Post-stroke depression, antidepressant treatment and rehabilitation results. A case-control study

The aim of this study was to assess the specific influence of poststroke depression (PSD) on both basal functional status and rehabilitation results. We performed a case-control study in 290 stroke inpatients, matched for age (+/-1 year) and onset admission interval (+/-3 days) and divided in two groups according to the presence (PSD+) or absence (PSD-) of PSD. All PSD+ patients were treated with antidepressants (AD), mainly with fluoxetine. PSD+ patients, despite similar severity of stroke, showed greater disability in coping with activities of daily living (ADL) on admission and greater disability both in ADL and mobility at discharge than PSD- patients. Although both groups exhibited similar average functional improvement during rehabilitation, PSD- patients were nearly twice as likely to show excellent recovery both on ADL and mobility as PSD+ patients (OR = 1.95, 95% CI = 1.01-3.75 and OR = 2.23, 95% CI = 1.14-4.35, respectively). All AD drugs improved depressive symptoms. Few relevant side effects were observed: fluoxetine was discontinued in 2 patients because of insomnia and in 2 patients because of nausea; paroxetine was stopped in 1 patient because of nausea and dry mouth. Our results confirm the unfavorable influence of PSD on functional outcome, despite pharmacological treatment.

Vascular dementia: a cognitive SPET-CBF activation study

OBJECTIVE

We investigated the pattern of regional cerebral blood flow (rCBF) responses to a cognitive task in vascular patients with and without dementia.

METHOD

We studied 8 controls and 18 vascular patients by quantitative rCBF assessed by (133)Xe inhalation method and SPET, both at rest and during a cognitive figure recognition task. Eight were mildly demented and 10 were nondemented vascular patients. According to their task performance, 12 patients were classified as 'good performers' (GPs) and 6 patients as 'poor performers' (PPs).

RESULTS

Vascular patients activated a larger number of brain areas than controls. No differences were observed between controls, nondemented and mildly demented patients in the pattern of rCBF activation. GPs presented a lower mean percentage of rCBF increase than either controls or PPs. GPs had lower values than PPs in the left temporal, parietal and occipital regions and in the right posterior cingulate and occipital regions.

CONCLUSIONS

These data suggest that vascular patients may functionally compensate for vascular damage by activating more brain areas than controls do and, consequently, by increasing the rate of regional activation.

Mobility status after inpatient stroke rehabilitation: 1-year follow-up and prognostic factors

OBJECTIVES

To evaluate the stability of mobility status achieved by stroke patients during hospital rehabilitation treatment over time and to identify reliable prognostic factors associated with mobility changes.

DESIGN

Follow-up evaluation in consecutive first-ever stroke patients 1 year after hospital discharge. Multiple logistic regressions were used to analyze increases and decreases in Rivermead Mobility Index (RMI) scores (dependent variables) between discharge and follow-up. Independent variables were medical, demographic, and social factors.

SETTING

Rehabilitation hospital.

PATIENTS

A cohort of 155 patients with sequelae of first stroke, with a final sample of 141.

MAIN OUTCOME MEASURES

Mobility status at 1-year follow-up, as measured by the RMI, and odds ratios (OR) for improvement and decline in mobility.

RESULTS

Functionally, 19.9% improved the mobility levels achieved during the inpatient rehabilitation treatment; levels of 42.6% worsened. Patients with global aphasia (OR = 5.66; 95% confidence interval [CI], 1.50-21.33), unilateral neglect (OR = 3.01; 95% CI, 1.21-7.50), and age 75 years or older (OR = 5.77; 95% CI, 1.42-23.34) had a higher probability of mobility decline than the remaining patients. Postdischarge rehabilitation treatment (PDT), received by 52.5% of the final sample, was significantly and positively associated with mobility improvement (OR = 5.86; 95% CI, 2.02-17.00). Absence of PDT was associated with a decline in mobility (OR = 3.73; 95% CI, 1.73-8.04).

CONCLUSIONS

In most cases, mobility status had not yet stabilized at hospital discharge. PDT was useful in preventing a deterioration in mobility improvement achieved during inpatient treatment and in helping increase the likelihood of further mobility improvement.

Correlation of cerebral hemodynamic changes during mental activity and recovery after stroke

OBJECTIVE

To investigate the correlation between changes in cerebral functional activity during mental engagement and the potential for neurologic recovery after stroke.

BACKGROUND

Transcranial Doppler ultrasonography (TCD) makes it possible to detect the dynamic adjustment of cerebral perfusion related to functional neuronal changes.

METHODS

TCD monitoring of flow velocity changes in the middle cerebral artery of 29 ischemic stroke patients was performed during an object recognition task. The study took place within 4 weeks from stroke onset. Based on recovery occurring after 2 months, the patients were divided into four groups depending on the side of hemispheric lesion and the presence or absence of neurologic recovery. Ten healthy subjects served as control subjects.

RESULTS

During the recognition task, control subjects showed a bilateral increase in flow velocity with respect to the rest phase (right side, 7.02 +/- 1.3%; left side, 6.65 +/- 1. 1%), with no side-to-side difference. In patients who experienced recovery, a similar pattern of bilateral activation was observed, irrespective of the side of the lesion. Conversely, in patients with no recovery, the increase of flow velocity was significantly higher on the side contralateral to the brain lesion (p < 0.0001) with respect to the lesion side. Performance during the recognition task was comparable in the four groups of patients.

CONCLUSIONS

These findings suggest that satisfactory recovery from a neurologic deficit requires the persistence of functional activity in the damaged hemisphere despite the presence of an anatomic lesion. The possibility of obtaining early prognostic indications with TCD may be relevant for an early selection of patients with the best probability of benefiting from rehabilitation therapy.

Early versus delayed inpatient stroke rehabilitation: a matched comparison conducted in Italy

OBJECTIVE

To assess the specific influence of onset-admission interval (OAI) on rehabilitation results.

DESIGN

A case-control study in consecutive stroke inpatients, enrolled in homogeneous subgroups, matched for age (within 1 year) and Barthel Index (BI) score at admission, and different for OAI to the rehabilitation ward. The short OAI group began rehabilitation treatment within the first 20 days from stroke, medium OAI group between days 21 and 40, and long OAI between days 41 and 60.

SETTING

Rehabilitation hospital.

PATIENTS

One hundred forty-five patients with sequelae of first stroke.

MAIN OUTCOME MEASURES

Efficiency (average increase in BI per day), effectiveness (proportion of potential improvement achieved during rehabilitation) of treatment, and percentage of low- and high-response patients, calculated on BI, were evaluated. Odds ratios (ORs) of dropouts and of poor and excellent therapeutic response were also quantified.

RESULTS

The short OAI subgroup had significantly higher effectiveness of treatment than did the medium (p < .05) and the long OAI groups (p < .005). Beginning treatment within the first 20 days was associated with a significantly high probability of excellent therapeutic response (OR = 6.11; 95% confidence interval [CI], 2.03-18.36), and beginning later was associated with a similar risk of poor response (OR = 5.18; 95% CI, 1.07-25.00). On the other hand, early intervention was associated with a five times greater risk of dropout than that of patients with delayed start of treatment (OR = 4.99; 95% CI, 1.38-18.03). The three subgroups were significantly (p < .05) different regarding the percentage of low and high responders.

CONCLUSION

Our results showed a strong association between OAI and functional outcome.

Bromocriptine and speech therapy in non-fluent chronic aphasia after stroke

The objectives of this study were to investigate the efficacy of bromocriptine (BR) combined with speech therapy (ST) to improve a late recovery in non-fluent aphasic stroke patients. We performed a double-blind study with high dosage of BR, prescribed according to a dose-escalating protocol, comprehensive of clinical data, relatives' impression, and language evaluations. The study was divided into the following phases: t-0, inclusion; t-30, language re-test to evaluate the stability of aphasia; t-90, placebo (PL) and ST; t-150, BR and ST; t-210, BR; t-270, wash-out. With respect to the baseline assessment, a significant improvement was observed in the following tests: dictation (F, 4.8; p < .004), reading-comprehension (F, 8.1; p < .0003), repetition (F, 3.8; p < .01) and verbal latency (F, 4.9; p < .01). High dosage of BR promoted a late recovery in stable chronic non-fluent aphasia and this improvement was enhanced by combination with ST.

One-year follow-Up in stroke patients discharged from rehabilitation hospital

This study was designed to evaluate functional status at a 1-year follow-up in consecutive first-stroke patients after discharge from rehabilitation hospital and to identify reliable prognostic factors associated with changes in their abilities. Functional evaluation was made of consecutive patients 1 year after discharge to their own homes. Two multiple logistic regressions (forward stepwise) were performed using both improvement and worsening of the Barthel Index score between discharge and follow-up as dependent variables. Independent variables were medical, demographic and social factors. The final sample included 157 out of 172 patients. During the follow-up, 10 patients (5.81%) died because of a new cerebrovascular event, 1 patient died of myocardial infarction, 2 patients had new strokes and 2 fractured their paretic legs. Functionally, 43.3% of the patients maintained the level they achieved during inpatient rehabilitation treatment, 23.6% improved and the remaining 33.1% worsened. Patients with hemineglect and aged >/=65 years had a higher probability of functional worsening (odds ratio, OR = 3.77, 95% confidence interval, CI = 1.42- 10.0 and OR = 3.93, 95% CI = 1. 72-8.95, respectively). Postdischarge rehabilitation (performed for 46.5% of the final sample) was significantly and positively associated with functional improvement (OR = 7.23, 95% CI = 2.89-18. 05), and its absence with functional worsening (OR = 12.32, 95% CI = 4.47-37.01). In conclusion, in nearly half of the cases, functional status was still not stabilized at the time of discharge from the rehabilitation hospital. Postdischarge outpatient treatment was useful for preventing worsening of the functional ability achived during inpatient treatment and increased the possibility of further functional improvement. Age >/=65 years and hemineglect were predictors of functional worsening at follow-up.

Cerebral hemodynamics in young hypertensive subjects and effects of atenolol treatment

The aim of this study was to evaluate changes in cerebral hemodynamics in young patients with uncomplicated hypertension before and after effective antihypertensive treatment with a beta-blocker drug. Changes in mean flow velocity in the middle cerebral artery from normal condition to hypercapnia were evaluated by means of a transcranial Doppler in 42 hypertensive patients and 21 healthy subjects comparable for age and sex distribution. We obtained hypercapnia with breath-holding and evaluated cerebrovascular reactivity with the breath-holding index (BHI). After a baseline evaluation (time 0), patients were randomly assigned to a placebo (group 1) or atenolol (group 2) therapy. The evaluation was repeated after 30 (time 1) and 60 (time 2) days of treatment. Before treatment, hypertensive patients had significantly lower BHI values (0.96 +/- 0.1 group 1 and 0.85 +/- 0.3 group 2) than controls (1.69 +/- 0.4) (P < 0.0001). During treatment, mean blood pressure significantly decreased in group 2 patients. In the same group, BHI values significantly increased with respect to the pre-treatment evaluation: 1.39 +/- 0.2 at time 1 and 1.44 +/- 0.2 at time 2 (P < 0.0001). On the contrary, mean blood pressure and BHI values remained unchanged in the placebo group. Furthermore, BHI values were significantly higher in group 2 than in group 1 patients at times 1 (P < 0.001) and 2 (P < 0.0001). These findings suggest that hypertension causes reduced capability of cerebral vessels to adapt to functional changes. This condition, which is reversible after treatment, could be implicated in the increased susceptibility to ischemic stroke in hypertension.

Cerebral hemodynamic patterns during stimuli tasks in multi-infarct and Alzheimer types of dementia

OBJECTIVES

To examine differences in cerebrovascular reactivity between multi-infarct and Alzheimer types of dementia.

PATIENTS AND METHODS

Using transcranial Doppler, measurements of flow velocity in the middle cerebral arteries during apnea, thumb-to-finger opposition and verbal and design discrimination tasks were recorded in patients with multi-infarct (n=10; mean age 68+/-7.5 years) and Alzheimer types of dementia (n=10; mean age 62+/-9.1 years). Controls were 20 healthy subjects matched for age and sex.

RESULTS

Cerebral reactivity to apnea was significantly lower (P<0.0001) in the multi-infarct group compared to the other 2 groups. During the motor task, a nearly selective increase of mean flow velocity in the middle cerebral artery contralateral to the hand performing the task occurred in both controls and Alzheimer patients. A bilateral increase, without side-to-side differences, of flow velocity during movement of each hand was observed in multi-infarct patients. With respect to baseline values, the cognitive tasks produced significant and distinct effects on the left and right side in the controls but not in the patients. Controls showed a significant increase of left middle cerebral artery mean flow velocity during a verbal task (P<0.0001), and of the right middle cerebral artery mean flow velocity during a design discrimination task (P<0.001) when side-to-side comparisons were done. Differently, a bilateral and comparable increase of flow velocity was observed in all patients during performance of the same cognitive tasks.

CONCLUSION

These data suggest that cerebrovascular reactivity to apnea could be an additional criterion for discriminating between MID and DAT patients. Transcranial Doppler assessment during cognitive and motor tasks could provide useful complementary information for comprehension changes in cerebral activity in patients with dementia.

Anticipation of onset age in hereditary essential tremor

The genetic anticipation phenomenon has been described in several neurological disorders, often associated with unstable trinucleotide repeats in the affected genes. The occurrence of this phenomenon in hereditary essential tremor is still debated. We describe a family in which three male members with essential tremor showed a progressive anticipation in onset age and an increased severity of clinical symptomatology.

Transcranial Doppler ultrasound battery reliably identifies severe internal carotid artery stenosis

BACKGROUND AND PURPOSE

There is a clinical imperative for noninvasive tests for carotid disease that have high sensitivity. Previous studies have shown that transcranial Doppler ultrasound (TCD) can identify intracranial collateral flow patterns and other hemodynamic consequences of carotid occlusion. We hypothesized that a battery of such TCD findings would have a greater sensitivity than any one TCD finding alone and would have clinical utility in identifying carotid disease.

METHODS

We determined the prevalence of seven TCD findings in patients with various degrees of carotid stenosis as measured by a blinded observer on 138 cerebral angiograms. We further determined the sensitivity and specificity of any one finding or any single abnormality in the TCD battery (the combination of all seven findings) for identifying severe (> or = 70%) carotid stenosis by angiography.

RESULTS

The following four individual TCD findings were associated (P < .001) with > or = 70% carotid stenosis on cerebral angiography: ophthalmic and anterior cerebral artery flow reversal and low middle cerebral artery flow acceleration and pulsatility. The presence of any single abnormality in the TCD battery had a similar association (P < .001) with > or = 70% carotid stenosis. The individual TCD findings had sensitivities of 3% to 83% and specificities of 60% to 100% for identifying > or = 70% carotid stenosis. The TCD battery had a sensitivity of 95% and specificity of 42% for identifying > or = 70% carotid stenosis.

CONCLUSIONS

A battery of TCD findings that can be routinely measured reliably identified patients with > or = 70% angiographic internal carotid artery stenosis with high sensitivity.

The evaluation of symptomatic carotid artery disease. A survey of specialty practices in Rhode Island

Severe, symptomatic carotid artery disease is most often diagnosed by conventional cerebral angiography. Noninvasive tests are commonly used to identify candidates for angiography and endarterectomy. The purpose of this study, a mail and telephone survey of academic and community neurologists, neurosurgeons, and vascular surgeons in Rhode Island in 1994, was to determine which noninvasive tests physicians used to evaluate these patients and how the test results were used to select patients for angiography. One hundred (86%) of a possible 116 responses were collected. Seventy-six percent of physicians chose carotid duplex ultrasound as the first diagnostic test, a percentage significantly higher than that for any other test (p < 0.0001). Fourteen percent chose angiography without a prior screening test; 3% chose magnetic resonance angiography (MRA) prior to angiography, 6% chose carotid duplex ultrasound plus MRA prior to angiography, and 1% chose MRA without angiography. The specific noninvasive test results required for angiography referral were surprisingly variable, both within and across the three physician specialties. Vascular surgeons and neurosurgeons were more likely to choose angiography without prior screening tests than were neurologists. In conclusion, the majority of specialty physicians in the state of Rhode Island chose carotid ultrasound as the screening test of choice for the evaluation of a potential endarterectomy candidate. Few responding physicians chose MRA in combination with carotid duplex ultrasound prior to angiography, or MRA prior to angiography or MRA alone. Awareness of the actual practice patterns of specialists may lead to programs of education for physicians to improve practice and patient outcome through more refined use of diagnostic tests prior to angiography or endarterectomy.

Patterns of neuropsychological impairment in mild dementia: a comparison between Alzheimer's disease and multi-infarct dementia

The objective was to investigate the clinical and psychometric differences between patients with dementia of Alzheimer type (DAT) and patients with multi-infarct dementia (MID), matched for age, sex, education, and severity. Sixteen patients with DAT, 16 patients with MID, and 30 healthy individuals, were drawn from a longitudinal study on aging and dementia. Subjects with medical or previous mental disorders were excluded. DAT and controls with focal brain abnormalities on magnetic resonance imaging (MRI) were excluded. Diagnosis of dementia was carried out according to DSM-III-R criteria. Dementia severity was staged using the Clinical Dementia Rating (CDR) scale, and only patients with a score of 0.5-1 on CDR were studied. The main outcome measures were quantitative clinical scales of the assessment of global mental status, depression and anxiety, as well as a wide battery of neuropsychological tests for the evaluation of executive/conceptual functions and memory, as well as attention verbal ability, and visuospatial skill functions. The performance of demented patients compared to normal controls was affected on all measurements except for depression and anxiety. DAT patients showed compared to MID patients a greater extent of impairment on tasks assessing verbal comprehension and memory while MID patients were more significantly impaired on measures of frontal lobe functioning. Clinically matched DAT and MID patients show a differential pattern of neuropsychological impairment when studied in an early stage of dementia and with a mild degree of severity. Such patterns might be of value for the development of clinical diagnostic criteria.

Spontaneous middle cerebral artery reperfusion in ischemic stroke. A follow-up study with transcranial Doppler

BACKGROUND AND PURPOSE

The aim of this study was to investigate by means of transcranial Doppler (TCD) ultrasonography how many spontaneous reperfusions of the middle cerebral artery (MCA) occurred during the first week after onset of acute ischemic stroke in the carotid territory.

METHODS

TCD examination, computed tomographic scan, and arterial digital angiography were performed in 56 patients with acute ischemic stroke within 6 hours of the onset of symptoms. The TCD examination was repeated within 24 hours, 48 hours, and 7 days after stroke; a further TCD examination was performed within 3 to 9 months in 27 patients.

RESULTS

At 6 hours, 33 patients presented abnormal TCD findings in the symptomatic MCA (16 "no flows" and 17 asymmetries). Of these, 4 patients (3 no flows and 1 asymmetry) died before the 7-day follow-up was completed, whereas of the 29 remaining patients undergoing all the TCD control examinations, only 14 presented permanently abnormal TCD findings (7 asymmetries and 7 no flows). These data are consistent with an MCA reperfusion occurring at any level of the MCA, although most frequently in the distal part, and in the majority of cases during the first 48 hours. One patient who showed MCA asymmetrical flow velocity at the day-7 TCD examination was normal at the TCD follow-up at 3 to 9 months.

CONCLUSIONS

TCD examination offers an easy and reliable way of monitoring MCA reopening and might be useful to identify subgroups of patients who may benefit most from pharmacological reperfusion.

Sjögren's syndrome presenting as ischemic stroke

BACKGROUND

We describe a young woman who presented with minor stroke as a first clinical symptom of Sjögren's syndrome (SS) in the absence of well-known risk factors for cerebrovascular disease.

CASE DESCRIPTION

The medical history included recurrent miscarriages and sun rashes, which directed the diagnosis toward immunologic disorders such as systemic lupus erythematosus and antiphospholipid antibody syndrome, which are often associated with stroke. Only complete laboratory testing, including SSB antibody studies, and ophthalmologic and salivary gland evaluation revealed the correct diagnosis.

CONCLUSIONS

Sjögren's syndrome should be considered among the causes of stroke, especially in a young female patient.

An absent ophthalmic artery or carotid siphon signal on transcranial Doppler confirms the presence of severe ipsilateral internal carotid artery disease

Transcranial Doppler ultrasound provides a useful adjunct to extracranial ultrasound in the diagnosis of carotid bifurcation disease. Previous studies have shown that collateral flow patterns and diminished flow velocities in the ipsilateral middle cerebral artery correlate with hemodynamically significant carotid disease. In a series of 7,054 carotid duplex and transcranial Doppler examinations, 12.5% (95% confidence interval [CI]: 8.7, 16.4) of 287 ophthalmic arteries ipsilateral to an apparent carotid occlusion had no detectable flow signal, compared with 0.5% (95% CI: 0.3, 0.7) of 6,767 ophthalmic arteries ipsilateral to a non-occluded carotid artery (p < 0.001). Carotid siphon signals were not detectable in 24.4% (95% CI: 19.4, 29.4) of arteries ipsilateral to the carotid occlusion, versus 1.0% (95% CI: 0.8, 1.3) ipsilateral to nonoccluded carotid arteries (p < 0.001). A significant number of absent ophthalmic artery and carotid siphon signals (5.7 and 8.7%, respectively) were also found in patients with 80 to 99% extracranial carotid stenosis. A subset of 216 studies with angiographic correlation confirmed the high association of these transcranial Doppler findings with severe stenosis or occlusion of the internal carotid artery. Primary ophthalmological disease or siphon occlusion did not explain these findings. An absent ophthalmic artery or carotid siphon signal on transcranial Doppler examination is believed to represent a failure to detect slow flow distal to severe carotid bifurcation lesions. As a sign of ipsilateral carotid occlusion, the sensitivities of absent ophthalmic artery and carotid siphon signals are quite low (12.5 and 24.4%, respectively). The high specificities of 99.5 and 99.0%, however, make these findings useful in confirming the diagnosis of presumptive carotid occlusion by carotid duplex ultrasound.

Detection of nephrotoxicity in cyclosporine-A amyotrophic lateral sclerosis patients by means of urinary cytology

Exfoliative urinary cytology was used for two amyotrophic lateral sclerosis patients treated with 3 mg/kg/day cyclosporine (CsA) therapy in order to detect the onset of the nephrotoxic side-effects of the drug before the apparent deterioration of the patients' clinical condition. Of the two patients, only one showed clear morphological features of drug-related damage in a one year course of cyclosporine therapy, but these followed the increase in the serum kidney and liver laboratory parameters and did not prove useful for the early detection of nephrotoxicity. However, in this patient the renal damage was hallmarked by an increasing number of tubular cells or clusters of ill-defined renal cells in the urinary specimen, suggesting an ongoing tubular injury. The slight cytological alterations may possibly be due to the low CsA dosage used for these patients. The significance of these observations is tempered by the limited number of patients and specimens studied to date and further studies in nontransplanted patients are therefore advocated, particularly when higher CsA doses are employed.

One year treatment with lisuride delivery pump in Parkinson's disease

1. A group of 14 fluctuating Parkinsonian patients underwent the subcutaneous Lisuride treatment, administered by an insulin delivery pump. Clinical response has been studied during a one year period. 2. Some patients (8 out of 14) were in combined therapy, assuming a relative small amount of oral L-Dopa together with subcutaneous Lisuride. 3. Lisuride confirmed, also by the subcutaneous route, its antiparkinsonian properties, without any loss of therapeutical efficacy during the 12 month period considered. 4. 7 patients dropped-out from the study, due to psychiatric or systemic side-effects and to "technical" management of the pump. 5. The only 2 patients assuming a 24 hour regimen of Lisuride infusion were among the withdrawn subjects. They were also the only to complain severe psychiatric disturbances.

Comparison between L-dopa and lisuride intravenous infusions: a clinical study

L-Dopa is still the most effective drug for the treatment of Parkinson's Disease, but after 5 years or more of therapy fluctuations in motor performance and abnormal involuntary movements commonly appear. Continuous intravenous infusions of L-Dopa abolish or strikingly reduce such fluctuations. Unfortunately, this is not suitable for daily treatment because of the low solubility of L-Dopa. Lisuride is a potent dopamine agonist and is very soluble in water. In this study the clinical effects of L-Dopa and lisuride continuous intravenous infusions were compared in a group of 20 fluctuating parkinsonian patients. L-Dopa controlled fluctuations in almost all the subjects, whereas only seven patients were continuously mobile while taking lisuride. Another seven patients showed a fluctuating response and the remaining six did not satisfactorily respond to lisuride. Dyskinesias were present in all patients during "on" phases, with both levodopa and lisuride treatment.