, New York, New York, USA
| | - J. Bernardo Barahona-Corrêa
- Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
- NOVA Medical School | Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Joey Hsu
- Berenson-Allen Center for Non-Invasive Brain Stimulation and
- Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Suhan Senova
- Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
- Neurosurgery Department and
- PePsy Department, Groupe Henri-Mondor Albert-Chenevier, Assistance Publique-Hôpitaux de Paris (APHP), Créteil, France
- Equipe 14, U955 INSERM, Institut Mondor de Recherche Biomedicale and
- Faculté de Médecine, Université Paris Est, Créteil, France
| | - Ricardo Ribeiro
- Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Louis Soussand
- Berenson-Allen Center for Non-Invasive Brain Stimulation and
- Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ana Velosa
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Vera Cruz e Silva
- Department of Neuroradiology, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Natalia Rost
- J. Philip Kistler Stroke Research Center, Department of Neurology and
| | - Ona Wu
- Athinoula A. Martinos Centre for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital
| | - Alexander L. Cohen
- Berenson-Allen Center for Non-Invasive Brain Stimulation and
- Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Boston Children’s Hospital, and
| | - Albino J. Oliveira-Maia
- Champalimaud Research and Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
- Department of Psychiatry and Mental Health, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
- NOVA Medical School | Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Michael D. Fox
- Berenson-Allen Center for Non-Invasive Brain Stimulation and
- Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Athinoula A. Martinos Centre for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Brain Circuit Therapeutics, Department of Neurology, Department of Psychiatry, Department of Neurosurgery, and Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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14
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Kwak EH, Wi S, Kim M, Pyo S, Shin YK, Oh KJ, Han K, Kim YW, Cho SR. Factors affecting cognition and emotion in patients with traumatic brain injury. NeuroRehabilitation 2020; 46:369-379. [PMID: 32310194 PMCID: PMC7306897 DOI: 10.3233/nre-192893] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cognitive and emotional disturbances are common serious issues in patients with traumatic brain injury (TBI). However, predictors associated with neuropsychological functions were not consistent. OBJECTIVE To investigate factors affecting cognition and emotion in patients with TBI, we evaluated executive function, memory, and emotion based on injury severity and lesion location. METHODS Neuropsychological outcomes of 80 TBI patients were evaluated via Wisconsin Card Sorting Test (WCST), Color Trail Test (CTT), Controlled Oral Word Association Test (COWAT), Everyday Memory Questionnaire (EMQ), Geriatric Depression Scale (GDS), State-Trait Anxiety Inventory (STAI), and Agitated Behavior Scale (ABS). WCST, CTT, and COWAT assessed executive function; EMQ assessed everyday memory; and GDS, STAI, and ABS assessed emotion. Patients were categorized according to lateralization of lesion and existence of frontal lobe injury. RESULTS Patients with longer duration of loss of consciousness (LOC) showed more severe deficits in everyday memory and agitated behaviors. The frontal lesion group showed poorer performance in executive function and higher agitation than the non-frontal lesion group. Patients with bilateral frontal lesion showed greater deficits in executive function and were more depressed than unilateral frontal lesion groups. Especially in those unilateral frontal lesion groups, right side frontal lesion group was worse on executive function than left side frontal lesion group. CONCLUSIONS Duration of LOC and lesion location are main parameters affecting executive function, everyday memory, and emotion in neuropsychological outcomes following TBI, suggesting that these parameters need to be considered for cognitive rehabilitation interventions.
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Affiliation(s)
- Eun Hee Kwak
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea.,Department of Psychology, Yonsei University, Seoul, Korea
| | - Soohyun Wi
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - MinGi Kim
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Soonil Pyo
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon-Kyum Shin
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Ja Oh
- Department of Psychology, Yonsei University, Seoul, Korea
| | - Kyunghun Han
- Division of Sport science, Pusan National University, Busan, Korea
| | - Yong Wook Kim
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea
| | - Sung-Rae Cho
- Department and Research Institute of Rehabilitation Medicine, Yonsei University Medical Center, Seoul, Korea.,Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea.,Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea.,Graduate Program of Nano Science and Technology, Yonsei University College of Medicine, Seoul, Korea
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15
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Chohan SA, Venkatesh PK, How CH. Long-term complications of stroke and secondary prevention: an overview for primary care physicians. Singapore Med J 2019; 60:616-620. [PMID: 31889205 PMCID: PMC7911065 DOI: 10.11622/smedj.2019158] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Despite a decline in mortality from stroke, the annual incidence in the general population is increasing. For many stroke survivors and their families, the acute stroke is the beginning of an ongoing struggle with physical impairment and subsequent disability. Over time, the immediate clinical consequences of the stroke are complicated by a variety of lesser-known medical, musculoskeletal and psychosocial difficulties. The primary care physician is best positioned to optimise chronic disease control, reduce risk and manage complications of stroke. Early screening and appropriate management is key. Instituting secondary prevention and attention to bowel and bladder problems can help reduce medical complications and re-admissions, while adequate analgesia, positioning/splinting of limbs and physiotherapy can lessen discomfort and preventable suffering. Primary care physicians can identify and treat post-stroke mood issues and involve psychological counselling for patients and caregivers. Adequate education and support may restore the independence of patients with stroke or minimise any resultant dependency.
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Affiliation(s)
| | | | - Choon How How
- Care and Health Integration, Changi General Hospital, Singapore
- Family Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore
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16
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Abstract
BACKGROUND Post stroke depression adversely affects long term outcome of stroke and increases mortality risk. Few studies have looked into the comprehensive picture of post stroke depression in past. AIM The current study aimed to look into the phenomenology, characteristic features and various correlates of post stroke depression. METHOD 142 consecutive stroke patients aged 60 years or above, fulfilling the inclusion criteria were assessed. Sociodemographic and clinical data were gathered using a specially designed pro-forma. Depression, apathy and psychosis were assessed by Post stroke depression rating scale, Apathy Evaluation Scale, and Brief Psychiatric Rating Scale respectively. Groups (with or without major depression) were compared using Mann-Whitney U, chi square or Fisher's exact test. One way ANOVA was conducted to see the relations of lesion location and laterality with various clinical parameters. Kaplan-Meier survival analysis was done to see the time to develop depression. The effect sizes were reported as r and partial eta squared. RESULTS Guilt was significantly higher (p<.05) with lesions in parietal lobe and remaining of middle cerebral artery territory. Catastrophic reaction (p<.05) and emotional dyscontrol (p<.05) were higher for diffuse lesions, periventricular lesions and lesions in frontal/occipital lobe. BPRS score, but not apathy, had a significant positive correlation with depression (Pearson's r=.692). Mean time to develop depression after stroke was 28.34 (95% CI 22.37 to 34.31) months. CONCLUSIONS Post stroke depression consists of various clinically important sub-components whose occurrence varies with different lesion locations. Post stroke depression is discriminable from apathy but is related to psychosis.
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Affiliation(s)
- Amlan Kusum Jana
- Department of Psychiatry, KPC Medical College and Hospital, Kolkata, West Bengal, India
| | - Suddhendu Chakraborty
- Department of Psychiatry, Bongaon J R Dhar Sub Divisional Hospital, Bongaon, West Bengal, India
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17
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Zhang E, Liao P. Brain‐derived neurotrophic factor and post‐stroke depression. J Neurosci Res 2019; 98:537-548. [DOI: 10.1002/jnr.24510] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/21/2019] [Accepted: 07/22/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Eric Zhang
- Western University of Health Sciences Pomona CA
| | - Ping Liao
- Calcium Signalling Laboratory National Neuroscience Institute Singapore
- Duke‐NUS Medical School Singapore
- Health and Social Sciences Singapore Institute of Technology Singapore
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18
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Emotional Semantic Congruency based on stimulus driven comparative judgements. Cognition 2019; 190:20-41. [PMID: 31022649 DOI: 10.1016/j.cognition.2019.04.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/15/2019] [Accepted: 04/16/2019] [Indexed: 12/12/2022]
Abstract
A common cognitive process in everyday life consists in the comparative judgements of emotions given a pair of facial expressions and the choice of the most positive/negative among them. Results from three experiments on complete-facial expressions (happy/angry) and mixed-facial expressions (neutral/happy-or-angry) pairs viewed with (Experiment 1 and 3) or without (Experiment 2) foveation and performed in conditions in which valence was either task relevant (Experiment 1 and 2) or task irrelevant (Experiment 3), show that comparative judgements of emotions are stimulus driven. Judgements' speed increased as the target absolute emotion intensity grew larger together with the average emotion of the pair, irrespective of the compatibility between the valence and the side of motor response: a semantic congruency effect in the domain of emotion. This result undermines previous interpretation of results in the context of comparative judgements based on the lateralization of emotions (e.g., SNARC-like instructional flexibility), and is fully consistent with our formalization of emotional semantic congruency: the direct Speed-Intensity Association model.
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19
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Maheras KJ, Peppi M, Ghoddoussi F, Galloway MP, Perrine SA, Gow A. Absence of Claudin 11 in CNS Myelin Perturbs Behavior and Neurotransmitter Levels in Mice. Sci Rep 2018; 8:3798. [PMID: 29491447 PMCID: PMC5830493 DOI: 10.1038/s41598-018-22047-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 02/15/2018] [Indexed: 12/20/2022] Open
Abstract
Neuronal origins of behavioral disorders have been examined for decades to construct frameworks for understanding psychiatric diseases and developing useful therapeutic strategies with clinical application. Despite abundant anecdotal evidence for white matter etiologies, including altered tractography in neuroimaging and diminished oligodendrocyte-specific gene expression in autopsy studies, mechanistic data demonstrating that dysfunctional myelin sheaths can cause behavioral deficits and perturb neurotransmitter biochemistry have not been forthcoming. At least in part, this impasse stems from difficulties in identifying model systems free of degenerative pathology to enable unambiguous assessment of neuron biology and behavior in a background of myelin dysfunction. Herein we examine myelin mutant mice lacking expression of the Claudin11 gene in oligodendrocytes and characterize two behavioral endophenotypes: perturbed auditory processing and reduced anxiety/avoidance. Importantly, these behaviors are associated with increased transmission time along myelinated fibers as well as glutamate and GABA neurotransmitter imbalances in auditory brainstem and amygdala, in the absence of neurodegeneration. Thus, our findings broaden the etiology of neuropsychiatric disease to include dysfunctional myelin, and identify a preclinical model for the development of novel disease-modifying therapies.
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Affiliation(s)
- Kathleen J Maheras
- Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Marcello Peppi
- Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Farhad Ghoddoussi
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Matthew P Galloway
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, 48201, USA
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Shane A Perrine
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Alexander Gow
- Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, 48201, USA.
- Carman and Ann Adams Dept of Pediatrics, Wayne State University School of Medicine, Detroit, MI, 48201, USA.
- Dept of Neurology, Wayne State University School of Medicine, Detroit, MI, 48201, USA.
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20
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Schönfeldt-Lecuona C, Schmidt A, Kregel T, Kassubek J, Dreyhaupt J, Freudenmann RW, Connemann BJ, Pinkhardt EH, Gahr M. Retinal changes in patients with major depressive disorder - A controlled optical coherence tomography study. J Affect Disord 2018; 227:665-671. [PMID: 29174740 DOI: 10.1016/j.jad.2017.11.077] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 10/26/2017] [Accepted: 11/12/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Recent studies on the pathophysiology of major depression (MD) indicate that degenerative and inflammatory processes may play a role. This finding is supported by magnetic resonance imaging (MRI)-based meta-analysis that show volume reductions in circumscribed areas of the brain in patients with MD. Using optical coherence tomography (OCT), retinal changes have been demonstrated in neurodegenerative disorders. In light of this inflammatory/degenerative hypothesis, we tested whether patients with MD exhibit retinal alterations that might correlate with the severity and duration of the disease. METHODS Patients with MD and age- and gender-matched healthy controls were recruited for the measurement of the total volume and thickness of their retina as well as the thicknesses and volumes of five different retinal layers using single-layer-analysis provided by the spectral-domain-OCT. RESULTS OCT data from 28 patients with MD and 20 healthy controls were available for evaluation. The exploratory intra-individual group comparison of the two eyes showed a small but significant difference in the retinal total volume (right = 8.69mm3; left = 8.72mm3; p = 0.03) only in patients with MD. There were no other significant differences between the patients with MD and the healthy controls with respect to the OCT measurements. LIMITATIONS The small group size as well as the absence of correction for multiple testing due to the exploratory design should be considered as limitations of our study. CONCLUSION While retinal total volume differs between the eyes of patients with MD, the comparison of retinal parameters between these patients and age- and gender-matched healthy volunteers did not show any differences.
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Affiliation(s)
| | - Arno Schmidt
- Department of Psychiatry and Psychotherapy III, University Clinic Ulm, Germany
| | - Thomas Kregel
- Department of Psychiatry and Psychotherapy III, University Clinic Ulm, Germany
| | - Jan Kassubek
- Department of Neurology, University Clinic Ulm, Germany
| | - Jens Dreyhaupt
- Institute of Epidemiology and Medical Biometry, University of Ulm, Germany
| | | | | | | | - Maximilian Gahr
- Department of Psychiatry and Psychotherapy III, University Clinic Ulm, Germany
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21
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Liu S, Han S, Dai Q, Li S, Li J. BICAO-induced ischaemia caused depressive-like behaviours and caspase-8/-9-dependent brain regional neural cell apoptosis in mice. Stroke Vasc Neurol 2017; 3:1-8. [PMID: 29600001 PMCID: PMC5870644 DOI: 10.1136/svn-2017-000109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/04/2017] [Accepted: 11/07/2017] [Indexed: 11/04/2022] Open
Abstract
Introduction Cerebral ischaemia-induced depression is among the most frequent neuropsychiatric consequences and adversely impact the prognosis and recovery of patients. Although several brain regions have been implied in the development of ischaemia-induced depression, the brain region-specific neural cell apoptosis pathways have not been clarified yet. Methods In this study, bilateral internal carotid artery occlusion (BICAO) mouse model was established to induce cerebral ischaemia. Sucrose preference, tail suspension and forced swim tests were conducted on mice at 7, 21 and 30 days after BICAO treatment. In addition, brain regional ischaemic neuron loss was investigated by using immunofluorescent staining of neuronal nuclei (NeuN) and caspase-8/-9-dependent cell apoptosis was also examined by western blot analysis. Results BICAO-induced cerebral ischaemia resulted in decreased sucrose preference and increased immobility times, which were representative depressive-like behaviours of mice until 30 days after BICAO treatment compared with Sham-operated mice. This outcome was associated with significant neuron loss by using immunofluorescent staining and increased cleavage levels of pro-caspase-3/-8/-9, but not pro-caspase-12, by western blot analysis in hypothalamus, midbrain, prefrontal cortex and hippocampus of mice. Conclusions This study showed that BICAO-induced ischaemia caused depressive-like behaviours and caspase-8/-9-dependent neural cell apoptosis in several brain regions, including hypothalamus and midbrain of mice.
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Affiliation(s)
- Shuiqiao Liu
- Department of Neurobiology and Center of Stroke, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Song Han
- Department of Neurobiology and Center of Stroke, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Qingqing Dai
- Department of Neurobiology and Center of Stroke, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Shujuan Li
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Junfa Li
- Department of Neurobiology and Center of Stroke, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
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22
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Karakus K, Kunt R, Memis CO, Kunt DA, Dogan B, Ozdemiroglu F, Sevincok L. The factors related to early-onset depression after first stroke. Psychogeriatrics 2017; 17:414-422. [PMID: 28387015 DOI: 10.1111/psyg.12266] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 02/16/2017] [Accepted: 02/17/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND The biological and psychological aspects of post-stroke depression (PSD) may vary based on the time since stroke onset. The sociodemographic and clinical correlates of early-onset PSD are not yet well understood. In the present study, we aimed to investigate the clinical correlates of early-onset depression following first stroke. We hypothesized that the severity of a stroke or disability (other than lesion characteristics) would likely be related to PSD in a sample of first stroke patients with single and unilateral lesions. METHODS Post-stroke patients with (n = 40) and without (n = 51) early-onset depression were compared with respect to several demographic and clinical variables. RESULTS There were no significant differences between the groups with respect to lesion location, lateralization, or volume. Scores on the Brief Disability Questionnaire, National Institutes of Health Stroke Scale, and Modified Rankin Scale were significantly higher in depressed post-stroke patients than in non-depressed patients. The anxiety, depression, and total scores of the Hospital Anxiety and Depression Scale were positively correlated with the Modified Rankin Scale, National Institutes of Health Stroke Scale, and Brief Disability Questionnaire scores. A previous history of depression and Brief Disability Questionnaire score were strongly associated with the occurrence of early-onset PSD. CONCLUSION Our findings suggest that early-onset PSD is likely to be correlated with the severity of stroke and functional disability.
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Affiliation(s)
- Kadir Karakus
- Department of Psychiatry, Medical School, Adnan Menderes University, Aydin, Turkey
| | - Refik Kunt
- Department of Neurology, Neurology Division, Aydin State Hospital, Aydin, Turkey
| | - Cagdas O Memis
- Department of Psychiatry, Medical School, Adnan Menderes University, Aydin, Turkey
| | - Duygu A Kunt
- Department of Psychiatry, Medical School, Adnan Menderes University, Aydin, Turkey
| | - Bilge Dogan
- Department of Psychiatry, Medical School, Adnan Menderes University, Aydin, Turkey
| | - Filiz Ozdemiroglu
- Department of Psychiatry, Medical School, Adnan Menderes University, Aydin, Turkey
| | - Levent Sevincok
- Department of Psychiatry, Medical School, Adnan Menderes University, Aydin, Turkey
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23
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Robinson RG. The Thrill of Discovery: A Personal Scientific Autobiography. Am J Geriatr Psychiatry 2017; 25:1033-1039. [PMID: 28595748 DOI: 10.1016/j.jagp.2017.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 05/05/2017] [Indexed: 10/19/2022]
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24
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Spitz G, Alway Y, Gould KR, Ponsford JL. Disrupted White Matter Microstructure and Mood Disorders after Traumatic Brain Injury. J Neurotrauma 2016; 34:807-815. [PMID: 27550509 DOI: 10.1089/neu.2016.4527] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Traumatic brain injury (TBI) is associated with an elevated frequency of mood disorders that may, in part, be explained by changes in white-matter microstructure. This study is the first to examine the relationship between mood disorders and white-matter pathology in a sample of patients with mild to severe TBI using a standardized psychiatric interview. This study reports on a sub-sample of 29 individuals recruited from a large prospective study that examined the evolution of psychiatric disorders following complicated, mild to severe TBI. Individuals with TBI were also compared with 23 healthy control participants. Individuals were invited to complete the Structured Clinical Interview for DSM-IV Disorders (SCID) to diagnose psychiatric disorders. Participants who developed a mood disorder within the first 3 years were categorized into a TBI-Mood group. Diffusion tensor tractography assessed white matter microstructure using atlas-based tract-averaged and along-tract approaches. Fractional anisotropy (FA) was used as the measure of white-matter microstructure. TBI participants with and without a mood disorder did not differ in regard to injury severity and other background factors. Nevertheless, TBI participants diagnosed with a mood disorder displayed significantly lower tract-averaged FA values for the right arcuate fasciculus (p = 0.011), right inferior longitudinal fasciculus (p = 0.009), and anterior segments I (p = 0.0004) and II (p = 0.007) of the corpus callosum, as well as the left (p = 0.014) and right (p = 0.015) fronto-occipital longitudinal fasciculi. The pattern of white matter disruption identified in the current study provides further support for a neurobiological basis of post-TBI mood disorders. Greater understanding of individuals' underlying neuropathology may enable better characterization and prediction of mood disorders. Integration of neuropathology may also inform the potential efficacy of pharmacological and psychological interventions.
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Affiliation(s)
- Gershon Spitz
- Monash Institute of Cognitive and Clinical Neurosciences, Monash University , Clayton, Australia .,Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia
| | - Yvette Alway
- Monash Institute of Cognitive and Clinical Neurosciences, Monash University , Clayton, Australia .,Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia
| | - Kate Rachel Gould
- Monash Institute of Cognitive and Clinical Neurosciences, Monash University , Clayton, Australia .,Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia
| | - Jennie L Ponsford
- Monash Institute of Cognitive and Clinical Neurosciences, Monash University , Clayton, Australia .,Monash-Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne, Australia
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25
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Barak Y, Lampl Y, Bodner E, Pinchas IS. Perception of Body Esteem Following Stroke. Neurorehabil Neural Repair 2016. [DOI: 10.1177/154596839901300102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Psychopathologic disturbances have been reported as a sequela of ischemic stroke. We have exammed various body esteem dimensions in 101 patients following a stroke. The patients were examined 6 months after the stroke. They were scored with the Barthel Index (BI) as the disability score, the Hamilton Depression Scale (HDS), and the Body Esteem Scale (BES). A significant lower body esteem (p < 0.0001) was found for both sexes and for all body esteem subscales in subjects suffering from a left corti cal lesion compared with other stroke locations. Physical attractiveness subscores among males were significantly lower in subjects with a right cortical lesion (p < 0.005). No correlation was found between time of disability and body esteem except on the upper body strength (V) subscale among males (p = 0.04). No correlation was found between the BI, size of lesion, or age and BES. These findings demonstrate that im pairment of body esteem following stroke is correlated with lesion location, not its size or associated disability score.
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26
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Nguyen VA, Carey LM, Giummarra L, Faou P, Cooke I, Howells DW, Tse T, Macaulay SL, Ma H, Davis SM, Donnan GA, Crewther SG. A Pathway Proteomic Profile of Ischemic Stroke Survivors Reveals Innate Immune Dysfunction in Association with Mild Symptoms of Depression - A Pilot Study. Front Neurol 2016; 7:85. [PMID: 27379006 PMCID: PMC4907034 DOI: 10.3389/fneur.2016.00085] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/23/2016] [Indexed: 12/14/2022] Open
Abstract
Depression after stroke is a common occurrence, raising questions as to whether depression could be a long-term biological and immunological sequela of stroke. Early explanations for post-stroke depression (PSD) focused on the neuropsychological/psychosocial effects of stroke on mobility and quality of life. However, recent investigations have revealed imbalances of inflammatory cytokine levels in association with PSD, though to date, there is only one published proteomic pathway analysis testing this hypothesis. Thus, we examined the serum proteome of stroke patients (n = 44, mean age = 63.62 years) and correlated these with the Montgomery–Åsberg Depression Rating Scale (MADRS) scores at 3 months post-stroke. Overall, the patients presented with mild depression symptoms on the MADRS, M = 6.40 (SD = 7.42). A discovery approach utilizing label-free relative quantification was employed utilizing an LC-ESI–MS/MS coupled to a LTQ-Orbitrap Elite (Thermo-Scientific). Identified peptides were analyzed using the gene set enrichment approach on several different genomic databases that all indicated significant downregulation of the complement and coagulation systems with increasing MADRS scores. Complement and coagulation systems are traditionally thought to play a key role in the innate immune system and are established precursors to the adaptive immune system through pro-inflammatory cytokine signaling. Both systems are known to be globally affected after ischemic or hemorrhagic stroke. Thus, our results suggest that lowered complement expression in the periphery in conjunction with depressive symptoms post-stroke may be a biomarker for incomplete recovery of brain metabolic needs, homeostasis, and inflammation following ischemic stroke damage. Further proteomic investigations are now required to construct the temporal profile, leading from acute lesion damage to manifestation of depressive symptoms. Overall, the findings provide support for the involvement of inflammatory and immune mechanisms in PSD symptoms and further demonstrate the value and feasibility of the proteomic approach in stroke research.
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Affiliation(s)
- Vinh A Nguyen
- Occupational Therapy, College of Science Health and Engineering, School of Allied Health, La Trobe University, Melbourne, VIC, Australia; Neurorehabilitation and Recovery, Stroke, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Leeanne M Carey
- Occupational Therapy, College of Science Health and Engineering, School of Allied Health, La Trobe University, Melbourne, VIC, Australia; Neurorehabilitation and Recovery, Stroke, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - Loretta Giummarra
- School of Psychology and Public Health, La Trobe University , Melbourne, VIC , Australia
| | - Pierre Faou
- School of Molecular Sciences, La Trobe University , Melbourne, VIC , Australia
| | - Ira Cooke
- School of Molecular Sciences, La Trobe University , Melbourne, VIC , Australia
| | - David W Howells
- School of Medicine, University of Tasmania , Hobart, TAS , Australia
| | - Tamara Tse
- Occupational Therapy, College of Science Health and Engineering, School of Allied Health, La Trobe University, Melbourne, VIC, Australia; Neurorehabilitation and Recovery, Stroke, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - S Lance Macaulay
- Commonwealth Science and Industrial Research Organisation (CSIRO) , Melbourne, VIC , Australia
| | - Henry Ma
- The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia; Monash University, Clayton, VIC, Australia
| | - Stephen M Davis
- The University of Melbourne, Parkville, VIC, Australia; Department of Medicine, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia; The University of Melbourne, Parkville, VIC, Australia
| | - Sheila G Crewther
- Neurorehabilitation and Recovery, Stroke, The Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia; School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
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Abstract
The ability to deal with and manage a chronic condition such as stroke requires a learning process embedded in personal experience that is often emotionally taxing as well as physically fatiguing. Stroke survivors typically need help in balancing demands and resources and in preventing or effectively coping with stress emotions to conserve energy. The major constructs outlined in this article provide a framework for psychosocial care to promote the experience of wellness in stroke survivors.
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Affiliation(s)
- Brenda L Lyon
- Department of Adult Health, Indiana University School of Nursing, Indianapolis, USA
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Abstract
BACKGROUND Considerable attention has been given to the identification of depression in stroke survivors with aphasia, but there is more limited information about other mood states. Visual analog scales are often used to collect subjective information from people with aphasia. However, the validity of these methods for communicating about mood has not been established in people with moderately to severely impaired language. OBJECTIVE The dual purposes of this study were to characterize the relative endorsement of negative and positive mood states in people with chronic aphasia after stroke and to examine congruent validity for visual analog rating methods for people with a range of aphasia severity. METHODS Twenty-three left-hemisphere stroke survivors with aphasia were asked to indicate their present mood by using two published visual analog rating methods. The congruence between the methods was estimated through correlation analysis, and scores for different moods were compared. RESULTS Endorsement was significantly stronger for "happy" than for mood states with negative valence. At the same time, several participants displayed pronounced negative mood compared to previously published norms for neurologically healthy adults. Results from the two rating methods were moderately and positively correlated. CONCLUSIONS Positive mood is prominent in people with aphasia who are in the chronic stage of recovery after stroke, but negative moods can also be salient and individual presentations are diverse. Visual analog rating methods are valid methods for discussing mood with people with aphasia; however, design optimization should be explored.
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Salter K, Bhogal SK, Foley N, Jutai J, Teasell R. The Assessment of Poststroke Depression. Top Stroke Rehabil 2014; 14:1-24. [PMID: 17573309 DOI: 10.1310/tsr1403-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Poststroke depression (PSD) is a common clinical consequence of stroke. PSD is associated with poor functional and social outcomes, reduced quality of life, the presence of cognitive impairment, and increased mortality. Despite the potential benefit associated with the identification and treatment of PSD, it often remains unrecognized and undertreated. The present study provides a critical review and synthesis of measurement properties for 10 instruments used in the assessment of depression following stroke. Assessment considerations specific to PSD are addressed, and tools are reviewed within the context of stroke. To facilitate the timely detection, diagnosis, and initiation of treatment for PSD, a two-step assessment process is recommended, thereby taking strategic advantage of the strengths and limitations associated with self-report and observer-rating assessment tools.
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Affiliation(s)
- Katherine Salter
- Department of Physical Medicine and Rehabilitation, St. Joseph's Health Care London, Parkwood Hospital, London, Ontario, Canada
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Reliability, validity, and factor structure of the Cognitive Behavioral Rating Scale for stroke patients. Int J Rehabil Res 2014; 37:343-8. [PMID: 25192007 DOI: 10.1097/mrr.0000000000000078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study was to explore the reliability, validity, and factor structure of a newly developed Cognitive Behavioral Rating Scale (CBRS), designed to assess cognitive function through observation. The study included 180 stroke patients and 58 orthopedic patients. The CBRS and the Functional Independence Measure (FIM) were administered. Data on discharge disposition were also collected. The inter-rater reliability, construct validity, concurrent validity, predictive validity, and factor structure of the CBRS were evaluated. The interclass correlation coefficient was 0.736 (P<0.0001). Cronbach's α for the CBRS was 0.92. Patients with stroke showed a significantly higher total CBRS score than those with orthopedic problems (P<0.0001). Spearman's rank correlation coefficient (rs) was -0.70 (P<0.01) for the total FIM score and the CBRS, and -0.72 (P<0.01) for the cognitive FIM and the CBRS. The return-to-home group had a significantly lower CBRS total score than the not-to-home group (P<0.01). The CBRS comprised three factors: (i) 'language and performance', (ii) 'control of performance', and (iii) 'space-self relation.' The CBRS appears to have a high reliability and validity for the assessment of cognitive function.
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da Costa RQM, Porto FHDG, Marrocos RP. Dissociation of depression from apathy in traumatic brain injury: a case report. Dement Neuropsychol 2013; 7:312-315. [PMID: 29213857 PMCID: PMC5619205 DOI: 10.1590/s1980-57642013dn70300014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Although not evident clinically, lesions to the prefrontal cortex cause great
social and functional impairment to patients. The anterior cingulate cortex is
intimately involved with motivational behavior and after injury to this area the
onset of an apathetic state can be observed. This paper describes the case of a
patient with traumatic brain injury to the prefrontal lobe presenting with a
depressive syndrome associated with apathetic symptoms. After appropriate
treatment for depression, intense apathy was revealed, an irreversible sequelae
of the traumatic brain injury, constituting the main barrier to the patient's
return of lifestyle and independence.
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Affiliation(s)
- Raquel Quimas Molina da Costa
- MD. Universidade Federal do Estado do Rio de Janeiro (Unirio). Escola de Medicina e Cirurgia (EMC). Hospital Universitário Gaffrée e Guinle (HUGG). Departamento de Medicina Especializada. Disciplina de Psiquiatria. Serviço de Psiquiatria
| | - Fábio Henrique de Gobbi Porto
- MD. Behavioral and Cognitive Neurology Unit, Department of Neurology, and Cognitive Disorders Reference Center (CEREDIC). Hospital das Clínicas of the University of São Paulo, São Paulo, SP, Brazil
| | - Rogério Paysano Marrocos
- MD, MSc. Universidade Federal do Estado do Rio de Janeiro (Unirio). Hospital Universitário Gaffrée e Guinle (HUGG)
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Abstract
PRIMARY OBJECTIVES This study examined the role of expressed emotion (EE) in post-stroke depression (PSD) and the extent to which partner/spouse EE interacted with lesion laterality in PSD. The relationship between (i) lesion location and levels of PSD and (ii) levels of EE and levels of PSD were investigated. The role of perceived EE in PSD was also explored. DESIGN Cross-sectional, between-subjects design. METHODS Measures applied to stroke survivors included Extended Activities of Daily Living Scale (EADL), Post-Stroke Depression Rating Scale (PSDRS) and Level of Expressed Emotion Scale (LEE); spouses/partners completed the LEE. RESULTS The interaction between lesion laterality and levels of partner/spouse EE on PSD was not statistically significant (p = 0.63, F = 0.24, df = 1,56). However, a clear relationship was found between lesion laterality and PSD (p = 0.028). As levels of spouse/partner LEE scores increased, levels of PSD also increased (p = 0.039). Perceived EE scores illustrated a significant interaction between lesion laterality and levels of EE on PSD (p = 0.005, F = 8.591, df = 1,56). CONCLUSION Whilst spouse/partner EE scores showed no interaction with lesion laterality to determine levels of PSD, a significant interaction was found when compared with stroke survivor perceived EE scores. Furthermore, left hemisphere (LHS) stroke survivors reported higher levels of depression than right hemisphere (RHS) stroke survivors. As levels of EE increased, PSD also increased, with LHS being greater than RHS.
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Affiliation(s)
- Naheed Rashid
- Department of Clinical Psychology and Psychological Therapies, The University of Hull, Hull, UK.
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Fleminger S, Oliver DL, Williams WH, Evans J. The neuropsychiatry of depression after brain injury. Neuropsychol Rehabil 2012; 13:65-87. [PMID: 21854328 DOI: 10.1080/09602010244000354] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Biological aspects of depression after brain injury, in particular traumatic brain injury (TBI) and stroke, are reviewed. Symptoms of depression after brain injury are found to be rather non-specific with no good evidence of a clear pattern distinguishing it from depression in those without brain injury. Nevertheless symptoms of disturbances of interest and concentration are particularly prevalent, and guilt is less evident. Variabilitiy of mood is characteristic. The prevalence of depression is similar after both stroke and TBI with the order of 20-40% affected at any point in time in the first year, and about 50% of people experience depression at some stage. There is no good evidence for areas of specific vulnerability in terms of lesion location, and early suggestions of a specific association with injury to the left hemisphere have not been confirmed. Insight appears to be related to depressed mood with studies of TBI indicating that greater insight over time post-injury may be associated with greater depression. We consider that this relationship may be due to depression appearing as people gain more awareness of their disability, but also suggest that changes in mood may result in altered awareness. The risk of suicide after TBI is reviewed. There appears to be about a three to fourfold increased risk of suicide after TBI, although much of this increased risk may be due to pre-injury factors in terms of the characteristics of people who suffer TBI. About 1% of people who have suffered TBI will commit suicide over a 15-year follow-up. Drug management of depression is reviewed. There is little specific evidence to guide the choice of antidepressant medication and most psychiatrists would start with a selective serotonin reuptake inhibitor (SSRI). It is important that the drug management of depression after brain injury is part of a full package of care that can address biological as well as psychosocial factors in management.
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Jun EM, Roh YH, Kim MJ. The effect of music-movement therapy on physical and psychological states of stroke patients. J Clin Nurs 2012; 22:22-31. [PMID: 22978325 DOI: 10.1111/j.1365-2702.2012.04243.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS AND OBJECTIVES This study evaluated the effects of combined music-movement therapy on physical and psychological functioning of hospitalised stroke patients. BACKGROUND Few studies have focused on music-movement therapy's effects on physical and psychological functioning of stroke patients. DESIGN A quasi-experimental design with pre- and post-tests was used. METHODS A convenience sample was used: patients hospitalised for stroke and within two weeks of the onset of stroke were randomised to either an experimental group (received music-movement therapy in their wheelchairs for 60 minutes three times per week for 8 weeks) or control group (received only routine treatment). The effect of music-movement therapy was assessed in terms of physical outcomes (range of motion, muscle strength and activities of daily living) and psychological outcomes (mood states, depression), measured in both groups pre- and post-test. RESULTS The experimental group had significantly increased shoulder flexion and elbow joint flexion in physical function and improved mood state in psychological function, compared with the control group. CONCLUSIONS Early rehabilitation of hospitalised stroke patients within two weeks of the onset of stroke was effective by using music-movement therapy. It improved their mood state and increased shoulder flexion and elbow joint flexion. RELEVANCE TO CLINICAL PRACTICE The findings of this study suggest that rehabilitation for stroke patients should begin as early as possible, even during their hospitalisation. Nursing practice should incorporate the concept of combining music and movements to improve stroke patients' physical and psychological states starting from the acute phase.
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Affiliation(s)
- Eun-Mi Jun
- Department of Nursing Science, Dong-eui University, Busan, Korea.
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Abstract
OBJECTIVE Stroke often produces marked physical and cognitive impairments leading to functional dependence, caregiver burden, and poor quality of life. We examined the course of disability during a 1-year follow-up period after stroke among patients who were administered antidepressants for 3 months compared to patients given placebo for 3 months. METHODS A total of 83 patients entered a double-blind randomized study of the efficacy of antidepressants to treat depressive disorders and reduce disability after stroke. Patients were assigned to either fluoxetine (N = 32), nortriptyline (N = 22) or placebo (N = 29). Psychiatric assessment included administration of the Present State Examination modified to identify DSM-IV symptoms of depression. The severity of depression was measured using the 17-item Hamilton Depression Rating Scale. The modified Rankin Scale was used to evaluate the disability of patients at initial evaluation and at quarterly follow-up visits for 1 year. Impairment in activities of daily living was assessed by Functional Independence Measure at the same time. RESULTS During the 1-year follow-up period, and after adjusting for critical confounders including age, intensity of rehabilitation therapy, baseline stroke severity, and baseline Hamilton Depression Rating Scale, patients who received fluoxetine or nortriptyline had significantly greater improvement in modified Rankin Scale scores compared to patients who received placebo (t [156] = -3.17, p = 0.002). CONCLUSIONS Patients treated with antidepressants had better recovery from disability by 1-year post stroke (i.e., 9 months after antidepressants were stopped) than patients who did not receive antidepressant therapy. This effect was independent of depression suggesting that antidepressants may facilitate the neural mechanisms of recovery in patients with stroke.
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Schönberger M, Ponsford J, Reutens D, Beare R, Clarke D, O'Sullivan R. The relationship between mood disorders and MRI findings following traumatic brain injury. Brain Inj 2011; 25:543-50. [PMID: 21534732 DOI: 10.3109/02699052.2011.565013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND High rates of depression have been reported in individuals with traumatic brain injury (TBI). The purpose of the current study was to investigate the relationship between structural MRI findings and the development of novel cases of post-injury depression in this population METHODS The study has a cross-sectional design. Assessments were conducted on average 2.2 years post-injury. Participants were 54 individuals (76% male, mean age 35 years, median PTA duration 16 days) who had sustained a TBI. Depression was assessed with the Structured Clinical Interview for DSM-IV (SCID-IV). Structural MRI scans were performed with a 1.5 Tesla machine. RESULTS The presence of lesions in the frontal, temporal, parietal and the sublobar regions was not related to depression. However, an imbalance of left vs right frontal and parietal viable brain volumes was related to the development of depression. DISCUSSION These findings are in support of Heller's model of emotion processing, but should be replicated using larger samples. Potential clinical implications are discussed in the manuscript.
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Affiliation(s)
- Michael Schönberger
- Department of Rehabilitation Psychology, Institute of Psychology, University of Freiburg, Germany.
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Microstructural alteration of the anterior cingulum is associated with apathy in Alzheimer disease. Am J Geriatr Psychiatry 2011; 19:644-53. [PMID: 21709610 DOI: 10.1097/jgp.0b013e31820dcc73] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To identify regional alterations of white matter integrity associated with apathy in Alzheimer disease (AD). DESIGN Cross-sectional study. SETTING University Dementia Clinic. PARTICIPANTS Fifty-one very mild or mild probable AD subjects. INTERVENTION Volumetric magnetic resonance imaging with diffusion tensor imaging. MEASUREMENTS Volume of interest analyses were performed to compare regional fractional anisotropy (FA) between apathy and apathy-free group, and to test linear relationship between regional FA and apathy severity. Apathy was assessed by the Neuropsychiatric Inventory. RESULTS Apathy group showed significantly lower FA values than apathy-free group in the left anterior cingulum (A-C), regardless of concomitant depression and psychotropic medications. Left A-C FA values also had significant linear relationship with apathy-composite scores as a measure of apathy severity, even after controlling gray matter density of the ipsilateral anterior cingulate cortex. CONCLUSIONS Our findings support that communication failure between the anterior cingulate cortex and other brain structures via the A-C contributes to the development and aggravation of apathy in AD, additionally supporting the general notion of disconnection syndrome for clinical manifestation of AD.
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Paradiso S, Anderson BM, Boles Ponto LL, Tranel D, Robinson RG. Altered neural activity and emotions following right middle cerebral artery stroke. J Stroke Cerebrovasc Dis 2011; 20:94-104. [PMID: 20656512 PMCID: PMC3014997 DOI: 10.1016/j.jstrokecerebrovasdis.2009.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Revised: 11/11/2009] [Accepted: 11/16/2009] [Indexed: 10/19/2022] Open
Abstract
Stroke of the right MCA is common. Such strokes often have consequences for emotional experience, but these can be subtle. In such cases diagnosis is difficult because emotional awareness (limiting reporting of emotional changes) may be affected. The present study sought to clarify the mechanisms of altered emotion experience after right MCA stroke. It was predicted that after right MCA stroke the anterior cingulate cortex (ACC), a brain region concerned with emotional awareness, would show reduced neural activity. Brain activity during presentation of emotional stimuli was measured in 6 patients with stable stroke, and in 12 age- and sex-matched nonlesion comparisons using positron emission tomography and the [(15)O]H(2)O autoradiographic method. MCA stroke was associated with weaker pleasant experience and decreased activity ipsilaterally in the ACC. Other regions involved in emotional processing including thalamus, dorsal and medial prefrontal cortex showed reduced activity ipsilaterally. Dorsal and medial prefrontal cortex, association visual cortex and cerebellum showed reduced activity contralaterally. Experience from unpleasant stimuli was unaltered and was associated with decreased activity only in the left midbrain. Right MCA stroke may reduce experience of pleasant emotions by altering brain activity in limbic and paralimbic regions distant from the area of direct damage, in addition to changes due to direct tissue damage to insula and basal ganglia. The knowledge acquired in this study begins to explain the mechanisms underlying emotional changes following right MCA stroke. Recognizing these changes may improve diagnoses, management and rehabilitation of right MCA stroke victims.
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Affiliation(s)
- Sergio Paradiso
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa 52242, USA.
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Tang WK, Lu JY, Chen YK, Chu WCW, Mok V, Ungvari GS, Wong KS. Association of frontal subcortical circuits infarcts in poststroke depression: a magnetic resonance imaging study of 591 Chinese patients with ischemic stroke. J Geriatr Psychiatry Neurol 2011; 24:44-9. [PMID: 21196531 DOI: 10.1177/0891988710392375] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Despite extensive research into poststroke depression (PSD), the role played by lesion location in the pathogenesis of PSD remains uncertain. The aim of this study was to estimate the magnetic resonance imaging (MRI) correlates of PSD in Chinese patients with first or recurrent stroke. A total of 591 patients with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong were recruited. A psychiatrist assessed all the patients 3 months after the stroke. The psychiatrist used the Structured Clinical Interview for Diagnostic and Statistical Manual, fourth edition (DSM-IV) to confirm whether the patients met the criteria of a depressive disorder. In addition, a host of demographic, clinical, and radiological variables were examined. A tota; of 475 and 116 patients had first and recurrent strokes, respectively. In all, 75 (12.7%) patients received a diagnosis of PSD. In univariate analysis of the MRI findings, the presence of infarcts in the frontal subcortical circuits ([FSC], 66.7% vs 53.3%) was significantly associated with PSD (P = .03) compared to the patients without PSD. The FSC infarct-PSD association remained significant (odds ratio = 2.6) in subsequent logistic regression analysis after adjusting for gender, history of depression, neurological impairment, level of social support, and major life events. In conclusion, FSC infarcts are independent predictors of PSD. Further work is needed to clarify whether these infarcts have an impact on the clinical presentation, treatment responses, and prognosis of PSD.
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Affiliation(s)
- Wai Kwong Tang
- Department of Psychiatry, Chinese University of Hong Kong, Hong Kong SAR, China.
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A morphometric examination of neuronal and glial cell pathology in the orbitofrontal cortex in late-life depression. Int Psychogeriatr 2011; 23:132-40. [PMID: 20561380 DOI: 10.1017/s1041610210000700] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The orbitofrontal cortex has been implicated as a key component in depression by several imaging studies. This study aims to examine morphometrically glial cell and neuronal density and neuronal volume in the orbitofrontal cortex of late-life major depression patients. METHODS Post mortem tissue from 13 patients with major depression and 11 matched controls was obtained and analyzed using the optical disector and nucleator methods. RESULTS No changes were found in glial cell, pyramidal or non-pyramidal neuron density, or in non-pyramidal and pyramidal neuron volume in the orbitofrontal cortex. CONCLUSIONS Based on previous findings, this study suggests variability in morphological changes within the orbitofrontal cortex, as well as the prefrontal cortex as a whole.
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Abstract
Stroke is a leading cause of death and a serious long-term disability in this country. Much of the research on stroke rehabilitation has focused on physical/functional recovery as the predominant measure of outcome. There is a gap in knowledge of social issues and integration into societal, family, and community roles after stroke. A descriptive, correlational survey design was used to examine the relationships of functional status, depression, and overall stroke recovery to social integration in a convenience sample of ischemic stroke survivors. The survey response rate was 21.4%. Results showed that functional status, overall stroke recovery, and depression are highly significant predictors of social integration, explaining 62% of the variance (adjusted R2). Comorbid depression was negatively (-.74) and significantly (.01, two-tailed) correlated to social integration, such that higher levels of depression are associated with lower levels of social integration. Finally, employment status after stroke dropped from 48% to 4.2%, and poststroke employment status was correlated to social integration (significance = .03). Care for patients with chronic conditions like stroke should address all domains of the individual-physical, psychosocial, and environmental. Factors including depression and perceptions of overall stroke recovery are significant and should be addressed in the rehabilitation process to better promote social integration. Social integration is an important and understudied aspect of stroke recovery that warrants further research.
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Cumming TB, Churilov L, Skoog I, Blomstrand C, Linden T. Little evidence for different phenomenology in poststroke depression. Acta Psychiatr Scand 2010; 121:424-30. [PMID: 20384602 DOI: 10.1111/j.1600-0447.2010.01558.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE It remains unclear whether mood depressive disorders after stroke have a distinct phenomenology. We evaluated the symptom profile of poststroke depression (PSD) and assessed whether somatic symptoms were reported disproportionately by stroke patients. METHOD The sample was 149 stroke patients at 18 months poststroke and 745 age- and sex-matched general population controls. A comprehensive psychiatric interview was undertaken and depression was diagnosed according to DSM-III-R criteria. RESULTS Depressed controls reported more 'inability to feel' (P = 0.002) and 'disturbed sleep' (P = 0.008) than depressed stroke patients. Factor analysis of the 10 depressive symptoms identified two main factors, which appeared to represent somatic and psychological symptoms. There was no difference in scores on these two factors between stroke patients and controls. CONCLUSION Phenomenology of depression at 18 months poststroke is broadly similar but not the same as that described by controls. Somatic symptoms of depression were not over-reported by stroke patients.
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Affiliation(s)
- T B Cumming
- National Stroke Research Institute, Melbourne, Vic., Australia
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Abstract
OBJECTIVE To review the world's (English-language) publications related to depression following stroke. METHOD The databases from MEDLINE and PubMed were reviewed for articles related to poststroke depression (PSD), depression and cerebral vascular accident, depression and cerebral vascular disease, and depression and cerebral infarction. RESULTS Most studies examined prevalence rates of depression and the clinical correlates of depression. Based on pooled data, the overall prevalence of major depression was 21.7% and minor depression was 19.5%. The strongest single correlate of depression was severity of impairment in activities of daily living. However, the existence of depression at baseline was found to be associated with greater impairment at follow-up, ranging from 6 weeks to 2 years in 83% of studies. Further, depression following acute stroke was also associated with greater cognitive impairment and increased mortality. PSD has been shown in 6 double-blind controlled studies to be effectively treated with antidepressants, and 1 study has recently shown that PSD can be effectively prevented. CONCLUSIONS During the past 20 years, significant progress has been made in the identification and treatment of depression following stroke. In the future, antidepressant treatment will likely play an increasing role in the management of patients with acute stroke. Further research is needed to identify the mechanisms of depression and why antidepressants lead to improved physical and cognitive recovery and decreased mortality.
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Nery FG, Stanley JA, Chen HH, Hatch JP, Nicoletti MA, Monkul ES, Matsuo K, Caetano SC, Peluso MA, Najt P, Soares JC. Normal metabolite levels in the left dorsolateral prefrontal cortex of unmedicated major depressive disorder patients: a single voxel (1)H spectroscopy study. Psychiatry Res 2009; 174:177-83. [PMID: 19910168 DOI: 10.1016/j.pscychresns.2009.05.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2007] [Revised: 05/06/2009] [Accepted: 05/15/2009] [Indexed: 02/02/2023]
Abstract
Few proton magnetic resonance spectroscopy ((1)H spectroscopy) studies have investigated the dorsolateral prefrontal cortex (DLPFC), a key region in the pathophysiology of major depressive disorder (MDD). We used (1)H spectroscopy to verify whether MDD patients differ from healthy controls (HC) in metabolite levels in this brain area. Thirty-seven unmedicated DSM-IV MDD patients were compared with 40 HC. Subjects underwent a short echo-time (1)H spectroscopy examination at 1.5 T, with an 8-cm(3) single voxel placed in the left DLPFC. Reliable absolute metabolite levels of N-acetyl aspartate (NAA), phosphocreatine plus creatine (PCr+Cr), choline-containing compounds (GPC+PC), myo-inositol, glutamate plus glutamine (Glu+Gln), and glutamate were obtained using the unsuppressed water signal as an internal reference. Metabolite levels in the left DLPFC did not statistically differ between MDD patients and HC. We found an interaction between gender and diagnosis on PCr+Cr levels. Male MDD patients presented lower levels of PCr+Cr than male HC, and female MDD patients presented higher levels of PCr+Cr than female HC. Moreover, length of illness was inversely correlated with NAA levels. These findings suggest that there is not an effect of diagnosis on the left DLPFC neurochemistry. Possible effects of gender on PCr+Cr levels of MDD patients need to be further investigated.
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Affiliation(s)
- Fabiano G Nery
- Department of Psychiatry, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Santos M, Kövari E, Hof PR, Gold G, Bouras C, Giannakopoulos P. The impact of vascular burden on late-life depression. ACTA ACUST UNITED AC 2009; 62:19-32. [PMID: 19744522 DOI: 10.1016/j.brainresrev.2009.08.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2008] [Revised: 08/19/2009] [Accepted: 08/27/2009] [Indexed: 02/07/2023]
Abstract
Small vessel pathology and microvascular lesions are no longer considered as minor players in the fields of cognitive impairment and mood regulation. Although frequently found in cognitively intact elders, both neuroimaging and neuropathological data revealed the negative impact on cognitive performances of their presence within neocortical association areas, thalamus and basal ganglia. Unlike cognition, the relationship between these lesions and mood dysregulation is still a matter of intense debate. Early studies focusing on the role of macroinfarct location in the occurrence of post-stroke depression (PSD) led to conflicting data. Later on, the concept of vascular depression proposed a deleterious effect of subcortical lacunes and deep white matter demyelination on mood regulation in elders who experienced the first depressive episode. More recently, the chronic accumulation of lacunes in thalamus, basal ganglia and deep white matter has been considered as a strong correlate of PSD. We provide here a critical overview of neuroimaging and neuropathological sets of evidence regarding the affective repercussions of vascular burden in the aging brain and discuss their conceptual and methodological limitations. Based on these observations, we propose that the accumulation of small vascular and microvascular lesions constitutes a common neuropathological platform for both cognitive decline and depressive episodes in old age.
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Affiliation(s)
- Micaela Santos
- Department of Psychiatry, University Hospitals and Faculty of Medicine of Geneva, Belle-Idée, Switzerland
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Santos M, Gold G, Kövari E, Herrmann FR, Bozikas VP, Bouras C, Giannakopoulos P. Differential impact of lacunes and microvascular lesions on poststroke depression. Stroke 2009; 40:3557-62. [PMID: 19696424 DOI: 10.1161/strokeaha.109.548545] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE Previous studies have postulated that poststroke depression (PSD) might be related to cumulative vascular brain pathology rather than to the location and severity of a single macroinfarct. We performed a detailed analysis of all types of microvascular lesions and lacunes in 41 prospectively documented and consecutively autopsied stroke cases. METHODS Only cases with first-onset depression <2 years after stroke were considered as PSD in the present series. Diagnosis of depression was established prospectively using DSM-IV criteria for major depression. Neuropathological evaluation included bilateral semiquantitative assessment of microvascular ischemic pathology and lacunes; statistical analysis included Fisher exact test, Mann-Whitney U test, and regression models. RESULTS Macroinfarct site was not related to the occurrence of PSD for any of the locations studied. Thalamic and basal ganglia lacunes occurred significantly more often in PSD cases. Higher lacune scores in basal ganglia, thalamus, and deep white matter were associated with an increased PSD risk. In contrast, microinfarct and diffuse or periventricular demyelination scores were not increased in PSD. The combined lacune score (thalamic plus basal ganglia plus deep white matter) explained 25% of the variability of PSD occurrence. CONCLUSIONS The cumulative vascular burden resulting from chronic accumulation of lacunar infarcts within the thalamus, basal ganglia, and deep white matter may be more important than single infarcts in the prediction of PSD.
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Affiliation(s)
- Micaela Santos
- Department of Psychiatry, University Hospitals and Faculty of Medicine of Geneva, Belle-Idée, Geneva, Switzerland
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van Rooijen MA, Gingher MC, Gordon CY, Mann WC. Depression in Post-CVA Patients Residing in Long Term Care Facilities. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2009. [DOI: 10.1080/j148v09n02_02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Friedland J, McColl M. Social Support for Stroke Survivors:. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2009. [DOI: 10.1080/j148v07n03_05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lindberg M. Quality of Life after Subarachnoid Haemorrhage, and its Relationship to Impairments, Disabilities and Depression. Scand J Occup Ther 2009. [DOI: 10.3109/11038129509106802] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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