Right hemisphere lesions

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Although the frequency of major depression in the acute poststroke period has been found in several studies to be greater following left frontal cortical or left basal ganglia lesions than for any other lesion location, depressions do occur in many patients with right hemisphere lesions during both the acute and chronic poststroke periods. We, therefore, examined the clinical correlates of depression associated with right hemisphere lesions to compare them with the clinical correlates of left hemisphere lesion location. This work included a consecutive series of 93 patients who had acute stroke lesions of the right hemisphere. Lesion location was based on CT findings and/or clinical diagnosis and patients were included only if there was no previous history or CT scan evidence of prior brain injury.

The 93 acute stroke patients consisted of both males and females in their late 50s and early 60s, primarily from lower socioeconomic classes (i.e., Hollingshead class IV and class V) examined 2 to 3 weeks poststroke (Table 10.5). There were 46 patients with no mood disturbance, 17 patients with major depression, 11 patients with minor depression, and 19 patients with undue cheerfulness. There were no statistically significant differences in age, gender, education, race, or marital status or time since stroke. The classification of "undue cheerfulness" was based on either a self-report of elevated or expansive mood or clinical observation of inappropriately cheerful affect or disinhibited behavior during the mental status interview.

One of the major findings was that patients with major depression had a significantly higher frequency of psychiatric disorder among their first- or second-degree relatives (i.e., 29% with 55% of these being alcoholism and 45% depression)

Table 10.5. Characteristics of right hemisphere lesion patients

Left

Right hemisphere hemisphere

Table 10.5. Characteristics of right hemisphere lesion patients

Left

Right hemisphere hemisphere

No

Undue

Major

Minor

Major

depression

cheerfulness

depression

depression

depression

Characteristic

(n = 46)

(n = 19)

(n = 17)

(n = 11)

(n = 27)

Age, years (mean ± SD)

64 ± 10

60 ± 14

60 ± 11

62 ± 8

56 ± 13

Gender (% females)

35

42

47

36

52

Race (% blacks)

65

74

41

55

59

Socioeconomic status:

Hollingshead class IV or V

87

74

82

82

89

Marital status (% married)

54

37

42

36

44

Handedness (% right-handed)

87

90

100

100

89

Education (mean years ± SD)

6.5 ± 3.7

8.2 ± 4.3

8.4 ± 3.4

8.8 ± 3.5

9.3 ± 2.8

Familial history of psychiatric

6

5

29

9

4

disorders (% positive*)

Personal history of psychiatric

15

5

29

36

6

disorders (% positive)

Time since stroke

13 ± 12

11 ± 6

16 ± 9

20 ± 18

14 ± 11

compared with other diagnostic groups (i.e., 6% for no diagnosis, 5% undue cheerfulness, 9% for minor depression, and 5% for major depression following left hemisphere stroke) (Fig. 10.7).

In addition, among patients with undue cheerfulness, there was a significantly higher frequency of lesions involving the right frontal operculum compared with depressed (major and minor) and non-depressed patients. Of 12 patients with undue cheerfulness, five had right frontal opercular lesions compared with four of 25 non-depressed and one of 17 depressed patients (p < 0.05). On the other hand, patients with depression (both major and minor) showed a significantly higher frequency of lesions involving either the right parietal cortex (i.e., six of nine with major depression and five of eight with minor depression compared to 1 of 12 with undue cheerfulness and 9 of 25 with no depression; p = 0.02) or the right lateral frontal cortex (i.e., two of nine with major depression and four of eight with minor depression compared to none of 12 with undue cheerfulness and one of 25 with no depression;p < 0.01).

Morris et al. (1990) examined family history in a study of 88 Australian patients in a rehabilitation hospital 8.4 weeks poststroke and found a significantly higher frequency of family history of psychiatric disorder among patients with major depression (i.e., 11 of 16 or 73%) compared to patients with minor depression (i.e., 5 of 18 or 28%) or no depression (i.e., 20 of 54 or 37%) (p < 0.03). Patients with major depression following right hemisphere lesions had a positive family

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Right lesion major depression (n = 17)

Right lesion/no depression (n = 46)

Left lesion/major depression (n = 27)

□ Positive family Hx □ Negative family Hx *p < 0.05

Figure 10.7 The percent of patients with and without a family history of psychiatric disorder (defined by having seen a professional for treatment of an emotional disorder) following an acute right hemisphere infarction. Patients with major depression following a right hemisphere lesion were significantly more likely to have a family history of psychiatric disorder than those without major depression or patients with major depression following a left hemisphere lesion. These data suggest that some poststroke depressions may be related to genetic vulnerability and the factors associated with major depression following right or left hemisphere lesions may be different.

history in 71% of the cases (i.e., five of seven) similar to patients with major depression following left hemisphere lesions (i.e., 67% or six of nine patients).

Patients with right hemisphere lesions have also been studied by Finset et al. (1989) who found that among 42 patients with CT-verified single right hemisphere lesions, ischemic damage involving white matter underlying the parietal cortex was associated with a higher frequency of depression (5 of 13 patients) than lesions in any other location in the right hemisphere (7 of 29 patients) (p < 0.02). House et al. (1990) reported on a group of 21 patients with CT-verified right hemisphere lesions examined 1 month following their first stroke. Of the three patients with major depression following a right hemisphere lesion, all of them had a right posterior lesion (i.e., three major depressions of eight patients with right posterior injury) compared with none of the patients with right anterior (n = 7) or right intermediate (n = 6) lesion locations (p < 0.03). Sinyor et al. (1986) examined 16 patients with single CT-verified right hemisphere lesions studied an average of 56 days poststroke. There was a significant quadratic relationship between depression scores and the distance between the anterior border of the lesion and the frontal pole in patients with right hemisphere lesions (i.e., patients with the most anterior and most posterior lesions of the right hemisphere had the highest depression scores, p < 0.05). Another study by Stern and Bachman (1991) examined 19 patients with CT-verified single right hemisphere lesions an average of 16 months poststroke. Lesions were classified as dorsal or ventral, frontal or non-frontal. Dysphoric mood was significantly more severe in patients with right ventral nonfrontal as compared with right ventral frontal lesions. This suggests that right temporal lesions are associated with depressed mood. Finally, Astrom et al. (1993) and Eastwood et al. (1989) found no association between lesion location in the right hemisphere and the existence of poststroke depression.

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