Effect of antidepressant therapy on executive function after stroke

Dementia after Ischemic Stroke, from Molecular Biomarkers to Therapeutic Options

Ischemic stroke is a leading cause of disability worldwide. While much of post-stroke recovery is focused on physical rehabilitation, post-stroke dementia (PSD) is also a significant contributor to poor functional outcomes. Predictive tools to identify stroke survivors at risk for the development of PSD are limited to brief screening cognitive tests. Emerging biochemical, genetic, and neuroimaging biomarkers are being investigated in an effort to unveil better indicators of PSD. Additionally, acetylcholinesterase inhibitors, NMDA receptor antagonists, dopamine receptor agonists, antidepressants, and cognitive rehabilitation are current therapeutic options for PSD. Focusing on the chronic sequelae of stroke that impair neuroplasticity highlights the need for continued investigative trials to better assess functional outcomes in treatments targeted for PSD.

Molecular mechanisms underlying major depressive disorder and post-stroke affective disorders

Two of the most common and incapacitating mental health disorders around the world are major depressive disorder (MDD) and post-stroke depression (PSD). MDD is thought to result from abnormal connectivity between the monoaminergic, glutamatergic, GABAergic, and/or cholinergic pathways. Additional factors include the roles of hormonal, immune, ageing, as well as the influence of cellular, molecular, and epigenetics in the development of mood disorders. This complexity of factors has been anticipated by the Swiss psychiatrists Paul Kielholz and Jules Angst who introduced a multimodal treatment of MDD. Depression is the predominant mood disorder, impacting around one-third of individuals who have experienced a stroke. MDD and PSD share common underlying biological mechanisms related to the disruption of monoaminergic pathways. The major contributor to PSD is the stroke lesion location, which can involve the disruption of the serotoninergic, dopaminergic, glutamatergic, GABAergic, or cholinergic pathways. Additionally, various other disorders such as mania, bipolar disorder, anxiety disorder, and apathy might occur post-stroke, although their prevalence is considerably lower. However, there are differences in the onset of MDD among mood disorders. Some mood disorders develop gradually and can persist for a lifetime, potentially culminating in suicide. In contrast, PSD has a rapid onset because of the severe disruption of neural pathways essential for mood behavior caused by the lesion. However, PSD might also spontaneously resolve several months after a stroke, though it is associated with higher mortality. This review also provides a brief overview of the treatments currently available in medical practice.

Pharmacological, non-invasive brain stimulation and psychological interventions, and their combination, for treating depression after stroke

BACKGROUND

Depression is an important morbidity associated with stroke that impacts on recovery, yet is often undetected or inadequately treated.

OBJECTIVES

To evaluate the benefits and harms of pharmacological intervention, non-invasive brain stimulation, psychological therapy, or combinations of these to treat depression after stroke.

SEARCH METHODS

This is a living systematic review. We search for new evidence every two months and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review. We searched the Specialised Registers of Cochrane Stroke, and Cochrane Depression Anxiety and Neurosis, CENTRAL, MEDLINE, Embase, five other databases, two clinical trials registers, reference lists and conference proceedings (February 2022). We contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing: 1) pharmacological interventions with placebo; 2) non-invasive brain stimulation with sham stimulation or usual care; 3) psychological therapy with usual care or attention control; 4) pharmacological intervention and psychological therapy with pharmacological intervention and usual care or attention control; 5) pharmacological intervention and non-invasive brain stimulation with pharmacological intervention and sham stimulation or usual care; 6) non-invasive brain stimulation and psychological therapy versus sham brain stimulation or usual care and psychological therapy; 7) pharmacological intervention and psychological therapy with placebo and psychological therapy; 8) pharmacological intervention and non-invasive brain stimulation with placebo and non-invasive brain stimulation; and 9) non-invasive brain stimulation and psychological therapy versus non-invasive brain stimulation and usual care or attention control, with the intention of treating depression after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, and extracted data from included studies. We calculated mean difference (MD) or standardised mean difference (SMD) for continuous data, and risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I² statistic and certainty of the evidence according to GRADE.

MAIN RESULTS

We included 65 trials (72 comparisons) with 5831 participants. Data were available for: 1) 20 comparisons; 2) nine comparisons; 3) 25 comparisons; 4) three comparisons; 5) 14 comparisons; and 6) one comparison. We found no trials for comparisons 7 to 9. Comparison 1: Pharmacological interventions Very low-certainty evidence from eight trials suggests pharmacological interventions decreased the number of people meeting the study criteria for depression (RR 0.70, 95% CI 0.55 to 0.88; P = 0.002; 8 RCTs; 1025 participants) at end of treatment and very low-certainty evidence from six trials suggests that pharmacological interventions decreased the number of people with inadequate response to treatment (RR 0.47, 95% CI 0.32 to 0.70; P = 0.0002; 6 RCTs; 511 participants) compared to placebo. More adverse events related to the central nervous system (CNS) (RR 1.55, 95% CI 1.12 to 2.15; P = 0.008; 5 RCTs; 488 participants; very low-certainty evidence) and gastrointestinal system (RR 1.62, 95% CI 1.19 to 2.19; P = 0.002; 4 RCTs; 473 participants; very low-certainty evidence) were noted in the pharmacological intervention than in the placebo group. Comparison 2: Non-invasive brain stimulation Very low-certainty evidence from two trials show that non-invasive brain stimulation had little to no effect on the number of people meeting the study criteria for depression (RR 0.67, 95% CI 0.39 to 1.14; P = 0.14; 2 RCTs; 130 participants) and the number of people with inadequate response to treatment (RR 0.84, 95% CI 0.52, 1.37; P = 0.49; 2 RCTs; 130 participants) compared to sham stimulation. Non-invasive brain stimulation resulted in no deaths. Comparison 3: Psychological therapy Very low-certainty evidence from six trials suggests that psychological therapy decreased the number of people meeting the study criteria for depression at end of treatment (RR 0.77, 95% CI 0.62 to 0.95; P = 0.01; 521 participants) compared to usual care/attention control. No trials of psychological therapy reported on the outcome inadequate response to treatment. No differences in the number of deaths or adverse events were found in the psychological therapy group compared to the usual care/attention control group. Comparison 4: Pharmacological interventions with psychological therapy No trials of this combination reported on the primary outcomes. Combination therapy resulted in no deaths. Comparison 5: Pharmacological interventions with non-invasive brain stimulation Non-invasive brain stimulation with pharmacological intervention reduced the number of people meeting study criteria for depression at end of treatment (RR 0.77, 95% CI 0.64 to 0.91; P = 0.002; 3 RCTs; 392 participants; low-certainty evidence) but not the number of people with inadequate response to treatment (RR 0.95, 95% CI 0.69 to 1.30; P = 0.75; 3 RCTs; 392 participants; very low-certainty evidence) compared to pharmacological therapy alone. Very low-certainty evidence from five trials suggest no difference in deaths between this combination therapy (RR 1.06, 95% CI 0.27 to 4.16; P = 0.93; 487 participants) compared to pharmacological therapy intervention and sham stimulation or usual care. Comparison 6: Non-invasive brain stimulation with psychological therapy No trials of this combination reported on the primary outcomes.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggests that pharmacological, psychological and combination therapies can reduce the prevalence of depression while non-invasive brain stimulation had little to no effect on the prevalence of depression. Pharmacological intervention was associated with adverse events related to the CNS and the gastrointestinal tract. More research is required before recommendations can be made about the routine use of such treatments.

Potential Mechanisms and Clinical Effectiveness of Acupuncture in Depression

Major depressive disorder is the most common mental disorder with significant economic burden and limited treatments. Acupuncture has emerged as a promising non-pharmacological treatment for reducing depressive symptoms. However, the potential mechanisms and clinical effectiveness of acupuncture are not fully understood. This review aimed to: (1) summarize the available evidence on the mechanisms and clinical effectiveness of acupuncture for depression, and then (2) compare with pharmacological interventions, guiding future studies. Studies with animal models of depression and patients have shown that acupuncture could increase hippocampal and network neuroplasticity and decrease brain inflammation, potentially to alleviating depressive disorders. Overall clinical studies indicated that acupuncture could relieve primary depression, particularly milder cases, and was helpful in the management of post-stroke depression, pain-related depression, and postpartum depression both as an isolated and adjunct treatment. It was emphasized that acupuncture combined with antidepressant pharmacological treatment not only enhanced the improvement of primary and secondary depressive symptoms but also reduced the side effects of the medical treatment, which is the main cause for high dropout rates with drug treatment. In summary, substantial evidence from animal and human researches supported the beneficial effect of acupuncture in depression. However, most clinical trials of acupuncture were small, and it is unclear whether their findings can be generalized, so more studies are needed.

The Relationship of Psychiatric Symptoms with Performance-Based and Self-Reported Cognitive Function After Ischemic Stroke

OBJECTIVE

Findings on the relationship of psychiatric symptoms with performance-based and self-reported cognitive function post-stroke are inconclusive. We aimed to (1) study the relation of depression and anxiety to performance-based cognitive function and (2) explore a broader spectrum of psychiatric symptoms and their association with performance-based versus self-reported cognitive function.

METHOD

Individuals with supratentorial ischemic stroke performed neuropsychological examination 3 months after stroke. For primary analyses, composite scores for memory and attention/executive function were calculated based on selected neuropsychological tests, and the Hospital Anxiety and Depression Scale (HADS) was used. Psychiatric symptoms and self-reported cognitive function for secondary aims were assessed using the Symptom-Checklist-90 - Revised (SCL-90-R).

RESULTS

In a sample of 86 patients [mean (M) age: 64.6 ± 9.2; Mini-Mental State Examination (MMSE), 3-7 days post-stroke: M = 28.4 ± 1.7; National Institutes of Health Stroke Scale (NIHSS) after 3 months: M = 0.7 ± 1.6] depressive symptoms (HADS) were associated with poorer memory performance after controlling for age, sex, and education (p ≤ .01). In a subsample (n = 41; Age: M = 65.7 ± 8.1; MMSE: M = 28.4 ± 1.8; NIHSS: M = 1.0 ± 1.9), symptoms of phobic anxiety (SCL-90-R) were associated with poorer performance-based memory and attention/executive function, and symptoms of anxiety (SCL-90-R) with lower attention/executive function. Higher levels of self-reported cognitive difficulties were associated with higher scores in all psychiatric domains (p ≤ .05).

CONCLUSION

Even in relatively well-functioning stroke patients, depressive symptoms are associated with poorer memory. The results also suggest that various psychiatric symptoms are more related to self-reported rather than to performance-based cognitive function. Screening for self-reported cognitive difficulties may not only help to identify patients with cognitive impairment, but also those who need psychological treatment.

(R,S)-Ketamine Promotes Striatal Neurogenesis and Sensorimotor Recovery Through Improving Poststroke Depression–Mediated Decrease in Atrial Natriuretic Peptide

Background

Poststroke social isolation could worsen poststroke depression and dampen neurogenesis. (R,S)-ketamine has antidepressant and neuroprotective effects; however, its roles and mechanisms in social isolation–mediated depressive-like behaviors and sensorimotor recovery remain unclear.

Methods

Mice were subjected to transient middle cerebral artery occlusion, and then were pair-housed with ovariectomized female mice or were housed isolated (ISO) starting at 3 days postischemia. ISO mice received 2 weeks of (R,S)-ketamine treatment starting at 14 days postischemia. Primary ependymal epithelial cells and choroid plexus epithelial cells were cultured and treated with recombinant human atrial natriuretic peptide (ANP) protein.

Results

The poststroke social isolation model was successfully established using middle cerebral artery occlusion combined with poststroke isolation, as demonstrated by a more prominent depression-like phenotype in ISO mice compared with pair-housed mice. (R,S)-ketamine reversed ISO-mediated depressive-like behaviors and increased ANP levels in the atrium. The depression-like phenotype was negatively correlated with ANP levels in both the atrium and plasma. Atrial GLP-1 and GLP-1 receptor signaling was essential to the promoting effects of (R,S)-ketamine on the synthesis and secretion of ANP from the atrium in ISO mice. (R,S)-ketamine also increased ANP and TGF-β1 levels in the choroid plexus of ISO mice. Recombinant human ANP increased TGF-β1 levels in both the primarily cultured ependymal epithelial cells and choroid plexus epithelial cells. Furthermore, (R,S)-ketamine increased TGF-β1 levels in the ischemic hemisphere and promoted striatal neurogenesis and sensorimotor recovery via ANP in ISO mice.

Conclusions

(R,S)-ketamine alleviated poststroke ISO-mediated depressive-like behaviors and thus promoted striatal neurogenesis and sensorimotor recovery via ANP.

Reduced left ventrolateral prefrontal cortex activation during verbal fluency tasks is associated with suicidal ideation severity in medication-naïve young adults with major depressive disorder: A functional near-infrared spectroscopy study

The reduction in the oxygenation dynamics in the prefrontal cortex (PFC) during cognitive tasks is a well-known occurrence in major depressive disorders (MDD). Studies focusing on oxygenation changes in the PFC in individuals with suicidal ideation are limited. Therefore, this study investigated and confirmed the presence of prefrontal dysfunction depending on the intensity of suicidal ideation among 77 young adults (45 patients with MDD and 32 healthy controls) using near-infrared spectroscopy (NIRS). All participants underwent assessment with the Beck Depression Inventory-II, Beck Anxiety Inventory, and Beck Scale for Suicidal ideation. NIRS revealed relative hypofunction in the left dorsolateral PFC, left ventrolateral PFC (LVLPFC), and both orbitofrontal cortices in young adults with MDD compared to that in the healthy controls during verbal fluency tasks. Furthermore, the oxyhaemoglobin changes in the LVLPFC mediated the indirect effect of depression severity on suicidal ideation intensity. Our results confirmed that functional NIRS is a useful auxiliary tool for objectively assessing the risk of suicidal ideation.

Fluoxetine to improve functional outcomes in patients after acute stroke: the FOCUS RCT

BACKGROUND

Our Cochrane review of selective serotonin inhibitors for stroke recovery indicated that fluoxetine may improve functional recovery, but the trials were small and most were at high risk of bias.

OBJECTIVES

The Fluoxetine Or Control Under Supervision (FOCUS) trial tested the hypothesis that fluoxetine improves recovery after stroke.

DESIGN

The FOCUS trial was a pragmatic, multicentre, parallel-group, individually randomised, placebo-controlled trial.

SETTING

This trial took place in 103 UK hospitals.

PARTICIPANTS

Patients were eligible if they were aged ≥ 18 years, had a clinical stroke diagnosis, with focal neurological deficits, between 2 and 15 days after onset.

INTERVENTIONS

Patients were randomly allocated 20 mg of fluoxetine once per day or the matching placebo for 6 months via a web-based system using a minimisation algorithm.

MAIN OUTCOME MEASURES

The primary outcome was the modified Rankin Scale at 6 months. Patients, carers, health-care staff and the trial team were masked to treatment allocation. Outcome was assessed at 6 and 12 months after randomisation. Patients were analysed by their treatment allocation as specified in a published statistical analysis plan.

RESULTS

Between 10 September 2012 and 31 March 2017, we recruited 3127 patients, 1564 of whom were allocated fluoxetine and 1563 of whom were allocated placebo. The modified Rankin Scale score at 6 months was available for 1553 out of 1564 (99.3%) of those allocated fluoxetine and 1553 out of 1563 (99.4%) of those allocated placebo. The distribution across modified Rankin Scale categories at 6 months was similar in the two groups (common odds ratio adjusted for minimisation variables 0.951, 95% confidence interval 0.839 to 1.079; p = 0.439). Compared with placebo, patients who were allocated fluoxetine were less likely to develop a new episode of depression by 6 months [210 (13.0%) vs. 269 (16.9%), difference -3.78%, 95% confidence interval -1.26% to -6.30%; p = 0.003], but had more bone fractures [45 (2.9%) vs. 23 (1.5%), difference 1.41%, 95% confidence interval 0.38% to 2.43%; p = 0.007]. There were no statistically significant differences in any other recorded events at 6 or 12 months. Health economic analyses showed no differences between groups in health-related quality of life, hospital bed usage or health-care costs.

LIMITATIONS

Some non-adherence to trial medication, lack of face-to-face assessment of neurological status at follow-up and lack of formal psychiatric diagnosis during follow-up.

CONCLUSIONS

20 mg of fluoxetine daily for 6 months after acute stroke did not improve patients' functional outcome but decreased the occurrence of depression and increased the risk of fractures. These data inform decisions about using fluoxetine after stroke to improve functional outcome or to prevent or treat mood disorders. The Assessment oF FluoxetINe In sTroke recoverY (AFFINITY) (Australasia/Vietnam) and Efficacy oF Fluoxetine - a randomisEd Controlled Trial in Stroke (EFFECTS) (Sweden) trials recruited an additional 2780 patients and will report their results in 2020. These three trials have an almost identical protocol, which was collaboratively developed. Our planned individual patient data meta-analysis will provide more precise estimates of the effects of fluoxetine after stroke and indicate whether or not effects vary depending on patients' characteristics and health-care setting.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN83290762.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 22. See the NIHR Journals Library website for further project information. The Stroke Association (reference TSA 2011101) funded the start-up phase.

Pharmacological, psychological, and non-invasive brain stimulation interventions for treating depression after stroke

BACKGROUND

Depression is an important morbidity associated with stroke that impacts on recovery yet often undetected or inadequately treated. This is an update and expansion of a Cochrane Review first published in 2004 and updated in 2008.

OBJECTIVES

Primary objective • To determine whether pharmacological therapy, non-invasive brain stimulation, psychological therapy, or combinations of these interventions reduce the prevalence of diagnosable depression after stroke Secondary objectives • To determine whether pharmacological therapy, non-invasive brain stimulation, psychological therapy, or combinations of these interventions reduce levels of depressive symptoms, improve physical and neurological function and health-related quality of life, and reduce dependency after stroke • To assess the safety of and adherence to such treatments SEARCH METHODS: We searched the Specialised Registers of Cochrane Stroke and Cochrane Depression Anxiety and Neurosis (last searched August 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1), in the Cochrane Library, MEDLINE (1966 to August 2018), Embase (1980 to August 2018), the Cumulative Index to Nursing and Alllied Health Literature (CINAHL) (1982 to August 2018), PsycINFO (1967 to August 2018), and Web of Science (2002 to August 2018). We also searched reference lists, clinical trial registers (World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) to August 2018; ClinicalTrials.gov to August 2018), and conference proceedings, and we contacted study authors.

SELECTION CRITERIA

Randomised controlled trials comparing (1) pharmacological interventions with placebo; (2) one of various forms of non-invasive brain stimulation with sham stimulation or usual care; (3) one of various forms of psychological therapy with usual care and/or attention control; (4) pharmacological intervention and various forms of psychological therapy with pharmacological intervention and usual care and/or attention control; (5) non-invasive brain stimulation and pharmacological intervention with pharmacological intervention and sham stimulation or usual care; (6) pharmacological intervention and one of various forms of psychological therapy with placebo and psychological therapy; (7) pharmacological intervention and non-invasive brain stimulation with placebo plus non-invasive brain stimulation; (8) non-invasive brain stimulation and one of various forms of psychological therapy versus non-invasive brain stimulation plus usual care and/or attention control; and (9) non-invasive brain stimulation and one of various forms of psychological therapy versus sham brain stimulation or usual care plus psychological therapy, with the intention of treating depression after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, and extracted data from all included studies. We calculated mean difference (MD) or standardised mean difference (SMD) for continuous data, and risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I² statistic and certainty of the evidence according to GRADE.

MAIN RESULTS

We included 49 trials (56 comparisons) with 3342 participants. Data were available for: (1) pharmacological interventions with placebo (with 20 pharmacological comparisons); (2) one of various forms of non-invasive brain stimulation with sham stimulation or usual care (with eight non-invasive brain stimulation comparisons); (3) one of various forms of psychological therapy with usual care and/or attention control (with 16 psychological therapy comparisons); (4) pharmacological intervention and various forms of psychological therapy with pharmacological intervention and usual care and/or attention control (with two comparisons); and (5) non-invasive brain stimulation and pharmacological intervention with pharmacological intervention and sham stimulation or usual care (with 10 comparisons). We found no trials for the following comparisons: (6) pharmacological intervention and various forms of psychological therapy interventions versus placebo and psychological therapy; (7) pharmacological intervention and non-invasive brain stimulation versus placebo plus non-invasive brain stimulation; (8) non-invasive brain stimulation and one of various forms of psychological therapy versus non-invasive brain stimulation plus usual care and/or attention control; and (9) non-invasive brain stimulation and one of various forms of psychological therapy versus sham brain stimulation or usual care plus psychological therapy. Treatment effects observed: very low-certainty evidence from eight trials suggests that pharmacological interventions decreased the number of people meeting study criteria for depression (RR 0.70, 95% CI 0.55 to 0.88; 1025 participants) at end of treatment, and very low-certainty evidence from six trials suggests that pharmacological interventions decreased the number of people with less than 50% reduction in depression scale scores at end of treatment (RR 0.47, 95% CI 0.32 to 0.69; 511 participants) compared to placebo. No trials of non-invasive brain stimulation reported on meeting study criteria for depression at end of treatment. Only one trial of non-invasive brain stimulation reported on the outcome <50% reduction in depression scale scores; thus, we were unable to perform a meta-analysis for this outcome. Very low-certainty evidence from six trials suggests that psychological therapy decreased the number of people meeting the study criteria for depression at end of treatment (RR 0.77, 95% CI 0.62 to 0.95; 521 participants) compared to usual care/attention control. No trials of combination therapies reported on the number of people meeting the study criteria for depression at end of treatment. Only one trial of combination (non-invasive brain stimulation and pharmacological intervention) therapy reported <50% reduction in depression scale scores at end of treatment. Thus, we were unable to perform a meta-analysis for this outcome. Five trials reported adverse events related to the central nervous system (CNS) and noted significant harm in the pharmacological interventions group (RR 1.55, 95% CI 1.12 to 2.15; 488 participants; very low-certainty evidence). Four trials found significant gastrointestinal adverse events in the pharmacological interventions group (RR 1.62, 95% CI 1.19 to 2.19; 473 participants; very low-certainty evidence) compared to the placebo group. No significant deaths or adverse events were found in the psychological therapy group compared to the usual care/attention control group. Non-invasive brain stimulation interventions and combination therapies resulted in no deaths.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggests that pharmacological or psychological therapies can reduce the prevalence of depression. This very low-certainty evidence suggests that pharmacological therapy, psychological therapy, non-invasive brain stimulation, and combined interventions can reduce depressive symptoms. Pharmacological intervention was associated with adverse events related to the CNS and the gastrointestinal tract. More research is required before recommendations can be made about the routine use of such treatments.

Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue following Stroke, 6th edition update 2019

The 2019 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Mood, Cognition and Fatigue following Stroke is a comprehensive set of evidence-based guidelines addressing three important issues that can negatively impact the lives of people who have had a stroke. These include post-stroke depression and anxiety, vascular cognitive impairment, and post-stroke fatigue. Following stroke, approximately 20% to 50% of all persons may be affected by at least one of these conditions. There may also be overlap between conditions, particularly fatigue and depression. If not recognized and treated in a timely matter, these conditions can lead to worse long-term outcomes. The theme of this edition of the CSBPR is Partnerships and Collaborations, which stresses the importance of integration and coordination across the healthcare system to ensure timely and seamless care to optimize recovery and outcomes. Accordingly, these recommendations place strong emphasis on the importance of timely screening and assessments, and timely and adequate initiation of treatment across care settings. Ideally, when screening is suggestive of a mood or cognition issue, patients and families should be referred for in-depth assessment by healthcare providers with expertise in these areas. As the complexity of patients treated for stroke increases, continuity of care and strong communication among healthcare professionals, and between members of the healthcare team and the patient and their family is an even bigger imperative, as stressed throughout the recommendations, as they are critical elements to ensure smooth transitions from acute care to active rehabilitation and reintegration into their community.

Hyperforin Promotes Post-stroke Neuroangiogenesis via Astrocytic IL-6-Mediated Negative Immune Regulation in the Ischemic Brain

Hyperforin has been shown to be capable of promoting angiogenesis and functional recovery after ischemic stroke in our previous study. However, the exact mechanisms involved are not fully elucidated. In this study, adult male mice were subjected to 60-min transient middle cerebral artery occlusion followed by reperfusion for 28 days. Hyperforin was administrated to MCAO mice every 24 h for 2 weeks starting at 14 days post-ischemia (dpi). Then flow cytometry, quantitative Real-time PCR (RT-qPCR), western blotting, immunohistochemistry, and functional assays were performed to explore the molecular mechanisms in vivo and in vitro. Our data showed that hyperforin increased astrocytic interleukin (IL)-6 in the ischemic hemisphere via TLR4 at 28 dpi. The astrocytic IL-6 was essential to the promoting effects of hyperforin on the neural precursor cells proliferation, neuronal differentiation, angiogenesis, and functional recovery after stroke. Furthermore, hyperforin promoted the infiltration of regulatory T cells (Tregs) to the ischemic hemisphere and increased Tregs-derived cytokine IL-10 and transforming growth factor-β (TGF-β) in a manner that was dependent on astrocytic IL-6. Astrocytic IL-6 was critical to the role of hyperforin in promoting the infiltration of T-helper (Th) type 2 cells to the ischemic hemisphere and Th2-derived cytokine IL-4, relative to Th1 and Th1-derived cytokine interferon-γ (IFN-γ), which decreased during stroke recovery. After depletion of CD25⁺ Tregs, the promoting effects of hyperforin on post-stroke neurogenesis was attenuated. Moreover, blockade of IL-4 and TGF-β abrogated the promoting role of hyperforin in post-stroke neurogenesis, angiogenesis and functional recovery. Our results reveal a previously uncharacterized role of astrocytic IL-6-mediated negative immune regulation in the promoting effects of hyperforin on post-stroke neurovascular regeneration and functional recovery.

Hyperforin improves post-stroke social isolation‑induced exaggeration of PSD and PSA via TGF-β

Stroke survivors often experience social isolation, which can lead to post-stroke depression (PSD) and post-stroke anxiety (PSA) that can compromise neurogenesis and impede functional recovery following the stroke. The present study aimed to investigate the effects and mechanisms of post-stroke social isolation-mediated PSD and PSA on hippocampal neurogenesis and cognitive function. The effects of the natural antidepressant hyperforin on post-stroke social isolation-mediated PSD and PSA were also investigated. In the present study, a model of PSD and PSA using C57BL/6J male mice was successfully established using middle cerebral artery occlusion combined with post-stroke isolated housing conditions. It was observed that PSD and PSA were more prominent in the isolated mice compared with the pair-housed mice at 14 days post-ischemia (dpi). Mice isolated 3 dpi exhibited decreased transforming growth factor-β (TGF-β) levels and impairment of hippocampal neurogenesis and memory function at 14 dpi. Intracerebroventricular administration of recombinant TGF-β for 7 consecutive days, starting at 7 dpi, restored the reduced hippocampal neurogenesis and memory function induced by social isolation. Furthermore, intranasal administration of hyperforin for 7 consecutive days starting at 7 dpi improved PSD and PSA and promoted hippocampal neurogenesis and memory function in the isolated mice at 14 dpi. The inhibition of TGF-β with a neutralizing antibody prevented the effects of hyperforin. In conclusion, the results revealed a previously uncharacterized role of hyperforin in improving post-stroke social isolation-induced exaggeration of PSD and PSA and, in turn, promoting hippocampal neurogenesis and cognitive function via TGF-β.

The Zürich Maxi Mental Status Inventory (ZüMAX): Test-Retest Reliability and Discriminant Validity in Stroke Survivors

OBJECTIVE

To examine discriminant validity and test-retest reliability of the Zürich maxi mental status inventory (ZüMAX) in patients with stroke.

BACKGROUND

The ZüMAX is a novel domain-specific cognitive assessment tool to screen for disturbances in neuropsychological function. The test can be used in stroke rehabilitation to estimate severity of cognitive impairment. Because evidence for validity and reliability is lacking, the tool's clinical use is limited.

METHODS

We administered the ZüMAX in a test-retest design to 33 community-dwelling stroke survivors, and once to 35 healthy controls matched for age and sex.

RESULTS

We found significant group differences in subscores for the cognitive domains of executive functions and language as well as total score (P=0.001 to 0.004); we did not find group differences for the domains of praxia (defined as the ability to perform purposeful actions), visual perception and construction, or learning and memory. Test-retest reliability of the total score was good (intraclass correlation coefficient=0.81), with the individual domain subscores ranging from poor to fair (0.59 to 0.79). The ZüMAX could detect changes in patients with low smallest detectable differences in executive functions, language, and praxia (0.05 to 1.49) and total score (0.09).

CONCLUSION

The ZüMAX has moderate to good test-retest reliability. Furthermore, the tool might discriminate between healthy persons and chronic stroke survivors on three of five subscales. The ZüMAX shows promise in measuring neuropsychological disturbances in stroke survivors; however, further trials are required with larger samples.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

The relationship between post-stroke depression and physical recovery

BACKGROUND

Post-stroke depression (PSD) is a serious and common complication of stroke. In this prospective study on the relationship between clinical PSD and physical recovery, we focused on (1) distinguishing between depression and apathy, (2) issues in assessment of PSD, and (3) timing of assessment.

METHODS

Japanese stroke patients (n=117) were studied. We used self-rating scales [Zung Self-Rating Depression Scale (SDS) for depression; Apathy Scale (AS) for apathy] and observer-rating scales [Montgomery-Åsberg Depression Rating Scale (MADRS) for depression; Neuropsychiatric Inventory-Nursing Home (NPI-NH) for apathy] to assess psychological state. We assessed physical disability using the Functional Independence Measurement (FIM). Two-way analysis of covariance was used to determine effects of depression and apathy on functional outcome. We evaluated PSD twice, within 10 days after hospitalization and four weeks later.

RESULTS

Objective scales gave higher prevalence than subjective scales for both depression and apathy. A significant effect of apathy on FIM recovery was seen with objective scale assessment during hospitalization; there was a marginal effect of depression at the same time.

LIMITATIONS

We did not consider the stroke size and location. In addition, we excluded patients with severe comprehension deficits or with a history of stroke.

CONCLUSIONS

Our findings indicate that depression and apathy could occur independently after stroke and could individually influence functional recovery. We obtained more accurate estimates of functional recovery using objective measures. Furthermore, our findings suggest that depression and apathy should be assessed not only at admission but also during hospitalization to estimate and enhance the functional recovery of stroke patients.

Diversity of approaches in assessment of executive functions in stroke: limited evidence?

Stroke is a leading cause of disability worldwide. Cognitive functions and, in particular, executive function, are commonly affected after stroke, leading to impairments in performance of daily activities, decrease in social participation and in quality of life. Appropriate assessment and understanding of executive dysfunction are important, firstly to develop better rehabilitation strategies for executive functions per se and secondly to consider executive function abilities on rehabilitation strategies in general. The purpose of this review was to identify the most widely used assessment tools of executive dysfunction for patients with stroke, and their psychometric properties.

We systematically reviewed manuscripts published in English in databases from 1999 to 2015. We identified 35 publications. The most frequently used instruments were the Stroop, Digit Span and Trail making tests. Psychometric properties were described for the Executive Function Performance Test, Executive Clock Drawing Task, Chinese Frontal Assessment Battery and Virtual Action Planning — Supermarket, and two subtests of the Cambridge Cognitive Examination — Revised.

There is a paucity of tools to reliably measure executive dysfunction after stroke, despite the fact that executive dysfunction is frequent. Identification of the best tools for executive dysfunction assessment is necessary to address important gaps in research and in clinical practice.

Executive function and depressive symptoms of retardation in nonelderly stroke patients

The depression-executive dysfunction syndrome, a late-onset depression of vascular origin with executive dysfunction and psychomotor retardation, has also been described after stroke. We verified whether this syndrome also occurs in nonelderly stroke patients by investigating the association between domains of depressive symptoms with executive functions in 87 first-ever ischemic stroke patients. The retardation domain of the 31-item Hamilton Rating Scale for Depression was associated with decreased performance on verbal fluency (assessed with FAS). The association was maintained for younger patients (aged <60 years) after adjusting for confounders. This result supports the clinical presentation of depression-executive dysfunction syndrome in younger stroke patients. Confirmation of this finding, its neural correlates, and clinical implication deserve further investigation.

Rehabilitation for post-stroke cognitive impairment: an overview of recommendations arising from systematic reviews of current evidence

BACKGROUND

Although cognitive impairments are common following stroke, there is considerable uncertainty about the types of interventions that can reduce activity restrictions and improve quality of life. Indeed, a recent project to identify priorities for research into life after stroke determined that the top priority for patients, carers and health professionals was how to improve cognitive impairments.

OBJECTIVE

To provide an overview of the evidence for the effectiveness of cognitive rehabilitation for patients with stroke and to determine the main gaps in the current evidence base.

METHODS

Evidence was synthesised for the six Cochrane reviews relating to rehabilitation for post-stroke cognitive impairment and any subsequently published randomized controlled trials to February 2012.

RESULTS

Data arising from 44 trials involving over 1500 patients was identified. Though there was support for the effectiveness of cognitive rehabilitation for some cognitive impairments, significant gaps were found in the current evidence base. All of the Cochrane reviews identified major limitations within the evidence they identified.

CONCLUSIONS

There is currently insufficient research evidence, or evidence of insufficient quality, to support clear recommendations for clinical practice. Recommendations are made as to the research required to strengthen the evidence base, and so facilitate the delivery of effective interventions to individuals with cognitive impairment after stroke.

Fluoxetine treatment promotes functional recovery in a rat model of cervical spinal cord injury

Spinal cord injury (SCI) is a severe condition leading to enduring motor deficits. When lesions are incomplete, promoting spinal cord plasticity might be a useful strategy to elicit functional recovery. Here we investigated whether long-term fluoxetine administration in the drinking water, a treatment recently demonstrated to optimize brain plasticity in several pathological conditions, promotes motor recovery in rats that received a C4 dorsal funiculus crush. We show that fluoxetine administration markedly improved motor functions compared to controls in several behavioral paradigms. The improved functional effects correlated positively with significant sprouting of intact corticospinal fibers and a modulation of the excitation/inhibition balance. Our results suggest a potential application of fluoxetine treatment as a non invasive therapeutic strategy for SCI-associated neuropathologies.

Fluoxetine induces vasodilatation of cerebral arterioles by co-modulating NO/muscarinic signalling

Ischaemic stroke patients treated with Selective Serotonin Reuptake Inhibitors (SSRI) show improved motor, cognitive and executive functions, but the underlying mechanism(s) are incompletely understood. Here, we report that cerebral arterioles in the rat brain superfused with therapeutically effective doses of the SSRI fluoxetine showed consistent, dose-dependent vasodilatation (by 1.2 to 1.6-fold), suppressible by muscarinic and nitric oxide synthase (NOS) antagonists [atropine, NG-nitro-l-arginine methyl ester (l-NAME)] but resistant to nicotinic and serotoninergic antagonists (mecamylamine, methylsergide). Fluoxetine administered 10–30 min. following experimental vascular photo-thrombosis increased arterial diameter (1.3–1.6), inducing partial, but lasting reperfusion of the ischaemic brain. In brain endothelial b.End.3 cells, fluoxetine induced rapid muscarinic receptor-dependent increases in intracellular [Ca²⁺] and promoted albumin- and eNOS-dependent nitric oxide (NO) production and HSP90 interaction. In vitro, fluoxetine suppressed recombinant human acetylcholinesterase (rhAChE) activity only in the presence of albumin. That fluoxetine induces vasodilatation of cerebral arterioles suggests co-promotion of endothelial muscarinic and nitric oxide signalling, facilitated by albumin-dependent inhibition of serum AChE.

Prevention of poststroke apathy using escitalopram or problem-solving therapy

OBJECTIVE

Apathy occurs frequently following stroke and prior studies have demonstrated the negative effect of apathy on recovery from stroke. This study was a secondary analysis examining the efficacy of escitalopram, problem-solving therapy (PST), or placebo administered for 1 year to prevent the onset of apathy among patients with recent stroke.

METHODS

Patients within 3 months of an index stroke who did not meet DSM-IV diagnostic criteria for major or minor depression and who did not have a serious comorbid physical illness were enrolled. Patients were recruited from three sites: University of Iowa, University of Chicago, and Burke Rehabilitation Hospital. One hundred fifty-four patients without evidence of apathy at initial evaluation were included in the randomized controlled trial using escitalopram (10 mg patients ≤65 years; 5 mg patients >65 years) (N = 51) or placebo (N = 47) or non-blinded PST (12 total sessions) (N = 56) over 1 year. At 3, 6, 9, and 12 months, patients were assessed for diagnosis and severity of apathy using the Apathy Scale.

RESULTS

Using a Cox proportional hazards model of time to onset of apathy, participants given placebo were 3.47 times more likely to develop apathy than patients given escitalopram and 1.84 times more likely to develop apathy than patients given PST after controlling for age, sex, cognitive impairment, and diabetes mellitus status (adjusted hazard ratio: 3.47, 95% CI: 1.79-6.73 [escitalopram group]; adjusted hazard ratio: 1.84, 95% CI: 1.21-2.80 [PST group]).

CONCLUSION

Escitalopram or PST was significantly more effective in preventing new onset of apathy following stroke compared with placebo.

Recognition of emotion from body language among patients with unipolar depression

Major depression may be associated with abnormal perception of emotions and impairment in social adaptation. Emotion recognition from body language and its possible implications to social adjustment have not been examined in patients with depression. Three groups of participants (51 with depression; 68 with history of depression in remission; and 69 never depressed healthy volunteers) were compared on static and dynamic tasks of emotion recognition from body language. Psychosocial adjustment was assessed using the Social Adjustment Scale Self-Report (SAS-SR). Participants with current depression showed reduced recognition accuracy for happy stimuli across tasks relative to remission and comparison participants. Participants with depression tended to show poorer psychosocial adaptation relative to remission and comparison groups. Correlations between perception accuracy of happiness and scores on the SAS-SR were largely not significant. These results indicate that depression is associated with reduced ability to appraise positive stimuli of emotional body language but emotion recognition performance is not tied to social adjustment. These alterations do not appear to be present in participants in remission suggesting state-like qualities.

Post-stroke depression and the aging brain

Ageing is associated with changes in the function of various organ systems. Changes in the cardiovascular system affect both directly and indirectly the function in a variety of organs, including the brain, with consequent neurological (motor and sensory performance) and cognitive impairments, as well as leading to the development of various psychiatric diseases. Post-stroke depression (PSD) is among the most frequent neuropsychiatric consequences of cerebral ischemia. This review discusses several animal models used for the study of PSD and summarizes recent findings in the genomic profile of the ageing brain, which are associated with age-related disorders in the elderly. Since stroke and depression are diseases with increased incidence in the elderly, great clinical benefit may especially accrue from deciphering and targeting basic mechanisms underlying PSD. Finally, we discuss the relationship between ageing, circadian rhythmicity and PSD.

Strategies to improve recovery in acute ischemic stroke patients: Iberoamerican Stroke Group Consensus

Stroke is not only a leading cause of death worldwide but also a main cause of disability. In developing countries, its burden is increasing as a consequence of a higher life expectancy. Whereas stroke mortality has decreased in developed countries, in Latin America, stroke mortality rates continue to rise as well as its socioeconomic dramatic consequences. Therefore, it is necessary to implement stroke care and surveillance programs to better describe the epidemiology of stroke in these countries in order to improve therapeutic strategies. Advances in the understanding of the pathogenic processes of brain ischemia have resulted in development of effective therapies during the acute phase. These include reperfusion therapies (both intravenous thrombolysis and interventional endovascular approaches) and treatment in stroke units that, through application of management protocols directed to maintain homeostasis and avoid complications, helps to exert effective brain protection that decreases further cerebral damage. Some drugs may enhance protection, and besides, there is increasing knowledge about brain plasticity and repair mechanisms that take place for longer periods beyond the acute phase. These mechanisms are responsible for recovery in certain patients and are the focus of basic and clinical research at present. This paper discusses recovery strategies that have demonstrated clinical effect, or that are promising and need further study. This rapidly evolving field needs to be carefully and critically evaluated so that investment in patient care is grounded on well-proven strategies.

[Executive function deficits following stroke]

BACKGROUND

Executive function deficit is a cognitive dysfunction resulting in a reduced ability to initiate, control and monitor targeted behaviour. Our clinical experience indicates that this often remains undiagnosed following stroke.

METHOD

The article is based on literature searches using the search terms «Stroke» and «Executive function» via the search engine McMaster Plus, in the databases Cochrane Library and PubMed, coupled with the authors' own experience.

RESULTS

Executive function deficit is a common form of stroke-related cognitive dysfunction which often accompanies emotional instability and depression. The condition is an important risk factor for loss of self-sufficiency and for reduced survival. Diagnosis is based on the patient's history and observation, supplemented by cognitive testing. Executive function deficits also occur in patients with no clinical signs of stroke, but who have image diagnostic signs of cerebral ischaemia, and with other cerebral diseases such as Parkinson's disease and dementia. Executive function is mainly located in the prefrontal cortex and the subcortical circuits, but executive function deficits are also seen in cases of lesions in other areas of the brain. The treatment of executive function deficits focuses on compensatory strategies and on recovery of lost function.

INTERPRETATION

Executive function deficits are common with stroke-related cognitive impairment, and may affect the prognosis. There is a need for systematic testing and strategies for treatment and prevention.

Post-stroke depression: mechanisms, translation and therapy

The interaction between depression and stroke is highly complex. Post-stroke depression (PSD) is among the most frequent neuropsychiatric consequences of stroke. Depression also negatively impacts stroke outcome with increased morbidity, mortality and poorer functional recovery. Antidepressants such as the commonly prescribed selective serotonin reuptake inhibitors improve stroke outcome, an effect that may extend far beyond depression, e.g., to motor recovery. The main biological theory of PSD is the amine hypothesis. Conceivably, ischaemic lesions interrupt the projections ascending from midbrain and brainstem, leading to a decreased bioavailability of the biogenic amines – serotonin (5HT), dopamine (DA) and norepinephrine (NE). Acetylcholine would also be involved. So far, preclinical and translational research on PSD is largely lacking. The implementation and characterization of suitable animal models is clearly a major prerequisite for deeper insights into the biological basis of post-stroke mood disturbances. Equally importantly, experimental models may also pave the way for the discovery of novel therapeutic targets. If we cannot prevent stroke, we shall try to limit its long-term consequences. This review therefore presents animal models of PSD and summarizes potential underlying mechanisms including genomic signatures, neurotransmitter and neurotrophin signalling, hippocampal neurogenesis, cellular plasticity in the ischaemic lesion, secondary degenerative changes, activation of the hypothalamo-pituitary-adrenal (HPA) axis and neuroinflammation. As stroke is a disease of the elderly, great clinical benefit may especially accrue from deciphering and targeting basic mechanisms underlying PSD in aged animals.

A critical review of the mechanism of action for the selective serotonin reuptake inhibitors: do these drugs possess anti-inflammatory properties and how relevant is this in the treatment of depression?

The selective serotonin reuptake inhibitors (SSRIs) are the most widely prescribed pharmacological treatment for depression. Since their introduction many have considered the primary mechanism by which the SSRIs produced therapeutic improvement in depression is their effect on monoaminergic signalling. In recent years, however, the credibility of the monoamine theory and the therapeutic efficacy of these compounds in the treatment of depression has been extensively criticized. In the current review the legitimacy of these criticisms is critically examined, in many instances the evidence base used to support these criticisms is found to be weak. Nevertheless, the apparent 'failure' of the monoamine theory has been of benefit in motivating research into alternative mechanisms through which the SSRIs may act. Given research demonstrating that depressive symptoms are intimately linked with disturbances in pro-inflammatory signalling, perhaps the most promising discovery has been the realisation that SSRIs posses significant anti-inflammatory properties. These recent findings are discussed and contextualised with respect to the neurogenic, neurotrophic and gluatamatergic effects that these drugs also possess.

Exofocal dopaminergic degeneration as antidepressant target in mouse model of poststroke depression

BACKGROUND

Although poststroke depression (PSD) is a frequent chronic complication of stroke with high relevance for outcome and survival, underlying pathomechanisms remain inadequately understood. This may be because suitable animal models are largely lacking and existing models are poorly characterized.

METHODS

Male 129/SV mice were subjected to 30-min middle cerebral artery occlusion (MCAo)/reperfusion and serial magnetic resonance imaging scans. A subset of animals received selective serotonin reuptake inhibitor citalopram starting 7 days after MCAo. Behavioral assessment was performed at 14 weeks. To identify biological correlates of PSD, we quantified corticosterone levels in serum and brain-derived neurotrophic factor levels in brain. The integrity of the mesolimbic dopaminergic system was assessed using tyrosine hydroxylase and dynorphin in situ hybridizations as well as dopamine transporter autoradiography.

RESULTS

Left, but not right, MCAo, elicited anhedonia and increased anxiety and despair. This depression-like syndrome was associated with alterations in the mesolimbic reward system. MCAo resulted in delayed degeneration of dopaminergic neurons in ipsilateral midbrain, which was accompanied by reduced dopamine concentrations and decreased levels of dopamine transporter density along with increased brain-derived neurotrophic factor protein levels in ischemic striatum and increased dynorphin messenger RNA expression in nucleus accumbens. Chronic antidepressant treatment initiated as late as 7 days after stroke reversed the behavioral phenotype, prevented degeneration of dopaminergic midbrain neurons, and attenuated striatal atrophy at 4 months.

CONCLUSIONS

Our results highlight the importance of the dopaminergic system for the development of PSD. Prevention of secondary neurodegeneration by antidepressants may provide a novel target for subacute stroke therapy.

Optimal dosages of fluoxetine in the treatment of hypoxic brain injury induced by 3-nitropropionic acid: implications for the adjunctive treatment of patients after acute ischemic stroke

AIM

The serotonin selective reuptake inhibitor fluoxetine (Flx) has tried to treat patients suffered acute ischemic stroke because of its possible neuroprotective actions. However, besides the neuroprotective effect, Flx at high concentration also induces some actions in contradiction to neuroprotection in the brain. The purpose of this study was to investigate whether Flx presents neuroprotective effect against 3-nitropropionic acid (3-NP)-induced hypoxic brain injury, and what is the most suitable dosage of Flx.

METHODS

Mouse model was established by subacute systemic administration of 3-NP. Rotarod and pole tests were used to evaluate motor deficit. The oxidative stress and oxidative DNA damage were assessed respectively by measuring malondialdehyde and 8-hydroxydeoxyguanosine content in brain homogenates.

RESULTS

According to measurements in the rotarod test, 7 days pretreatment plus 5 days treatment of Flx at low (2.5 mg/kg/day) and, to a lesser degree, medium (5 mg/kg/day) doses exerted a rapid and strong protection against the neurotoxicity induced by 3-NP, whereas Flx at high dose (10mg/kg/day) showed a much late and light effect. Similarly, in the pole test, Flx at 2.5 mg/kg/day had the strongest protective effects. Again, only Flx administration at 2.5 mg/kg/day canceled out the enhancement of malondialdehyde and 8-hydroxydeoxyguanosine in striatum following 3-NP neurotoxication.

CONCLUSIONS

Flx attenuated the motor deficits induced by 3-NP in a dose-dependent manner. In contrary to the high dose, Flx at the lower doses had a more remarkable effect against 3-NP insult, similar to acute ischemic stroke.

Fluoxetine increases hippocampal neurogenesis and induces epigenetic factors but does not improve functional recovery after traumatic brain injury

The selective serotonin reuptake inhibitor fluoxetine induces hippocampal neurogenesis, stimulates maturation and synaptic plasticity of adult hippocampal neurons, and reduces motor/sensory and memory impairments in several CNS disorders. In the setting of traumatic brain injury (TBI), its effects on neuroplasticity and function have yet to be thoroughly investigated. Here we examined the efficacy of fluoxetine after a moderate to severe TBI, produced by a controlled cortical impact. Three days after TBI or sham surgery, mice were treated with fluoxetine (10 mg/kg/d) or vehicle for 4 weeks. To evaluate the effects of fluoxetine on neuroplasticity, hippocampal neurogenesis and epigenetic modification were studied. Stereologic analysis of the dentate gyrus revealed a significant increase in doublecortin-positive cells in brain-injured animals treated with fluoxetine relative to controls, a finding consistent with enhanced hippocampal neurogenesis. Epigenetic modifications, including an increase in histone 3 acetylation and induction of methyl-CpG-binding protein, a transcription factor involved in DNA methylation, were likewise seen by immunohistochemistry and quantitative Western immunoblots, respectively, in brain-injured animals treated with fluoxetine. To determine if fluoxetine improves neurological outcomes after TBI, gait function and spatial learning and memory were assessed by the CatWalk-assisted gait test and Barnes maze test, respectively. No differences in these parameters were seen between fluoxetine- and vehicle-treated animals. Thus while fluoxetine enhanced neuroplasticity in the hippocampus after TBI, its chronic administration did not restore locomotor function or ameliorate memory deficits.

Effect of selective serotonin re-uptake inhibitors (SSRIs) on functional outcome in patients with acute ischemic stroke treated with tPA

BACKGROUND

Selective serotonin re-uptake inhibitors (SSRIs) may have therapeutic potential in the treatment of ischemic stroke by effects on neuronal cell survival and the plasticity of brain processes. In the present study, we investigated whether prior treatment with a SSRI is associated with more favorable functional outcome in a cohort of patients with acute ischemic stroke treated with tissue plasminogen activator (tPA).

METHODS

In a prospective observational cohort study of 476 acute ischemic stroke patients treated with tPA we investigated the relationship between prior SSRI treatment and functional outcome at 3 months. Ischemic stroke subtypes were defined according to the Oxfordshire Community Stroke Project Classification. Favorable outcome was defined as a modified Rankin Scale score <or=2.

RESULTS

In the cohort of 476 patients, 22 (5%) patients used a SSRI at stroke onset. At 3 months, 217 (46%) patients had a favorable outcome of whom 9 (41%) on SSRI treatment and 208 (46%) not using SSRIs (p=0.65). In a multivariable analysis SSRI treatment showed a trend to association with unfavorable outcome (OR 0.4, 95% CI 0.14-1.13, p=0.08). In the 376 patients with cortical stroke, SSRI treatment was associated with an unfavorable outcome (OR 0.17, 95% CI 0.04-0.73, p=0.017).

CONCLUSION

Our data suggest that in patients with acute ischemic stroke treated with tPA, prior SSRI use may be associated with a less favorable outcome, especially in cortical stroke.

Cognitive performance in nondemented nonpsychotic Parkinson disease patients with or without a history of depression prior to the onset of motor symptoms

In Parkinson disease (PD), cognitive impairment is common, occurs mainly in the form of milder deficits (as opposed to dementia), and commonly coincides with depression. In this cross-sectional study, we evaluated whether depression that existed before the onset of typical motor symptoms (pre-PD depression) reflected on the actual cognitive performance. Nondemented nonpsychotic PD patients with (test, n = 27) and without (control, n = 112) a history of pre-PD depression, caliper-matched for age, education, and disease duration were assessed for motor and nonmotor disease characteristics and in a battery of cognitive tests. Test patients had higher actual depression/anxiety levels. Gradual multivariate and mediation analysis indicated unfavorable effects of pre-PD depression on cognition: a direct effect on mental set shifting/response inhibition (independent of actual depression/ anxiety or other factors); and indirect effects on other cognitive domains mediated through the increased depression/anxiety. Data suggest that pre-PD depression favors poorer cognitive abilities in nondemented patients at a given time after PD has been diagnosed.

The neuroanatomical model of post-stroke depression: towards a change of focus?

One third of all stroke survivors develop post-stroke depression (PSD). Depressive symptoms adversely affect rehabilitation and significantly increase risk of death in the post-stroke period. One of the theoretical views on the determinants of PSD focuses on psychosocial factors like disability and social support. Others emphasize biologic mechanisms such as disruption of biogenic amine neurotransmission and release of proinflammatory cytokines. The "lesion location" perspective attempts to establish a relationship between localization of stroke and occurrence of depression, but empirical results remain contradictory. These divergences are partly related to the fact that neuroimaging methods, unlike neuropathology, are not able to assess precisely the full extent of stroke-affected areas and do not specify the different types of vascular lesions. We provide here an overview of the known phenomenological profile and current pathogenic hypotheses of PSD and present neuropathological data challenging the classic "single-stroke"-based neuroanatomical model of PSD. We suggest that vascular burden due to the chronic accumulation of small macrovascular and microvascular lesions may be a crucial determinant of the development and evolution of PSD.

Antidepressant drugs and cardiovascular pathology: a clinical overview of effectiveness and safety

OBJECTIVE

To review data examining the relationships between depression, antidepressants and cardiovascular disease.

METHOD

Structured searches of PubMed, Medline and Embase conducted in March 2008.

RESULTS

Depression and cardiovascular disease are closely associated clinical entities. Depression appears both to cause and worsen cardiovascular disease. Cardiovascular disease is in turn associated with a high incidence of depression. Depression is associated with increased mortality in cardiovascular disease, and after myocardial infarction (MI) and stroke. Many antidepressants have cardiotoxic properties. Tricyclic drugs are highly cardiotoxic in overdose and may induce cardiovascular disease and worsen outcome in established cardiovascular disease. Reboxetine, duloxetine and venlafaxine are known to increase blood pressure. Other antidepressants have neutral or beneficial effects in various cardiovascular disorders.

CONCLUSION

Sertraline, fluoxetine, citalopram, bupropion and mirtazapine appear to be safe to use after MI; the use of sertraline, and response to citalopram and mirtazapine may improve mortality. Paroxetine and citalopram appear to be safe to use in patients with established coronary artery disease. Limited data suggest that a variety of antidepressants are effective and safe to use after stroke.

Interventions for preventing depression after stroke

BACKGROUND

Depression is an important consequence of stroke that impacts on recovery yet often is not detected or is inadequately treated.

OBJECTIVES

To determine if pharmaceutical or psychological interventions can prevent depression and improve physical and psychological outcomes in patients with stroke.

SEARCH STRATEGY

We searched the Trials Registers of the Cochrane Stroke Group (October 2007) and the Cochrane Depression Anxiety and Neurosis Group (February 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2008), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), CINAHL (1982 to May 2006), PsycINFO (1967 to May 2006), Applied Science and Technology Plus (1986 to May 2006), Arts and Humanities Index (1991 to September 2002), Biological Abstracts (1969 to September 2002), BIOSIS Previews (2002 to May 2006), General Science Plus (1994 to September 2002), Science Citation Index (1992 to May 2006), Social Sciences Citation Index (1991 to May 2006), SocioFile (1974 to May 2006) ISI Web of Science (2002 to February 2008), reference lists, trial registers, conference proceedings and dissertation abstracts, and contacted authors, researchers and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing pharmaceutical agents with placebo, or psychotherapy against standard care (or attention control) to prevent depression in patients with stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed trial quality. Primary analyses were the proportion of patients who met the standard diagnostic criteria for depression applied in the trials at the end of follow up. Secondary outcomes included depression scores on standard scales, physical function, death, recurrent stroke and adverse effects.

MAIN RESULTS

Fourteen trials involving 1515 participants were included. Data were available for 10 pharmaceutical trials (12 comparisons) and four psychotherapy trials. The time from stroke to entry ranged from a few hours to seven months, but most patients were recruited within one month of acute stroke. The duration of treatment ranged from two weeks to one year. There was no clear effect of pharmacological therapy on the prevention of depression or other endpoints. A significant improvement in mood and the prevention of depression was evident for psychotherapy, but the treatment effects were small.

AUTHORS' CONCLUSIONS

A small but significant effect of psychotherapy on improving mood and preventing depression was identified. More evidence is required before recommendations can be made about the routine use of such treatments after stroke.

Escitalopram and problem-solving therapy for prevention of poststroke depression: a randomized controlled trial

CONTEXT

Depression occurs in more than half of patients who have experienced a stroke. Poststroke depression has been shown in numerous studies to be associated with both impaired recovery in activities of daily living and increased mortality. Prevention of depression thus represents a potentially important goal.

OBJECTIVE

To determine whether treatment with escitalopram or problem-solving therapy over the first year following acute stroke will decrease the number of depression cases that develop compared with placebo medication.

DESIGN, SETTING, AND PARTICIPANTS

A multisite randomized controlled trial for prevention of depression among 176 nondepressed patients was conducted within 3 months following acute stroke from July 9, 2003, to October 1, 2007. The 12-month trial included 3 groups: a double-blind placebo-controlled comparison of escitalopram (n = 59) with placebo (n = 58), and a nonblinded problem-solving therapy group (n = 59).

MAIN OUTCOME MEASURES

The main outcome measure was the development of major or minor poststroke depression based on symptoms elicited by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) and the diagnostic criteria from DSM-IV for depression due to stroke with major depressive-like episode or minor depression (ie, research criteria).

RESULTS

Patients who received placebo were significantly more likely to develop depression than individuals who received escitalopram (11 major and 2 minor cases of depression [22.4%] vs 3 major and 2 minor cases of depression [8.5%], adjusted hazard ratio [HR], 4.5; 95% confidence interval [CI], 2.4-8.2; P < .001) and also more likely than individuals who received problem-solving therapy (5 major and 2 minor cases of depression [11.9%], adjusted HR, 2.2; 95% CI, 1.4-3.5; P < .001). These results were adjusted for history of mood disorders and remained significant after considering possible confounders such as age, sex, treatment site, and severity of impairment in the model. Using an intention-to-treat conservative method of analyzing the data, which assumed that all 27 patients who did not start randomized treatment would have developed depression, and controlling for prior history of mood disorders, escitalopram was superior to placebo (23.1% vs 34.5%; adjusted HR, 2.2; 95% CI, 1.2-3.9; P = .007), while problem-solving therapy was not significantly better than placebo (30.5% vs 34.5%; adjusted HR, 1.1; 95% CI, 0.8-1.5; P = .51). Adverse events, including all-cause hospitalizations, nausea, and adverse effects associated with escitalopram were not significantly different between the 3 groups.

CONCLUSIONS

In this study of nondepressed patients with recent stroke, the use of escitalopram or problem-solving therapy resulted in a significantly lower incidence of depression over 12 months of treatment compared with placebo, but problem-solving therapy did not achieve significant results over placebo using the intention-to-treat conservative method of analysis.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00071643.