Post-Stroke Neuropsychiatric Complications: Types, Pathogenesis, and Therapeutic Intervention

Targeting microglial NAAA-regulated PEA signaling counters inflammatory damage and symptom progression of post-stroke anxiety

Post-stroke anxiety (PSA) manifests as anxiety symptoms after stroke, with unclear mechanisms and limited treatment strategies. Endocannabinoids, reported to mitigate fear, anxiety, and stress, undergo dynamic alterations after stroke linked to prognosis intricately. However, endocannabinoid metabolism in ischemic microenvironment and their associations with post-stroke anxiety-like behavior remain largely uncovered. Our findings indicated that endocannabinoid metabolism was dysregulated after stroke, characterized by elevated N-palmitoylethanolamide (PEA) hydrolase N-acylethanolamine-acid amidase (NAAA) in activated microglia from ischemic area, accompanied by rapid PEA exhaustion. Microglial PEA metabolite exhaustion is directly associated with more severe pathological damage, anxiety symptoms and pain sensitivity. Naaa knockout or pharmacological supplementation to boost PEA pool content can effectively promote stroke recovery and alleviate anxiety-like behaviors. In addition, maintaining PEA pool content in ischemic area reduces overactivated microglia by confronting against mitochondria dysfunction and inflammasome cascade triggered IL-18 release and diffusion to contralateral hemisphere. Meanwhile, maintenance of microglial PEA pool content in ischemic-damaged lesion can preserve contralateral vCA1 synaptic integrity, enhancing anxiolytic pBLA-vCA1Calb1+ circuit activity by alleviating microglial phagocytosis-mediated synaptic loss. Thus, we conclude that microglial NAAA-regulated lipid signaling in the ischemic focus remodels contralateral anxiolytic circuit to participate in post-stroke anxiety progression. Blocking PEA signaling breakdown promotes stroke recovery and mitigates anxiety-like symptoms.

Downregulation of the HCN1 Channel Alleviates Anxiety- and Depression-Like Behaviors in Mice With Cerebral Ischemia-Reperfusion Injury by Suppressing the NLRP3 Inflammasome

BACKGROUND

Post-stroke depression (PSD) is a prevalent neuropsychiatric complication of stroke. However, the mechanisms underlying PSD are still unclear. Here, we aimed to investigate the role of HCN1 (hyperpolarization-activated cyclic nucleotide-gated cation channel 1) in the pathogenesis of PSD and its underlying mechanisms.

METHODS

The PSD mice model was established by middle cerebral artery occlusion in vivo. Four weeks after middle cerebral artery occlusion, anxiety- and depression-like behaviors of mice were evaluated by various behavioral tests. HCN channels were downregulated by pharmacological inhibitor or neuron-specific adeno-associated virus. The oxygen-glucose deprivation/reoxygenation model in SY5Y cells was used to study the pathogenesis of PSD in vitro.

RESULTS

Mice exhibited anxiety- and depression-like behavior 4 weeks after middle cerebral artery occlusion, along with a significant increase in HCN1 protein expression in the ischemic hippocampus. Furthermore, the Ih current on neurons in the hippocampus was notably enhanced, whereas neuronal excitability was decreased in PSD mice. Treatment with HCN channel selective inhibitor ZD7288 protected SY5Y cells against oxygen-glucose deprivation/reoxygenation injury by suppressing K+ efflux. Additionally, we observed a significant increase in protein expressions of NLRP3 (nucleotide-binding domain-like receptor protein 3) inflammasome pathway-related molecules in the ischemic hippocampus of PSD mice. Knockdown of HCN1 channels via virus injection into the hippocampus resulted in decreased protein expressions of NLRP3 inflammasome-related molecules and improvement in anxiety- and depression-like behaviors in PSD mice.

CONCLUSIONS

Downregulation of HCN1 channels has a beneficial effect on PSD by suppressing the NLRP3 inflammasome pathway, thus offering promise as a strategy for preventing and treating PSD.

Relationship between elevated homocysteine levels and the degree of white matter lesions in stroke patients

This study explores the relationship between elevated homocysteine (Hcy) levels and white matter lesion (WML) severity in stroke patients, aiming to clarify Hcy role in stroke pathology and support clinical treatment and prevention strategies for cerebrovascular diseases. A retrospective analysis was conducted on 200 stroke patients from Guyuan People's Hospital (2022-2024). Hcy levels were measured using a Beckman AU5800 analyzer, and WML severity was assessed via magnetic resonance imaging using the Fazekas scale. Carotid intima-media thickness (cIMT) was measured by ultrasound. The mean Hcy level was significantly higher in the moderate to severe WML group (16.2 ± 5.3 μmol/L) compared to the mild group (11.4 ± 3.8 μmol/L, P < .001), showing a positive correlation with WML severity. The moderate to severe group also had significantly higher left and right cIMT (P < .001). Logistic regression identified age, hypertension, diabetes, Hcy levels, and right-sided cIMT as independent predictors of moderate to severe WML. Receiver operating characteristic curve analysis indicated high diagnostic value for both Hcy levels and right-sided cIMT, with combined use improving assessment accuracy. Elevated Hcy levels and increased right-sided cIMT are independent risk factors for moderate to severe WML in stroke patients. Combining these measures improves assessment accuracy and highlights the need for targeted interventions. Future research should investigate Hcy and cIMT mechanisms and interventions to enhance clinical application.

The effect of inhaled aromatherapy on cognitive function in patients with cognitive impairment: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Cognitive function is the basis of human thinking and behavior. Cognitive impairment has a serious impact on each individual and imposes a financial burden to families and healthcare systems. Inhalation aromatherapy has advantages, due to its safety, convenience, lack of toxicity, and wide use in the treatment of cognitive impairment. This systematic review was conducted to provide evidence for the use of inhaled aromatherapy in patients with cognitive impairment.

METHODS

We searched nine databases for pertinent Chinese and English studies published through November 2024 studies using inhaled aromatherapy in patients with cognitive impairment. Literature screening and data extraction were performed independently by two researchers and evaluated using the Cochrane Collaboration's quality criteria and were then cross-checked. A meta-analysis was carried out using Cochrane's Review Manager (RevMan, version 5.4), and we followed the PRISMA guidelines.

RESULTS

We included fourteen studies involving 888 patients with cognitive impairment in our study. Meta-analyses indicated that inhaled aromatherapy increased Mini-mental State Examination (MMSE, mean difference MD = 3.89 95 % CI [3.19, 4.58], P < 0.00001) and Montreal Cognitive Assessment Scale (MoCA, MD = 4.11, 95 % CI [3.54, 4.68], P < 0.00001) scores and decreased Homocysteine levels (Hcy, MD = -2.27 95 % CI [-2.80, -1.74], P < 0.00001) in patients with cognitive impairment compared with controls.

CONCLUSION

Inhaled aromatherapy could improve global cognition and lower Hcy in patients with cognitive impairment.

Evaluation of the Prevalence of Sleep Disorders and Their Association with Stroke: A Hospital-Based Retrospective Study

Background: Sleep disturbances are prevalent among stroke survivors, significantly impacting their recovery and quality of life. This study aimed to evaluate the prevalence of sleep disorders, sleep quality, risk of obstructive sleep apnea (OSA), and daytime sleepiness among stroke survivors and to identify potential associations with clinical and demographic factors. Materials and Methods: A retrospective observational study analyzed adult stroke survivors (aged ≥ 18 years) attending neurology clinics at our institution from November 2022 to November 2024. The primary outcome measures included overall sleep quality, sleep apnea and daytime sleepiness assessment. Data were collected using validated Arabic versions of the Pittsburgh Sleep Quality Index (PSQI), STOP-Bang Questionnaire, and Epworth Sleepiness Scale (ESS). Statistical analyses, including Chi-square tests and t-tests, were performed using SPSS version 30.1. Results: A total of 100 stroke survivors, mostly aged 40-60 years, were recruited in our study. The prevalence of sleep disorders was 60.0%, with poor sleep quality reflected by a mean global PSQI score of 9.13 ± 14.40. Additionally, 19.0% were at high risk of OSA, and 24.0% experienced abnormal daytime sleepiness. While no statistically significant associations were found between sleep disorders and clinical or demographic factors, trends indicated higher sleep disorder prevalence in those with hemorrhagic stroke and high-risk OSA profiles. Conclusions: Our study highlights a high prevalence of sleep disorders among stroke survivors, emphasizing the need for regular sleep assessments. Future studies should explore objective assessments and larger sample sizes to validate these findings and to assess their potential implication in stroke recovery and quality of life.

Association between malnutrition, depression, anxiety and fatigue after stroke in older adults: a cross-lagged panel analysis

BACKGROUND

Malnutrition, post-stroke depression (PSD), post-stroke anxiety (PSA), and post-stroke fatigue (PSF) in stroke survivors have complex relationships and are associated with adverse stroke outcomes.

AIMS

This research aims to explore the temporal and directional relationships between malnutrition, PSD, PSA, and PSF after stroke in older adults.

METHODS

Patients aged 65 years and older with their first ischemic stroke from two centers were selected and assessed at baseline, 3 months and 12 months. Malnutrition was evaluated using the Controlling Nutritional Status (CONUT) score, the Geriatric Nutritional Risk Index (GNRI), and the Prognostic Nutritional Index (PNI). PSD, PSA and PSF were measured with 24-item Hamilton Depression Scale (HAMD-24), 14-item Hamilton Anxiety Scale (HAMA-14) and Fatigue Severity Scale (FSS), respectively. The cross-lagged panel model (CLPM) was employed to investigate the temporal and directional relationships among these variables.

RESULTS

Among the 381 older patients included, 54.33%, 43.57%, and 7.87% were found to have malnutrition according to the CONUT, GNRI, and PNI scores, respectively. Significant bidirectional relationships were found between malnutrition and PSD, as well as between PSD, PSA, and PSF, but no significant bidirectional relationships between malnutrition, PSA and PSF were observed, irrespective of the malnutrition index used (CONUT, GNRI, or PNI).

CONCLUSIONS

Nutritional status and post-stroke neuropsychiatric disorders in older stroke survivors are worthy of attention. Specifically, early malnutrition after stroke can predict later PSD and vice versa. PSD, PSA, and PSF are mutually predictable. Further studies are required to investigate the mechanisms of these findings.

Mechanism of Treadmill Exercise Combined with Rich Environmental Stimulation to Improve Depression in Post-stroke Depression Model Rats

BACKGROUND

Post-stroke depression (PSD) is a common complication, occurring in approximately one-third of these patients. The neurological symptoms of PSD affect patients' daily life and subsequent recovery. Analyzing the pathogenesis of post-stroke depression from a psychological perspective, it was found that PSD patients often feel despair and anxiety, and it is crucial to explore non-pharmacological ways to improve post-stroke depressive symptoms. A combination of exercise and rich environmental stimulation (RES) has been found effective in improving post-stroke depressive symptoms. Therefore, this study aimed to explore the effects of exercise and rich environmental stimulation on PSD in rats and their potential underlying mechanisms and to provide a theoretical basis for managing PSD.

METHODS

The PSD rat model was constructed, and the depression-like behaviors of rats in each group were evaluated using the open field test (OFT), sucrose preference test (SPT), and forced swimming test (FST). Moreover, changes in the morphological behavior of rat hippocampus were observed using hematoxylin-eosin (HE) staining and Nissl staining. The expression levels of 5-hydroxytryptamine (5-HT) and norepinephrine (NE) in hippocampus tissues were assessed using enzyme linked immunosorbent assay (ELISA), and the levels of tryptophan-related proteins were determined employing western blot analysis. Additionally, a kynurenine-3-monooxygenase (KMO) inhibitor was administered to the combined stimulation group, and the levels of tryptophan (TRP), 5-HT, kynurenine (KYN), 3-hydroxy-kynurenine (3-HK), and quinolinic acid (QA) were evaluated using liquid chromatography mass spectrometry/mass spectrometry (LC-MS/MS).

RESULTS

Treadmill exercise combined with rich environmental stimulation significantly reduced the immobility time in the FST (p < 0.01), increased the exploratory behavior in the OFT (p < 0.05), and increased the sucrose water consumption in the SPT (p < 0.01), indicating that the depression-like behavior was improved. Treadmill exercise combined with rich environmental stimulation also improved the shape of the damaged hippocampus and increased the number of neurons in the hippocampus. Additionally, treadmill exercise combined with rich environmental stimulation significantly increased the levels of 5-HT and NE in hippocampus tissues (p < 0.01) and decreased KMO protein level (p < 0.01). In the KMO inhibitor group, the neural function was efficiently restored, the levels of 3-HK, QA, and KMO in the hippocampus were substantially reduced (p < 0.01), and the expression level of 5-HT was increased (p < 0.01).

CONCLUSIONS

Exercise stimulation combined with enriched environmental stimuli alleviates post-stroke depression in rats, and the underlying mechanisms may be related to TRP/KYN/3-HK/QA excitotoxicity pathways and increased 5-hydroxytryptamine levels.

Cognitive behavioural therapy for depression, quality of life, and cognitive function in the post-stroke period: systematic review and meta-analysis

The post-stroke period is associated with a lot of sequelae, including depression, decreased quality of life, and decline of cognitive function. Apart from the pharmacotherapy, it is also important to find a non-pharmacological treatment to relieve the sequelae. Cognitive behavioural therapy (CBT) might be a potential candidate, which can be clarified by a systematic review and meta-analysis. The eligible criteria of enrolled studies in the systematic review and meta-analysis were the randomised clinical trials (RCTs) using CBT to treat post-stroke depression, or with the focus on quality of life or cognitive function in the post-stroke period. The endpoint scores of depression, quality of life, and cognitive function scales were the targeted outcome for the final meta-analysis in the random effects model. Ten RCTs with 432 post-stroke patients receiving CBT and 385 controls were included. The meta-analysis results showed significant improvements in depression severity and quality of life. However, no significant difference between CBT and control groups was found in cognitive function. In addition, significant heterogeneity was derived from the meta-analysis. According to the meta-analysis results, CBT might be beneficial for relieving depression severity and improving quality of life. However, cognitive function might not be influenced by CBT. Further studies with a more consistent CBT design with greater sample sizes should be warranted to clarify and confirm the treatment effects of CBT for post-stroke depression and quality of life.

Rapid Intravenous Glyceryl Trinitrate in Ischemic Damage (RIGID): A potential neuroprotection strategy for acute ischemic stroke (AIS) patients

Despite advances in intravenous thrombolysis and endovascular thrombectomy, numerous acute ischemic stroke survivors continue to experience various disability levels. The nitric oxide (NO) donor, Glyceryl Trinitrate (GTN), has been identified as a potential neuroprotective agent against ischemic damage. We evaluated the safety and feasibility of intravenous GTN in AIS patients. Subsequently, we conducted a secondary analysis to assess for possible efficacy of GTN as a neuroprotectant. We conducted a prospective, double-blind, randomized controlled trial in the Stroke Intervention & Translational Center (SITC) in Beijing Luhe Hospital, Capital Medical University (ChiCTR2100046271). AIS patients within 24 h of stroke onset were evenly divided into GTN or control groups (n = 20 each). The GTN group received intravenous GTN (5 mg in 50 ml saline at a rate of 0.4 mg/h for 12.5 h/day over 2 days), while controls were administered an equivalent volume of 0.9% saline. Both groups followed standard Stroke Guidelines for treatment. Safety measures focused on SBP<110 mmHg and headache occurrence. Efficacy was assessed via the 90-day modified rankin score (mRS) and the national institutes of health stroke score (NIHSS). Of the 40 AIS patients, baseline characteristics such as age, gender, risk factors, and pre-mRS scores showed no significant difference between the groups. Safety measures of SBP<110 mmHg and headache occurrence were comparable. Overall, 90-day mRS (1 vs. 1) and NIHSS (1 vs. 1) did not significantly differ between groups. However, the GTN-treated group had a benefit in enhancing NIHSS recovery (△NIHSS 4.5 vs. 3, p = 0.028), indicating that GTN may augment recovery. Subgroup analyses revealed a benefit in the GTN group at the 90-day NIHSS score and △NIHSS follow up for non-thrombolysis patients (1 vs. 2, p = 0.016; 5 vs. 2, p = 0.001). Moreover, the GTN group may benefit mild stroke patients in NIHSS score at 90 day and △NIHSS observed at 90 days (1 vs. 1, p = 0.025; 3 vs. 2 p = 0.002). Overall, while preliminary data suggest GTN might aid recovery in NIHSS improvement, the evidence is tempered due to sample size limitations. The RIGID study confirms the safety and feasibility of intravenous GTN administration for AIS patients. Preliminary data also suggest that the GTN group may provide improvement in NIHSS recovery compared to the control group. Furthermore, a potential benefit for non-thrombolysis patients and those with mild stroke symptoms was identified, suggesting a possible potential role as a tailored intervention in specific AIS subgroups. Due to the limited sample size, further larger RCT will be necessary to replicate these results. TRIAL REGISTRATION: www.chictr.org.cn, identifier: ChiCTR2100046271.

Post-Stroke Depression in Older Adults: An Overview

Detailed data on post-stroke depression (PSD) in older adults are limited in spite of the high vulnerability of this population to stroke. In fact, PSD prevalence in older adults ranges from 16.0 to 43.9%; however, timing and instruments of evaluation often differ significantly across all available studies. The etiology, genetic and inflammatory factors, as well as structural brain alterations, are claimed as part of a multifaceted mechanism of action in PSD onset. Thus, the aim of this narrative review was to further elaborate on the prevalence, etiology, diagnosis, consequences and treatment of PSD in older adults. The consequences of PSD in older adults may be devastating, including a poor functional outcome after rehabilitation and lower medication adherence. In addition, lower quality of life and reduced social participation, higher risk of new stroke, rehospitalization, and mortality have been reported. In this scenario, treating PSD represents a crucial step to prevent these complications. Both pharmacological and non-pharmacological therapies are currently available. The pharmacological treatment utilizes antidepressant drugs, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TAs) and new multimodal antidepressants (NMAs). Non-pharmacological therapies include psychological interventions and non-invasive brain stimulation techniques, while excluding drug administration. In the general population experiencing PSD, SSRIs (sertraline in particular) are the most prescribed, whereas the combination of antidepressants and psychotherapy is underused. Furthermore, about one-third of patients do not receive treatment for PSD. In regard to older adults with PSD, the possibility of more adverse effects or contraindications to antidepressant prescription due to comorbidities may limit the therapeutic window. Although drugs such as citalopram, escitalopram, sertraline, venlafaxine, and vortioxetine are usually well tolerated by older patients with PSD, the few randomized controlled trials (RCTs) specifically considering older adults with PSD have been conducted with fluoxetine, fluvoxamine, reboxetine, citalopram and nortriptyline, often with very small patient samples. Furthermore, data regarding the results of non-pharmacological therapies are scarce. High-quality RCTs recruiting large samples of older adults are needed in order to better manage PSD in this population. In addition, adequate screening and diagnosis instruments, with reliable timing of evaluation, should be applied.

Inflammatory Pathogenesis of Post-stroke Depression

Post-stroke depression (PSD) is a complex mood disorder that emerges in individuals following a stroke, characterized by the development of depressive symptoms. The pathogensis of PSD is diverse, with inflammation playing a vital role in its onset and progression. Emerging evidence suggests that microglial activation, astrocyte responses, nuclear factor κB(NF-κB) signaling, dysregulation of the hypothalamic pituitary adrenal (HPA) axis, alterations in brain-derived neurotrophic factor (BDNF) expression, neurotransmitter imbalances, adenosine triphosphate (ATP) and its receptors and oxidative stress are intricately linked to the pathogenesis of PSD. The involvement of inflammatory cytokines in these processes highlights the significance of the inflammatory pathway. Integrating these hypotheses, the inflammatory mechanism offers a novel perspective to expand therapeutic strategies for PSD.

Treating depression in clinical practice: new insights on the multidisciplinary use of trazodone

Depression is estimated to be a leading contributor to the global mental health-related burden. The determinants of this huge prevalence lie in the fact that depressive symptoms may be comorbid in a wide variety of disorders, thus complicating and exacerbating their clinical framework. This makes the treatment of depressive symptoms difficult, since many pharmacological interactions should be considered by physicians planning therapy. Hence, depression still represents a challenge for both psychiatrists and other clinicians, in terms of its high rates of relapse and resistance despite well-established protocols. It is also complicated by the well-known latency in its complete response to current antidepressant treatments. In this context, the search for new strategies regarding antidepressant treatment is mandatory. Revising the use of "old" pharmacotherapies by considering their specific features may help to perfecting the treatment of depression, both in its standalone psychiatric manifestation and in the framework of other clinical conditions. Using a nominal group technique approach, the results of a consensus of expert physicians regarding the possible use of trazodone as a valuable strategy for addressing the "real world" unmet needs of depression treatment in different fields (psychiatry, primary care, neurology and geriatrics) is herein provided. This idea is based on the unique characteristics of this drug which delivers a more rapid antidepressant action as compared to other selective serotonin reuptake inhibitors. It also has pharmacodynamic malleability (i.e., the possibility of exerting different effects on depressive symptoms at different dosages) and pharmacokinetic tolerability (i.e., the possibility of being used as an add-on to other antidepressants with scarce interaction and achieving complimentary effects) when used in the milieu of other drugs in treating comorbid depressive symptoms. Moreover, the large number of formulations available permits finite dosage adjustments, and the use of trazodone for specific pathologies, such as dysphagia. Therefore, although additional studies exploring the real-world conditions of antidepressant treatment are warranted, experts agree on the idea that depressive disorder, in both its standalone and its comorbid manifestations, may surely take advantage of the particular characteristics of trazodone, thus attempting to reach the greatest effectiveness in different contexts.