Lacunar stroke, deep white matter disease and depression: a meta-analysis

Depression following small vessel stroke is common and more prevalent in women

OBJECTIVES

We sought to examine the frequency of depression after small vessel-type stroke (SVS) and associated risk factors.

MATERIALS AND METHODS

We conducted a retrospective analysis of a prospective cohort of patients enrolled in the American Stroke Association-Bugher SVS Study, which included 200 participants within 2-years of SVS and 79 controls without a history of stroke from 2007 to 2012 at four sites. The primary outcome was PHQ-8, with scores ≥10 consistent with post-stroke depression (PSD). A logistic regression adjusted for age, race, sex, history of diabetes and Short-Form Montreal Cognitive Assessment score (SF-MoCA) was used to compare the risk of having depression after SVS compared to controls. Another logistic regression, adjusted for age, sex, race, level of education, SF-MoCA, white matter disease (WMD) burden, stroke severity (NIHSS), time between stroke and depression screen, history of diabetes, and history of hypertension was used to identify factors independently associated with depression in participants with SVS.

RESULTS

The cohort included 161 participants with SVS (39 excluded due to missing data) and 79 controls. The mean interval between stroke and depression screening was 74 days. Among participants with SVS, 31.7% (n = 51) had PSD compared to 6.3% (n = 5) of controls (RR = 5.44, 95% CI = 2.21-13.38, p = 0.0002). The only two variables independently associated with PSD in participants with SVS were female sex (RR = 1.84, 95% CI = 1.09-3.09, p = 0.020) and diabetes (RR 1.69, 95% CI 1.03-2.79).

CONCLUSIONS

After adjusting for several demographic and clinical variables, having a SVS was associated with an approximate 5-fold increased risk of depression and was more frequent in women and in those with diabetes. The extent of WMD was not independently associated with PSD, suggesting that small vessel disease in the setting of an overt SVS may not account for the increased prevalence of depression.

Clinical Phenotypes Associated With Cerebral Small Vessel Disease: An Overview of Systematic Reviews

BACKGROUND AND OBJECTIVES

Cerebral small vessel disease (cSVD) causes lacunar and hemorrhagic stroke and is an important contributor to vascular cognitive impairment. Other potential physical and psychological consequences of cSVD have been described across various body systems. Descriptions of cSVD are available in journals specific to those individual body systems, but a comprehensive assessment of clinical manifestations across this disparate literature is lacking. We conducted an overview of systematic reviews describing clinical cSVD phenotypes.

METHODS

We searched multidisciplinary databases from inception to December 2023. We included reviews describing concurrent clinical phenotypes in individuals with neuroimaging evidence of cSVD, defined using the STandards for ReportIng Vascular changes on nEuroimaging criteria. We broadly classified phenotypes into cognitive, mood and neuropsychiatric, respiratory, cardiovascular, renal-urinary, peripheral nervous system, locomotor, and gastrointestinal. We included both studies assessing multiple cSVD features and studies examining individual cSVD markers. We extracted risk factor-adjusted effect estimates, where possible, and assessed methodologic quality using the Assessment of Multiple Systematic Reviews-2 tool.

RESULTS

After screening 6,156 publications, we included 24 systematic reviews reporting on 685 original studies and 1,135,943 participants. Cognitive and neuropsychiatric phenotypes were examined most often, particularly in relation to white matter hyperintensities (range of risk ratios [RRs] for cognitive phenotypes 1.21-1.49, range of 95% CI 1.01-1.84; for neuropsychiatric, RR 1.02-5.71, 95% CI 0.96-19.69). Two reviews focused solely on perivascular spaces. No reviews assessed lacunes or small subcortical infarcts separately from other cSVD features. Reviews on peripheral nervous system, urinary, or gastrointestinal phenotypes were lacking. Fourteen reviews had high methodologic quality, 5 had moderate quality, and 5 had low quality. Heterogeneity in cSVD definitions and phenotypic assessments was substantial.

DISCUSSION

Neuroimaging markers of cSVD are associated with various clinical manifestations, suggesting a multisystem phenotype. However, features classically associated with cSVD, for example, gait, had limited supporting evidence, and for many body systems, there were no available reviews. Similarly, while white matter hyperintensities were relatively well studied, there were limited data on phenotypes associated with other cSVD features. Future studies should characterize the full clinical spectrum of cSVD and explore clinical associations beyond neurocognitive and neuropsychiatric presentations.

Changes in depressive symptoms before and after the first stroke: A longitudinal study from China Family Panel Study (CFPS)

OBJECTIVES

The study sought to examine the impact of longitudinal changes in depressive symptoms in middle-aged adults before and after their first stroke, and the impact of different ages.

METHODS

The study monitored middle-aged patients with a first stroke in the China Family Panel Study (CFPS) survey from 2016 to 2020. This study examined longitudinal changes in depressive symptoms in middle-aged adults and their controls before and after stroke using multilevel models, and also explored factors influencing middle-aged adults at the time of their respective stroke and depressive symptoms using conditional regression models and stepwise regression models, respectively. A chi-square test was used to determine whether long-term changes in depressive symptoms in patients before and after stroke could be attributed to changes in a single depressive symptom.

RESULTS

The study identified 582 first-time stroke patients and 5522 controls from a population of 17,588 participants. Middle-aged populations may have an increased risk of depressive symptoms after a first stroke compared to older populations. First-time stroke victims showed increased severity of depressive symptoms in both the two years before and the two years after stroke when depressive symptoms were assessed. Differences in the presentation of a single depressive symptom were most pronounced in sleep-related symptoms.

CONCLUSIONS

The link between first stroke and changes in the trajectory of increased depressive symptoms is complex and bidirectional. Age is an important factor influencing changes in depressive symptoms, some attention should be paid to the middle-aged population. Special attention should also be paid to sleep-related symptoms in the long-term care of patients.

Hip Osteoarthritis and the Risk of Lacunar Stroke: A Two-Sample Mendelian Randomization Study

Whether hip osteoarthritis (OA) could increase the risk of lacunar stroke (LS) is not well understood. This two-sample Mendelian randomization (MR) study aimed to investigate in depth the effect of genetically predicted hip OA on LS risk. Hip OA-related instrumental variables (IVs) were selected from a genome-wide association study (GWAS) of 393,873 individuals. The summary data of LS were obtained from a GWAS meta-analysis, including 16,030 cases and 248,929 controls. We used the inverse-variance weighted (IVW) as the primary MR analysis method. Moreover, the weighted-median, MR-Egger regression, and the MR pleiotropy residual sum and outlier (MR-PRESSO) test were supplementary methods. The sensitivity analysis was performed using the leave-one-out test. We identified the positive causal relationship between hip OA and the risk of LS (odds ratio [OR] = 1.20, 95% confidence interval [CI]: 1.07, 1.36; p = 0.002 using the IVW method). The weighted median method provided similar results. There was no evidence of directed pleiotropy, and sensitivity analysis results were stable, suggesting the robustness of our study. This study showed a causal effect of hip OA on the risk of LS, and more efforts should be made to explore the potential mechanisms in the future.

Long-term Changes in Depressive Symptoms Before and After Stroke

BACKGROUND AND OBJECTIVES

To determine the trajectory of depressive symptoms several years before and after incident stroke.

METHODS

We analyzed data from 10,797 participants from the English Longitudinal Study of Ageing without a history of stroke at baseline (wave 1). We matched participants with first-ever stroke during the 12-year follow-up (waves 2-7) to stroke-free individuals using propensity scores accounting for age, sex, education, ethnicity, and vascular risk factors. Trajectories of depressive symptoms before and after stroke were analyzed using multilevel models.

RESULTS

Among the 10,797 participants (mean age 64.6 ± 9.9 years, 54.8% women), we identified 425 individuals with incident stroke. At the assessment before stroke, these individuals demonstrated an increase in depressive symptoms when compared with matched controls. There was a further increase in depressive symptoms in stroke survivors after the acute event, which persisted for several years. Symptom-level analyses revealed that differences in depressive symptoms between stroke survivors and stroke-free controls before and after stroke were most pronounced for mood-related and fatigue-related symptoms.

DISCUSSION

Incident stroke is associated with long-term increases in depressive symptoms. A small part of this increase occurs in the years before stroke, perhaps indicating the incipient pathologic process. Particular attention should be paid to depressive symptoms in the long-term care of patients, and especially to fatigue-related symptoms.

Post-stroke Cognition at 1 and 3 Years Is Influenced by the Location of White Matter Hyperintensities in Patients With Lacunar Stroke

Lacunar strokes are a common type of ischemic stroke. They are known to have long-term cognitive deficits, but the influencing factors are still largely unknown. We investigated if the location of the index lacunar stroke or regional WMH and their change at 1 year could predict the cognitive performance at 1 and 3 years post-stroke in lacunar stroke patients. We used lacunar lesion location and WMH-segmented data from 118 patients, mean age 64.9 who had a brain MRI scan soon after presenting with symptoms, of which 88 had a repeated scan 12 months later. Premorbid intelligence (National Adult Reading Test) and current intelligence [Addenbrooke's Cognitive Exam-Revised (ACE-R)] were measured at 1, 12, and 36 months after the stroke. ANCOVA analyses adjusting for baseline cognition/premorbid intelligence, vascular risk factors, age, sex and total baseline WMH volume found that the recent small subcortical infarcts (RSSI) in the internal/external capsule/lentiform nucleus and centrum semiovale did not predict cognitive scores at 12 and 36 months. However, RSSI location moderated voxel-based associations of WMH change from baseline to 1 year with cognitive scores at 1 and 3 years. WMH increase in the external capsule, intersection between the anterior limb of the internal and external capsules, and optical radiation, was associated with worsening of ACE-R scores 1 and 3 years post-stroke after accounting for the location of the index infarct, age and baseline cognition.

Cerebral Small-Vessel Disease and Risk of Incidence of Depression: A Meta-Analysis of Longitudinal Cohort Studies

Background

Results of several longitudinal cohort studies suggested an association between cerebral small‐vessel disease and depression. Therefore, we performed a meta‐analysis to explore whether cerebral small‐vessel disease imparts increased risk for incident depression.

Methods and Results

We searched prospective cohort studies relevant to the relationship between cerebral small‐vessel disease and incident depression published through September 6, 2019, which yielded 16 cohort studies for meta‐analysis based on the relative odds ratio (OR) calculated with fixed‐ and random‐effect models. Baseline white matter hyperintensities (WMHs) (pooled OR, 1.37; 95% CI, 1.14–1.65), enlarged perivascular spaces (pooled OR, 1.33; 95% CI, 1.03–1.71), and cerebral atrophy (pooled OR, 2.83; 95% CI, 1.54–5.23) were significant risk factors for incident depression. Presence of deep WMHs (pooled OR, 1.47; 95% CI, 1.05–2.06) was a stronger predictor of depression than were periventricular WMHs (pooled OR, 1.31; 95% CI, 0.93–1.86). What's more, the pooled OR increased from 1.20 for the second quartile to 1.96 for the fourth quartile, indicating that higher the WMH severity brings greater risk of incident depression (25th–50th: pooled OR, 1.20; 95% CI, 0.68–2.12; 50th–75th; pooled OR, 1.42; 95% CI, 0.81–2.46; 75th–100th: OR, 1.96; 95% CI, 1.06–3.64). These results were stable to subgroup analysis for age, source of participants, follow‐up time, and methods for assessing WMHs and depression.

Conclusions

Cerebral small‐vessel disease features such as WMHs, enlarged perivascular spaces, and cerebral atrophy, especially the severity of WMHs and deep WMHs, are risk factors for incident depression.

White matter microstructural damage and depressive symptoms in patients with mild cognitive impairment and cerebral small vessel disease: the VMCI-Tuscany Study

BACKGROUND AND PURPOSE

Disruption of cortical-subcortical circuits related to small vessel disease (SVD) may predispose to depression in the elderly. We aimed to determine the independent association between white matter (WM) microstructural damage, evaluated with diffusion tensor imaging (DTI), and depressive symptoms in a cohort of elderly subjects with mild cognitive impairment (MCI) and SVD.

METHODS

The vascular mild cognitive impairment (VMCI)-Tuscany Study is an observational multicentric longitudinal study that enrolled patients with MCI and moderate to severe degrees of WM hyperintensities on MRI. Lacunar infarcts, cortical atrophy, medial temporal lobe atrophy, microbleeds, and DTI-derived indices (mean diffusivity, MD and fractional anisotropy, FA) were evaluated on baseline MRI. Geriatric Depression Scale (GDS) (score 0-15) was used to assess depressive symptoms. An extensive neuropsychological battery, Instrumental Activities of Daily Living scale, and the Short Physical Performance Battery were used for cognitive, functional, and motor assessments, respectively.

RESULTS

Seventy-six patients (mean age: 75.1 ± 6.8 years) were included. Univariate analyses showed a significant association between GDS score and both DTI-derived indices (MD: r = 0.307, p = 0.007; FA: r = -0.245; p = 0.033). The association remained significant after adjustment for age, WM hyperintensities severity, global cognitive, functional and motor performances, and antidepressant therapy (MD: r = 0.361, p = 0.002; FA: r = -0.277; p = 0.021).

CONCLUSIONS

These results outline the presence of an association between WM microstructural damage and depressive symptoms in MCI patients with SVD. This relationship does not seem to be mediated by disability, cognitive, and motor impairment, thus supporting the vascular depression hypothesis.

Baseline characteristic of patients presenting with lacunar stroke and cerebral small vessel disease may predict future development of depression

OBJECTIVE

Cerebral small vessel disease (SVD) is associated with late-onset depression and increases the risk for depression after stroke. We aimed to investigate baseline predictors of depression after long-term follow-up in patients with SVD, initially presenting with first-ever lacunar stroke, free of depression and cognitive impairment.

METHODS

A total of 294 patients with SVD were evaluated 3-5 years after the qualifying event. We analyzed baseline demographic data, vascular risk factors, functional status expressed as a score on modified Rankin Scale (mRS), cognitive status, presence of depression, total number of lacunar infarcts and severity of white matter hyperintensities (WMH) on MRI with Age-Related White Matter Changes scale total score (tARWMC) and Fazekas scale periventricular and deep subcortical scores.

RESULTS

On follow-up, depression was registered in 117 (39.8%) SVD patients. At the baseline, patients with depression compared with non-depressed were older (64.4 vs 60.9 years; p = 0.007), had higher mRS score (2.8 ± 0.7 vs 1.5 ± 0.7; p < 0.0001) and had more severe lesions on MRI scales (p < 0.0001 for all parameters). On follow-up, depressed patients more frequently exhibited cognitive decline (75.2% depressed vs 56.5% non-depressed; p = 0.003). No difference was detected in risk factor frequency between groups. Multivariate Cox regression analysis adjusted by age and gender revealed independent predictors of depression: baseline mRS >2 (HR 2.17, 95%CI 1.74-2.72; p < 0.0001) and tARWMC (HR 1.05, 95%CI 1.02-1.09; p = 0.005), and cognitive decline on follow-up (HR 1.80, 95%CI 1.12-2.89; p = 0.015).

CONCLUSIONS

Baseline functional status and severity of WMH and development of cognitive decline predict the occurence of late-onset depression in patients with SVD.

Difference in Motor Fatigue between Patients with Stroke and Patients with Multiple Sclerosis: A Pilot Study

Fatigue is often reported in stroke patients. However, it is still unclear if fatigue in stroke patients is more prominent, more frequent or more "typical" than in patients with multiple sclerosis (MS) and if the pathophysiology differs between these two populations. The purpose of this study was to compare motor fatigue and fatigue-induced changes in kinematic gait parameters between stroke patients, MS patients, and healthy persons. Gait parameters at the beginning and end of a treadmill walking test were assessed in 10 stroke patients, 40 MS patients, and 20 healthy subjects. The recently developed Fatigue index Kliniken Schmieder (FKS) based on change of the movement's attractor and its variability was used to measure motor fatigue. Six stroke patients had a pathological FKS. The FKS (indicating the level of motor fatigue) in stroke patients was similar compared to MS patients. Stroke patients had smaller step length, step height and greater step width, circumduction with the right and left leg, and greater sway compared to the other groups at the beginning and at the end of test. A severe walking impairment in stroke patients does not necessarily cause a pathological FKS indicating motor fatigue. Moreover, the FKS can be used as a measure of motor fatigue in stroke and MS and may also be applicable to other diseases.

Commentary on: Amnestic mild cognitive impairment and incident dementia and Alzheimer's disease in geriatric depression

In this month's “Paper of the Month,” Steffens and colleagues (Steffens et al., 2014) report on the relationship between depression, mild cognitive impairment (MCI) and future risk of progression to dementia. It has long been known that there is a complex relationship between depression and cognitive impairment, with depression common in those with cognitive impairment and dementia, and subsequent cognitive decline frequent in patients with depression (Wallin et al., 2013). This relationship has often been difficult to study, not least because definitions have often been mutually exclusive. For example, many studies of MCI have excluded patients with depression. This is not unreasonable to increase diagnostic certainty and obtain a more “pure” group of those with MCI who are likely to progress to Alzheimer's disease, but of course at the same time limits the ability to determine interactions between MCI and depression. On the other hand, it is known that non-cognitive symptoms, most particularly depression, frequently occur in those with MCI and have been shown to increase the risk of likely future decline.