Treatment of post dominant hand stroke syndrome with Depakote
Behavioral problems associated with treating patients suffering from right-hemisphere stroke (or trauma) make the treatment of the patient difficult if not impossible. Depending on the site of the injury, age, and sex, various symptoms can appear with different intensities. They usually manifest as cognitive deficits that can include impaired attention, insight, judgment, thought, reduced processing speed, distractibility, and deficits in executive functions such as abstract reasoning, planning, problem-solving and multitasking. Probably the main difference between right hemispheric patients and that of the left hemispheric patients is the intensity of affect and impulsivity. Their condition has some of the characteristics of Disinhibition Syndrome.
This type of patient has a tendency to be badly impulsive and guarded; they do not follow the staff's directions and often put themselves into harm's way. They appear like a rebellious adolescent or a bipolar patient in the manic episode. However, the problem is quite different and is probably associated with the fundamental function of the right hemisphere of the brain. As indicated by Luria and E. Goldberg, the right hemisphere of the brain is mostly in charge of learning new information. Once the information is processed, it gets stored in the left hemisphere of the brain. Therefore, patients with right hemisphere injury, although they would understand and momentarily comprehend and internalize new information, they have difficulty retaining that information and continue on with behaviors from which they have been taught to abstain. The best example is when the patient with right hemisphere injury, who is having left-sided weakness, is directed by the staff not to get out of their bed or chair without assistance, as there is a high likelihood of falls. Typically, the patient would agree with the instructions and make some kind of a promise that they would refrain from such behavior and a few minutes later the patient would get out of the chair or bed, fall, and when confronted, would deny ever having made such a promise.
The extent of this group of behaviors is vast and could reach the point that the patient might be verbally or physically abusive to the treating staff.
Numerous research studies have been conducted on the problems associated with this type of impulsivity, disinhibition, and labile mood. However there is no accepted universal treatment for control of the symptoms. Due to the noncompliance of these patients with treatment and their inability to retain newly learned behaviors, counseling and behavior therapy is usually fruitless. Therefore, treatment is mostly limited to the use of psychiatric medications. Although these medications can help at times, there are no real treatments in most cases. Anti-depressants take too long to take effect and mostly lead to further agitation. Anti-anxiety and antipsychotic medications usually have extreme effects; they either do not work or cause heavy sedation. Anti-consultants like Dilantin and Keppra have very little effect.
Valporoic acid (VPA): marketed under the brand names Depakote, Depakote ER, Depakene, Depacon, Depakine and Stavzor, is a chemical compound that has found clinical use as an anticonvulsant and mood-stabilizing drug, primarily in the treatment of epilepsy, bipolar disorder, and, less commonly, major depression. It is also used in treatment of migraine headaches and schizophrenia. Valporoic acid is used alone or along with other medications when used for seizures. It can be used to treat outbursts of aggression in children with attention deficit hyperactivity disorder, chorea, and certain conditions that affect thinking, learning and understanding.
The case of Mr. M.
Mr. M who is a 50 year old, white, married, male who was admitted to our unit on 8/31/2009, for status post-ventriculostomy and coiling of ruptured anterior communicating artery aneurysm with development of right frontal lobe and right thalamic infarctions. On the first day of admission he was manifesting typical symptoms of non-dominant hand, post stroke syndrome. He was angry, uncooperative, at times vulgar and intimidating and would run out of energy and fall asleep. The treating staff's report of treatment from different departments was almost identical, indicating that this was not just a personality conflict with certain staff members. Treatment with anti-anxiety medications would cause the patient to fall asleep. The patient was at risk of harming himself and others and was not a candidate for transfer to a psychiatric unit. We started the patient on with Depakote 250 q h.s. The effect of this treatment was astonishing; the patient's agitation began to improve the following day after the first dose of Depakote and continued to improve rapidly. Within less than two days, the patient was able to participate in therapies and all symptoms came under control, and interestingly, the patient was quite mad at himself for having insulted the staff. The patient was discharged from the hospital after about 4 weeks. Neuropsychological testing conducted after discharge was mostly indicative of visual deficits. Subsequently, the patient was referred to a clinical psychologist to deal with the adjustment related issues. During our final contact last week the patient and his wife were both quite pleased with the outcome of the treatment and they both attributed the patient's sudden improvement to the introduction of Depakote into the treatment regiment.
The case of Mr. J.
Mr. J is a 58 year old, white, married male who is an ex-police officer. He sustained a severe head injury from a criminal with a baseball bat. The CT was positive for a "small subdural hematoma in the right middle cranial fossa with bilateral temporal lobe contusions" The patient was originally referred to us for neuropsychological testing. Since most of the findings were within normal limits, we referred him to a psychiatrist for treatment for the post-head injury symptoms. The patient's behavioral problems included agitation, impulsivity, frequent temper outbursts, developing family disputes and panic disorder with agoraphobia. The patient received psychiatric treatment including the use of anti-anxiety, anti-depressants, and anti-psychotic medications. However, his condition continued and his family problems escalated, getting close to a divorce. In consultation with the treating psychiatrist, we informed the patient and his family of the good results that we had seen with treatment of this condition with Depakote. The patient's doctor added Depakote 250 bid, and the patient's symptoms came under control within less than a week. The progress notes from the nurse practitioner indicated that he "felt much better, Depakote had helped considerably. His energy level is still low and his mood is stable. He is able to tolerate functions and many people. Agoraphobia is in remission, he went to a canine function to help the training of the dogs. The medical component of depression was explained to him, and Dr. Sadeghian explained to him how Depakote works on right sided brain injury. He was stable and had no dizziness."
The Case of Ms. M.