Auditory spatial cueing reduces neglect after right-hemispheric stroke: A proof of concept study.

Spatial neglect after right-hemispheric stroke, characterized by the failure to attend or respond to the contralesional space, is a strong negative outcome predictor. Neglect is a supramodal syndrome affecting not only the visual but also the auditory modality. Preliminary studies used this audio-visual cross-modal effect to show short-lasting effects on attention towards the neglected space. The aim of the present study was to introduce a new technique of auditory stimulation combining the unspecific effect of music (i.e., patients choose their preferred music) with the effects of auditory spatial cueing (i.e., the music is presented dynamically as moving from right to left). The effect of this new auditory stimulation technique was investigated in two proof-of-concept experiments using repeated-measures, cross-over designs including 21 patients with visual neglect after a first right-hemispheric stroke. In Experiment I (n = 9), neglect patients showed a significantly larger improvement in Letter Cancellation after listening to preferred music with than without auditory spatial cueing. After granting the feasibility of this new auditory stimulation technique, we investigated the long-term aftereffects in Experiment II (n = 12). Herefore, we used video-oculography during Free Visual Exploration, a sensitive and reliable tool to assess spatial attention over time. Listening to music with auditory spatialcueing - as compared to music without auditory spatialcueing - significantly improved neglect severity in terms of visual exploration behaviour for up to 3h. A voxel-based-lesion-symptom mapping analysis over all patients revealed that the response variability in listening to music with auditory spatial cueing is determined by the integrity of the right inferior parietal lobule, the second branch of the superior longitudinal fascicle, and parieto-parietal callosal fibres. Our study shows that listening to music with auditory spatial cueing significantly reduces neglect severity and has the potential to be used as an add-on in the neurorehabilitation of neglect.

From competition to cooperation: Visual neglect across the hemispheres.

Visuospatial neglect is a frequent and disabling consequence of injuries to the right hemisphere. Patients with neglect show signs of impaired attention for left-sided events, which depends on dysfunction of fronto-parietal networks. After unilateral injury, such as stroke, these networks and their contralateral homologs can reorganize following multiple potential trajectories, which can be either adaptive or maladaptive. This article presents possible factors influencing the profile of evolution of neglect towards recovery or chronicity, and highlights potential mechanisms that may constrain these processes in time and space. The integrity of white matter pathways within and between the hemisphere appears to pose crucial connectivity constraints for compensatory brain plasticity from remote brain regions. Specifically, the availability of a sufficient degree of inter-hemispheric connectivity might be critical to shift the role of the undamaged left hemisphere in spatial neglect, from exerting maladaptive effects, to promoting compensatory activity.

Visual and motor neglect: Clinical and neurocognitive aspects.

Attention allows us to prioritize the processing of external information according to our goals, but also to cope with sudden, unforeseen events. Attention processes rely on the coordinated activity of large-scale brain networks. At the cortical level, these systems are mainly organized in fronto-parietal networks, with functional and anatomical asymmetries in favor of the right hemisphere. Dysfunction of these right-lateralized networks often produce severe deficit of spatial attention, such as visual neglect. Other brain-damaged patients avoid moving the limbs contralateral to their brain lesion, even in the absence of sensorimotor deficits (motor neglect). This paper first summarizes past and current evidence on brain networks of attention; then, it presents clinical and experimental findings on visual and motor neglect, and on the possible mechanisms of clinical recovery.

Secondary solid cancer following hematopoietic cell transplantation in patients with thalassemia major.

Hematopoietic cell transplant (HCT) recipients have a substantial risk of developing secondary solid cancers (SSCs). The aim of this retrospective study was to compare the incidence of SSC in a monocentric cohort of thalassemia major (TM) patients (n=122) who received HCT versus an hematopoietic cell donor monocentric cohort (n=122) and versus a large multicenter cohort of age- and sex-matched TM patients (n=244) who received conventional therapy. With a median follow-up of 24 years, 8 transplanted patients were diagnosed with SSC at a median of 18 years after HCT and at a median age of 33 years. Three patients died of cancer progression and 5 are living after a follow-up ranging from 10 months to 16 years after SSC diagnosis. The 30-year cumulative incidence of developing SSC was 13.24%. The occurrence of solid cancers in the hematopoietic cell donor cohort was limited to only one case for a significantly lower cumulative incidence (3.23%, P=0.02) and to 3 cases in the cohort of nontransplant patients for a significantly lower cumulative incidence (1.32%, P=0.005). This study shows that the magnitude of increased risk of SST is fourfold to sixfold for patients treated with HCT as compared with hematopoietic cell donors and nontransplant patients.

Spermatogonial kinetics in humans.

The human spermatogonial compartment is essential for daily production of millions of sperm. Despite this crucial role, the molecular signature, kinetic behavior and regulation of human spermatogonia are poorly understood. Using human testis biopsies with normal spermatogenesis and by studying marker protein expression, we have identified for the first time different subpopulations of spermatogonia. MAGE-A4 marks all spermatogonia, KIT marks all B spermatogonia and UCLH1 all Apale-dark (Ap-d) spermatogonia. We suggest that at the start of the spermatogenic lineage there are Ap-d spermatogonia that are GFRA1High, likely including the spermatogonial stem cells. Next, UTF1 becomes expressed, cells become quiescent and GFRA1 expression decreases. Finally, GFRA1 expression is lost and subsequently cells differentiate into B spermatogonia, losing UTF1 and acquiring KIT expression. Strikingly, most human Ap-d spermatogonia are out of the cell cycle and even differentiating type B spermatogonial proliferation is restricted. A novel scheme for human spermatogonial development is proposed that will facilitate further research in this field, the understanding of cases of infertility and the development of methods to increase sperm output.

Pregnancy outcome following hematopoietic cell transplantation for thalassemia major.

The aim of this study was to investigate the methods of conception and delivery, as well as the course and outcome of 42 pregnancies occurring in 15 female patients (27 pregnancies) and partners of 8 male patients (15 pregnancies) with ß-thalassemia major who were successfully treated with allogeneic hematopoietic cell transplantation (HCT). Most pregnancies (n=21) were achieved with spontaneous conception in female patients. There were two miscarriages. Five pregnancies were late preterm. Delivery was vaginal in 4 cases and by caesarean section in 18. Overall, 22 term pregnancies resulted in successful deliveries of 23 neonates. Two of 23 neonates were symmetrical small for gestational age / intrauterine growth restriction. All 15 pregnancies that occurred in partners of men who received an allogeneic HCT were achieved with spontaneous conception. No miscarriage was observed. Overall, 14 term pregnancies resulted in successful deliveries of 14 live-born singletons. Delivery was vaginal in nine cases and by caesarean section in five. All infants were full-term. Many patients with ß-thalassemia major who received an allogeneic HCT retained or recovered their fertility after transplant. In these patients, pregnancy has been a practical and safe possibility and usually had a favorable outcome as in the normal population.

Differential actigraphy for monitoring asymmetry in upper limb motor activities.

Most applications of accelerometry-based actigraphy require a single sensor, properly located onto the body, to estimate, for example, the level of activity or the energy expenditure. Some approaches adopt a multi-sensor setup to improve those analyses or to classify different types of activity. The specific case of two symmetrically placed actigraphs allowing, by some kind of differential analysis, for the assessment of asymmetric motor behaviors, has been considered in relatively few studies. This article presents a novel method for differential actigraphy, which requires the synchronized measurements of two triaxial accelerometers (programmable eZ430-Chronos, Texas Instruments, USA) placed symmetrically on both wrists. The method involved the definition of a robust epoch-related activity index and its implementation on-board the adopted programmable platform. Finally, the activity recordings from both sensors allowed us to define a novel asymmetry index AR24 h ranging from -100% (only the left arm moves) to +100% (only the right arm moves) with null value marking a perfect symmetrical behavior. The accuracy of the AR24 h index was 1.3%. Round-the-clock monitoring on 31 healthy participants (20-79 years old, 10 left handed) provided for the AR24 h reference data (range -5% to 21%) and a fairly good correlation to the clinical handedness index (r = 0.66, p < 0.001). A subset of 20 participants repeated the monitoring one week apart evidencing an excellent test-retest reliability (r = 0.70, p < 0.001). Such figures support future applications of the methodology for the study of pathologies involving motor asymmetries, such as in patients with motor hemisyndromes and, in general, for those subjects for whom a quantification of the asymmetry in daily motor performances is required to complement laboratory tests.

Haploidentical, G-CSF-primed, unmanipulated bone marrow transplantation for patients with high-risk hematological malignancies: an update.

Ninety-seven patients affected by high-risk hematological malignancies underwent G-CSF primed, unmanipulated bone marrow (BM) transplantation from a related, haploidentical donor. All patients were prepared with an identical conditioning regimen including Thiotepa, Busilvex, Fludarabine (TBF) and antithymocyte globulin given at myeloablative (MAC = 68) or reduced (reduced intensity conditioning (RIC) = 29) dose intensity and received the same GvHD prophylaxis consisting of the combination of methotrexate, cyclosporine, mycofenolate-mofetil and basiliximab. Patients were transplanted in 1st or 2nd CR (early phase: n = 60) or in > 2nd CR or active disease (advanced phase: n = 37). With a median time of 21 days (range 12-38 days), the cumulative incidence (CI) of neutrophil engraftment was 94 ± 3%. The 100-day CI of III-IV grade acute GvHD and the 2-year CI of extensive chronic GvHD were 9 ± 3% and 12 ± 4%, respectively. Overall, at a median follow-up of 2.2 years (range 0.3-5.6), 44 out of 97 (45%) patients are alive in CR. The 5-year probability of overall survival (OS) and disease-free survival (DFS) for patients in early and advanced phase was 53 ± 7 vs 24 ± 8% (P = 0.006) and 48 ± 7 vs 22 ± 8% (P = 0.01), respectively. By comparing MAC with RIC patient groups, the transplant-related mortality was equivalent (36 ± 6 vs 28 ± 9%) while the relapse risk was lower for the MAC patients (22 ± 6 vs 45 ± 11%), who showed higher OS (48 ± 7 vs 29 ± 10%) and DFS (43 ± 7 vs 26 ± 10%). However, all these differences did not reach a statistical significance. In multivariate analysis, diagnosis and recipient age were significant factors for OS and DFS. In conclusion, this analysis confirms, on a longer follow-up and higher number of patients, our previous encouraging results obtained by using MAC and RIC TBF regimen as conditioning for G-CSF primed, unmanipulated BM transplantation from related, haploidentical donor in patients with high-risk hematological malignancies, lacking an HLA-identical sibling or unrelated donor and in need to be urgently transplanted.

DTI-MR tractography of white matter damage in stroke patients with neglect.

Left visual neglect is a dramatic neurological condition that impairs awareness of left-sided events. Neglect has been classically reported after strokes in the territory of the right middle cerebral artery. However, the precise lesional correlates of neglect within this territory remain discussed. Recent evidence strongly suggests an implication of dysfunction of large-scale perisylvian networks in chronic neglect, but the quantitative relationships between neglect signs and damage to white matter (WM) tracts have never been explored. In this prospective study, we used diffusion tensor imaging (DTI) tractography in twelve patients with a vascular stroke in the right hemisphere. Six of these patients showed signs of neglect. Nonparametric voxel-based comparisons between neglect and controls on fractional anisotropy maps revealed clusters in the perisylvian WM and in the external capsule. Individual DTI tractography identified specific disconnections of the fronto-parietal and fronto-occipital pathways in the neglect group. Voxel-based correlation statistics highlighted correlations between patients' performance on two visual search tasks and damage to WM clusters. These clusters were located in the anterior limb of the internal capsule and in the WM underlying the inferior frontal gyrus, along the trajectory of the anterior segment of the arcuate fasciculus (asAF). These results indicate that chronic visual neglect can result from, and correlate with, damage to fronto-parietal connections in the right hemisphere, within large-scale cortical networks important for orienting of spatial attention, arousal and spatial working memory.

Representation and disconnection in imaginal neglect.

Patients with neglect failure to detect, orient, or respond to stimuli from a spatially confined region, usually on their left side. Often, the presence of perceptual input increases left omissions, while sensory deprivation decreases them, possibly by removing attention-catching right-sided stimuli (Bartolomeo, 2007). However, such an influence of visual deprivation on representational neglect was not observed in patients while they were imagining a map of France (Rode et al., 2007). Therefore, these patients with imaginal neglect either failed to generate the left side of mental images (Bisiach & Luzzatti, 1978), or suffered from a co-occurrence of deficits in automatic (bottom-up) and voluntary (top-down) orienting of attention. However, in Rode et al.'s experiment visual input was not directly relevant to the task; moreover, distraction from visual input might primarily manifest itself when representation guides somatomotor actions, beyond those involved in the generation and mental exploration of an internal map (Thomas, 1999). To explore these possibilities, we asked a patient with right hemisphere damage, R.D., to explore visual and imagined versions of a map of France in three conditions: (1) 'imagine the map in your mind' (imaginal); (2) 'describe a real map' (visual); and (3) 'list the names of French towns' (propositional). For the imaginal and visual conditions, verbal and manual pointing responses were collected; the task was also given before and after mental rotation of the map by 180 degrees . R.D. mentioned more towns on the right side of the map in the imaginal and visual conditions, but showed no representational deficit in the propositional condition. The rightward inner exploration bias in the imaginal and visual conditions was similar in magnitude and was not influenced by mental rotation or response type (verbal responses or manual pointing to locations on a map), thus suggesting that the representational deficit was robust and independent of perceptual input in R.D. Structural and diffusion MRI demonstrated damage to several white matter tracts in the right hemisphere and to the splenium of corpus callosum. A second right-brain damaged patient (P.P.), who showed signs of visual but not imaginal neglect, had damage to the same intra-hemispheric tracts, but the callosal connections were spared. Imaginal neglect in R.D. may result from fronto-parietal dysfunction impairing orientation towards left-sided items and posterior callosal disconnection preventing the symmetrical processing of spatial information from long-term memory.

Fotemustine plus etoposide, cytarabine and melphalan (FEAM) as a new conditioning regimen for lymphoma patients undergoing auto-SCT: a multicenter feasibility study.

BEAM is a widely used conditioning regimen for relapsed/refractory lymphoma patients undergoing auto-SCT. We conducted a multicenter study with an alternative regimen (fotemustine plus etoposide, cytarabine and melphalan (FEAM)) in which BCNU was substituted by the chloroethylnitrosourea fotemustine (FTM). Eighty-four patients with relapsed/refractory Hodgkin's (n=20) and non-Hodgkin's lymphoma (n=64) were conditioned with a FEAM regimen (FTM 150 mg/m(2) on days -7, -6, etoposide 200 mg/m(2) and cytarabine 400 mg/m(2) on days -5, -4, -3, -2 and melphalan 140 mg/m(2) on day -1). Patients were evaluated for toxicity and engraftment parameters. Median times to neutrophil (>500 x 10(9)/l) and plt (>20 000 x 10(9)/l) engraftment were 11 and 13 days, respectively. Grade 3 mucositis occurred in 19 patients (23%), while G3 nausea/vomiting and G3 diarrhea were observed in 13 (15%) and 6 (7%) patients, respectively. No severe hepatic, renal or pulmonary toxicity was detected. Seven patients (7%) experienced G4 mucositis, while no other G4 toxicities or unexpected adverse events of any grade were recorded. Transplant-related mortality was 2.4%. We conclude that a FEAM regimen is feasible and safe. Although toxicity and engraftment times compared favorably with BEAM, longer follow-up is needed to evaluate fully its efficacy and long-term safety.

Pre-emptive treatment of acute GVHD: a randomized multicenter trial of rabbit anti-thymocyte globulin, given on day+7 after alternative donor transplants.

We have previously shown that hemopoietic stem cell transplant (HSCT) recipients can be stratified on day+7 as having low, intermediate or a high risk of transplant-related mortality (TRM). With the aim of reducing TRM and GVHD, intermediate and high-risk patients (n=170) were randomized to receive anti-thymocyte globulin (ATG, thymoglobuline) on day+7 (n=84) or no treatment (n=86) (controls). There was a reduction of TRM from 35% in controls to 29% in ATG patients (P=0.3), of acute GVHD III-IV from 15 to 5% (P=0.02) and of chronic GVHD from 26 to 11% (P=0.03); survival was comparable. The predictive value of the day+7 score on TRM was confirmed for controls (19 vs 42% for intermediate vs high risk, respectively, P=0.03), whereas ATG abrogated this predictive effect (29 vs 29%). ATG reduced GVHD (P=0.006) in high-risk patients, but not in patients with an intermediate risk. In conclusion, we confirm that TRM can be predicted on the basis of day+7 laboratory values, after alternative donor HSCT; in high-, but not intermediate-risk patients, the administration of ATG on day+7 reduces GVHD. These results may represent a platform for risk-adapted post transplant immune modulation.

[Presentation of an assessment battery for visual mental imagery and visual perception]. / Normalisation d'une batterie d'évaluation de l'imagerie mentale visuelle et de la perception visuelle.

INTRODUCTION: The relationship between visual perception and visual mental imagery are at the center of a lively theoretical debate between those postulating common neurocognitive processes between perception and imagery and those who emphasize the differences between these two entities. Neuropsychology can make an important contribution to this debate, by assessing associations and dissociations between perceptual and imaginal deficits in patients with brain damage. However, currently there is no standardized test battery available for such assessments. MATERIAL AND METHODS: Here we present a battery of paper-and-pencil tests assessing different domains of visual mental imagery and visual perception abilities: object form and color, animals, orthographic material, numbers, faces, and space. We also explored the effects of age, educational level and gender on performance on a group of 103 participants free of neurological damage. RESULTS: The battery includes two parts: one composed of 14 tests assessing mental imagery and the second part composed of eight tests assessing the abilities of visual perception. We calculated the correlations between the tests, and found that, with the exception of orthographic material, there were generally poor correlations between imagery and perceptual tests. CONCLUSION: This result seems inconsistent with hypotheses postulating a strict correspondence between perceptual and imagery abilities.

[Unilateral spatial neglect: 30 years of research, discoveries, hope, and (especially) questions]. / La négligence spatiale unilatérale : trente ans de recherches, de découvertes, d'espoirs et (surtout) de questions.

Unilateral spatial neglect (USN) was defined 30 years ago as "a failure to report, respond, or orient to stimuli that are presented contralateral to a brain lesion, provided that this failure is not due to elementary sensory or motor disorders" by Heilman and Valenstein (1979). Even though this definition still holds, the last 30 years have been characterized by a profusion of clinical descriptions, neuroanatomical investigations and theoretical models of neglect. This article summarizes the wealth of neuroanatomical, clinical and experimental data concerning USN, by focusing on attentional and spatial deficits. Finally, some perspectives on neglect research are outlined.

Brain networks of spatial awareness: evidence from diffusion tensor imaging tractography.

Left unilateral neglect, a dramatic condition which impairs awareness of left-sided events, has been classically reported after right hemisphere cortical lesions involving the inferior parietal region. More recently, the involvement of long range white matter tracts has been highlighted, consistent with the idea that awareness of events occurring in space depends on the coordinated activity of anatomically distributed brain regions. Damage to the superior longitudinal fasciculus (SLF), linking parietal to frontal cortical regions, or to the inferior longitudinal fasciculus (ILF), connecting occipital and temporal lobes, has been described in neglect patients. In this study, four right-handed patients with right hemisphere strokes underwent a high definition anatomical MRI with diffusion tensor imaging (DTI) sequences and a pencil and paper neglect battery of tests. We used DTI tractography to visualise the SLF, ILF and the inferior fronto-occipital fasciculus (IFOF), a pathway running the depth of the temporal lobe, not hitherto associated with neglect. Two patients with cortical involvement of the inferior parietal and superior temporal regions, but intact and symmetrical fasciculi, showed no signs of neglect. The other two patients with signs of left neglect had superficial damage to the inferior parietal cortex and white matter damage involving the IFOF. These findings suggest that superficial damage to the inferior parietal cortex per se may not be sufficient to produce visual neglect. In some cases, a lesion to the direct connections between ventral occipital and frontal regions (ie, IFOF) may contribute to the manifestation of neglect by impairing the top down modulation of visual areas from the frontal cortex.

Efficacy of caspofungin as secondary prophylaxis in patients undergoing allogeneic stem cell transplantation with prior pulmonary and/or systemic fungal infection.

Transplanted patients with a history of invasive fungal infection (IFI) are at high risk of developing relapse and fatal complications. Eighteen patients affected by hematological malignancies and a previous IFI were submitted to allogeneic stem cell transplantation, using Caspofungin as a secondary prophylaxis. Patients had a probable or proven fungal infection and 16 had a pulmonary localization. No side effects were recorded during treatment with Caspofungin. Compared to pre-transplant evaluation, stability or improvement of the previous IFI was observed in 16 of the 18 patients at day 30, in 13 of the 15 evaluable patients at day 180 and in 11 of the 11 evaluable patients at day 360 post transplant. In particular, all the six patients with a proven fungal infection were alive, with a stable or improved IFI after 1 year from transplant. At a maximum follow-up of 31 months, eight patients died for disease progression or transplant-related complications, but only two had evidence of fungal progression. Secondary prophylaxis with Caspofungin may represent a suitable approach to limit IFI relapse or progression, allowing patients with hematological malignancies to adhere to the planned therapeutic program.

[Unilateral spatial neglect: a dramatic but often neglected consequence of right hemisphere damage]. / Négligence spatiale unilatérale: une conséquence dramatique mais souvent négligée des lésions de l'hémisphère droit.

INTRODUCTION: Unilateral Spatial Neglect (USN) is a common consequence of right brain damage. In the most severe cases, behavioral signs of USN can last several years and compromise patients' autonomy and social rehabilitation. These clinical facts stress the need for reliable procedures of diagnosis and rehabilitation. STATE OF THE ART: The last 3 decades have witnessed an explosion of studies on USN, which raises issues related to complex cognitive activities such as mental representation, spatial attention and consciousness. USN is probably a heterogeneous syndrome, but some of its underlying mechanisms might be understood as an association of disorders of spatial attention. A bias of automatic orienting towards right-sided objects seems typical of left USN. Afterwards, patients find it difficult to disengage their attention in order to explore the rest of the visual scene. Neglected objects are sometimes processed in an "implicit" way. PERSPECTIVES: The development of behavioural paradigms and of neuroimaging techniques and their application to the study of USN has advanced our understanding of the functional mechanisms of attention and spatial awareness, as well as of their neural bases. A number of new procedures for rehabilitation have recently been proposed. CONCLUSION: The present review describes the clinical presentation of USN, its anatomical basis and some of possible accounts of different aspects of neglect behavior. Results of computer simulations and of rehabilitation techniques are also presented with implications for the functioning of normal neurocognitive systems.

Looking while imagining: the influence of visual input on representational neglect.

BACKGROUND: Subjects with hemispatial neglect often exhibit representational neglect: a failure to report details from the left side of mentally visualized images. This failure could reflect impaired ability to generate the left side of the mental image, or it could reflect failure to explore the left side of a normally generated mental image. When subjects with hemispatial neglect look at pictures or drawings, their attention tends to be drawn to objects on the right side, thereby aggravating their failure to explore the left side. If representational neglect represents a failure to explore the left side of a normally generated mental visual image, then it should be improved by blindfolding, which removes the attention-catching right-sided stimuli. However, if representational neglect represents a failure to generate the left side of the mental visual image, then blindfolding should have little impact on reporting of details of the image. METHODS: To determine which of these explanations is correct, we asked eight normal participants and eight brain-damaged patients with left representational neglect to imagine the map of France and to name as many towns as possible in 2 minutes. In different sessions, participants performed the task with eyes open or while blindfolded. RESULTS: Normal participants mentioned more towns while blindfolded than with vision, thus suggesting a distracting effect of visual details on mental imagery. Patients with neglect, however, showed no appreciable effect of blindfolding on reporting of details from either side of mental images. CONCLUSION: Representational neglect may represent a failure to generate the left side of mental images.

Right spatial neglect after left hemisphere stroke: qualitative and quantitative study.

OBJECTIVES: Comparatively little research has been conducted on right neglect after left brain damage. The authors sought to assess contralateral neglect in subacute left hemisphere stroke patients using a comprehensive test battery validated in a large control group after right hemisphere stroke. METHODS: Seventy-eight left hemisphere stroke patients were assessed. The test battery included a preliminary assessment of anosognosia and visual extinction, a clinical assessment of gaze orientation and personal neglect, and paper-and-pencil tests of spatial neglect in the peripersonal space. Only nonverbal tests were used. RESULTS: Drawing and cancellation tasks revealed neglect in 10 to 13% of patients. The combined battery was more sensitive than any single test alone. A total of 43.5% of patients showed some degree of neglect on at least one measure. Anatomic analyses showed that neglect was more common and severe when the posterior association cortex was damaged. CONCLUSIONS: The frequency of occurrence of right neglect was, as expected, much lower than that reported in a study using the same assessment battery in right brain damage stroke patients. Nevertheless, neglect was found in a substantial proportion of patients at a subacute stage, suggesting that it should be considered in the rehabilitation planning of left brain damage stroke patients.