Poststroke depression: Prevalence,course, and associated factors

Despite the considerable amount of research that has been undertaken on poststroke depression, a review of the literature demonstrates that there are many inconclusive findings in the area. In particular, the causes and course of the disorder remain to be firmly established. While studies of prevalence differ with respect to the nature and timing of their assessment procedures, most conclude that poststroke depression has a negative impact on the rehabilitation of the stroke patient. Very little research is available on the relationship between poststroke depression and care-giver burden. However, recent studies have adopted more rigorous methodological procedures, allowing some insights into the complex mixture of factors which determine the occurrence of poststroke depression.     

Ankle Intrinsic Stiffness in Subcortical Poststroke Subjects

The authors' purpose was to evaluate bilateral ankle intrinsic stiffness in subcortical poststroke subjects. Ten subcortical poststroke subjects and 10 healthy controls participated in this study. The ankle passive stiffness at 3 different speeds and the electromyographic activity of the soleus, the gastrocnemius, and the tibialis anterior muscles of poststroke contralesional (CONTRA) and ipsilesional (IPSI) limbs and of one limb of healthy subjects were assessed. Ankle electromyographic activity was collected to ensure that reflexive or voluntary muscle activity was not being elicited during the passive movements. A significant interaction was observed between the effects of the limb (IPSI vs. CONTRA vs. control) and ankle position, F(4, 28) = 3.285, p = .025, and between the effects of the limb and the velocity of stretch, F(2, 14) = 4.209, p = .037. While increased intrinsic stiffness was observed in the CONTRA limb of poststroke subjects at ankle neutral position when the passive stretch was applied with a velocity of 1°/s (p = .021), the IPSI limb of poststroke subjects presented increased stiffness at 20º of plantar flexion when the stretch was applied with a velocity of 5°/s (p = .009) when compared to healthy group. Subcortical poststroke subjects present increased intrinsic stiffness in both the CONTRA and IPSI limbs in specific ankle amplitudes.     

One year after ischemic stroke: Changes in leg movement path stability in a speed–accuracy task but no major effects on the hands

First year after the stroke is essential for motor recovery. The main motor control strategy (i.e., faster movement production at the expense of lower movement accuracy and stability, or greater movement accuracy and stability at the expense of slower movement) selected by poststroke patients during a unilateral speed–accuracy task (SAT) remains unclear. We aimed to investigate the poststroke (12 months after stroke) effects on the trade-off between movement speed and accuracy, and intraindividual variability during a motor performance task. Healthy right-handed men (n = 20; age ∼ 66 years) and right-handed men after ischemic stroke during their post rehabilitation period (n = 20; age ∼ 69 years) were asked to perform a simple reaction task, a maximal velocity performance task and a SAT with the right and left hand, and with the right and left leg. In the hand movement trial, reaction time and movement velocity (V_max) in the SAT were slower and time to V_max in the SAT was longer in the poststroke group (P < .01). In the leg movement trial, poststroke participants reached a greater V_max in the SAT than the healthy participants (P < .01). The greatest poststroke effect on intraindividual variability in movements was found for movement path in the SAT, which was significantly greater in the legs than in the hands. Poststroke patients in the first year after stroke mainly selected an impulsive strategy for speed over hand and leg motor control, but at the expense of lower movement accuracy and greater variability in movement.     

Case study of a Thai conduction aphasic

A case study of a 55-year-old nonfamilial left-handed monolingual Thai patient with clinical and pathoanatomic evidence of major infarction in the left temporoparietal region is presented. He was studied at 9 years poststroke with a Thai adaptation of the Boston Diagnostic Aphasia Exam and supplementary tests. His language characteristics included fluent spontaneous speech, near-normal auditory language comprehension, and poor repetition, leading to a diagnosis of conduction aphasia. In regard to this aphasic syndrome, issues concerning classification, neuroanatomic correlates, and underlying neuropsychological mechanisms are addressed. The nature of his grammatical disturbance is examined critically in light of the notion of “information load.”     

Prognostic relevance of quantitative topographical EEG in patients with poststroke aphasia

In this prospective study we analyzed the prognostic value of topographical quantitative EEG (qEEG) in poststroke aphasia. Twenty-three right-handed patients (ages 56 +/- 12 years) with different types of aphasia were studied. Quantitative EEG under resting conditions and an aphasia test battery were applied twice, 2 and 8 weeks after a stroke. EEG power fast Fourier transform was performed for delta (2-3.5 Hz), theta (4-7.5 Hz), alpha (8-13 Hz), and beta (13.5-20 Hz) frequency bands. EEG abnormalities within and outside speech relevant areas are related to restitution of poststroke aphasia. In the ischemic regions they indicate local disturbances; outside they reflect failures in neuronal networks involved in the generation and propagation of the alpha rhythm.     

Recovery from occipital stroke: a self-report and an inquiry into visual processes

This report summarizes the behavioural effects of a right occipital stroke in the author. An upper left quandrantanopia resolved over the first 50 poststroke days to leave a scotoma that included the left upper quadrant of the fovea and extended upwards about 6 degrees and lateral about 15 degrees. There was no further reduction in size over the next 4 years. In the early stages of recovery there was an inability to detect consciously either the presence of objects or their motion, except upon reflection once an object entered the intact visual field. This has been referred to previously as blindsight. On about the fourth day poststroke, part of the scotoma became visually active, producing a scintillating aura, which remains. Shortly thereafter colour perception returned in the scotoma, as did motion detection. Although there was little additional change in the field defect after 2 months, the author's visual abilities have continued to improve, in large part because of a shift in fixation such that information at the centre of the visual field now falls about 1.5 degrees into the lower right portion of the fovea. The implications of the visual and behavioural changes are discussed in the context of multiple visual systems and with respect to recovery of function.     

Speed and Rhythm Affect Temporal Structure of Variability in Reaching Poststroke: A Pilot Study

Temporal structure reveals the potential adaptive strategies employed during upper extremity movements. The authors compared the temporal structure of upper extremity joints under 3 different reaching conditions: preferred speed, fast speed, and reaching with rhythmic auditory cues in 10 individuals poststroke. They also investigated the temporal structure of these 3 reaching conditions in 8 healthy controls to aid in the interpretation of the observed patterns in the poststroke cohort. Approximate entropy (ApEn) was used to measure the temporal structure of the upper extremity joints. ApEn was similar between conditions in controls. After stroke, ApEn was significantly higher for shoulder, elbow, and wrist both at fast speed and with rhythmic cues compared with preferred speed. ApEn at index finger was significantly higher only with rhythmic cues compared with preferred speed. The authors propose that practice reaching at faster speed and with rhythmic cues as a component of rehabilitation interventions may enhance adaptability after stroke.     

Comparison of upper limb kinematics in two activities of daily living with different handling requirements

IntroductionRecently, kinematic analysis of the drinking task (DRINK) has been recommended to assess the quality of upper limb (UL) movement after stroke, but the accomplishment of this task may become difficult for poststroke patients with hand impairment. Therefore, it is necessary to study ADLs that involve a simpler interaction with a daily life target, such as the turning on a light task (LIGHT). As the knowledge of movement performed by healthy adults becomes essential to assess the quality of movement of poststroke patients, the main goal of this article was to compare the kinematic strategies used by healthy adults in LIGHT with those that are used in DRINK.Methods63 adults, aged 30 to 69 years old, drank water and turned on a light, using both ULs separately, while seated. The movements of both tasks were captured by a 3D motion capture system. End-point and joint kinematics of reaching and returning phases were analysed. A multifactorial analysis of variance with repeated measures was applied to the kinematic metrics, using age, sex, body mass index and dominance as main factors.ResultsMean and peak velocities, index of curvature, shoulder flexion and elbow extension were lower in LIGHT, which suggests that the real hand trajectory was smaller in this task. In LIGHT, reaching was less smooth and returning was smoother than DRINK. The instant of peak velocity was similar in both tasks. There was a minimal anterior trunk displacement in LIGHT, and a greater anterior trunk displacement in DRINK. Age and sex were the main factors which exerted effect on some of the kinematics, especially in LIGHT.ConclusionThe different target formats and hand contact in DRINK and LIGHT seem to be responsible for differences in velocity profile, efficiency, smoothness, joint angles and trunk displacement. Results suggest that the real hand trajectory was smaller in LIGHT and that interaction with the switch seems to be less demanding than with the glass. Accordingly, LIGHT could be a good option for the assessment of poststroke patients without grasping ability. Age and sex seem to be the main factors to be considered in future studies for a better match between healthy and poststroke adults.     

Depression at 3 Months Poststroke in the Elderly: Predictors and Indicators of Prevalence

The prevalence and determinants of depression in 79 elderly patients were assessed at 3 months poststroke. Predictor variables included gender, age, history of previous stroke, and hemispheric location of stroke. Indicator variables included two measures of physical functioning and seven aspects of cognitive functioning. Results indicated that 56% of patients had impairment in activities of daily living, and 39% reported clinically significant levels of depression. Prevalence of cognitive impairment ranged from 31% on a measure of basic cognitive functioning, through to 89% on a measure of complex attention. The results from a hierarchical multiple regression analysis showed that the combination of predictor and indicator variables explained 53% of the variance in depression scores. The three individual variables of history of previous stroke, physical functioning, and simple attention all made significant unique contributions to the variance in depression scores. The contribution of these findings to the ongoing debate concerning lesion location and poststroke depression is discussed.     

Neurodevelopmental Disorders Across the Lifespan: A Neuroconstructivist Approach.

Objectives. To investigate neuropsychological and neurobehavioral outcome in children with arterial ischemic stroke (AIS).

Background. Childhood stroke can have consequences on motor, cognitive, and behavioral development. We present a cross-sectional study of neuropsychological and neurobehavioral outcome at least one year poststroke in a uniquely homogeneous sample of children who had experienced AIS.

Method. Forty-nine children with AIS aged 6 to 18 years were recruited from a specialist clinic. Neuropsychological measures of intelligence, reading comprehension, attention, and executive function were administered. A triangulation of data collection included questionnaires completed by the children, their parents, and teachers, rating behavior, executive functions, and emotions.

Key Findings. Focal neuropsychological vulnerabilities in attention (response inhibition and dual attention) and executive function were found, beyond general intellectual functioning, irrespective of hemispheric side of stroke. Difficulties with emotional and behavioral regulation were also found. Consistent with an “early plasticity” hypothesis, earlier age of stroke was associated with better performance on measures of executive function.

Conclusions. A significant proportion of children poststroke are at long-term risk of difficulties with emotional regulation, executive function, and attention. Data also suggest that executive functions are represented in widespread networks in the developing brain and are vulnerable to unilateral injury.     

The Caregivers of Stroke Patients: An Investigation of Factors Associated with Depression

Caregivers of the elderly and infirm are often under more stress and report lower life satisfaction than matched groups of noncaregivers. Forty caregivers of stroke patients (usually a spouse) were interviewed an average of 9 months poststroke to determine the factors associated with poorer caregiver adjustment. Four classes of variables were expected to be related to depression in caregivers: level of functioning of the patient, caregiver perceptions of increased work and burden due to the stroke, the quality of the patient-caregiver relationship, and caregivers' interpretations of their situation. Background characteristics were also measured. As predicted, variables in each class were significantly related to depression. Multiple regression analysis showed three significant independent predictors of caregiver depression. Caregivers are more depressed if the patient is more physically impaired, if caregivers report disharmony in the family, and if they have lesser perceptions of hope Ways to apply these findings to the development of interventions to ameliorate caregiver depression are discussed.     

Personality Changes Associated with Localized Brain Injury in Elderly Populations

Emotional disturbances following brain damage have been frequently reported in the literature. However, systematic investigation of these disorders and their specific causes were not common until the last 30 years. However, the number of research studies into this area remains slight compared to the voluminous literature on the cognitive effects of brain injury. The completed research has fallen into 3 major areas: (1) The study of clients with localized brain injuries to evaluate whether the site of the injury predicts the emotional reactions; (2) the effect of time poststroke on personality changes; and (3) the relation of neuropsychological deficits to emotional changes. This paper provides a comprehensive review of the research that has been completed in this area with elderly subjects along with an analysis of the current state of the knowledge in this area. Future directions for research to further our understanding are discussed.     

Improved picture naming in chronic aphasia after TMS to part of right Broca's area: an open-protocol study

Functional imaging studies with nonfluent aphasia patients have observed "over-activation" in right (R) language homologues. This may represent a maladaptive strategy; suppression may result in language improvement. We applied slow, 1 Hz repetitive transcranial magnetic stimulation (rTMS) to an anterior portion of R Broca's homologue daily, for 10 days in four aphasia patients who were 5-11 years poststroke. Significant improvement was observed in picture naming at 2 months post-rTMS, with lasting benefit at 8 months in three patients. This preliminary, open trial suggests that rTMS may provide a novel treatment approach for aphasia by possibly modulating the distributed, bi-hemispheric language network.     

Test-retest reliability of fMRI during nonverbal semantic decisions in moderate-severe nonfluent aphasia patients

Cortical reorganization in poststroke aphasia is not well understood. Few studies have investigated neural mechanisms underlying language recovery in severe aphasia patients, who are typically viewed as having a poor prognosis for language recovery. Although test-retest reliability is routinely demonstrated during collection of language data in single-subject aphasia research, this is rarely examined in fMRI studies investigating the underlying neural mechanisms in aphasia recovery. The purpose of this study was to acquire fMRI test-retest data examining semantic decisions both within and between two aphasia patients. Functional MRI was utilized to image individuals with chronic, moderate-severe nonfluent aphasia during nonverbal, yes/no button-box semantic judgments of iconic sentences presented in the Computer-assisted Visual Communication (C-ViC) program. We investigated the critical issue of intra-subject reliability by exploring similarities and differences in regions of activation during participants' performance of identical tasks twice on the same day. Each participant demonstrated high intra-subject reliability, with response decrements typical of task familiarity. Differences between participants included greater left hemisphere perilesional activation in the individual with better response to C-ViC training. This study provides fMRI reliability in chronic nonfluent aphasia, and adds to evidence supporting differences in individual cortical reorganization in aphasia recovery.     

The evolution of pure alexia: a longitudinal study of recovery

This case report documents the partial recovery, over a 12-month period, of pure alexia in an adult female following a left occipital infarction. Measures of speed and accuracy were obtained on an oral reading and a lexical decision task immediately postonset and then on 10 subsequent occasions. Explicit letter-by-letter reading was observed only during the first week poststroke but a significant effect of word length was seen in all testing sessions. Reading accuracy was relatively good at all stages and reading latency showed a remarkable decrease over time but did not reach normal reading rates. The inability to use higher-order orthographic knowledge, as manifest in the absence of a word superiority effect, was still noted at one year postonset. We therefore concluded that the change in behavior was attributable to increased proficiency in the use of the adaptive letter-by-letter procedure rather than to the resolution of the underlying deficit. It is suggested that longitudinal neurobehavioral studies add to our understanding of the alexic deficit and provide insight into the recovery process.     

Kinematic descriptions of upper limb function using simulated tasks in activities of daily living after stroke

Assessment of upper limb function poststroke is critical for clinical management and determining the efficacy of interventions. We designed a unilateral upper limb task to simulate activities of daily living to examine how chronic stroke survivors manage reaching, grasping and handling skills simultaneously to perform the functional task using kinematic analysis. The aim of the study was to compare the motor strategies for performing a functional task between paretic and nonparetic arms. Sixteen chronic stroke survivors were instructed to control an ergonomic spoon to transfer liquid from a large bowl to a small bowl using paretic or nonparetic arm. Kinematic data were recorded using a Vicon motion capture system. Outcome measures included movement duration, relative timing, path length, joint excursions, and trial-to-trial variability. Results showed that movement duration, spoon path length, and trunk path length increased significantly when participants used paretic arm to perform the task. Participants tended to reduce shoulder and elbow excursions, and increase trunk excursions to perform the task with paretic arm and altered the relative timing of the task. Although participants used different motor strategies to perform the task with their paretic arms, we did not find the significant differences in trial-to trial variability of joint excursions between paretic and nonparetic arms. The results revealed differences in temporal and spatial aspects of motor strategies between paretic and nonparetic arms. Clinicians should explore the underlying causes of pathological movement patterns and facilitate preferred movement patterns of paretic arm.     

Norepinephrine and brain damage: alpha noradrenergic pharmacology alters functional recovery after cortical trauma

The goal of these experiments was to evaluate the effects of some drugs affecting noradrenergic (NE) synaptic transmission, commonly prescribed following stroke or traumatic brain injury, on functional recovery. Measurement of recovery from a transient hemiplegia produced by a traumatic unilateral focal contusion in sensorimotor cortex (SMCX) of rats was used to assess the effects of chronic haloperidol (HAL) treatment begun early (1 day) or late (18 days to recovered animals) after injury. Additionally, using the same model, the effects of a single administration of drugs with selective action at NE receptors were also evaluated early or late (30 days) after injury. These drugs were: phenoxybenzamine (PBZ), an alpha 1-NE antagonist; prazosin (PRAZ), an alpha 1-NE antagonist; yohimbine (YOH), an alpha 2-NE antagonist; propranolol (PROP), a beta 1- and 2-NE receptor antagonist; methoxymine (METHOX), an alpha 1-NE agonist; and clonidine (CLON), an alpha 2-NE agonist. The data indicate that drugs with antagonistic effects at alpha 1 NE receptors, including HAL and PRAZ but not PROP, administered early after SMCX contusion retard locomotor recovery. Beneficial effects of enhancing NE transmission by METHOX or YOH were not observed. In animals recovered from beam walk (BW) deficits, a single administration of PBZ or PRAZ (alpha 1 NE antagonists) or CLON (alpha 2 NE agonist) transiently reinstated hemiplegic symptoms. The nonspecific beta NE receptor antagonist PROP had no effect in recovered animals. A single dose of HAL had no effect in recovered animals, but a BW deficit transiently developed in some animals following chronic treatment. The data are discussed with reference to drug contraindications noted in clinical studies of recovery from poststroke aphasia and cognition in demented patients with degenerative brain disease.     

Reliability of upper extremity kinematics while performing different tasks in individuals with stroke

Assessments of upper extremity performance typically include qualitative rather than quantitative measures of functional ability. Kinematic analysis is an objective, discriminative measure that quantifies movement biomechanics; however, the use within the poststroke impaired upper extremity is not well established. The purpose of this study was to examine the reliability of upper extremity kinematics in 18 individuals with stroke and 9 healthy controls. Participants performed reaching and grasping tasks over 2 separate days and metrics included movement time, peak velocity, index of curvature, trunk displacement, maximum aperture, and percentage of the movement cycle where maximum aperture occurred. The results showed moderate to high intraclass correlation and low standard error of measurement values for most variables, demonstrating that kinematic analysis may be a feasible and useful tool to quantify upper extremity movement after stroke.     

Quantitative CT scan studies in aphasia. I. Infarct size and CT numbers

Infarct si?e (number of 1-mm² pixels in the lesion) on CT scans of 30 aphasia patients was obtained with a semiautomated computer program. The mean number of lesion pixels present per slice containing lesion was approximately 500 for mild aphasias (transcortical motor and conduction), 700 for Wernicke's, 1000 for Broca's, 1500 for mixed, and 2000 for globals. These differences were significant for $\text{11}\text{15}$ of the group pairwise comparisons. When lesion locus was controlled for in the anterior/posterior plane, 73–100% of the aphasia patients were correctly classified as to type of aphasia by a discriminant analysis utilizing only the number of lesion pixels present on two CT slices. Different slice combinations were used for different aphasia group comparisons. There was a significant correlation between severity of aphasia and lesion size. There was a significant correlation between lesion size and the CT numbers in the lesion. This type of analysis may be useful to predict the prognosis for recovery potential in aphasics who have CT scans performed at 2 months poststroke.     

EMG Activity in Selected Target Muscles During Imagery Rising on Tiptoes in Healthy Adults and Poststrokes Hemiparetic Patients

The authors sought to gain further knowledge about activation of target muscles during imagery engagement in a motor task. Six hemiparetic patients and 9 healthy participants performed 3 real rises on tiptoes and then, after pausing, 3 imagery rises on tiptoes. Metronome beats guided the rate of rises and descents. Electromyographic (EMG) activity from the medial gastrocnemius and the rectus femoris muscles were monitored bilaterally throughout the performance of both tasks. In 3 healthy participants and 3 individuals with hemiparesis, EMG activity was related to the imagery task in at least 1 of the target muscles. Conversely, in the other participants, motor imagery practice was not accompanied by task-related EMG activity in the monitored muscles. In all cases, the increment in activation level during motor imagery practice was very low in comparison with that of real performance. The findings were not unequivocal; therefore, EMG activity may sometimes, but not always, be recorded during motor imagery practice both in healthy individuals and in poststroke hemiparetic participants. Further research is needed to align motor imagery practice with the objectives of motor rehabilitation.