The Relationship Between Visuoconstructive Abilities and Language Performance in Patients With Aphasia After Stroke

This study aimed to investigate the visuoconstructive abilities and the relationship between visuoconstructive function and language performance in aphasic patients. Right-handed 24 aphasic patients (males 14, females 10) with at least 3 months post-stroke and 32 age-matched healthy controls participated in this study. Visuoconstructive function was assessed by 3 levels of task difficulty: simple (drawing objects), intermediate (clock drawing), and complex (copy subtest of Rey complex figure test and block construction). Aphasic patients were divided into 3 sub-groups (mild, moderate to severe, and very severe group) according to severity of aphasia and compared with the control group, respectively. We analyzed the relation all levels of visuoconstructive tasks to aphasia quotient (AQ) and sub-domain scores of K-WAB.Moderate to severe aphasia group demonstrated no significant differences in scores of simple drawing objects compared to controls, but clock drawing, Rey complex figure copy and block design showed significantly decreased scores. Very severe group showed significantly lower scores in all levels of visuoconstructive tasks than the control. Correlation between all levels of visuoconstructive tasks except drawing objects and AQ were found to be statistically significant.Among the tasks, the clock drawing test revealed the highest correlation with language performance. Visuoconstructive abilities varied according to the severity of aphasia and the level of visuoconstructive tasks. Therefore, a thorough individual assessment of visuoconstructive function is needed to plan and predict the treatment and prognosis of aphasia and the clock drawing test may be a useful screening tool to evaluate this function.

Development of a Short Version of ICF Core Set for Stroke Adapted for Rehabilitation in Korea: a Preliminary Study

This study aimed to develop a short version of the International Classification of Functioning, Disability, and Health (ICF) core set and verify functioning levels of patients for stroke rehabilitation in Korea. Using the Delphi technique, a 3-round consensus process was conducted. Thirty multidisciplinary rehabilitation experts from different hospitals completed the consensus study. The questionnaire for this study adopted the comprehensive ICF core set for stroke developed by the Geyh group. A 7-point Likert-type scale was used by participants to weigh the impact of each category on activities of daily living or rehabilitation after a stroke. The consensus of ratings was assessed with Spearman's rho and inter-quartile range indices. A core set to assess functioning levels of patients with stroke was developed from those categories. A short version of ICF core set to assess and verify functioning levels of patients with stroke was developed for 12 categories, including 3 categories (consciousness, muscle power, and attention) from body functions, 1 (structure of brain) from body structures, 5 (eating, walking, moving around, changing basic body position, and carrying out daily routine) from activities and participation, and 3 (individual attitudes of immediate family members, immediate family, and personal care providers/personal assistants) from environmental factors. This preliminary study developed a Delphi consensus process, gathering statistical evidence and expert commands based on the short version of ICF core set for rehabilitation of stroke patients in Korea.

Shape and Volumetric Differences in the Corpus Callosum between Patients with Major Depressive Disorder and Healthy Controls

Objective@#This study aimed to investigate the morphometric differences in the corpus callosum between patients with major depressive disorder (MDD) and healthy controls and analyze their relationship to gray matter changes. @*Methods@#Twenty female MDD patients and 21 healthy controls (HCs) were included in the study. To identify the difference in the regional gray matter concentration (GMC), VBM was performed with T1 magnetic resonance imaging. The shape analysis of the corpus callosum was processed. Diffusion tensor imaging (DTI) fiber-tracking was performed to identify the regional tract pathways in the damaged corpus callosal areas. @*Results@#In the shape analysis, regional shape contractions in the rostrum and splenium were found in the MDD patients. VBM analysis showed a significantly lower white matter concentration in the genu and splenium, and a significantly lower GMC in the frontal, limbic, insular, and temporal regions of the MDD patients compared to the HCs. In DTI fiber-tracking, the fibers crossing the damaged areas of the genu, rostrum, and splenium were anatomically connected to the areas of lower GMC in MDD patients. @*Conclusion@#These findings support that major depressive disorder may be due to disturbances in multiple neuronal circuits, especially those associated with the corpus callosum.

Shape Deformation in the Brainstem of Medication-Naïve Female Patients with Major Depressive Disorder

Objective@#Although neuroimaging studies have shown volumetric reductions, such as the anterior cingulate, prefrontal cortices, and hippocampus in patients with major depressive disorder (MDD), few studies have investigated the volume of or shape alterations in the subcortical regions and the brainstem. We hypothesized that medication-naïve female adult patients with MDD might present with shape and volume alterations in the subcortical regions, including the brainstem, compared to healthy controls (HCs). @*Methods@#A total of 20 medication-naïve female patients with MDD and 21 age-matched female HCs, underwent 3D T1-weighted structural magnetic resonance scanning. We analyzed the volumes of each subcortical region and each brainstem region, including the midbrain, pons, and medulla oblongata. We also performed surface-based vertex analyses on the subcortical areas and brainstem. @*Results@#Female patients with MDD showed non-significant volumetric differences in the subcortical regions, whole brainstem, and each brainstem region compared to the HCs. However, in the surface-based vertex analyses, significant shape contractions were observed in both cerebellar peduncles located on the lateral wall of the posterior brainstem [threshold-free cluster enhancement, corrected for family-wise error (FWE) at p<0.05] in patients with MDD. @*Conclusion@#We revealed shape alterations in the posterior brainstem in female patients with MDD.

Incidence and Clinical Characteristics of Ischemic Stroke Patients with Underlying Cancer

Cancer and ischemic stroke (IS) are leading causes of death and disability, worldwide. It is reported that cancer increases IS incidence with various unknown mechanism. We retrospectively reviewed medical records of single tertiary medical center between January 2012 and December 2016. A total of 40,047 patients with cancer were analyzed and 63 patients (0.16%) were diagnosed of IS with underlying cancer. Lung (27.0%), gastric (14.3%) and colorectal (12.7%) cancers were the most frequent types of cancers and adenocarcinoma was the most common histologic type. We compared the clinical variables (demographic data, comorbidities, cancer stage, infarction pattern and severity) between adenocarcinoma and non-adenocarcinoma groups. And the results showed low coexistence of dyslipidemia and smoking history, and higher rate of multiple vascular territory infarct in adenocarcinoma group (p < 0.05). Six-month post stroke mortality rate was 34.6% and systemic metastasis and multi-territorial infarction were significantly relevant with the six-month mortality (p < 0.001). Also, initial National Institute of Health Stroke Scale (p < 0.05) and modified Rankin Scale scores were statistically significantly worse in mortality group (p < 0.05). In conclusion, the most frequent cancer type was lung cancer and adenocarcinoma the most common histologic type. Mortality at 6-month post stroke was high, and it was associated with stage of cancer and initial neurological severity.

Reliability and Validity of the Comprehensive Limb and Oral Apraxia Test: Standardization and Clinical Application in Korean Patients With Stroke

OBJECTIVE: To develop and standardize the Limb and Oral Apraxia Test (LOAT) for Korean patients and investigate its reliability, validity, and clinical usefulness for patients with stroke. METHODS: We developed the LOAT according to a cognitive neuropsychological model of limb and oral praxis. The test included meaningless, intransitive, transitive, and oral praxis composed of 72 items (56 items on limb praxis and 16 items on oral praxis; maximum score 216). We standardized the LOAT in a nationwide sample of 324 healthy adults. Intra-rater and inter-rater reliability and concurrent validity tests were performed in patients with stroke. We prospectively applied the LOAT in 80 patients and analyzed the incidence of apraxia. We also compared the clinical characteristics between the apraxia and non-apraxia groups. RESULTS: The internal consistency was high (Cronbach’s alpha=0.952). The inter-rater and intra-rater reliability and concurrent validity were also high (r=0.924–0.992, 0.961–0.999, and 0.830, respectively; p0.05). Among the 80 patients with stroke, 19 (23.8%) had limb apraxia and 21 (26.3%) had oral apraxia. Left hemispheric lesions and aphasia were significantly more frequently observed in the limb/oral apraxia group than in the non-apraxia group (p<0.001). CONCLUSION: The LOAT is a newly developed comprehensive test for limb and oral apraxia for Korean patients with stroke. It has high internal consistency, reliability, and validity and is a useful apraxia test for patients with stroke.

Neuroanatomical Predictors of Dysphagia after Stroke: Voxel-Based Lesion Symptom Mapping Study / 대한연하장애학회지

OBJECTIVE: Dysphagia is a common consequence of stroke with a negative effect on the clinical outcome. Given these potential outcomes, it is important to identify the precursors to dysphagia after stroke. The aims of this study were to identify lesions associated with dysphagia after an ischemic supratentorial stroke using voxel-based lesion symptom mapping (VLSM) and compare the difference in the lesion pattern between the oral and pharyngeal phase dysphagia. METHODS: Stroke patients who met the following inclusion criteria were screened retrospectively between January 2012 and November 2014: a first-ever stroke, supratentorial lesion and who underwent brain MRI and functional dysphagia scale (FDS) from videofluoroscopic swallowing study (VFSS). Finally, the MRI data of 83 patients were analyzed. Statistical maps of the lesion contribution related to dysphagia were generated using VLSM. RESULTS: VLSM showed that FDS was associated with damage to the putamen, caudate, insula, frontal precentral gyrus, and inferior frontal gyrus. The lesions were distributed more widely in the left than right hemisphere. Lesions correlated with the FDS oral score were distributed mainly in the frontal lobe and insula. Otherwise, the associated lesion with the FDS pharyngeal score was mainly the basal ganglia. CONCLUSION: In these results, lesions that correlated with dysphagia were distributed more widely in the left hemisphere, reflecting the possibility of lateralization of the swallowing function. Oral phase dysphagia was associated with left frontal lobe and insula; the lesion correlated with the cognitive function or apraxia. On the other hand, VLSM revealed the lesions associated with pharyngeal dysphagia to be the basal ganglia, which is a structure that plays a role in the automatic motor control network.

Current Clinical Applications of Diffusion-Tensor Imaging in Neurological Disorders

Diffusion-tensor imaging (DTI) is a noninvasive medical imaging tool used to investigate the structure of white matter. The signal contrast in DTI is generated by differences in the Brownian motion of the water molecules in brain tissue. Postprocessed DTI scalars can be used to evaluate changes in the brain tissue caused by disease, disease progression, and treatment responses, which has led to an enormous amount of interest in DTI in clinical research. This review article provides insights into DTI scalars and the biological background of DTI as a relatively new neuroimaging modality. Further, it summarizes the clinical role of DTI in various disease processes such as amyotrophic lateral sclerosis, multiple sclerosis, Parkinson's disease, Alzheimer's dementia, epilepsy, ischemic stroke, stroke with motor or language impairment, traumatic brain injury, spinal cord injury, and depression. Valuable DTI postprocessing tools for clinical research are also introduced.

Validation of Korean Version of Coma Recovery Scale-Revised (K-CRSR)

OBJECTIVE: To determine the validity and reliability of the Korean version of the Coma Recovery Scale-Revised (K-CRSR) for evaluation of patients with a severe brain lesion. METHODS: With permission from Giacino, the developer of the Coma Recovery Scale Revised (CRSR), the scale was translated into Korean and back-translated into English by a Korean physiatrist highly proficient in English, and then verified by the original developer. Adult patients with a severe brain lesion following traumatic brain injury, stroke, or hypoxic brain injury were examined. To assess the inter-rater reliability, all patients were tested with K-CRSR by two physiatrists individually. To determine intra-rater reliability, the same test was re-administered by the same physiatrists after three days. RESULTS: Inter-rater reliability (k=0.929, p < 0.01) and intra-rater reliability (k=0.938, p < 0.01) were both high for total K-CRSR scores. Inter- and intra-rater agreement rates were very high (94.9% and 97.4%, respectively). The total K-CRSR score was significantly correlated with K-GCS (r=0.894, p < 0.01), demonstrating sufficient concurrent validity. CONCLUSION: K-CRSR is a reliable and valid instrument for the assessment of patients with brain injury by trained physiatrists. This scale is useful in differentiating patients in minimally conscious state from those in vegetative state.

Complex Regional Pain Syndrome of Non-hemiplegic Upper Limb in a Stroke Patient: A Case Report

Complex regional pain syndrome (CRPS) type I in stroke patients is usually known to affect the hemiplegic upper limb. We report a case of CRPS presented in an ipsilesional arm of a 72-year-old female patient after an ischemic stroke at the left middle cerebral artery territory. Clinical signs such as painful range of motion and hyperalgesia of her left upper extremity, swollen left hand, and dystonic posture were suggestive of CRPS. A three-phase bone scintigraphy showed increased uptake in all phases in the ipsilesional arm. Diffusion tensor tractography showed significantly decreased fiber numbers of the corticospinal tract and the spinothalamic tract in both unaffected and affected hemispheres. Pain and range of motion of the left arm of the patient improved after oral steroids with a starting dose of 50 mg/day.

Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016

“Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” is the 3rd edition of clinical practice guideline (CPG) for stroke rehabilitation in Korea, which updates the 2nd edition published in 2014. Forty-two specialists in stroke rehabilitation from 21 universities and 4 rehabilitation hospitals and 4 consultants participated in this update. The purpose of this CPG is to provide optimum practical guidelines for stroke rehabilitation teams to make a decision when they manage stroke patients and ultimately, to help stroke patients obtain maximal functional recovery and return to the society. The recent two CPGs from Canada (2015) and USA (2016) and articles that were published following the 2nd edition were used to develop this 3rd edition of CPG for stroke rehabilitation in Korea. The chosen articles' level of evidence and grade of recommendation were decided by the criteria of Scotland (2010) and the formal consensus was derived by the nominal group technique. The levels of evidence range from 1++ to 4 and the grades of recommendation range from A to D. Good Practice Point was recommended as best practice based on the clinical experience of the guideline developmental group. The draft of the developed CPG was reviewed by the experts group in the public hearings and then revised. “Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” consists of ‘Chapter 1; Introduction of Stroke Rehabilitation’, ‘Chapter 2; Rehabilitation for Stroke Syndrome, ‘Chapter 3; Rehabilitation for Returning to the Society’, and ‘Chapter 4; Advanced Technique for Stroke Rehabilitation’. “Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” will provide direction and standardization for acute, subacute and chronic stroke rehabilitation in Korea.

Clinical Features of an Artery of Percheron Infarction: a Case Report

The artery of Percheron (AOP) is an uncommon variant of the paramedian artery, a solitary trunk branching off from the posterior cerebral arteries, supplying both paramedian thalami, and also often the rostral midbrain and the anterior thalamus. The typical clinical manifestations of the AOP infarction include altered mental status, cognitive impairment, and oculomotor dysfunction. We report a rare case with AOP infarction, and the clinical characteristics and rehabilitation courses for alertness disorder, cognitive dysfunction, and other accompanied symptoms.

Relationship Between Cognitive Function and Dysphagia After Stroke

OBJECTIVE: To investigate the characteristics of cognitive deficits in patients with post-stroke dysphagia, and to analyze the relationships between cognitive dysfunction and severity of dysphagia in supratentorial stroke. METHODS: A total of 55 patients with first-ever supratentorial lesion stroke were enrolled retrospectively, within 3 months of onset. We rated dysphagia from 0 (normal) to 4 (severe) using the dysphagia severity scale (DSS) through clinical examinations and videofluoroscopic swallowing studies (VFSS). The subjects were classified either as non-dysphagic (scale 0) or dysphagic (scale 1 to 4). We compared general characteristics, stroke severity and the functional scores of the two groups. We then performed comprehensive cognitive function tests and investigated the differences in cognitive performance between the two groups, and analyzed the correlation between cognitive test scores, DSS, and parameters of oral and pharyngeal phase. RESULTS: Fugl-Meyer motor assessment, the Berg Balance Scale, and the Korean version of the Modified Barthel Index showed significant differences between the two groups. Cognitive test scores for the dysphagia group were significantly lower than the non-dysphagia group. Significant correlations were shown between dysphagia severity and certain cognitive subtest scores: visual span backward (p=0.039), trail making tests A (p=0.042) and B (p=0.002), and Raven progressive matrices (p=0.002). The presence of dysphagia was also significantly correlated with cognitive subtests, in particular for visual attention and executive attention (odds ratio [OR]=1.009; 95% confidence interval [CI], 1.002–1.016; p=0.017). Parameters of premature loss were also significantly correlated with the same subtests (OR=1.009; 95% CI, 1.002–1.016; p=0.017). CONCLUSION: Our results suggest that cognitive function is associated with the presence and severity of post-stroke dysphagia. Above all, visual attention and executive functions may have meaningful influence on the oral phase of swallowing in stroke patients with supratentorial lesions.

Comparison of Clinical Characteristics Between Patients With Different Causes of Vocal Cord Immobility

OBJECTIVE: To analyze the clinical characteristics between neurogenic and non-neurogenic cause of vocal cord immobility (VCI). METHODS: The researchers retrospectively reviewed clinical data of patients who underwent laryngeal electromyography (LEMG). LEMG was performed in the bilateral cricothyroid and thyroarytenoid muscles. A total of 137 patients were enrolled from 2011 to 2016, and they were assigned to either the neurogenic or non-neurogenic VCI group, according to the LEMG results. The clinical characteristics were compared between the two groups and a subgroup analysis was done in the neurogenic group. RESULTS: Among the 137 subjects, 94 patients had nerve injury. There were no differences between the neurogenic and non-neurogenic group in terms of demographic data, underlying disease except cancer, and premorbid events. In general characteristics, cancer was significantly higher in the neurogenic group than non-neurogenic group (p=0.001). In the clinical findings, the impaired high pitched ‘e’ sound and aspiration symptoms were significantly higher in neurogenic group (p=0.039 for impaired high pitched ‘e’ sound; p=0.021 for aspiration symptoms), and sore throat was more common in the non-neurogenic group (p=0.014). In the subgroup analysis of neurogenic group, hoarseness was more common in recurrent laryngeal neuropathy group than superior laryngeal neuropathy group (p=0.018). CONCLUSION: In patients with suspected vocal cord palsy, impaired high pitched ‘e’ sound and aspiration symptoms were more common in group with neurogenic cause of VCI. Hoarseness was more frequent in subjects with recurrent laryngeal neuropathy. Thorough clinical evaluation and LEMG are important to differentiate underlying cause of VCI.

Neuroanatomical Mechanism of Cerebellar Mutism After Stroke

Cerebellar mutism (CM) is a rare neurological condition characterized by lack of speech due to cerebellar lesions. CM is often reported in children. We describe a rare case of CM after spontaneous cerebellar hemorrhage. The patient showed mutism, irritability, decreased spontaneous movements and oropharyngeal apraxia. Diffusion tensor imaging revealed significant volume reduction of medial frontal projection fibers from the corpus callosum. In Tracts Constrained by UnderLying Anatomy (TRACULA) analysis, forceps major and minor and bilateral cingulum-angular bundles were not visualized. Cerebello-frontal pathway reconstructed from the FMRIB Software Library showed continuity of fibers, with decreased number of fibers on qualitative analysis. These results suggest that cerebello-frontal disconnection may be a neuroanatomical mechanism of CM. Damage of brain network between occipital lobe, cingulate and cerebellum caused by hemorrhage may also have role in the mechanism of CM in our case.

Amusia After Right Temporoparietal Lobe Infarction: A Case Report

Which brain regions participate in musical processing remains controversial. During singing and listening a familiar song, it is necessary to retrieve information from the long-term memory. However, the precise mechanism involved in musical processing is unclear. Amusia is impaired perception, understanding, or production of music not attributable to disease of the peripheral auditory pathways or motor system. We report a case of a 36-year-old right-handed man who lost the ability to discriminate or reproduce rhythms after a right temporoparietal lobe infarction. We diagnosed him as an amusic patient using the online version of Montreal Battery of Evaluation of Amusia (MBEA). This case report suggests that amusia could appear after right temporoparietal lobe infarction. Further research is needed to elucidate the dynamic musical processing mechanism and its associated neural structures.

Relationship of Vascular Factors on Electrophysiologic Severity of Diabetic Neuropathy

OBJECTIVE: To investigate the impact of vascular factors on the electrophysiologic severity of diabetic neuropathy (DPN). METHODS: Total 530 patients with type 2 diabetes were enrolled retrospectively. We rated severity of DPN from 1 (normal) to 4 (severe) based on electrophysiologic findings. We collected the data concerning vascular factors (including brachial-ankle pulse wave velocity [PWV], ankle brachial index, ultrasound of carotid artery, lipid profile from the blood test, and microalbuminuria [MU] within 24 hours urine), and metabolic factors of diabetes (such as glycated hemoglobin [HbA1c]). We analyzed the differences among the four subgroups using χ2 test and ANOVA, and ordinal logistic regression analysis was performed to investigate the relationship between significant variables and severity of DPN. RESULTS: The severity of DPN was significantly associated with duration of diabetes, HbA1c, existence of diabetic retinopathy and nephropathy, PWV, presence of plaque, low density lipoprotein-cholesterol and MU (p<0.05). Among these variables, HbA1c and presence of plaque were more significantly related with severity of DPN in logistic regression analysis (p<0.001), and presence of plaque showed the highest odds ratio (OR=2.52). CONCLUSION: Our results suggest that markers for vascular wall properties, such as PWV and presence of plaque, are significantly associated with the severity of DPN. The presence of plaque was more strongly associated with the severity of DPN than other variables.

Effect of Age on Cortical Activation during Swallowing: An fMRI Study / 대한연하장애학회지

OBJECTIVE: Understanding the neural functional organization of swallowing in the elderly is essential when diagnosing and treating older adults with swallowing difficulties. While brain-imaging studies in young adults have implicated multiple cortical regions in swallowing, only a few investigations were performed on older subjects. In this study, we aimed to compare neural activation in regions for swallowing between healthy young and older adults and to better understand neural control of deglutition, complex sensory-motor process which occurs as a result of old age. METHOD: Fifteen young and fifteen older healthy individuals without a swallowing problem were examined with functional magnetic resonance imaging (fMRI) during voluntary saliva swallowing. Functional image data was obtained with a T2 gradient-echo, echo planar imaging (EPI) pulse sequence optimized for blood-oxygen level dependent (BOLD) contrast. Two samples t-test was conducted to perform group comparison (younger adults versus older adults) for the areas in which the activation was larger for the swallowing condition than the non-swallow condition. RESULT: Both groups showed activations in areas involved in the motor control and execution. In both groups, main regions of activation included bilateral prefrontal cortex, primary somatosensory cortex, insula, basal ganglia, and cerebellum. Between-group comparisons revealed statistically stronger activations in the prefrontal cortex and middle temporal gyrus of older adults during swallowing. CONCLUSION: This study provides evidence that swallowing requires larger and more widespread areas of neural control in older adults group, especially in prefrontal cortex and inferior frontal gyrus. These findings suggest that more demanding swallowing tasks are necessary for elderly patients because of their inefficient neural network due to their age.

Community Integration and Quality of Life in Aphasia after Stroke

PURPOSE: To examine community integration and contributing factors in people with aphasia (PWA) following stroke and to investigate the relationship between community integration and quality of life (QOL). MATERIALS AND METHODS: Thirty PWA and 42 age-and education-matched control subjects were involved. Main variables were as follows: socioeconomic status, mobility, and activity of daily living (ADL) (Modified Barthel Index), language function [Frenchay Aphasia Screening Test (FAST)], depression [Geriatric Depression Scale (GDS)], Community Integration Questionnaire (CIQ) and Stroke and Aphasia Quality of Life Scale-39 (SAQOL-39). Differences between aphasia and control groups and factors affecting community integration and QOL were analyzed. RESULTS: Home and social integration and productive activity were significantly decreased in the aphasia group compared to the control group; 8.5 and 18.3 points in total CIQ score, respectively. Amount of time spent outside the home and frequency of social contact were also significantly reduced in the aphasia group. Total mean score on the SAQOL-39 was 2.75+/-0.80 points and was significantly correlated with economic status, gait performance, ADL, depressive mood, and social domain score on the CIQ. Depression score measured by GDS was the single most important factor for the prediction of QOL, but the FAST score was significantly correlated only with the communication domain of the SAQOL-39. CONCLUSION: Community activities of PWA were very limited, and depression was highly associated with decreased community integration and QOL. Enhancing social participation and reducing emotional distress should be emphasized for rehabilitation of PWA.

Erratum: Inpatient Stroke Rehabilitation Outcomes in Korea Derived from the Korean Brain Rehabilitation Centers' Online Database System for the Years 2007 to 2011

In this article (J Korean Med Sci 2015; 30: 644-50), one author's name is misspelled. Correct Sung-Hun Im into Seong Hoon Lim.