Psychiatric manifestation of cerebrovascular stroke Presented by Dr: Islam shaaban MD of psychiatry

Introduction Both neurology and psychiatry deal with diseases of the same organ (the brain). Mental disorders and Stroke have a bidirectional relationship, as not only are patients with stroke at greater risk of developing mental disorders, but patients with mental disorders have a greater risk of developing a stroke, even after controlling for other risk factors. (patients with depression have a two-fold greater risk of developing a stroke).

Introduction Psychological definition:  “A stroke is a sudden traumatic major life event that usually occurs with minimal warning and results in life-changing consequences” (Donnellan et al., 2006)  “We’re not just legs and arms and a mouth…we are human beings with a mixture of emotions. All these feelings…self esteem, confidence, identity …they’re under attack after a stroke.

Impact of stroke on self & others Physical Sensory Communication Cognitive Behavioural Emotional

Impact of stroke on self & others Physical Sensory Communication Cognitive Behavioural Emotional They affect many levels -: Personal Sense of self Identity Family Role change Work Responsibilities Finance Society Stigma Social networks Health services

The prevalence rates and types of psychiatric disorders after stroke Depression: (PSD) common 30 – 50%  The occurrence of PSD peaks three to six months after a stroke.  Approximately 20% of patients who have a stroke meet criteria for major depressive disorder another 20 % meet criteria for minor depression

The prevalence rates and types of psychiatric disorders after stroke Cognitive impairment Delirium occurs in 30% to 40% of patients during the first week after a stroke, especially after a hemorrhagic stroke. Dementia is common following stroke, occurring in approximately 25% of patients at 3 months after stroke (vascular dementia ).

The prevalence rates of common types of psychiatric disorders after stroke Anxiety is common in ischemic stroke, frequently present with PSD Between 30-49% up to 12 years post stroke Phobias, generalised anxiety, panic PTSD 20% (Flashbacks, avoidance, hyperarousal) Catastrophic reaction: 20% Emotional Incontinence common in patients with frontal lobe lesions due to traumatic brain injury, multiple sclerosis, pseudobulbar palsy Apathy : 20% Obsessive-Compulsive Disorder reported after strokes, affecting the basal ganglia or brainstem Bipolar disorder: rare Psychosis: rare approximately 1%mostly after lesions of the brain stem. sexual dysfunction sexual intercourse does not increase risk for stroke.

The Impact of mental disorders on the course of the stroke Delayed psychological intervention can lead to  Higher rates of mortality  Increased disability  Secondary health problems(diabetes,dyslipidemia, dyscoagulation and hypertension)  Secondary psychiatric problems (e.g. Depression, Health & / or Social anxiety, Panic Disorder +-agoraphobia)  Suicide  Hospital readmission  Higher utilisation of outpatient services

The Mechanisms of the effect of mental disorders on stroke There are potential mechanisms to explain the relationship between mental disorders and cerebrovascular mortality and morbidity  Behavioral mechanisms  Physiological mechanisms  Others as side effects of psychotropic drugs

Behavioral mechanisms Poor concentration and adherence to medication regimens. Lack of motivation to adhere to lifestyle changes (e g good diet, exercise). Increased prevalence of habits with negative health consequences (e.g., smoking. binge- eating). Reduced activity and social isolation/anxiety making it more difficult to participate in rehabilitation programs

Physiological mechanisms Hyperactivity of the HPA axis, results in elevated catecholamine secretion with adverse effects on the heart, blood vessels and platelets. Augmented platelet responsiveness or activation, increasing the risk of clot formation and atherosclerosis. Disrupted circadian rhythms and reduced heart rate, leading to arrhythmogenesis.

Side effects of psychotropic drugs  Low-potency conventional antipsychotics (e.g., chlorpormazine) and atypical antipsychotics, quetiapine, olanzapine and clozapine, are associated with higher risk of hyperlipidemia  Arrhythmogenic and hypotensive effects of TCAs in cardiac patients  Recent controlled studies suggest that antipsychotics can impair glucose regulation by decreasing insulin action, and inducing weight gain.

Mental disorders and Smoking patients with current psychiatric disorders have significantly higher rates of smoking (51% on average) were: 88% for schizophrenia, 70% for mania, 49% for major depression, 47% for anxiety disorders, 46% for personality disorders, and 45% for adjustment disorders.

Correlation between lesion location and neuropsychiatric manifestation Gerstmann's syndrome, manifested by dyscalculia, finger agnosia, left-right disorientation, and dysgraphia, is a classic manifestation of left parietal lesions, although it is rarely seen in its full form frontal lesion can disrupt usual frontal functions. Difficulties with executive function, disinhibition, and apathy are possible manifestations. If the lesion is left temporoparietal, it may affect Wernicke's area and result in an aphasia. patients with anxiety and mania more often have right- hemispheric lesions the left frontal cortex and left basal ganglia lesions are most often associated with the poststroke depression.

Clinical presentation Mental Disorders may be the first presentation of cerebrovascular stroke as vascular depression, behavioral changes and psychotic features Some patients with conversion disorder present with acute onset of neurological symptoms, they may be misdiagnosed as having transient ischemic attacks or strokes. So we must differentiate between mental Disorders and psychiatric manifestation of cerebrovascular stroke

Features That Point to a psychiatric manifestation of cerebrovascular stroke Atypical features: ( History ) Atypical onset (within hours or minutes, Atypical age of Onset Atypical clinical course. Atypical response to treatment. Atypical disturbances of perception (non auditory hallucination) Catatonia Neurological symptoms:  loss of consciousness  urine / stool incontinence  seizures  head injury  change in headache pattern

Features That Point to a psychiatric manifestation of cerebrovascular stroke Family history:  Complete lack of positive family history of the disorder Past history:  Association of Significant Injury  Medical illness  Substance abuse

Vascular depression (silent stroke) patients with vascular depression are more likely to present with the following criteria  late-onset symptoms of depression.  Clinical and/or neuroradiological evidence of diffuse bilateral white matter lesion or small vessel disease.  Chronic cerebrovaseular risk factors (CVRF) such as hypertension, diabetes, carotid stenosis, atrial fibrillation and hyper-lipidaemia.

Vascular depression The symptoms of vascular depression consist of mood abnormalities, neuropsychological disturbances as impairment of executive functions, a greater tendency to psychomotor retardation, poor insight and impaired activities of daily living patients with PSD are more likely to present with catastrophic reactions, hyper activity, and diurnal mood variation than patients with idiopathic depression, Duration of PSD symptoms appears to depend on the vascular branch of the stroke, longer durations identified in patients with a stroke in the middle cerebral artery, than in the posterior circulation.

Potential pathogenic mechanisms for post-stroke depression Many risk factors associated with PSD have included location and size of the stroke, there is relation between PSD and stroke of temporal lobe, and the size of the ventricles. There is a relationship between PSD and left hemispheric stroke specially left frontal dorsolateral cortical regions and basal ganglia. depression appear more than one year after the stroke, right-sided lesions are more frequent. There is significant correlation between the severity of disability and depression,

Impact of post-stroke depression on the course of the stroke The presence of PSD has been found to have a negative impact on: recovery of cognitive function recovery of ability to perform ADL mortality risks. in recent study of 976 stroke patients followed for one year, those with PSD had 50% higher mortality than those without.

Management There are many similarities in diagnosing and treating mental Disorders in the stroke and primary mental disorders,Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), stimulants, and electroconvulsive therapy (ECT) have all been effective in the treatment of poststroke depression Antidepressants have been used as prophylaxis to prevent PSD, physical impairment and mortality Avoid antidepressants that interact with the medical illness, e.g.. arrhythmogenic and hypotensive effects of TCAs in cardiac patients

Management Avoid antidepressants with side effects that may worsen symptoms of the medical illness, e.g.. venlafaxine in hypertension, mirtazapine or TCAs in diabetes Avoid psychotropic drugs that may interact with other drugs that patients may be using for the medical illness, e.g., fluvoxamine with warfarin, fluoxetine and paroxetine with codeine; TCAs with quinidine Be aware of age-and illness-related changes in pharmacokinetics, e.g., liver disease and hepatic dysfunction may reduce metabolism and increase serum levels of psychotropic drugs

Management 'Start low, go slow, keep going, stay longer': start with lower than usual doses, titrate up slowly to usual therapeutic doses, and maintain on medications for a longer duration. relapse with discontinuation of psychotropic drugs is very common so maintenance treatment of two year; or longer is recommended ECT was found useful in many retrospective studies. None of the pts developed exacerbations of stroke or new neurological deficits.

Conclusion “No health without mental health” Depression & anxiety are the most common post- stroke syndromes. Both depression and anxiety increase morbidity and delay rehabilitation. There are very few treatment studies available. we must treat post-stroke psychiatric disorders as early as possible to improve outcome and quality of life.

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