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Depression and an increased risk of suicide are well recognized after stroke1, and are more frequent than would be expected on the basis of disability alone2. Patients with symptomatic severe carotid stenosis or occlusion are also at high risk of depression, even in the absence of cerebral infarction3,4. However, the need to assess such risks in these patients is not mentioned in published guidelines5,6,7.
A man of 53 was referred to a neurology clinic with episodes of transient loss of vision in the left eye and episodes of clumsiness and weakness in his right arm. These usually lasted only a few seconds and tended to come on with exertion, suggesting low cerebral perfusion. There had been no previous cerebrovascular episodes, but he was a longterm heavy smoker, had had a myocardial infarction 5 years earlier and was on aspirin and was taking a lipid-lowering agent for hypercholesterolaemia. He lived with a partner and had no history of depression, self-harm or other psychiatric illness. However, later reports from family members suggested that he had become uncharacteristically depressed since the onset of his symptoms. Visual acuity in the left eye was 6/18, with evidence of ischaemic retinopathy. No other neurological or cardiovascular abnormality was found. Colour-flow doppler ultrasound of the internal carotid arteries showed complete occlusion on the left and 50% stenosis on the right. CT brain scan was normal.
Dipyridamole was added to the treatment and the patient was advised to stop smoking. In view of the carotid occlusion, he was not a candidate for carotid endarterectomy. The plan was to review his progress one month later and to consider anticoagulation or extracranial-intracranial bypass surgery if his symptoms persisted. Unfortunately the attacks continued and, although they did not change or increase in severity, he committed suicide by overdose before his next appointment.
Although it is impossible to be certain that this patient's medical condition led to his suicide, there seemed to be no other precipitant. According to relatives, his low mood started at around the same time as his symptoms, about three months before his death, and before any changes were made in his treatment.
In patients with stroke the risk of depression and suicide is high1,8,9. The reported frequency of depression after stroke ranges from 20% to 65%9, and frequencies of suicide are up to 14 times greater than expected1.
There is also evidence of an increased risk of depression in patients with symptomatic carotid artery stenosis who have had a transient ischaemic attack (TIA) rather than a stroke3,4,10. One study compared the frequency of symptoms of depression in elderly patients with stroke (n=25), symptomatic carotid stenosis with TIA (n=25) or non-vascular disease (n=25). Both the symptomatic carotid stenosis group and the stroke group had a significantly higher frequency of symptoms of depression than the non-vascular disease group, and there was a tendency for depression to occur more frequently in those patients with greater than 80% carotid stenosis3. Studies of cognitive impairment in TIA patients have also tended to show an association with severe carotid stenosis4,8,9,10.
The cause of psychological disturbance associated with carotid occlusive disease without stroke is not known. It is likely to be partly related to anxiety associated with symptoms and the worry about the risk of stroke, but it may also be directly related to chronic cerebral hypoperfusion. A case has been reported of a woman aged 72 presenting with severe depression who was found to have greater than 95% stenosis of her left internal carotid artery. Her depression had not responded to medical therapy but it resolved permanently and completely within four days of a left carotid endarterectomy11.
Although evidence of a link between carotid disease and depression is mainly anecdotal, our case report illustrates the need to be aware of the possibility of depression and the risk of suicide in patients with symptomatic severe carotid stenosis or occlusion. Guidelines on the management of patients with carotid occlusive disease do not currently mention the assessment of depression and suicide risk9,10,11. We suggest that these patients should be asked specifically about symptoms of depression so that appropriate therapy can be given. Further research is required to investigate the relationship between carotid stenosis and depression, and to identify the best method of treatment for these patients.