**6. Large strokes and the effect on poststroke depression**

In patients that suffer from large ischemic or hemorrhagic strokes, they are often left with a serious physical disability [2]. A proximal middle cerebral artery occlusion can result in severe expressive, or receptive aphasias, hemiparesis, facial weakness, sensory loss inability to swallow, neglect, apraxia, and a propensity toward developing seizures [34]. If the patient is relatively young, the probability of cerebral edema is high, which could result in complications such as brain herniation if a hemicraniectomy is not performed. Intracerebral hemorrhage in these vascular territories can result in similar findings that may necessitate an extra ventricular drain to remove blood from the ventricles, or a decompressive hemicraniectomy to evacuate the hemorrhage [34]. A patient with a large stroke in the posterior circulation can result in the patient being obtunded, having chronic balance issues, hemiparesis, vision loss, and ataxia [3].

Patients that survive these large strokes often experience the most debility, with the majority becoming bedbound, requiring a percutaneous endoscopic gastrostomy tube for nutrition and tracheostomy tube for assistance with breathing. Due to the severity of their disability, these patients require 24-hour care, by their families or nursing professionals. The majority of these patients experience severe depression and guilt, due to feeling like a financial or physical burden on their loved ones [35]. They also experience loss of autonomy due to their deficits. They are no longer able to manage their own activities of daily living, which results in feelings of inadequacy, and resentment for those that are doing the caregiving. Depression has also seen to be positively correlated with the national institute of health stroke scale (NIHSS) which measures stroke severity, wherein the higher the stroke scale, the more severe the depressive symptoms [36].

Patients with large strokes and increased debility often require management in a skilled nursing facility (SNF). At SNF, the patients do not participate in as much rehabilitation activities, as compared to other stroke patients in an inpatient rehabilitation setting [32]. These patients are therefore at disadvantage because their exposure to rehabilitation is limited. The combination of decreased functionality, less access to rehabilitation, and depression impairs the recovery for these patients. They too lose the desire to participate in meaningful interaction due to their disability [32].
