1. The neuropsychiatry of stroke
John O’Donovan

2. Stroke Third most common cause of death post MI and cancer
11% of deaths in UK and Wales
20% of acute beds and 25% of long term beds occupied by stroke patients
Acute focal neurological deficit resulting from vascular disease.
TIA not very accurate really, concept of less then 24 hours, note TIA with risks can suggest a 30% chance of a full stroke happening. Be cautious with these patients!

3. Types of stroke Nearly all arterial, less then 1% is venous.
85% are infarctions
15% are haemorrhagic, which can be intercranial or subarachnoid
3 mechanisms of ischemic stroke, thrombosis, embolism or hypoperfusion.

4. Risk factors Age: incidence doubles each decade post 55
Hypertension: 25% of adult population 140/90
Smoking
Diabetes: 2 fold increase
A fib: 5% of over 60s, 4% per year risk of stroke
Dyslipidemia
Alcohol
Obesity
Carotid stenosis
Drug misuse

5. Lacunar Stroke
Small discrete lesion, generally deep tissue and associated with hypertension/ischemia.
5 classical types
1: pure motor hemiparesis
2: sensorimotor
3: pure sensory
4: ataxic hemiparesis
5: dysarthria/clumsy Hand

6. Lacunar Stroke 2
Can be associated with cognitive impairment
Can be associated with depression
Can be silent
Can be associated with unusual sub types such as antiphospholipid AB syndrome and CADASIL
No cortical signs
No neglect
DWI test of choice.
If pronnounced may cause leucoaraiosis

7. Large Vessel Disease
Cortical signs
Note: amarosis fugax
Generally large vessel occlusion, embolic
Tends to be MCA territory
ACA is less common
Lesion site is obviously important for presentation

8. Haemorrhage
Much less common, 10-15%
Much worse outcome
Big risk is hypertension

9. SAH
Nearly always rupture of an aneurysm
Mortality of 50%
10/100,000 incidence
Risks: genetics, connective tissue problems, smoking, hypertension, female sex
Also AVM
Cavernous angiomas

10. Rare causes of stroke CADASIL Venous Shunting, PFO Moya moya disease
Carotid dissection
Vasculitis
Thrombophilias
Mitochondrial
Farby’s disease

11. Psychiatry and stroke Psychiatric patients Medical patients
Risk factors
Smoking
Increased mortality
Insulin resistance
Poor compliance with medical therapy
Common problem
Post stroke depression or mood changes
Post stroke emotionalism
Post stroke cognitive impairment
Stroke risk and development of dementia

12. Stroke and psychiatric effects
Basic ideas
Certain stroke syndromes are likely to cause specific presentations.
Stroke may not always be apparent.
As patients get older the odds of having cerebrovascular disease increases.
Stroke is very common and should be considered in atypical depression, cognitive impairment or any unusual psychiatric presentation.

13. Prevalence of psychiatric disorders post stroke
• Depression:  35%
• Mania: rare
• Bipolar disorder: rare
• Anxiety disorder: 25%
• Apathy : 20%
• Psychosis: rare
• Pathologic affect 20%
• Catastrophic reaction: 20%

14. Depression post stroke
Prevalence studies vary from 10-79% depending on location of study, time of study and case ascertainment.
In general hospital studies report higher rates.
Interesting clinical point is that depression more or less immediately post stroke does not predict further problem
Depression at six months, suggests ongoing problems for another year.

15. Risk factors for depression post stroke
Definite
Argued
Prior psychiatric illness
Dysphasia
Poor social support
Age
Gender
Lesion location
Lesion volume
Impaired ADLs

16. Clinical features Core psychopathology Stroke related depression
Core features of sustained low mood and anhedonia need to be distinguished from common medical problems such as fatigue and sleep disturbance.
Concentrate on cognitive features.
Some authors argue in favor of a more somatic approach
Peak at 3-6 months post event.
Generally prevalence reduces by up to half at one year.

17. Mechanism Psychological Physical Weak evidence of lesion location
High rates in many medical illnesses
Treatment effects, are not very convincing
Loss and obvious psychological mechanisms
Loss of role, independence, future effects
High prevalence of depression in stroke
Frontal striatal mechanism
Lesion location, head of caudate, frontal akinesis etc
Differential response to noradrenergic anti depressants
Occurs in anosognosia

18. Post stroke depression treatment
Psychological
Pharmacological
Firstly depression post stroke is clearly both psychological and biological
Rehabilitation is crucial
Pain management
Social supports
Encourage independence again, sense of future hope
Good evidence for SSRIs post stroke
Suggestion that they may prevent depression post stroke and improve rehabilitation outcomes.
Cochrane database reviews do not give clear outlines for any intervention

19. Post stroke mania Rare 1-5% prevalence
Classically non dominant temporal lobe
However this is a non robust finding
Increased rate in BPAD patients
Concept of manic defence for exams
Treatment with antipsychotics/mood stabilisers (note increased risk of CVA with anti psychotics and dementia)

20. Post stroke apathy Apathy Depression
Absence of concern about the environment and self
Little interest in doing things
Frontal type initiation, not uncommon in stroke
Look at lesion location, frontal?
Trial of ADTs anyway?
Some suggest that noradrenergic and or stimulants more effective
nearly always has features of apathy
Distinction difficult
Generally core cognitions will distinguish

21. Post stroke anxiety disorders
20% of post stroke patients.
GAD and panic
No clear evidence about what treatments are best.
Frequently interlinked with depression

22. Post stroke catastrophic reactions
Up to 19% post stroke
Associated with basal ganglia lesions and frontal lesions
Outbreak of severe distress when unable to perform simple tasks secondary to new disability.
Release phenomena commonly

23. Hyperemotionalism Pathological affect Emotional lability
Inability to control affect in response to emotional or other stimuli
Frequently seen as part of a pseudobulbar affect.
Some evidence for SSRIs (weak-case series data)

24. Psychosis post stroke
Allegedly very rare in longitudinal case series with prevalence below 1%
I doubt this and would suggest that it depends on how long the psychosis must last to be identified, certainly stroke is not uncommonly associated with delirium and this frequently is associated with psychosis.

25. ACAM anuerysm
Can cause a WKS
Same structures as affected in Wernick’e anatomically
Patients can end up profoundly amnestic, with a degree of confabulation from disruption of thalamic connections.
Generally seen post SAH/neurosurgery.

26. Hypoxic ischemic encephalopathy
Any age
Most commonly describe in children
Also adults how suffer pump failure/global hypoperfusion/hpoxia/CO poisoning
Selective hippocampal loss and watershed infarcts, vulnerable areas
Global cognitive problems but classically amnestic due to hippocampal damage.

27. Head of the caudate lesion
In this example bilateral
Classically associated with outflow problems from basal ganglia to frontal cortices
“akinetic mutism”
Can mimic catatonia but acuity of onset is classical.

28. Bilateral thalamic damage
Can occur in general from embolic causes (rare)
When it does occur, prominent psychiatric features can result of disorientation, impaired memory, visual hallucinosis and longer term amnestic type state. Diencaphalic amnesia
Can also be similar to bilateral caudate problems.

29. Bilateral occipital/parietal stroke
In general hospital, most commonly seen post CABG
Hypoperfusion injury or embolic
Can have a very odd presentation and frequently the team seek psychiatric opinion.
Generally has features of cortical blindness and visuospatial integration problems

30. Conclusion Stroke is very common
Significantly complicated by psychiatric disturbance
Need to consider physical rehab, psychiatric and psychological aspects
Sometimes a trial of treatment when things are not clear is a valid option.
Remember language disturbance may make diagnosis difficult