Antonio Carota

A prospective study of predictors of poststroke depression

Objective: To investigate the association between early depressive behavior after stroke onset and occurrence of poststroke depression (PSD) at 3- and 12-month follow-up evaluations. Methods: The study prospectively included 273 patients with first-ever single uncomplicated ischemic stroke. In the stroke unit, nurses scored crying, overt sadness, and apathy daily using an observational method to include patients with comprehension deficits. The Barthel Index was used to assess disability. Follow-up evaluation at months 3 and 12 included psychiatric assessment based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Results: Crying (19.8%), overt sadness (50.5%), and apathy (47.6%) were observed. Of the patients observed crying, 4 showed pathologic crying, 19 emotionalism, and 12 catastrophic reactions. Crying and overt sadness, but not apathy, were associated with a subjective experience of depression (p < 0.05). Thirty of 52 (58%) patients observed crying, 12 of 19 (63%) patients with emotionalism, and 5 of 12 (41%) patients with catastrophic reactions developed PSD within the first year. Multiple logistic regression analysis showed that only severe functional disability (odds ratio [OR], 4.31; 95% CI, 2.41 to 7.69), crying behaviors (OR, 2.66; 95% CI, 1.35 to 5.27), and an age <68 years (OR, 2.32; 95% CI, 1.30 to 4.13) were (p < 0.05) predictors of late PSD development (13% of the variance). Conclusions: In the stroke unit, crying and overt sadness are more reliable indicators of depressed mood than apathy. In patients with first-ever stroke, crying behaviors soon after stroke, a younger age, and severe disability are predictors of poststroke depression occurrence within the first year after stroke onset.

Emotions, behaviours and mood changes in stroke.

The brain mediates and integrates all cognitive activities, emotional experiences and finally behaviours. Stroke is undoubtedly a privileged disease for human behavioural studies, because of its high incidence. Recent advances in high‐resolution magnetic resonance imaging techniques and functional neuroimaging allow both the precise localization of lesions and on‐line visualization of the activity of cerebral areas and networks. Nevertheless, the neuropsychiatry of stroke remains uncertain in its relationship with brain dysfunction. Clinical studies on registry populations, single case studies, and functional neuroimaging data provide interesting findings, but differences in methods and great individual intervariability still prevent a complete understanding of emotional perception and behavioural responses in stroke. We adopted an anatomical‐functional model as an operational framework in order to systematize the recent literature on emotional, behavioural and mood changes after stroke. The dysfunction of the areas subserving fundamental and executive functions induces behavioural and affective changes (such as depression, anxiety, apathy) that reflect the dysfunction of the whole system. Conversely, lesions in the system of instrumental functions induce signature syndromes (aphasia, anosognosia). At any delay from stroke, the diagnosis and treatment of mood and behavioural changes are a priority for clinicians and healthcare professionals to improve the quality of life of patients. Curr Opin Neurol 15:57–69.

Catastrophic reaction in acute stroke: A reflex behavior in aphasic patients

Twelve patients with a catastrophic reaction (CR) (an outburst of frustration, depression, and anger when confronted with a task) were identified in a prospective cohort population (n = 326) with first-ever stroke admitted within 48 hours from onset. The authors’ findings suggest that CR is a rare though not exceptional phenomenon in acute stroke and is associated with nonfluent aphasias and left opercular lesions. CR, poststroke depression, and emotionalism are distinct but related disorders.

Emotional behavior in acute stroke: the Lausanne emotion in stroke study.

Objective:To study emotional behaviors in an acute stroke population. Background:Alterations in emotional behavior after stroke have been recently recognized, but little attention has been paid to these changes in the very acute phase of stroke. Methods:Adult patients presenting with acute stroke were prospectively recruited and studied. We validated the Emotional Behavior Index (EBI), a 38-item scale designed to evaluate behavioral aspects of sadness, aggressiveness, disinhibition, adaptation, passivity, indifference, and denial. Clinical, historical, and imaging (computed tomography/magnetic resonance imaging) data were obtained on each subject through our Stroke Registry. Statistical analysis was performed with both univariate and multivariate tests. Results:Of the 254 patients, 40% showed sadness, 49% passivity, 17% aggressiveness, 53% indifference, 76% disinhibition, 18% lack of adaptation, and 44% denial reactions. Several significant correlations were identified. Sadness was correlated with a personal history of alcohol abuse (r = P < 0.037), female gender (r = P < 0.028), and hemorrhagic nature of the stroke (r = P < 0.063). Aggressiveness was correlated with a personal history of depression (r = P < 0.046) and hemorrhage (r = P < 0.06). Denial was correlated with male gender (r = P < 0.035) and hemorrhagic lesions (r = P < 0.05). Emotional behavior did not correlate with either neurologic impairment or lesion localization, but there was an association between hemorrhage and aggressive behavior (P < 0.001), lack of adaptation (r = P < 0.015), indifference (r = P < 0.018), and denial (r = P < 0.045). Conclusions:Systematic observations of acute emotional behaviors after stroke suggest that emotional alterations are independent of mood and physical status and should be considered as a separate consequence of stroke.

The Long-Term Effect of Repeated Intravenous Lidocaine on Central Pain and Possible Correlation in Positron Emission Tomography Measurements

UNLABELLED Functional neuroimaging suggests that similar brain regions are involved in the processing of pain in healthy subjects and in patients with chronic neuropathic central pain. We present a patient with chronic neuropathic central pain due to a unique lesion to the trigeminal and spinothalamic pathway who had persistent pain relief after repeated IV lidocaine infusions. Positron emission tomography scan results showed a relative hypoactivity of the left posterolateral thalamus before treatment which disappeared after therapy. This case may suggest a stereo-selective analgesic effect of lidocaine accompanied by regional cerebral blood flow changes in the thalamus, indicating that sodium channels could, in fact, be highly expressed or modified in the thalamus after thalamic deafferentation. IMPLICATIONS We present a case of persistent central pain after encephalitis in a patient who had long-term pain relief after a series of IV lidocaine infusions. A positron emission tomography scan study, done before and after treatment, suggested that lidocaine for the diagnosis of chronic neuropathic pain may have a specific site of action in the brain.

Defective Spatial Imagery with Pure Gerstmann’s Syndrome

Gerstmann’s syndrome comprises finger agnosia, peripheral agraphia, anarithmetia, and right-left confusion. We here report a single-case study of an 85-year-old ambidextrous man who exhibited pure Gerstmann’s syndrome (i.e., without aphasia) 10 weeks after a stroke involving the angular gyrus in the left parietal lobe. We hypothesize that, in this case, the main cognitive denominator of Gerstmann’s tetrad was a severe dysfunction in mental rotation and translation. This report provides further evidence for the spatial nature of Gerstmann’s syndrome.

Assessment of post-stroke fatigue: the fatigue scale for motor and cognitive functions.

Background/Aims: Post-stroke fatigue (PSF) is an important but still controversial issue since knowledge on its nature is still humble. The aim of the present study was to characterize PSF beyond the subacute phase. Methods: Thirty-one stroke patients (gender: 6 female, 25 male; age range: 35–76 years; 28 patients with ischemic stroke, 3 patients with hemorrhagic stroke; mean delay after stroke: 50.65 ± 31.57 days) were recruited and assessed by measures of fatigue (Fatigue Scale for Motor and Cognitive Functions [FSMC], Fatigue Severity Scale, and Modified Fatigue Impact Scale), depression (Beck Depression Inventory Fast Screen), cognition (Brief Repeatable Battery of Neuropsychological Tests) and upper and lower extremity functions (Nine-Hole Peg Test and 25-foot walk). Results: Depending on the different scales, PSF prevalence ranged from 16.1 to 58.1%. Depression measures correlated significantly (r(29) ≥ 0.46; p < 0.01) with the results of all fatigue scales. Seventy-one percent of patients showed cognitive deficits in at least one cognitive domain. Cognitive fatigue measured by one subscale of the FSMC correlated most significantly with mental speed, working memory, and verbal short-term memory, while the motor subscale was associated with upper and lower extremity functions, mental speed, visual short-term memory, and working memory. A differentiation between lesion localization and fatigue severity in the motor or cognitive domain was only possible when applying the FSMC. Patients with cortical lesions scored higher on the cognitive subscale, while patients with subcortical lesions showed higher physical subscale scores. Conclusion: The present pilot study revealed differences between lesion localization and subdomains of fatigue after stroke by applying a new fatigue scale (FSMC). The results underline the necessity for separate assessment of motor and cognitive fatigue in stroke patients.

Mood disorders after stroke.

Mood disorders occurring after stroke are a major concern to public health as they are frequent, difficult to diagnose and to treat, and have high impact on the quality of life of patients and caregivers. The association of manic symptoms (rare) in the acute phase of stroke with strategic locations within the right hemisphere is clinically significant. However, the link among poststroke depression and anxiety (most prevalent), brain circuitries, clinical signs and individual psychological factors is not yet disentangled. The involvement of too many variables produces methodological difficulties and, therefore, the findings of a great number of studies are not systematically replicated. Thus, there is a need for research in this area of stroke medicine. Investigations on poststroke mood disorders might increase insight into the pathogenesis of mood disorders (which share the same clinical profile) occurring in people without brain lesions.

Repeating through the insula: Evidence from two consecutive strokes

Mixed transcortical aphasia is a very rare syndrome characterized by intact repetition, despite severe impairment in all other language modalities. In some cases, however, preservation of repetition is accompanied by intact reading. We report the case of a left-handed man who, after a subcortical stroke in the left hemisphere, showed the typical features of mixed transcortical aphasia with spared repetition and reading. After 10 days, a second stroke, involving the anterior insula and adjacent white matter bundles, markedly deteriorated repetition while his reading abilities recovered. By comparing features of repetition and reading before and after the second stroke, we provide evidence for the existence of a modular organization of language abilities, pointing to the primary role of the insula and surrounding white matter in phonological processing.

Pure left hippocampal stroke: a transient global amnesia-plus syndrome

Dear Sirs, Human and animal studies have provided undeniable evidence that the hippocampus is critically involved in supporting declarative–recollective memory [1, 2]. Isolated unilateral first-ever ischemic stroke that is specifically confined to the hippocampal region is an extremely rare event [3, 4] and similar cases have not generally been studied with standardized neuropsychological assessment in the acute phase. A 41-year-old right-handed office worker presented abruptly with a dense amnesic syndrome (both anterograde and retrograde memory deficit) resembling transient global amnesia (TGA). Knowledge of personal identity was maintained, other cognitive domains were spared and he repeatedly asked questions such as ‘‘where am I?, what are we doing?’’. However, differently than what is generally expected with TGA, the patient had frequent anomic pauses in spontaneous speech and committed significant errors in naming tests, mostly omissions (‘‘amnesic aphasia’’). Brain MRI at day 3 after admission (Fig. 1) showed a unique acute infarction of the dorsal part of the left hippocampal body, most likely explained by occlusion of the most distal PCA branches (middle or posterior hippocampal artery as suggested in [3]). The etiology was a large patent foramen ovale as other disorders were not identified. The amnesic syndrome resolved within 24–48 h (including retrograde amnesia) but verbal anterograde memory deficits persisted over 4 weeks and afterwards normalized. The neuropsychological assessment was performed within the first week after stroke. The patient performances were in the norms in the following domains: attention (WAIS code, TMT-A, TAP), immediate memory (Hebb and Corsi test), calculation (Barcelona battery), gestural praxis (Florida Apraxia Battery), visuo-perceptive attitudes (Rey-complex figure copy, bisection and cancelation tasks, face recognition, Hooper test), executive functions (FAB, WCST, BADS, Ruff Figural Fluency, TMT B, color stroop), reasoning (SPM47), retrograde memory (autobiographical memory interview). Language (Monreal Toulouse Protocol) was normal except for mild anomia and reduced literal fluencies. There was a dissociation of performance between verbal (forward 4, backward 3) and visual (forward 7, backward 6) span tests. Verbal learning was assessed through the Rey auditory verbal learning test (15 words), nonverbal learning by means of the Rey visual design learning test (15 designs), the recall phase of the Rey-complex figure (RCF) and recognition memory test for words and faces. In the verbal modality, free recall (sum of five trials: 27, 30-min delayed recall: 1) and delayed recognition (score: 4) were impaired, while the same domains were within normal limits in the visual modality (sum of five trials: 45, 30-min recall: 11, recognition: 13) (Fig. 2a). Intrusions (sum of five trials: 28) and errors in recognition (score: 10) of the learning tests were limited to the verbal modality (Fig. 2b). The results of the RCF immediate and delayed recall were in the normal range (40 and 50 percentile). A. Carota (&) Hildebrand Clinic, Rehabilitation Center, 6614 Brissago, Switzerland e-mail: a.carota@bluewin.ch