Response to Speech and Language Therapy According to Artery Involvement and Lesion Location in Post-stroke Aphasia.

PURPOSE: Aphasia is one of the most common complications after stroke and occurs in 21-38% of the patients during acute period. The present study aimed to investigate the response to speech and language therapy according to artery involvement and lesion location in patients with post-stroke aphasia. METHOD: The medical records of 107 patients with post-stroke aphasia (mean age, 58.8 ± 14.8 years) who were admitted to a single rehabilitation center for usual care after stroke were reviewed. Location of the ischemic lesion and involved artery was determined assessing the brain MRI of the patients. All the patients received 24 sessions speech and language therapy (3 days a week) as a part of 8-week rehabilitation program. Evaluation of the aphasia was performed with Gülhane Aphasia Test-2 (GAT-2) at baseline and at the end of the rehabilitation program. RESULTS: Baseline GAT-2 scores was significantly worse in patients with middle cerebral artery (MCA) involvement compared to patients with other artery involvements (p = 0.007). While the GAT-2 scores of patients with MCA involvement were improved significantly after speech and language therapy (p < 0.001), the changes in those with anterior cerebral artery (ACA) and posterior cerebral artery (PCA) involvements were not significant (p > 0.05). CONCLUSIONS: The present findings suggested that speech functions might be more affected in ischemic lesion of MCA and response to SLT might be better in patients with MCA involvement.

Differences in Ischemic Anterior and Posterior Circulation Strokes: A Clinico-Radiological and Outcome Analysis.

BACKGROUND: There are limited data comparing posterior (PC) and anterior (AC) circulation acute ischemic strokes (AIS). We aimed to identify specific features of PC and AC strokes regarding clinical, etiological, radiological, and outcome factors. METHODS: Patients from the Acute STroke Registry and Analysis of Lausanne, a prospective cohort of consecutive AIS, from years 2003 to 2008 were included. The stroke territory was determined by a combination of neuroimaging and clinical symptoms. Patients with uncertain localization or with simultaneous AC and PC strokes were excluded. Multivariate associations between territory and multiple variables were investigated. RESULTS: A total of 1449 patients were included, 466 (32.2%) had a PC territory stroke and 983 (67.8%) an AC. On multivariate analysis, those with PC AIS had lower National Institutes of Health Stroke Scale at admission, more often showed decreased consciousness, visual field defects, and vestibulo-cerebellar signs, but less hemisyndromes, dysarthria, and cognitive symptoms compared to AC AIS patients. Male sex, arterial dissection, lacunar mechanisms, and endovascular recanalization were more frequent in PC strokes, whereas cardioembolic strokes and IV-thrombolysis rates were lower. Less early ischemic signs on admission CT, overall arterial pathology, and 24-hour recanalization were present in PC strokes but intracranial arterial pathology was more prevalent than in AC. The adjusted clinical outcome at 3 months was similar in both groups. CONCLUSIONS: In this large retrospective consecutive AIS series, there were specific differences in clinical presentation, etiology, and arterial pathology between PC and AC strokes which did not influence clinical outcome. These findings could lead to a tailored diagnostic work-up, acute treatment strategies, and secondary prevention.

e-NIHSS: an Expanded National Institutes of Health Stroke Scale Weighted for Anterior and Posterior Circulation Strokes.

BACKGROUND: The National Institutes of Health Stroke Scale (NIHSS) is the most widespread clinical scale used in patients presenting with acute stroke. The merits of the NIHSS include simplicity, quickness, and agreement between clinicians. The clinical evaluation on posterior circulation stroke remains still a limit of NIHSS. METHODS: We assessed the application of a new version of NIHSS, the e-NIHSS (expanded NIHSS), adding specific elements in existing items to explore signs/symptoms of a posterior circulation stroke. A total of 22 consecutive patients with suspected vertebrobasilar stroke were compared with 25 patients with anterior circulation stroke using NIHSS and e-NIHSS. RESULTS: We compared the NIHSS and e-NIHSS scores obtained by the 2 examiners, in patients with posterior circulation infarct (POCI), using the Wilcoxon test. Patients with POCI evaluated with e-NIHSS had an average of 2 points higher than patients evaluated with classical NIHSS. The difference was statistically significant (P < .05), weighted by the new expanded items. CONCLUSIONS: The NIHSS is a practical scale model, with high reproducibility between trained, different examiners, focused on posterior circulation strokes, with the same total score and number of items of the existing NIHSS. The e-NHISS could improve the sensitivity of NIHSS in posterior circulation stroke and could have an impact on clinical trials, as well as on outcomes. Further studies are needed to investigate a larger number of patients and the correlation between the e-NIHSS score and neuroimaging findings.

¿Síndromes o síntomas en la evaluación de los pacientes afásicos? / Syndromes or symptoms in the assessment of aphasic patients?

El procedimiento generalmente empleado para diagnosticar a los pacientes afásicos consiste en analizar sus síntomas y en base a esos síntomas clasificarlos en uno de los síndromes clásicos. Sin embargo, esa taxonomía tiene algunos problemas importantes, el principal que no tiene en cuenta la variedad de pacientes afásicos existentes, ya que hay muchos más trastornos de los que recogen los síndromes. Con objeto de comprobar el grado de homogeneidad de una muestra de pacientes pertenecientes a diferentes síndromes, en este estudio se aplicaron nueve tareas de comprensión y producción oral a quince pacientes (cinco afásicos de Broca, cinco de Wernicke y cinco de Conducción) y a cinco personas sanas, con edades comprendidas entre 38 y 81 años. Los resultados muestran la existencia de una gran heterogeneidad entre los pacientes etiquetados bajo un mismo síndrome, tal como indica la variabilidad de puntuaciones dentro de los grupos en cada tarea. Por otra parte se observa un escaso ajuste al perfil esperado, ya que algunos pacientes presentan síntomas correspondientes a otros síndromes. Nuestros resultados sugieren la necesidad de estudiar a cada paciente de forma individual e interpretar sus trastornos independientemente de los síndromes (AU)

The procedure generally used to diagnose aphasic patients consists of classifying them in one of the classic syndromes on the basis of the analysis of their symptoms. However, this taxonomy has several important problems, the main one being that it does not take into account the variability of aphasic patients, as there are many more disorder profiles than those included in the syndromes. In order to test the homogeneity of a sample of patients diagnosed with the classic taxonomy, 15 aphasic patients (5 Broca, 5 Wernicke and 5 Conduction) and 5 healthy controls were tested with nine comprehension and production tasks. Participants were aged 38 to 81 years old. The results indicate the existence of great variability in patients labeled with the same diagnosis, as revealed by the differences in within-group scores in each task, and a limited adjustment to the expected profile, with some patients showing symptoms allegedly corresponding to other syndromes. Our results call attention to the need to study each patient individually and interpret their disorders regardless of the syndromes (AU)

Involuntary masturbation and hemiballismus after bilateral anterior cerebral artery infarction.

Ischemia of the areas supplied by the anterior cerebral artery is relatively uncommon. In addition, combined hemiballismus and masturbation have rarely been reported in patients with cerebrovascular disease. We describe herein a 62-year-old right-handed man simultaneously exhibiting right side hemiballismus and involuntary masturbation with the left hand after bilateral infarction of the anterior cerebral artery territory. Right side hemiballismus was related to the disruption of afferent fibers from the left frontal lobe to the left subthalamic nucleus. Involuntary masturbation using the left hand was exclusively linked to a callosal type of alien hand syndrome secondary to infarction of the right side of the anterior corpus callosum. After 2 weeks, these abnormal behaviours were completely extinguished. This report stresses the wide diversity of clinical manifestations observed after infarction of the anterior cerebral artery territory.

Is anterior cingulate cortex necessary for cognitive control?

Functional neuroimaging studies in normal humans suggest that dorsal anterior cingulate cortex (dACC) plays an important role in cognitive control. This brain area is reliably activated when tasks require the ongoing adjustment of the allocation of attention. The dACC has come to occupy a central role in theories of attention and cognitive control, which hold that dACC either monitors response conflict, signalling the need for adjustments in cognitive processes, or directly mediates such adjustments. However, functional imaging results cannot establish that a brain area is necessary for a particular cognitive process. This requires evidence from loss-of-function studies. Here we assessed cognitive control in four human subjects with damage to dACC and 12 age- and education-matched control subjects using several measures drawn from the functional imaging literature. All four subjects with dACC damage showed normal adjustments in performance following manipulation of response conflict in both Stroop and go-no go tasks. Furthermore, damage to the dACC did not impair the phenomenon of post-error slowing, nor alter the ability to adjust performance in response to explicit speed or accuracy instructions. Thus, cognitive control, as assessed by four different measures in two different tasks, appears to be intact in these subjects, arguing against a necessary role for dACC in this process.

The impact of extensive medial frontal lobe damage on 'Theory of Mind' and cognition.

The ability of humans to predict and explain other people's behaviour by attributing to them independent mental states, such as desires and beliefs, is considered to be due to our ability to construct a 'Theory of Mind'. Recently, several neuroimaging studies have implicated the medial frontal lobes as playing a critical role in a dedicated 'mentalizing' or 'Theory of Mind' network in human brains. Here, we report a patient, G.T., who suffered an exceptionally rare form of stroke-bilateral anterior cerebral artery infarction, without rupture or the complications associated with anterior communicating artery aneurysms. Detailed high-resolution neuroanatomical investigations revealed extensive damage to the medial frontal lobes bilaterally, including regions identified to be critical for 'Theory of Mind' by functional neuroimaging of healthy human subjects. For the first time in such a patient, we carried out a thorough assessment of her cognitive profile including, critically, an experimental investigation of her performance on a range of tests of 'Theory of Mind'. G.T. had a dysexecutive syndrome characterized by impairments in planning and memory, as well as a tendency to confabulate. Importantly, however, she did not have any significant impairment on tasks probing her ability to construct a 'Theory of Mind', demonstrating that the extensive medial frontal regions destroyed by her stroke are not necessary for this function. These findings have important implications for the functional anatomy of 'Theory of Mind', as well as our understanding of medial frontal function. Possible reasons for the discrepancies between our results and neuroimaging studies are discussed. We conclude that our findings urge caution against using functional imaging as the sole method of establishing cognitive neuroanatomy.

Spectrum of anterior cerebral artery territory infarction: clinical and MRI findings.

To evaluate and review the clinical spectrum of anterior cerebral artery (ACA) territory infarction, we studied 48 consecutive patients who admitted to our stroke unit over a 6-year period. We performed magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) in all patients, and diffusion magnetic resonance imaging (DWI) in 21. In our stroke registry, patients with ACA infarction represented 1.3% of 3705 patients with ischemic stroke. The main risk factors of ACA infarcts was hypertension in 58% of patients, diabetes mellitus in 29%, hypercholesterolemia in 25%, cigarette smoking in 19%, atrial fibrillation in 19%, and myocardial infarct in 6%. Presumed causes of ACA infarct were large-artery disease and cardioembolism in 13 patients each, small-artery disease (SAD) in the territory of Heubner's artery in two and atherosclerosis of large-arteries (<50% stenosis) in 16. On clinico-radiologic analysis there were three main clinical patterns depending on lesion side; left-side infarction (30 patients) consisting of mutism, transcortical motor aphasia, and hemiparesis with lower limb predominance; right side infarction (16 patients) accompanied by acute confusional state, motor hemineglect and hemiparesis; bilateral infarction (two patients) presented with akinetic mutism, severe sphincter dysfunction, and dependent functional outcome. Our findings suggest that clinical and etiologic spectrum of ACA infarction may present similar features as that of middle cerebral artery infarction, but frontal dysfunctions and callosal syndromes can help to make a clinical differential diagnosis. Moreover, at the early phase of stroke, DWI is useful imaging method to locate and delineate the boundary of lesion in the territory of ACA.