Global aphasia without hemiparesis: language profiles and lesion distribution

OBJECTIVES: Global aphasia without hemiparesis (GAWH) is an uncommon stroke syndrome involving receptive and expressive language impairment, without the hemiparesis typically manifested by patients with global aphasia after large left perisylvian lesions. A few cases of GAWH have been reported with conflicting conclusions regarding pathogenesis, lesion localisation, and recovery. The current study was conducted to attempt to clarify these issues. METHODS: Ten cases of GAWH were prospectively studied with language profiles and lesion analysis; five patients had multiple lesions, four patients had a single lesion, and one had a subarachnoid haemorrhage. Eight patients met criteria for cardioembolic ischaemic stroke. RESULTS: Cluster analysis based on acute language profiles disclosed three subtypes of patients with GAWH; these clusters persisted on follow up language assessment. Each cluster evolved into a different aphasia subtype: persistent GAWH, Wernicke's aphasia, or transcortical motor aphasia (TCM). Composite lesion analysis showed that persistent GAWH was related to lesioning of the left superior temporal gyrus. Patients with acute GAWH who evolved into TCM type aphasia had common lesioning of the left inferior frontal gyrus and adjacent subcortical white matter. Patients with acute GAWH who evolved into Wernicke's type aphasia were characterised by lesioning of the left precentral and postcentral gyri. Recovery of language was poor in all but one patient. CONCLUSIONS: Although patients with acute GAWH are similar on neurological examination, they are heterogeneous with respect to early aphasia profile, language recovery, and lesion profile.     

脑卒中后抑郁与部位的相关性研究

目的：探讨急性期脑卒中患者影像学改变在脑卒中后抑郁（PSD）患者中的相关性和临床意义,期望早期发现PSD患者并为及时干预提供帮助。方法：对329例急性脑卒中后1个月内患者采用系统的神经心理评估和MRI检查。所有患者均常规行汉密尔顿抑郁量表（HAMD）评分,根据头颅MRJ结果分析病变部位。结果：PSD的发病率以左侧半球脑卒中患者明显高于双侧和右侧半球脑卒中患者,且左侧额叶和基底节尤为突出。不同病灶数目组间比较,PSD的发生率以多灶患者明显高于单灶患者（P〈0．01）。结论：急性脑卒中后PSD与病变部位在左侧半球尤其是左侧额叶、颞叶和基底节区具有显著相关性。完全前循环梗死也是易患PSD的危险因素。     

Pathogenesis of reduplicative paramnesia.

The incidence of reduplicative paramnesia was sampled with a structured interview in 50 consecutive alcoholic inpatients. Four had reduplicative paramnesia (RP group) and 46 did not (non-RP group). Three of four patients in RP group had acute right hemispheric lesions and none had a left hemispheric lesion; 19 non-RP patients had left hemispheric lesions, 2 had right, and 25 had none. These data are in keeping with the previous suggestions that the neuroanatomical basis for reduplicative paramnesia is an acute right hemispheric lesion superimposed on chronic diffuse or bifrontal deficit.     

Depression after stroke: the importance of cerebral hemisphere asymmetries.

The pattern of brain asymmetries was visualized on computed tomography (CT) scan in patients with a single acute cerebrovascular lesion. Patients were divided into those with typical or reversed frontal and/or occipital asymmetries. Among patients with a typical occipital asymmetry, those with left frontal or left basal ganglia lesions showed a significantly higher frequency of major depression and significantly higher depression scores than patients with similar lesion location but with reversed occipital asymmetry or those with a typical asymmetry and lesions in other (left or right) brain areas. Among patients with a reversed occipital asymmetry, there was no significant association between left frontal or left basal ganglia lesions and depression. This study demonstrates that the previously reported significant association between post-stroke major depression and lesion location is restricted to patients with a typical occipital asymmetry and is not present in patients with a reversed occipital asymmetry.     

A case of acute cerebellar ataxia with an MRI abnormality

A 5-year-old boy with acute cerebellar ataxia was examined by means of magnetic resonance imaging (MRI) and was found to have a lesion showing low and high signal intensity in T1- and T2-weighted images, respectively, in the left cerebellar peduncle in the acute phase. The lesion disappeared in the convalescent phase.     

Crossed aphasia: a PET follow up study of two cases.

Two cases of aphasia after right hemispheric stroke in right handed patients are described. The first patient had a severe mixed transcortical aphasia, apraxia and neglect after a lesion involving the right lenticular nucleus and periventricular white matter; aphasia was still present after three months. The second patient had a mild, transient fluent aphasia after a small right hemispheric periventricular lesion. Studies with [18F]FDG and positron emission tomography (PET) showed functional depression extending to the structurally unaffected left hemisphere in both patients in the acute stage. After three months, in the patient with persistent aphasia, metabolism was still reduced in the right hemisphere, with some recovery of hypometabolism on the left, while metabolic values had returned to normal in the patient with full language recovery. A close parallelism between glucose metabolism and clinical course in crossed aphasia is shown, as well as the presence of a functional involvement of the structurally unaffected left hemisphere in the acute stage.     

Intracerebral hematoma associated with reduced apparent diffusion coefficient mimicking acute stroke

We report the case of a 67 year old patient admitted at our institution for acute onset of left hemiplegia. MRI was done 2 h 30 after symptom onset. Diffusion weighted images showed a hyperintense lesion in the right basal ganglia region with restricted apparent diffusion coefficient (ADC=428. 10(-6) mm(2)/s), a 50% decrease in value compared to the normal left side, consistent with acute ischemia. The lesion was hyperintense and moderately heterogeneous at FLAIR imaging, best seen on echo planar T2W images, with hypointense rim consistent with magnetic susceptibility artifact. The appearance and location of the lesion suggested the possibility of hematoma, which was confirmed at CT. Interpretation of ADC values must be performed in correlation with results at imaging including sequences sensitive to magnetic susceptibility artifacts such as echo planar T2*W and T2W sequences in order to exclude the possibility of underlying hematoma.     

Right-sided anarchic (alien) hand: a longitudinal study.

A patient with a bilateral frontal vascular lesion, encroaching upon the mesial cortex on the left and damage of the corpus callosum showed the 'alien hand' phenomenon on the right. The various hypotheses as to the nature of the lesion for the alien hand phenomenon to appear are discussed. It is proposed that an acute clinical condition, following a lesion of the corpus callosum only, should be differentiated from a chronic condition resulting from the additional fronto-mesial lesion.     

Important considerations in lesion‐symptom mapping: Illustrations from studies of word comprehension

Lesion‐symptom mapping is an important method of identifying networks of brain regions critical for functions. However, results might be influenced substantially by the imaging modality and timing of assessment. We tested the hypothesis that brain regions found to be associated with acute language deficits depend on (1) timing of behavioral measurement, (2) imaging sequences utilized to define the “lesion” (structural abnormality only or structural plus perfusion abnormality), and (3) power of the study. We studied 191 individuals with acute left hemisphere stroke with MRI and language testing to identify areas critical for spoken word comprehension. We use the data from this study to examine the potential impact of these three variables on lesion‐symptom mapping. We found that only the combination of structural and perfusion imaging within 48 h of onset identified areas where more abnormal voxels was associated with more severe acute deficits, after controlling for lesion volume and multiple comparisons. The critical area identified with this methodology was the left posterior superior temporal gyrus, consistent with other methods that have identified an important role of this area in spoken word comprehension. Results have implications for interpretation of other lesion‐symptom mapping studies, as well as for understanding areas critical for auditory word comprehension in the healthy brain. We propose that lesion‐symptom mapping at the acute stage of stroke addresses a different sort of question about brain–behavior relationships than lesion‐symptom mapping at the chronic stage, but that timing of behavioral measurement and imaging modalities should be considered in either case. Hum Brain Mapp 38:2990–3000, 2017. © 2017 Wiley Periodicals, Inc.     

Hyperkinesia contralateral to acute hemiplegia: relevance of previous frontal lesions

Two patients with a hyperkinetic syndrome contralateral to acute hemiplegia are presented. One patient showed a right-sided hemiplegia associated with abnormal movements of the left upper limb. In the other patient hemiplegia was localised on the left side while abnormal movements involved the right lower limb. Brain imaging showed acute infarctions (respectively left middle cerebral artery area and right lacunar infarctions) associated with a pre-existing contralateral infarction involving anterior non-primary motor areas. Hyperkinetic syndromes in stroke are mainly related to acute lesion of the contralateral subcortical areas. In our patients, the acute lesions were located ipsilateral to the hyperkinetic body part while the pre-existing lesions were located contralateral to the hyperkinetic side. We speculated that these pre-existing lesions might play a role in the pathophysiology of this clinical syndrome.     

Neglect severity after left and right brain damage

While unilateral spatial neglect after left brain damage is undoubtedly less common than spatial neglect after a right hemisphere lesion, it is also assumed to be less severe. Here we directly test this latter hypothesis using a continuous measure of neglect severity: the so-called Center of Cancellation (CoC). Rorden and Karnath (2010) recently validated this index for right brain damaged neglect patients. A first aim of the present study was to evaluate this new measure for spatial neglect after left brain damage. In a group of 48 left-sided stroke patients with and without neglect, a score greater than -0.086 on the Bells Test and greater than -0.024 on the Letter Cancellation Task turned out to indicate neglect behavior for acute left brain damaged patients. A second aim was to directly compare the severity of spatial neglect after left versus right brain injury by using the new CoC measure. While neglect is less frequent following left than right hemisphere injury, we found that when this symptom occurs it is of similar severity in acute left brain injury as in patients after acute right brain injury.     

Seizure disorder mimicking an acute confusional state as clinical presentation of neurocysticercosis: neuroimaging, EEG findings and clinical correlations

Epilepsy is the main clinical manifestation of neurocysticercosis (NC). We studied an adult subject who presented a seizure disorder mimicking an acute confusional state as clinical expression of NC. Diagnosis was made with neuroimaging and western blot determination of specific antibodies on serum. Computed tomography and magnetic resonance imaging displayed multiple calcifications and a few transitional cysts in the cerebral parenchyma. Electroencephalography showed a pattern of periodic lateralized epileptiform discharges (PLEDs) which could be related topographically to a cystic lesion located in the left parietal lobe. In our view there was a clear pathogenic correlation between the seizure disorder and the parasitic cyst located in the left parietal lobe. Neither antiepileptic drugs nor steroids were prescribed. Follow-up to one year ruled out other clinical manifestations of the disease. This case is an example of acute symptomatic seizure related to a transitional cystic lesion of NC. Received: 31 February 2001 / Accepted in revised form: 13 July 2001     

Changes in brain functional connectivity patterns are driven by an individual lesion in MS: a resting-state fMRI study

Diffuse inflammation in multiple sclerosis (MS) extends beyond focal lesion sites, affecting interconnected regions; however, little is known about the impact of an individual lesion affecting major white matter (WM) pathways on brain functional connectivity (FC). Here, we longitudinally assessed the effects of acute and chronic lesions on FC in relapsing-remitting MS (RRMS) patients using resting-state fMRI. 45 MRI data sets from 9 RRMS patients were recorded using 3T MR scanner over 5 time points at 8 week intervals. Patients were divided into two groups based on the presence (n?=?5; MS+) and absence (n?=?4; MS-) of a lesion at a predilection site for MS. While FC levels were found not to fluctuate significantly in the overall patient group, the MS+ patient group showed increased FC in the contralateral cuneus and precuneus and in the ipsilateral precuneus (p?<?0.01, corrected). This can be interpreted as the recruitment of intact cortical regions to compensate for tissue damage. During the study, one patient developed an acute WM lesion in the left posterior periventricular space. A marked increase in FC in the right pre-, post-central gyrus, right superior frontal gyrus, the left cuneus, the vermis and the posterior and anterior lobes of the cerebellum was noted following the clinical relapse, which gradually decreased in subsequent follow-ups, suggesting short-term functional reorganization during the acute phase. This strongly suggests that the lesion-related network changes observed in patients with chronic lesions occur as a result of reorganization processes following the initial appearance of an acute lesion.     

Ultrasonic evaluation of movement of the diaphragm after acute cerebral infarction.

Respiratory dysfunction is an important complication of acute stroke but its mechanisms are poorly understood. Previous indirect assessments suggest that paralysis of the diaphragm occurs contralateral to the cerebral lesion. Diaphragmatic excursion was studied with real time ultrasound during quiet and deep breathing in 50 patients within 72 hours of acute stroke and 40 controls. During quiet breathing, hemidiaphragmatic movements were not significantly different between right hemispheric stroke, left hemispheric stroke, and controls. During deep inspiration, there was a significant bilateral reduction in hemi-diaphragmatic excursion in patients with stroke, for both right hemispheric stroke and left hemispheric stroke when compared with controls (both P < 0.001). Thus isolated hemidiaphragmatic paresis does not occur but maximal excursion of the diaphragm is reduced bilaterally in patients with acute stroke. This is a likely contributor to the respiratory dysfunction after acute stroke.     

Focal limb dystonia in a patient with a cerebellar mass.

BACKGROUND: Focal dystonia of acute onset is indicative of a structural lesion in the nervous system. Cerebellar lesions have rarely been associated with dystonia. CASE DESCRIPTION: A 42-year-old woman was admitted to the neurology ward because of fever, confusion, and gait unsteadiness. She was diagnosed as having tuberculous meningitis, and, after a few days of antituberculous treatment, she developed prominent dystonia of the left upper limb. Cranial nuclear magnetic resonance imaging showed an isolated lesion compatible with a tuberculoma in the left cerebellar hemisphere. Both the limb dystonia and the tuberculoma resolved with maintained antituberculous treatment. CONCLUSIONS: In the patient described, the presence of upper-limb dystonia ipsilateral to a focal cerebellar lesion and the resolution of the dystonia and the mass lesion following treatment suggest that the cerebellum or its connections to the thalamus and/or basal ganglia could be involved in the pathophysiology of the dystonia.     

Aphemia as a presenting symptom in acute stroke

Aphemia is an apraxia of speech characterized by complete articulatory failure in the presence of preserved writing, comprehension and oropharyngeal function and can be the presenting manifestation of acute stroke. The responsible lesion is commonly in the left inferior frontal gyrus or the left motor cortex near the face M1 area. Three patients who developed aphemia due to acute ischemic stroke are described here. All had apraxia of speech due to acute infarct in the left motor cortex near face M1 area. Understanding the underlying speech disorder is crucial in planning the appropriate rehabilitation strategy.     

Poststroke depression in acute phase after stroke.

We studied factors associated with acute poststroke depression in 100 patients, aged 27-70, 2 weeks after their first clinically significant stroke. Depressive symptoms were relatively common (27% Beck Depression Inventory > or =10), but the prevalence of major depression was only 5.6%. Older patients were most vulnerable to poststroke depression. Patients with left hemisphere lesion had no more depression than other patients, but when the lesion was in the left hemisphere or in the brainstem, stroke severity was associated with depression.     

Takotsubo Cardiomyopathy Following Cerebral Infarction Involving the Insular Cortex

Background

Takotsubo cardiomyopathy is characterized by clinical features similar to those of acute myocardial ischemia, but without angiographic evidence of obstructive coronary artery disease. We present a patient with takotsubo cardiomyopathy following acute infarction involving the left insular cortex.

Case Report

A 52-year-old man was admitted with acute infarction of the left middle cerebral artery territory and acute chest pain. Acute myocardial infarction was suspected because of elevated serum troponin levels and hypokinesia of the left ventricle on echocardiography. However, a subsequent coronary angiography revealed no stenosis within the coronary arteries or ballooning of the apical left ventricle.

Conclusions

We postulated that catecholamine imbalance due to the insular lesion could be responsible for these interesting features.     

A case of brain infarction associated with viral encephalitis: MRI and pathological findings

A 10-year-old girl had an infarction in the left brain during an acute viral meningoencephalitis. She initially showed seizure, unconsciousness and fever, and right hemiplegia gradually developed. She died at the 48th day of disease from respiratory disturbance and renal failure. Cranial MRI during the acute phase of the disease, when there was no clinical sign of right hemiplegia, showed a high intensity lesion in the left parietal and occipital areas on T-2 weight image. Autopsy disclosed the findings suggesting viral encephalitis, including multiple focal necrosis, perivascular round cell infiltration, proliferation of glial cells and spongy degeneration with some intranuclear inclusion bodies, and infarction in the left hemisphere. These findings suggest that T-2 high intensity lesion on MRI reflected infarction.     

Single photon emission CT in diagnosis of herpes simplex encephalitis--fronto-parietal hypo-accumulation associated with temporal hyper-accumulation]

Single photon emission CT (SPECT) using 123I-iodoamphetamine and magnetic resonance imaging (MRI) were performed in acute, subacute and chronic stages of a herpes simplex encephalitis (HSE). On the 5th day after onset, SPECT showed left temporal hyperaccumulation associated with decreased accumulation in ipsilateral posterior frontal and anterior parietal lobes. These altered accumulations were normalized on the 26th day, and a broad hypoaccumulation appeared in left temporal and surrounded area on the 91st day. The lesion in MRI was restricted to left temporal lobe and insula throughout the clinical course. Several authors reported temporal hyperaccumulation of lipophilic tracer in SPECT study of acute HSE, but its mechanism is controversial. Some postulate local hyperperfusion and others infer altered binding site of tracer. The fronto-parietal hypoaccumulation observed in our acute SPECT study suggests steal phenomenon in the territory of ipsilateral internal carotid artery, and supports temporal hyperperfusion as the origin of increased accumulation.