Post-stroke depression: an update.

Those caring for stroke victims should be aware of new developments in our understanding of depression following stroke, its diagnosis, prevalence, pathophysiology, clinical features, and treatment. Appropriate diagnosis and treatment will improve quality of life, self-care independence, and mortality.

Effect of lesion location on upper limb motor recovery after stroke.

BACKGROUND AND PURPOSE: The purpose of this study was to assess the effects of stroke involvement of primary and secondary hemispheric motor systems and corticofugal tracts on arm and hand recovery. METHODS: Forty-one patients participating in an inpatient stroke rehabilitation database, admitted 17+/-2 (SEM) days after initial unilateral hemispheric ischemic stroke, with neuroimaging studies performed >48 hours after stroke and with minimal upper limb (UL) movement (admission Fugl-Meyer UL motor scores 18, synergies+isolated movements. Lesions affecting the following structures were recorded: primary motor cortex, premotor area, supplementary motor area, anterior half of the middle third of corona radiata (secondary motor efferents), posterior half of the middle third of corona radiata (primary motor efferents), genu, anterior and posterior limbs of the internal capsule (PLIC), basal ganglia, and thalamus. chi(2) Analysis and ANOVA were used to study the significance of stroke location on UL motor recovery. RESULTS: The effect of involvement of primary, premotor, or supplementary motor areas on motor recovery did not reach statistical significance. Patients with purely cortical stroke were likely to recover UL isolated movement (3 of 4) compared with purely subcortical (1 of 17) or mixed cortical-subcortical stroke location (2 of 20) (P:=0.009). Of those with cortical, subcortical, or mixed cortical plus subcortical lesions sparing the PLIC, 5 of 13 recovered isolated UL movement (P:=0.01). Only 1 of 28 patients with involvement of the PLIC plus adjacent corona radiata, basal ganglia, or thalamus recovered isolated UL movement (P:=0.01). Patients with small lacunar strokes affecting only the PLIC did not have sufficient motor deficits 2 weeks after stroke to meet inclusion criteria. CONCLUSIONS: The probability of recovery of isolated UL movement decreases progressively with lesion location as follows: cortex, corona radiata, and PLIC. This is consistent with our current understanding of redundant cortical motor representation and convergence of corticofugal motor efferents as they pass through the corona radiata to the PLIC.

Comparison of partial body weight-supported treadmill gait training versus aggressive bracing assisted walking post stroke.

PURPOSE: To test the hypothesis that partial body weight-supported treadmill training (PBWSTT) provides more effective gait training than an equally supportive but less physiologic aggressive bracing assisted walking (ABAW) program. METHODS: Following informed consent, patients participating in an inpatient rehabilitation program with significant leg weakness and need for at least moderate assistance for walking, without orthostatic hypotension, symptomatic dyspnea, or angina pectoris were randomized to receive PBWSTT vs. ABAW. PBWSTT was provided by a commercially available, overhead motorized hoist attached to a parachute-type body harness, which provided partial support of the patient's weight over a treadmill. Therapists assisted with weight shifting, leg advancement, and foot placement as needed. ABAW included aggressive early therapist-assisted ambulation using knee-ankle combination bracing and hemi-bar if needed. Treatment sessions of up to 45 minutes per day, five days per week were given as tolerated for the duration of the inpatient stay or until patients could walk over-ground unassisted. All patients had an additional 45-minute session of functionally oriented physical therapy each day with or without bracing as judged appropriate by the patient's individual therapist. RESULTS: Fifty-six patients a mean age of 71 +/- 1 SEM were enrolled 40 +/- 3 days post stroke. Although the outcome of the two groups as a whole did not differ, a subgroup with major hemispheric stroke defined by the presence of hemiparesis, hemianopic visual deficit, and hemihypesthesia who received more than 12 treatment sessions showed significantly better over-ground endurance (90 +/- 34 vs. 44 +/- 10 meters) and speed scores (12 +/- 4 vs. 8 +/- 2 meters/minute) for PBWSTT vs. ABAW, respectively. CONCLUSIONS: PBWSTT and ABAW are equally effective gait training techniques except for a subset of patients with major hemispheric stroke who are difficult to mobilize using ABAW alone.

Patients with stroke confined to basal ganglia have diminished response to rehabilitation efforts.

Prediction of the functional outcome for patients with stroke has depended on the severity of impairment, location of brain injury, age, and general medical condition. This study compared admission and discharge functional outcome (Functional Independence Measure, FIM) and deficit severity (Fugl-Meyer, F-M) scores in a retrospective study of patients with similar neurologic impairments: homonymous hemianopia, hemisensory loss, and hemiparesis. CT-verified stroke location was the independent variable: cortical (n = 11), basal ganglia and internal capsule (normal cortex and thalamus, n = 13), or combined (cortical, basal ganglia, and internal capsule, n = 22). By 3 months on average after stroke, all groups demonstrated significantly improved motor function as measured by F-M scores. Patients with cortical lesions had the least CT-imaged damage and the best outcome. Patients with combined lesions and more extensive brain injury had significantly higher FIM scores (P < 0.05) than patients with injury restricted to the basal ganglia/ internal capsule. Patients with basal ganglia/internal capsule injury were more likely to have hypotonia, flaccid paralysis, and persistently impaired balance and ambulation performance. While all patients had a comparable rehabilitation experience, these results suggest that patients with stroke confined to the basal ganglia and internal capsule benefited less from therapy. Isolated basal ganglia stroke may cause persistent corticothalamic-basal ganglia interactions that are dysfunctional and impede recovery.

Functional outcome for patients with hemiparesis, hemihypesthesia, and hemianopsia. Does lesion location matter?

BACKGROUND AND PURPOSE: Patients with hemiparesis, hemisensory loss, and hemianopsia ("HHH" deficits) due to stroke may have large cortical lesions caused by middle cerebral trunk vessel occlusion or smaller subcortical lesions due to lenticulostriate involvement. We studied the usefulness of lesion location in predicting functional recovery within this syndrome. METHODS: We reviewed our records and found 41 patients who had a single ischemic hemispheric stroke, HHH deficits, and an available CT scan performed more than 24 hours after the onset of symptoms. CT scans were read independently and blindly by the authors. Lesions were initially categorized by arterial distribution on the basis of CT templates published by Kinkel. The numerous combinations of arterial branch vessel occlusions observed did not allow for statistical analyses because of the small number of subjects within each subgroup. Lesions were therefore classified as cortical (C), subcortical (S), or mixed (M). RESULTS: There were no significant differences among the three anatomic groups for age, sex, interval after stroke, Mini-Mental Status Examination score, or admission Barthel Index score. Functional outcome measures did not differ significantly for the three groups: mean +/- SD discharge Barthel score (C, 64 +/- 31; S, 47 +/- 20; M, 57 +/- 21), length of stay ([days] C, 64 +/- 25; S, 77 +/- 24; M, 73 +/- 28), and frequency of nursing home placement (C, 4/8; S, 3/6; M, 2/16). CONCLUSIONS: For patients with HHH deficits, the anatomic location of the lesion (C versus S versus M) does not affect functional outcome.

The Burke dysphagia screening test: validation of its use in patients with stroke.

The objective of this study was to validate a dysphagia screening test to identify patients in the rehabilitation phase post stroke at risk for pneumonia, recurrent upper airway obstruction, and death. The setting was an inpatient stroke rehabilitation unit. One hundred thirty-nine consecutive patients met the following criteria: stroke confirmed by clinical history and neurological exam with compatible computed tomography (CT) or magnetic resonance imaging (MRI) scan; ages 20 to 90 years inclusive; and no known history of significant oral or pharyngeal anomaly. The main outcome measures were pneumonia, recurrent upper airway obstruction, and death. The Burke Dysphagia Screening Test (BDST) identified 11 of 12 patients who subsequently developed pneumonia, recurrent upper airway obstruction, or death (Fisher's exact test: p = .03). The relative risk for the occurrence of any of these complications was 7.65 times greater for those failing versus passing the BDST. The BDST identified 9 of 9 patients who developed pneumonia (Fisher's exact test: p = .01). We concluded that the BDST is of value in identifying patients in the rehabilitation phase poststroke at risk for pneumonia, recurrent upper airway obstruction, and death.

Aspiration and relative risk of medical complications following stroke.

OBJECTIVE: To determine the relative risk of pneumonia, dehydration, and death associated with videofluoroscopic evidence of aspiration, silent aspiration, aspiration of 10% or greater on one or more barium test swallows, and aspiration of thick liquid or more solid consistencies in the subacute phase after stroke. DESIGN: Prospective, longitudinal cohort study. SETTING: Inpatient stroke rehabilitation unit. PATIENTS: There were 114 consecutive patients who met the following criteria: (1) stroke as defined by clinical history and neurological examination with compatible computed tomographic or magnetic resonance imaging scan; (2) age 20 to 90 years, inclusive; (3) no known history of significant oropharyngeal anomaly; and (4) videofluoroscopic evidence of dysphagia. Of 122 eligible patients, eight refused participation. MAIN OUTCOME MEASURES: Development of pneumonia, dehydration, and death. RESULTS: The relative risk for developing pneumonia was 6.95 times greater (P = .027) for those patients who aspirated compared with those who did not, 5.57 times greater (P = .012) for those who aspirated silently compared with those who coughed when aspirating or who did not aspirate, and 8.36 times greater (P = .002) for those who aspirated 10% or greater on one or more barium test swallows compared with those who aspirated less than 10% or did not aspirate. CONCLUSION: Aspiration, silent aspiration, and aspiration of 10% or greater on one or more barium test swallows during videofluoroscopic evaluation are associated with an increased risk of pneumonia, but not dehydration or death, during the subacute phase after stroke.

Dysphagia therapy following stroke: a controlled trial.

OBJECTIVE: To determine the effect of graded levels of intervention by a dysphagia therapist on the occurrence of pneumonia, dehydration, calorie-nitrogen deficit, recurrent upper airway obstruction, and death following stroke. DESIGN: A randomized control trial. SETTING: Inpatient stroke rehabilitation unit. PATIENTS: All patients met the following eligibility criteria: (1) stroke defined by clinical history and neurologic examination with compatible CT or MRI, (2) ages 20 to 90 years inclusive, (3) no known history of significant oral or pharyngeal anomaly, (4) laboratory values below end point criteria, (5) failure on the Burke Dysphagia Screening Test, and (6) modified barium swallow evaluation evidence of dysphagia (patients who aspirated > or = 50% of all consistencies presented, even using compensatory swallowing techniques, were excluded). Of 123 eligible patients, eight refused study participation. One hundred fifteen patients were randomized. INTERVENTIONS: Three graded levels of dysphagia therapist control of diet consistency and reinforcement of compensatory swallowing techniques were provided during the inpatient rehabilitation stay. MAIN OUTCOME MEASURES: Pneumonia, dehydration, calorie-nitrogen deficit, recurrent upper airway obstruction, and death. RESULTS: The log rank statistic showed no significant difference between the three treatment groups for the distribution of time until end point during the inpatient stay or to 1 year post-stroke. CONCLUSION: Limited patient and family instruction regarding use of diet modification and compensatory swallowing techniques during inpatient rehabilitation is as effective as therapist control of diet consistency and daily rehearsal of compensatory swallowing techniques for the prevention of medical complications associated with dysphagia following stroke.

Validation of the 3-oz water swallow test for aspiration following stroke.

A 3-oz water swallow test identified 80% (16/20) of patients aspirating during a subsequent videofluoroscopic modified barium swallow examination (sensitivity, 76%; specificity, 59%). It also identified patients with more severe dysphagia aspirating larger amounts (sensitivity, 94%; specificity, 26%) or thicker consistencies (sensitivity, 94%; specificity, 30%) of test material. The 3-oz water swallow test is a sensitive screening tool for identifying patients at risk for clinically significant aspiration who need referral for more definitive modified barium swallow evaluation.

Fresnel prisms improve visual perception in stroke patients with homonymous hemianopia or unilateral visual neglect.

We randomly assigned 39 patients with stroke and homonymous hemianopia or unilateral visual neglect to treatment with 15-diopter plastic press-on Fresnel prisms (n = 18) or to serve as controls (n = 21). Baseline evaluations of visual perception and activities-of-daily-living (ADL) function were similar for both groups. After 4 weeks, the prism-treated group performed significantly better than controls on the following: (1) Motor Free Visual Perception Test; (2) Line Bisection Task; (3) Line Cancellation Task; (4) Harrington Flocks Visual Field Screener; and (5) Tangent Screen Examination. There was no significant difference in Barthel ADL assessment at 4 weeks. Thus, treatment with 15-diopter Fresnel prisms improves visual perception test scores but not ADL function in stroke patients with homonymous hemianopia or unilateral visual neglect.

Rehabilitation outcome following initial unilateral hemispheric stroke. Life table analysis approach.

Life table analysis is a powerful statistical tool that has become the preferred technique for studying both the natural history of and the effect of treatment on disease outcome. We have found only one report using life table analysis to study rehabilitation outcome after stroke. We assessed the recovery of both independent ambulation and overall self-care function in 95 consecutive patients with unilateral hemispheric stroke using life table analysis. Our results support the segregation of patients into the following prognostic subgroups at the time of entry into the rehabilitation program (mean +/- SD 5 +/- 3 weeks after stroke): 1) motor deficit only, 2) motor deficit plus somatic sensory deficit, and 3) motor deficit plus somatic sensory deficit plus homonymous visual deficit. The probabilities of reaching independence in ambulation, being able to walk 150 feet with assistance, reaching independence in self-care function, and reaching a point of assisted self care (Barthel Index score of greater than or equal to 60) are highly significantly different among subgroups. The interval after stroke required to reach the plateau phase of recovery is also significantly different among subgroups. We propose that life table analysis can be used 1) to define patient outcome goals, 2) to define the time required to reach such goals, 3) to identify patients with medical or behavioral comorbidity who are functioning below their expected level, and 4) to assess the effect of alternative treatment regimens on both final outcome and time to reach that outcome.

Stroke rehabilitation.

Based on the number of patients involved, stroke dominates the field of neurologic rehabilitation. The prevalence of stroke in the United States population is 1.4 million. This represents a prevalence for stroke of 612 per 100,000 population, compared with 157 for Parkinson's disease, 50 for spinal-cord injury, 42 for multiple sclerosis, and 16 for head-injured survivors with neurologic sequelae. This article provides an overview of stroke rehabilitation and covers patient management for the acute phase, subacute phase, and chronic phase poststroke. Medical and nursing care are discussed throughout and physical, occupational, and speech therapy for patients in these three phases are explored.

Antidepressant therapy after stroke. A double-blind trial.

Twenty-seven inpatients participating in a stroke rehabilitation program were randomized to receive either placebo or trazodone hydrochloride (Desyrel) beginning a mean (+/- SEM) of 44 +/- 4 days after stroke. The target dosage was 200 mg/d. Patients with either a clinical diagnosis of depression or abnormal Zung depression scores showed a consistent trend toward greater improvement in Barthel activities of daily living (ADL) scores with trazodone than with placebo. An abnormal dexamethasone suppression test result was associated with significant improvement in the Barthel ADL scores of patients receiving trazodone (38 +/- 6 vs 20 +/- 6 for placebo). Patients with stroke and evidence of depression are therefore likely to benefit from treatment with trazodone.

Red blood cell abnormalities in Alzheimer disease.

In a prospective, double-blind study of 84 unselected persons in a dementia clinic, the red blood cell/plasma choline ratios were found to be significantly higher in 47 subjects with clinically defined Alzheimer disease (DAT) than in 37 non-DAT, nondepressed subjects (3.54 +/- 0.48 versus 2.04 +/- 0.34, p less than 0.02). The latter group included intellectually intact subjects as well as patients with other dementias who were comparable to the Alzheimer patients in age, sex, and degree of cognitive impairment. The elevated mean ratio reflected the greater proportion of Alzheimer patients with high red blood cell plasma choline ratios. These elevated ratios appeared to be related to both increases in red cell content and decreases in plasma choline. The authors conclude that the results confirm and extend those previously reported in short series of patients and agree with other evidence that Alzheimer disease has systemic manifestations in nonneural cells, which may be useful in further investigations of the disease's cellular pathophysiology.

Follow up of patients referred to a dementia service.

Eighty-five patients referred to a dementia clinic in a prosperous suburban setting were followed for as long as 48 months. Progressive dementia occurred in 55 of the 56 patients in whose cases it was predicted. Three-year mortality rates were 83 per cent for multi-infarct dementia, 57 per cent for mixed vascular plus Alzheimer dementia, and 37 per cent for Alzheimer disease. The differences in death rates among the different diagnostic groups support the validity of the clinical distinctions drawn. A subspecialty clinic can accurately identify progressive intellectual impairment in the elderly. The data suggest that patients who have depression complicating organic brain disease are at risk for progressive intellectual impairment, even if not demented when first seen. Intellectual deterioration appears to be a poor prognostic sign in older people.

Overdiagnosis of dementia.

Accurate diagnosis of the dementias is difficult. Of 100 patients referred to a specialized outpatient dementia clinic, at least 26 were not demented. Fifteen had depression, 7 had miscellaneous other neuropsychiatric disorders, and 4 were normal. Specialized dementia clinics help to improve diagnostic accuracy. Three diagnostic errors appeared particularly important: failure to recognize depression, especially in the presence of mild organic brain disease; equating brain atrophy on the computerized tomogram with clinical dementia; and failure to distinguish focal from global intellectual impairment. For confirmation, the diagnosis of dementia requires follow-up evaluation, brain biopsy, or autopsy.