Post-stroke depression: Mechanisms and pharmacological treatment

Risk Factors for Depressive Symptoms in Korean Adult Stroke Survivors: The Korea National Health and Nutrition Examination Survey IV-VII (2007-2018)

Depressive symptoms are common in stroke survivors, and they are associated with poor outcomes. Therefore, this study aimed to investigate the depressive symptoms in stroke survivors and the risk factors for depressive symptoms in stroke survivors. We included 33,991 participants who were 19 years or older and had completed a questionnaire about the history of stroke from the Korea National Health and Nutrition Examination Survey (KNHANES) IV–VII (from 2007 to 2018). The mean Patient Health Questionnaire-9 score and the prevalence of major depression, depressive symptoms, antidepressant treatment, suicidal ideation, and suicide attempts were significantly higher in stroke survivors than in non-stroke participants (4.4 vs. 2.6, 16.2% vs. 5.3%, 24.7% vs. 9.3%, 3.8% vs. 1.4%, 21.7% vs. 4.8%, and 2.5% vs. 0.6%, respectively, all p < 0.001). Complex sample multivariate logistic regression analysis revealed that the female sex, unemployment, a low education level, a low family income, and activity limitations were independent risk factors for depressive symptoms in stroke survivors. Activity limitations showed the highest odds ratio among the independent factors, and its causes were further analyzed. The most common causes of activity limitations were stroke sequelae and musculoskeletal problems. To reduce depressive symptoms in stroke survivors, attention needs to be paid to minimizing stroke sequelae and musculoskeletal problems along with regular screening for depressive symptoms.

Prevalence, predictors, and prognoses of prestroke neuropsychiatric symptoms at 3 months poststroke

OBJECTIVES

Prior neuropsychiatric disturbances are risk factors for stroke. There is a knowledge gap on the predictors of prestroke psychopathology, as well as their association with stroke outcomes in survivors living in low- and middle-income countries (LMICs). We estimated prevalence, predictors, and association of prestroke neuropsychiatric symptoms with poststroke depression (PSD), disability, and mortality.

DESIGN

Prospective observation.

SETTING

Nigeria.

PARTICIPANTS

Adult ischemic and hemorrhagic stroke survivors.

MEASUREMENTS

Prestroke psychopathology were ascertained using the Neuropsychiatric Inventory Questionnaire (NPI-Q). Outcomes were assessed using validated tools, including the Centre for Epidemiologic Studies - Depression Scale (CES-D 10) and modified Rankin scale (mRS). Independent associations were investigated using regression models with Bonferroni corrections, and presented as standardized mean differences (SMD) and odds ratios (OR) within 95% confidence intervals (CI).

RESULTS

Among 150 participants, prestroke neuropsychiatric symptoms were found in 78 (52%). In multivariate logistic regression analyses, prestroke sleep disturbance was associated with systemic hypertension (OR = 5.39, 95% CI = 1.70-17.08). Prestroke neuropsychiatric symptoms independently predicted worse motor disability scores (SMD = 0.92, 95% CI = 0.21-1.62) and greater odds of poststroke mortality (OR = 2.7, 95% CI = 1.1-7.0) at 3 months. However, prestroke depression was not significantly associated with PSD.

CONCLUSION

Prestroke sleep disturbances was associated with systemic hypertension, a key index of high cardiovascular risk profile and stroke. The findings should energize before-the-stroke identification and prioritization of limited treatment resources in LMICs to persons with sleep symptoms who have multiple, additional, risks of stroke.

Inflammatory neuropsychiatric disorders and COVID-19 neuroinflammation

Neuropsychiatric sequalae to coronavirus disease 2019 (COVID-19) infection are beginning to emerge, like previous Spanish influenza and severe acute respiratory syndrome episodes. Streptococcal infection in paediatric patients causing obsessive compulsive disorder (PANDAS) is another recent example of an infection-based psychiatric disorder. Inflammation associated with neuropsychiatric disorders has been previously reported but there is no standard clinical management approach established. Part of the reason is that it is unclear what factors determine the specific neuronal vulnerability and the efficacy of anti-inflammatory treatment in neuroinflammation. The emerging COVID-19 data suggested that in the acute stage, widespread neuronal damage appears to be the result of abnormal and overactive immune responses and cytokine storm is associated with poor prognosis. It is still too early to know if there are long-term-specific neuronal or brain regional damages associated with COVID-19, resulting in distinct neuropsychiatric disorders. In several major psychiatric disorders where neuroinflammation is present, patients with abnormal inflammatory markers may also experience less than favourable response or treatment resistance when standard treatment is used alone. Evidence regarding the benefits of co-administered anti-inflammatory agents such as COX-2 inhibitor is encouraging in selected patients though may not benefit others. Disease-modifying therapies are increasingly being applied to neuropsychiatric diseases characterised by abnormal or hyperreactive immune responses. Adjunct anti-inflammatory treatment may benefit selected patients and is definitely an important component of clinical management in the presence of neuroinflammation.

The Clinical Significance of Serum IL-33 and sST2 Alterations in the Post-Stroke Depression

Introduction

This study was to test whether the serum levels of IL-33 and sST2 are correlated with the development of depression after acute ischemic stroke.

Methods

Patients diagnosed with acute ischemic stroke were selected. This study took the 24-item Hamilton Depression Rating Scale (HAMD) (score ≥20) as the diagnostic criteria for depression. On the 21st day after admission, patients who met the depression diagnostic criteria were included in the depression group, and patients who failed to meet the diagnostic criteria were included in the non-depression group. The serum levels of IL-33, sST2 and hsCRP were measured by enzyme-linked immunosorbent assay (ELISA).

Results

On 1st day after stroke, compared with the non-depression group, there was no significant difference in the serum IL-33, sST2 and hsCRP levels in the depression group; on 21st day after stroke, compared with the non-depression group, the serum IL-33 and hsCRP levels were significantly increased, while the sST2 level was significantly decreased in the depression group. Correlation analysis showed that IL-33 was positively correlated with the depression quantitative score and hsCRP, while sST2 was negatively correlated with the depression quantitative score and hsCRP. Regression analysis showed that IL-33 and sST2 were independent risk factors for the depression after acute ischemic stroke.

Discussion

The abnormal alterations of serum IL-33 and sST2 levels in the stroke patients may serve as one of the risk factors for the occurrence and exacerbation of the depression, and its mechanism may be related to the promotion of inflammatory factor production in vivo.

Happiness: A Novel Outcome Measure in Stroke?

In this narrated review, we draw attention to the use of happiness as a novel outcome measure in clinical research studies regarding patients with stroke. Commonly used outcome measures in clinical trials in stroke rehabilitation include the modified Rankin Score (mRS), Functional Impairment Measures (FIM), Barthel Index and quality of life (QoL). Despite being a part of QoL, happiness is arguably a significant construct on its own. While QoL assesses perceptions of various extrinsic aspects of life, happiness may be used as a measure of subjective enjoyment of life after an illness. We review the literature discussing the use of happiness as a formal outcome measure in stroke care and subacute and long-term stroke rehabilitation. Ultimately we recommend the wider use of happiness as an outcome measure where appropriate in these settings.

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From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke

Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond.

Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT.

Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability.

Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.

Does the physical environment matter? - A qualitative study of healthcare professionals' experiences of newly built stroke units

Purpose: Organized care in specialist stroke units is fundamental for achieving better outcomes for persons with stroke. Although the importance of the physical environment for health and well-being is well recognized, research regarding how environmental features can influence stroke care is limited. The aim was to elucidate healthcare professionals’ experiences of the physical environment in newly built stroke units with respect to stroke care.Methods: Healthcare professionals (n = 42) representing eight professions participated in semi-structured, face-to-face interviews. Qualitative content analysis was used.Results: The physical environment both facilitated and restricted the professionals’ ability to provide stroke care. Five categories were identified: “Working towards patient engagement in single rooms”, “Hampered rehabilitation in an environment not always adapted to patients’ difficulties”, “Addressing patients’ psychosocial needs in the environment”, “Ensuring patient safety by using the environment in accordance with individual needs”, and “Collaboration and task fulfilment—a challenge due to care unit design”.Conclusions: The healthcare professionals viewed the physical environment mainly in relation to stroke patients’ specific needs, and several environmental features were considered poorly adapted to meet these needs. The physical environment is essential to high-quality care; thus, the process of planning and designing stroke units should be based on existing evidence.

Sex Differences in Post-Stroke Depression in the Elderly

OBJECTIVE

Post-stroke depression (PSD) occurs in approximately one-third of ischemic stroke patients. However, there is conflicting evidence on sex differences in PSD. We sought to assess sex differences in risk and time course of PSD in US ischemic stroke (IS) patients. We hypothesized that women are at greater risk of PSD than men, and that a greater proportion of women experience PSD in the acute post-stroke phase.

MATERIALS AND METHODS

We conducted a retrospective cohort study of 100% de-identified data for US Medicare beneficiaries admitted for ischemic stroke from July 1, 2016 to December 31, 2017. We calculated Kaplan-Meier unadjusted cumulative risk of depression, stratified by sex, up to 1.5 years following index admission. We performed Cox regression to report the hazard ratio (HR) for diagnosis of depression up to 1.5 years post-stroke in females vs. males, adjusting for patient demographics, comorbidities, length of stay, and acute stroke interventions.

RESULTS

In elderly stroke patients, females (n=90,474) were 20% more likely to develop PSD than males (n=84,427) in adjusted models. Cumulative risk of depression was consistently elevated for females throughout 1.5 years of follow-up (0.2055 [95% CI 0.2013-0.2097] vs. 0.1690 [95% CI 0.1639-0.1741] (log-rank p < 0.0001). HR for PSD in females vs. males remained significant in fully adjusted analysis at 1.20 (95% CI 1.17-1.23, p < 0.0001).

CONCLUSIONS

Over 1.5 years of follow-up, female stroke patients had significantly greater hazard of developing PSD, highlighting the need for long-term depression screening in this population and further investigation of underlying reasons for sex differences.

The Usefulness of Functional Near-Infrared Spectroscopy for the Assessment of Post-Stroke Depression

Background: Post-stroke depression (PSD) is the most common mood disorder following stroke and is also the main factor that limits the recovery and rehabilitation of patients with stroke. The prevalence of PSD is ~30%. Since there is no gold standard for the diagnosis and evaluation of PSD, it is important to raise awareness of PSD and to establish methods for its evaluation, early diagnosis, and treatment. In the field of psychiatry, functional near-infrared spectroscopy (fNIRS) has been used as a diagnostic tool for the measurement of oxygenated hemoglobin (oxy-Hb). This study aimed to assess whether fNIRS could be applied in the diagnosis and evaluation of PSD.

Methods: We recruited 45 patients with stroke, who were admitted to Nagasaki Kita Hospital between May 2015 and April 2019. The 17-item Hamilton Rating Scale for Depression (HAMD17), which is considered to be a useful screening and evaluation tool for PSD, was used for the assessment of patients after stroke; moreover, oxy-Hb was measured in the pre-frontal cortex. The subjects were divided into two groups: the depressed group (n = 13) and the non-depressed group (n = 32). We evaluated the correlation between the oxy-Hb integral values and HAMD17 scores.

Results: We investigated the relationship between the oxy-Hb integral values and HAMD17 total scores, and found a negative correlation between them (ρ = −0.331, P < 0.005). There was a significant difference in the oxy-Hb integral values during the activation task period between the depressed and non-depressed groups (3.16 ± 2.7 and 1.71 ± 2.4, respectively; P = 0.040). The results indicated that the patients of the depressed group showed lower oxy-Hb integral values and lower activation in the frontal lobe in comparison with the patients of the non-depressed group.

Conclusion: The present study highlights that the measurement of oxy-Hb by using fNIRS is a useful methodology for the diagnosis of PSD in patients after stroke.

Brain-Derived Neurotrophic Factor as a Clinical Biomarker in Predicting the Development of Post-Stroke Depression: A Review of Evidence

Studying the relationship between brain-derived neurotrophic factor (BDNF) and post-stroke depression (PSD) may help determine the potential for depression in stroke patients at the earliest stage possible. Current research has identified changes in BDNF levels in PSD patients. Thus, this article was intended as a review of evidence with respect to changes in the expression of BDNF in patients with PSD by integrating extant findings.

We conducted a search in the electronic databases PubMed, EMBASE, and PsycINFO (all records from January 1, 2000, through October 20, 2020) using keywords: “brain-derived neurotrophic factor OR BDNF,” “post-stroke depression OR PSD,” “expression level,” “association,” and “relationship.” Returned articles were considered for inclusion in this review if they were empirical studies investigating the association between BDNF expression and PSD.

Seven original papers were selected for review and revealed inconsistent findings. Five out of seven studies reported a significant decrease in BDNF levels in PSD patients at a certain stage (most likely the early stage) of stroke after admission, whereas the other two showed contrasting findings.

Overall, this review reveals associations between changes in serum BDNF levels and depression following stroke. Whether serum BDNF levels, especially in the early phase of stroke, can be a potentially effective biomarker for predicting the risk of subsequent PSD development is still open to debate.

Association between neurological outcome and poststroke comorbid mood and anxiety disorders: A real-life experience

INTRODUCTION

Poststroke depression (PSD) and anxiety (PSA) are prevalent and have a strong impact on functional outcome. Beside stroke severity, little is known on their clinical determinants. This study investigated the association between stroke mechanism, neurological poststroke complications and remaining vascular risk factors and the presence of comorbid PSD and PSA, termed poststroke emotional distress (PSED).

METHODS

This was a retrospective analysis of a prospectively compiled medical records database of consecutive patients evaluated during a follow-up visit 3- to 4-month poststroke. HAD scale was used to define PSED category (PSD+PSA vs. NoPSD+NoPSA). Stroke mechanism and poststroke complications were identified clinically or using appropriate scales. Their association with PSED was tested using a multivariate logistic regression model.

RESULTS

The sample included 2,300 patients (male: 64.8%); 19% had a PSED and 56.39% were free of any depression or anxiety. The most frequent poststroke complications were fatigue/fatigability (58.4%), sleep problems (26.7%), and pain (20.4%). While no association was observed between PSED and stroke mechanism, higher functional disability (OR:1.572), lower cognitive abilities (OR:0.953), sleep problems (OR:2.334), pain (OR:1.478), fatigue/fatigability (OR:2.331), and abnormal movements (OR:2.380) were all independent risk factors. Persisting tobacco consumption (OR:1.360) was the only vascular significant risk factor.

CONCLUSIONS

The frequency of comorbid PSED remains high (1/5 patient) despite improved awareness of these conditions. The association between poststroke complications and the presence of PSED emphasizes the need for standardized neurological and psychological evaluations at follow-up. These results foster the need to improve the management of addictive behaviors to reduce the burden of PSED.

The advances of post-stroke depression: 2021 update

Post-stroke depression (PSD) is one of common and serious sequelae of stroke. Approximately, one in three stroke survivors suffered from depression after stroke. It heavily affected functional rehabilitation, which leaded to poor quality of life. What is worse, it is strongly associated with high mortality. In this review, we aimed to derive a comprehensive and integrated understanding of PSD according to recently published papers and previous classic articles. Based on the considerable number of studies, we found that within 2 years incidence of PSD has a range from 11 to 41%. Many factors contribute to the occurrence of PSD, including the history of depression, stroke severity, lesion location, and so on. Currently, the diagnosis of PSD is mainly based on the DSM guidelines and combined with various depression scales. Unfortunately, we lack a unified mechanism to explain PSD which mechanisms now involve dysregulation of hypothalamic-pituitary-adrenal (HPA) axis, increased inflammatory factors, decreased levels of monoamines, glutamate-mediated excitotoxicity, and abnormal neurotrophic response. At present, both pharmacotherapy and psychological therapies are employed in treating PSD. Although great advance has been made by researchers, there are still a lot of issues need to be addressed. Especially, the mechanism of PSD is not completely clear.

Association of Lymphocyte-to-Monocyte Ratio with Poststroke Depression in Patients with Acute Ischemic Stroke

Background

Poststroke depression (PSD) is a common neuropsychiatric disorder after stroke. The neuroinflammatory response exerts a vital effect in the development of PSD. Lymphocyte-to-monocyte ratio (LMR), a systemic inflammation biomarker, is associated with poor prognosis of acute ischemic stroke (AIS). The purpose of this study was to determine the association between LMR and PSD at 3 months.

Material/Methods

AIS patients (507) were included in this study. Patients were categorized into 3 tertiles and each tertile contains 169 patients: tertile1 (>4.85), tertile 2 (2.96 to 4.85), and tertile 3 (<2.96), based on LMR values and the numbers of patients. PSD was diagnosed with a 17-item Hamilton Depression Scale score of 8 or higher.

Results

Patients (141; 27.8%) were diagnosed with PSD at 3-month follow-up. Patients in the PSD group presented with more severe stroke and lower LMR values (P<0.001). Decreased LMRs were independently associated with occurrence of PSD (middle tertile: odds ratio [OR] 1.823, P=0.037; lowest tertile: OR 3.024, P<0.001). A significant association of a lower LMR value with PSD severity was found (middle tertile: OR 1.883, P=0.031; lowest tertile: OR 2.633, P=0.001). The receiver operating characteristic curve indicates that the optimal threshold of LMR as a predictor for PSD was 3.14, which yielded a sensitivity of 72.4% and a specificity of 68.1%.

Conclusions

Decreased LMR is independently associated with PSD and increased PSD severity.

Tuina plus acupuncture for post-stroke depression: A protocol for systematic review and meta-analysis

BACKGROUND

Post-stroke depression (PSD) is the most common mental health issue, affecting approximately 33% of stroke survivors. Tuina and acupuncture treatments are often combined to treat PSD; however, there has been no meta-analysis on their synergistic effect. Therefore, we aimed to perform a systematic review and meta-analysis to estimate the effectiveness of Tuina and acupuncture in PSD treatment.

METHODS

The following electronic databases will be searched: PubMed, the Cochrane Library, Embase, Web of Science, Medline, CNKI, Chinese Biomedical Literature Database, VIP, and Wan Fang databases. We will consider articles published between database initiation and April 2021. Clinical randomized controlled trials related to Tuina combined with acupuncture for post-stroke depression will be included in the study. Language is limited to Chinese and English. Research selection, data extraction, and research quality assessment were independently completed by 2 researchers. Data were synthesized using a fixed effect model or random effect model, depending on the heterogeneity test. The Hamilton depression rating scale (HDRS) and effective rate were the primary outcomes. The post-stroke depression rating scale (PSDRS), patient health questionnaire-9 (PHQ-9), and the incidence of adverse events will also be assessed as secondary outcomes. RevMan V.5.4 statistical software will be used for meta-analysis. If it is not appropriate for a meta-analysis, a descriptive analysis will be conducted. Data synthesis uses the risk ratio and the standardized or weighted average difference of continuous data to represent the results.

RESULTS

This study provides a high-quality synthesis to assess the effectiveness and safety of Tuina for post-stroke depression.

CONCLUSION

This systematic review will provide evidence to determine whether Tuina plus acupuncture is an effective and safe intervention for patients with post-stroke depression.

ETHICS AND DISSEMINATION

The protocol of the systematic review does not require ethical approval because it does not involve humans. This article will be published in peer-reviewed journals and presented at relevant conferences.

SYSTEMATIC REVIEW REGISTRATION

INPLASY202140098.

Jiedu Tongluo Granules Ameliorates Post-stroke Depression Rat Model via Regulating NMDAR/BDNF Signaling Pathway

Post-stroke depression (PSD) is one of the most common stroke complications, which seriously affects stroke’s therapeutic effect and brings great pain for patients. The pathological mechanism of PSD has not been revealed. Jiedu Tongluo granules (JDTLG) is an effective traditional Chinese medicine for PSD treatment which is widely used in clinical treatment. JDTLG has a significant therapeutic effect against PSD, but the mechanism is still unclear. The PSD rat model was established by carotid artery embolization combined with chronic sleep deprivation followed by treating with JDTLG. Neurobehavioral and neurofunctional experiments were engaged in studying the neural function of rats. Histomorphology, proteomics, and western blotting researches were performed to investigate the potential molecular mechanisms related to JDTLG therapy. Oral treatment of JDTLG could significantly improve the symptoms of neurological deficit and depression symptoms of PSD rats. Proteomic analysis identified several processes that may involve the regulation of JDTLG on the PSD animal model, including energy metabolism, nervous system, and N-methyl-D-aspartate receptor (NMDAR)/brain-derived neurotrophic factor (BDNF) signal pathway. Our results showed that JDTLG could reduce glutamate (Glu) level and increase gamma-aminobutyric acid (GABA) level via regulating the NMDAR/BDNF pathway, which may play a vital role in the occurrence and development of PSD.

Serotonin Levels and Cognitive Recovery in Patients with Subacute Stroke after Rehabilitation Treatment

Post-stroke depression and cognitive impairment are common conditions affecting patients after stroke. Serotonin is a neurotransmitter involved in modulating, among others, mood, cognition, learning, and memory. Sub-optimal serotonin activity may be in part responsible for cognitive deficits seen in depression. In this pilot study serotonin levels were evaluated in 29 patients with sub-acute stroke before and after a rehabilitation treatment (consisting of a program of upper limb robotic rehabilitation in addition to conventional physical therapy treatment). We employed the Back Depression Inventory scale to evaluate symptoms of depression, and specific tools to evaluate cognitive functions. We found a significant reduction of the serotonin levels after rehabilitation in the whole group (T0: 85.9 ± 92.4 ng/mL; T1: 61.9 ± 58.4 ng/mL; p = 0.0018), as well as in the subgroup of patients untreated with Selective Serotonin Reuptake Inhibitors (SRRI), (mean serotonin at T0: 154.0 ± 102.3 ng/mL; mean serotonin at T1: 92.9. ± 68.7 ng/mL at T1; p = 0.005). We also found a correlation with cognitive assessment: in particular, the change from baseline of the serotonin (ΔSerotonin) was correlated with the changes from baseline of the Rey’s Figure (ΔROCF) (r = 0.535; p < 0.05), the Tower of London (ΔToL) (subscore point: r = 0.621; p < 0.005; subscore time: r = −0.619; p < 0.005) meaning that a serotonin levels decrease is associated with a worsening of cognitive functions. Considering patients treated and untreated with SSRIs separately, in patients treated with SSRIs (n = 16) we found only a positive correlation between ∆Serotonin and ∆ToL (subscore point: r= 0.587; p = 0.045), whereas in patients untreated with SSRIs (n = 13) we found a positive correlations between ΔSerotonin and ΔROCF (r = 0.700; p = 0.036), ∆Stroop (subscore time: r = 0.750; p = 0.020) and ∆Tol (subscore point: r = 0.740; p = 0.023) and a negative correlation between ΔSerotonin and ∆Tol (subscore time: r= −0.833; p = 0.005). These results suggest that variation of serotonin levels should be monitored in patients during a rehabilitation program, not only for their relationship with depression symptoms, but also for the correlation with cognitive performance.

Ketamine Induces Lasting Antidepressant Effects by Modulating the NMDAR/CaMKII-Mediated Synaptic Plasticity of the Hippocampal Dentate Gyrus in Depressive Stroke Model

Background

Ketamine has been shown to possess lasting antidepressant properties. However, studies of the mechanisms involved in its effects on poststroke depression are nonexistent.

Methods

To investigate these mechanisms, Sprague-Dawley rats were treated with a single local dose of ketamine after middle cerebral artery occlusion and chronic unpredicted mild stress. The effects on the hippocampal dentate gyrus were analyzed through assessment of the N-methyl-D-aspartate receptor/calcium/calmodulin-dependent protein kinase II (NMDAR/CaMKII) pathway, synaptic plasticity, and behavioral tests.

Results

Ketamine administration rapidly exerted significant and lasting improvements of depressive symptoms. The biochemical analysis showed rapid, selective upregulation and downregulation of the NMDAR2-β and NMDAR2-α subtypes as well as their downstream signaling proteins β-CaMKII and α-phosphorylation in the dentate gyrus, respectively. Furthermore, the colocalization analysis indicated a significant and selectively increased conjunction of β-CaMKII and postsynaptic density protein 95 (PSD95) coupled with a notable decrease in NMDAR2-β association with PSD95 after ketamine treatment. These changes translated into significant and extended synaptic plasticity in the dentate gyrus.

Conclusions

These findings not only suggest that ketamine represents a viable candidate for the treatment of poststroke depression but also that ketamine's lasting antidepressant effects might be achieved through modulation of NMDAR/CaMKII-induced synaptic plasticity in key brain regions.

Alteration of Gut Microbiome and Correlated Lipid Metabolism in Post-Stroke Depression

Background

The pathogenesis of post-stroke depression (PSD) remains largely unknown. There is growing evidence indicating that gut microbiota participates in the development of brain diseases through the gut-brain axis. Here, we aim to determine whether and how microbial composition and function altered among control, stroke and PSD rats.

Materials and Methods

After the PSD rat model was successfully established, gut microbiome combined with fecal metabolome approach were performed to identify potentially PSD-related gut microbes and their functional metabolites. Then, correlations between behavior indices and altered gut microbes, as well as correlations between altered gut microbial operational taxonomic units (OTUs) with differential metabolites in PSD rats were explored. Enrichment analysis was also conducted to uncover the crucial metabolic pathways related to PSD.

Results

Although there were some alterations in the microbiome and metabolism of the control and stroke rats, we found that the microbial and metabolic phenotypes of PSD rats were significantly different. The microbial composition of PSD showed a decreased species richness indices, characterized by 22 depleted OTUs mainly belonging to phylum Firmicutes, genus Blautia and Streptococcus. In addition, PSD was associated with disturbances of fecal metabolomics, among them Glutamate, Maleic acid, 5-Methyluridine, Gallocatechin, 1,5-Anhydroglucitol, L-Kynurenine, Daidzein, Cyanoalanine, Acetyl Alanine and 5-Methoxytryptamine were significantly related to disturbed gut microbiome (P ≤ 0.01). Disordered fecal metabolomics in PSD rats mainly assigned to lipid, amino acid, carbohydrate and nucleotide metabolism. The steroid biosynthesis was particularly enriched in PSD.

Conclusions

Our findings suggest that gut microbiome may participate in the development of PSD, the mechanism may be related to the regulation of lipid metabolism.

Comparison of poststroke depression between acute ischemic and hemorrhagic stroke patients

OBJECTIVES

Depression is the most common mental complication in stroke survivors with about one-third of patients suffering from poststroke depression (PSD). This was the first prospective study aimed to compare the prevalence of PSD and its symptoms between two cohorts of patients with acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH).

METHODS

Both AIS and ICH patients were simultaneously enrolled in the study. Depression symptoms were measured using the 17-item Hamilton Depression Rating Scale (HAMD-17) after a 1-month follow-up. Patients were diagnosed with PSD according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition and the HAMD-17 (HAMD scores >7).

RESULTS

The prevalence of PSD (42.3%) in the ICH group was significantly higher than that (22.9%) in the AIS group (p < 0.001). After adjustment for conventional confounding factors, the odds ratio of PSD was 2.65 (95% CI, 1.34-5.24, p = 0.005) for ICH compared to AIS. Depressive symptoms consisting of anxiety, loss of interest, insomnia, and fatigue were more frequent in patients with ICH than in AIS patients.

CONCLUSIONS

PSD was more prevalent, and the risk was over twofold higher in patients with ICH than AIS.

Gadd45b is a novel mediator of depression-like behaviors and neuroinflammation after cerebral ischemia

BACKGROUND

Poststroke depression (PSD) is an important consequence after stroke, with a negative impact on stroke outcome. Recent evidence points to a modulatory role of Growth arrest and DNA-damage-inducible protein 45 beta (Gadd45b) in depression. Herein, we evaluated the antidepressant efficacy and mechanism underlying the potent therapeutic effects of Gadd45b after cerebral ischemia.

METHODS

Adult male Sprague-Dawley rats were subjected to cerebral ischemia by permanent middle cerebral artery occlusion (MCAO). The sucrose preference test (SPT), forced swim test (FST), and tail suspension test (TST) were performed after completing MCAO to study the antidepressant-like effects. The expression of brain-derived neurotrophic factor (BDNF) and neuroinflammation were determined in the hippocampus.

RESULTS

We showed that Gadd45b knockdown induced depression-like behaviors after cerebral ischemia, including increased immobility time in the FST and TST and reduced sucrose preference. Gadd45b knockdown enhanced the expression of pro-inflammatory cytokines IL-6 and TNF-α, accompanying with decreased protein levels of BDNF in the hippocampus. Moreover, the levels of phosphorylated ERK and CREB, which have been implicated in events downstream of BDNF signaling, were also decreased after cerebral ischemia.

CONCLUSION

Hence, the results showed that Gadd45b is a promising drug candidate for treating PSD and possibly other nervous system diseases associated with neuroinflammation. Gadd45b may have therapeutic potential for PSD through BDNF-ERK-CREB pathway and neuroinflammation.

Study on quantitative diagnosis model of TCM syndromes of post-stroke depression based on combination of disease and syndrome

BACKGROUND

Post-stroke depression (PSD) is one of the most common stroke complications with high morbidity. Researchers have done much clinical research on Traditional Chinese Medicine (TCM) treatment, but very little research on diagnosis. Based on the thought of combination of disease and syndrome, this study will establish a unified and objective quantitative diagnosis model of TCM syndromes of PSD, so as to improve the clinical diagnosis and treatment of PSD.

OBJECTIVE

First: To establish a unified and objective quantitative diagnosis model of TCM syndromes in PSD under different disease courses, and identify the corresponding main, secondary, and concurrent symptoms, which are based on the weighting factor of each TCM symptom. Second: To find out the relationship between different stages of PSD and TCM syndromes. Clarify the main syndrome types of PSD under different stages of disease. Reveal the evolution and progression mechanism of TCM syndromes of PSD.

METHODS AND ANALYSIS

This is a retrospective study of PSD TCM diagnosis. Three hundred patients who were hospitalized in the First Teaching Hospital of Tianjin University of TCM with complete cases from January 2014 to January 2019 are planned to be recruited. The study will mainly collect the diagnostic information from the cases, find the related indicators of TCM and Western medicine in PSD, and clarify the relationship between different disease stages and TCM syndromes. Finally, the PSD TCM syndrome quantitative diagnosis model will be established based on the operation principle of Back Propagation (BP) artificial neural network.

CONCLUSION

To collect sufficient medical records and establish models to speed up the process of TCM diagnosis.

Intestinal Barrier Dysfunction Participates in the Pathophysiology of Ischemic Stroke

The gastrointestinal tract is a major organ for the body to absorb nutrients, water and electrolytes. At the same time, it is a tight barrier to resist the invasion of harmful substances and maintain the homeostasis of the internal environment. Destruction of the intestinal barrier is linked to the digestive system, cardiovascular system, endocrine system and other systemic diseases. Mounting evidence suggests that ischemic stroke not only changes the intestinal microbes, but also increases the permeability of the intestinal barrier, leading to bacterial translocation, infection, and even sepsis. The intestinal barrier, as part of the gut-brain axis, has also been proven to participate in the pathophysiological process of ischemic stroke. However, little attention has been paid to it. Since ischemic stroke is a major public health issue worldwide, there is an urgent need to know more about the disease for better prevention, treatment and prognosis. Therefore, understanding the pathophysiological relationship between ischemic stroke and the intestinal barrier will help researchers further uncover the pathophysiological mechanism of ischemic stroke and provide a novel therapeutic target for the treatment of ischemic stroke. Here, we review the physiology and pathology between ischemic stroke and intestinal barrier based on related articles published in the past ten years about the relationship between ischemic stroke, stroke risk factors and intestinal flora, intestinal barrier, and discuss the following parts: the intestinal barrier; possible mechanisms of intestinal barrier destruction in ischemic stroke; intestinal barrier destruction caused by stroke-related risk factors; intestinal barrier dysfunction in ischemic stroke; targeting the intestinal barrier to improve stroke; conclusions and perspectives.

Risk and Predictors of Depression Following Acute Ischemic Stroke in the Elderly

OBJECTIVE

We sought to comprehensively evaluate predictors of poststroke depression (PSD) in the United States and to compare PSD to post-myocardial infarction (MI) depression to determine whether ischemic stroke uniquely elevates risk of depression.

METHODS

This is a retrospective cohort study of 100% deidentified inpatient, outpatient, and subacute nursing Medicare data from 2016 to 2017 for US patients ≥65 years of age from July 1, 2016, to December 31, 2017. We calculated Kaplan-Meier unadjusted cumulative risk of depression up to 1.5 years after the index admission. We performed Cox regression to report the hazard ratio for diagnosis of depression up to 1.5 years after stroke vs MI and independent predictors of PSD, and we controlled for patient demographics, comorbid conditions, length of stay, and acute stroke interventions.

RESULTS

In fully adjusted models, patients with stroke (n = 174,901) were ≈50% more likely than patients with MI (n = 193,418) to develop depression during the 1.5-year follow-up period (Kaplan-Meier cumulative risk 0.1596 ± 0.001 in patients with stroke vs 0.0973 ± 0.000778 in patients with MI, log-rank p < 0.0001). History of anxiety was the strongest predictor of PSD, while discharge home was most protective. Female patients, White patients, and patients <75 years of age were more likely to be diagnosed with depression after stroke.

CONCLUSIONS

Despite the similarities between MI and stroke, patients with stroke were significantly more likely to develop depression. There were several predictors of PSD, most significantly history of anxiety. Our findings lend credibility to a stroke-specific process causing depression and highlight the need for consistent depression screening in all patients with stroke.

The Unmet Needs of Community-Dwelling Stroke Survivors: A Systematic Review of Qualitative Studies

The unmet needs perceived by community-dwelling stroke survivors may truly reflect the needs of patients, which is crucial for pleasant emotional experiences and a better quality of life for community-dwelling survivors not living in institutionalized organizations. The purpose of the study is to identify the scope of unmet needs from the perspectives of stroke patients in the community. A qualitative meta-synthesis was performed according to the Joanna Briggs Institute method. Six electronic databases were searched from inception to February 2020. A total of 24 articles were involved, providing data on 378 stroke survivors. Eight categories were derived from 63 findings, and then summarized into four synthesized findings based on the framework of ICF: (1) unmet needs regarding with the disease-related information; (2) unmet physical recovery and activity/participation needs; (3) unmet needs for social environmental resources; (4) unmet psycho-emotional support needs. We found the framework of ICF mostly complete, but unmet information needs still remain. The needs that are mainly unsatisfied include physical, psychosocial and informational, as well as the practical support from professional or environment resources. The ever-present unmet needs perceived by community-dwelling stroke survivors who do not live in institutions are discoverable and mitigable. Future studies should focus on quantifying unmet needs comprehensively derived from experiential domains, assessing the rationality of the unmet needs expressed by patients' perspectives and developing flexible strategies for long-term and changing needs.

Heart and brain interactions : Pathophysiology and management of cardio-psycho-neurological disorders

Cardiovascular diseases (CVD) and mental health disorders (MHD; e.g. depression, anxiety and cognitive dysfunction) are highly prevalent and are associated with significant morbidity and mortality and impaired quality of life. Currently, possible interactions between pathophysiological mechanisms in MHD and CVD are rarely considered during the diagnostic work-up, prognostic assessment and treatment planning in patients with CVD, and research addressing bidirectional disease mechanisms in a systematic fashion is scarce. Besides some overarching pathogenetic principles shared by CVD and MHD, there are specific syndromes in which pre-existing neurological or psychiatric illness predisposes and contributes to CVD development (as in Takotsubo syndrome), or in which the distorted interplay between innate immune and central nervous systems and/or pre-existing CVD leads to secondary MHD and brain damage (as in peripartum cardiomyopathy or atrial fibrillation). Clinical manifestations and phenotypes of cardio-psycho-neurological diseases depend on the individual somatic, psychosocial, and genetic risk profile as well as on personal resilience, and differ in many respects between men and women. In this article, we provide arguments on why, in such conditions, multidisciplinary collaborations should be established to allow for more comprehensive understanding of the pathophysiology as well as appropriate and targeted diagnosis and treatment. In addition, we summarize current knowledge on the complex interactions between the cardiovascular and central nervous systems in Takotsubo syndrome and peripartum cardiomyopathy, and on the neurological and psychiatric complications of atrial fibrillation.

Multiple biomarkers covering several pathways for the prediction of depression after ischemic stroke

BACKGROUND

To assess the potential incremental utility of multiple biomarkers reflecting several pathological pathways for the risk prediction of depression after stroke.

METHODS

We used data from the China Antihypertensive Trial in Acute Ischemic Stroke, and a panel of 13 circulating biomarkers were measured. The study outcome was depression (24-item Hamilton Depression Rating Scale score≥8) at 3 months after ischemic stroke. Logistic regression models were performed to evaluate the risk of depression associated with multiple biomarkers. Discrimination and risk reclassification for depression were analyzed.

RESULTS

Among 631 included ischemic stroke patients, elevated growth differentiation factor-15, anticardiolipin antibodies, antiphosphatidylserine antibodies and matrix metalloproteinase-9 were individually associated with increased risks of depression after stroke. The multiple biomarker analysis showed a clear gradient in the risk of depression with increasing numbers of elevated biomarkers, and multivariate adjusted odds ratio (95% confidence interval) of patients with 4 elevated biomarkers was 6.52 (2.24-18.95) compared with those without elevation in any of 4 biomarkers. The simultaneous inclusion of all 4 biomarkers to the conventional model significantly improved discrimination (C statistic increased from 0.702 to 0.748, P=0.004) and risk reclassification (net reclassification improvement 45.0%; integrated discrimination improvement 6.2%; both P<0.001) for depression after stroke.

LIMITATIONS

We selected biomarkers that had previously been reported to be promising predictors of depression after stroke, while other novel biomarkers not tested might have additional predictive value.

CONCLUSIONS

Simultaneously adding multiple biomarkers from several pathophysiological pathways to traditional risk factors provided substantial incremental utility of the risk stratification for depression after stroke.

Neuropsychiatric Complications after Stroke

Neuropsychiatric disturbances represent a common and uniquely challenging consequence of stroke. These disorders arise at the intersection of lesion-related brain dysfunction and psychological distress related to the event and its aftermath, making it difficult to identify what symptom is a direct physiological consequence of the stroke. Depression, anxiety, fatigue, apathy, emotionalism, and anger are the most common of these syndromes, and posttraumatic stress disorder related to the stroke event has become increasingly recognized as a relevant entity. Mania, obsessive-compulsive disorder, and psychosis are less commonly encountered but potentially highly debilitating conditions that may be underrecognized. Early identification and treatment may mitigate functional impairment and improve quality of life. Evidence-based guidelines from the general population are often relied upon to guide treatment. Further research is needed to understand and tailor treatment of these disorders in the poststroke population.

Saikosaponin A improved depression-like behavior and inhibited hippocampal neuronal apoptosis after cerebral ischemia through p-CREB/BDNF pathway

Post-stroke depression(PSD) is a common complication and associates with poor physical recovery, low quality of life and high mortality after cerebral infarction. However, the pathogenesis of PSD have not been elucidated thoroughly now, and there is a lack of effective therapy in clinic. It reported that Saikosaponin A, one of the main constituents from Chinese herb Bupleurum chinense, has pharmacological activity in anti-depression. Thus, this study aimed to elucidate the potential effects and mechanisms of Saikosaponin A on the depression-like behavior after cerebral ischemic injury in rats. The rat model of PSD was induced by middle cerebral artery occlusion(MCAO) combined with chronic unpredictable mild stress(CUMS) and isolation. Behavior tests including open field test, beam-walking test, sucrose preference and forced swimming tests were performed. Western blot and immunohistochemistry were adopted to evaluate expression of phosphorylated cAMP response element binding protein(p-CREB), brain derived neurotrophic factor(BDNF) and apoptosis-related molecules in the dentate gyrus region of rat hippocampus. The TUNEL assay was used to determine neuronal apoptosis. We found that the rats subjected to MCAO combined with CUMS and isolation experienced significant depressive-like behavior. Administration of Saikosaponin A significantly ameliorated depressive-like behavior, and inhibited neuronal apoptosis, enhanced the level of p-CREB, BDNF and Bcl-2, reduced the level of Bax, Caspase-3 in the hippocampus of PSD rats. These results revealed that Saikosaponin A improved depression-like behavior and inhibited hippocampal neuronal apoptosis after cerebral ischemia, presumably through increasing the expression of BDNF, p-CREB and Bcl-2, as well as decreasing the level of Bax, Caspase-3.

Plasma soluble suppression of tumorigenicity 2 and depression after acute ischemic stroke

BACKGROUND AND PURPOSE

Soluble suppression of tumorigenicity 2 (sST2) might be related to stroke and depression, but the association of sST2 with poststroke depression (PSD) is unclear. The study aimed to prospectively assess the association between plasma sST2 levels and PSD.

METHODS

A total of 635 acute ischemic stroke patients with sST2 measurements from the China Antihypertensive Trial in Acute Ischemic Stroke were included in this analysis. We used the 24-item Hamilton Rating Scale for Depression to assess depression at 3 months, and PSD was defined as a score of ≥8. Logistic regression analysis was performed to estimate the risk of PSD associated with sST2, and net reclassification index (NRI) and integrated discrimination improvement (IDI) were calculated to assess the predictive value of sST2.

RESULTS

Two hundred fifty (39.4%) patients developed depression at 3 months after ischemic stroke. Patients with PSD had higher sST2 levels than patients without PSD (172.7 vs. 153.8 pg/ml; p = 0.003). After adjustment for age, sex, education, National Institutes of Health Stroke Scale score, and other covariates, the odds ratio for the highest quartile of sST2 compared with the lowest quartile was 1.84 (95% confidence interval, 1.10-3.08) for PSD. Adding sST2 to a conventional model notably improved risk prediction for PSD (category-free NRI = 19.34%, 95% confidence interval = 4.39%-34.28%, p = 0.017; IDI = 1.20%, 95% confidence interval = 0.25%-2.15%, p = 0.014).

CONCLUSIONS

Increased plasma sST2 levels in the acute phase of ischemic stroke were significantly associated with the increased risk of PSD, independently of conventional risk factors.

Neurogenesis and Neuroplasticity in Major Depression: Its Therapeutic Implication

The neurochemical model of depression, based on monoaminergic theories, does not allow on its own to understand the mechanism of action of antidepressants. This approach does not explain the gap between the immediate biochemical modulations induced by antidepressants and the time required for their clinical action. Several hypotheses have been developed to try to explain more precisely the action of these molecules, each of them involving mechanisms of receptor regulation. At the same time, data on the neuroanatomy of depression converge toward the existence of specific lesions of this pathology. This chapter aims to provide an overview of recent advances in understanding the mechanisms of neural plasticity involved in pathophysiology depression and in its treatment.

Hemispheric stroke: Mood disorders

Stroke causes many forms of disability, including emotional and mood disorders. Depression is the most common of these, affecting approximately one-third of stroke patients. Other disorders like mania, bipolar disorder, anxiety disorder, or apathy may also develop following stroke, although they are less common. The development of mood and emotional disorders is dependent on the severity of brain injury, the side of injury, and hemispheric location. Whereas a left hemispheric stroke often results in depression or a catastrophic reaction with anxiety, injury to the right hemisphere has predominantly been associated with the development of emotional indifference (anosodiaphoria) or euphoria. In this chapter, we discuss the mood disorders associated with hemispheric strokes and the neuropsychological mechanisms that might account for the clinical manifestations of these affective disorders.

Relationship Between Abnormalities in Resting-State Quantitative Electroencephalogram Patterns and Poststroke Depression

PURPOSE

Spectral power analysis of quantitative EEG has gained popularity in the assessment of depression, but findings across studies concerning poststroke depression (PSD) have been inconsistent. The goal of this study was to determine the extent to which abnormalities in quantitative EEG differentiate patients with PSD from poststroke nondepressed (PSND) subjects.

METHODS

Resting-state EEG signals of 34 participants (11 patients with PSD and 23 PSND subjects) were recorded, and then the spectral power analysis for six frequency bands (alpha1, alpha2, beta1, beta2, delta, and theta) was conducted at 16 electrodes. Pearson linear correlation analysis was used to investigate the association between depression severity measured with the Hamilton Depression Rating Scale (HDRS) total score and absolute power values. In addition, receiver operating characteristic curves were used to assess the sensitivity and specificity of quantitative EEG in discriminating PSD.

RESULTS

In comparison with PSND patients, PSD patients showed significantly higher alpha1 power in left temporal region and alpha2 power at left frontal pole. Higher theta power in central, temporal, and occipital regions was observed in patients with PSD. The results of Pearson linear correlation analysis showed significant association between HDRS total score and the absolute alpha1 power in frontal, temporal, and parietal regions.

CONCLUSIONS

Absolute powers of alpha and theta bands significantly distinguish between PSD patients and PSND subjects. Besides, absolute alpha1 power is positively associated with the severity of depression.

The therapeutic effects and safety of bright light therapy combined with escitalopram oxalate on insomnia in patients with poststroke depression

INTRODUCTION

Bright light therapy (BLT) is known to treat depression and sleep disorders in clinical practice, but its efficacy on poststroke depression (PSD) has not been studied.

OBJECTIVE

To investigate the therapeutic effects and safety of BLT combined with escitalopram oxalate (ESC) on insomnia in patients with PSD.

METHODS

Ischemic stroke patients with depressive symptoms and a score of ≥8 on the Hamilton Depression Scale (HAMD-17) while meeting DSM-IV criteria were diagnosed as having PSD. A total of 112 PSD patients with symptoms of insomnia were randomly assigned to polytherapy (BLT plus ESC) and monotherapy (ESC only) groups. Each regimen continued for 6 weeks. The primary outcomes were a change in scores on the Pittsburgh Sleep Quality Index (PSQI) and a remission rate (PSQI ≤7 at the endpoint). The secondary outcomes included changes in the HAMD-17 and Barthel Index (BI) scores. Adverse effects were assessed by the Adverse Events Scale.

RESULTS

The endpoint assessment included 106 patients (monotherapy, 54; polytherapy, 52). The mean changes in the PSQI scores for the monotherapy and polytherapy groups were 4.85 (1.47) and 5.87 (1.72) (P = 0.001), respectively. Compared to monotherapy, polytherapy improved PSQI remission rate (71.4% vs 50.0%; χ2 = 5.390; P = 0.020), and HAMD-17 score (6.70 [2.12] vs 4.75 [1.98]; P < 0.001). Both treatments improved BI score, with no statistical difference, and were well tolerated, with few significant differences in treatment-associated adverse events.

CONCLUSION

BLT combined with ESC is effective and well tolerated for the treatment of PSD-associated insomnia.

Monocyte-to-Lymphocyte Ratio is Associated with Depression 3 Months After Stroke

PURPOSE

To explore the relationship between the monocyte-to-lymphocyte ratio (MLR) and depression three months after acute ischemic stroke.

PATIENTS AND METHODS

From May 2013 to September 2014, 203 patients with acute ischemic stroke were recruited within 7 days post-stroke from Shanghai Ruijin Hospital and blood samples were collected after admission. The Hamilton Depression Scale and Clinical Review were evaluated at 3 months after stroke. Based on the Diagnostic and Statistical Manual of Mental Disorders-IV diagnostic criteria, we divided patients into post-stroke depression (PSD) and non-PSD groups. We analyzed the intergroup difference in MLR and the contributing factors. Moreover, dynamic changes in monocytes, lymphocytes and MLR at four different time intervals for all the stroke patients and their relationship with PSD patients were also studied.

RESULTS

The NIHSS scores and MLR in the PSD group were significantly higher than in the non-PSD group (p<0.05). Logistic regression analysis revealed MLR was an independent risk factor for PSD (odds ratio: 18.020, 95% confidence interval: 1.127‒288.195, p=0.041). MLR correlated negatively with cholesterol and low-density lipoprotein (r=-0.160 and -0.165, respectively, p<0.05). Within 7 days post-acute ischemic stroke, monocytes gradually increased while lymphocytes remained unchanged for all the stroke patients. The MLR value was significantly higher in the PSD group than in the non-PSD group within 24 h post-stroke (p<0.05), but there was no difference in the other three time-intervals between the two groups.

CONCLUSION

The admission MLR, particularly within 24 h post-stroke, was associated with PSD at 3 months, implying that the MLR might be involved in the PSD inflammatory mechanism.

Depressed Mood after Stroke: Predictive Factors at Six Months Follow-Up

We aimed to know the prevalence of post-stroke depression (PSD) in our context, identify the variables that could predict post-stroke depression, by using the Hamilton Depression Rating Scale, occurring within six months after stroke, and identify patients at high risk for PSD. Methods: descriptive, cross-sectional and observational study. We included 173 patients with stroke (transient ischemic attack (TIA) included) and collected sociodemographic and clinical variables. We used the Hamilton Depression Scale (HDS) for depression assessment and Barthel Index and modified Rankin Scale (mRS) for functional assessment. The neurological severity was evaluated by the National Institutes of Health Stroke Scale (NIHSS). Results: 35.5% were women, aged 71.16 (±12.3). Depression was present in 42.2% patients (n = 73) at six months after stroke. The following variables were significantly associated with PSD: diagnosis of previous depression (p = 0.005), the modified Rankin Scale at discharge (p = 0.032) and length of hospital stay (p = 0.012). Conclusion: PSD is highly prevalent after stroke and is associated with the severity, left location of the stroke, and the degree of disability at discharge. Its impact justifies the evaluation and early treatment that still continues to be a challenge today.

Patient Health Questionnaire-9 predicts the functional outcome of stroke patients in convalescent rehabilitation ward

INTRODUCTION

Poststroke depression (PSD) negatively affects the functional outcome of stroke patients. Patient Health Questionnaire-9 (PHQ-9) is a validated screening tool for detecting PSD. This study investigated the relationship between PHQ-9 score and functional outcomes in stroke patients in a convalescent rehabilitation ward by evaluating functional independence measure (FIM) gain scores and the proportion of patients discharged.

METHODS

In this retrospective study conducted from January 2017 to September 2019, consecutive stroke patients who were admitted to the convalescent rehabilitation ward and could answer PHQ-9 were assessed. The association between PHQ-9 scores at the time of admission to the convalescent rehabilitation ward and outcomes (FIM gain score and the proportion of patients discharged) was statistically analyzed.

RESULTS

Among the 215 patients enrolled in the study, 62 (28.8%) were assessed as having depression, in whom PHQ-9 scores were 5 or above. Multivariate analysis revealed that the PHQ-9 score on admission to the convalescent rehabilitation ward was a significant independent factor influencing the FIM gain score (p = .009). In addition, a multivariate analysis revealed that the PHQ-9 score at the time of admission to the convalescent rehabilitation ward was a significant independent factor influencing the inability to discharge a patient (odds ratio 1.24, 95% confidence interval 1.12-1.39, p < .001).

CONCLUSIONS

The PHQ-9 score is a useful tool for predicting patient functional outcome, admission to the facility, and screening for poststroke depression.

Oxidative Stress at the Crossroads of Aging, Stroke and Depression

Epidemiologic studies have shown that in the aging society, a person dies from stroke every 3 minutes and 42 seconds, and vast numbers of people experience depression around the globe. The high prevalence and disability rates of stroke and depression introduce enormous challenges to public health. Accumulating evidence reveals that stroke is tightly associated with depression, and both diseases are linked to oxidative stress (OS). This review summarizes the mechanisms of OS and OS-mediated pathological processes, such as inflammation, apoptosis, and the microbial-gut-brain axis in stroke and depression. Pathological changes can lead to neuronal cell death, neurological deficits, and brain injury through DNA damage and the oxidation of lipids and proteins, which exacerbate the development of these two disorders. Additionally, aging accelerates the progression of stroke and depression by overactive OS and reduced antioxidant defenses. This review also discusses the efficacy and safety of several antioxidants and antidepressants in stroke and depression. Herein, we propose a crosstalk between OS, aging, stroke, and depression, and provide potential therapeutic strategies for the treatment of stroke and depression.

Eslicarbazepine acetate in post-stroke epilepsy: Clinical practice evidence from Euro-Esli

Objectives

To assess the effectiveness and safety/tolerability of eslicarbazepine acetate (ESL) in patients included in the Euro‐Esli study who had focal seizures associated with post‐stroke epilepsy (PSE).

Materials and Methods

Euro‐Esli was a pooled analysis of 14 European clinical practice studies. Effectiveness assessments (evaluated after 3, 6 and 12 months of ESL treatment and at final follow‐up [“last visit”]) included rates of response (≥50% seizure frequency reduction), seizure freedom (no seizures since at least the prior visit) and retention. Safety/tolerability was assessed throughout ESL treatment by evaluating adverse events (AEs) and discontinuation due to AEs. A post hoc analysis was conducted of patients with PSE versus patients without PSE (“non‐PSE”).

Results

Of 1656 patients included in the analysis, 76 (4.6%) had PSE and 1580 (95.4%) had non‐PSE. Compared with non‐PSE patients, PSE patients were significantly older, had significantly shorter epilepsy duration, significantly lower total baseline seizure frequency, and were treated with significantly fewer prior and concomitant antiepileptic drugs (P < .001 for all). At the last visit, the responder rate was significantly higher in PSE versus non‐PSE patients (72.9% vs 60.6%; P = .040), as was the seizure freedom rate (48.6% vs 31.7%; P = .003). After 12 months, retention was significantly higher in PSE versus non‐PSE patients (87.8% vs 77.4%; P = .035). The incidence of AEs was similar for PSE versus non‐PSE patients (36.0% vs 35.8%; P = .966).

Conclusions

These findings suggest that ESL may be an effective and well‐tolerated treatment option for patients with focal seizures due to PSE.

Reduced Amygdala Microglial Expression of Brain-Derived Neurotrophic Factor and Tyrosine Kinase Receptor B (TrkB) in a Rat Model of Poststroke Depression

Background

Previous studies have implicated reduced brain-derived neurotrophic factor (BDNF) expression and BDNF-TrkB receptor signaling as well as microglial activation and neuroinflammation in poststroke depression (PSD). However, the contributions of microglial BDNF-TrkB signaling to PSD pathogenesis are unclear.

Material/Methods

We compared depression-like behaviors as well as neuronal and microglial BDNF and TrkB expression levels in the amygdala, a critical mood-relating limbic structure, in rat models of stroke, depression, and PSD. Depression-like behaviors were assessed using the sucrose preference test, open-field test, and weight measurements, while immunofluorescence double staining was employed to estimate BDNF and TrkB expression by CD11b-positive amygdala microglia and NeuN-positive amygdala neuron. Another group of PSD model rats were examined following daily intracerebroventricular injection of proBDNF, tissue plasminogen activator (t-PA), or normal saline (NS) for 7 days starting 4 weeks after chronic unpredictable mild stress (CUMS).

Results

The numbers of BDNF/CD11b- and TrkB/CD11b-immunofluorescence-positive cells were lowest in the PSD group at 4 and 8 weeks after CUMS (P<0.05). PSD rats also showed reduced weight, sucrose preference, locomotion, and rearing compared with controls (P<0.05). The coexpression of BDNF/NeuN- and TrkB/NeuN-positive cells were not significantly different between groups at 4 and 8 weeks after CUMS (P>0.05). Injection of t-PA increased BDNF/CD11b- and TrkB/CD11b-positive cells in the amygdala of PSD rats and normalized behavior compared with NS or proBDNF injection (P<0.05). In contrast, proBDNF injection reduced BDNF and TrkB expression compared with NS (P<0.05).

Conclusions

These results suggest that decreased BDNF and TrkB expression by amygdala microglia may contribute to PSD pathogenesis and depression-like behaviors.

Depression in Poststroke Aphasia

Purpose The aim of this tutorial is to provide speech-language pathologists with foundational knowledge of poststroke depression comorbidly occurring with aphasia. Given the negative effect of depression on functional outcomes and mortality, it is crucial that speech-language pathologists possess this knowledge in order to better advocate for and treat their patients. Method and Results Three areas of complementary expertise (speech-language pathology, psychology, and neurology) collaborated on this tutorial to address the following areas: (a) provide terminology associated with depression and related mood disorders, (b) describe the potential underlying pathophysiology of depression in the general population, (c) provide an overview of our existing understanding of comorbid poststroke depression and aphasia, and (d) summarize current assessment methods and interventions for poststroke depression in adults with aphasia. Conclusion Given the compounding impact aphasia and depression have on rehabilitation outcomes, it is imperative that speech-language pathologists understand terminology, assessment, and treatment practices for depression.

Decreased Serum Netrin-1 as a Predictor for Post-Stroke Depression in Chinese Patients with Acute Ischemic Stroke

BACKGROUND AND AIMS

Experimental studies demonstrated that netrin-1 (NT-1) is an important factor influencing the recovery after ischemic stroke. However, whether NT-1 levels were associated with the post-stroke depression (PSD) remains unclear. We aimed to evaluate the relationship between NT-1 levels and PSD at 3 months in patients with ischemic stroke.

METHODS

From January 2018 to December 2019, consecutive Chinese patients with first-ever ischemic stroke were prospectively recruited. Serum NT-1 levels were measured at admission. Patients with a 17-item Hamilton Depression Scale score of ≥7 were given the Structured Clinical Interview of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, for diagnosis of PSD.

RESULTS

A total of 238 patients (mean age, 62.5 years; 45.4% female) were enrolled. The median NT-1 concentrations were 467.8 pg/mL (interquartile range, 351.8-581.0 pg/mL). During the 3-month follow-up period, 64 patients (26.9%) experienced PSD. Serum NT-1 levels were significantly lower in PSD patients than in patients without PSD (median, 380.3 pg/mL versus 478.5 pg/mL; P = 0.001). After adjusting for demographic characteristic, National Institutes of Health stroke score, and other potential confounders by multiple logistic regression analysis, patients with NT-1 levels in the first quartile were more likely to have 3-month PSD (as compared with the fourth quartile, odds ratio 3.83, 95% confidence intervals, 1.53-9.63, P = 0.004). Similar significant findings were observed when the NT-1 levels were added as a continuous variable.

CONCLUSIONS

Our data demonstrated that decreased serum NT-1 levels, in a Chinese population, were significantly associated with PSD at 3 months.

Sex-Dependent Pathology in the HPA Axis at a Sub-acute Period After Experimental Traumatic Brain Injury

Over 2.8 million traumatic brain injuries (TBIs) are reported in the United States annually, of which, over 75% are mild TBIs with diffuse axonal injury (DAI) as the primary pathology. TBI instigates a stress response that stimulates the hypothalamic-pituitary-adrenal (HPA) axis concurrently with DAI in brain regions responsible for feedback regulation. While the incidence of affective symptoms is high in both men and women, presentation is more prevalent and severe in women. Few studies have longitudinally evaluated the etiology underlying late-onset affective symptoms after mild TBI and even fewer have included females in the experimental design. In the experimental TBI model employed in this study, evidence of chronic HPA dysregulation has been reported at 2 months post-injury in male rats, with peak neuropathology in other regions of the brain at 7 days post-injury (DPI). We predicted that mechanisms leading to dysregulation of the HPA axis in male and female rats would be most evident at 7 DPI, the sub-acute time point. Young adult age-matched male and naturally cycling female Sprague Dawley rats were subjected to midline fluid percussion injury (mFPI) or sham surgery. Corticotropin releasing hormone, gliosis, and glucocorticoid receptor (GR) levels were evaluated in the hypothalamus and hippocampus, along with baseline plasma adrenocorticotropic hormone (ACTH) and adrenal gland weights. Microglial response in the paraventricular nucleus of the hypothalamus indicated mild neuroinflammation in males compared to sex-matched shams, but not females. Evidence of microglia activation in the dentate gyrus of the hippocampus was robust in both sexes compared with uninjured shams and there was evidence of a significant interaction between sex and injury regarding microglial cell count. GFAP intensity and astrocyte numbers increased as a function of injury, indicative of astrocytosis. GR protein levels were elevated 30% in the hippocampus of females in comparison to sex-matched shams. These data indicate sex-differences in sub-acute pathophysiology following DAI that precede late-onset HPA axis dysregulation. Further understanding of the etiology leading up to late-onset HPA axis dysregulation following DAI could identify targets to stabilize feedback, attenuate symptoms, and improve efficacy of rehabilitation and overall recovery.

Complementary and alternative therapies for poststroke depression: A protocol for systematic review and network meta-analysis

BACKGROUND

Poststroke depression (PSD) is an important complication of stroke, resulting in increased disability and mortality, which is a great threat to stroke survivors and public health. Complementary and alternative medicine (CAM) therapies is widely used in the treatment of PSD, However, the selection strategies of different CAM approaches in clinical practice is still not clear, and the purpose of this protocol is to compare the efficacy and acceptability of different CAM therapies using systematic review and network meta-analysis.

METHODS

According to the strategy, the authors will retrieve a total of seven electronic databases by August 2020, including PubMed, the Cochrane Library, EMbase, China National Knowledge Infrastructure, China Biological Medicine, Chinese Scientific Journals Database, and Wan-fang databases. The network meta-analysis will be performed using Aggregate Data Drug Information System 1.16.8 and Stata 13.0 software. In addition, the Cochrane Collaboration's tool is employed for the methodological quality, and the quality of evidence will be evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

This study will provide a reliable evidence for the selection strategy of CAM therapies for PSD.

CONCLUSION

The results of this study will provide references for evaluating the effects of different CAM therapies on PSD, and provide decision-making references for clinical practitioners, patients, and health policy makers.

ETHICS AND DISSEMINATION

This study does not require ethical approval. the results will be disseminated through a peer-reviewed publication.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/TNGH6.

How Long Are Reperfusion Therapies Beneficial for Patients after Stroke Onset? Lessons from Lethal Ischemia Following Early Reperfusion in a Mouse Model of Stroke

Ischemic stroke caused by cerebral artery occlusion induces neurological deficits because of cell damage or death in the central nervous system. Given the recent therapeutic advances in reperfusion therapies, some patients can now recover from an ischemic stroke with no sequelae. Currently, reperfusion therapies focus on rescuing neural lineage cells that survive in spite of decreases in cerebral blood flow. However, vascular lineage cells are known to be more resistant to ischemia/hypoxia than neural lineage cells. This indicates that ischemic areas of the brain experience neural cell death but without vascular cell death. Emerging evidence suggests that if a vascular cell-mediated healing system is present within ischemic areas following reperfusion, the therapeutic time window can be extended for patients with stroke. In this review, we present our comments on this subject based upon recent findings from lethal ischemia following reperfusion in a mouse model of stroke.

Are Depression and Dementia a Common Problem for Stroke Older Adults? A Review of Chosen Epidemiological Studies

Stroke is the second leading cause of death in the world. It is often associated with various long-term physical and neuropsychological consequences. The aim of this article is to present the results of research on the occurrence of dementia and post-stroke depression. Using the keywords: post-stroke dementia, post-stroke depression, post-stroke cognitive impairment, stroke, Polish and foreign bibliographic databases were searched: PubMed, Science Direct, Wiley, Google Scholar. Documents that met the eligibility criteria were selected for inclusion in this review. After the conducted analyses, 7 Polish articles and 13 English-language articles were qualified for the review. In the group of people after stroke, there is an increased risk of depression and dementia. According to the data, up to every third person can deal with one of these neuropsychiatric disorders. The presented research analyses indicate that the results obtained by the respondents, at any time after the stroke, indicate the presence of mild cognitive impairment or slight degree dementia among the majority of respondents. It was also shown that people with a stroke in the dominant hemisphere are more likely to experience post-stroke depression. Depression and post-stroke dementia are a common and significant complication of stroke that negatively affects the functional outcome. The huge focus on neuropsychiatric disorders occurring after stroke in modern research is very important because of their negative impact on recovery, quality of life and survival after stroke.

Post-stroke depression: A 2020 updated review

BACKGROUND

Post-stroke depression (PSD) is common and associated with higher mortality, poorer recovery, more pronounced cognitive deficits, and lower quality of life than is stroke without depression. This manuscript will conduct an updated, comprehensive and clinically-useful review of the risk factors, pathophysiology, assessment, prevention, and treatment of PSD.

METHODS

This narrative review summarizes articles obtained on PubMed, Medline, EMBase, Google Scholar and the Cochrane Database. This review prioritized articles with a more robust level of evidence, such as original articles with longitudinal data and/or larger samples, randomized controlled trials, systematic reviews, and metaanalyses.

RESULTS

One hundred twenty-four articles were reviewed, of which 44 (35%) were published before 2016 and 80 (65%) that were published since 2016.

DISCUSSION

Rates of PSD range from 18 to 33%, yet it is vastly underdiagnosed and undertreated. Risk factors for PSD include female sex, history of psychiatric illness, large or multiple strokes, injuries in frontal/anterior areas or in the basal ganglia, stroke occurrence within the past year, poor social support, and pronounced disability. The pathophysiology of PSD is multifactorial and likely involves decreased levels of monoamines, abnormal neurotrophic response, increased inflammation with dysregulation of hypothalamic-pituitary-adrenal axis, and glutamate-mediated excitotoxicity. The evidence for preventive interventions for PSD is somewhat inconsistent and modest. The best treatment for PSD consists of the combination of pharmacological, psychosocial and stroke-focused interventions.

CONCLUSION

PSD is a common, treatable condition that is associated with several negative outcomes. Early detection and proper management are critical to obtain better outcomes in individuals with PSD.

An iPad application-based intervention for improving post-stroke depression symptoms in a convalescent rehabilitation ward: A pilot randomized controlled clinical trial protocol

BACKGROUND

Post-stroke depression (PSD) is a neuropsychiatric sequela that causes serious adverse effects on the prognosis of stroke patients. Our developed iPad application is a very innovative approach designed to improve participants' depressive symptoms by presenting positive words stimuli in a video. Although this application has fewer side effects than existing pharmacological and non-pharmacological interventions and is likely less burdensome for patients and caregivers, its efficacy for PSD has not been investigated. Here we present a pilot randomized controlled trial (RCT) protocol to investigate the therapeutic potential of this application intervention for PSD patients.

METHODS

This study is designed as a 5-week, single-center, open-label, parallel-group, pilot RCT. Thirty-two patients with PSD will be randomly assigned to a combination of the iPad application and usual rehabilitation or usual rehabilitation alone (1:1 allocation ratio). The iPad application intervention lasts 3 min a day, and the usual rehabilitation lasts 3 h a day. The primary outcome is the change from baseline in The Center for Epidemiologic Studies Depression Scale score at the end of the 5-week intervention.

DISCUSSION

This pilot RCT is the first study to investigate the potential of iPad application interventions to reduce depressive symptoms in PSD patients. This pilot RCT determines whether this is a viable and effective intervention and informs the design for a full-scale trial. If our hypothesis is correct, this trial can provide evidence to augment the standard practice of iPad application interventions to improve depressive symptoms in patients with PSD.