Neurorehabilitation and Neural Repair

Objective : To determine whether antidepressants that differ in their monoamine re uptake inhibitory effects—desipramine (noradrenergic), trazodone (relatively sero tonergic), and fluoxetine (selectively serotonergic)—differentially affect recovery from stroke associated with depression.

Background: Animal models and limited studies in man show that noradrener gic agents enhance sensorimotor and visual recovery after brain injury, whereas sero tonergic agents impede such recovery.

Methods: Twenty-four stroke rehabilitation inpatients meeting DSM3R crite ria for organic mood disorder with depression were randomized to receive desipramine (N = 13), trazodone (N= 6), or fluoxetine (N = 5). The initial and target doses of desipramine were 50 mg and 100 mg, respectively, fluoxetine, 10 mg and 20 mg, and trazodone, 50 mg and 100 mg.

Results: The age, sex, interval post stroke, type and location of stroke, type of neurologic deficit, severity of depression (Hamilton Depression Scale [HDS]), func tional disability (Functional Independence Measure [FIM]), and neurologic impair ment (Fugl-Meyer Scale [F-M]) at baseline were comparable for the three treatment groups. Eighteen patients completed four weeks of study. Treatment was discontinued because of possible side effects in six patients, five of whom were taking desipramine. Patients in the trazodone and fluoxetine groups had significantly greater gain in FIM than patients in the desipramine group both at two weeks and at four weeks (p < 0.05). F-M and HDS scores improved equally among the three groups.

Conclusions: Serotonergic agents were associated with better functional recov ery and fewer side effects. Noradrenergic and serotonergic agents were equally effec tive in treating depression following stroke.

Objectives : To identify variables associated with the development of pneumonia in patients with ischemic stroke and to assess the utility of both the clinical swallowing examination and the videofluoroscopic modified barium swallow (VMBS) to identify stroke patients at risk for aspiration and subsequent pneumonia and to measure the effect of pneumonia on hospital outcomes.

Design/Methods: Bedside clinical evaluation and VMBS were performed on 102 patients admitted with acute ischemic stroke who were referred for swallowing eval uation because of clinical suspicion of dysphagia. The clinical features, stroke loca tion and severity, pneumonia, length of stay (LOS), mortality, and costs were evalu ated retrospectively.

Results: Pneumonia occurred in 21 of 102 patients (20.6%) and was more fre quent in those with aspiration on VMBS (p < 0.01). Those with pneumonia had longer median LOS (29 days vs. 10 days), higher total costs ($27,764 vs. $9,753, p < 0.0001), higher mortality (24 percent vs. 3.7 percent, p < 0.01), and worse 24-hour stroke severity scores (p = 0.001).

The VMBS correlated better with developing pneumonia than did the clinical swallowing assessment alone, but the combined use of both tests yielded the highest sensitivity (0.86) and a negative predictive value (0.91) for pneumonia.

Conclusions: Pneumonia complicating ischemic stroke significantly correlates with increased mortality, increased LOS, higher costs, and 24-hour stroke severity scores. Pneumonia was more frequent in patients who aspirated on VMBS and in pa tients who had an impaired level of consciousness. The combined use of clinical swal lowing evaluation and VMBS has high negative predictive value in assessing risk for pneumonia.

Objectives To examine the amplitude, latency, and bilateral symmetry of long loop pos tural reflexes after stroke.

Rationale: Computerized platform posturography is a new technique for assess ing neural control of posture and balance. It may help quantify stroke-related neuro logic impairments and measure their improvement over time.

ABS1:Methods: As part of an ongoing study of postural control after stroke, patients with normal EquiTest sensory analysis scores were randomly selected for study. Their performance was compared with that of normal community volunteers. Postural control was assessed by preprogrammed anterior and posterior horizontal forceplate movements using an EquiTest dynamic posturography system five to eight weeks after an initial stroke. Subjects included 24 patients (13 males and 11 females) with acute stroke admitted to the Burke Rehabilitation Hospital. Patients had a mean age of 63.1 years, and the community controls had a mean age of 69.2 years.

Results: Postural control was severely disrupted in the paretic leg. Motor con trol results were abnormal in 75 percent of the patients after stroke (18 of 24) when compared with the controls. Significant differences in the latencies and amplitude of long loop postural reflexes were seen between the affected and nonaffected leg in the same patient during movement forward (p < 0.005) and backward (p < 0.005) and response strength (p < 0.005). The nonaffected leg had normal reflex latencies while the response latencies in the affected leg were either absent or slowed and of decreased amplitude.

Conclusion: With posturographic assessment, the amplitude, latency, and bilat eral symmetry of long loop postural reflex latencies are abnormal in hemiparetic pa tients. These reflexes may be useful in the study of the mechanism of gait and bal ance dysfunction in patients after stroke.

A single case study is presented of a 22-year-old women who sustained severe abulia and akinesia after a traumatic brain injury. After intensive rehabilitation and unsuc cessful pharmacologic interventions, a trial of naltrexone coincided with a significant improvement in Functional Independence Measure (FIM) scores. Key Words: Nal trexone—Brain injury—Abulia.