http://journals.lww.com/clinicalneuropharm/Abstract/2003/09000/Lamotrigine_Treatment_for_Post_Stroke_Pathological.6.aspx
Ramasubbu, Rajamannar
Abstract
Pathologic laughing and crying (PLC) is a common
distressing and socially disabling condition in stroke patients.
Antidepressants, particularly selective serotonin reuptake inhibitors
(SSRIs), have been increasingly recognized as the treatment of choice
for pathologic crying (PC). However, little is known about etiologies
and other treatment options for various clinical manifestations of PLC.
This case report illustrates the beneficial effect of lamotrigine, a
novel antiepileptic drug with antidepressant and mood-stabilizing
properties in post-stroke PLC. A 60-year-old woman developed PLC after
an ischemic stroke affecting the left frontal and temporal lobes. She
was treated with lamotrigine initially at the dose of 50 mg a day, which
was gradually increased to 100 mg a day over a 4-week period. There was
a significant and rapid recovery in both laughing and crying components
of PCL with lamotrigine treatment. The symptoms of pathologic laughing
have shown a better response to lamotrigine than PC. Controlled
investigations are needed to evaluate the beneficial as well as the
differential effects of lamotrigine on PLC.
The syndrome of pathologic laughing and crying (PLC)
involves uncontrollable motor expression of emotion in the absence of
corresponding feelings of sadness or happiness. PLC is often
precipitated by nonspecific stimuli. 1 Emotional lability is a second
type of pathologic affect that represents a rapid fluctuation in
emotional expression that is out of proportion to an appropriate
stimulus or situation and is accompanied by an alteration in mood
states. 1 The validity of the existence of these two types has not been
substantiated because of a great deal of overlap in the phenomenology
between PLC and emotional lability. 2 In this context, a commonly used
instrument, namely the pathologic laughing and crying scale (PLCS), has
included items to measure both the intensity of pathologic laughing (PL)
and pathological crying (PC) and also the severity of emotional
lability. 3 The other terms used in the literature to describe the
pathologic affect of laughing and crying include emotionalism, 4
emotional incontinence, 5 and pseudobulbar affect. 6
PLC is a common emotional consequence of stroke.
Approximately 15% to 20% of patients may experience this condition
during the first year after stroke. 7 Pathologic crying is the most
common manifestation in stroke patients. However, some patients may have
episodes of laughing without episodes of crying and some display both
laughing and crying. Brain stem lesions and right frontal damage are
frequently associated with PLC. 7 Double-blind placebo-controlled
studies documented the efficacy of both tricyclics (nortriptyline,
amitriptyline) and selective serotonin reuptake inhibitors (SSRIs)
(citalopram, fluoxetine, sertraline) in PLC. 3,8–11 However, since the
controlled treatment studies to date focused largely on patients with PC
and only a few patients with PL were in the cohort, our understanding
of the efficacy of antidepressants in PL is limited. Furthermore,
anecdotal reports described a rapid transition of PC to PL during
treatment with SSRIs 12 and a slow transformation of PC to PL as a
natural course of PLC in some patients. 13,14
L-dopa was reported to be effective in patients with
PL in an open trial. 15 However, taking into account the depressogenic
side effect of l-dopa 16 and the frequent co-occurrence of depression
with PLC in stroke patients, 7 l-dopa may not be a suitable agent for
post-stroke patients with PLC and depression. This report describes a
case of post-stroke PLC that markedly improved with lamotrigine, a novel
antiepileptic drug with antidepressant and mood stabilizing properties.
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