The study on clinical characteristics and relationship between levels of depression and cranial mri in patients with lacunar infarcts in supratentorial region – Dang Viet Hung

Journal of military pharmaco-medicine no5-2018 193 THE STUDY ON CLINICAL CHARACTERISTICS AND RELATIONSHIP BETWEEN LEVELS OF DEPRESSION AND CRANIAL MRI IN PATIENTS WITH LACUNAR INFARCTS IN SUPRATENTORIAL REGION Dang Viet Hung*; Nguyen Minh Hien**; Nguyen Tram Anh*** SUMMARY Objectives: To study clinical characteristics, and relationship between levels of depression and cranial MRI of patients with lacunar infarction. Subjects and methods: Cross-sectional study and self-design research questionnaire. A total of 90 patients with lacunar infarcts and signs of depression collected from Department of Neurology of Viet - Czech Friendship Hospital between March 2013 and May 2015. Results: The time of onset of lacunar infarction from 6 to 12 am accounted for 53.33%. Among onset symptoms in the majority of patients, hemiplegia accounted for 85.56%, and language disorders accounted for 55.56%, motor dysfunction accounted for 60%. Mild depression, moderate depression, severe depression accounted for 43.33%, 35.56%, and 21.11%, respectively. Locations of lacuna in internal capsule, gray matter, and temporal lobe have not been found to affect levels of depression in cerebral infarction. Frontal lobe damage increased the risk of severe depression by 7.31 times than that of mild depression and 5.81 times than that of moderate depression. Left cerebral hemisphere damage increased the risk of severe depression 4.88 times more than mild depression. Conclusion: There is no clear relationship between levels of depression and cranial MRI in patients with lacunar infarction. * Keywords: Lacunar infarction; Clinical characters; Level of depression; Cranial MRI. INTRODUCTION Stroke has become an increasingly important medical problem due to the average life increasing more and more, the stroke rates have increased according to the age. It is predicted that if there were 12.8% of Americans > 65 years had stroke in 1995, there would be 18.7% in 2025. Lacunar infarction, which accounts for 20 to 26% of total cerebral infarction cases, results from occlusion of penetrating branches that cause small lacuna; necrotic brain tissues forms a small sinus. The question is that whether there is a relationship between the dominant brain hemisphere damage and depression after a stroke. Previous studies have shown that patients with left hemisphere infarction, especially those with frontal lobe damage, are more likely to suffer from depression. Today, thanks to diagnostic imaging devices, medical images become more sensitive and specific. In the world, there are many studies on the relationship between depression after stroke and locations of brain damage. At present, there are not many studies on this issue in Vietnam, so the relationship between depression levels and cranial imaging in patients with lacunar infarction in supratentorial region. * ** *** Corresponding author: Dang Viet Hung (bshungvcvt@gmail.com) Date received: 26/02/2018 Date accepted: 30/05/2018 Journal of military pharmaco-medicine no5-2018 194 SUBJECTS AND METHODS 1. Subjects. 90 patients diagnosed with lacunar infarction were treated at Department of Neurology of Vietnam - Czech Friendship Hospital from March 2013 to November 2015. - The subjects fully met the criteria for diagnosis of lacunar infarcts, on CT-scans or MRI. - All patients were diagnosed with depression according to ICD 10 (1992). - Patients were conscious and cooperated in the process of medical examination, consultation and research. - Patients gave consent to research. * Exclusion criteria: - Patients with other severe diseases. - Patients with a history of depressive symptoms prior to admission. - Patients do not cooperate in the medical examination and inquiry. - Patients with clinical symptoms, but without infarction on MRI. - Patients with cerebral infarction caused by brain tumors, injury, infection, cerebral hemorrhage, and so on. 2. Methodology. - Cross-sectional description - The patients in the study group were monitored from hospital arrival to discharge. - Self-designed research questionnaire. - Use of the Beck Depression Inventory (BDI) to assess the severity of the patients’ depression. - Use of SPSS 16.0 software and Excel software to process data. RESULTS AND DISCUSSION * The time of onset of lacunar infarction: The most common time of infarction to occur was from 6 am to 12 pm, accounting for 53.33% (48 patients). The second most common time was 12 pm - < 6 pm, accounting for 26.67% (24 patients). 12 am - < 6 am accounted for 12.22% (11 patients). 6 pm - < 12 am occupied the least percentage (7 patients = 7.78%). According to Nguyen Thi Thu Huyen and Nguyen Van Chuong, stroke onset time in was generally from 6 to 12 hours, followed by 12 - 18 hours (during work hours). * Onset symptoms: Cognitive decline: 16 patients (17.78%); hemiplegia: 77 patients (85.56%); sensory disorder: 19 patients (21.11%); language disorder: 50 patients (55.56%); swallowing disorders: 8 patients (8.89%); epilepsy: 1 patient (1.11%); hemianopia: 0; coordination disorder: 3 patients (3.3%). According to Nguyen Van Oanh, the most common onset symptoms were motor hemiplegia in 92.2%, language disorders in 44%, and cognitive disorders in 16%. According to Phuong Viet Trung, the proportion of hemiplegia in patients with lacunar infarcts accounted for 98.1%. Duong Tuan Bao showed that the rate of 93.7%. Journal of military pharmaco-medicine no5-2018 195 Table 1: Clinical symptoms of lacunar infarction. Symptoms n = 90 Rate % Pure motor hemiplegia Face - Hand - Foot 33 61.11 60.0 Dominant hand paralysis 14 25.93 Dominant foot paralysis 7 12.96 Communication disorder and hand clumsiness 2 2.22 Sensory and motor disorder 12 13.33 Hemiparesis and ataxia 11 12.22 Pure sensory disorder 11 12.22 Pure motor hemiplegia accounted for the highest rate at 60%. Some studies in Vietnam showed the similar rate, ranging from 51% to 53%. Study of Gan. R showed the rate of 45% and that of Landi. G was 70%. There was a low percentage of language disorder and hand clumsiness at 2.22%. The study results matched those of Le Van Thu and Nguyen Van Oanh. * Results from the shortened Beck Depression Inventory: In our 90 patients, the prevalence of mild depression was 43.33% (39 patients), moderate depression accounted for 35.56% (32 patients), and severe depression accounted for 21.11% (19 patients). According to Dang Hoang Anh, when studying the clinical characteristics of mental disorders in stroke patients with hypertension, the findings showed that mild depression accounted for 23%, moderate depression accounted for 10%, and severe depression was 2%. The rates of depression in our study were higher compared to Dang Hoang Anh's, because patients with depression had been screened for inclusion in the study. Table 2: Relationship between levels of depression and locations of lacuna in internal capsule. Levels of depression Locations of lacuna p OR (95%CI) Internal capsule (n = 51) Other (n = 39) Total (n = 90) n % n % Mild (1) 22 56.41 17 43.59 39 p3.1: 0.914 1,07 (0.31 - 3.78) Moderate (2) 18 56.25 14 43.75 32 p2.1: 0.989 0.99 (0.35 - 2.84) Severe (3) 11 57.89 8 42.11 19 p3.2: 0.909 1.07 (0.29 - 3.97) The prevalence of depression was similar in patients with internal capsule damage. The difference is not statistically significant. Journal of military pharmaco-medicine no5-2018 196 Table 3: Relationship between levels of depression and locations of lacuna in thalamus. Levels of depression Locations of lacuna p OR (95%CI) Thalamus (n = 19) Other (n = 71) Total (n = 90) n % n % Mild (1) 7 17.95 32 82.05 39 p3.1: 0.460 1.63 (0.34 - 7.19) Moderate (2) 7 21.88 25 78.12 32 p2.1: 0.679 1.28 (0.33 - 4.89) Severe (3) 5 26.32 14 73.68 19 p3.2: 0.718 1.28 (0.26 - 5.72) Patients with thalamus lesions had a 1.63-times greater risk of major depression than mild depression. However, this difference was not statistically significant with p > 0.05. Table 4: Relationship between levels of depression and locations of lacuna in frontal lobe. Levels of depression Locations of lacuna p OR (95%CI) Frontal lobe (n = 5) Other (n = 85) Total (n = 90) n % n % Mild (1) 1 2.56 38 97.44 39 p3.1: 0.062 7.13 (0.51 - 383.55) Moderate (2) 1 3.13 31 96.87 32 p2.1: 0.887 1.23 (0.02 - 98.72) Severe (3) 3 15.79 16 84.21 19 p3.2: 0.104 5.81 (0.41 - 314.69) Patients with frontal lobe lesion were more likely to get severe depression 7.14 times than mild depression and 5.81 times than moderate depression. However, the difference was not statistically significant with p > 0.05. Table 5: Relationship between levels of depression and locations of lacuna in left hemisphere. Levels of depression Locations of lacuna p OR (95%CI) Left hemisphere (n = 40) Other (n = 50) Total (n = 90) n % n % Mild (1) 12 30.77 27 69.23 39 p3.1: 0.007 4.88 (1.3 - 19.16) Moderate (2) 15 46.88 17 53.12 32 p2,1: 0.164 1.99 (0.67 - 5.88) Severe (3) 13 68.42 6 31.58 19 p3.2: 0.135 2,46 (0.65 - 9.83) Patients with left hemisphere lesions had a 4.88-times greater risk of major depression than mild depression (95%CI: 1.30 - 19.16). The difference is statistically significant with p < 0.05. Journal of military pharmaco-medicine no5-2018 197 Table 6: Relationship between levels of depression and locations of lacuna in right hemisphere. Levels of depression Locations of lacuna p OR (95%CI) Right hemisphere (n = 36) Other (n = 54) Total (n = 90) n % n % Mild (1) 16 41.03 23 58.97 39 p3.1: 0.487 0.66 (0.17 - 2.39) Moderate (2) 14 43.75 18 56.25 32 p2.1: 0.817 1.12 (0.39 - 3.19) Severe (3) 6 31.58 13 68.42 19 p3.2: 0.389 0.59 (0.15 - 2.24) The prevalence of depression was similar in patients with right hemisphere lesions. The difference is not statistically significant with p > 0.05. According to Duong Minh Tam, patients have infarction in various locations. Temporal lobe infarction is the most common, in which 13.6% of the left temporal lobe, 20.2% of the right temporal lobe. Comparing depression rates between left hemisphere and left hemisphere, the authors found that depression caused by left hemisphere injury was 95%CI, but risk factors was not statistically significant with OR = 1.052 (0.61-1.81). According to Vataja R et al, typical depression was not related to cerebral injury locations while atypical depression was. Bhogal et al argued that the location of post-stroke brain injury only played a role when depression occurred in the early stages of infarction. Clarke and colleagues found that the association between cerebral lesions and post-stroke depression, patients with left hemisphere injury had higher rates of depression than those with right hemisphere one. They also reviewed recent studies and found that in patients with stroke in the early stages after onset or during hospitalization, left hemisphere injury was related to depression after infarction. CONCLUSION According to the study on 90 patients diagnosed with lacunar infarcts suffering from depression, treated in the Department of Neurology of Viet - Czech Friendship Hospital from March 2013 to May 2015, the following conclusions were drawn: - The most frequent onset time of lacunar infarction was from 6 am to 12 am, accounting for 53, 33%. - Onset symptoms of the majority of patients were hemiplegia accounting for 85.56%, and language disorders accounting for 55.56%. - Regarding the symptoms of lacunar infarction, pure motor hemiplegia accounted for the highest rate of 60%. - Mild, moderate, and severe depression accounted for 43.33%, 35.56%, and 21.11%, respectively Journal of military pharmaco-medicine no5-2018 198 - Locations of lacuna in internal capsule, gray matter, and temporal lobe did not affect the levels of depression in lacunar infarction. - Frontal lobe injury was more likely to cause severe depression 7.14 times than mild depression and 5.81 times than moderate depression. - Left hemisphere injury caused a 4.88- times greater risk of major depression than that of mild depression. REFERENCES 1. Duong Minh Tam. Clinical characteristics of depression after cerebral infarction. Journal of Practical Medicine 2011, 9 (783), pp.50-53. 2. Nguyen Thanh Long. Survey of rates and factors related to depression after cerebrovascular accidents. Doctoral thesis. University of Medicine and Pharmacy of Hochiminh City. 2011 3. Nguyen Van Tuan, Nguyen Minh Hien, et al. Characteristics of cerebral infarctions in 103 Military Hospital. Military Medicine. Vietnam Military Medical University, 2016, 11 (41), pp.56-62. 4. Le Van Thinh. Clinical features and risk factors of lacunar infarctions. Scientific workshop on the 47 th anniversary of establishment of Department of Neurology. Bach Mai Hospital. 2003. 5. Nguyen Van Oanh. Study of clinical features, MRI, and causes of lacunar infarction. Dotoral Thesis. Hanoi Medical University. 2006. 6. Caeiro L, Ferro J.M, Santos C.O, Figueira M.L. Depression in acute stroke. Journal of Psychiatry and Neuroscience, 2006, 31 (6), p.377. 7. Carota A, Berney A, Aybek S, Iaria G, Staub F, Ghika-Schmid F, Bogousslavsky J. A prospective study of predictors of poststroke depression. Neurology. 2005, 64 (3), pp.428-433. 8. Hackett M.L, Yapa C, Parag V, Anderson C.S. Frequency of depression after stroke: a systematic review of observational studies. Stroke. 2005, 36 (6), pp.1330-1340. 9. Herrmann M, Bartels C, Schumacher M, Wallesch C.W. Poststroke depression: is there a pathoanatomic correlate for depression in the postacute stage of stroke?. Stroke. 1995, 26 (5), pp.850-856. 10. Hsieh L, Kao H. Depressive symptoms following ischemic stroke: a study of 207 patients. Acta Neurologica Taiwanica. 2005, 14 (4), p.187.