1
ABSTRACT
Cerebral stroke is always a hot issue for the health care sector in all nations
in the world because cerebral strokes have very high rates of acquisition,
mortality and disability which badly impacts the economy, family psychology
and society [1]. Of all the types of cerebral strokes, cerebral infarcts account for
80- 85%, and cerebral hemorrhage 15- 20%. According to Nguyen Van Chuong,
lacunar infarcts account for 16.67% of all stroke patients and 21.93% of patients
with cerebral infarcts [2]. Boiten, lacunar infarcts account for 25% of patients
with cerebral stroke [3]. Psychologists recognised post-stroke depression more
than 100 years ago; however, systematic research was not conducted until 1970.
Depression occurs in a big proportion of patients and is a significant complication
of stroke, leading to major impairment and increased mortality rates [4]. According
to Egeto et al, lacunar infarcts account for 20% of stroke patients. One third of
stroke patients have depression symptoms. The relation between depression and
lacunar infarcts is not obvious [5]. According to Ramasubbu, depression is the
most common post-stroke psychotic disorder, badly affecting the recovery of
stroke [6]. Ayerbe et al observe that the rate of post-stroke depression is 29% and
extends up to 10 years following the stroke. The occurence rate is 39- 52% within
the first five years after strokes. The recovery rate of depression one month post
stroke is between 15- 57% [7].
We conduct the research “Study the clinical and subclinical
characteristics, risk factors, depression in patients with lacunar infarcts in
supratentorial region” with the following objectives:
1- Describe the clinical and subclinical characteristics, and risk factors in
patients with lacunar infarcts in supratentorial region.
2- Review the characteristics of depression and its relation to imaging and
clinical diagnosis of lacunar infarcts in supratentorial region.
Structure of the dissertation
The dissertation consists of 124 pages, including Abstract 2 pages, Overview of
the dissertation 36 pages, Research subject and method 13 pages, Research
outcomes 30, Discussion 36, Conclusion 2 pages, Recommendations 1 page.
The dissertation have 39 tables, 5 charts with clear and sufficient notes and
explanations. Reference materials 142 (92 materials in Vietnamese language, 92
2
materials in English language), of which more than 50 % of the reference
materials are of the last 5 years.
NEW CONTRIBUTION OF THE DISSERTATION
Risk factors: hypertension 95.56%. Blood lipid disorder 46.67%. Diabetes
mellitus 33.33%. TIA 22.22%. Tobacco addict 18.89%. Cardiovascular diseases
8.89%. Obesity 7.78%. hyperlipidemia, increased cholesterol and increased
LDL accounting for 40%. Increased triglyceride 24.44%. reduced HDL 15.56%.
Patients with 2 combined risk factors: hyperlipidemia and hypertension 45.56%.
3 combined risk factors of hyperlipidemia, hypertension and diabetes mellitus
16.67%.
About depression in relation to imaging and clinical diagnosis in patients with
lacunar infracts in the supratentorial region. Typical symptoms of depression:
low mood 92.22%; loss of interest 62.22%; loss of energy, fatigue and less
active 54.44%.
- Common symptoms of insomnia, difficult to fall asleep 97.78%. Wake early
and unable to sleep again 90%; trouble focusing 68.89%. Bleach outlook &
pessimistic 62.22%. Loss of appetite 60%. Loss of self esteem and confidence
53.33%. Feeling of guilt, and worthlessness 25.56%. Thinking of suicide 2.22%.
Mild depression 43.33%. Moderate depression 35.56%. Severe depression
21.11%. No relation to depression has been observed between cerebral infarcts
in the internal capsule, lentiform nucleus, temporal lobes, thalamus, caudate
nucleus and that of the occipital lobes.
- Patients with injuries of both hemispheres mainly have mild depression p <
0.05. Injuries of the frontal lobes are of high risks of 7.31 times of severe
depression than mild depression and 5.81 times than moderate depression.
Patients with injuries in the left hemisphere have 4.88 times of severe depression
than mild depression.
- Patients with mild hemiparesis, ataxic hemiparesis and pure sensory
impairement have a high rate of depression than those with movement and
somatosensory disorders with p< 0.05.
3
CHAPTER 1
OVERVIEW OF THE DOCUMENT
1.1. The neurological anatomy, physiology and biochemistry basis
1.2. The functional anatomy of the brain related to psychotic.
1.2.1. Injury of the frontal lobe.
1.2.2. Injury of the parietal lobe.
1.2.3. Injury of the temporal lobe.
1.2.4. Injury of the occipital lobe.
1.2.5 Some neurological – psychotic symptoms and syndromes
1.3. Lacunar infarcts
1.3.1. Definition:
Lacunae which are small infarcts of < 1.5 cm in diameter are situated in the
territory of deep penetrating arteries due to primary vascular pathologies in
branches of big arteries.
1.3.2 Causes
Occlusion of tiny penetrating arteries develops tiny and specific lacunae
and brain tissue necrosis then leave a tiny sinus.
1.3.3. Pathophysiology
1.3.4. Pathogenesis
1.3.5. Pathological anatomy
1.3.6. Clinical presentation of lacunar stroke
1.3.7. Radiographic features of lacunar infarcts
1.3.8 Hematology and biochemistry tests
1.4. Risk factors in stroke patients
1.4.1. Irreversible group
1.4.2. Reversible group
1.5. Depression
1.5.1 Definition of depression and endogenous depression
1.5.2 Epidemiology of depression
4
1.5.3. Clinical presentation of depression
1.6. Study of post-stroke depression
1.6.1 Symptoms of post-stroke depression
1.6.2 Distinctive fetures of post-stroke depression
1.6.3 Main causes of post-stroke depression
1.6.4 Consequences of post-cerebral-stroke depression
1.6.5 Some reseach on local and international cerebral infarctions
CHAPTER 2
RESEARCH SUBJECTS AND METHOD
2.1 Research subjects
2.1.1. Number of patients under study.
- Calculation of sample size: Counting sample size “estimate the rate within
a population” used the following equation:
n=Z 21−α /2
p( 1− p )
d2
According to the equation, n = 79.1 patients. The sample size must
therefore be at least 80 patients. A number of 90 patients diagnosed of lacunar
infarct with depression symptoms who are under treatment at the Neurology
Department of Viet Tiep Hospital between March 2013 and November 2015 are
selected for our study.
2.1.2 Selection criteria.
- The studied subjects must meet all criteria of lacunar infarcts and there
are images of lacunar infarcts either on their CT or MRI scans.
- They have depressive disorder.
2.1.2.1. Criteria for lacunar infarct diagnosis.
- Clinical presentation:
Patients having one of the 5 following syndromes:
+ Pure hemiparesis
+ Pure sensory disorder
+ Mild ataxic hemiparesis
+ Language disorder – clumsy
5
+ Movement – sensory disorder syndrome.
- Subclinical:
Brain CT scan: there appear round or oval hypointenses in white matter
and basal ganglia, with < 1, 5 cm in diameter.
2.1.2.2 Diagnosis of depression
- All the pateints are diagnosed of depression according to ICD 10
+ Depressive disorder consists of 3 main symptoms:
+ In addition, there are 7 other common symptoms
For a diagnosis of depression, there must be at least 2 main symptoms plus
3 common symptoms [61].
* Part F06.32 (endogenous depressive disorder).
2.1.3 Exclusion criteria
- Lacunar infarcts inferior of the tentorial cerebellum
- Combined physical illness
- History of depression symptoms prior to admission.
- No cooperation during examination and enquiries.
- There are clinical symptoms but no appearance of lacunar lessions on
radiology imanaging.
- Illiteracy.
- There are cerebral infarct due to brain tumor, trauma, inflammation,
intracerebral or menigeal hamorrhage, etc. There are unclear lacunar infarcts on
CT or MRI scans, which look similar to images of other pathologies such as
hypointensive brain tumor or cerebral inflammation. Allergy to contrast dyes.
Pregnant women.
2.2. Research method
2.2.1 Research Design
- Employ prospective case-control cross-sectional method for clinical
feature survey
2.2.2 Research contents
- Diagnosis of hypertension based on the 2015 Guidelines of the Vietnam
Cardiosvascular Association.
- Diabetes mellitus: in compliant with the 2017 Guidelines for Type II
6
Diabetes mellitus Diagnosis and Treatment by the Ministry of Health [77].
- Body mass in dex (BMI).
- Diagnosis of lipidemia in complaint with the National cholesterol
education program (NCEP) [79].
- Use the Beck Scale for screeing and diagnosing depression.
2.3. Research data analysis
The research data are analysed by SPSS 16.0 software (Statistical Package
For Social Science) and Excel.
RESEARCH AGORITHM
Cerebral stroke patients admitted
Cranial CT or MRI scan,
Blood tests
Lacunar infarcts in
supratentorial region
With depression symptoms
(according to ICD.10)
(Test Beck)
W
Lacunar infarct in supratentorial region with depression
Risk factors
Clinical
symptoms of
lacunar infarct
Relation between clinical
presentation, subclinical
investigations, and imaging
7
CHAPTER 3
RESEARCH RESULTS
3.1. Common features of the research subjects
The male-female ratio is 67. 78% and 32. 22 % (2.1 male per 1 female).
The most common age group of lacunar infarcts is 60- 69 years old, accounting
for 34.45%. Mean age is 69.31 ± 10,13.
Table 3.1 Duration from stroke onset till coming to hospital
Time duration
Rate %
Patients number n=90
<4,5h
20
22,22
4,5 – 24h
35
38,89
24 - <48h
17
18,89
≥ 48h
18
20,00
Patients coming to hospital between 4.5 – 24 h are 38.89%; <4.5 h are
22.22%; ≥ 48 h are 20.00%. Patients coming to hospital between 24 to <48 h are
18.89%.
3.2 Clinical presentation of research subjects.
Table 3.2 Onset symptoms of research subjects
Symptoms
n=90
Rate %
Declined cognitive function
16
17,78
Hemiplegia
77
85,56
Sensory disorder
19
21,11
Language disorder
50
55,56
Dysphagia
8
8,89
Convulsion
1
1,11
Hemianopia
0
0
Combined movement disorder
3
3,3
Hemiplegia are of 85,56%. Language disorder are of 55.56%. Sensory
disorder are of 21.11%. Declined cognitive function are of 17.78%. Dysphagia
are of 8.89%. Combined movement disorder are of 3.30%. Convulsion 1.11%.
8
Table 3.3 Clinical syndromes of lacunar infarcts
Symptoms
n=90
33
Face – arm – leg
Rate %
61.11
Dominant arm
25.93
14
Pure hemiplegia
paralysis
60.0
Dominant leg
12.96
7
paralysis
2.22
Language disorder and clumsy hand
2
13.33
Sensorimotor disorder
12
12.22
Mild hemiparesis, ataxia
11
12.22
Pure sensory disorder
11
Pure hemiplegia are of 60%. Sensorimotor disorder are of 13.33%. Mild
ataxic hemiparesis, pure sensory disorder are of 12.22%. Language disorder and
clumsy hand 2.22%.
3.3
Observation
of
lesions
on
the
imaging
scans
2.22
30
52.22
1 lacune
2 lacunes
3 lacunes
>3 lacunes
15.56
Chart 3.1 Number of lacunar infarcts on imaging scans
9
Number of patients with one lacune are highest 52.22%. Patients with 3
lacunes on imaging scans account for 30.0%. Patients with 2 lacunes accounts
for 15.56%. And patients with more than 3 lacunes account for 2.22%.
10
Table 3.4 Diameter of lacunes
Diameter
n=164
Rate %
5 mm - <10 mm
101
61.59
38.41
≥ 10 mm -15 mm
63
There are 164 lacunes in 90 patients, of which there are 101 lacunes of 5
mm - <10 mm in diameter, 61.59%; 63 of ≥ 10 mm -15 mm in diameter,
38.41%.
3.4 Risk factors of the research subjects
Table 3.5 Frequency of risk factors
Risk factors
n=90
Rate %
Hypertension
86
95.56
Diabetes mellitus
30
33.33
Lipidemia
42
46.67
Obesity
7
7.78
Tobacco addict
17
18.89
Cardiovascular pathologies
8
8.89
TIA (transient ischemic attack)
20
22.22
≥ 2 risk factors
Hyperlipidemia and hypertension
74
41
82.20
45.56
16.67
15
Hypertension patients 95.56%. Lipidemia 46.67%. Diabetes mellitus
33.33%. TIA patients TIA 22.22%. Tobacco addict patients 18.89%. Patients with
≥ 2 risk factors account for 82.2 %. Patients with combined 2 risk factors of
hyperlipidemia and hypertension account for 45.56%.
3.5 Depression symptoms according to ICD 10.
Hyperlipidemia, hypertension & diabetes
Table 3.6 Main depression symptoms
Symptoms
n= 90
%
Low mood
83
92.22
Loss of all interests
56
62.22
Reduced energy, fatigue and less active
49
54.44
11
Patients with low mood account for 92.22%. Patients losing all interests
account for 62.22%. Patient with reduced energy, faigue and less active account
for 54.44%.
Table 3.7 Common symptoms of depression
Symptom
n= 90
%
Difficult to focus
62
68.89
Loss of self-esteem and confidence
48
53.33
Thinking of guilt and worthlessness
23
25.56
Bleach outlook and pessimistic
56
62.22
Suicidal thought
2
2.22
88
97.78
Insomnia, difficult to fall asleep, wake up early
60.0
Loss of appetite
54
Common symptoms of depression: insomnia, difficult to fall asleep
account for 97.78%. Difficult to focus account for 68.89%. Bleach outlook &
pessimistic account for 62.22%. Loss of appetite account for 60%. Loss of selfesteem and confidence account for 53.33%. Thinking of guilt and worthlessness
account for 25.56%. Suicidal thought account for 2.22%.
Table 3.8 Severity level of depression
n= 90
%
Mild depression
39
43.33
Moderate depression
32
35.56
Severe depression
19
21.11
Beck depression inventory II
Mild depression account for 43.33%. Moderate depression account for
35.56%. Severe depression account for 21.11%.
3.6 The relation between the severity level of depression and location of
lesions.
12
Table 3.9 The relation between the severity level of depression and the
location of lacunes in the internal capsule
Location of lacunes
Severity
level of
depressio
n
Internal
capsule
n= 51
Qnt
%
y
Others
n=39
Qnt
y
%
Total
n=90
P
OR
(95%CI)
Mild (1)
22
43.14
17
43.59
39
p3.1: 0.914
1.07
(0.31-3.78)
Moderate
(2)
18
35.29
14
35.90
32
p2.1: 0.989
0.99
(0.35-2.84)
Severe (3)
11
21.57
8
20.51
19
p3.2: 0.909
1.07
(0.29-3.97)
The differences are not statistically significant with p > 0.05.
Table 3.10: The relation between the severity level of depression and the
lacune location in the lentiform nucleus
Location of lesion
Severity
level of
depressio
n
Mild (1)
Moderate
(2)
Severe (3)
Lentiform
nucleus
Others
Total
n=58
n=90
P
39
p3,1: 0.944
32
p2,1: 0.894
19
p3,2: 0.859
n= 32
Qnt
y
%
Qnt
y
%
14
43.75
25
43.10
11
34.38
21
36.21
7
21.87
12
20.69
OR
(95%CI)
1.04
(0.28-3.71)
0.94
(0.31-2.78)
1.11
(0.28-4.21)
13
This difference is not statistically significant with p > 0,05.
Table 3.11 The relation between the severity level of depression and the
lacunes in the thalamus
Location of lesion
Severity level
of depression
Thalamus
n= 19
Qnt
%
y
Others
n=71
Qnt
%
y
Total
n=90
P
OR
(95%CI)
Mild (1)
7
36.84
32
45.07
39
p3,1: 0.460
1.63
(0.34-7.19)
Moderate
(2)
7
36.84
25
35.21
32
p2,1: 0.679
1.28
(0.33-4.89)
Severe (3)
5
26.32
14
19.72
19
p3,2: 0.718
1.28
(0.26-5.72)
Patients with lesion at the thalamus are at risk of 1.63 times of severe
depression than mild depression. It is not statistically significant as p> 0.05.
Table 3.12 The relation between the severity level of depression and the
lacunes in the frontal lobe
Location of lesion
Severity
level of
depressio
n
Frontal
lobe
n= 5
Qnt
%
y
Others
n=85
Qnt
y
%
Total
n=90
P
OR
(95%CI)
Mild (1)
1
20.00
38
44.71
39
p3,1: 0.062
7.13
(0.51-383,55)
Moderate
(2)
1
20.00
31
36.47
32
p2,1: 0.887
1.23
(0.02-98.72)
14
Severe (3)
3
60.00
16
18.82
19
p3,2: 0.104
5.81
(0.41-314.69)
Patients with lesions in the frontal lobe have 7.13 and 5.81 times of severe
depression than mild depression and moderate depression respectively. The
difference is not statistically significant as p > 0.05.
Table 3.13 The relation between the severity level of depression and the
lacunes in the left hemisphere
Location of lesion
Left
Severity level
hemisphere
of depression
y
Moderate
(2)
Severe (3)
Total
n=50
n=90
n= 40
Qnt
Mild (1)
Others
%
12
30.00
15
37.50
13
32.50
Qnt
y
P
OR
(95%CI)
%
27
54.00
17
34.00
6
12.00
4.88
39
p3,1: 0.007
32
p2,1: 0.164
19
p3,2: 0.135
(1.3-19.16)
1.99
(0.67-5.88)
2.46
(0.65-9.83)
Patients with lesion in the left hemisphere have 4.88 times of severe
depression than mild depression (95%CI: 1.30-19.16). This difference is
statistically significatn as p < 0.05.
15
Table 3.14 The relation between the severity level of depression and
number of lacunes
Number of lacunes
Severity
level of
depressio
n
≥ 2 lacunes
1 lacune
Total
n= 43
n=47
n=90
Qnty
%
Qnt
P
OR
(95%CI)
%
y
Mild (1)
Moderate
(2)
Severe (3)
19
44.19
14
32.56
10
23.25
20
41.55
18
38.30
9
19.15
1.17
39
p3,1: 0.780
32
p2,1: 0.676
19
p3,2: 0.539
(0.34-4.05)
8.82
(0.29-2.32)
1.43
(0.39-5.20)
Patients with lacune number ≥ 2 are of 23.25% severe depression, which
is lower than moderate and mild depression of 32.56% and 44.19% respectively.
This difference is not statistically significant as p> 0.05.
CHAPTER 4
DISCUSSION
With the study of clinical and subclinical features, risk factors and
depressive disorder in 90 patients with lacunar infarcts, we would like to
propose the following discussions:
4.1. About the common characteristics of the research subjects.
4.1.1. Sex
Benavente O. R. et al’s research of post-lacunar-infarct strokes showed that
of 3005 patients, the average age is 63 years old, with 62% male. The author
found that female patients have more lacunar stroke in the thalamus than male
patients (p<0.001) [30]. Poynter B. et al’s research of the sex difference in poststroke patients found that depression are common in both genders, but seem
more common in female than male [82].
16
In Sifap 1 research, the research of depression in young stroke patients
betwen 18 and 55, Tanislava C. et al: depression appears in 10.1% of the
patients. Depression associated with risk factors of cerebral infarct but not
related to any brain lesion in imaging scans [85].
Alajbegovic A. et al, post-stroke depression is more common in younger
patient (52- 60 years old) 39.2%; age group of 61-70 are 32%. Female are of
higher depression rate than male with p= 0.019. Depression more commonly
occurs in the group with stroke in the left hemisphere (63%), the mean NIHSS
score is 16.07 (11- 22 score) [86].
4.1.2. Time of lacunar stroke onset
Serena J. et al studied 1248 patients with acute stroke: 24.1% occur while
sleeping, 75.9% while awake. Time frame of peak stroke onset is from 6-12
hundred hours [95]. Elliott W.J thinks cerebral strokes between 6-12 a.m are
49% higher than other time of the day [96].
Many studies have shown that cerebral strokes often occur right after
getting up early in the morning, more common during day time than night time.
Our results fit well with many other local and foreign authors.
4.1.3. Time duration from stroke onset till reaching hospital
According to Phung Duc Lam, the duration till reaching hospital of < 4,5
hours account for 22%. Between 4.5 and < 24 hours account for 42%. Between
24 and 48 hours account for 17.5%. More than 48 hours account for 18.5% [51].
Nguyen Minh Hien et al: the time till reaching hospital before 3 hours is 2.3%,
before 6 hours is 15.5%. This is the golden hour for decomposing the fibrins by
rTPA via venous or arterial tracts [93]. Nguyen Van Tuan et al: reaching
hospital before 4.5 hours is 7.78%, before 8 hours is 13.10% [23]. Hence, the
sooner (before 4.5 hours) patients reach hospital after stroke onset the better.
That is the golden hour for patients to be injected with fibrin degradation
products, reduce disability risks or consequences.
4.2. Clinical features of the research subjects.
4.2.1 Onset symptoms of the research subjects
According to Duong Minh Tam, at the stroke onset there are 77 (97.47%)
patients who are consiuos (97,47%), 2 (2.53%) patients who are confused. No
patients of precoma and coma at the stroke onset [87].
17
4.2.2 Clinical syndromes of lacunar infarcts
According to Nghiem Thi Thuy Giang, one of the five lacunar stroke
syndromes not seen in this research is the language disorder-clumsy hand
syndrome. Of the other four, pure motor hemiplegia is most common (62.03),
pure sensory disorder is seen with the frequency of 13.92%, mild, ataxic
hemiparesis is seen in 10 patients (12.66%) and sensorimotor disorder accounts
for 11.39% [80]. Nguyen Van Thinh studied the clinical characteristics and risk
factors of lacunar infarcts: there are 32 patients (53%) with pure motor
hemiplegia; 7 patients (11%) with language disorder & clumsy hand; 6 (10%)
patients with mild ataxic hemiparesis; 11 patients (19%) with hemiplegia
combined with sensorimotor disorder; 3 patients (4%) with pure sensory
disorder; and one patient (2%) with other lacunes [36].
4.3 About lesions on radiography scans
4.3.1 Number of lacunes on radiography scans
Jiang, Lin studied the relative risks in cerebral stroke patients with
depression: there is a higher rate of stroke lesions in the left hemisphere than the
right or both hemispheres. There is significant difference in depression rates
between multiple lacunar lesions and single lacunar lesion (p< 0.005) [88]. Egeto
P. et al thinks that not only in the thalamus, white matter and number of lacunes
but the size of lacunes also affect the rates of depression [5].
4.3.2 Distribution of lesions in the cerebral spheres
Le Van Tuan et al assessed the similarity between neurological anatomy
and acute-post-stroke depression of 34 depression patients out of 92 stroke
patients: the results of neurological radiography imaging of depression patients
show 16 cases (47%) with lesions in the left cerebral hemisphere, 11 cases
(32.3%) with lesions in the right hemisphere, 5 cases (14.7%) with lesions in the
basal ganglia & internal capsule, 3 cases (8.8%) with lesion in the thalamus, 4
cases (11.8%) with lesion in cortex region and most posterior fossa suffering
from depression [70]. Sun N. et al studied more than 465 post-stroke patients
with depression in China, showing very high rate of post-stroke depression.
Depression patients were assessed by a scale developed by him, SDS scale &
Hamilton scale and there were 146 cases (31.4%) identified as depression. In
addition, linear regression analysis showed that stroke risk factors include
18
gender, location of lesion, post-stroke process and the severity of paralysis (p<
0.05). The risk factors of depression patients are significant and can be useful
references for treatment [100].
4.3.3 Cerebral lacunar diameters on radiography scans
Feng C. et al found blood pressure change is the indepedent risk factor of
uneven lacunar infarcts. The size and number of lacunes, and the progression of
uneven lacunes make point mRS higher [101].
Asdaghi N. et al’s study of 1679 patients with lacunar infarct provided the
following results: oval-shape lacunar infarcts are of 63%, leaf shape are of 12%,
coma shape are of 7%, multiple shapes are of 17%. The mean infarct volume of
oval infarct compared to other shapes are 0.46; 0.65; 0.54; 0.9 ml respectively, p
< 0.001. The distribution of vascular risks is similar. However, patient groups of
oval, spherical and coma shapes are more significantly associated with diabetes
mellitus and hypertension on their admission. The volume of lacunes are not
related to vascular risk factor. The authors concluded that in patients with
lacunar infarcts, the vascular risk factors are similar between shapes of sizes of
different lacunes. The size of lacunes is associated with the motor function. The
shapes and sizes of lacunes are not related to recurrence of stroke [34]. Gold G.
et al, the size of lacunes in the thalamus, basal ganglia, lentifrom nucleus and
white matter is associated with progressive depression [102].
4.4 Risk factors of research subjects
4.4.1 Frequency of risk factors
Raoul P. et al: age, previous stroke and weight gain are related to lacunar
infarct in the basal ganglia and deep white matter regions. Less than 70% artery
stenosis, smoking 10 packs of cigarettes per annum, hypertension, obesity are at
higher risk of lacunar infarct [49]. Bessy B. et al, while studying the risk factors
of infarct, found that smoking is a significant factor of cerebral infarct in young
people. The change of risk factors by giving up smoking may reduce the risk of
cerebral infarcts in adults [108].
Omura T. et al studied depression in patients with injury in thalamus
region: There is no significant difference between patients with and without
depression related to age, gender, injury, previous hypertension, diabetes
mellitus, alcoholic, smoking and previous stroke [109]. According to Le Van
19
Thinh, hypertension causes 8.9 times higher of lacunar infarcts than the control
group [36]. Feng C. et al: the change of blood pressure is an independent risk
factor of uneven lacunar infarcts [101].
Altmann M. et al, while studying 113 patients, of which 75% cases of
lacunar infarcts, 25% cases of none lacunar infarcts, concluded that there is no
clinical presentation difference between the two groups. The linear regression
analysis found a relation between hypertension and lacunar infarcts. There is no
other factor related to blood pressure in both groups [114].
The SPS3 research studied 3020 post-lacunar-stroke patients found no
difference about the rates of reoccurence or mortality, but only significant
reduction of cerebral hemorrhage. There is a crucial disadvantage associated
with no regular treatment of blood pressure problems [115].
4.5 Depressive symptoms according to ICD 10.
4.5.1 Distinctive symptoms of depression
Duong Minh Tam, while studying distinctive symptoms of early stage
post-stroke depression: 86.6% depression patients have poor mood. 50 cases
(65.8%) lost all interests. The least number of patients with energy loss
symptom leading to fatigue account for 60.5%. The assessment of severity
levels of depression shows that only 17% are of severe depression and 39.5%
are of moderate depression and the rest are mild depression in the first month of
depression onset [87]. In the analysis by Narushima K. et al: there is no relation
between post-stroke depression and location of injury. The authors conducted
another research to reassess the hypothesis by analyze the relation between the
severity level of post-stroke depression and injuries in the frontal lobe region
which had not been analysed in the above-mentioned research. The results
showed a significant inverse correlation between the severity level of depression
and the distance of injuries in the frontal lobe region in 163 patients with injuries
in the left hemisphere. This research has supported the hypothesis that stroke
risks are associated with location of cerebral stroke injuries [128]. According to
Tanislava et al, depression occurs at a relative high rate in young patients [85].
4.5.2 Severity level of depression in patients with lacunar infarcts
Paradiso S. et al’s study of post-stroke depression found that mild
depression are more associated with young age, location of injuries in the left
20
hemisphere and more lesions. The authors confirmed the importance of lesions
in the posterior regions of the left hemisphere affecting mild post-stroke
depression [129]. Ching-Shu et al’s study of depression in one-year post-stroke
patients in Hong Kong found that the rate of onset in the first, third, sixth and
nineth months are 4%, 8%, 9%, 10% respectively and the overall rate after one
year is 11%. In the multiple regression analysis: in female, the higher depression
scores and severe levels are significant factors. In group analysis, higher
depression score are significantly associated with depression regardless of
gender. However, the severity of stroke is only a risk factor in the female group
[130].
4.6 Severity of depression and location on cranial imaging scans
4.6.1 Relation between severity of depression and location of lacunes in the
internal capsule region
Grool M. et al: age, body weight and previous stroke are related to
depression in lacunar infarcts in the basal ganlia region [49]. In LADIS’s study,
lacunar infarcts in the basal ganglia region are less related to depression whereas
no relation in the other regions [57]. Herrmann et al believe that more injuries in
the basal ganglia are seen in lacunar infarcts. The size of lacunes in the basal
ganglia are related to progressive depression [120]. A study of 249 patients with
silent lacunar infarcts with and without depressive symptoms, in a monovariable analysis, Wu R. H., Li Q. found a significantly higher rate of patients
with cerebral infarcts in the basal ganglia region than the group without any
depressive symptoms. It is a significant difference between the two groups. In
the multiple variable analysis where some cofounding factors have been
eliminated, lacunar infarcts in basal ganglia are still significant about depression.
Lacunar infarcts in basal ganglia are more related to depression risk [33].
4.6.2 Relation between severity of depression and lacune position in lentiform
nucleus
Nishiyama Y. et al studied depressive symptoms in post-stroke in
combination with injury areas in the left lentiform nucleus internal capsule. The
study has clearly proven that of all the injuries under analysis only the injuries in
the internal capsule of the left lentifrom nucleus being the dependently
determinant factor for early depressive symptoms in patients with cerebral
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