- Last edited on February 3, 2022
Stroke
Primer
A stroke (also called a cerebrovascular accident, CVA) is an acute disturbance of the cerebral perfusion or vasculature. Approximately 85% of strokes are ischemic (blockage of a vessel) and remainder are hemorrhagic. Post-stroke, individuals are at risk for developing neuropsychiatric syndromes such as post-stroke depression and pseudobulbar affect.
Approach
For a detailed approach to diagnosing, managing, and follow up of stroke presentations, see the above main article.
Post-stroke Depression (PSD)
Epidemiology
- Following a stroke, the onset of depression is acute, usually occurring within 1 day or a few days of the cerebrovascular accident (CVA).[1]
- Approximately 33% of stroke survivors develop PSD at some point, with the frequency being highest in the first year of stroke (and declines thereafter).
Pathophysiology
- The pathophysiology of PSD involves both biological and psychosocial factors.
Localization
- Historically, left-sided strokes were thought to place patients at greater risk for PSD, but newer studies show mixed findings (i.e. - outpatient clinics actually see depression more commonly in right-sided strokes).[2]
- PSD can be longer lasting compared to non-stroke depression due its multifactorial nature, and is more difficult to treat with antidepressants.
Treatment
- Citalopram, escitalopram, and sertraline are the most commonly recommended SSRIs in post-stroke depression.[3]
- Cognitive-behavioural therapy (CBT) or interpersonal therapy (IPT) are also first line treatments for depressive symptoms post-stroke.[4]
Don't Try to Use Antidepressants as a Prophylaxis to Prevent PSD!
The prophylactic use of SSRIs in post-stroke neurological recovery is not beneficial. Two recent randomized control trials demonstrated no difference from placebo, and in fact, an increased risk of fractures, falls, and seizures.[5][6][7] However, SSRIs can still be used to treat post-stroke depression.Pseudobulbar affect
Pseudobulbar affect (PBA) (also known as emotional lability, reflex crying or laughing, emotional incontinence, and involuntary emotional expression disorder) is a neuropsychiatric syndrome common in neurological disorders including stroke, amyotrophic lateral sclerosis (ALS), Parkinson’s, traumatic brain injury, multiple sclerosis, dementia, Wilson’s disease, and brain tumors. PBA is not a mood disorder, but rather an abnormal display of affect that does not match an individual’s true (internal) feelings.