Left Hemisphere Lesions Research Articles

Performance on the Rey-Osterrieth complex figure test and the correlation with the magnetic resonance imaging brain lesion volume in multi-infract versus small vessel disease dementia

Background/Aim. Regarding several cognitive domains, including visuospatial and visuoconstructional abilities, little is known about the differences between vascular dementia (VaD) subtypes, even in the most common sub-types, such as multi-infarct dementia (MID) and subcortical ischemic small vessel disease dementia (SSVD). This paper aimed to identify the differences between the performances on the Rey-Osterrieth Complex Figure (ROCF) test in MID and SSVD and correlate the ROCF scores in both groups with magnetic resonance imaging (MRI) ischemic lesion load. Methods. Sixty VaD patients with matching severity of dementia, age, and education were included in this study: 32 with SSVD and 28 with MID ac-cording to the NINDS-AIREN (National Institute of Neuro-logical Disorders and Stroke and Association Internationale pour la Recherch? et l'Enseignement en Neurosciences) neuroradiological criteria. A quantitative scoring system was performed. ROCF was given to all subjects in three test conditions: copy, immediate recall after 3 minutes, and delayed recall after 45 min. Magnetic resonance imaging (MRI) of the is-chemic brain volumes of anterior and posterior lesions, left and right hemispheric lesions, left and right-sided basal ganglia lesions, and total lesion load (TLL) were calculated in both groups. Results. The MID group was more impaired than SSVD on ROCF copy (p = 0.008), immediate recall (p= 0.005) and delayed recall (p = 0.001). There were significant correlations between ROCF copy score and the TLL (p < 0.05) and posterior brain lesion volume (p< 0.05) in the MID group. Conclusion. The importance of visuospatial, visuoconstructional deficit and impairment of visual memory is disregarded in VaD subtypes. These impairments are more severe in MID than SSVD and the deficit of ROCF copying in MID patients correlates with posterior and total MRI lesion volume.

Chapter 4 - Disorders of vocal emotional expression and comprehension: The aprosodias

Language is traditionally considered to be a dominant function of the left hemisphere because of its role in modulating the propositional or literal aspects of language (what is said). This chapter, however, will address the vital role of the right hemisphere in modulating the nonverbal, affective-prosodic aspects of speech (how it is said) that are essential for appropriate interpersonal interactions, communication competency, and psychosocial well-being. Focal right hemisphere lesions cause various disorders of affective prosody (aprosodic syndromes) that are analogous to the various aphasic syndromes that occur following focal left hemisphere lesions. Disorders of affective prosody may present clinically as loss of psychosocial well-being with disruption of interpersonal relationships. This chapter will review the research published over the last four decades that has helped to elucidate the neurobiology of affective prosody and the pathophysiology underlying the aprosodic syndromes.

The Margins of the Language Network in the Brain

This review paper summarizes the various brain modules that are involved in speech and language communication in addition to a left-dominant language network that, for the present purpose, has been restricted to elementary formal-linguistic and largely disembodied functions such as abstract phonology, syntax, and very basic lexical functions. This left-dominant perisylvian language network comprises parts of inferior frontal gyrus, premotor cortex, and upper temporal lobe, and a temporoparietal interface. After introducing this network, first, the various roles of neighboring and functionally connected brain regions are discussed. As a second approach, entire additional networks were considered rather than single regions, mainly motivated by resting-state studies indicating more or less stable connectivity patterns within these networks. Thirdly, some examples are provided for language tasks with functional demands exceeding the operating domain of the core language network. The rationale behind this approach is to present some outline of how the brain produces and perceives language, accounting, first, for a bulk of clinical studies showing typical forms of aphasia in case of left-hemispheric lesions in the core language network and second, for wide-spread activation patterns beyond this network in various experimental studies with language tasks. Roughly, the brain resources that complement the core language system in a task-specific way can be described as a number of brain structures and networks that are related to (1) motor representations, (2) sensory-related representations, (3) nonverbal memory structures, (4) affective/emotional processing, (5) social cognition and theory of mind, (6) meaning in context, and (7) cognitive control. After taking into account all these aspects, first, it seems clear that natural language communication cannot really work without additional systems. Second, it also becomes evident that during language acquisition the core language network has to be built up from outside, that is, from various neuronal activations that are related to sensory input, motor imitation, nursing, pre-linguistic sound communication, and pre-linguistic pragmatics. Furthermore, it might be worth considering that also in cases of aphasia the language network might be restored by being trained from outside.

A Comparative Study on the Effect of Task Specific Training on Right Versus Left Chronic Stroke Patients.

Functional impairment of the upper limb (UL) after stroke is a great problem. Finding methods that can improve UL function after stroke is a major concern to all medical service providers. This study was intended to compare the effect of upper limb task specific training (TST) on brain excitability of the affected hemisphere and motor function improvements in patients with left and right stroke. Forty male patients with mild impairment of UL functions were divided into two equal groups; G1 consisted of patients with left hemisphere affection (right side stroke) while G2 consisted of patients with right hemisphere affection (left side stroke). All patients received TST for the affected UL for one hour, three sessions per week for six consecutive weeks. Evaluation was performed twice, pre-, and post-treatment. Outcome measures used were Wolf Motor Function Test (WMFT) and Box and Block Test (BBT) as measures of UL motor function and Quantitative Electroencephalogram (QEEG) of motor and sensory areas of the affected hemisphere as a measure of brain reorganization post-stroke. Both groups showed improvement in motor function of the affected UL measured by WMFT and BBT with reported significant difference between them. G1 showed greater improvement in motor function of the affected UL post-treatment compared to G2. Additionally, there was a significant increase in peak frequency of motor and sensory areas with higher and significant excitability in G1 only. These findings imply that brain reorganization in the left hemisphere responded more to TST compared to the right hemisphere. Based on findings of the current study, we can recommend adding TST to the physical therapy program in stroke patients with left hemisphere lesions.

The Relevance of Right and Left Hemisphere Classification to Predict Cognitive Outcome After Stroke

Introduction: Stroke is the fifth leading cause of disability-adjusted life years (DALYs) in the world. Cognitive impairment is one of the disabilities found in the acute phase of stroke and persists in long-term outcomes which can be assessed using the Mini-Mental State Examination (MMSE). However, a clinical classification to predict the cognitive outcome remained unclear. This study is aimed to identify differences of MMSE results in stroke patients between right and left hemisphere lesions to ensure the mentioned location classifications may contribute to cognitive outcome prediction.Method: With the cross-sectional analytic observational design, 32 acute phase patients hospitalized in the Neurology Department Soetomo General Hospital from October–December 2019 were assessed using the Indonesian version of MMSE with purposive sampling and analyzed using the chi-square test.Result: There was no significant difference between MMSE scores in right or left hemisphere lesion. This might happen because (1) MMSE was insensitive and not a domain-specific test; (2) a more specific infarct location was needed to predict cognitive outcome post-stroke, including microarchitecture of the brain especially those involved in the cortico-striato-thalamocortical loop.Conclusion: The right or left hemisphere lesion classification did not contribute significantly to predict cognitive impairment.

The correlation between apraxia and neglect in the right hemisphere: A voxel-based lesion-symptom mapping study in 138 acute stroke patients

Apraxia is frequently described after left hemisphere stroke and results from lesions to a complex network for motor cognition with dorso-dorsal, ventro-dorsal and ventral processing streams. Apraxia also occurs after right hemisphere stroke, but lesion correlates and underlying mechanisms remain to be elucidated.To clarify the role of the right hemisphere in apraxic deficits and the influence of neglect, we prospectively examined apraxia (imitation of meaningless postures and pantomime of tool use) and neglect in 138 acute right hemisphere stroke patients with first-ever ischemic stroke in the middle cerebral artery territory and identified corresponding lesion correlates using voxel-based lesion-symptom mapping.Imitation of meaningless postures was impaired as frequently as after left hemisphere stroke (38.4%) and was significantly associated with neglect. Imitation of meaningless postures was related to temporal (middle temporal gyrus, temporoparietal junction, superior temporal gyrus and sulcus), parietal (angular gyrus, parieto-occpitpial sulcus), secondary sensorimotor cortex and (peri-)insular lesions. Presence of neglect dichotomized the results: a lesion correlate for isolated imitation without neglect was found in the right parieto-occipital cortex, while imitation deficits, when co-occurring with neglect, were related to lateral occipito-temporal, superior temporal sulcus and (peri-)insular lesions. Pantomime of tool use deficits, typical for apraxia after left hemisphere lesions, were found in only 5 cases (3.6%) and only in the context of neglect, and were associated with occipital lobe, ventral and anterior temporal lobe, and inferior frontal (areas 45/47) lesions.The syndrome of apraxia after right hemisphere stroke differs from apraxia after left hemisphere stroke. Imitation deficits are found in both hemispheres after dorso-dorsal stream lesions. Neglect also leads to and explains deficits in imitation and pantomime in patients with right ventral stream lesions. Therefore, in right hemisphere lesions, apraxia can either be explained as impaired visuomotor transformation or as a result of visuospatial deficits.

An Efficient Bedside Measure Yields Prognostic Implications for Language Recovery in Acute Stroke Patients.

It is estimated that ∼30% of stroke survivors have aphasia, a language disorder resulting from damage to left-hemisphere language networks. In acute care settings, efficient identification of aphasia is critical, but there is a paucity of efficient bedside assessments. To determine whether objective measures on a picture description task administered within 48 hours post stroke (a) predict language recovery, (b) estimate left-hemisphere lesion volume and location, and (c) correlate with other bedside language assessments. Behavioral data were scored at acute and chronic time points. Neuroimaging data were used to determine associations between the picture description task, other language assessments, and lesion volume and location. Acute content units, age, and total lesion volume predicted communication recovery; F3,18 = 3.98, P = 0.024; r = 0.40. Significant correlations were found between the picture description task and lesion volume and location. Picture description outcomes were also associated with other clinical language assessments. This picture description task quickly predicted the language performance (communication recovery and outcome) for patients who suffered a left-hemisphere stroke. Picture description task measures correlated with damage in the left hemisphere and with other, more time-consuming and cumbersome language assessments that are typically administered acutely at bedside. The predictive value of this picture description task and correlations with existing language assessments substantiate the clinical importance of a reliable yet rapid bedside measure for acute stroke patients that can be administered by a variety of health care professionals.

Is the Weigl Colour-Form Sorting Test Specific to Frontal Lobe Damage?

The Weigl Colour-Form Sorting Test is a brief, widely used test of executive function. So far, it is unknown whether this test is specific to frontal lobe damage. Our aim was to investigate Weigl performance in patients with focal, unilateral, left or right, frontal, or non-frontal lesions. We retrospectively analysed data from patients with focal, unilateral, left or right, frontal (n = 37), or non-frontal (n = 46) lesions who had completed the Weigl. Pass/failure (two correct solutions/less than two correct solutions) and errors were analysed. A greater proportion of frontal patients failed the Weigl than non-frontal patients, which was highly significant (p < 0.001). In patients who failed the test, a significantly greater proportion of frontal patients provided the same solution twice. No significant differences in Weigl performance were found between patients with left versus right hemisphere lesions or left versus right frontal lesions. There was no significant correlation between performance on the Weigl and tests tapping fluid intelligence. The Weigl is specific to frontal lobe lesions and not underpinned by fluid intelligence. Both pass/failure on this test and error types are informative. Hence, the Weigl is suitable for assessing frontal lobe dysfunction.

Effects of transcranial magnetic stimulation on the performance of the activities of daily living and attention function after stroke: a randomized controlled trial

Objective: We aimed to interrogate the effects of transcranial magnetic stimulation (TMS) on the performance in activities of daily living (ADL) and attention function after stroke. Design: Randomized controlled trial. Setting: Inpatient rehabilitation hospital. Subjects: We randomized 62 stroke patients with attention dysfunction who were randomly assigned into two groups, and two dropped out from each group. The TMS group (n = 29) and a sham group (n = 29), whose mean (SD) was 58.12 (6.72) years. A total of 33 (56.9%) patients had right hemisphere lesion while the rest 25 (43.1%) patients had left hemisphere lesion. Interventions: Patients in the TMS group received 10 Hz, 700 pulses of TMS, while those in the sham group received sham TMS for four weeks. All the participants underwent comprehensive cognitive training. Main measures: At baseline, and end of the four-week treatment, the performance in the activities of daily living was assessed by Functional Independence Measure (FIM). On the other side, attention dysfunction was screened by Mini-Mental State Examination (MMSE), while the attention function was assessed by the Trail Making Test-A (TMT-A), Digit Symbol Test (DST) and Digital Span Test (DS). Results: Our data showed a significant difference in the post-treatment gains in motor of Functional Independence Measure (13.00 SD 1.69 vs 4.21 SD 2.96), cognition of Functional Independence Measure (4.69 SD 1.56 vs 1.52 SD 1.02), total of Functional Independence Measure (17.69 SD 2.36 vs 5.72 SD 3.12), Mini-Mental State Examination (3.07 SD 1.36 vs 1.21 SD 0.62), time taken in Trail Making Test-A (96.67 SD 25.18 vs 44.28 SD 19.45), errors number in Trail Making Test-A (2.72 SD 1.03 vs 0.86 SD 1.03), Digit Symbol Test (3.76 SD 1.09 vs 0.76 SD 0.87) or Digital Span Test (1.69 SD 0.54 vs 0.90 SD 0.72) between the TMS group and the sham group (P < 0.05). Conclusions: Taken together, we demonstrate that TMS improves the performance in the activities of daily living and attention function in patients with stroke.

EEG features of brain injury during extracorporeal membrane oxygenation in children.

To examine EEG features of major pathophysiology in children undergoing extracorporeal membrane oxygenation (ECMO). This was a single-center, retrospective study of 201 pediatric patients on ECMO, using the first 24 hours of continuous EEG (cEEG) monitoring, collating background activity and electrographic seizures (ES) with imaging, ECMO type, and outcome. Severely abnormal cEEG background occurred in 12% (25/201), and was associated with death (sensitivity 0.23, specificity 0.97). ES occurred in 16% (33/201) within 3.2 (0.6-20.3) hours (median [interquartile range]) of cEEG commencement, and higher ES burden was associated with death. ES was always associated with ipsilateral injury (p = 0.006), but occurred in only one-third of cases with abnormal imaging. In 28 patients with isolated hemisphere lesion, type of arterial ECMO cannulation was associated with side of injury: right carotid cannulation was associated with right hemisphere lesions, and ascending aorta cannulation with left hemisphere lesions (odds ratio, 0.29 [95% confidence interval, 0.08-0.98], p = 0.03). After starting ECMO, cEEG background activity has the potential to inform prognosis. Type of arterial (carotid vs aortic) ECMO correlates with side of focal cerebral injury, which in ≈33% is associated with presence of ES. We hypothesize that the differential distribution reflects abnormal flow dynamics or embolic injury.

Cerebellar neuromodulation improves naming in post-stroke aphasia.

Transcranial direct current stimulation has been shown to increase the efficiency of language therapy in chronic aphasia; however, to date, an optimal stimulation site has not been identified. We investigated whether neuromodulation of the right cerebellum can improve naming skills in chronic aphasia. Using a randomized, double-blind, sham-controlled, within-subject crossover study design, participants received anodal cerebellar stimulation (n = 12) or cathodal cerebellar stimulation (n = 12) + computerized aphasia therapy then sham + computerized aphasia therapy, or the opposite order. There was no significant effect of treatment (cerebellar stimulation versus sham) for trained naming. However, there was a significant order x treatment interaction, indicating that cerebellar stimulation was more effective than sham immediately post-treatment for participants who received cerebellar stimulation in the first phase. There was a significant effect of treatment (cerebellar stimulation versus sham) for untrained naming immediately post-treatment and the significant improvement in untrained naming was maintained at two months post-treatment. Greater gains in naming (relative to sham) were noted for participants receiving cathodal stimulation for both trained and untrained items. Thus, our study provides evidence that repetitive cerebellar transcranial direct stimulation combined with computerized aphasia treatment can improve picture naming in chronic post-stroke aphasia. These findings suggest that the right cerebellum might be an optimal stimulation site for aphasia rehabilitation and this could be an answer to handle heterogeneous participants who vary in their size and site of left hemisphere lesions.

Effects of age and left hemisphere lesions on audiovisual integration of speech

Neuroimaging studies have implicated left temporal lobe regions in audiovisual integration of speech and inferior parietal regions in temporal binding of incoming signals. However, it remains unclear which regions are necessary for audiovisual integration, especially when the auditory and visual signals are offset in time. Aging also influences integration, but the nature of this influence is unresolved. We used a McGurk task to test audiovisual integration and sensitivity to the timing of audiovisual signals in two older adult groups: left hemisphere stroke survivors and controls. We observed a positive relationship between age and audiovisual speech integration in both groups, and an interaction indicating that lesions reduce sensitivity to timing offsets between signals. Lesion-symptom mapping demonstrated that damage to the left supramarginal gyrus and planum temporale reduces temporal acuity in audiovisual speech perception. This suggests that a process mediated by these structures identifies asynchronous audiovisual signals that should not be integrated.

Dissociation of visual extinction and neglect in the left hemisphere

Visual neglect and extinction are two distinct visuospatial attention deficits that frequently occur after right hemisphere cerebral stroke. However, their different lesion profiles remain a matter of debate. In the left hemisphere, a domain-general dual-loop model with distinct computational abilities onto which several cognitive functions may project, has been proposed: a dorsal stream for sensori-motor mapping in time and space and a ventral stream for comprehension and representation of concepts. We wondered whether such a distinction may apply to visual extinction and neglect in left hemisphere lesions. Of 165 prospectively studied patients with acute left hemispheric ischemic stroke with a single lesion on MRI, 122 had no visuospatial attention deficit, 10 had extinction, 31 neglect and 2 had both, visual extinction and neglect. Voxel-based-lesion-symptom mapping (VLSM, FDR<.05) showed a clear anatomical dissociation. Extinction occurred after damage to the parietal cortex (anterior bank of the intraparietal sulcus, inferior parietal lobe, and supramarginal gyrus), while visual neglect occurred after damage mainly to the temporal lobe (superior and middle temporal lobe, anterior temporal pole), inferior ventral premotor cortex, frontal operculum, angular gyrus, and insula. Direct comparison of both conditions linked extinction to intraparietal sulcus and supramarginal gyrus (FDR<.05). Thus, in the left hemisphere extinction seems to be related to dorsal stream lesions, whereas neglect maps more on the ventral stream. These data cannot be generalized to the right hemisphere. However, a domain-general point-of-view may stimulate discussion on visuospatial attention processing also in the right hemisphere.

Hemispheric lateralization of depression and attention deficit

Objective: There is a complex interaction among to the ischemic cerebrovascular diseases, cognition and depression. The aim of present study is to investigate the relationship between lesion side and depression and attention deficit in patients with Middle Cerebral Artery (MCA) infarction.&#x0D; Methods: This study was conducted on 41 patients with right and left MCA infarction. Beck Depression Inventory (BDI) was used for determination of depression severity of patients and Montreal Cognitive Assessment (MoCA) scoring was used for evaluation of cognitive status. Attention sub-test of MoCA score was also examined.&#x0D; Results: 20 patients had right MCS. The mean age of the patients was 72.21 years. 51.2% of the patients were male. BDI mean score was found to be 11.25 in patients with right MCA infarction and 16.9 in patients with left MCA infarction (p:0.04). The total MoCA scores between two groups were similar (right/left MCA infarction: 20.8/21.3). It was seen to be lower attention sub-score in patients with right hemisphere effects compared to patients with left hemispheric lesion (3.1/5.9; p:0.00).&#x0D; Conclusion: According to our findings, it is understood that attention of patients with right MCA infarction is more affected and patients with left MCA infarction is more depressed. In future studies, depression and attention affects which are at risk of developing after MCA infarctions should be evaluated in detail and should be put emphasis to rehabilitation of these areas.

Brain Connectivity Modulation After Exoskeleton-Assisted Gait in Chronic Hemiplegic Stroke Survivors: A Pilot Study.

The aim of this study was to investigate electroencephalographic (EEG) connectivity short-term changes, quantified by node strength and betweenness centrality, induced by a single trial of exoskeleton-assisted gait in chronic stroke survivors. Study design was randomized crossover. Electroencephalographic data (64-channel system) were recorded before gait (baseline) and after unassisted overground walking and overground exoskeleton-assisted walking. Coherence was estimated for alpha1, alpha2, and beta frequency ranges. Graph analysis assessed network model properties: node strength and betweenness centrality. Nine participants were included in the final analysis. In the group (four participants) with a left-hemisphere stroke lesion (dominant hemisphere), over the vertex, node strength increased in alpha1, alpha2, and beta bands, and betweenness centrality decreased in alpha2 both after unassisted overground walking and exoskeleton-assisted walking. In the group (five participants) with a right-hemisphere lesion (nondominant hemisphere), node strength increased in alpha1 and alpha2 over the contralesional sensorimotor area and ipsilesional prefrontal area after overground exoskeleton-assisted walking, compared with baseline and unassisted overground walking. A single session of exoskeleton training provides short-term neuroplastic modulation in chronic stroke. In participants with a nondominant hemisphere lesion, exoskeleton training induces activations similar to those observed in able-bodied participants, suggesting a role of lesion lateralization in networks' reorganization.

Functional dissociation of multiple-object tracking mechanisms based on hemispheric asymmetries.

A number of theoretical accounts have been put forward to explain the ability to simultaneously track multiple visually indistinguishable objects over a period of time. Serial processing models of visual tracking focus on the maintenance of the spatial locations of every single item over time. A more recent mechanism describes multiple object tracking as the ability to maintain a higher order representation of an abstract spatial configuration built by the illusory connection of the tracked items through their transition. The current study investigates the correspondence between these serial and parallel tracking accounts and the right hemispheric specialization for the space-based vs. left hemispheric for object-based attentional processing. Electrophysiological brain responses were recorded in two groups of patients with right- and left hemispheric lesions while performing in a multiple object tracking task. The results suggest a failure to distinguish single item information for the right hemispheric patients accompanied by the absence of a known electrophysiological marker associated with single item tracking. Importantly, left hemispheric patients showed a graded behavioral and electrophysiological response to probe stimuli as a function of the congruence of the probe with the relevant target stimuli. The current data suggest that the differential contribution of serial and parallel tracking mechanisms during object tracking can partly be explained by the different functional contributions of the right and left brain hemispheres.

Differences in linguistic cohesion within the first year following right- and left-hemisphere lesions

ABSTRACT Background: Characterizing productive language deficits following lesions to the right (RH) or left hemispheres (LH) is valuable in identifying appropriate therapeutic goals. While damage to the LH classically is associated with deficits in language, RH lesions also result in changed communication beyond prosody due to cognitive-linguistic effects. Cohesion, reference to introduced content across sentences within discourse, relies on a listener’s clear and unambiguous understanding that a reference has occurred. To date, we are not aware of any prior work that has compared patterns of cohesive strategy between RH and LH lesioned individuals with cohesion deficits. Aims: The purpose of the present study is to determine whether individuals with communication deficits following RH and LH lesions differ in the inclusion and clarity of cohesive markers. Methods & Procedures: Seventy-six RH samples and 145 LH samples were used for comparison of cohesion performance in a Cookie Theft picture description task. It was hypothesized that individuals with LH lesions would present a different pattern of cohesion behaviour than RH lesioned individuals when considered both acutely and chronically. Outcomes & Results: Overall, samples from LH and RH groups did not differ in word counts or cohesive marker usage. However, the patterns of markers they chose to employ were different. LH samples used conjunctions and personal pronouns more frequently and used lexical cohesive markers less frequently than RH samples. Acutely, patterns of cohesive marker use between LH and RH samples were more similar. Chronically, LH samples contained more personal pronouns and the differences in lexical cohesive markers remained unchanged. When cohesion was unsuccessful, LH and RH damage were associated with different patterns of error. LH samples tended to omit information needed to clarify the intended referent, resulting in incomplete cohesion errors. RH samples tended to sustain breakdowns in cohesion from sentence to sentence, not resolving incorrectly chosen pronouns or ambiguities left in their samples. Conclusions: LH and RH lesions resulted in differing patterns of chosen cohesive markers and errors when cohesion was unsuccessful. This was particularly true in lexical cohesion, which has been far less studied than closed-class cohesive markers like referential pronouns. It was also noted that cohesive behavior did not appear to “recover” for either group, suggesting the spontaneous recovery is minimal and present strategies for language therapy may not effectively address this linguistic function.

Paraplegia in a Teenage Girl

CASE A 16-year-old female presented to the Emergency Department unable to walk. She reported having fallen on the stairs and sustaining a right knee injury 3 months prior. Since that time, she had increasing difficulty walking to the point that her family had obtained a wheelchair for her. While the pain from the injury subsided, her left leg became weaker, which the family attributed to the left leg having “taken the strain” due to the right-sided injury. Over the past week, she developed difficulty with urination and reduced perianal sensation on wiping. She denied back pain or pain elsewhere. She otherwise felt well with no fevers and good appetite. On review of systems, no other symptoms were reported. Her only notable medical history was severe obesity, with a weight of 108 kg. She was born in the United Kingdom to parents who originated from the Democratic Republic of Congo. She had no travel history outside of the United Kingdom. She had no known contact with infectious persons. She had been fully immunized according to the UK vaccination schedule. She lived on the third floor of an apartment block with her parents and siblings. On examination, she appeared well. She was orientated to time, place and person and was lucid in conversation. She had a temperature of 36.7°C, heart rate of 99 beats/min, respiratory rate of 22 breaths/min, blood pressure of 133/85 mm Hg and oxygen saturation of 99% in ambient air. Cardiovascular, respiratory and abdominal examinations were unremarkable. There was no jaundice, anemia, clubbing, cyanosis, edema or lymphadenopathy noted. However, she had no detectable strength in the muscle groups throughout both lower limbs and had increased tone and absent reflexes. There was a sensory level at T10, perianal anesthesia and reduced anal tone. Upper limb neurologic examination was normal. Her back was nontender and had no external signs of trauma. Laboratory studies revealed a hemoglobin of 122 g/L; white cell count of 5.69 × 109/L with differential of 43.7% neutrophils, 40.1% lymphocytes, 9.3% monocytes, 6.7% eosinophils and 0.2% basophils; and platelet count 270 × 109/L. Renal, liver and thyroid function studies were normal. She had a prothrombin time 10.3 seconds, activated partial thromboplastin time of 23 seconds, and fibrinogen of 4.90 g/L. C-reactive protein was 10.6 mg/L, and erythrocyte sedimentation rate was 24 mm/h. Angiotensin-converting enzyme was 53 U/L. Serologic testing for hepatitis B, hepatitis C, HIV and human T-lymphotropic virus were all negative, but serum IgG for varicella-zoster virus was positive. She underwent emergency magnetic resonance imaging (MRI) of the spinal cord, which demonstrated a well-circumscribed, lobulated and enhancing intramedullary mass lesion extending from the inferior aspect of T10 to the inferior aspect of T11, almost filling the vertebral canal at this level. There was associated edematous change within the spinal cord between T7 and the conus at L1. The vertebrae and vertebral disks were normal. Dexamethasone was commenced, and she was transferred to the regional neurosciences specialty center. Cerebrospinal fluid was clear and colorless, with <1 white cell per mm3, and microscopy was negative for organisms including acid-fast bacilli. CSF was also negative by polymerase chain reaction for Varicella-Zoster virus, Herpes-Zoster virus1 and Herpes-Zoster virus2, Epstein-Barr virus, cytomeganovirus, enterovirus and Mycobacterium tuberculosis complex. CSF had total IgG of 51 mg/L with albumin 231 mg/L. Oligoclonal bands were negative in both serum and CSF. Serum testing for aquaporin 4, antineuronal, antinuclear, antineutrophil cytoplasm, double-stranded DNA and extractable nuclear antigen antibodies were all negative. She underwent further MRI of the brain and spinal cord (Fig. 1), which demonstrated avid, homogeneous enhancement of the intramedullary lesion and an additional left cerebellar hemispheric lesion without any meningeal enhancement. The lesions were isointense on T1 and hypointense on weighted T2 sequences, without evidence of restricted diffusion. Subsequent biopsy of the spinal lesion led to the diagnosis.FIGURE 1.: MRI images at presentation. A: Gadolinium-enhanced T2-weighted sagittal view of spine demonstrating intramedullary enhancement; (B) coronal fluid-attenuated inversion recovery sequence of brain demonstrating left cerebellar lesion without associated enhancement.

An Individualized Approach to Neuroplasticity After Early Unilateral Brain Damage.

Introduction: Reorganization after early lesions in the developing brain has been an object of extensive scientific work, but even growing data from translational neuroscience studies in the last 20 years does not provide unified factors for prediction of type of reorganization and rehabilitation potential of patients with unilateral cerebral palsy (UCP) due to pre/perinatal insult. Aim: To analyze the type of motor, language, and sensory brain reorganization in patients with right-sided cerebral palsy due to pre/perinatal isolated left-sided brain lesions taking into consideration the type (cortico-subcortical or periventricular) and extent (gray and white matter damage) of the lesion, etiology, comorbidity, and other postnatal factors that could have played a role in the complex process of brain plasticity. Material and Methods: Eight patients with unilateral right cerebral palsy were included in the study. The individual data from fMRI of primary sensory, motor, and language representation were analyzed and compared with respective comprehensive etiological, clinical, and morphological data. Patients were examined clinically and psychologically, and investigated by structural and functional 3T GE scanner. A correlation between the type and extent of the lesion (involvement of cortical and subcortical structures), timing of lesion, type of reorganization (laterality index), and clinical and psychological outcome was done. Results: Significant interindividual diversity was found in the patient group predominantly in the patterns of motor reorganization. Patients with small periventricular lesions have ipsilesional representation of primary motor, sensory, and word generation function. Patients with lesions involving left cortico-subcortical regions show various models of reorganization in all three modalities (ipsilesional, contralesional, and bilateral) and different clinical outcome that seem to be impossible for prediction. However, patients with UCP who demonstrate ipsilesional motor cortical activation have better motor functional capacity. Conclusion: The type and size of the pre/perinatal lesion in left hemisphere could affect the natural potential of the young brain for reorganization and therefore the clinical outcome. Much larger sample and additional correlation with morphological data (volumetry, morphometry, tractography) is needed for determination of possible risk or protective factors that could play a role in the complex process of brain plasticity.

Difference in gait recovery rate of hemiparetic stroke patients according to paralyzed side: A cross-sectional study based on a retrospective chart review.

In Donguibogam, a representative encyclopedic source of knowledge on traditional Korean medicine, left-sided hemiparesis due to stroke is called “Tan” as a sort of “Heyol-Byeong,” while right-sided hemiparesis due to stroke is called “Tan” as a sort of “Gi-Byeong.” According to the theory of Donguibogam, diseases on the left or right side of the human body must be treated differently. Clinically, the symptoms caused by left and right hemisphere lesions in stroke patients differ, as the functions of the left and right hemispheres differ. Considering these facts, when treating patients in clinical practice, it may be useful to distinguish between diseases on the left or right side according to Donguibogam. This study set out to confirm whether side-dependent gait rehabilitation could be used to treat hemiparetic stroke patients. Gait was selected for analysis, as it is the most important factor in returning stroke patients to daily life.This study conducted a retrospective chart review of stroke patients who satisfied the following criteria: outpatient or inpatient at the Wonkwang University Korean Medicine Hospital in Gwangju (WKUGH) with hemiparesis due to stroke; aged between 19 and 85 years old; with a stroke onset within the past 6 months; having undergone gait analysis (GAITRite) more than twice between September 1, 2017 and June 30, 2018 at the WKUGH, with a minimum 2-week interval between the first and next gait analysis; right-handed stroke patient; able to walk unaided. The spatio-temporal parameters for analysis included the FAP, walking velocity, step length, stance time, and swing time as obtained with GAITRite.In the initial gait analysis, there was no significant difference between the 2 groups in all spatio-temporal parameters. However, in the follow-up gait analysis, the left hemiparesis group showed a significantly higher FAP and faster walking velocity than the right hemiparesis group.This study found a difference in the recovery rate between the left and right hemiparesis groups. Based on this, we suggest that a different treatment strategy for gait rehabilitation can be used according to the paralyzed side.This study was approved by the Institutional Review Board (IRB) of the Wonkwang University Korean Medicine Hospital in Gwangju (WKUGH), Republic of Korea (WKIRB 2018 – 25, November 28, 2018). This trial was registered with the Clinical Research Information Service (CRIS) of the Korea National Institute of Health (NIH), Republic of Korea (KCT0002984).