White matter hyperintensities and post-stroke depression: A systematic review and meta-analysis

Major depressive disorder and the development of cerebral small vessel disease: A Mendelian randomization study

BACKGROUND

Although observational studies indicate a complex, bidirectional association between major depressive disorder (MDD) and cerebral small vessel disease (CSVD), the results are frequently inconsistent. This study investigated the potential correlation of MDD with both CSVD clinical outcomes and radiological markers, utilizing a bidirectional Mendelian randomization (MR) study design.

METHODS

Instrumental variables for MDD were obtained from the latest and largest genome-wide association study (GWAS). For CSVD, we extracted genetic instruments from GWAS datasets corresponding to both clinical outcomes and radiological markers, including intracerebral hemorrhage, small vessel ischemic stroke, white matter hyperintensities volume, mean diffusivity (MD), fractional anisotropy, brain microbleeds, and enlarged perivascular space (PVS). We employed the inverse variance weighting method as the primary analysis, complemented by conducting extensive sensitivity and heterogeneity tests.

RESULTS

In the forward MR analyses, we discovered that the genetically predicted risk of MDD exhibits a potential causal relationship with two CSVD phenotypes demonstrating microscopic white matter (WM) damage: mean diffusivity (β = 0.784, 95 % CI 0.285-1.283, p = 0.002) and WM-PVS (OR = 1.053, 95%CI 1.010-1.097, p = 0.015). A single SNP (rs2232423) was identified as significantly influencing the causal relationship between MDD and WM. After excluding this SNP, our estimated association between MDD and increased MD (β = 0.516, 95%CI -0.001-1.033, p = 0.048) remained. The effects of MDD on WM-PVS passed all the tests for heterogeneity and pleiotropy. Reverse MR analyses showed no evidence of reverse causality between MDD and an altered CSVD risk.

CONCLUSIONS

This study supports a potential causal association between MDD and CSVD-related indicators of impaired WM microstructure. These insights hold promise for improving risk assessment methods in CSVD.

Vascular depression: A comprehensive exploration of the definition, mechanisms, and clinical challenges

Vascular depression (VaDep), which was proposed over two decades ago, is a distinct subtype of depression primarily observed in patients with stroke and cerebral small-vessel disease and is characterized by white matter hyperintensities; however, the lack of standardized diagnostic criteria and consensus limits its clinical application. This review explores the pathological conditions and vascular risk factors that may precipitate VaDep, particularly in relation to stroke and cerebral small-vessel disease. VaDep is distinguished by unique pathophysiological mechanisms and treatment responses. We categorize these mechanisms into three groups: 1) macroscopic mechanisms, including vascular aging, cerebral hypoperfusion, blood-brain barrier disruption, and neural circuit dysfunction; 2) microscopic mechanisms, involving the inflammatory response, hypothalamic-pituitary-adrenal axis dysregulation, impaired monoamine synthesis, and mitochondrial dysfunction; and 3) undetermined mechanisms, such as microbiota-gut-brain axis dysbiosis. These insights support VaDep as a distinct depression subtype, differentiating it from late-life depression and major depressive disorder. Treatment is challenging, as patients with VaDep often exhibit resistance to conventional antidepressants. Addressing vascular risk factors and protecting vascular integrity are essential for effective management. Future research should validate these mechanisms and develop novel diagnostic and therapeutic approaches to improve VaDep outcomes.

Plasma polyamines levels and post-stroke depression in ischemic stroke patients: A multicenter prospective study

BACKGROUND AND AIMS

Polyamines have been suggested to implicated in inflammation, ischemic stroke, and mental disorders, but the associations of polyamines with post-stroke depression (PSD) remain unclear. We aimed to prospectively investigate the associations of plasma putrescine, spermidine and spermine with PSD among ischemic stroke patients in a multicenter cohort study.

METHODS

We measured plasma putrescine, spermidine and spermine levels at baseline among 635 ischemic stroke patients from a preplanned ancillary study of the CATIS (China Antihypertensive Trial in Acute Ischemic Stroke). The study outcome was depression (Hamilton Depression Rating Scale score ≥8) at 3-month follow-up after ischemic stroke.

RESULTS

Plasma putrescine and spermidine were positively associated with the risk of PSD. The adjusted odds ratios of PSD for the highest versus lowest tertile of putrescine and spermidine were 1.77 (95 % CI, 1.13-2.78; ptrend = 0.014) and 1.77 (95 % CI, 1.11-2.82; ptrend = 0.013), respectively. Multivariable-adjusted spline regression analyses showed linear associations of plasma putrescine (p = 0.002 for linearity) and spermidine (p = 0.008 for linearity) with PSD. In addition, plasma putrescine (continuous net reclassification improvement [NRI]: 26.33 %, p = 0.002; integrated discrimination improvement [IDI]: 1.06 %, p = 0.009) and spermidine (continuous NRI: 20.72 %, p = 0.013; IDI: 1.04 %, p = 0.010) could significantly improve the risk reclassification of PSD beyond the established risk factors.

CONCLUSIONS

High plasma putrescine and spermidine levels were associated with increased risk of PSD among ischemic stroke patients. Our findings suggest that plasma polyamines should be implicated in the pathophysiologic processes of PSD and may be the potential intervention targets for PSD.

Behavioral Monitoring in Transient Ischemic Attack and Stroke Patients: Exploratory Micro- and Macrostructural Imaging Insights for Identifying Post-Stroke Depression with Accelerometers in UK Biobank

To examine the association between post-stroke depression (PSD) and macrostructural and microstructural brain measures, and to explore whether changes in accelerometer-measured physical activity (PA) are associated with PSD, we conducted an exploratory study in UK Biobank with dementia-free participants diagnosed with at least one prior stroke. Eligible participants (n = 1186) completed an MRI scan. Depression was classified based on positive depression screening scores (PHQ-2 ≥ 3). Multivariate linear regression models assessed the relationships between depression and structural and diffusion measures generated from brain MRI scans. Logistic regression models were used to examine the relationship between accelerometer-measured daily PA and future depression (n = 367). Depression was positively associated with total white matter hyperintensities (WMHs) volume (standardized β [95% CI]-0.1339 [0.012, 0.256]; FDR-adjusted p-value-0.039), periventricular WMHs volume (standardized β [95% CI]-0.1351 [0.020, 0.250]; FDR-adjusted p-value-0.027), and reduced MD for commissural fibers (standardized β [95% CI]--0.139 [-0.255, -0.024]; adjusted p-value-0.045). The odds of depression decreased by 0.3% for each daily minute spent in objectively measured light PA, while each minute spent in sleep from midnight to 6:00 AM was associated with a 0.9% decrease in the odds of depression. This early-stage analysis using a population cohort offers a scientific rationale for researchers using multimodal data sources to investigate the heterogenous nature of PSD and, potentially, identify stroke patients at risk of poor outcomes.

Irritability in stroke: a protocol for a prospective study

Background

Poststroke irritability (PSI) is common among stroke survivors and can lead to a poor quality of life, difficulties in social interactions, criticism from caregivers, and caregiver stress. The planned study will evaluate the clinical, neuropsychological, and magnetic resonance imaging (MRI) correlates of PSI in a cohort of stroke survivors. In addition, the study will examine the 15-month progression of PSI.

Methods

This will be a prospective cohort study that will recruit 285 participants. Participants and their caregivers will undergo detailed assessments at a research clinic at 3, 9, and 15 months after stroke onset (T1/T2/T3). The irritability/lability subscale of the Chinese version of the Neuropsychiatric Inventory (CNPI) will be completed by caregivers. Potential covariates will also be measured. Patients will undergo MRI, including diffusion-weighted imaging, within 1 week of stroke onset. A stepwise logistic regression will be performed to evaluate the importance of lesions in the regions of interest (ROIs) along with other significant variables identified in univariate analyses. These analyses will be repeated for patients with and without PSI at T2 and T3. Repeated measures analysis of covariance (ANCOVA) will be used to assess changes in CNPI scores for the entire sample. In ANCOVA analyses, the frequency of infarcts in the ROIs will be treated as the predictor.

Discussion

This will be the first MRI study on PSI in stroke survivors. The findings will provide insights into the association of the orbitofrontal cortex, anterior cingulate cortex, anterior temporal lobe, insula, amygdala, thalamus, and basal ganglia lesions with the risk of PSI.

Innate immunity-mediated neuroinflammation promotes the onset and progression of post-stroke depression

Post-stroke depression (PSD) is a prevalent psychiatric disorder after stroke, with the incidence of approximately one-third among stroke survivors. It is classified as an organic mental disorder and has a well-documented association with stroke affecting various aspects of patients, such as the recovery of limb motor function, daily living self-care ability, and increasing the mortality of stroke survivors. However, the pathogenesis of PSD is not yet fully understood. Currently, immune inflammation is a research hotspot. This review focuses on the pathogenesis of PSD, particularly elucidating the role of inflammation in mediating neuroinflammation through innate immunity. Simultaneously, we highlight that peripheral inflammation following a stroke may trigger a detrimental cycle of neuroinflammation by activating innate immune pathways within the central nervous system, which could potentially contribute to the development of PSD. Lastly, we summarize potential treatments for PSD and propose targeting cytokines and innate immune pathways as novel therapeutic approaches.

The clinical and neuropsychological profiles of Alzheimer's disease with white matter hyperintensity in North China

Background

Patients with Alzheimer's disease (AD) often exhibit characteristic clinical manifestations, particularly neuropsychiatric symptoms. Previous studies have shown that white matter hyperintensity (WMH) is strongly associated with AD progression, as well as neuropsychiatric symptoms. The purpose of this study was to investigate the clinical and neuropsychological characteristics of AD patients with WMH.

Methods

This retrospective study involved 104 18-fluorodeoxyglucose-positron emission computed tomography (18FDG-PET-CT)-defined AD patients treated at Tianjin Huanhu Hospital from January 2010 to December 2022. Cranial magnetic resonance imaging (MRI) provided semi-quantitative data on brain structure and WMH. Collect and analyze patient clinical data. Neuropsychological assessments were used to evaluate cognitive function and psychobehavioral traits.

Results

Among the 104 patients, 66 were in the WMH group (63.5%) and 38 in the non-white matter hyperintensity (non-WMH) group (36.5%). There were no significant differences in gender, age, age of onset, education, BMI, smoking, drinking, diabetes, coronary heart disease, dementia family history, fasting blood glucose, total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) between the two groups. The WMH group showed higher rates of hypertension, homocysteine (Hcy) levels, NPI, and CDR scores as compared to the non-WMH group (p < 0.05). MMSE and MoCA scores were significantly lower in the WMH group (p < 0.05). In the MMSE subitem analysis, patients in the WMH group showed a decrease in attention, recall, and language scores. In the MOCA subitem analysis, WMH patients had lower scores in executive function, naming, attention, language, abstraction, and orientation (p < 0.05). Furthermore, subgroup analysis of NPI showed a higher incidence of delusions, depression, and apathy in the WMH group (p < 0.05). According to the hierarchical analysis of mild, moderate and severe dementia groups, the hypertension, leukoencephalopathy, Hcy level, Fazekas total score, PWMH and DWMH scores in the severe dementia group were significantly higher than those in the mild and moderate dementia groups (p < 0.05). As the disease progresses, more and more patients show increased white matter hyperintensity.

Conclusion

White matter lesions are closely correlated with cognitive decline and psychobehavioral symptoms in AD patients, and may be used as an indicator of disease progression. Priority should be given to early screening and prevention of WMH-related risk factors.

Pathophysiology, Assessment, and Management of Post-Stroke Cognitive Impairment, Depression, and Fatigue

Post-stroke cognitive impairment, depression, and fatigue are common, persistent, and disabling. This review summarizes current knowledge on the pathophysiology, assessment, and management of these debilitating neuropsychiatric sequelae of stroke. We briefly review evolving knowledge on the neural mechanisms and risk factors for each condition. We describe patient-reported outcome measures and clinician rating techniques that can be used to assist in screening and comprehensive assessment. We then discuss behavioral and pharmacologic management strategies. Heterogeneity of stroke remains a challenge in management and new research is still needed to optimize and personalize treatments for stroke survivors.

Current perspectives on prevention of vascular cognitive impairment and promotion of vascular brain health

INTRODUCTION

The true global burden of vascular cognitive impairment (VCI) is unknown. Reducing risk factors for stroke and cardiovascular disease would inevitably curtail VCI.

AREAS COVERED

The authors review current diagnosis, epidemiology, and risk factors for VCI. VCI increases in older age and by inheritance of known genetic traits. They emphasize modifiable risk factors identified by the 2020 Lancet Dementia Commission. The most profound risks for VCI also include lower education, cardiometabolic factors, and compromised cognitive reserve. Finally, they discuss pharmacological and non-pharmacological interventions.

EXPERT OPINION

By virtue of the high frequencies of stroke and cardiovascular disease the global prevalence of VCI is expectedly higher than prevalent neurodegenerative disorders causing dementia. Since ~ 90% of the global burden of stroke can be attributed to modifiable risk factors, a formidable opportunity arises to reduce the burden of not only stroke but VCI outcomes including progression from mild to the major in form of vascular dementia. Strict control of vascular risk factors and secondary prevention of cerebrovascular disease via pharmacological interventions will impact on burden of VCI. Non-pharmacological measures by adopting healthy diets and encouraging physical and cognitive activities and urging multidomain approaches are important for prevention of VCI and preservation of vascular brain health.

Predictive microbial feature analysis in patients with depression after acute ischemic stroke

Introduction

Post-stroke depression (PSD) is the most common emotional problem following a stroke, which requires early diagnosis to improve the prognosis. Gut microbiota plays important role in the pathological mechanisms of acute ischemic stroke and influences the outcome of patients. However, the relationship between PSD and gut microbiota remains unknown. Here, we explored whether the microbial signatures of gut microbiota in the patients with stroke could be an appropriate predictor of PSD.

Methods

Fecal samples were collected from 232 acute ischemic stroke patients and determined by 16s rRNA sequencing. All patients then received 17-Hamilton Depression Rating Scale (HAMD-17) assessment 3 months after discharge, and were further divided into PSD group and non-PSD group. We analyzed the differences of gut microbiota between these groups. To identify gut microbial biomarkers, we then established microbial biomarker model.

Results

Our results showed that the composition of gut microbiota in the PSD patients differed significantly from that in non-PSD patients. The genus Streptococcus, Akkermansia, and Barnesiella were significantly increased in PSD patients compared to non-PSD, while the genus Escherichia-Shigella, Butyricicoccus, and Holdemanella were significantly decreased. Correlation analyses displayed that Akkermansia, Barnesiella, and Pyramidobacter were positively correlated with HAMD score, while Holdemanella was negatively correlated with HAMD score. The optimal microbial markers were determined, and the combination achieved an area under the curve (AUC) value of 0.705 to distinguish PSD from non-PSD.

Conclusions

Our findings suggest that PSD patients had distinct gut microbiota compared to non-PSD patients, and explore the potential of microbial markers, which might provide clinical decision-making in PSD.