Longitudinal study of regional cerebral blood flow changes in depression after stroke

A Comparative Study of Regional Cerebral Blood Flow Asymmetry Index in Stroke Patients with or without Poststroke Depression Using 99mTc-ECD Single-Photon Emission Computed Tomography

Introduction  Stroke is a major cause of death and disability around the globe. The development of depression following a stroke further increases the disability and impairs functional recovery. In recent decades, despite the advancement in structural and nuclear medicine imaging, the pathophysiologic basis of poststroke depression (PSD) is not well understood. Etiopathogenesis of PSD is multifactorial and afflictions of the frontal lobe, hippocampus, limbic region, and basal ganglia projections are implicated.

Aim  The aim of this study was to assess the regional cerebral blood flow (rCBF) using ^99m Tc-ethyl cysteinate dimer single-photon emission computed tomography (SPECT) in patients with (PSD + ) or without PSD (PSD–).

Materials and Methods  To evaluate the hemispheric asymmetry, the percentage of asymmetry index (AI) was calculated for frontal, temporal, parietal, occipital, putamen, caudate, and thalamic regions of brain and compared between PSD+ and PSD–. The correlation between AIs over the different brain regions was also established in patients of PSD+ and PSD–. Our study cohort included 122 patients between 6 weeks and 1 year of stroke. Depression was present in 52 (42.6%) patients, assessed by hospital anxiety and depression scale (HADS) and general health questionnaire-28 items (GHQ-28) scale. The 28 patients with PSD+ and 18 PSD– gave consent for SPECT study.

Results  Our results are based on 46 patients who underwent SPECT study. In patients with PSD+ and PSD–, the HADS and GHQ-28 scores were 8.93 ± 2.77 vs. 3.94 ± 2.15 ( p  = 0.001) and 40.96 ± 9.48 vs. 17.72 ± 5.38 ( p  = 0.001), respectively. A significant difference in rCBF AI was found in the temporal lobe ( p  = 0.03) between patients of PSD+ and PSD–. On logistic regression analysis, the odds ratio of rCBF AI for temporal lobe was 0.89 (95% confidence interval [CI]: 0.80–0.99; p  = 0.04) and caudate nucleus was 0.85 (95% CI: 0.73–0.98; p  = 0.03), which were statistically significant. PSD correlated with AI in temporal region ( r  = –0.03; p  = 0.03) but did not show significant correlation with other regions of brain between PSD+ and PSD–.

Conclusion  The presence of temporal lobe rCBF AI on SPECT is significantly associated with PSD. This may reflect the dysfunction of the limbic system and contribute to the occurrence of PSD.

Lesions in the right Rolandic operculum are associated with self-rating affective and apathetic depressive symptoms for post-stroke patients

Stroke survivors majorly suffered from post-stroke depression (PSD). The PSD diagnosis is commonly performed based on the clinical cut-off for psychometric inventories. However, we hypothesized that PSD involves spectrum symptoms (e.g., apathy, depression, anxiety, and stress domains) and severity levels. Therefore, instead of using the clinical cut-off, we suggested a data-driven analysis to interpret patient spectrum conditions. The patients’ psychological conditions were categorized in an unsupervised manner using the k-means clustering method, and the relationships between psychological conditions and quantitative lesion degrees were evaluated. This study involved one hundred sixty-five patient data; all patients were able to understand and perform self-rating psychological conditions (i.e., no aphasia). Four severity levels—low, low-to-moderate, moderate-to-high, and high—were observed for each combination of two psychological domains. Patients with worse conditions showed the significantly greater lesion degree at the right Rolandic operculum (part of Brodmann area 43). The dissimilarities between stress and other domains were also suggested. Patients with high stress were specifically associated with lesions in the left thalamus. Impaired emotion processing and stress-affected functions have been frequently related to those lesion regions. Those lesions were also robust and localized, suggesting the possibility of an objective for predicting psychological conditions from brain lesions.

Lower cognitive control network connectivity in stroke participants with depressive features

Around one-third of people develop depression following ischaemic stroke, yet the underlying mechanisms are poorly understood. Post-stroke depression has been linked to frontal infarcts, mainly lesions in the left dorsolateral prefrontal cortex (DLPFC). But depression is a network disorder that cannot be fully characterised through lesion-symptom mapping. Researchers of depression in non-stroke populations have successfully tapped into the cognitive control network (CCN) using the bilateral DLPFC as a seed, and found that CCN resting-state connectivity is reduced in even mildly depressed subjects, compared to healthy controls. Hence, we aimed to investigate the association between post-stroke depressive features and the CCN resting-state connectivity in a stroke population. We analysed DLPFC resting-state connectivity in 64 stroke participants, 20 of whom showed depressive features assessed with the Patient Health Questionnaire (PHQ-9) at 3 months after stroke. We directly compared groups showing symptoms of depression with those who did not, and performed a regression with PHQ-9 scores in all participants, controlling for age, gender, lesion volume and stroke severity. Post-stroke depression was associated with lower connectivity between the left DLPFC and the right supramarginal gyrus (SMG) in both group and regression analyses. Neither the seed nor the results overlapped with stroke lesions. These findings confirm an important role of the left DLPFC in post-stroke depression, but now show that large-scale network disruptions following stroke associated with depressive features occur without lesions in the DLPFC.

Depression after Stroke in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Objective

We aimed to conduct a systematic review and meta-analysis of prevalence and characteristics of poststroke depression (PSD) in sub-Saharan Africa (SSA).

Methods

We searched Medline, PsycINFO, and African Journals OnLine using keywords for stroke and depression and the .mp. operator for all 54 SSA countries/regions. Further information was retrieved through a manual search of references from relevant published and unpublished articles. We included only peer-reviewed original studies with epidemiological or experimental designs, conducted random-effect meta-analysis, and identified the most commonly associated factors by weight (inverse of variance method).

Results

Seventeen studies, comprising 1483 stroke survivors, met the criteria for syntheses. The pooled frequency of clinically diagnosed PSD was 31% (95% CI = 26%–36%), versus 13.9% in healthy control pairs. Prevalence did not vary much across healthcare settings but was affected by methods of depression ascertainment. PSD was significantly associated with low education, cognitive impairment, physical disability, poor quality of life, and divorced marital status.

Conclusion

Almost 1 in 3 individuals with stroke in SSA has clinical depression. Despite limitations around quality of identified studies, results of the present systematic review overlap with findings in the global literature and highlight useful targets for the design and trial of tailored intervention for PSD in SSA.

Neuroanatomic pathways associated with poststroke affective and apathetic depression

OBJECTIVES

Our goal was to localize lesions in poststroke depression patients using magnetic resonance imaging, based on the statistical parametric maps image analysis technique that can be used to combine image data from multiple participants and correlate these images with other data sets.

METHODS

Magnetic resonance imaging acquisitions were obtained from 149 poststroke patients, who were assessed for affective and apathetic symptoms using the Hospital Anxiety and Depression Scale and the Apathy Scale, respectively. We created a statistical parametric map that displayed an association between lesion location and affective and apathetic symptoms.

RESULTS

Among the patients with higher depressive scores, the lesion overlap centered on the brainstem, left basal ganglia, and left frontal cortex. Among the patients with higher apathy scores, the lesion overlap centered on the brainstem and bilateral striatum. The overlap lesion for both affective and apathetic depression centered mainly on the brainstem; however, the two types of depression often did not overlap.

CONCLUSIONS

Two core symptoms that can occur after stroke, affective and apathetic symptoms, appear to be associated with different monoaminergic neuroanatomic pathways (serotonergic and dopaminergic).

A brief history of poststroke depression neuroimaging

The past 25 years have witnessed a dramatic rise and fall in clinical research investigating lesion localization in poststroke depression patients. Early studies focused on basic lesion characteristics, such as left versus right hemisphere and anterior versus posterior location, that would dominate studies in this field for the next 15 years. While results were inconsistent, some studies suggested that the left hemisphere and more anterior lesions were associated with increased prevalence and severity of depression. Recent studies have suggested lesion preference in components of the basal ganglia and frontal–subcortical circuitry and have proposed a combined effect of large stroke lesions and other lesions, such as white matter hyperintensities and lacunar infarcts. The effect of lesion location on poststroke depression requires further clarification.

Poststroke depression in patients with small subcortical infarcts

OBJECTIVES

Small subcortical infarcts (SSIs) can result from small vessel disease (SVD) and intracranial and extracranial large artery disease (LAD). No study has explored poststroke depression (PSD) in different etiological types of SSIs.

METHODS

Patients with SSIs resulting from LAD and SVD were included in the study. Poststroke depression was evaluated with the 15-item version of the geriatric depression scale (GDS) 3 months after stroke.

RESULTS

Of the 127 patients with SSIs, 44 had LAD and 83 had SVD. The LAD group had a significantly higher mean GDS score and higher frequency of PSD (p<0.05). The etiological type LAD was a significant independent risk factor for PSD.

CONCLUSION

PSD is more common in patients with SSIs resulting from LAD. This suggests that cerebral blood perfusion may play an important role in the development of PSD.

'Insistence on recovery' as a positive prognostic factor in Japanese stroke patients

AIM

The present study used two-step analyses to examine the effect of acceptance of disability or 'insistence on recovery' in Japanese stroke patients: first on their functional improvement and second, on their psychological symptoms.

METHODS

Disability was assessed using functional independence measurements (FIM), examining the stage of acceptance of disability by observation using Fink's theory (from shock to defensive retreat, acknowledgement, and acceptance/change stage), and estimation of insistence on recovery (on a scale of 1-4) by observation. The differences over time and the effects on the improvement in their FIM were then assessed. Depression was measured using the Zung Self-rating Depression Scale (SDS); apathy was measured using the Apathy Scale (AS), and the correlation with the acceptance stage or insistence on recovery was analyzed.

RESULTS

The acceptance stage and functional improvement progressed significantly, but insistence on recovery did not change significantly during hospitalization. Multiple regression indicated that the insistence on recovery score (but not the acceptance stage) was a good predictor of the degree of improvement in FIM (FIM gain per week) in the elderly group. Post-hoc testing showed that the SDS or AS score decreased from the first stage to the fourth stage (but increased at the third stage) of acceptance; whereas for insistence on recovery score, the SDS and AS scores decreased as insistence on recovery score changed from 1 to 3, and then increased as insistence on recovery score changed from 3 to 4.

CONCLUSIONS

The appropriate level of insistence on recovery reduced depression and apathy, resulting in enhanced improvement of disability after a stroke in elderly stroke patients.

Depression or apathy and functional recovery after stroke

OBJECTIVES

While depression and apathy are common after stroke, past studies have done little to examine the influence of these two symptoms on functional outcome respectively. This study was designed to examine the effect of depression or apathy on functional recovery after stroke in 237 Japanese stroke patients.

METHODS

We assessed the psychological status using self-rating scales [the Zung Self-Rating Depression Scale (SDS) for depression and the Apathy Scale (AS) for apathy] and an observer-rating scale [the Neuropsychiatric Inventory (NPI)]. We assessed physical disability using the Functional Independence Measurement (FIM). Post-hoc test and multiple regression analysis were used to determine the independent effects of post-stroke depression and apathy on functional outcome.

RESULTS

Depression was observed in 75 (31.6%) using SDS and 88 (40.2%) using NPI, and apathy in 95 (40.1%) using AS and 42 (19.2%) using NPI, respectively. Post-hoc test and multiple regression analysis indicated that the cognitive variable (Mini-Mental State Examination: MMSE score) and AS score, but not SDS score, correlated negatively with improvement in FIM.

CONCLUSIONS

Apathy might be more frequently associated with functional abilities and likely interact with the recovery process as compared with depression after stroke.

Sitting balance as an early predictor of functional improvement in association with depressive symptoms in stroke patients

The aim of the present study was to assess the relationship between sitting balance at an early stage and activities of daily living (ADL) function in 452 stroke patients. The effect of sitting balance on the two core elements of depression (apathy and depressive mood) was also examined. The ability to maintain a sitting position for 10 min (10-min sitting balance) was assessed, along with ADL using the Functional Independence Measurement, and psychological status using the Zung Self-rating Depression Scale (depressive mood), Apathy Scale (apathy) and Neuropsychiatric Inventory. Proportional-hazards analysis was used to determine the independent effect of post-stroke depression on functional outcome. Comparisons between sitting balance and psychological status were performed using logistic multiple regression analysis. Cox multiple regression analysis showed that significant differences were obtained for the sitting balance (P < 0.0002) and Mini-Mental State Examination scores (P < 0.02) in all six ADL subscales, and for age in four of the six ADL subscales (Dressing-Upper Body and Dressing-Lower Body, Toileting, Walking). Kaplan-Meier survival curves for reaching independence in ADL subscales showed highly significantly differences in achievement rate and time to reach goal for each subgroup on 10-min sitting balance (with or without assistance) and on age (young, <65; elderly, >/=65 years). Ten-minute sitting balance correlated with depressive mood and apathy. A rapid and simple screening method, 10-min sitting balance was related to scores for two core depressive symptoms, lowered mood and apathy, and was predictive of post-stroke ADL outcomes in the rehabilitation unit along with age.

Post-stroke affective or apathetic depression and lesion location: left frontal lobe and bilateral basal ganglia

This study was designed to examine the correlation between damage to the basal ganglia or frontal lobe and depression status (both affective and apathetic dimensions) in 243 stroke patients. We assessed the affective dimension in post-stroke depression (PSD) using the Zung Self-rating Depression Scale (SDS) and the apathetic dimension in PSD using the apathy scale (AS). We classified basal ganglia or frontal lobe damage into four groups: no damage, damage to the left side only, damage to the right side only, and damage to both sides. Affective and/or apathetic PSD was found in 126 patients (51.9%). The severity of affective depression (SDS score) was associated with left frontal lobe (but not basal ganglia) damage, and that of apathetic depression (AS score) was related to damage to the bilateral basal ganglia (but not to the frontal lobe). The anatomical correlates of PSD differ depending on the PSD dimension (affective or apathetic) and may explain interstudy differences regarding the association between lesion location and type of PSD.

Cerebrovascular disease and late life depression: an age old association revisited

OBJECTIVES

To examine the relationship between depression and cerebrovascular disease in three distinct settings: depression in established cerebrovascular disease, cerebrovascular disease in established depression and depression in vascular dementia.

METHODS

Medline, EMBASE, PsychLit and PsychInfo databases were scanned to locate relevant articles. Data were also extracted from other articles, cited by those articles generated from the above databases.

RESULTS

Using operational criteria, the prevalence of depression is higher than controls only within the first year after stroke, but most studies have not employed control groups. The prevalence of depression in vascular dementia compared with Alzheimer's disease is higher in the majority of studies, but matching for sociodemographic factors and severity of cognitive impairment has been inconsistent. An association between frontal/subcortical cerebrovascular lesions and depression in later life has been observed, but there may be methodological flaws underlying this observation in some computerized tomography studies.

CONCLUSION

There is some evidence that cerebrovascular disease has an aetiopathological role in late life depression. The increased likelihood of damage to frontal/subcortical brain circuitry following stroke, transient ischaemia and hypertension may explain the high prevalence of depression in older people with vascular risk factors. More valid definitions of lesion location and the use of appropriately matched control groups would seek to clarify this issue. The extrapolation to care settings from the high prevalence of depression accompanying cerebrovascular disease and the prolongation of disability in depressed people with stroke, suggests closer liaison between old age psychiatrists, neurologists and physicians caring for the elderly.

Major life events as risk factors for post-stroke depression

Depression is a significant sequela of stroke which contributes to increased morbidity and mortality in stroke survivors. Psychosocial stressors, such as major life events, pose risk factors for developing depression in non-stroke populations. This study evaluated major life events as a risk factor for developing post-stroke depression (PSD) during the first year post-stroke. One hundred and eleven patients who completed the Center for Epidemiological Studies-Depression Scale at four time periods during the first year post-stroke were assessed for PSD and asked if they had experienced a major life event in the prior 6 months (other than the stroke). The subjects completed the evaluations acutely (7-10 days), and at 3, 6, and 12 months post-stroke. At 6 months post-stroke patients were significantly more likely to be depressed if they had a major life event in the prior 6 months (other than the stroke) than if they had not, chi 2 (df = 1) = 4.83, p < 0.028, relative risk = 2.31, 95% confidence interval 1.15-4.62. Life events pose significant risks for developing PSD at 6 months post-stroke. Stroke patients need to be asked about these events and treated for PSD.

Clinical implications of poststroke hypothalamo-pituitary adrenal axis dysfunction: A critical literature review

Persistent hypothalamo-pituitary adrenal axis dysregulation occurs in up to 40% of patients who have suffered a stroke. The degree of hypercortisolemia is partly determined by the size and site of the vascular lesion. Adrenocortical hyperactivity begins almost immediately after a cerebrovasacular infarct but is persistent in an important subgroup of patients. In the early poststroke period (1 day to 1 month) high corticosteroid levels correlate with the presence of an acute confusional state. In the medium term (1 month to 1 year) hypercortisolemia is associated with the development of a major depressive episode and also relates to functional outcome and survival. Neuroanatomical deficits (particularly in the frontal or medial temporal lobes), age of onset, cognitive impairment, and reduced functional status may act as maintaining factors in both the poststroke depression and the adrenocortical hyperactivity. Patients with persisting hypercortisolemia, with or without depression or cognitive impairment, have a worse prognosis with an increased mortality rate. The mechanism for this effect may involve induced hyperglycemia or direct glucocorticoid neurotoxicity, which impairs the brain's capacity for recovery. It is suggested that the cautions use of antiglucocorticoid strategies may be of value in the medical management of the neuropsychiatric complications that follow cerebrovascular accidents.

Poststroke depression: an examination of the literature

OBJECTIVE

To examine literature on poststroke depression (PSD).

DATA SOURCES

More than 200 articles related to stroke and depression were selected from a computer-based search spanning 1985 to 1995.

STUDY SELECTION

All relevant articles on PSD. Articles in foreign languages, case studies, anecdotal reports, book chapters, and reviews were excluded.

DATA EXTRACTION

Summary findings were independently reviewed by the authors.

DATA SYNTHESIS

PSD remains a frequent sequela of stroke; its prevalence remains uncertain because of continued methodologic problems in defining subject groupings and in utilizing psychiatrically normed assessment tools with neurologically impaired individuals, and because of the poor specificity/sensitivity of neuroendocrine markers in determining a diagnosis. The etiology of PSD appears to be complex and not fully understood. Although there has been much research on PSD, this review highlights the sparsity of available literature on its treatment.

CONCLUSION

The review points out the further need for more carefully designed studies of PSD that examine both assessment and treatment.

Psychiatric profiles and patterns of cerebral blood flow in focal epilepsy: interactions between depression, obsessionality, and perfusion related to the laterality of the epilepsy

OBJECTIVES

In a study of patients with focal epilepsy the hypothesis was explored that different measurements of psychopathology are related to specific distributions of cerebral perfusion.

METHODS

Forty patients had SPECT performed with (99m)Tc-HMPAO. In addition, patients received a psychiatric evaluation with the following psychiatric questionnaires: the Beck depression inventory, the Leyton obsessionality inventory, the Bear-Fedio questionnaire, and the social stress and support interview. Patients were analysed in two groups according to the laterality of the epilepsy. Nine patients were excluded based on poor quality scans (n = 1), unlateralised epilepsy (n = 4), and left or ambidextrous handedness (n = 4).

RESULTS

There were no overall differences between the left and right epilepsy groups on measures of psychopathology. Associations were found between scores on some of the rating scales and regional cerebral blood flow. Specifically, for patients with left sided epilepsy, higher scores on the Beck depression inventory were associated with lower contralateral temporal and bilateral frontal perfusion, and higher occipital perfusion. For patients with right sided epilepsy higher scores on the Leyton obsessionality inventory were associated with increased perfusion in ipsilateral temporal, thalamic, and basal ganglia regions and bilateral frontal regions.

CONCLUSION

The results do not support the notion that lateralised epileptogenic lesions are associated with different levels of depression, obsessionality, or personality traits. They support the view that certain psychopathological symptom patterns are related to specific regional dysfunctions depending on the laterality of a hemispheric lesion.

Poststroke depression: prevalence, course, and associated factors

Despite the considerable amount of research that has been undertaken on poststroke depression, a review of the literature demonstrates that there are many inconclusive findings in the area. In particular, the causes and course of the disorder remain to be firmly established. While studies of prevalence differ with respect to the nature and timing of their assessment procedures, most conclude that poststroke depression has a negative impact on the rehabilitation of the stroke patient. Very little research is available on te relationship between poststroke depression and care-giver burden. However, recent studies have adopted more rigorous methodological procedures, allowing some insights into the complex mixture of factors which determine the occurrence of poststroke depression.

Factors complicating the diagnosis of depression in cerebrovascular disease, Part II--Neurological deficits and various assessment methods

Neurological deficits associated with cerebrovascular disease such as aphasia, dementia, anosognosia and aprosodia may impair the ability to express or experience depressive symptoms. Identification of depression in the absence of verbal report on subjective mood state is a difficult task. The value of various diagnostic methods including depressive rating scales, standard psychiatric interviews and biological variables in the diagnosis of depression in cerebrovascular disease is considered. This review concludes by focusing on the deficiencies of existing approaches in the diagnostic assessment of depression in patients with severe communication and comprehension deficits and emphasizes the importance of devising a standard diagnostic method with less reliance on verbal responses.