논문제목: Post-stroke depression and emotional incontinence: correlation with the lesion location

Abstract

Background and purpose The correlation between the location of stroke and post-stroke depression (PSD) and emotional incontinence (inappropriate or excessive laughing and/or crying, PSEI) remains controversial. Methods We prospectively studied 148 patients with single, unilateral stroke at 2-4 months after the onset of stroke with regard to the presence of PSD (using DSM-IV criteria and Beck Depression Inventory) and PSEI. The patients with prior history of depression were excluded. The lesion location was analyzed by CT and/or MRI. Results There were 94 men and 54 women with their mean age of 61.5 years. Twenty seven patients (18.2 %) had PSD and 50 (33.8 %) had PSEI. The lesions included 126 infarcts and 22 hemorrhages. The presence of PSD and PSEI was not related to the laterality and the size of the lesion. The frequency of PSEI but not PSD was higher in women (than in men) and in ischemic stroke (than hemorrhagic one) (p< 0.05, respectively). Although both PSD and PSEI were related to motor dysfunction and location (anterior vs. posterior cortex) of the lesion, the latter was a stronger determinant for PSD (p<0.05). The frequency of PSD and PSEI were: 75% and 100 % in the frontal stroke of anterior cerebral artery territory (n=4), 50 % and 0 % in temporal lobe stroke (n=4), 30 % and 40 % in predominantly frontal stroke of middle cerebral artery territory (n=10), 19 % and 45.2 % in lenticulocapsular stroke (n=42), 12.5 % and 0 % in occipital stroke (n=8), 10.5 % and 15.8 % in thalamic stroke (n=19), 0 % and 33.3 % in midbrain stroke (n=3), 15.8 % and 52.6 % in pontine base stroke (n=19), 36.4 % and 54.5 % in medullary stroke (n=11) and 0 % and 22.2 % in cerebellar stroke (n=9), respectively. No patients with lesions at parietal lobe (n=10) and dorso-lateral pons (n=5) exhibited PSD or PSEI. PSEI was more closely associated with lenticulocapsular strokes as compared to PSD (p<0.01).
Conclusions Our results illustrate that PSD and PSEI are strongly influenced by the lesion location, probably associated with chemical neuroanatomy related to the anterior frontal/temporal lobe-basal ganglia-pontine base-medullary area circuitry. Although the lesion distribution was similar between PSD and PSEI. The latter is more closely related to lenticulocapsular stroke.  

       It has been well known that patients often develop depression after the occurrence of stroke (Ghika-Schmid, Starkstein). The frequency of this post-stroke depression (PSD) has been reported to range from 12 % to 64 % (Robinson 1984, Ebrahim 1987;Herrmann 1995;Sinyor 1986;Ebrahim, 1987;Wade 1987;Starkstein, 1989;House 1991 ). The wide variation in the frequency of PSD seems to be attributed to methodological heterogeneity including the differences in criteria for depression, time of assessment after stroke and the sampled subject population. Equally controversial, however, has been the relationship between the location of stroke and PSD. Despite numerous reports regarding PSD, anatomical substrates have been poorly studied in many of the previous literature. Thus, while some reported that PSD occurred more often after left anterior lesion (Robinson et al, 1984), other have addressed the importance of right sided lesion in producing this symptom (Dam et al, 1989; MacHale, 1998), and still others failed to find any evidence of association of PSD with the lesion location (Anderson al, 1995; Burvill et al, 1996;Hermann et al, 1998 Pohjasvaara et al, 1998).  
     In addition, sporadic reports addressed that unilateral strokes sometimes cause emotional incontinence (inappropriate or excessive laughter/crying) (Poek, Ceccaldi, Kim). While basal ganglionic or pontine lesions have been shown to be related closely to post stroke emotional incontinence (PSEI) (  ), the anatomical substrates related to PSEI have not been sufficiently studied as well. In this report, we studied PSD and PSEI in patients who suffered from stroke and attempted to correlate these symptoms with the lesion location and other variables.