2 Stroke Third most common cause of death post MI and cancer 11% of deaths in UK and Wales20% of acute beds and 25% of long term beds occupied by stroke patientsAcute 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 infarctions15% are haemorrhagic, which can be intercranial or subarachnoid3 mechanisms of ischemic stroke, thrombosis, embolism or hypoperfusion.
4 Risk factors Age: incidence doubles each decade post 55 Hypertension: 25% of adult population 140/90SmokingDiabetes: 2 fold increaseA fib: 5% of over 60s, 4% per year risk of strokeDyslipidemiaAlcoholObesityCarotid stenosisDrug misuse
5 Lacunar StrokeSmall discrete lesion, generally deep tissue and associated with hypertension/ischemia.5 classical types1: pure motor hemiparesis2: sensorimotor3: pure sensory4: ataxic hemiparesis5: dysarthria/clumsy Hand
6 Lacunar Stroke 2Can be associated with cognitive impairmentCan be associated with depressionCan be silentCan be associated with unusual sub types such as antiphospholipid AB syndrome and CADASILNo cortical signsNo neglectDWI test of choice.If pronnounced may cause leucoaraiosis
7 Large Vessel DiseaseCortical signsNote: amarosis fugaxGenerally large vessel occlusion, embolicTends to be MCA territoryACA is less commonLesion site is obviously important for presentation
8 HaemorrhageMuch less common, 10-15%Much worse outcomeBig risk is hypertension
9 SAHNearly always rupture of an aneurysmMortality of 50%10/100,000 incidenceRisks: genetics, connective tissue problems, smoking, hypertension, female sexAlso AVMCavernous angiomas
11 Psychiatry and stroke Psychiatric patients Medical patients Risk factorsSmokingIncreased mortalityInsulin resistancePoor compliance with medical therapyCommon problemPost stroke depression or mood changesPost stroke emotionalismPost stroke cognitive impairmentStroke risk and development of dementia
12 Stroke and psychiatric effects Basic ideasCertain 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.
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 problemDepression at six months, suggests ongoing problems for another year.
15 Risk factors for depression post stroke DefiniteArguedPrior psychiatric illnessDysphasiaPoor social supportAgeGenderLesion locationLesion volumeImpaired 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 approachPeak 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 illnessesTreatment effects, are not very convincingLoss and obvious psychological mechanismsLoss of role, independence, future effectsHigh prevalence of depression in strokeFrontal striatal mechanismLesion location, head of caudate, frontal akinesis etcDifferential response to noradrenergic anti depressantsOccurs in anosognosia
18 Post stroke depression treatment PsychologicalPharmacologicalFirstly depression post stroke is clearly both psychological and biologicalRehabilitation is crucialPain managementSocial supportsEncourage independence again, sense of future hopeGood evidence for SSRIs post strokeSuggestion 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 lobeHowever this is a non robust findingIncreased rate in BPAD patientsConcept of manic defence for examsTreatment 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 selfLittle interest in doing thingsFrontal type initiation, not uncommon in strokeLook at lesion location, frontal?Trial of ADTs anyway?Some suggest that noradrenergic and or stimulants more effectivenearly always has features of apathyDistinction difficultGenerally core cognitions will distinguish
21 Post stroke anxiety disorders 20% of post stroke patients.GAD and panicNo clear evidence about what treatments are best.Frequently interlinked with depression
22 Post stroke catastrophic reactions Up to 19% post strokeAssociated with basal ganglia lesions and frontal lesionsOutbreak 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 stimuliFrequently seen as part of a pseudobulbar affect.Some evidence for SSRIs (weak-case series data)
24 Psychosis post strokeAllegedly 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 anuerysmCan cause a WKSSame structures as affected in Wernick’e anatomicallyPatients 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 ageMost commonly describe in childrenAlso adults how suffer pump failure/global hypoperfusion/hpoxia/CO poisoningSelective hippocampal loss and watershed infarcts, vulnerable areasGlobal cognitive problems but classically amnestic due to hippocampal damage.
27 Head of the caudate lesion In this example bilateralClassically 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 amnesiaCan also be similar to bilateral caudate problems.
29 Bilateral occipital/parietal stroke In general hospital, most commonly seen post CABGHypoperfusion injury or embolicCan 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 disturbanceNeed to consider physical rehab, psychiatric and psychological aspectsSometimes a trial of treatment when things are not clear is a valid option.Remember language disturbance may make diagnosis difficult
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