Differences

Last edited on August 17, 2023

This shows you the differences between two versions of the page.

--- geri:stroke [on March 17, 2018]
+++ geri:stroke [on August 17, 2023]
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+====== Stroke ======
+{{INLINETOC}}
+===== 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 =====
+<alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See main article: **[[neurology:approach-stroke|]]**</alert>
+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).[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
+  * 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, but certain stroke lesions and locations are associated with a higher risk for post-stroke depression.[([[https://pubmed.ncbi.nlm.nih.gov/37559511/|Robinson, R. G., Jorge, R. E., & Starkstein, S. E. (2023). Poststroke Depression: An Update. The Journal of Neuropsychiatry and Clinical Neurosciences, 00-00.]])]
+==== 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).[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647458/|Robinson, R. G., & Spalletta, G. (2010). Poststroke depression: a review. The Canadian Journal of Psychiatry, 55(6), 341-349.]])]
+  * PSD can be longer lasting compared to non-stroke depression due its multifactorial nature, and is more difficult to treat with antidepressants.
+==== Prophylaxis ====
+  * The prophylactic use of SSRIs in post-stroke neurological recovery is debated.
+  * Two recent randomized control trials demonstrated no difference from placebo, and in fact, an increased risk of fractures, falls, and seizures.[([[https://pubmed.ncbi.nlm.nih.gov/32702334/|Hankey, G. J., Hackett, M. L., Almeida, O. P., Flicker, L., Mead, G. E., Dennis, M. S., ... & Lung, T. (2020). Safety and efficacy of fluoxetine on functional outcome after acute stroke (AFFINITY): a randomised, double-blind, placebo-controlled trial. The Lancet Neurology, 19(8), 651-660.]])][([[https://pubmed.ncbi.nlm.nih.gov/32702335/|Lundström, E., Isaksson, E., Näsman, P., Wester, P., Mårtensson, B., Norrving, B., ... & Hankey, G. J. (2020). Safety and efficacy of fluoxetine on functional recovery after acute stroke (EFFECTS): a randomised, double-blind, placebo-controlled trial. The Lancet Neurology, 19(8), 661-669.]])][([[https://pubmed.ncbi.nlm.nih.gov/32702322/|Kwakkel, G., Meskers, C., & Ward, N. S. (2020). Time for the next stage of stroke recovery trials. The Lancet. Neurology, 19(8), 636-637.]])]
+  * There is some debate about whether or not the study population is representative of typical stroke populations (e.g., most enrolled individuals had milder forms of stroke)[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8610752/|Woranush, W., Moskopp, M. L., Sedghi, A., Stuckart, I., Noll, T., Barlinn, K., & Siepmann, T. (2021). Preventive approaches for post-stroke depression: where do we stand? A Systematic Review. Neuropsychiatric Disease and Treatment, 3359-3377.]])]
+  * Thus, the use of antidepressants as prophylaxis for post-stroke depression has not been routinely recommended.
+    * A comprehensive risk-benefit analysis should be considered along with a personalized approach to treatment, with monitoring of side effects if antidepressant therapy is pursued.
+==== Treatment ====
+  * [[meds:antidepressants:ssri:citalopram|Citalopram]], [[meds:antidepressants:ssri:escitalopram|escitalopram]], and [[meds:antidepressants:ssri:sertraline|sertraline]] are the most commonly recommended SSRIs in post-stroke depression.[([[https://www.strokebestpractices.ca/recommendations/mood-cognition-and-fatigue-following-stroke/post-stroke-depression|Canadian Stroke Best Practices: Post Stroke Depression]])]
+  * [[psychotherapy:cbt|Cognitive-behavioural therapy (CBT)]] or [[psychotherapy:ipt|interpersonal therapy (IPT)]] are also first line treatments for depressive symptoms post-stroke.[([[https://www.strokebestpractices.ca/recommendations/mood-cognition-and-fatigue-following-stroke/post-stroke-depression|Canadian Stroke Best Practices: Post Stroke Depression]])]
+===== Pseudobulbar affect =====
+<alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See main article: **[[teaching:pseudobulbar-affect|]]**</alert>
+**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.
+===== Other Syndromes =====
+==== Akinetic Mutism ====
+  * [[https://pubmed.ncbi.nlm.nih.gov/14642361/|Nagaratnam, N., Nagaratnam, K., Ng, K., & Diu, P. (2004). Akinetic mutism following stroke. Journal of Clinical Neuroscience, 11(1), 25-30.]]
+==== Obsessive-compulsive symptoms ====
+<alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">
+See main article: **[[ocd:z-other-oc-medical|]]**
+</alert>
+===== Guidelines =====
+<alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See also: **[[teaching:clinical-practice-guidelines-cpg|]]**</alert>
+{{page>teaching:clinical-practice-guidelines-cpg#stroke&nouser&noheader&nodate&nofooter}}