| BackgroundStroke is a serious public health problem and common disease, not only causing a variety of physical, cognitive and language dysfunction, but also leading a series of emotional changes in behavior and other psychological problems. Depression is the most common psychological disorder after stroke which is called post-stroke depression (PSD). At present, there is not a clear definition for PSD. The definition of PSD is generally agreed that there are defferent degrees of post-stroke depressive symptoms and the symptoms persisted for more than2weeks. Folstein first reported that depression is a common comorbidity after stroke, and the incidence rate of acute perior is about33%, while the incidence rate of recovery is slightly higher. A multi-center study showed that about61%of stroke patients suffer depression. The overall incidence rate is40%-50%, indicated by Chinese Depressive Disorder Prevention And Treatment Guidelines. PSD patients have decreasing of inrerest to participate in activities and extend recovery time, resulting in reducing medication compliance, increasing the physical and mental burden, affecting daily life and increasing family and social burden. PSD has the characteristics of high incidence, high recurrence, high disability, high suicide. With the bio-medical model to biological-psychological-social medical model of conversion, PSD and antidepressant drugs are both taken more seriously.Pathogenesis of PSD is not yet explicit. It may be involved the psychosocial stress and biological mechanisms (something about mood regulation-related neurochemistry, neural pathways, genetic predisposition to disease).(1) The correlation of PSD and neurotransmitters:The low activity of5-HT and NE is considered to be the core of physiological mechanism of depression. Starkstein and Robinson regarded that PSD is resulted of the lesions of5-HT neurons,NE neurons and their pathways, which caused the reducing of these two neurotransmitter. In addition, dopamine and homocysteine are also correlated with the PSD. Cerebral vascular disease make the neurotransmitter system dysfunction, and lead to a series of complications, such as depression and dementia.(2) PSD and neuroanatomy related research:Some studies show that the stroke lesion is PSD determinants. Nobuhara found that the patients are more vulnerable to depressive symptoms with the destruction of neural micro-structure on the frontal and temporal lobes. Vataja regarded that the patients are more susceptible to PSD with the infarction on prefrontal pathway. However, some studies suggest that the stroke site is not relevant to PSD.(3) The correlation of PSD and genetic susceptibility: Some valuable researches have obtained a certain consensus, several genes such as5-HT, COMT,5-HTT and Apo Es, are considered to be the hot candidate genes for depression.(4) PSD and psychosocial factors related research:Most studies suggest that poor physical function, lack of social support and resorting to negative coping style may be the reasons for PSDtI4-161.But there are srill some contrary conclusions.At present, it is generally believed that there are some organic changes in brain tissue in depression patients. And it mainly located in the limbic-cortical-striatal-pallidal-thalamic (LCSPT) loop。Therefore, the basal ganglia is an important part of the loop, earlier studies also comfimed that the basal ganglia infarction would lead to the symptoms of depression. Hama have found that the apathetic scale is correlated with the bilateral basal ganglia damage in depression patients with apathy. A MRI study has showed, The brain infarcts that affected structures of the pallidum and caudate (especially on the left side) predisposes stroke patients to depression. The size of the infarcts at these sites in the depressed patients is larger. Using a Logistic regression analysis, a brain infarct that affected pallidum was a strong independent MRI correlate for poststroke depression. A study conducted on a depression patient with thalamus infarct has found that the DTI (diffusion tensor imaging) reveals markedly reduced limbic projections from the thalamus and subgenual anterior cingulate cortex to the amygdala in the stroke-affected hemisphere. A highly selective right mediothalamic lesion is associated with the onset of refractory depression. Consequently, there is an important theoretical value and clinical significance to explore the correlation of the nerve fiber damage in basal ganglia and PSD.So, is there any way to predict such patients will occur PSD and the depression level? Currently, DTI is the only technology which could display the traveling, direction, rank and myelin of nerve fiber bundle. Researches have shown that compared to the anatomical description, the structure of the white matter displayed by DTI has no obvious difference. Focal basal ganglia infarction causes the damage of nerve fiber, DTI not only can show this phenomenon with visible image, but also can quantitative analysis the water diffusion characteristics within the lesion organization in the three-dimensional space, measure the extent of the damage accurately in the form of data. In this study, we analysis the anatomical abnormalities of nervenucleus (including the caudate nucleus, globus pallidus, putamen, and dorsal thalamus) in basal ganglia with DTI, in order to understand what happens in these depression patients following basal ganglia infarction. Furthermore, psychological and social factors are always important risk factors in different stages after stroke. Chau regarded that the presence of PSD symptom is associated with low levels of state self-esteem, social support satisfaction and functional ability. Logistic regression analysis revealed that these variables were statistically significant in predicting the probability of having depression,Teoh has showed, compared to nondepressed participants, depressed participants had significantly poor social support, optimism, self-esteem and physical function. Domestic Literaturesreported that compared with non-depression post stroke group, the scores of socia support, subjective support and the accessibility of support were significantly lower,the score of confrontation of MCMQ is lower, the resignation is higher in PSD groups. But there are some studies came to the opposite conclusion. This article also describes the relationship between some psychosocial factors and the occurrence of PSD, in order to understand the mechanism of the PSD in the general.Objective1.To study the effect of some psychosocial factors on the status of depression after basal ganglia infarction;2.To study the anatomical abnormalities of basal ganglia and research their influence in depression level in PSD patients with basal ganglia infarction by magnetic resonance diffusion tensor imaging.MethodsPatients with basal ganglia infarction were recruited from the neurology Department of Zhu Jiang Hospital, diagnosed by the diagnostic criteria formulated in the Fourth National Cerebrovascular Conference and the Hamilton Depression Rating Scale (HAMD). Experimental subjects were divided into two groups:7 cases of PSD patients (4cases of male and3cases of female) and19cases of non-depression patients (14cases of male and5cases of female).1. Clinical data of subjects was collected, including age, gender, educational level and the comorbidity of hypertension, diabetes, hyperlipidemia, coronary heart desease and the history of TIA. All the patients were evaluated with National Institute Of Health Stroke Scale (NIHSS), Social Sustain Rating Scale (SSRS) and Medical Coping Modes Questionnaire (MCMQ).2. All the patients were checked by conventional MRI and DTI sequence. Fractional anisotropy (FA), average diffusion coefficient (ADC) values and neural fiber lines were measured in the regions of interest (ROI), including bilateral caudatum, pallidum, putamen and thalamus.3. StatisticsSPSS13.0medical statistical software was applied in the study. The measurement data was analyzed by t-test, and the count data by chi-square test. The FA value, ADC value and the number of nerve fibers in each ROI between the two groups was compared by the t-test. The correlation of the body social factors, DTI data and HAMD score was analyzed by univariate Spearman correlation analysis. a=0.05(two tails)Results1. There is no significant defference of the age, gender, educational level, vascular risk factors (the comorbidity of hypertension, diabetes, hyperlipidemia, coronary heart desease and the history of TIA), the scores of the SSRS and that of confrontation,evasion in MCMQ between the two groups (all P>0.05). The score of NIHSS (t=2.219,P=0.036) and that of resignation in MCMQ (t=2.491,P=0.020) was significantly higher in PSD group than in non-depression group. In Spearman correlations analysis, the HAMD score was positively correlated to the NIHSS score (r=0.464, P=0.017) and the score of resignation in MCMQ (r=0.812, P<0.001).2. No significant difference was found between the2groups for DTI data of ROIs (t=0.056-1.618,all P>0.05). Compared with contralateral construction, the FA value was decreased on the left putamen inside the PSD group (t=2.243,P=0.045). There was no significant defference of the DTI data between the bilateral caudatum, pallidum and dorsal thalamus (t=0.482-1.846,all P>0.05). In Spearman correlations analysis, the FA values of left pallidum (r=-0.563,P=0.005), right pallidum (r=-0.416,P=0.035) and left putamen (r=-0.428,P=0.029) were negative correlation with HAMD score.Conclusions1. The neurological deficit was more serious in PSD group than non-depression group. And the level of PSD was positively relevant to NIHSS score. The resignation was more likely applied by PSD patients, and the depression level was positively correlated to the score of resignation in MCMQ. Therefore, the rebabilitation and psychological intervention is necessary to conduct after cerebral infarction.2. The depressive level was correlated with the reductions of bilateral pallidum and left putamen FA values. It has confirmed the important role of basal ganglia (especially the bilateral pallidum and left putamen) which as the significant part of the LCSPT loop on the PSD. These information contributes to our evaluation on the PSD degree. |
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