Subjective fatigue, defined as a feeling of early exhaustion developing during mental activity, with weariness, lack of energy and aversion to effort, remains virtually unstudied in patients with stroke, bur recent surveys suggest that it is a major, commonly overlooked, stroke sequela. While the few existing series did not show significant correlations between fatigue and stroke severity, lesion location, cognitive and neurological impairment and depression, recent neurobehavioral studies have highlighted an association between fatigue and brainstem and thalamic lesions. This suggests that fatigue may be linked to the interruption of neural networks involved in tonic attention, such as the reticular activating system. In fact, several subtypes of fatigue may develop after stroke, in connection with cognitive sequelae, neurological impairment, psychological factors and sleep disorders. A challenge is to identify and delineate these different subtypes and to distinguish them from mood disorders, which frequently coexist. We emphasize the concept of ‘primary’ poststroke fatigue, which may develop in the absence of depression or a significant cognitive sequela, and which may be linked to attentional deficits resulting from specific damage to the reticular formation and related structures involved in the subcortical attentional network. In the patients with excellent neurological and neuropsychological recovery, poststroke fatigue may be the only persisting sequela, which may severely limit their return to previous activities. The recognition of poststroke fatigue may be critical during recovery and rehabilitation after stroke.

Keywords:
Fatigue, Depression, Stroke outcome, Quality of life
1.
Beard G: Neurasthenia, or nervous exhaustion. Boston Med Surg J 1869;3:217–221.
2.
Holmes GP, Kaplan JE, Ganz NM, Komaroff AL, Schonberger LB, Strauss SE, Jones JF, Dubois RE, Cunningham-Rundles C, Pahwa S, Tosato G, Zegans LS, Purtilo DT, Brown N, Schooley RT, Brus I: Chronic fatigue syndrome: A working case definition. Ann Intern Med 1988;108:387–389.
3.
Colosimo C, Millefiorini E, Grasso MG, Vinci F, Fiorelli M, Koudriavtseva T, Pozzili C: Fatigue in MS is associated with specific clinical features. Acta Neurol Scand 1995;92:353–355.
4.
Krupp LB, LaRocca NC, Muir-Nash J, Steinberg AD: The fatigue severity scale: Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol 1989;46:1121–1123.
5.
Vercoulen J, Hommes OR, Swanink C, Jongen P, Fennis J, Galama J, van der Meer JWM, Bleijenberg B: The measurement of fatigue in patients with multiple sclerosis: A multidimensional comparison with patients with chronic fatigue syndrome and healthy subjects. Arch Neurol 1996;53:642–649.
6.
Van der Werf SP, Jongen PJ, Lycklama A, Nijeholt GJ, Barkhof F, Hommes OR, Bleijenberg G: Fatigue in multiple sclerosis: Interrelations between fatigue complaints, cerebral MRI abnormalities and neurological disability. J Neurol Sci 1998;160:164–170.
7.
Colombo B, Martinelli Boneschi F, Rossi P, Rovartis M, Maderna L, Filippi M, Comi G: MRI and motor evoked potential findings in nondisabled multiple sclerosis patients with and without symptoms of fatigue. J Neurol 2000;247:506–509.
8.
Hess CW, Mills KR, Murray NMF, Schreifer TN: Magnetic brain stimulation: Central motor conduction studies in multiple sclerosis. Ann Neurol 1987;22:744–752.
9.
Chao CC, DeLaHunt M, Hu S, Close K, Peterson PK: Immunologically mediated fatigue: A murine model. Clin Immunol Immunolopathol 1992;64:161–165.
10.
Krupp LB, Coyle PK, Doscher C, Miller A, Cross AH, Jandorf L, Halper J, Johnson B, Morgante L, Grimson R: Fatigue therapy in multiple sclerosis: Results of a double-blind, randomized, parallel trial of amantadine, pemoline, and placebo. Neurology 1995;45:1956–1961.
11.
Friedman J, Friedman H: Fatigue in Parkinson’s disease. Neurology 1993;43:2016–2019.
12.
Owen AM, Roberts AC, Hodges JR, Summers BA, Polkey CE, Robbins TW: Contrasting mechanisms of impaired attentional set-shifting in patients with frontal lobe damage or Parkinson’s disease. Brain 1993;116:1159–1175.
13.
Bruno RL, Cohen JM, Galski T: The neuroanatomy of post-polio fatigue. Arch Phys Med Rehab 1994;75:498–504.
14.
Ingles JL, Eskes GA, Phillips SJ: Fatigue after stroke. Arch Phys Med Rehabil 1999;80:173–178.
15.
Fisk JD, Ritvo PG, Ross L, Haase DA, Marrie TJ, Schlech WF: Measuring the functional impact of fatigue: Initial validation of the fatigue impact scale. Clin Infect Dis 1994;21:9–14.
16.
Brink TL, Yesavage JA, Lum O, Heersema P, Adey M, Rose TL: Screening test for geriatric depression. Clin Gerontol 1982;1:37–43.
17.
EC/IC Bypass Study Group: The international cooperative study of extracranial/intracranial arterial anastomosis. Stroke 1985;16:397–406.
18.
Mahoney FI, Barthel DW: Functional evaluation: The Barthel Index. Md Med J 1965;14:61–65.
19.
Bamford JM, Sandercock PAG, Warlow CP, Slattery J: Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1989;20:828.
20.
Leegaard OF: Diffuse cerebral symptoms in convalescents from cerebral infarction and myocardial infarction. Acta Neurol Scand 1983;67:348–355.
21.
Van Zandvoort MJE, Kappelle LJ, Algra A, De Haan EHF: Decreased capacity for mental effort after single supratentorial lacunar infarct may affect performance in everyday life. J Neurol Neurosurg Psychiatry 1998;65:697–702.
22.
Blanco M, Espinosa M, Arpa J, Barreiro P, Rodriguez-Albarino A: Hypersomnia and thalamic and brain stem stroke: A study of seven patients. Neurologia 1999;14:307–314.
23.
Mohsenin V, Valor R: Sleep apnea in patients with hemispheric stroke. Arch Phys Med Rehabil 1995;76:71–76.
24.
Gordon WA, Hibbard MR: Poststroke depression: An examination of the literature. Arch Phys Med Rehabil 1997;78:658–663.
25.
Starkstein SE, Robinson RG: Affective disorders and cerebral vascular disease. Br J Psychiatry 1989;154:170–182.
26.
Parikh RM, Lipsey JR, Robinson RG, Price TR: Two-year longitudinal study of poststroke mood disorders: Dynamic changes in correlates of depression at one and two years. Stroke 1987;18:579–584.
27.
Fedoroff JP, Starkstein SE, Parikh RM, Price TR, Robinson RG: Are depressive symptoms nonspecific in patients with acute stroke? Am J Psychiatry 1991;148:1172–1176.
28.
Malec JF, Richardson JW, Sinaki M, O’Brien MW: Types of affective response to stroke. Arch Phys Med Rehabil 1990;71:279–284.
29.
Staub F, Annoni JM, Bogousslavsky J: Fatigue after stroke: A pilot study. Cerebrovasc Dis 2000;10(suppl 2):62.
30.
Assal G: Batterie des examens neuropsychologiques du CHUV. Lausanne, 1985.
31.
Hamilton M: A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56–62.
32.
Bruno RL, Creange SJ, Frick NM: Parallels between post-polio fatigue and chronic fatigue syndrome: A common pathophysiology? Am J Med 1998;105(suppl 1):66–73.
33.
Stein PN, Sliwinsky MJ, Gordon WA, Hibbard MR: Discriminative properties of somatic and nonsomatic symptoms for post stroke depression. Clin Neuropsychol 1996;10:141–148.
34.
Pohjasvaara T, Leppavuori A, Siira I, Vataja R, Kaste M, Erkinjuntti T: Frequency and clinical determinants of poststroke depression. Stroke 1998;29:2311–2317.
35.
Williams LS, Weinberger M, Harris LE, Clark DO, Biller J: Development of a stroke-specific quality of life scale. Stroke 1999;30:1362–1369.
© 2001 S. Karger AG, Basel
2001
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