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Lesion Location in Poststroke Depression and Emotional Incontinence

Behavioral neurology classically associates poststroke depression (PSD) with left frontal infarcts and pseudobulbar symptoms of emotional incontinence (PSEI) with bifrontal lesions, but evidence for these associations is inconsistent. In this prospective study, undertaken to better understand the neuroanatomic localization of PSD and PSEI, 148 consecutive patients (mean age, 62) were evaluated 2 to 4 months poststroke. One author, a neurologist, performed the neurologic examination and review of radiologic images; the other, a nurse, independently assessed patients for PSD and PSEI.

Twenty-seven patients (18 percent) had PSD, and 50 patients (34 percent) had PSEI. Of these patients, 18 (15 percent) had both PSD and PSEI. The prevalence of PSD was high with lesions of the fronto-temporal areas compared with the parietal-occipital and other areas: In frontal lobe ACA territory, prevalence was 75 percent; in frontal lobe MCA territory, 30 percent; temporal lobe, 50 percent; subcortical MCA territory, 25 percent; occipital lobe, 13 percent; lenticulocapsular area, 19 percent; thalamus, 11 percent; pontine base, 16 percent; and medulla, 36 percent. An association was found between PSD and motor dysfunction (although lesion location was more important), but not between PSD and the size or laterality of the lesion. PSEI lesions were associated with lesions of frontal lobe ACA territory (100 percent), frontal lobe MCA territory (40 percent), lenticulocapsular area (45 percent), thalamus (16 percent), midbrain (33 percent), pontine base (53 percent), medulla (55 percent), and cerebellum (22 percent). PSEI was also associated with female sex, ischemic stroke, and severe motor dysfunction. The authors concluded that (1) PSD and PSEI are more common with anterior than posterior cortical strokes, (2) PSEI occurs more frequently after subcortical strokes, and (3) neurotransmitter systems may be involved in these syndromes.

Comment: These results are consistent with a number of previous studies in which anterior lesions were more closely associated with PSD and with a study in which left hemisphere lesions were associated with poststroke PSD but not with subacute or chronic PSD. If the authors had analyzed lesions in thalamus, basal ganglia, cerebellum, and brainstem as part of cortical networks, the associations might have been even stronger. Because PSD can be treated and because patients and caregivers need to understand PSEI, both syndromes are important to recognize. This useful study offers help in predicting when PSD, PSEI, or both will develop after brain lesions in different areas.

— AE Budson

Andrew E. Budson, MD, is Associate Neurologist, Division of Cognitive and Behavioral Neurology, Brigham and Women's Hospital, Boston, MA.

Published in Journal Watch Neurology July 21, 2000

Citation(s):

Kim JS and Choi-Kwon S. Poststroke depression and emotional incontinence: Correlation with lesion location. Neurology 2000 May 09 54 1805 -1810.

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