Cognitive impairment in young adults following cerebellar stroke: Prevalence and longitudinal course.

INTRODUCTION: Cognitive impairment is a well-known result of a stroke, but for cerebellar stroke in young patients detailed knowledge on the nature and extent of cognitive deficits is limited. This study examined the prevalence and course of cognitive impairment in a large cohort of patients with cerebellar stroke. METHODS: Sixty young (18-49 years) cerebellar stroke patients completed extensive neuropsychological assessments in the subacute (<9 months post-stroke) and/or chronic phase (≥9 months post-stroke). Performance and course were assessed using standardized scores and Reliable Change Index analyses. Associations between cognitive deficits and lesion locations were explored using subtraction analyses, and associations with subjective cognitive complaints and fatigue were examined. RESULTS: Sixty patients (52% male) were included with a mean age at event of 43.1 years. Cognitive impairment was observed in 60.3% of patients in the subacute phase and 51.2% during the chronic phase. Deficits were most frequent for visuo-spatial skills and executive functioning (42.5-54.6%). Both improvement and decline were observed over time, in 17.9% and 41.0% of participants, respectively. Cognitive deficits seem to be associated with lesions in certain cerebellar regions, however, no distinct correlation was found for a specific subregion. Subjective cognitive complaints were present in the majority of participants (61-80.5%) and positively correlated with fatigue in both phases (ρ = -.661 and ρ = -.757, p < .001, respectively). DISCUSSION: Cognitive impairment in cerebellar stroke patients is common, with deficits most pronounced for visuo-spatial skills and executive functioning, as in line with the Cerebellar Cognitive Affective Syndrome. The course of cognitive performance was heterogenous, with cognitive decline despite the fact that no recurrent strokes occurred. No clear association between lesion location and cognitive deficits was observed. Subjective cognitive complaints and fatigue were prevalent and positively correlated. Clinicians could use this information to actively screen for and better inform patients about possible cognitive sequalae.

Lifespan differences in visual short-term memory load-modulated functional connectivity.

Working memory is critical to higher-order executive processes and declines throughout the adult lifespan. However, our understanding of the neural mechanisms underlying this decline is limited. Recent work suggests that functional connectivity between frontal control and posterior visual regions may be critical, but examinations of age differences therein have been limited to a small set of brain regions and extreme group designs (i.e., comparing young and older adults). In this study, we build on previous research by using a lifespan cohort and a whole-brain approach to investigate working memory load-modulated functional connectivity in relation to age and performance. The article reports on analysis of the Cambridge center for Ageing and Neuroscience (Cam-CAN) data. Participants from a population-based lifespan cohort (N = 101, age 23-86) performed a visual short-term memory task during functional magnetic resonance imaging. Visual short-term memory was measured with a delayed recall task for visual motion with three different loads. Whole-brain load-modulated functional connectivity was estimated using psychophysiological interactions in a hundred regions of interest, sorted into seven networks (Schaefer et al., 2018, Yeo et al., 2011). Results showed that load-modulated functional connectivity was strongest within the dorsal attention and visual networks during encoding and maintenance. With increasing age, load-modulated functional connectivity strength decreased throughout the cortex. Whole-brain analyses for the relation between connectivity and behavior were non-significant. Our results give additional support to the sensory recruitment model of working memory. We also demonstrate the widespread negative impact of age on the modulation of functional connectivity by working memory load. Older adults might already be close to ceiling in terms of their neural resources at the lowest load and therefore less able to further increase connectivity with increasing task demands.

Mid-range visual functions in relation to higher-order visual functions after stroke.

INTRODUCTION: We aimed to investigate whether associations between deficits in "mid-range" visual functions and deficits in higher-order visual cognitive functions in stroke patients are more in line with a hierarchical, two-pathway model of the visual brain, or with a patchwork model, which assumes a parallel organization with many processing routes and cross-talk. METHODS: A group of 182 ischemic stroke patients was assessed with a new diagnostic set-up for the investigation of a comprehensive range of visuosensory mid-range functions: color, shape, location, orientation, correlated motion, contrast and texture. With logistic regression analyses we investigated the predictive value of these mid-range functions for deficits in visuoconstruction (Copy of the Rey-Complex Figure Test), visual emotion recognition (Ekman 60 Faces Test of the FEEST) and visual memory (computerized Doors-test). RESULTS: Results showed that performance on most mid-range visual tasks could not predict performance on higher-order visual cognitive tasks. Correlations were low to weak. Impaired visuoconstruction and visual memory were only modestly predicted by a worse location perception. Impaired emotion perception was modestly predicted by a worse orientation perception. In addition, double dissociations were found: there were patients with selective deficits in mid-range visual functions without higher-order visual deficits and vice versa. CONCLUSIONS: Our findings are not in line with the hierarchical, two-pathway model. Instead, the findings are more in line with alternative "patchwork" models, arguing for a parallel organization with many processing routes and cross-talk. However, future studies are needed to test these alternative models.

Mid-range visual deficits after stroke: Prevalence and co-occurrence.

Visual deficits are common after stroke and are powerful predictors for the chronic functional outcome. However, while basic visual field and recognition deficits are relatively easy to assess with standardized methods, selective deficits in visual primitives, such as shape or motion, are harder to identify, as they often require a symmetrical bilateral posterior lesion in order to provoke full field deficits. Therefore, we do not know how often they occur. Nevertheless, they can have severe repercussions for daily-life functioning. We aimed to investigate the prevalence and co-occurrence of hemifield "mid-range" visual deficits (i.e. color, shape, location, orientation, correlated motion, contrast, texture and glossiness), using a novel experimental set-up with a gaze-contingent presentation of the stimuli. To this end, a prospective cohort of 220 ischemic (sub)cortical stroke patients and a healthy control group was assessed with this set-up. When comparing performance of patients with controls, the results showed that deficits in motion-perception were most prevalent (26%), followed by color (22%), texture (22%), location (21%), orientation (18%), contrast (14%), shape (14%) and glossiness (13%). 63% of the stroke patients showed one or more mid-range visual deficits. Overlap of deficits was small; they mostly occurred in isolation or co-occurred with only one or two other deficits. To conclude, it was found that deficits in "mid-range" visual functions were very prevalent. These deficits are likely to affect the chronic post-stroke condition. Since we found no strong patterns of co-occurrences, we suggest that an assessment of deficits at this level of visual processing requires screening the full range of visual functions.

Accelerated Long-Term Forgetting: Prolonged Delayed Recognition as Sensitive Measurement for Different Profiles of Long-Term Memory and Metacognitive Confidence in Stroke Patients.

OBJECTIVE: Deficits in episodic memory are frequently reported after ischemic stroke. In standard clinical care, episodic memory is assessed after a 20-30 min delay, with abnormal memory decay over this period being characterized as rapid forgetting (RF). Previous studies have shown abnormal forgetting over a prolonged interval (days to weeks) despite normal acquisition, referred to as accelerated long-term forgetting (ALF). METHOD: We examined whether ALF is present in stroke patients (N = 91) using immediate testing (T1), testing after a short delay (20-30 min, T2), and testing after a prolonged delay (one week, T3). Based on performance compared to matched controls (N = 85), patients were divided into (1) patients without forgetting, (2) patients with RF between T1 and T2, and (3) patients with ALF at T3. Furthermore, confidence ratings were assessed. RESULTS: ALF was present in a moderate amount of stroke patients (17%), but ALF was even more prevalent in our stroke sample than RF after a 20-30 min delay (which was found in only 13% of our patients). Patients reported a lower confidence for their responses, independent of their actual performance. CONCLUSIONS: Adding a one-week delayed measurement may potentially assist in identifying patients with memory decrements that may otherwise go undetected.

Are visual working memory and episodic memory distinct processes? Insight from stroke patients by lesion-symptom mapping.

Working memory and episodic memory are two different processes, although the nature of their interrelationship is debated. As these processes are predominantly studied in isolation, it is unclear whether they crucially rely on different neural substrates. To obtain more insight in this, 81 adults with sub-acute ischemic stroke and 29 elderly controls were assessed on a visual working memory task, followed by a surprise subsequent memory test for the same stimuli. Multivariate, atlas- and track-based lesion-symptom mapping (LSM) analyses were performed to identify anatomical correlates of visual memory. Behavioral results gave moderate evidence for independence between discriminability in working memory and subsequent memory, and strong evidence for a correlation in response bias on the two tasks in stroke patients. LSM analyses suggested there might be independent regions associated with working memory and episodic memory. Lesions in the right arcuate fasciculus were more strongly associated with discriminability in working memory than in subsequent memory, while lesions in the frontal operculum in the right hemisphere were more strongly associated with criterion setting in subsequent memory. These findings support the view that some processes involved in working memory and episodic memory rely on separate mechanisms, while acknowledging that there might also be shared processes.

Consequence of stroke for feature recall and binding in visual working memory.

Visual memory for objects involves the integration, or binding, of individual features into a coherent representation. We used a novel approach to assess feature binding, using a delayed-reproduction task in combination with computational modeling and lesion analysis. We assessed stroke patients and neurotypical controls on a visual working memory task in which spatial arrays of colored disks were presented. After a brief delay, participants either had to report the color of one disk cued by its location or the location of one disk cued by its color. Our results demonstrate that, in the controls, report imprecision and swap errors (non-target reports) can be explained by a single source of variability. Stroke patients showed an overall decrease in memory precision for both color and location, with only limited evidence for deviations from the predicted relationship between report precision and swap errors. These deviations were primarily deficits in reporting items rather than selecting items based on the cue. Atlas-based lesion-symptom mapping showed that selection and reporting deficits, precision in reporting color, and precision in reporting location were associated with different lesion profiles. Deficits in binding are associated with lesions in the left somatosensory cortex, deficits in the precision of reporting color with bilateral fronto-parietal regions, and no anatomical substrates were identified for precision in reporting location. Our results converge with previous reports that working memory representations are widely distributed in the brain and can be found across sensory, parietal, temporal, and prefrontal cortices. Stroke patients demonstrate mostly subtle impairments in visual working memory, perhaps because representations from different areas in the brain can partly compensate for impaired encoding in lesioned areas. These findings contribute to understanding of the relation between memorizing features and their bound representations.

Post-Stroke Working Memory Dysfunction: A Meta-Analysis and Systematic Review.

This review investigates the severity and nature of post-stroke working memory deficits with reference to the multi-component model of working memory. We conducted a systematic search in PubMed up to March 2019 with search terms for stroke and memory. Studies on adult stroke patients, that included a control group, and assessed working memory function, were selected. Effect sizes (Hedges' g) were extracted from 50 studies (in total 3,084 stroke patients) based on the sample size, mean and standard deviation of patients and controls. Performance of stroke patients was compared to healthy controls on low-load (i.e. capacity) and high-load (executively demanding) working memory tasks, grouped by modality (verbal, non-verbal). A separate analysis compared patients in the sub-acute and the chronic stage. Longitudinal studies and effects of lesion location were systematically reviewed. Stroke patients demonstrated significant deficits in working memory with a moderate effect size for both low-load (Hedges' g = -.58 [-.82 to -.43]) and high-load (Hedges' g = -.59 [-.73 to -.45]) tasks. The effect sizes were comparable for verbal and non-verbal material. Systematically reviewing the literature showed that working memory deficits remain prominent in the chronic stage of stroke. Lesions in a widespread fronto-parietal network are associated with working memory deficits. Stroke patients show decrements of moderate magnitude in all subsystems of working memory. This review clearly demonstrates the global nature of the impairment in working memory post-stroke.

A comparison of visual working memory and episodic memory performance in younger and older adults.

Working memory and episodic memory decline with age.  However, as they are typically studied separately, it is largely unknown whether age-associated differences are similar. A task design was developed in which visual working memory and episodic memory performances were measured using the same stimuli, with both tasks involving context binding. A 2-back working memory task was followed by a surprise subsequent recognition memory task that assessed incidental encoding of object locations of the 2-back task. The study compared performance of younger (N=30; Mage=23.5, SDage=2.9, range=20-29) and older adults (N=29; Mage=72.1, SDage=6.8, range=62-90). Older adults performed worse than younger adults, without an interaction effect. In younger, but not in older adults, performance on the two tasks was related. We conclude that although age differences (Young>Older) are similar in the working memory and incidental associative memory tasks, the relationship between the two memory systems differs as a function of age group.