Case Presentation
A 63-year-old Caucasian woman, with known co-morbidities of diabetes and dyslipidemia, suddenly experienced difficulties walking. Moreover, she had right-sided paralysis and severe speech impairment, which were later found to be symptoms of stroke. This episode began 1.5 hours before she sought medical attention, with her NIHSS indicating a severity level of 13. Neurovascular imaging showed a blockage in her basilar artery, prompting successful recanalization through endovascular therapy within five hours of symptom onset. Although she regained strength on her right side, subsequent brain imaging revealed bilateral cerebellar and pontine ischemia. This was the likely cause of her lingering deficits.
Examination: Stroke
During her hospital stay, she started experiencing spontaneous tearfulness. This hindered her ability to engage in conversations, particularly in response to routine questions. A follow-up assessment using the PHQ-9 conducted 7 days after, revealed a score of 18, indicating moderately severe depressive symptoms. Notably, despite the emotional challenges, she exhibited an awareness of the inappropriateness of her emotional responses. This characteristic is not always associated with this type of emotional disturbance known as Pseudobulbar Affect (PBA). She had no history of depression, anxiety, or mood disorders. However, the uncontrollable tearfulness impeded her communication with clinical staff.
Management
In response to this depressive episode, she was prescribed escitalopram at a dosage of 10 mg. This resulted in gradual improvement in emotional lability over subsequent weeks. This positive change allowed for more effective engagement in stroke rehabilitation. As part of her recovery plan, she was transferred to a long-term rehabilitation centre for several months. She continued to make progress.
Follow-up
One year later, during follow-up visits, she still experienced some residual effects, including right-sided weakness and ataxia in her right arm and leg. Despite these challenges, her emotional state remained stable with the continued use of escitalopram. She retained full independence in her basic activities of daily living (ADLs) and required only minimal assistance with certain instrumental ADLs. The journey from sudden-onset symptoms to ongoing recovery highlights the importance of addressing both physical and emotional aspects in rehabilitation, with tailored interventions contributing to an improved quality of life for the patient.
Pseudobulbar affect (PBA)
Pseudobulbar affect (PBA) manifests as an emotional dysregulation observed in 17–20% of individuals experiencing acute ischemic stroke. The typical symptoms involve bouts of crying or laughter that are disproportionate and inappropriate to the context. They can do it multiple times a day and beyond full voluntary control. Although the symptoms tend to resolve between emotional outbursts, PBA often goes unrecognized by healthcare professionals. This leads to missed, timely intervention. Recognizing and addressing PBA early in the course of recovery can significantly impact the quality of life and patient engagement with rehabilitation. This can ultimately contribute to an improved post-recovery.
While PBA is commonly linked to damage in the cortex and limbic system, it is essential to highlight that it can also be a concern for patients with cerebellar and pontine strokes. The dysregulation leading to PBA can stem from injury or dysfunction along the cortico-ponto-cerebellar pathway. In children, post-surgical removal of posterior fossa tumours may lead to cerebellar cognitive-affective syndrome. This further emphasizes the diverse impact of cerebellar conditions on emotional well-being.
Emotion Processing
Emotion processing is a complex function involving various brain regions, including the cortex, subcortex, and cerebellum. Damage along this intricate pathway can lead to diverse emotional impairments. In the case of patients with pseudobulbar affect (PBA), there may be a notable impact on their insight into emotional responses. Although formal research in this area is limited, a potential link between impaired insight and the location of the lesion along the cortical-ponto-cerebellar pathway has been suggested. Anecdotal evidence suggests that cortical lesions may result in a loss of emotional insight, while lesions of the pons or cerebellum may spare insight. This dissociation aligns with the notion that cortical and subcortical regions are more involved in emotional processing and interpretation. The pons and cerebellum modulate motor output. While not yet fully established, this relationship presents an avenue for further investigation.
Speculatively, intact cortical and subcortical regions may be necessary for preserved insight, as indicated by the current case presentation. Increased emotionality with retained insight may offer unique insights linking cortical and subcortical areas with emotional reasoning in PBA. Beyond affecting one’s interpretation of their emotional state, untreated PBA can significantly impede post-recovery recovery. The symmetric expression of emotion often causes distress and embarrassment, leading to social withdrawal and reduced participation in rehabilitation and social interactions. Early recognition of PBA becomes crucial for effective rehabilitation practices.
Furthermore, PBA can worsen pre-existing anxiety and depression, further complicating rehabilitation efforts. Although direct reports on how PBA influences rehabilitation outcomes are lacking, it is established that emotional impairments like depression can hinder and delay recovery. Caregivers of individuals with PBA also report higher levels of distress and upsetting experiences compared to caregivers of non-PBA patients. Overall, early PBA treatment can mitigate emotional outbursts, potentially contributing to improved outcomes. Commonly used treatments for PBA include antidepressants and dextromethorphan-quinidine, with adjunctive cognitive therapy being a potentially beneficial option.
Conclusion: PBA after stroke
In summary, while PBA may manifest in individuals with damage to the cortex and limbic system, it can also occur in the context of an ischemic stroke affecting the cerebellum and pons. We propose that clinicians should consider PBA when observing emotional dysmetria. Early detection is crucial, as swift intervention can enhance quality of life, and alleviate concurrent depression and anxiety. This promotes active involvement in post-rehabilitation. The case discussed highlights the significance of ischemic injury to the cerebellum and pons as a potential trigger for PBA while maintaining the individual’s awareness of emotional responses. Identifying PBA in this particular patient enabled the timely commencement of a selective serotonin reuptake inhibitor. This led to a reduction in emotional lability and facilitated her engagement in post-stroke rehabilitation.
