JANUARY 23, 2004 MY 62 YEAR OLD HUSBAND WOKE ME, BY HAVING WHAT
RESEMBLED A SIEZURE.  HIS MOVEMENTS WERE VERY STIFF, AND JERKY. NOT
THE TREMOR TYPE. HIS FACE WAS DISTORTED AND I COULD NOT GET RESPONSE
FROM HIM ON THE COMMAND TO OPEN HIS EYES.  HE WAS RUSHED TO THE
HOSPITAL, THEY DETERMINED THAT HE HAD "PROBABLY HAD A MINOR
STROKE,TIA, BROUGHT ON BY THE SIEZURE.  AFTER SEVERAL HOURS OF
OBSERVATION, HE WAS ADMITTED.  MY HUSBAND HAS A HISTORY OF BLOOD
CLOTS, AND HAS BEEN ON COUMADIN THERAPY FOR OVER 30 YEARS. 10 DAYS
PRIOR TO THIS "EVENT" HIS "INR" WAS 1.7 (TARGET NUMBERS FOR HIS
CONDITION ARE 2.5 TO 3.0) SO ALTHOUGH HIS INR WAS MARKEDLY LOW ON AN
UNRELATED HOSPITAL VISIT, NOTHING OF CONSEQUENCE WAS DONE ABOUT THE
LOW INR.  [NOW I KEEP A SUPPLY OF DALTEPARIN SODIUM (INJECTABLE) TO
BRIDGE THE PERIODS OF LOW INR UNTIL THE COUMADIN CAN STABALIZE THE
NUMBERS]   ANYWAY, THE NEXT DAY, (SATURDAY) BILL WAS UP AND WALKING,
AND TALKING, ALTHOUGH STRENGTH WAS INTERMITTENT AND INCONSISTENT. 
SUNDAY MORNING, HE HAD LOST ALL ABILITY AND MOTOR SKILLS ON THE RIGHT
SIDE. SPEECH WAS LOST AS WELL AS THE MOTOR SKILL OF SWALLOWING.
RESULTING TESTS, MRI, MRA, ANGIOGRAM, ULTRASOUND, ETC, ETC. DETERMINED
THAT HE HAD SUFFERED A STROKE AFFECTING THE BASAL GANGLIA. TPA, WAS
NOT USED SINCE THE TIME OF ONSET WAS UNSURE, AND THE CHANCE OF THE
CLOT BECOMMING A HEMMORAGIC STROKE, AND AFFECTING LARGER AND MORE
PARTS OF THE BRAIN WAS CRITICAL IN THIS DECISION.  AFTER THREE DAYS I
CONVINCED DR'S TO HANG HEPARIN TO RAISE HIS INR. THIS NUMBER I
CONTINULY MONITORED DAILY WITH THE NURSE ON DUTY.

NOW FOR THE QUESTION:  ASIDE FROM THE MOTOR CONTROL LOSSES ASSOCIATED
WITH THE BASAL GANGLIA STROKE VICTIM, WHAT IS THE CHANCE THAT THE
"MENTAL AGE" OF THE PATIENT WOULD REGRESS/ IE: LOSS OF CONTROL OF
IMPULSE ACTIONS, REFUSAL TO COMPLY WITH HOME THERAPY, BY SPOUSE, BUT
WILLING TO COMPLY WITH PROFESSIONALS, WHO "DOTE" ON HIS EVERY
MOVEMENT.  THE BLOOD CLOT WAS LOCATED IN THE LEFT CAROTID ATRERY, TOO
FAR UP IN THE BRAIN TO PROVE SURGICAL.  MY FEARS ARE THAT THE ADULT I
MARRIED, MAY HAVE BECOME THE CHILD I NOW HAVE TO RAISE, WITHOUT
TREATING HIM OPENLY LIKE A CHILD, SO THAT SELF RESPECT CAN BE
MAINTAINED.  HE PUTS ON A FRONT FOR FAMILY AND FRIENDS, BUT BECOMES
SULKY AND SULLEN WHEN ALONE.
UNWILLING TO PARTICIPATE IN LENGTHY CONVERSATIONS WITH LOVED ONES, FOR
FEAR HE WILL FAIL TO FIND THE WORDS.   I AM FRIGHTENED, AS THE SOLE
CARE GIVER, AND HIS CHILDREN ALL BELIEVE HE IS OKAY.  WE JUST RETURNED
FROM A 6,00 MILE 6 WEEK TRAVEL TRAILER VACATION,[I DID ALL THE
DRIVING, AND 'TRAILER WORK']  BOTH WITH FAMILY AND TO SEE FAMILY.  MY
HUSBAND, WHO USED TO HOOK THE TRAILER, AND HANDLE THE "SET-UP" DID
ABSOLUTELY NOTHING, CLAIMING NOT TO REMEMBER HAVING DONE IT. HE IS NOT
ALLOWED TO DRIVE, UNDERSTANDABLY TO MOST, BUT AFTER A 20 YEAR CAREER
AS A PROFESSIONAL DRIVER, A SLAP IN THE FACE OF HIS VARILITY, I'M
SURE.  WELL I'V HIT THE HIGH SPOTS OF THE FACTS.... WHAT MENTAL AND
SOCIAL SKILL REVERSALS SHOULD BE WATCHED FOR IN THIS TYPE OF STROKE? 
IS THIS COMMON, OR PERHAPS A PASSING EMOTIONAL STAGE THAT SHOULD BE
ADDRESSED BEFORE IT BECOMES, PERMANENT?

ALL HELP APPRECIATED.
THANKS, 
GLORIA

Hello gloriaval-ga,

First of all, I'm sorry to hear of your situation and with you the
best of luck. It takes a lot of strength and patience to care for a
loved one at home. I did so for my grandmother, with her lung cancer
many years ago and it's hard on both the ill person and the caregiver.

I've been doing some research into the basil ganglia strokes and the
symptoms you've mentioned and I believe I have an idea about what is
going on with your husband and how you can help him. Let me give you a
brief outline of how I'd like to cover this information.

I'm going to give you some information on how the stroke affected your
husband, how it ties into his behaviors and what you can expect from
him in the future regarding behavior, and what are some things you can
do to lessen the stress of this for all involved parties.

Let's start with the information. The basil ganglia are groups of
structures (large collections of nuclei) inside the brain that help
with movement and also play a role in thinking and emotions.
Unfortunately, this is one of those things that while it has been
studied, it's not extensive, so there's not a massive amount of
information out there about how it affects people, unlike with AIDS or
cancer. However, we do know this much.

The motor cortex sends information to both the basil ganglia and
cerebellum, and both structures send information right back to the
cortex via the thalamus. The output of the cerebellum is excitatory,
while the basal ganglia are inhibitory. The balance between these two
systems allows for smooth, coordinated movement, and a disturbance in
either system will show up as movement disorders.

Therefore, that in a nutshell, explains the movement issues your
husband is facing. Now, let's move on to the mental issues that are
going on. There has been research into how basil ganglia strokes and
anything affecting the basil ganglia can cause depression and other
psychiatric problems. Some of the emotional and psychiatric systems
that occur when the basil ganglia gets affected are emotional and/or
personality problems, such as depression, apathy, inappropriate
behavior, or paranoia. In addition, an inability to think clearly,
concentrate, or recall. This seems to apply very well to your
situation as you mentioned him not being able to recall hooking up
your travel trailer. You also mentioned his unwillingness to work with
people and his sullen mood. Those all fall into place with the
depression, apathy, and inappropriate behavior symptoms.

I found a great research study and presentation called "Post-stroke
depression and emotional incontinence: correlation with the lesion
location" They define emotional incontinence as "inappropriate or
excessive laughing and/or crying.?
It determined that there was a higher of PSD (Post Stroke Depression)
and PSEI (Emotional Incontinence) with people with basil ganglia
lesions. However, the size of the lesions really did not have a lot to
do with how strong the PSD and PSEI affected the patient. Therefore,
this once again explains the behaviors your husband is going through.
It's not really a "mental age" thing as you put it. It's more than
likely he's suffering from PSD, PSEI, and the frustration that happens
with this type of medical problem. It has to be very hard emotionally
and physically to deal with this and the behaviors your seeing are a
manifestation of the stroke and the emotions surrounding it.

The PSD can fall into one of two categories Major depression or minor
depression. Here are the differences between the two.

Major depression has symptoms and behaviors such as sadness, anxiety,
tension, loss of interest and concentration, sleep disturbances with
early morning awakening, loss of appetite with weight loss, difficulty
in concentrating and thinking, and thoughts of death.

Minor depression is a lesser form of depression and is characterized
by anhedonia (the inability to gain pleasure from normally pleasurable
experiences) and up to three additional symptoms of major depression.

The DSM IV (Diagnosis Criteria for Mental Disorders) classifies
depression like this.

Table 1: Criteria for a major depressive episode.

I. Five (or more) of the following symptoms have been present during the same 
2-week period and represent a change from previous functioning; at
least one of the symptoms is either (1) depressed mood or (2) loss of
interest or pleasure.

A. depressed mood most of the day, nearly every day, as indicated by
either subjective report (e.g., feels sad or empty) or observation

B. markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day (as indicated by either
subjective account or observation made by others)

C. significant weight loss when not dieting or weight gain (e.g., a
change of more than 5% of body weight in a month), or decrease or
increase in appetite nearly every day

D. insomnia or hypersomnia nearly every day

E. psychomotor agitation or retardation nearly every day (observable
by others, not merely subjective feelings of restlessness
or being slowed down)

F. fatigue or loss of energy nearly every day

G. feelings of worthlessness or excessive or inappropriate guilt
(which may be delusional) nearly every day (not merely self-reproach
or guilt about being sick)

H. diminished ability to think or concentrate, or indecisiveness,
nearly every day (either by subjective account or as observed by
others)

I. recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation without a specific plan, or a suicide attempt or a
specific plan for committing suicide

You may be able to treat these behavioral symptoms with an
anti-depressant or some other medication. I recommend talking to your
physician or making a psychiatric appointment for your husband. The
biggest thing he needs, in addition to those is a strong support
system. This can't be easy for him either, and the more people who
understand and can offer sympathy and empathy the better.

Here are some links with more information for you.
http://health.discovery.com/encyclopedias/3037.html
http://www.healthandage.com/PHome/135!gid2=629
http://plaza.snu.ac.kr/~nurse21/csm/smi-abs1.html
http://www.neuro-net.net/diseases/journals/acutestroke/depress.html
http://thalamus.wustl.edu/course/cerebell.html
http://www.netdoctor.co.uk/special_reports/depression/anhedonia.htm
http://mysite.verizon.net/res7oqx1/index.html

I found all of this information for you with a google search.
BASAL GANGLIA STROKE
://www.google.com/search?hl=en&ie=UTF-8&oe=UTF-8&q=BASAL%20GANGLIA%20STROKE&btnG=Google+Search

If this answer requires further explanation, please request
clarification before rating it, and I'll be happy to look into this
further.
Nenna-GA
Google Answers Researcher

---

Request for Answer Clarification by gloriaval-ga on 20 Jul 2004 00:51 PDT

TODAY WE MET WITH OUR PRIMARY CARE PHYSICIAN: THE APPOINTMENT TOOK TWO
HOURS, AND OUR PHYSICIAN WAS VERY THOROUGH!  HE HAS CHANGED MY
HUSBANDS PREVIOUS ANTI-DEPRESSANT, (ZOLOFT) TO PROZAC (20 MG TO
START).  MOST OF YOUR ANSWER WAS VERY THOROUGH, AND FAIRLY CLEAR. OUR
PCP APPARENTLY TENDS TO AGREE WITH YOUR SUMATION, EVEN THOUGH HE HAS
NOT SEEN THIS, AS THE TREATMENT PLAN IS TWO FOLD, TREAT MY HUSBANDS
OBVIOUS PSD AND MONITOR AND TREAT MY OBVIOUS "CAREGIVER BURNOUT"
I HAVE TENDED TO EVERY CONCIEVABLE AND INCONCIEVABLE NEED, I HAVE
SHIELDED HIM FROM STRESSFUL EVENTS AND HANDLED EVERTHING THAT CAME AT
US, I PLANNED TRAVEL, FAMILY INVOLVEMENT, AND ENTERTAINMENT,
ANTICIPATED HIS PHYSICAL NEEDS PRIOR TO HIS RETURN HOME, AND TENDED TO
HIM PERSONALLY WHILE HE WAS STILL IN THE HOSPITAL, SO THE DOCTOR MAY
HAVE PEGGED MY PROBLEM, AS WELL AS MY HUSBANDS. ( and here I thought I
was just in the middle of a 'Pity-Party'

THE ONLY CLARIFICATION I REQUEST, IS TWO DEFINITIONS:
"D. HYPERSOMNIA"
"E. PSYCHOMOTOR AGITATION, OR RETARDATION"

I AM FAMILIAR WITH ALL THE OTHER TERMS YOU USED AND CLEARLY DESCRIBED,
BUT SINCE I STRIVE TO FULLY UNDERSTAND MY HUSBANDS CONDITION AND THE
TREATMENT, I WOULD APPRECIATE THIS MINOR CLARIFICATION.

Otherwise, I wish to thank you for a good- answer, consistent and well
thought out and apparently well researched.
Thanks,
Gloria Val

---

Clarification of Answer by nenna-ga on 20 Jul 2004 10:36 PDT

Hello Gloria,

Thanks for your kind workds about my answer. Let me define those terms for you. 

Hypersomnis is defined as:
"Hypersomnia is characterized by recurrent episodes of excessive
daytime sleepiness or prolonged nighttime sleep. Different from
feeling tired due to lack of or interrupted sleep at night, persons
with hypersomnia are compelled to nap repeatedly during the day, often
at inappropriate times such as at work, during a meal, or in
conversation."

You can read more about the condition here:
http://www.ninds.nih.gov/health_and_medical/disorders/hypersomnia.htm

Psychomoter retardation or agitation is defined as:
"You think, talk and act more slowly than usual" It comes from an
emotional state of depression rater than a physical condition.

You can read more about it here:
http://www.depnet.com.au/universe1/depression/symptoms/psychomotor_skills.asp

And please Gloria, like your Doctor said, take care of yourself as
well. Caregiver burn out can be very rough. You may want to check into
these online resources for yourself.

http://www.seniormag.com/caregiverresources/articles/caregiverarticles/supportgroup.htm
http://my.webmd.com/content/pages/9/1675_57788.htm
http://www.4woman.gov/faq/caregiver.htm

Once again Gloria, I wish you and your husband the best of luck.

Nenna-GA

RESEARCH APPARENTLY THOROUGH, ANSWER WELL THOUGHT OUT AND ORGANIZED,
MOST TECHNO-JARGON WAS FOLLOWED BY A 'LAYMAN'S' DEFINITION. THIS WAS
MISSING ON ONLY TWO VERY NEW- ANBD UNFAMILIAR TERMS, TO WHICH I
REQUESTED CLARRIFICATION.  THANKS AGAIN FOR THE WORK ON THIS ONE, I
HOPE THAT SHARING IT WITH OUR CHILDREN WILL HELP THEM FULLY UNDERSTAND
AND ' APPRECIATE' THE SEVERITY OF HIS CURRENT CONDITION, AND THE LONG
ROAD HE STILL HAS TO TRAVEL.

This sounds like a difficult time for you. I admire your efforts to
care for your husband. I just wanted to offer the little information
that I know. The basal ganglia are important structures mainly for
movement (they are what are affected in parkinsons disease and
huntingtons disease-- parkinsons causes hypokinesia, and huntington's
causes kyperkinesia), affecting fine motor movements and posture. This
is also why your husband was unable to speak-- the basal ganglia play
an important part in the speech pathway, and the stroke caused what's
called Broca's or Expressive Aphasia (affecting the left side of the
brain, important in speech, and hence the right side of the body). The
basal ganglia are also involved to a lesser extent in cognition, mood,
and behavior. This is because the basal ganglia connect with
prefrontal regions (thought) and limbic regions (emotion). Thus 1) his
ability to use verbal skills in problem solving, deciding on
behavioral responses, may be diminished 2) he may be more irritable,
labile, misunderstanding of social cues, and lack empathy, maybe even
displaying signs anywhere from obsessive-compulsive disorder to
depression, 3)be unable to initiate movement (the numbers here
represent different "cicuits" or neural pathways of the basal ganglia
that have been studied after being destroyed). The reason that the
symptoms didn't onset until after the stroke is that neuron
communication can actually tell the neurons to die long after the
first damage has been done. This is done through neurotransmitters
such as glutamate as well as calcium signals and inflammation. Once
the neurons are damaged, they really cannot be repaired. Hence his
condition is already a quite permanent one. Some improvement may be
able to happen, but only if neurons are able to establish new
connections. Anyway, surely these conditions will be not only
frustrating to you, but also to him, and you will both probably have
to learn how to deal with it. This can be very difficult, and seeing
as I have not gone through such a thing myself, I'm sure there are
others out there who could respond to that part of your questions
better than I. Also I think discussing this with your children will
help you and them a lot. I hope this helps you understand more of the
neurological effects of the stroke.

PS-- you may want to be careful not to intake too much vitamin K, as
it inhibits the effects of coumadin and promotes coagulation. I was
going to say also that you should look into a thrombolytic drug, but
those are contraindicated if you've had a previous CVA or intracranial
process. You may consider an antiplatelet drug (like aspirin, 160
mg/day, no more than that is necessary since that amount completely
inactivates platelet cyclooxygenase for the life of the platelet,
about 7-10 days)-- make sure you talk with the doc first though, since
he knows your entire medical history, and since the major danger with
these drugs is overdosing and bleeding to death). Hope that helps!

I believe your real question was how to live with a stroke victim.
These websites should be of some help:

www.stroke.org

http://www.caregiver-information.com

I would recommend seeking out a support group to help cope with his
behavior's affect on you.  Depression is extremely common in stroke
victims and that could only affect you as well. If he is depressed and
your physician is unaware, bring this to his attention. This man you
love has changed (perhaps not permanantly), but he is still a man. 
Treat him with respect and tolerance and remain optimistic. Do not
forget to take time for yourself and ask your family for added moral
support.  Also, with your physician's approval (depending on your
spouse's condition), he could be retrained to drive, regaining some of
his independence.

Best wishes,

S.L.D. Cowen