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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 pages, Overview of the dissertation 36 pages, Research subject and method 13 pages, Research outcomes 30, Discussion 36, Conclusion pages, Recommendations page The dissertation have 39 tables, charts with clear and sufficient notes and explanations Reference materials 142 (92 materials in Vietnamese language, 92 materials in English language), of which more than 50 % of the reference materials are of the last 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 combined risk factors: hyperlipidemia and hypertension 45.56% 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 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 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 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: 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 following syndromes: + Pure hemiparesis + Pure sensory disorder + Mild ataxic hemiparesis + Language disorder – clumsy + Movement – sensory disorder syndrome 5 - Subclinical: Brain CT scan: there appear round or oval hypointenses in white matter and basal ganglia, with < 1, 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 main symptoms: + In addition, there are other common symptoms For a diagnosis of depression, there must be at least main symptoms plus 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 Diabetes mellitus Diagnosis and Treatment by the Ministry of Health [77] 6 - 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 CHAPTER RESEARCH RESULTS 3.1 Common features of the research subjects The male-female ratio is 67 78% and 32 22 % (2.1 male per 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 0.05 CHAPTER 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