P.A. Joseph

Fluoxetine in early poststroke depression : A double-blind placebo-controlled study

BACKGROUND AND PURPOSE Early poststroke depression (PSD) is a frequent and specific entity that impairs the rehabilitation and functional recovery of hemiplegic patients. This trial was designed to study the efficacy and tolerance of fluoxetine (FLX) in the treatment of early PSD. METHODS This was a multicenter, double-blind, placebo-controlled study. Recent hemiplegic patients (<3 months) suffering from major depressive disorder (determined by International Classification of Diseases, 10th Revision, and Montgomery-Asberg Depression Rating Scale [MADRS] >19) were randomized to receive either 20 mg/d fluoxetine (FLX) or placebo for 6 weeks. Patients were evaluated by use of the Motricity Index, Mini-Mental State Examination, Functional Independence Measure, and MADRS. Statistical analysis was performed by using an intent-to-treat approach comparing the 2 groups at day 0 (baseline) and days 15, 30, and 45 (end point). RESULTS Of 121 patients screened, 31 were included in the study, 16 in the FLX group and 15 in the placebo group. There were no significant differences in baseline characteristics among the 2 groups. The FLX-treated patients compared with placebo-treated patients demonstrated significant improvement in mean MADRS scores at end point (11.8+/-6. 7 [mean+/-SD] versus 18.7+/-10.0, respectively; P=0.05). FLX-treated patients compared with placebo-treated patients also demonstrated greater response rate (62.5% versus 33.3%, respectively) and greater mean decrease of MADRS (16.6 versus 8.4, respectively; P=0.02). There were no differences in motor, cognitive, or functional improvement and no significant side effects after FLX treatment, except for a patient with a moderate and transient increase of transaminases. CONCLUSIONS FLX is an efficacious and well-tolerated treatment for early PSD. Further research is needed to evaluate the efficacy and safety of long-term treatment in this population.

Functional MRI follow-up study of language processes in healthy subjects and during recovery in a case of aphasia.

Background and Purpose— The goal of this study was to develop a functional MRI (fMRI) paradigm robust and reproducible enough in healthy subjects to be adapted for a follow-up study aiming at evaluating the anatomical substratum of recovery in poststroke aphasia. Methods— Ten right-handed subjects were studied longitudinally using fMRI (7 of them being scanned twice) and compared with a patient with conduction aphasia during the first year of stroke recovery. Results— Controls exhibited reproducible activation patterns between subjects and between sessions during language tasks. In contrast, the patient exhibited dynamic changes in brain activation pattern, particularly in the phonological task, during the 2 fMRI sessions. At 1 month after stroke, language homotopic right areas were recruited, whereas large perilesional left involvement occurred later (12 months). Conclusions— We first demonstrate intersubject robustness and intrasubject reproducibility of our paradigm in 10 healthy subjects and thus its validity in a patient follow-up study over a stroke recovery time course. Indeed, results suggest a spatiotemporal poststroke brain reorganization involving both hemispheres during the recovery course, with an early implication of a new contralateral functional neural network and a later implication of an ipsilateral one.

Unilateral neglect syndrome rehabilitation by trunk rotation and scanning training

OBJECTIVE Assessment of a new rehabilitation method for unilateral neglect syndrome (UNS), using a specific device (Bon Saint Comes device) that associates exploratory reconditioning with voluntary trunk rotation. DESIGN Study 1, randomized control trial during 2 months; study 2, nonrandomized control trial during 2 months. SETTING Neurorehabilitation units in private and public center. PATIENTS In study 1, 22 consecutive patients with UNS resulting from recent stroke (< 3 months) were randomly assigned to an Experimental Group (11 patients) or to a Control Group (11 patients). The 2 groups were very similar in terms of general and neurological data. In study 2, 5 consecutive patients with chronic UNS resulting from an old stroke (> 6 months) showing the same characteristics were included. INTERVENTION In study 1, patients in Group E followed the experimental program 1 hour a day for 1 month (20 hours) and Group C followed usual neurorehabilitation during the same time. In study 2, every patient followed the experimental program 1 hour a day for 1 month (20 hours). MAIN OUTCOME MEASURES Assessment in both studies was done at day 0, day 30, and day 60 using a battery of UNS tests (Albert, Scheckenberg, bell) and an activities of daily living (ADL) test (the Functional Independence Measure [FIM]). Mean scores of each test were compared between the 2 groups with the Wilcoxon nonparametric test. RESULTS In study 1 all UNS test results and the FIM improved significantly more in Group E than in Group C. In Group E, UNS disappeared in 5 patients and improved in 6. In Group C, UNS disappeared in 1 patient, improved in 4, and was unchanged in 6. In Study 2, UNS remitted in 2 patients, improved in 2 patients, and was unchanged in 1. CONCLUSION The Bon Saint Come method seems to significantly improve recent and chronic UNS, as well as ADL function. These encouraging results could have resulted from a synergistic effect of spatial reconditioning and voluntary trunk rotation. It must be assessed by a new study with more patients.

Language features in the acute phase of post-stroke severe aphasia could predict the outcome.

BACKGROUND Aphasia recovery remains difficult to predict initially in particular for the most severe cases. The features of impaired verbal communication which are the basis for cognitive-linguistic diagnosis and treatment could be part of prediction of recovery from aphasia. AIM This study investigated whether some components of language screening in the acute phase of stroke are reliable prognostic factors for language recovery in the post-acute phase. DESIGN Monocentric prospective study. SETTING University hospital stroke unit. POPULATION Eighty-six patients aged between 21 and 92 years (mean=67.4, SD=15.3) were admitted after a first left hemisphere stroke with aphasia and were consecutively included. METHODS Language assessment was performed in the acute phase and 3 months post-stroke with the LAnguage Screening Test (LAST) and the Aphasia Severity Rating Scale (ASRS) of the Boston Diagnostic Aphasia Examination (BDAE). Severe aphasia was defined as ASRS<3. Good recovery was defined as an ASRS≥4. Language scores and other potential predictors of recovery were analysed by comparing groups of patients with good versus poor recovery and as predictors of change with multiple regression approaches. RESULTS LAST Total score as well as all the individual items of LAST, NIHSS and ASRS measured in the acute phase significantly differentiated good and poor recovery from aphasia at three months for all aphasic patients and for the most severe cases. In multivariable analyses the repetition score of LAST at the acute phase was significantly associated with the delta of ASRS between the acute phase and 3 months after the stroke reflecting changes in symptom severity. CONCLUSIONS For patients with initial severe aphasia, word repetition from a language screening task seems to be a more relevant predictor of recovery than initial severity to enrich the prognosis of poststroke aphasia recovery three month after a stroke. These findings show the importance of phonological perception and production as well as speech motor components in the recovery of language. These linguistic aspects of the assessment seem more relevant than severity for prediction in the acute phase. CLINICAL REHABILITATION IMPACT These findings could improve aphasia management pathway for people with severe aphasia and their families and minimize the evidence-practice gap for speech pathologists.

Toxine botulique et traumatisme crânien

Resume La toxine botulique est une therapeutique de la spasticite focalisee en plein essor. Cet article a pour objet d’etudier les donnees de la litterature concernant son utilisation chez les patients traumatises crâniens, dont les troubles de la motricite et du tonus sont caracterises par un important polymorphisme tant sur le plan de l’expression clinique que sur le plan evolutif. Malgre la rarete des etudes portant specifiquement sur cette indication et l’absence d’etude controlee, la toxine botulique semble avoir, comme dans d’autres indications, sa place dans le traitement de la spasticite focalisee chez les traumatises crâniens. Elle peut avoir une influence favorable sur les capacites fonctionnelles et le confort de ces patients.