Brian Im

Should This Patient With Ischemic Stroke Receive Fluoxetine

You admit T.R., a 75-year-old man, to your inpatient rehabilitation unit 10 days after a stroke. He has a medical history of hypertension and type II diabetes. On the day of his admission to the neurology service, he experienced a sudden onset of severe left-sided weakness with a facial droop and slurring of speech. His husband was driving them both to a social event at the time and detoured immediately to the emergency department, where the patient received tissue plasminogen activator (tPA) for a large, right middle cerebral artery thrombosis seen on magnetic resonance imaging. There was no hemorrhage noted on the initial scan, but a very small area of peri-infarct hemorrhage was noted after the administration of tPA. The tPA resulted in a modest improvement in weakness. Family history was significant for a mother and sister both successfully treated for severe, idiopathic depression with oral medications. Social history reveals that T.R. is a retired accountant who lives in a groundstory home with his husband of 30 years, who is also retired and is in good health. The patient’s acute hospital course was complicated by aspiration pneumonia that required intravenous antibiotics and blood sugars ranging from 200 to 300 that required insulin coverage in addition to his oral hypoglycemic medications. He experienced a few episodes of orthostasis with lightheadedness while going from sitting to standing, but this lightheadedness resolved with adjustment of blood pressure medications. On admission to your rehabilitation unit, T.R. is a quiet, elderly man who speaks only when asked a question but offers no spontaneous information. He demonstrates a moderate left hemiparesis with manual muscle testing scores of 3þ in most upper and lower extremity muscle groups. He also has sensory extinction on the left and mild visual neglect. On the first day, he required moderate assistance with most activities of daily living because of poor trunk balance and neglect. He walked 15 feet with rolling platform walker with moderate assistance for advancing the left leg, left-sided neglect, and poor balance. Medications on admission to rehabilitation included glyburide, hydrochlorothiazide, losartan, lisinopril, clopidogrel, aspirin, as-needed acetaminophen for shoulder pain, oral cephalexin, and subcutaneous unfractionated heparin. The husband spent time searching the Internet for stroke treatments and approaches you about starting T.R. on fluoxetine 20 mg daily. As part of the conversation, the husband states that T.R. does not appear depressed to him and that his partner has always been a “man of few words,” a stoic type. Should this patient be given fluoxetine to improve motor function? Dr Heidi Schambra will argue that fluoxetine should be administered. Dr Brian Im argues that fluoxetine should not be administered at this time.

Traumatic brain injury results in altered physiologic, but not subjective responses to emotional stimuli

ABSTRACT Background: While the cognitive sequelae of traumatic brain injury (TBI) are well known, emotional impairments after TBI are suboptimally characterized. Lack of awareness of emotional difficulties can make self-report unreliable. However, individuals with TBI demonstrate involuntary changes in heart rate variability which may enable objective quantification of emotional dysfunction. Methods: Sixteen subjects with chronic TBI and 10 age-matched controls were tested on an emotional function battery during which they watched a series of film clips normed to elicit specific positively and negatively valenced emotions: amusement, sexual amusement, sadness, fear and disgust. Subjective responses to the emotional stimuli were also obtained. Additionally, surface electrodes measured cardiac and respiratory signals to compute heart rate variability (HRV), from which measures of parasympathetic activity, the respiratory frequency area (RFA) and sympathetic activity, the low frequency area (LFA), of the HRV frequency spectrum were derived. The Neurobehavioral Rating Scale-Revised (NRS-R) and the King-Devick (KD) test were administered to assess neurobehavioral dysfunction. Results: The two groups showed no differences in subjective ratings of emotional intensity. Subjects with TBI showed significantly decreased sympathetic activity when viewing amusing stimuli and significantly increased sympathetic activity when viewing sad stimuli compared to controls. Most of the subjects did not show agitation, anxiety, depression, blunted affect, emotional withdrawal, decreased motivation or mental fatiguability on the NRS-R. However, 13/16 subjects with TBI demonstrated attention difficulty on the NRS-R which was positively correlated with the increased sympathetic activity during sad stimuli. Both attention difficulty and abnormal autonomic responses to sad stimuli were correlated with the timing on the KD test, which reflected difficulty with visual attention shifting. Conclusions: The HRV spectrum may be useful to identify subclinical emotional dysfunction in individuals with TBI. Attention difficulites, specifically impairment in visual attention shifting, may contribute to abnormal reactivity to sad stimuli that may be detected and potentially treated to improve emotional function.

Poster 15 Acute Vision Loss after Treatment with Amantadine in the Setting of Traumatic Brain Injury in a Patient with History of Fuchs' Dystrophy: A Case Report

Results or Clinical Course: The comfortable 10-m gait speed was significantly faster at 4 weeks than at baseline (baseline: 0.83 0.28 m/s, 4 weeks: 0.91 0.25 m/s; P < .05). However, there was no significant difference between baseline and 4 weeks in 6MWT (baseline: 274.3 84.1 m, 4 weeks: 293.7 90.2 m; P 1⁄4 .076) and TUG (baseline: 15.0 4.0 s, 4 weeks: 14.3 3.1 s; P 1⁄4 .13). Conclusion: In this study, gait training and gait-related training with FES yielded statistically significant improvement in comfortable walking speed for chronic stroke patients. Our study provided encouraging evidence that rehabilitation intervention with FES can have a positive impact for chronic stroke patients. In the future, it will be necessary to do a randomized controlled trial to compare the effects of gait training and gait-related training without FES.

Poster 78 Physiologic Mechanisms of Emotional Impairment in Traumatic Brain Injury

Interventions: PubMed, CINAHL, PsycINFO and EMBASE were queried with the subject heading terms “pressure sore,” “pressure ulcer,” “position or turn in bed, wheelchair,” “ pressure relief,” and “ pressure release.” Results or Clinical Course: We identified 2820 publications, of which 49 met inclusion criteria. Of these the subject population was 2834 (923 persons with SCI, 717 non-SCI patients, 1194 healthy controls). Procedures for measuring skin pressure and metabolism were highly variable by anatomic location, measurement technique, outcome measure, study site, participant characteristics, description of positioning/turning for bed and seated interventions. Several studies suggest that skin response to pressure differs between SCI and non-SCI subjects. No clear optimal bed positioning or turning frequency could be determined beyond the 90 degree lateral position resulting in high pressure over the trochanters. Conflicting results and insufficient evidence for optimal bed and seated positioning, and turning and pressure reliefs to prevent pressure ulcers in both SCI and non-SCI populations were limiting factors. Conclusion: Based on the existing evidence, current “guidelines” cannot be considered evidence-based and consideration should be given to reevaluating existing guideline-based turning intervals and related policy implications for this high-risk population. We conclude that PU risk is highly individualized, with the SCI population at a higher risk, which demands flexible PU prevention strategies for bed/seated positioning and pressure reliefs.