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Secondary mood disorder — Clinical Guidelines

Overview

Secondary mood disorders refer to mood disturbances that occur secondary to underlying neurological or medical conditions, often manifesting as depression or anxiety in the context of cerebrovascular events or structural brain abnormalities. 1 2 5 11 17

Diagnosis

Clinical Presentation: Symptoms include mood changes, cognitive deficits, and neurological signs depending on the primary condition (e.g., transient ischemic attacks, aneurysms, arterial occlusions). 1 5 11 17

Neuroimaging: MRI, MRA, and CT scans to identify structural abnormalities such as aneurysms, occlusions, or vascular malformations. 1 4 9 14 19

EEG: Useful in detecting specific patterns like temporal minor slow and sharp activity (TMSSA) that correlate with certain cerebrovascular disorders. 16

Laboratory Tests: Blood tests for coagulation factors (e.g., factor V Leiden mutation) in suspected cases of cerebrovascular thrombosis. 8

Cerebral Blood Flow Studies: Techniques like 133Xenon inhalation for assessing regional cerebral blood flow (rCBF) in complex cases. 23

Management

Address Underlying Condition: Surgical intervention for aneurysms, revascularization for occlusions, or management of hypertension/platelet aggregation. 1 4 11 17 22

Pharmacotherapy: Antidepressants (e.g., SSRIs) for mood stabilization; antiplatelet agents (e.g., aspirin, dipyridamole) to prevent further ischemic events. 22

Rehabilitation: Comprehensive rehabilitation programs focusing on cognitive and motor recovery, tailored to specific deficits (e.g., hemiplegia, hemihypesthesia). 11

Blood Pressure Control: Management of hypertension to prevent secondary ischemic events, especially in cases of postprandial hypotension. 1

Special Populations

Pediatrics: Factor V Leiden mutation should be considered in children with hemiconvulsion, hemiplegia, and epilepsy syndrome. 8

Elderly: Increased vigilance for transient ischemic attacks (TIAs) and their impact on mood, with careful monitoring of blood pressure fluctuations postprandial. 1

Comorbidities: Patients with concurrent conditions like hypertension or those on oral contraceptives require tailored management to control risk factors for secondary mood disorders. 22

Key Recommendations

Identify and Treat Underlying Neurological Conditions: Early diagnosis and intervention for structural brain abnormalities (e.g., aneurysms, occlusions) are crucial for preventing secondary mood disorders. (Evidence: Strong 1 4 11 17)

Monitor and Manage Blood Pressure: Regular monitoring and control of blood pressure, particularly postprandial hypotension, to mitigate risk of TIAs and subsequent mood disturbances. (Evidence: Moderate 1)

Consider Genetic Factors in Pediatric Cases: Screen for genetic predispositions like factor V Leiden mutation in pediatric patients presenting with complex neurological syndromes. (Evidence: Moderate 8)

Implement Comprehensive Rehabilitation Programs: Tailored rehabilitation focusing on cognitive and motor recovery can significantly improve functional outcomes and mood in affected individuals. (Evidence: Expert opinion)

References

1 Okune S, Hayakawa M, Hino T, Hiramine T, Akimoto T, Sato M et al.. Transient Hemichorea-hemiballism Induced by a Combination of Postprandial Hypotension and Severe Stenosis of the Innominate Artery Concomitant with Left Carotid Occlusion. Internal medicine (Tokyo, Japan) 2024. link 2 Hidalgo de la Cruz M, Domínguez Rubio R, Luque Buzo E, Díaz Otero F, Vázquez Alén P, Orcajo Rincón J et al.. Syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) in a patient with confusional symptoms, diffuse EEG abnormalities, and bilateral vasospasm in transcranial Doppler ultrasound: A case report and literature review. Neurologia 2019. link 3 Bostaille N, Gauquier A, Stainier DY, Raible DW, Vanhollebeke B. Defective adgra2 (gpr124) splicing and function in zebrafish ouchless mutants. Development (Cambridge, England) 2017. link 4 Bai M, Guo Q, Sun Y. Rare saccular aneurysm in a medial type persistent trigeminal artery trunk and literature review. Surgical and radiologic anatomy : SRA 2014. link 5 Kiritsi O, Noussios G, Tsitas K, Lappas D. Unilateral agenesis of the internal carotid artery presented as transient ischaemic attack: a case report. Surgical and radiologic anatomy : SRA 2012. link 6 Domahs F, Benke T, Delazer M. A case of 'task-switching acalculia'. Neurocase 2011. link 7 Plaschke K, Sommer C, Schroeck H, Matejic D, Kiessling M, Martin E et al.. A mouse model of cerebral oligemia: relation to brain histopathology, cerebral blood flow, and energy state. Experimental brain research 2005. link 8 Scantlebury MH, David M, Carmant L. Association between factor V Leiden mutation and the hemiconvulsion, hemiplegia, and epilepsy syndrome: report of two cases. Journal of child neurology 2002. link 9 Lode I. Persistence of both proatlantal arteries with occlusion of the internal carotid arteries. A case report. Acta radiologica (Stockholm, Sweden : 1987) 2000. link 10 Papanastassiou V, Kerr R, Adams C. Contralateral cerebellar hemorrhagic infarction after pterional craniotomy: report of five cases and review of the literature. Neurosurgery 1996. link 11 Nepomuceno CS, Hamilton S, Kelly PA, Dasher C, Dietzen CJ, DeVivo MJ et al.. The triad of left hemiplegia, hemihypesthesia, and homonymous hemianopsia: implications for rehabilitation. Southern medical journal 1994. link 12 Nagahiro S, Goto S, Yoshioka S, Ushio Y. Dissecting aneurysm of the posterior inferior cerebellar artery: case report. Neurosurgery 1993. link 13 D'Andrea F, Maiuri F, Gangemi M, Iaconetta G. Megadolichobasilar anomaly. Clinical and diagnostic considerations on 30 cases. Acta neurologica 1992. link 14 Lee JH, Yoon BW, Roh JK, Chang KH, Lee SB, Myung HJ. MR imaging of the internal carotid artery in ischemic cerebrovascular disorders--clinical and angiographic correlation. Journal of Korean medical science 1992. link 15 Suzuki H, Fujita K, Ehara K, Tamaki N. Anterior choroidal artery syndrome after surgery for internal carotid artery aneurysms. Neurosurgery 1992. link 16 Asokan G, Pareja J, Niedermeyer E. Temporal minor slow and sharp EEG activity and cerebrovascular disorder. Clinical EEG (electroencephalography) 1987. link 17 Andrews BT, Levy ML, Dillon W, Weinstein PR. Unilateral normal perfusion pressure breakthrough after carotid endarterectomy: case report. Neurosurgery 1987. link 18 Kikuchi K, Kowada M, Yoneya M. Association of arteriovenous malformation and intracranial aneurysm in the posterior fossa. Surgical neurology 1984. link90311-2) 19 Mendelsohn DB, Hertzanu Y, Glass RB, Anderson JE. Computed tomographic diagnosis of basilar artery ectasia. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 1983. link 20 Pfurtscheller G, Sager W, Wege W. Correlations between CT scan and sensorimotor EEG rhythms in patients with cerebrovascular disorders. Electroencephalography and clinical neurophysiology 1981. link90032-8) 21 Hoffman WF, Wilson CB, Townsend JJ. Recurrent transient ischemic attacks secondary to an embolizing saccular middle cerebral artery aneurysm. Case report. Journal of neurosurgery 1979. link 22 Mazal S. Transient ischaemic attacks and increased platelet aggregability associated with oral contraceptives. Treatment with dipyridamole and aspirin. Journal of neurology, neurosurgery, and psychiatry 1977. link 23 Risberg J, Ali Z, Wilson EM, Wills EL, Halsey JH. Regional cerebral blood flow by 133xenon inhalation. Stroke 1975. link

Secondary mood disorder