1. The patient is a man who suffered a large left MCA stroke with hemorrhagic transformation, leaving him with severe expressive aphasia and speech comprehension deficits. 2. The doctor found signs that the patient was likely suffering from post-stroke depression (PSD) due to damage from the stroke to areas of the brain involved in mood regulation. 3. The doctor's recommendations included starting an antidepressant medication and discontinuing another medication due to contraindications, as well as non-pharmacological recommendations to engage the patient in activities and facilitate communication.

1. 1
Mental Health Consultation
Patient Name: post-stroke depression (PSD)/MCA Facility: XXXX
Date: 11-11-13
Additional history can be found elsewhere in this chart and will not be repeated here.
Reasonfor Referral: XX-year-old, white, xxxxx, male… I was asked to evaluate him “because
of his mood and anger about placement”. He was admitted from the XXXX on 12-20-12 where
he underwent Rehab for a left MCA stroke. He is right handed.
Background Information: See DC summary from the XXXX—11/20/12
On 10/20/12, he was treated @ XXX for a large left MCA stroke with hemorrhagic
transformation. He has “severe expressive aphasia with speech comprehension problems”.
Current Medications: Sinemet 25/100 bid, Folic Acid, Glipizide, Pepcid, Metoprolol, Insulin,
Nitro, Risperdal 0.25mg bid, Flomax, Imodium,
Medical History: GERD, Type II Diabetes Mellitus, Hypertension, Coronary Artery Disease,
Atrial-Fibrillation, Dysphagia, Aphasia, Hx of thrombocytopenia, Hyperlipidemia, Left-sided
stroke with right-sided hemiplegia.
Mental Status Exam: A slim, bespectacled, animated, easily frustrated but also easily calmed
man with a pronounced expressive (Broca’s) aphasia who produced enough accurate words for
me to usually grasp the essence of his communication. When I informally tested his speech
comprehension (“touch your W/C…lift your arm”) results were mixed. He also did not seem to
be able to use symbolic gesture (thumbs up for yes). He seemed to think he could communicate
well with others and “said” he has never used a communication board. He “paced” about in his
W/C throughout the interview. He adamantly denied depression and biological signs of
depression such as early morning awakening, loss of appitite with weight loss, anedonia, low
energy and crying spells. There were no obvious signs of psychosis. He was determined to be
discharged home soon but did not know what treatment goals had to be reached before that could
happen. His insight and judgment were limited.
Findings and Recommendations: He had a large left MCA ischemic stroke with a hemorrhagic
transformation which left him with a severe expressive (Broca’s type) aphasia as well as speech
comprehension deficits. The middle cerebral artery supplies the frontal lobe and part of the
temporal lobe. Damage was worse in his case because of the hemorrhagic transformation. A
large infarction on the dominant side in this area of the cortex could produce symptoms such as
disinhibition, reduced verbal output and psychomotor slowing and almost certainly would
produce a post-stroke depression (PSD). Patients with left anterior infarcts are subject to a
syndrome known as post-stroke depression. Although the depression is partly a reaction to
cognitive and motor impairment caused by the stroke, it is also caused directly by the brain
infarct itself due to the depletion of biogenic amines and the interruption of high numbers of
downstream pathways. The depression signs are atypical and may include: anxiety, agitation,
irritability, emotional incontinence and anxious foreboding. Stroke patients with left anterior
cerebral infarcts often manifest previously uncharacteristic anger. Furthermore, patients suffering
from anterior aphasia are prone to depression because they are aware of their cognitive deficits
and experience intense frustration as they struggle unsuccessfully to communicate.

2. 2
1. Would start Lexapro 10mg qd x two weeks then increase to 20mg qd. If after a month,
there is no significant improvement in mood would add Abilify 2mg qd to augment the
Lexapro. This will be necessary on a permanent basis to replace the neurotransmitters no
longer produced by the cortical neurons damaged by the stroke.
2. Risperdal cannot be used with Sinemet because Sinemet is a dopamine agonist and
Risperdal is highly antidopaminergic. I cannot imagine why he is taking Sinemet.
Because of the contraindication with Risperdal would DC Sinemet.
3. Stroke patients with depression or PSD often become withdrawn isolated and dependent.
The further into isolation and dependency they retreat, the worse the depression and vice
versa. Higher levels of activity and independence lead to a better prognosis for the
depression and recovery. Therefore, it is important to keep him actively engaged in
treatment and facility activities.
4. When communicating with him look directly at him, speak slowly and distinctly, point and
use gesture. Encourage him to point, use gesture or draw his communications to you.
5. Try to engage him around intact areas of non-dominant hemisphere functioning. For
example, listen to music, make simple drawings and look at photographs of familiar
people and objects with him.
6. For the time being try communicating with him using yes or no questions. To confirm the
accuracy of his responses, ask him to raise his left arm when he does not understand your
question. When he doesn’t understand, rephrase your question until you are certain he
understands. Ask a few obvious factual questions to test his speech comprehension. Try
setting up a communication board for him. The speech therapist should have the template
for this. Ask about it.
7. Be sure to keep him informed about the goals of his therapies and his progress to date
toward achieving each goal. If necessary, set up a chart for him.
8. Try to keep him from engaging in complex tasks which can lead to failure and frustration
followed by a catastrophic reaction and the expression of negative emotions.
9. Fatigue may also be a contributing factor; be sure he gets frequent rest periods.
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist