11/26/2019 The Neuropsychology of Objectives 1. Identify various cognitive sequelae that may result from stroke Stroke: Cognitive & 2. Explain how stroke may impact emotional functioning, both acutely and long-term Emotional Sequelae COX HEALTH STROKE CONFERENCE BRITTANY ALLEN, PHD, ABPP, MBA 12/13/2019 Epidemiology of Stroke Stroke Statistics • > 795,000 people in the United States have a stroke • 5th leading cause of death for Americans • ~610,000 are first or new strokes • Risk of having a first stroke is nearly twice as high for blacks as whites • ~1/4 occur in people with a history of prior stroke • Blacks have the highest rate of death due to stroke • ~140,000 Americans die every year due to stroke • Death rates have declined for all races/ethnicities for decades except that Hispanics have seen • Approximately 87% of all strokes are ischemic an increase in death rates since 2013 • Costs the United States an estimated $34 billion annually • Risk for stroke increases with age, but 34% of people hospitalized for stroke were < 65 years of • Health care services age • Medicines to treat stroke • Women have a lower stroke risk until late in life when the association reverses • Missed days of work • Approximately 15% of strokes are heralded by a TIA • Leading cause of long-term disability • Reduces mobility in > 50% of stroke survivors > 65 years of age Source: Centers for Disease Control Stroke Death Rates Neuropsychological Assessment • Task Engagement • Memory • Language • Visuospatial Functioning • Attention/Concentration • Executive Functioning • Sensorimotor Abilities • Emotion & Personality 1 11/26/2019 A Quick Note Regarding TIA & Cognitive Impairment • Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia; no evidence of acute infarction on imaging • Duration of symptoms: • 60% resolve within 1 hour • 70% in < 2 hours • Only 14% last > 6 hours • Classic neuroanatomical effects can be seen with TIAs Cognitive Impairment • Relatively little is known about cognitive changes in the first few days following TIA • Relatively little is known about whether or not such symptoms have prognostic value • Nearly 40% of patients showed “transient cognitive impairment” (i.e., MMSE score > 2 points lower than at follow-up) 1-7 days following TIA or minor stroke • These patients showed higher 5-year risk of subsequent cognitive impairment • Between 10 and 50% of patients have a stroke within 3 months of TIA with ½ of those happening within 48 hours Stroke and Cognitive Impairment Ischemic Stroke • Cognitive impairment is present in up to 64% of individuals with a history of stroke • Reduction or loss of blood flow • Nearly 1/3 develop frank dementia • Can be focal or global (e.g., cardiac arrest) • Core and penumbra • Degree of tissue damage depends on: • Location of ischemia • Duration of ischemia • Individual variations in vascular structure and collateral blood supply • Surrounding tissue edema • Type and timing of therapeutic intervention • Secondary insults (e.g., hypotension, hypoxia) • Deficits typically follow cerebral vascular neuroanatomic territory MCA Distribution Stroke ACA Distribution Stroke • Contralateral motor weakness, especially for dexterity • Contralateral weakness of feet/legs with falls • Emotional and behavioral changes • Contralateral sensory deficits • Urinary incontinence • Executive dysfunction • Hemi-Inattention (more common with right hemisphere strokes) LEFT ACA RIGHT ACA BILATERAL ACA • LEFT MCA RIGHT MCA • Executive dysfunction • Executive dysfunction Learning and memory impairment (e.g., • May be more pronounced with dominant • Poor social insight and judgment retrieval deficits, inefficient consolidation, • Aphasia hemisphere lesions • Impersistence problematic recognition and prospective • Constructional apraxia • Ideomotor apraxia • Poor verbal reasoning • Abulia memory) • Aprosodia • Short delay recall may be worse than long • Language deficits (e.g., poor verbal fluency, • Motor impersistence • Apathy • Dressing apraxia • Abulia delay recall confrontation naming, repetition, comprehension, • Difficulty with complex and divided • Executive dysfunction • Behavioral apathy reading, and/or writing) attention • Memory impairment, typically disproportionately • Expressive language deficits (e.g., • Memory impairment, typically disproportionately • Expressive language deficits (most affecting visual memory transcortical motor aphasia) affecting verbal recall severely: mutism) • • Visuoconstructional deficits (e.g., maintain the Behavioral apathy • Lack of initiation Gestalt, but missing details) • • Mood changes Gerstmann’s syndrome • Bilateral weakness (legs greater than • Executive dysfunction arms) 2 11/26/2019 PCA Distribution Stroke Hemorrhagic Stroke • Contralateral homonymous hemianopia (or • Constructional apraxia quadrantanopsia) • Memory loss (short and long delay) • Can result in more diffuse dysfunction • Contralateral hemi-sensory loss • Can involve areas of several different vascular territories RIGHT PCA LEFT PCA • Memory loss (nonverbal/visual worse than verbal) • Memory loss (verbal worse than nonverbal/visual) • Agnosias (e.g., prosopagnosia) • Receptive language deficits • Color anomia • Ideomotor apraxia • Hemi-neglect/inattention • Gerstmann’s syndrome • Visuconstructional and visuospatial deficits (e.g., details • Transcortical sensory aphasia symptoms preserved, but Gestalt lost) • Alexia with or without agraphia • Irritability, distractibility, agitation, frank psychosis • Visuconstructional deficits (Gestalt maintained, but • Possibility for visual hallucinations, cortical blindness loss of details) Treatment for Post-Stroke Cognitive Emotional/Personality Changes Impairment Associated With Stroke • Neurorehabilitation services RIGHT HEMISPHERE LEFT HEMISPHERE • Neuropsychological evaluation (as appropriate) to clarify strengths and weaknesses, and help inform planning for the future • Emotional/affective “flatness” • Depression (especially with damage to the caudate and frontal lobe) • Psychoeducation (e.g., setting expectations, appreciating importance of staying engaged) • Indifference • May present acutely with depression with • • Difficulty perceiving emotional cues, facial symptoms that resolve over time Compensatory strategies expression, body language, speech prosody • • Tearfulness and anxiety Psychological intervention • Speech may be monotone, appear dysphoric • • May be disconnect between speech “Catastrophic reaction” characteristics and emotional state • Possibility for pseudobulbar affect • Possibility for paranoia and perseveration • Reduction in social activities years after stroke • Increasing incidence of depression and anxiety months and years after stroke Emotional/Personality Changes with Treatment for Post-Stroke Psychological Frontal and Subcortical Strokes Disturbances • Frontal lobe damage • Psychopharmacological intervention • Behavioral flattening • Neuropsychological evaluation to clarify premorbid emotional and personality issues, current • Apathy emotional functioning, and treatment needs • Abulia • Psychoeducation • Orbitofrontal damage: disinhibition, irritability, diminished concern for others, reduced personal hygiene • Cognitive behavioral therapy • Disruption to cortico-striato-thalamic-cortico circuitry: perseveration, compulsiveness • Alternative treatments (e.g., acupuncture) • Limited research support • Damage to corticobulbar pathways: pseudobulbar affective expression 3.