Latent profile analysis of cognitive decline and depressive symptoms after intracerebral hemorrhage

Outcome Trajectories after Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (ICH) is the most morbid of all stroke types with a high early mortality and significant early disability burden. Traditionally, outcome assessments after ICH have mirrored those of acute ischemic stroke, with 3 months post-ICH being considered a standard time point in most clinical trials, observational studies, and clinical practice. At this time point, the majority of ICH survivors remain with moderate to severe functional disability. However, emerging data suggest that recovery after ICH occurs over a more protracted course and requires longer periods of follow-up, with more than 40% of ICH survivors with initial severe disability improving to partial or complete functional independence over 1 year. Multiple other domains of recovery impact ICH survivors including cognition, mood, and health-related quality of life, all of which remain under studied in ICH. To further complicate the picture, the most important driver of mortality after ICH is early withdrawal of life-sustaining therapies, before initiation of treatment and evaluating effects of prolonged supportive care, influenced by early pessimistic prognostication based on baseline severity factors and prognostication biases. Thus, our understanding of the true natural history of ICH recovery remains limited. This review summarizes the existing literature on outcome trajectories in functional and nonfunctional domains, describes limitations in current prognostication practices, and highlights areas of uncertainty that warrant further research.

Cognitive Outcome after Acute Spontaneous Intracerebral Hemorrhage: Analysis of the iDEF Randomized Trial

INTRODUCTION

The impact of intracerebral hemorrhage (ICH) on cognition and the determinants of cognitive recovery early after ICH remain elusive. In this post hoc analysis of the intracerebral hemorrhage deferoxamine (iDEF) trial, we examined the trajectories of cognitive impairment and the determinants of early cognitive recovery after ICH.

METHODS

We examined baseline factors associated with a 90-day cognitive outcome and constructed generalized linear mixed models to examine the trajectory of cognitive function over time among iDEF participants. Cognition was measured by the Montreal Cognitive Assessment (MoCA) scores on days 7, 30, and 90.

RESULTS

291 were available for analysis under the trial's modified intention-to-treat definition (38% female, mean age 60.3 ± 12.0 years, median NIHSS 13, IQR 8-18). The median baseline ICH volume was 12.9 IQR (6.4-26.0) mL; 59 (20%) of the ICH cases were lobar, 120 (41%) had intraventricular extension. There was an overall significant increase in total MOCA score with time (p < 0.0001). Total MOCA score increased by an estimated 3.9 points (95% CI: 3.1, 4.7) between the day 7 and day 30 assessments and by an additional 2.9 points (95% CI: 2.2, 3.6) between the day 30 and day 90 assessments. Despite the overall improvement, 134 of 205 (65%) patients with an available 90-day MoCA score remained cognitively impaired with a score <26 on day 90. Older age, higher NIHSS score, baseline ICH volume, intraventricular hemorrhage, and perihematoma edema had an adjusted negative impact on cognitive recovery.

CONCLUSIONS

Although ICH survivors exhibit significant improvement of cognitive status over the first 3 months, cognitive performance remains impaired in the majority of patients. Among factors independently associated with worse cognitive recovery, higher baseline ICH, intraventricular blood and perihematomal edema volumes, are potential therapeutic targets that merit further exploration.

Depressive Symptoms in Young and Middle-Aged Stroke Patients: A Transition Analysis

BACKGROUND

There is heterogeneity in depressive symptoms. However, latent classes of depressive symptoms and the transition and influences of these in young and middle-aged stroke patients are unclear.

OBJECTIVES

The aim of this study was to identify the latent classes of depressive symptoms and their transition patterns over time and the influencing factors in young and middle-aged stroke patients from stabilization to 6 months after discharge.

METHODS

This is a longitudinal study following the Strengthening the Reporting of Observational Studies in Epidemiology checklist. A total of 272 young and middle-aged stroke participants were recruited from a hospital neurology ward in Henan Province, China. Participants completed a questionnaire on sociodemographic and health information. Latent transition analysis was used to evaluate the transition pattern of latent classes from stabilization to 6 months after discharge and its influencing factors.

RESULTS

One hundred seventy-nine participants were included in the analysis. Three latent classes of depressive symptoms were identified as "mild symptoms," "grief-sleep-fatigue symptoms," and "severe symptoms." Most participants remained in the original latent class from stabilization to 6 months after discharge (probability of 83.8%, 83.8%, and 88.8%). From 3 to 6 months after discharge, the participants with fewer complications were more likely to transition into the mild symptom class.

DISCUSSION

The findings indicate that from stabilization to 6 months after discharge, depressive symptoms in young and middle-aged stroke patients in China transitioned gradually from the severe symptom class to the mild symptom. Patients with fewer numbers of poststroke complications were more likely to transition to the mild symptoms class. Future research should focus on depressive symptoms in early-stage stroke patients and provide sufficient psychological support to patients with a high number of complications.

Brain health imaging markers, post-stroke aphasia and Cognition: A scoping review

For the past decade, brain health has been an emerging line of scientific inquiry assessing the impact of age-related neurostructural changes on cognitive decline and recovery from brain injury. Typically, compromised brain health is attributed to the presence of small vessel disease (SVD) and brain tissue atrophy, which are represented by various neuroimaging features. However, to date, the relationship between brain health markers and chronic aphasia severity remains unclear. Thus, the goal of this scoping review was to assess the current body of evidence regarding the relationship between SVD-related brain health biomarkers and post-stroke aphasia and cognition. In all, 187 articles were identified from 3 databases, of which 16 articles met the criteria for inclusion. Among these studies, 11 focused on cognition rather than aphasia, while 2 investigated both. Of the 10 studies that used white matter hyperintensities (WMHs) as an indicator of SVD severity, 8 studies (80%) demonstrated a relationship between WMH load and worse cognition in stroke patients. Interestingly, among the studies that specifically investigated aphasia, all 5 studies (100%) demonstrated a relationship between SVD and worse language performance. They also indicated that factors other than brain health (e.g., lesion, age, time post onset) played an important role in determining aphasia severity at a single timepoint. These findings suggest that brain health is likely a crucial factor in the context of aphasia recovery, possibly indicating the necessity of cognitive reserve thresholds for the multimodal cognitive demands associated with language recovery. While SVD and structural brain health are not commonly considered as predictors of aphasia severity, more comprehensive models incorporating brain health have the potential to improve prognosis of post-stroke cognitive and language deficits. Given the variability in the existing literature, a uniform grading system for overall SVD would be beneficial for future research on the mechanisms related to brain networks and neuroplasticity, and their translational impact.

Association of Depression Onset and Treatment With Blood Pressure Control After Intracerebral Hemorrhage

BACKGROUND

Blood pressure (BP) control represents a crucial intervention to improve long-term outcomes following spontaneous intracerebral hemorrhage (ICH). However, fewer than half of ICH survivors achieve target treatment goals. ICH survivors are also at very high risk for poststroke depression, which may contribute to inadequate BP control. We, therefore, sought to determine whether depressive symptoms after ICH are associated with inadequate BP control. We also investigated whether associations between depression after ICH and BP measurements were mediated by treatment with selective serotonin reuptake inhibitors or norepinephrine-serotonin reuptake inhibitors antidepressants.

METHODS

We leveraged data from a single-center longitudinal study of ICH conducted at Massachusetts General Hospital (Boston, MA) between 2006 and 2018. We collected data from semiautomated review of electronic health records, baseline and follow-up interviews, and computed tomography imaging. Information on BP measurements, depression diagnoses, antidepressants medication use, and medical visits were collected longitudinally and analyzed using mixed effects models. Primary outcomes included systolic and diastolic BP measurements during long-term follow-up after ICH.

RESULTS

We included 1243 consecutive ICH patients without pre-stroke depression history. Of these, 721 (58%) were diagnosed with incident depression over a median follow-up time of 52.8 months (interquartile range, 42.1-60.5). Depression onset was associated with subsequent increase in systolic (+8.3 mm Hg, SE, 2.4 mm Hg, P=0.012) and diastolic (+4.4 mm Hg, SE, 1.2 mm Hg) BP measurements. Resolution of depressive symptoms was associated with subsequent decrease in systolic (-5.9 mm Hg, SE, 1.4 mm Hg, P=0.031) and diastolic (-3.4 mm Hg, SE, 1.1 mm Hg, P=0.041) BP measurements. We also found associations between higher systolic BP measurements and use of selective serotonin reuptake inhibitor and noradrenaline-serotonin reuptake inhibitor antidepressants, independent of whether depression symptoms were active or not (all P<0.05).

CONCLUSIONS

ICH survivors displayed increasing BP values after receiving a diagnosis of depression, followed by decreasing values among those experiencing resolution of depressive symptoms. Use of selective serotonin reuptake inhibitor and noradrenaline-serotonin reuptake inhibitor antidepressants was independently associated with higher systolic BP measurements. Clinicians ought to closely monitor BP for ICH survivors being treated for depression, especially using selective serotonin reuptake inhibitor and noradrenaline-serotonin reuptake inhibitor. Future studies will also be required to investigate the mechanisms underlying these associations.

Psychiatric traits and intracerebral hemorrhage: A Mendelian randomization study

BACKGROUND

Psychiatric traits have been associated with intracerebral hemorrhage (ICH) in observational studies, although their causal relationships remain uncertain. We used Mendelian randomization analyses to infer causality between psychiatric traits and ICH.

METHODS

We collected data from genome-wide association studies of ICH (n = 361,194) and eight psychiatric traits among Europeans, including mood swings (n = 451,619), major depressive disorder (n = 480,359), attention-deficit/hyperactivity disorder (n = 53,293), anxiety (n = 459,560), insomnia (n = 462,341), schizophrenia (n = 77,096), neuroticism (n = 374,323), and bipolar disorder (n = 51,710). We performed a series of bidirectional two-sample Mendelian randomization and related sensitivity analyses. A Bonferroni corrected threshold of p < 0.00625 (0.05/8) was considered to be significant, and p < 0.05 was considered suggestive of evidence for a potential association.

RESULTS

Mendelian randomization analyses revealed suggestive positive causality of mood swings on ICH (odds ratio = 1.006, 95% confidence interval = 1.001-1.012, p = 0.046), and the result was consistent after sensitivity analysis. However, major depressive disorder (p = 0.415), attention-deficit/hyperactivity disorder (p = 0.456), anxiety (p = 0.664), insomnia (p = 0.699), schizophrenia (p = 0.799), neuroticism (p = 0.140), and bipolar disorder (p = 0.443) are not significantly associated with the incidence of ICH. In the reverse Mendelian randomization analyses, no causal effects of ICH on mood swings (p = 0.565), major depressive disorder (p = 0.630), attention-deficit/hyperactivity disorder (p = 0.346), anxiety (p = 0.266), insomnia (p = 0.102), schizophrenia (p = 0.463), neuroticism (p = 0.261), or bipolar disorder (p = 0.985) were found.

CONCLUSION

Our study revealed that mood swings are suggestively causal of ICH and increase the risk of ICH. These results suggest the clinical significance of controlling mood swings for ICH prevention.

Main features of hereditary cerebral amyloid angiopathies: A systematic review

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Cerebral Amyloid Angiopathy (CAA) is a major contributor to stroke risk, cognitive decline, as well as multiple neurobehavioral and neuropsychiatric disturbances.

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Most CAA cases are sporadic, but many hereditary forms exist and present as familial monogenic disorders with early-onset hemorrhagic stroke and dementia.

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Hereditary CAA is usually characterized by earlier age at onset and more severe course when compared to sporadic CAA.

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Most forms of hereditary CAA are caused by APP mutations, leading to accumulation of amyloid beta in vascular deposits within the small vessels of the central nervous system.

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Cognitive decline is a common manifestation of hereditary CAA, either due to recurrent hemorrhagic stroke events or as chronic progression of small vessel vasculopathy.

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Recent studies highlighted increased risk for behavioral and psychiatric disorders among individuals affect by sporadic CAA, thus warranting similarly focused future investigations for hereditary CAA.

The term Cerebral Amyloid Angiopathy (CAA) refers to a group of neurovascular disorders characterized by amyloid deposition within the walls of leptomeningeal and cortical blood vessels of the brain, with specific predilection for arterioles, and (less often) capillaries and veins. Most CAA cases in the general population are sporadic in nature, and represent primarily an age-related condition affecting individuals in the fifth decade of life and beyond. Sporadic CAA is caused by deposition of amyloid-β (Aβ), originating from proteolytic cleavage of the Amyloid Precursor Protein (APP), within the walls of cerebral small caliber vessels. However, hereditary forms of CAA have also been described, generally presenting as rare familial disorder with monogenic (predominantly autosomal dominant) inheritance patterns. Hereditary CAA forms tend to affect younger individuals, and their course and clinical progression is more severe. Studies to date primarily focused on the vascular manifestations of sporadic and hereditary CAA, chiefly symptomatic lobar Intracerebral Hemorrhage (ICH). However, in the past decade sporadic CAA has also been consistently linked to progressive neurocognitive, neurobehavioral, and neuropsychiatric symptoms. This systematic review focuses on the genetics, pathogenesis, neuroimaging, neuropathology, and clinical manifestations of hereditary CAA with specific emphasis on previously overlooked cognitive, behavioral, and psychiatric symptoms.

Relationship Between Depression After Hemorrhagic Stroke and Auditory Event-Related Potentials in a Chinese Patient Group

PURPOSE

Post-stroke depression (PSD) is the most common psychiatric sequelae of stroke. Numerous studies revealed that event-related potentials (ERP) can reflect depression severity to a certain extent, while there is almost no research on depression after hemorrhagic stroke. Therefore, we employed a prospective cross-sectional study to explore the relationship between ERP and depression after hemorrhagic stroke.

METHODS

A total of 74 patients with intracranial hemorrhage were included in this study. Neurological deficits were evaluated using the National Institutes of Health Stroke Scale (NIHSS) on admission. Depression severity and cognitive impairment were measured using the 17-item Hamilton Depression Scale (HAMD-17) and the Chinese version of the Montreal Cognitive Assessment (MoCA) after two weeks of treatment. All patients were conducted auditory Oddball paradigm for event-related potential mismatch negativity (MMN) and P300.

RESULTS

In total, 36 patients were diagnosed with PSD at the two weeks of treatment, for a percentage of 48.6%. Depression severity of ICH patients correlated positively with both the latency of MMN (r = 0.376, P = 0.001) and P300 (r = 0.325, P = 0.005), and correlated negatively with both the amplitude of MMN (r=-0.385, P = 0.001) and P300 (r=-0.311, P = 0.007). Depression severity was negatively correlated with cognitive function after hemorrhagic stroke (r=-0.347, P = 0.002).

CONCLUSION

The latency and amplitude of MMN and P300 can well reflect the degree of depression after hemorrhagic stroke, which may help in the early diagnosis and effective treatment of PSD.