Bibliometric and visual analysis of post-stroke hemiplegia in the past 20 years

Objective:The purpose of this study is to use CiteSpace software to examine the development patterns and hotspots in post-stroke hemiplegia research during the last 20 years.Methods:Articles about post-stroke hemiplegia from January 2005 to December 2024 were analyzed in the Web of Science database.CiteSpace software was used to conduct co-citation analysis of the articles about post-stroke hemiplegia as well as cooperative network analyses of authors,countries,and institutions,as well as keyword co-occurrence,clustering,emergence,and time line analyses.The results were displayed in a visual atlas.Result:A total of 2625 papers were obtained,and there were more publications overall.China and the United States had the most number of articles,while Chae,John was the author with the most number of articles.Capital Med University and Ohio State University had the most articles among their agencies.The keywords"stroke"and"rehabilitation"were used the most.The key word analysis indicates that the present study focus is on exercise rehabilitation measures and post-stroke treatment.Conclusion:Using CiteSpace software to analyze the literature on post-stroke hemiplegia,it is discovered that the use of new technologies in the field of mechanical thrombectomy and the effectiveness of rehabilitation techniques like mirror treatment are the key areas of study attention.This study has positive significance for finding safer and more effective treatments for post-stroke hemiplegia.

Effectiveness on post-stroke hemiplegia in patients:electroacupuncture plus cycling vs electroacupuncture alone

OBJECTIVE:To evaluate the effectiveness of cycling in combination with electroacupuncture in treatment of poststroke hemiplegia patients at National Hospital of Acupuncture,Vietnam.METHODS:The study was designed as a single-centre,outcome-assessor-blinded parallel randomised controlled trial with 120 post-stroke hemiplegia patients randomly assigned into two groups:electroacupuncture plus cycling(CT group) and electroacupuncture(AT group).Patients were assessed before and after the treatment(using muscle grading,modified Rankin,Barthel,Orgorozo scores and electromyography).Statistical Man–Whitney U test,and Fisher’s exact tests were used to compare between CT and AT groups.RESULTS:The results reported statistically significant improvement in motor function in patients suffering from hemiplegia following ischemic stroke in both CT and AT groups.Patients in CT group experienced a greater improvement compared to those in AT group including better muscle contraction(increased frequency and amplitude of electromyography and increased muscle grading scale);increased recovery(Orgogozo scale),increased independency(Barthel scale) and decreased disability(Modified Rankin scale)(P < 0.01).CONCLUSIONS:Combination with cycling training significantly improves the recovery of post-stroke patients treated with electroacupuncture.

Electroencephalogram findings in 10 patients with post-stroke epilepsy:A retrospective study

BACKGROUND Post-stroke epilepsy is a common and easily overlooked complication of acute cerebrovascular disease.Long-term seizures can seriously affect the prognosis and quality of life of patients.Electroencephalogram(EEG)is the simplest way to diagnose epilepsy,and plays an important role in predicting seizures and guiding medication.AIM To explore the EEG characteristics of patients with post-stroke epilepsy and improve the detection rate of inter-seizure epileptiform discharges.METHODS From January 2017 to June 2020,10 patients with post-stroke epilepsy in our hospital were included.The clinical,imaging,and EEG characteristics were collected.The stroke location,seizure type,and ictal and interictal EEG manifestations of the patients with post-stroke epilepsy were then retrospectively analyzed.RESULTS In all 10 patients,epileptiform waves occurred in the side opposite to the stroke lesion during the interictal stage;these manifested as sharp wave,sharp-wave complex,or spike discharges in the anterior head lead of the side opposite to the lesion.CONCLUSION In EEG,epileptiform waves can occur in the side opposite to the stroke lesion in patients with post-stroke epilepsy.

Mechanism of acupuncture for limb spasm of post-stroke spasticity based on GABA and BDNF/Trkb-KCC2 signaling pathway

Background:To investigate the effects of acupuncture on post-stroke limb spasm model rats and the underlying mechanism.Methods:A total of 50 Sprague-Dawley rats were randomly divided into three groups,Control group(10),Model group(20)and Zhishen Tiaoxing(ZSTX)acupuncture group(20).Middle cerebral artery occlusion was conducted in SD rats to establish post-stroke limb spasm rats,which were treated with ZSTX acupuncture.Behavioral assays were determined by the Narrow ally test,the limb muscle tension was detected by the BL-420S test system,and infarct volume was assessed after the cerebral infarction by 2,3,5-triphenyltetrazolium chloride staining.Heterogeneous neurotransmitterγ-aminobutyric acid(GABA)and its receptors GABAA and GABAB in the cerebral cortex of the infarct area were determined by immunofluorescence assay.The release of Trkb and K-Cl cotransporter isoform 2 was detected by an immunofluorescence double labeling study.Western Blot was utilized to measure the expression of BDNF and Trkb.Results:The results showed that the behavioral assays in post-stroke limb spasm rats were significantly improved by the treatment of ZSTX acupuncture.14 days of ZSTX acupuncture can effectively inhibit muscle tone and decrease Infarct volume,which was measured with BL-420S biological function experiment system and triphenyltetrazolium chloride.Meanwhile,the results of Double-Label Immunofluorescence Assays showed that ZSTX acupuncture improved the expression of GABA,GABAA,GABAB,BDNF,and K-Cl cotransporter isoform 2.Double-Label Immunofluorescence Assays and WB results showed that 14 days ZSTX acupuncture declined the expression of Trkb.Conclusions:Our results suggest that 14 days of ZSTX acupuncture can significantly improve post-stroke limb spasm.Meanwhile,the pathogenesis of post-stroke limb spasm and the efficacy of ZSTX acupuncture involve metabolic pathways of neurotransmitters,and electro-acupuncture can treat post-stroke limb spasm by regulating BDNF/Trkb-KCC2 signaling pathway.

Early screening for post-stroke depression and its effect on functional outcomes, quality of life, and mortality: A meta-analysis

BACKGROUND Post-stroke depression(PSD)is a common and debilitating condition affecting stroke survivors,significantly impacting their recovery and overall quality of life.AIM To assess the effects of early PSD screening on functional outcomes,quality of life,and mortality.METHODS From an initial pool of 1065 articles,6 studies met the inclusion criteria and were selected for analysis.Functional outcomes were measured using the functional independence measure(FIM).RESULTS The analysis revealed a significant improvement in FIM scores for a PSD scree-ning group compared to controls[standardized mean difference(SMD)=8.90,95%confidence interval(CI):4.65-13.15,P<0.01].Quality of life was assessed using the Stroke-Specific Quality of Life Scale,with the screening group showing significantly higher scores(SMD=20.83,95%CI:15.27-26.38,P<0.01).Mortality analysis indicated a reduction in five-year mortality rates for the PSD screening group.CONCLUSION Early PSD screening enhances functional recovery,improves quality of life,and reduces mortality rates in stroke survivors.Thus,integrating PSD screening into routine stroke care improves long-term outcomes for patients.

Impact of extended nursing model after multi-disciplinary treatment on young patient with post-stroke

BACKGROUND Stroke has become one of the most serious life-threatening diseases due to its high morbidity,disability,recurrence and mortality rates.AIM To explore the intervention effect of multi-disciplinary treatment(MDT)extended nursing model on negative emotions and quality of life of young patients with post-stroke.METHODS A total of 60 young stroke patients who were hospitalized in the neurology department of our hospital from January 2020 to December 2021 were selected and randomly divided into a control group and an experimental group,with 30 patients in each group.The control group used the conventional care model and the experimental group used the MDT extended nursing model.After the inhospital and 3-mo post-discharge interventions,the differences in negative emotions and quality of life scores between the two groups were evaluated and analyzed at the time of admission,at the time of discharge and after discharge,respectively.RESULTS There are no statistically significant differences in the negative emotions scores between the two groups at admission,while there are statistically significant differences in the negative emotions scores within each group at admission and discharge,at discharge and post-discharge,and at discharge and post-discharge.In addition,the negative emotions scores were all statistically significant at discharge and after discharge when compared between the two groups.There was no statistically significant difference in quality of life scores at the time of admission between the two groups,and the difference between quality of life scores at the time of admission and discharge,at the time of discharge and post-discharge,and at the time of admission and post-discharge for each group of patients was statistically significant.CONCLUSION The MDT extended nursing mode can improve the negative emotion of patients and improve their quality of life.Therefore,it can be applied in future clinical practice and is worthy of promotion.

Scalp-cluster acupuncture with electrical stimulation can improve motor and living ability in convalescent patients with post-stroke hemiplegia

OBJECTIVE: To determine whether patients with post-stroke hemiplegia could benefit from long-term treatment with scalp cluster(SC) acupuncture combined with electrical stimulation(ES)and to evaluate the feasibility of this treatment to improve motor and living abilities.METHODS: Twenty patients were enrolled and divided into two groups: SC acupuncture and SC acupuncture with ES(SC and SC + ES, respectively). All participants also received rehabilitation training.All participants were blindly evaluated using the Fugl-Meyer assessment scale for motor ability, the modified Barthel Index for living ability, and a scale for the degree of neurological deficits. Outcome was assessed at three points before randomized grouping, at the beginning or treatment, and after4 weeks of treatment.RESULTS: Following 4 weeks treatment, all the patients exhibited significant improvements in aspects of motor ability, living ability, and the severity of neurological deficits. The experimental group(SC + ES) scored higher on the Fugl-Meyer assessment scale(68 ± 12) and the modified Barthel Index(49 ± 9) than the control(SC) group(50 ± 13,36 ± 13, respectively).CONCLUSION: When patients with post-stroke hemiplegia are treated using SC acupuncture with ES, motor and living ability can improve more than if they were treated with SC acupuncture alone.

Effect of Combined Jin's Three-needle and Rehabilitation Care on Post-stroke Hemiplegia

Objective:To observe and compare the efficacy differences between combined Jin's three-needle and rehabilitation training and rehabilitation training alone for hemiplegia following an ischemic stroke. Methods:A total of 94 cases who met the inclusion criteria were randomized into an observation group using combined Jin's three-needle and rehabilitation training and a control group using rehabilitation training alone. The therapeutic efficacies were then assessed respectively before treatment, 14 d and 28 d after treatment using neurological deficient scale (NDS) and short-form Fugl-Meyer assessment (SFFMA) scale. Results:After treatment, the NDS and SFFMA scores in both groups were significantly improved (P<0.05); after 28-day treatment, the inter-group comparison showed a statistical significance (P<0.05). Conclusion:Combined Jin's three-needle and rehabilitation training and rehabilitation training alone can both enhance the nerve function recovery of patients with post-stroke hemiplegia and improve their motor function; however, the former could obtain better effects than the latter.

P25/CDK5-mediated Tau Hyperphosphorylation in Both Ipsilateral and Contralateral Cerebra Contributes to Cognitive Deficits in Post-stroke Mice

Objective Post-stroke cognitive impairment(PSCI)develops in approximately one-third of stroke survivors and is associated with ingravescence.Nonetheless,the biochemical mechanisms underlying PSCI remain unclear.The study aimed to establish an ischemic mouse model by means of transient unilateral middle cerebral artery occlusions(MCAOs)and to explore the biochemical mechanisms of p25/cyclin-dependent kinase 5(CDK5)-mediated tau hyperphosphorylation on the PSCI behavior.Methods Cognitive behavior was investigated,followed by the detection of tau hyperphosphorylation,mobilization,activation of kinases and/or inhibition of phosphatases in the lateral and contralateral cerebrum of mice following ischemia in MACO mice.Finally,we treated HEK293/tau cells with oxygen-glucose deprivation(OGD)and a CDK5 inhibitor(Roscovitine)or a GSK3βinhibitor(LiCl)to the roles of CDK5 and GSK3βin mediating ischemia-reperfusion-induced tau phosphorylation.Results Ischemia induced cognitive impairments within 2 months,as well as causing tau hyperphosphorylation and its localization to neuronal somata in both ipsilateral and contralateral cerebra.Furthermore,p25 that promotes CDK5 hyperactivation had significantly higher expression in the mice with MCAO than in the shamoperation(control)group,while the expression levels of protein phosphatase 2(PP2A)and the phosphorylation level at Tyr307 were comparable between the two groups.In addition,the CDK5 inhibitor rescued tau from hyperphosphorylation induced by OGD.Conclusion These findings demonstrate that upregulation of CDK5 mediates tau hyperphosphorylation and localization in both ipsilateral and contralateral cerebra,contributing to the pathogenesis of PSCI.

Effect of Needle-retaining Time on Therapeutic Efficacy for Post-stroke Hemiplegia

Objective： To observe the effect of needle-retaining time in scalp acupuncture on therapeutic efficacy for post-stroke hemiplegia. Methods： A total of 82 cases who met the inclusion criteria were randomly allocated into a control group （22 cases）, a short-time needle- retaining group （30 cases） and a long-time needle-retaining group （30 cases）. Conventional Bobath therapy was employed in the control group while the scalp acupuncture was combined in the short-time （0.5 h） needle-retaining group and long-time （24 h） needle-retaining group. Then functional assessments were made 1 month and 3 months after treatment using FugI-Meyer motor scale {FMMS）, FugI-Meyer assessment of balance （FMA-B） and modified Barthel index （MBI） score. Results： Cases in the long-time needle-retaining group obtained better effects in motor function of the limbs and activities of daily living （ADL） than the other two groups （P〈0.05）. In addition, there was no statistical significance between the short-time needle-retaining group and the control group （P〉0.05）. Conclusion： The needle-retaining time in scalp acupuncture is substantially associated with the effect for post-stroke hemiplegia and long-time needle-retaining is more advisable.

“Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality,complications,or outcomes”:Commentary

In this commentary,we summarize some of the key points of the original paper“Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality,complications,or outcomes”and offer support for the proposed results.Specifically,we address how early percutaneous endoscopic gastrostomy(PEG)tube placement may reduce hospital length of stay and costs.We also discuss topics related to the article including PEG weaning and post-stroke nutritional formulation.However,we note that concerns purported by previous studies that early PEG placement may worsen outcomes are not fully addressed,and further research is needed.

Perspectives on multidimensional assessment of post-stroke sequelae: fromclinimetrics to holism

In this work,we intended to connect clinimetrics with holism in traditional Chinese medicine towards multidimensional assessment of post-stroke sequelae in real-world setting,as a bridge between inheritance and innovation.Firstly,a systematic search of current evidence that supported integrated treatment of traditional Chinese and Western medicine for post-stroke sequelae sufferers was performed.Secondly,on the basis of available evidence,we presented couples of implications.Lastly,as psychosomatic perspective is one of the main academic paradigms of traditional Chinese medicine holism,we chiefly proposed comprehensive assessment for both motor and non-motor severities to probably match consonance with traditional Chinese medicine practice that treats psycho-/somatic-complains simultaneously.

Clinical Study of Acupuncture Combined with Emotional Intervention in Patients with Post-Stroke Depression

Objective:To investigate the clinical efficacy of acupuncture combined with emotional intervention in patients with post-stroke depression(PSD).Methods:A total of 100 patients with PSD who met the inclusion criteria were randomly divided into an experimental group(50 cases)and a control group(50 cases)using the random number table method,and the enrollment was in order of admission time.The control group used conventional treatment of oral antidepressant Deanxit tablets(0.5 mg flupenthixol+10 mg melitracen)with the dose appropriately adjusted according to the patient’s medication effect,and modern rehabilitation treatment given selectively according to the patient’s condition.The experimental group had similar treatment as the control group with the addition of traditional Chinese medicine(TCM)acupuncture combined with emotional intervention.The application effects of both groups before and after treatment were verified using the Hamilton Depression Rating Scale(Ham-D),National Institutes of Health Stroke Scale(NIHSS),and Activities of Daily Living(ADL),serotonin levels were measured,and statistical analyses were carried out.Results:The total effective rate of patients in the experimental group was significantly higher than that in the control group,and the Ham-D score,NIHSS score,ADL score,and serotonin level after treatment were significantly higher than those in the control group,and the difference between the two groups was statistically significant(P<0.05).Conclusion:For patients with PSD,adding TCM acupuncture with emotional intervention on top of conventional treatment significantly improve the clinical efficacy and better improve the daily life ability of patients.

The Promoting Role of TCM Nursing in the Rehabilitation of Stroke Hemiplegia Patients

Objective: To explore the promoting function of TCM nursing in the rehabilitation of hemiplegia patients with stroke. Methods: 78 stroke hemiplegic patients admitted from April 2022 to April 2024 were randomly divided into a control group of 38 cases who received routine care, and an experimental group of 40 cases who received routine nursing basis plus traditional Chinese medicine nursing;the nursing effects of the two groups of patients were compared. Results: After 12 days of nursing care, the experimental group showed better psychological status [SAS score (21.71 ± 3.21), SDS score (22.18 ± 2.31)], limb motor function, daily living ability, and neurological function [NIHSS score (12.23 ± 2.21)] than the control group, with significant differences in data (P Conclusion: Traditional Chinese medicine nursing for stroke hemiplegia patients is more conducive to promoting rehabilitation than routine nursing.

Effects of Acupuncture and Tuina Combined with Rehabilitation Therapy on Oxidative Stress Response and Motor Function in Stroke Hemiplegia Patients

Objective:To explore the effects of acupuncture and tuina combined with rehabilitation therapy on oxidative stress response and motor function in stroke hemiplegia patients.Methods:Sixty stroke hemiplegia patients were randomly divided into observation and control groups,with 30 cases each.The control group received conventional rehabilitation therapy,while the observation group also underwent acupuncture and tuina.After 8 weeks of treatment,oxidative stress indicators[malondialdehyde(MDA),superoxide dismutase(SOD),glutathione peroxidase(GSH-Px)],neurological deficit scores(NIHSS),Fugl-Meyer motor function scores(FMA),and activities of daily living(Barthel Index)were compared between the two groups.Results:Before treatment,there were no significant differences in MDA,NIHSS scores,FMA scores,and Barthel Index between the two groups(P>0.05).After 8 weeks,the observation group had lower MDA and NIHSS scores,but higher SOD,GSH-Px,FMA scores,and Barthel Index compared to the control group,with statistically significant differences(P<0.05).Conclusion:Acupuncture and tuina combined with rehabilitation therapy can effectively improve oxidative stress levels,promote neurological recovery,enhance motor function,and improve daily living activities in stroke hemiplegia patients.This combined therapy is recommended for clinical application.

Analyzing the Combination Effects of Repetitive Transcranial Magnetic Stimulation and Motor Control Training on Balance Function and Gait in Patients with Stroke-Induced Hemiplegia

Objective:To analyze the effects of repetitive transcranial magnetic stimulation combined with motor control training on the treatment of stroke-induced hemiplegia,specifically focusing on the impact on patients’balance function and gait.Methods:Fifty-two cases of hemiplegic stroke patients were randomly divided into two groups,26 in the control group and 26 in the observation group,using computer-generated random grouping.All participants underwent conventional treatment and rehabilitation training.In addition to these,the control group received repetitive transcranial magnetic pseudo-stimulation therapy+motor control training,while the observation group received repetitive transcranial magnetic stimulation therapy+motor control training.The balance function and gait parameters of both groups were compared before and after the interventions and assessed the satisfaction of the interventions in both groups.Results:Before the invention,there were no significant differences in balance function scores and each gait parameter between the two groups(P>0.05).However,after the intervention,the observation group showed higher balance function scores compared to the control group(P<0.05).The observation group also exhibited higher step speed and step frequency,longer step length,and a higher overall satisfaction level with the intervention compared to the control group(P<0.05).Conclusion:The combination of repetitive transcranial magnetic stimulation and motor control training in the treatment of stroke-induced hemiplegia has demonstrated positive effects.It not only improves the patient’s balance function and gait but also contributes to overall physical rehabilitation.

Comprehensive Rehabilitation Therapy of Traditional Chinese Medicine Combined with Modern Rehabilitation Training Improves the Spasticity and Motor Function of Hemiplegia after Stroke

Objective:To analyze the impact of comprehensive rehabilitation therapy of traditional Chinese medicine(TCM)(based on modern rehabilitation training)on the spasticity and motor function in stroke patients with hemiplegia.Methods:Seventy-nine stroke and hemiplegia patients admitted to the hospital from June 2021 to June 2023 were selected and randomly divided into a control group(39 cases)using modern rehabilitation training,and an observation group combined with comprehensive TCM rehabilitation therapy(40 cases),over 1 month.The clinical index data of the two groups were compared.Results:There were differences in the clinical index data between the two groups.The total effective rate after 2 treatment in the observation group(92.50%)was higher than that of the control group(74.36%)(χ^(2)=4.727,P<0.05).All central sensitization inventory(CSI)and stroke quality of life(PRO)scores in both groups were lower after treatment,with the observation group having lower scores as compared to the control group(P<0.05).The scores of FMA(upper limbs,lower limbs),Barthel index scores,and Functional Ambulation Categories(FAC)scores of both groups increased after treatment,with the observation group having higher scores as compared to the control group(P<0.05).Conclusion:Comprehensive TCM rehabilitation therapy had a significant therapeutic effect on patients with hemiplegia after stroke.It improved the patient’s spasticity,limb movement,and walking function.Their daily living abilities and quality of life were also enhanced.

CLINICAL STUDY ON THE TREATMENT OF POST-STROKE DEPRESSION WITH ELECTROACUPUNCTURE OF “NIWAN BAZHEN” POINTS

Objective To observe the therapeutic effect of electroacupuncture （EA） of ＂Niwan Bazhen＂ points in the treatment of post-stroke depression. Methods A total of 66 post-stroke depression patients were randomized into treatment group （EA＋oral administration of Prozac-20, n =31 ） and control group （o- ral administration of Prozac-20, 20 mg/d, 28 days altogether, n =30）. For patients of treatment group, EA （2/100 Hz, a tolerable stimulation strength） was applied to ＂Niwan Bazhen＂ points [Baihui （百会 GV20）, etc. ] for 30 min, once daily, （except weekends） continuously for one month. Halmiton Rating Scale （HAMD） for Depression and Chinese Scale for Stroke （CSS） were used to evaluate the therapeutic effect. Results After the treatment, of the 30 and 31 cases in control and treatment groups, 4 and 6 were cured, 10 and 14 experienced marked improvement.in their symptoms, 6 and 7 had an improvement, 6 and 4 failed, with the cure＋ markedly effective rates being 46.7% and 64.5% respectively. The therapeutic effect of treatment group was significantly superior to that of control group （ P〈0.05）. The decreased values of both HAMD and C,,SS of treatment group were remarkably lower than those of control group （P〈0.01,0.05） . Conclusion EA of ＂Niwan Bazhen＂ points is an effective remedy for post-stroke depression.

Central post-stroke pain due to injury of the spinothalamic tract in patients with cerebral infarction： a diffusion tensor tractography imaging study

Many studies using diffusion tensor tractography（DTT） have demonstrated that injury of the spinothalamic tract（STT） is the pathogenetic mechanism of central post-stroke pain（CPSP） in intracerebral hemorrhage; however, there is no DTT study reporting the pathogenetic mechanism of CPSP in cerebral infarction. In this study, we investigated injury of the STT in patients with CPSP following cerebral infarction, using DTT. Five patients with CPSP following cerebral infarction and eight age-and sex-matched healthy control subjects were recruited for this study. STT was examined using DTT. Among DTT parameters of the affected STT, fractional anisotropy and tract volume were decreased by more than two standard deviations in two patients（patients 1 and 2） and three patients（patients 3, 4, and 5）, respectively, compared with those of the control subjects, while mean diffusivity value was increased by more than two standard deviations in one patient（patient 2）. Regarding DTT configuration, all affected STTs passed through adjacent part of the infarct and three STTs showed narrowing. These findings suggest that injury of the STT might be a pathogenetic etiology of CPSP in patients with cerebral infarction.

miR-137, a new target for post-stroke depression?

Expression of miR-137 is downregulated in brain tissue from patients with depression and suicidal behavior, and is also downregulated in peripheral blood from stroke patients. However, it is not yet known if miR-137 acts as a bridge between stroke and depression. To test this, we used middle cerebral artery occlusion and chronic mild stress to establish a post-stroke depression model in rats. Compared with controls, we found significantly lower miR-137 levels in the brain and peripheral blood from post-stroke depression rats. Injection of a miR-137 antagonist into the brain ventricles upregulated miR-137 levels, and improved behavioral changes in post-stroke depression rats. Luciferase assays showed miR-137 bound to the 3＇UTR of Grin2A, regulating Grin2A expression in a neuronal cell line. Grin2A gene overexpression in the brain of post-stroke depression rats, no- ticeably suppressed the inhibitory effect of miR-137 on post-stroke depression. Overall, our results show that miR-137 suppresses Grin2A protein expression through binding to Grin2A mRNA, thereby exerting an inhibitory effect on post-stroke depression. Our results offer a new therapeutic direction for post-stroke depression.