Clinical implications of poststroke hypothalamo-pituitary adrenal axis dysfunction: A critical literature review

Persistent hypothalamo-pituitary adrenal axis dysregulation occurs in up to 40% of patients who have suffered a stroke. The degree of hypercortisolemia is partly determined by the size and site of the vascular lesion. Adrenocortical hyperactivity begins almost immediately after a cerebrovasacular infarct but is persistent in an important subgroup of patients. In the early poststroke period (1 day to 1 month) high corticosteroid levels correlate with the presence of an acute confusional state. In the medium term (1 month to 1 year) hypercortisolemia is associated with the development of a major depressive episode and also relates to functional outcome and survival. Neuroanatomical deficits (particularly in the frontal or medial temporal lobes), age of onset, cognitive impairment, and reduced functional status may act as maintaining factors in both the poststroke depression and the adrenocortical hyperactivity. Patients with persisting hypercortisolemia, with or without depression or cognitive impairment, have a worse prognosis with an increased mortality rate. The mechanism for this effect may involve induced hyperglycemia or direct glucocorticoid neurotoxicity, which impairs the brain's capacity for recovery. It is suggested that the cautions use of antiglucocorticoid strategies may be of value in the medical management of the neuropsychiatric complications that follow cerebrovascular accidents.