Effects of Fluoxetine on Outcomes at 12 Months After Acute Stroke: Results From EFFECTS, a Randomized Controlled Trial

Treatment of Stroke at a Delayed Timepoint with a Repurposed Drug Targeting Sigma 1 Receptors

Sigma 1 receptors are intracellular chaperone proteins that have been explored as a subacute treatment to enhance post-stroke recovery. We recently identified the antitussive oxeladin as a selective sigma 1 receptor agonist with the ability to stimulate the release of brain-derived neurotrophic factor from neurons in vitro. In this study, we hypothesized that oral oxeladin citrate would stimulate BDNF secretion and improve stroke outcomes when administered to male rats starting 48 h after transient middle cerebral artery occlusion. Oxeladin did not alter blood clotting and crossed the blood brain barrier within 30 min of oral administration. Rats underwent 90 min of transient middle cerebral artery occlusion. Forty-eight hours later rats began receiving daily oxeladin (135 mg/kg) for 11 days. Oxeladin significantly improved neurological function on days 3, 7, and 14 following MCAO. Infarct size was not altered by a single dose, but the final extent of infarct after 14 days was decreased. However, there was no significant reduction in astrogliosis or microgliosis compared to vehicle-treated control rats. In agreement with in vitro studies, oxeladin increased the amount of mature BDNF in the cerebral cortex 2, 6, and 24 h after single oral dose. However, the increase in BDNF did not result in increases in cellular proliferation in the subventricular zone or dentate gyrus when compared to vehicle-treated controls. These results suggest that oxeladin may reduce the extent of infarct expansion in the subacute phase of stroke, although this action does not appear to involve a reduction in inflammation or increased cell proliferation.

Stroke, depression, and self-harm in later life

PURPOSE OF THE REVIEW

To examine recently published results of randomized placebo-controlled trials investigating the clinical effects of selective serotonin reuptake inhibitors on the prevalence of clinically significant symptoms of depression and suicidal ideation after an acute stroke.

RECENT FINDINGS

The prevalence of poststroke depression varies markedly according to the approach used to define depression, with recently published data suggesting that about one in every three stroke survivors will experience clinically significant symptoms of depression over a period of 12 months. The proportion of stroke survivors with clinically significant symptoms of depression decreases progressively with time, but in 30% of them symptoms persist or recur over 12 months. Routine daily treatment with 20 mg of fluoxetine for 6 months does not affect the prevalence of depression in this population, nor is it effective at treating or preventing poststroke depressive symptoms. Treatment discontinuation, gastrointestinal adverse effects, seizures and bone fractures are more frequent among stroke survivors treated with antidepressants than placebo. Moreover, current data show that thoughts about death or suicide are more frequent among adults who had a stroke than the general population, although recurring suicidal thoughts are uncommon. Routine daily treatment with 20 mg of fluoxetine for 6 months does not change the proportion of people who disclose suicidal thoughts over a period of 12 months after an acute stroke.

SUMMARY

Current evidence raises concerns about the efficacy and safety of antidepressants for the management and prevention of poststroke clinically significant symptoms of depression. It is unclear if these findings can be generalized to people with severe strokes or to stroke survivors with moderate to severe major depressive episodes.

Essential information for neurorecovery clinical trial design: trajectory of global disability in first 90 days post-stroke in patients discharged to acute rehabilitation facilities

BACKGROUND

Many stroke recovery interventions are most beneficial when started 2-14d post-stroke, a time when patients become eligible for inpatient rehabilitation facilities (IRF) and neuroplasticity is often at its peak. Clinical trials focused on recovery need to expand the time from this plasticity to later outcome timepoints.

METHODS

The disability course of patients with acute ischemic stroke (AIS) and intracranial hemorrhage (ICH) enrolled in Field Administration of Stroke Therapy Magnesium (FAST-MAG) Trial with moderate-severe disability (modified Rankin Scale [mRS] 3-5) on post-stroke day4 who were discharged to IRF 2-14d post-stroke were analyzed.

RESULTS

Among 1422 patients, 446 (31.4%) were discharged to IRFs, including 23.6% within 2-14d and 7.8% beyond 14d. Patients with mRS 3-5 on day4 discharged to IRFs between 2-14d accounted for 21.7% (226/1041) of AIS patients and 28.9% (110/381) of ICH patients, (p < 0.001). Among these AIS patients, age was 69.8 (± 12.7), initial NIHSS median 8 (IQR 4-12), and day4 mRS = 3 in 16.4%, mRS = 4 in 50.0%, and mRS = 5 in 33.6%. Among these ICH patients, age was 62.4 (± 11.7), initial NIHSS median 9 (IQR 5-13), day 4 mRS = 3 in 9.4%, mRS = 4 in 45.3%, and mRS = 5 in 45.3% (p < 0.01 for AIS vs ICH). Between day4 to day90, mRS improved ≥ 1 levels in 72.6% of AIS patients vs 77.3% of ICH patients, p = 0.3. For AIS, mRS improved from mean 4.17 (± 0.7) to 2.84 (± 1.5); for ICH, mRS improved from mean 4.35 (± 0.7) to 2.75 (± 1.3). Patients discharged to IRF beyond day14 had less improvement on day90 mRS compared with patients discharged between 2-14d.

CONCLUSIONS

In this acute stroke cohort, nearly 1 in 4 patients with moderate-severe disability on post-stroke day4 were transferred to IRF within 2-14d post-stroke. ICH patients had nominally greater mean improvement on mRS day90 than AIS patients. This course delineation provides a roadmap for future rehabilitation intervention studies.

The efficacy and safety of fluoxetine versus placebo for stroke recovery: a meta-analysis of randomized controlled trials

BACKGROUND

Fluoxetine is one of the selective serotonin reuptake inhibitors that can improve motor and function recovery after a stroke. Several randomized controlled trials (RCTs) have investigated the efficacy and safety of fluoxetine compared to placebo in post-stroke recovery. However, the results are still controversial.

AIM

This meta-analysis aimed to provide an updated analysis of the efficacy and safety of fluoxetine versus placebo in post-stroke recovery.

METHOD

RCTs were searched from electronic databases of PubMed, Embase, Clinical Trials, and the Cochrane Central Register of Controlled Trials from inception until July 2022. Google Scholar and the reference lists of included studies were screened to identify additional studies. Outcomes were analyzed using risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI).

RESULTS

Fourteen RCTs (6584 patients) were included. The fluoxetine group showed a significantly higher Fugl-Meyer motor scale (FMMS) score than the placebo group (MD 15.93, 95%CI 9.76-22.7, P < 0.01). No significant differences were observed in the modified Rankin Scale (mRS) (mRS ≤ 2, RR 1.00, 95%CI 0.88-1.15, P = 0.95), the Barthel index (MD 12.11, 95%CI - 0.71 to 24.92, P = 0.06), and the National Institutes of Health Stroke Scale scores (MD - 0.19, 95%CI - 0.43 to 0.04, P = 0.1) between the two groups. The fluoxetine group showed a lower rate of depression or anxiety than the placebo group (RR 0.67, 95% CI 0.49-0.92, P < 0.05). There were no significant differences between the groups regarding gastrointestinal adverse reactions (P > 0.05), drowsiness (P > 0.05) or insomnia (P > 0.05).

CONCLUSION

Fluoxetine improved FMMS and reduced anxiety and depression. More well-designed and large sample-size RCTs are required to further analyze the efficacy of fluoxetine in post-stroke recovery.

Platelet depletion does not alter long-term functional outcome after cerebral ischaemia in mice

Platelets are key mediators of thrombus formation and inflammation during the acute phase of ischaemic stroke. Particularly, the platelet glycoprotein (GP) receptors GPIbα and GPVI have been shown to mediate platelet adhesion and activation in the ischaemic brain. GPIbα and GPVI blockade could reduce infarct volumes and improve functional outcome in mouse models of acute ischaemic stroke, without concomitantly increasing intracerebral haemorrhage. However, the functional role of platelets during long-term stroke recovery has not been elucidated so far.

Thus, we here examined the impact of platelet depletion on post-stroke recovery after transient middle cerebral artery occlusion (tMCAO) in adult male mice. Platelet depleting antibodies or isotype control were applied from day 3–28 after tMCAO in mice matched for infarct size. Long-term functional recovery was assessed over the course of 28 days by behavioural testing encompassing motor and sensorimotorical functions, as well as anxiety-like or spontaneous behaviour. Whole brain flow cytometry and light sheet fluorescent microscopy were used to identify resident and infiltrated immune cell types, and to determine the effects of platelet depletion on the cerebral vascular architecture, respectively.

We found that delayed platelet depletion does not improve long-term functional outcome in the tMCAO stroke model. Immune cell abundance, the extent of thrombosis and the organisation of the cerebral vasculature were also comparable between platelet-depleted and control mice. Our study demonstrates that, despite their critical role in the acute stroke setting, platelets appear to contribute only marginally to tissue reorganisation and functional recovery at later stroke stages.

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Stable and safe global platelet depletion can be achieved for a prolonged period.

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Platelets only play a minor role in neurological recovery during the chronic phase.

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Platelet depletion after infarct maturation does not alter inflammatory response.

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Cerebral architecture after stroke is not influenced by delayed platelet depletion.

Safety and Efficacy of SSRIs in Improving Poststroke Recovery: A Systematic Review and Meta-Analysis

Background

Several studies investigated the role of selective serotonin reuptake inhibitors (SSRIs) in improving poststroke recovery; thus, we have decided to conduct this systematic review and meta‐analysis to investigate the efficacy and safety of SSRIs in poststroke recovery.

Methods and Results

In this meta‐analysis we searched the following databases: PubMed, Cochrane, Scopus, and Google Scholar. The studies were included if they were placebo‐controlled trials in design and reported SSRIs’ effects on poststroke depression, anxiety, disability, dependence, motor abilities, and cognitive functions. The quality of the included studies was assessed using the revised Cochrane risk‐of‐bias tool for randomized trials. The search yielded 44 articles that included 16 164 patients, and about half of the participants were treated with SSRIs. Our results showed that SSRIs had a significant effect on preventing depression (weighted mean difference [WMD], −7.05 [95% CI, −11.78 to −2.31]), treating depression according to the Hamilton Rating Scale for Depression score (WMD, −1.45 [95% CI, −2.77 to −0.14]), anxiety (relative risk, 0.23 [95% CI, 0.09–0.61]), dependence (WMD, 8.86 [95% CI, 1.23–16.48]), motor abilities according to National Institutes of Health Stroke Scale score (WMD, −0.79 [95% CI, −1.42 to −0.15]), and cognitive functions (WMD, 1.00 [95% CI, 0.12–1.89]). On the other hand, no significant effect of SSRIs on disability was observed. Additionally, we found that treating with SSRIs increased the risk of seizures (relative risk, 1.44 [95% CI, 1.13–1.83]), whereas there was no difference in the incidence of gastrointestinal symptoms or bleeding between SSRIs and a placebo.

Conclusions

Our study showed that SSRIs are effective in preventing and treating depression, and improving anxiety, motor function, cognitive function, and dependence in patients after stroke. These benefits were only reproducible with the citalopram subanalysis but not fluoxetine. Further well‐conducted placebo‐controlled trials are needed to investigate the safety and efficacy of citalopram among patients after stroke.

Registration

URL: www.crd.york.ac.uk/prospero/; Unique identifier: CRD42021285766.

The glymphatic system and subarachnoid hemorrhage: disruption and recovery

The glymphatic system, or glial-lymphatic system, is a waste clearance system composed of perivascular channels formed by astrocytes that mediate the clearance of proteins and metabolites from the brain. These channels facilitate the movement of cerebrospinal fluid throughout brain parenchyma and are critical for homeostasis. Disruption of the glymphatic system leads to an accumulation of these waste products as well as increased interstitial fluid in the brain. These phenomena are also seen during and after subarachnoid hemorrhages (SAH), contributing to the brain damage seen after rupture of a major blood vessel. Herein this review provides an overview of the glymphatic system, its disruption during SAH, and its function in recovery following SAH. The review also outlines drugs which target the glymphatic system and may have therapeutic applications following SAH.

Effıcacy of cıtalopram on stroke recurrence: A randomızed clınıcal trıal

Post-stroke depression is one of the main causes of cerebrovascular and cardiovascular diseases. The aim of the present study was to investigate the efficacy of citalopram on stroke recurrence. A 52-week, randomized, double-blind, studyinvolved 440 ischemic stroke patients with depression. Patients with depression who met depression criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and V) and Hamilton Depression Rating Scale ≥ 8 (HAM-DRS) were dichotomized into patients receiving citalopram (225 patients), titrated according to clinical response, and patients with placebo (215 patients) for 52 weeks. The primary outcome measure was stroke recurrence and the secondary outcome measures were cardiovascular events and mortality. Stroke recurrence (66% vs 34%; P = 0.001) and cardiovascular events (76% vs. 24%; P = o.oo1) were significantly higher in the placebo group compared to those treated with citalopram. Multivariable analysis showed that hypertension, atrial fibrillation, and large-artery disease were significantly associated with stroke recurrence. Executive processing disorder was more associated with stroke recurrence than other neuropsychological disorders (OR, 1.74; CI95%, 1.04-2.89; P = 0.035). Survival analysis showed that treatment for depression interacted with time to reduce stroke recurrence by nearly half (39% vs. 61%; P = 0.05). The current study supports the importance of depression treatment in protecting the patients from recurrent strokes. This result warrants further studies to demonstrate the efficacy of depression treatment on stroke recurrence.

Sleep and Stroke: Opening Our Eyes to Current Knowledge of a Key Relationship

PURPOSE OF REVIEW

To elucidate the interconnection between sleep and stroke.

RECENT FINDINGS

Growing data support a bidirectional relationship between stroke and sleep. In particular, there is strong evidence that sleep-disordered breathing plays a pivotal role as risk factor and concur to worsening functional outcome. Conversely, for others sleep disorders (e.g., insomnia, restless legs syndrome, periodic limb movements of sleep, REM sleep behavior disorder), the evidence is weak. Moreover, sleep disturbances are highly prevalent also in chronic stroke and concur to worsening quality of life of patients. Promising novel technologies will probably allow, in a near future, to guarantee a screening of commonest sleep disturbances in a larger proportion of patients with stroke. Sleep assessment and management should enter in the routinary evaluation of stroke patients, of both acute and chronic phase. Future research should focus on the efficacy of specific sleep intervention as a therapeutic option for stroke patients.