Left-sided Brain Lesions Research Articles

Measurements of fetal dose with Mevion S250i proton therapy system with HYPERSCAN.

To characterize potential dose to the fetus for all modes of delivery (dynamic adaptive aperture, static adaptive aperture, and no adaptive aperture) for the Mevion S250i Proton Therapy System with HYPERSCAN and compare the findings with those of other available proton systems. Fetal dose measurements were performed for all three modes of dose delivery on the Mevion S250i Proton therapy system with HYPERSCAN (static aperture, dynamic aperture and uncollimated). Standard treatment plans were created in RayStation for a left-sided brain lesion treated with a vertex field, a left lateral field, and a posterior field. Measurements were performed using WENDI and the RANDO with the detector placed at representative locations to mimic the growth and movement of the fetus at different gestational stages. The fetal dose measurements varied with fetus position and the largest measured dose was 64.7 μSv per 2 Gy (RBE) fraction using the dynamic aperture. The smallest estimated fetal dose was 45.0 μSv per 2 Gy (RBE) at the base of the RANDO abdomen (47 cm from isocenter to the outer width of WENDI and 58.5 cm from the center of the WENDI detector) for the static aperture delivery. The vertex fields at all depths had larger contributions to the total dose than the other two and the dynamic aperture plans resulted in the highest dose measured for all depths. The reported doses are lower than reported doses using a double-scattering system. This work suggests that avoiding vertex fields and using the static aperture will help minimize dose to the fetus.

Right-sided weakness in a Rwandan patient with untreated Tetralogy of Fallot

BackgroundTetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease encountered in pediatrics with surgical repair being the definitive treatment. Long-term survival after surgical repair has improved; however, reported mortality rates in untreated TOF are significant. Associated complications include neurological sequelae such as brain abscess and stroke. In countries without early intervention for congenital heart disease (including TOF), delayed presentations and complications require recognition by healthcare workers.Case presentationA 22-year-old male with a history of untreated TOF presented to Rwanda’s tertiary university hospital, University Teaching Hospital of Kigali, with acute right-sided hemiparesis. Diagnostic imaging identified a left-sided brain lesion consistent with brain abscess and cardiac mass, concerning endocardial vegetation. He was managed with intravenous antibiotics but subsequently died due to complications of septicemia.DiscussionIn countries where surgical repair of TOF is not available, early recognition and medical management are key in temporizing the development of devastating sequelae. Describing the prevalence of CHD in Rwanda is urgent, requiring further research by which effective prevention and treatment strategies can be developed.

Depression among Rural Stroke Survivors: A Cross-Sectional Study.

Background:Depression is a major neuropsychiatric complication of stroke. Poststroke depression (PSD) can lead to inadequate functional recovery, social withdrawal, poor quality of life, and suicidal ideations.Objective:The study explored the PSD among stroke survivors.Materials and Methods:A cross-sectional survey was conducted among 151, purposively selected rural stroke survivors of Kozhikode district, Kerala, India. Patient health questionnaire-9 (PHQ-9) was used to assess PSD.Results:The age of participants ranged from 28 to 80 years with a mean (standard deviation) age of 64.58 (10.3) years. The majorities of the participants were males (53.6%), had an ischemic stroke (76.2%), and had left-sided brain lesions (75.5%). The median (interquartile range) depression scores on PHQ-9 were 9 (12–6). Most of the participants had either mild (47%), moderate (21.2%), or moderately severe depression (11.9%). Low energy, sleep disturbances, low self-esteem, and anhedonia were the common depressive symptoms experienced by the stroke survivors.Conclusions:High prevalence of undiagnosed depression remains as a significant challenge to primary care.

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.

Atypical temporal activation pattern and central-right brain compensation during semantic judgment task in children with early left brain damage

In this study we investigated the event-related potentials (ERPs) during the semantic judgment task (deciding if the two Chinese characters were semantically related or unrelated) to identify the timing of neural activation in children with early left brain damage (ELBD). The results demonstrated that compared with the controls, children with ELBD had (1) competitive accuracy and reaction time in the semantic judgment task, (2) weak operation of the N400, (3) stronger, earlier and later compensational positivities (referred to the enhanced P200, P250, and P600 amplitudes) in the central and right region of the brain to successfully engage in semantic judgment. Our preliminary findings indicate that temporally postlesional reorganization is in accordance with the proposed right-hemispheric organization of speech after early left-sided brain lesion. During semantic processing, the orthography has a greater effect on the children with ELBD, and a later semantic reanalysis (P600) is required due to the less efficient N400 at the former stage for semantic integration.

Functional strength training and movement performance therapy produce analogous improvement in sit-to-stand early after stroke: early-phase randomised controlled trial

ObjectivesRestoring independence in the sit-to-stand (STS) task is an important objective for stroke rehabilitation. It is not known if a particular intervention, strength training or therapy focused on movement performance is more likely to improve STS recovery. This study aimed to compare STS outcomes from functional strength training, movement performance therapy and conventional therapy. DesignRandomised controlled trial. SettingAcute stroke units. ParticipantsMedically well patients (n=93) with recent (<42 days) stroke. The mean age of patients was 68.8 years, mean time post ictus was 33.5 days, 54 (58%) were male, 20 showed neglect (22%) and 37 (40%) had a left-sided brain lesion. InterventionsSix weeks of either conventional therapy, functional strength training or movement performance therapy. Subjects were allocated to groups on a random basis. Main outcome measuresSTS ability, timing, symmetry, co-ordination, smoothness and knee velocity were measured at baseline, outcome (after 6 weeks of intervention) and follow-up (3 months after outcome). ResultsNo significant differences were found between the groups. All three groups improved their STS ability, with 88% able to STS at follow-up compared with 56% at baseline. Few differences were noted in quality of movement, with only symmetry when rising showing significantly greater improvement in the movement performance therapy group; this benefit was not evident at follow-up. ConclusionsRecovery of the STS movement is consistently good during stroke rehabilitation, irrespective of the type of therapy experienced. Changes in quality of movement did not differ according to group allocation, indicating that the type of therapy is less important.Clinical trial registration number NCT00322192.

Acute ischemic stroke in young adults-a hospital based study in North India

Objectives: To see the risk factors, clinical presentations and radiological profile of acute ischemic stroke in young adults in a tertiary-care hospital of North India. Methods: This study was conducted among 50 acute ischemic stroke patients (clinically and radiologically confirmed) irrespective of sex within the age group of 15-45 years admitted to Department of Medicine (Emergency Unit) after getting clearance from Institutional Ethical Committee (IEC). A proforma for each of the acute ischemic stroke patients was maintained where all clinical information in brief including particulars of the subject, chief complaints, past history, proper general physical examination and systemic examinations etc were recorded. The patients had been undergone plain CT (computed tomography) scan/MRI (Magnetic Resonance Imaging) brain on admission for radiological confirmation and to localize the site of lesion in brain. Results: Hypertension (56%) was the most common risk factor among acute ischemic stroke in young adults, followed by heart disease (54%). Majority of the acute ischemic stroke patients presented with hemiplegia (84%). Beside, imaging findings confirmed left sided brain lesion in majority of the patients (52%) and anterior circulation as the most common territory involved in the brain. Conclusions: Hypertension is very common among the young acute ischemic stroke patients. Most common clinical presentation is hemiplegia. Thus, the knowledge of the risk factors, clinical presentation and radiological findings of acute ischemic stroke in young adults can help in prevention, better understanding and therapeutic decision making in the disease management.

Organic causation of morbid jealousy

This article describes the organic contribution to morbid jealousy. Although the true prevalence of morbid jealousy is unknown, organic factors contribute significantly to its development. We present an assortment of five case histories to highlight the importance of organic causation in this phenomenon. The first two cases portray organic delusional disorder arising as an aftermath of cerebral infarcts. They are both associated with left sided brain lesions. Though organic processes generally respond poorly to treatment, case 3 (patient with head injury), is unusual as it describes a young man whose symptoms resolve on recovering from the effects of a head injury. Likewise, case 4 (patient with a meningioma) who made a complete recovery following surgery, emphasizes the need for early detection of reversible causes. The difficulty in identifying the common substrate for a phenomenon with such a wide variety of causations is amply displayed by the abundance of theories forwarded. The blurred demarcation between normal jealousy and pathological jealousy leads to further uncertainty. The excess representation of morbid jealousy in organic conditions is not enlightened by these theories. Organic pathology, by affecting the higher centers of the brain, may remove the control over instinctual behaviour. Evidence for this is hard to establish but the evolutionary perspective of jealousy akin to that of the animal kingdom alludes to possible explanations.

Language Organisation in Left Perinatal Stroke

Right-hemispheric organisation of language has been observed following early left-sided brain lesions. The role of the site of damage is still controversial, as other aspects influence the pattern of speech organisation including timing of the lesion and the presence of epilepsy. We studied a group of 10 term-born children homogeneous for timing/type of lesion and clinical picture. All subjects had left perinatal arterial stroke, right hemiplegia, normal cognitive functions and no or easily controlled epileptic seizures. In half the patients, the lesion clearly involved Broca's area, in the other half it was remote from it. Language lateralization was explored by an fMRI covert rhyme generation task. Eight of 10 subjects showed a right lateralisation of language, including all five patients with a damaged left Broca and 3/5 of those without it. Group analysis in patients with right hemispheric organisation showed brain activations homotopic to those found in the left hemisphere of a matched control group. Our findings confirm that, at the end of gestation, the human brain exhibits extraordinary (re-)organisational capabilities. Language organisation in the right hemisphere is favoured by the presence of destructive lesions of the left Broca's area at birth, and occurs in brain regions homotopic to those usually involved in language processing.

Cerebellar activation in right-hemispheric language dominance following early left-sided brain lesions

Cerebellar activation in right-hemispheric language dominance following early left-sided brain lesions

Deviation of eyes and head in acute cerebral stroke

BackgroundIt is a well-known phenomenon that some patients with acute left or right hemisphere stroke show a deviation of the eyes (Prévost's sign) and head to one side. Here we investigated whether both right- and left-sided brain lesions may cause this deviation. Moreover, we studied the relationship between this phenomenon and spatial neglect. In contrast to previous studies, we determined not only the discrete presence or absence of eye deviation with the naked eye through clinical inspection, but actually measured the extent of horizontal eye-in-head and head-on-trunk deviation. In further contrast, measurements were performed early after stroke onset (1.5 days on average).MethodsEye-in-head and head-on-trunk positions were measured at the bedside in 33 patients with acute unilateral left or right cerebral stroke consecutively admitted to our stroke unit.ResultsEach single patient with spatial neglect and right hemisphere lesion showed a marked deviation of the eyes and the head to the ipsilesional, right side. The average spontaneous gaze position in this group was 46° right, while it was close to the saggital body midline (0°) in the groups with acute left- or right-sided stroke but no spatial neglect as well as in healthy subjects.ConclusionA marked horizontal eye and head deviation observed ~1.5 days post-stroke is not a symptom associated with acute cerebral lesions per se, nor is a general symptom of right hemisphere lesions, but rather is specific for stroke patients with spatial neglect. The evaluation of the patient's horizontal eye and head position thus could serve as a brief and easy way helping to diagnose spatial neglect, in addition to the traditional paper-and-pencil tests.

Reduced prefrontal N-acetylaspartate in stroke patients with apathy

Background Although substantial numbers of stroke patients suffer from apathy, its causes are still poorly understood. Previous studies suggest that dysfunction of the frontal lobes is implicated in the pathophysiology of motivation. Our aim was to investigate the association between proton magnetic resonance spectroscopy (H 1-MRS) measurements in unaffected frontal lobes and apathy in a group of first-time stroke patients. Methods 31 patients with a first-time ischemic stroke located outside the frontal lobes and 20 healthy subjects were included in the study. The authors performed single voxel H 1-MRS in order to measure the N-acetylaspartate/creatine (NAA)/Cr, glutamate + glutamine (Glx)/Cr, choline (Cho)/Cr and myo-inositol (mI)/Cr ratios in the frontal lobes. Patients were assessed between days 7 and 12 post stroke. Diagnosis of apathy was made on the basis of clinical observation, interview and Apathy Scale. Results 13 out of 31 patients (42%) demonstrated apathy. Patients with apathy had lower NAA/Cr ratios in the right frontal lobe than non-apathetic subjects. The patient group was divided into two subgroups: Those with left hemisphere strokes, and those with right hemisphere strokes. Of these subjects, significantly lowered NAA/Cr ratios were found in the right hemispheres of apathetic patients in the subgroup with left-sided brain lesions. Conclusions These findings point to the association between apathy and frontal lobe integrity, suggest different reactions of the hemispheres and indicate that changes in the NAA/Cr ratio are related to the apathy.

Right-Hemispheric Organization of Language Following Early Left-Sided Brain Lesions: Functional MRI Topography

Left-hemispheric (LH) brain lesions acquired early in life can induce language organization in the undamaged right hemisphere (RH). This study addresses the anatomical correlates of language processing in the RH of such individuals. Five hemiparetic patients with left periventricular brain lesions of pre- and perinatal origin were included, in whom fMRI during a word generation task had yielded predominantly RH activation; five age- and sex-matched healthy right-handers served as controls. The patterns of activation in the RH of patients showed a striking similarity with the LH patterns of the normal controls, and voxel-wise comparison failed to detect significant differences. This demonstrates that in patients with early LH damage, RH recruitment for language occurs in brain areas homotopic to the LH regions involved in language processing under normal circumstances.

Early left periventricular brain lesions induce right hemispheric organization of speech.

Right-hemispheric organization of speech has been observed following early left-sided brain lesions involving the language cortex. The authors studied speech organization in hemiparetic patients with pre- and perinatally acquired lesions in the left periventricular white matter using fMRI, and found that right-hemisphere activation correlated with left facial motor tract involvement. This suggests that the impairment of speech motor output from the left hemisphere plays an important role in this alteration of language representation.

The topography of right-hemispheric language dominance following early left-sided brain lesions

The topography of right-hemispheric language dominance following early left-sided brain lesions

Cognitive outcome of children with early-onset hemiparesis.

The aim of this study was to examine the cognitive outcome of children with congenital and acquired early-onset unilateral brain lesions associated with hemiparesis. The neuropsychologic evaluation was done using the NEPSY test battery on 37 children with hemiparesis and 13 sex- and age-matched healthy controls. Compared to the controls, children with left-sided brain lesions had significant delay in phonologic and language functions, while children with right-sided brain lesions performed more poorly in visual and spatial skills and in somatosensory functions. There were more left-handed children in the former (6 of 23) than in the latter (1 of 14) group. There was no significant difference in cognitive outcome between children with congenital and acquired lesions. The cognitive outcome of boys and that of children with active epilepsy was more affected. Overall, the patients showed impairment in many cortical functions and diffuse cognitive delay compared to controls and the side of lesion, active epilepsy, and male gender were significant factors in predicting cognitive outcome.

The stroke impairment assessment set: Its internal consistency and predictive validity

Tsuji T, Liu M, Sonoda S, Domen K, Chino N. The Stroke Impairment Assessment Set: its internal consistency and predictive validity. Arch Phys Med Rehabil 2000;81:863-8. Objective: To study the scale quality and predictive validity of the Stroke Impairment Assessment Set (SIAS) developed for stroke outcome research. Design: Rasch analysis of the SIAS; stepwise multiple regression analysis to predict discharge functional independence measure (FIM) raw scores from demographic data, the SIAS scores, and the admission FIM scores; cross-validation of the prediction rule. Setting: Tertiary rehabilitation center in Japan. Patients: One hundred ninety stroke inpatients for the study of the scale quality and the predictive validity; a second sample of 116 stroke inpatients for the cross-validation study. Main Outcome Measures: Mean square fit statistics to study the degree of fit to the unidimensional model; logits to express item difficulties; discharge FIM scores for the study of predictive validity. Results: The degree of misfit was acceptable except for the shoulder range of motion (ROM), pain, visuospatial function, and speech items; and the SIAS items could be arranged on a common unidimensional scale. The difficulty patterns were identical at admission and at discharge except for the deep tendon reflexes, ROM, and pain items. They were also similar for the right- and left-sided brain lesion groups except for the speech and visuospatial items. For the prediction of the discharge FIM scores, the independent variables selected were age, the SIAS total scores, and the admission FIM scores; and the adjusted R2 was.64 (p <.0001). Stability of the predictive equation was confirmed in the cross-validation sample (R2 =.68, p <.001). Conclusions: The unidimensionality of the SIAS was confirmed, and the SIAS total scores proved useful for stroke outcome prediction. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Osteoporosis in hemiplegic stroke patients as studied with dual-energy x-ray absorptiometry

Objectives: To compare bone mineral densities (BMDs) of the affected and unaffected limbs in stroke patients at multiple sites; to study longitudinal changes during a 3-month rehabilitation program; and to relate BMDs to demographic, impairment, and disability variables. Design: Descriptive study. Setting: Tertiary rehabilitation center. Patients: One hundred four consecutive hemiplegic inpatients, 69 men, age 56.5 ± 13.2yrs, 47 with left-sided brain lesion. Median days from onset to admission and median length of stay days were 83 and 105.5, respectively. Main Outcome Measures: BMDs of proximal humerus, distal radius, femoral neck, and calcaneus bilaterally, and third lumbar vertebra, measured with dual-energy x-ray absorptiometry (DXA), were compared between affected and unaffected sides at admission and discharge. Results: Stroke Impairment Assessment Set (SIAS) motor scores, Functional Independence Measure (FIM) scores, grip strength, and awake/sleep heart rate counts (activity index) improved significantly at discharge. Affected/unaffected BMD ratios were 88.3% to 98.4% at admission and 79.6% to 98.8% at discharge, lowest for the humerus. Discharge/admission ratios were 89.1% to 97.8% for the affected and 97.4% to 100% for the unaffected side. All BMDs were intercorrelated (R = .438 to .873). They correlated significantly with age, body weight, grip strength, FIM scores, and activity index. Factors selected to explain BMD with multiple regression analysis differed according to the site and timing of the measurement. Conclusions: BMDs of the affected side were lower and most marked in the humerus. Longitudinally, not only the affected but the unaffected BMDs decreased. Age, sex, duration of stroke, anthropometric measurements, motor paralysis, muscle strength, and activity level contributed differently to bone loss according to the site and timing of the measurement.

Right Personal Neglect Following a Left Hemisphere Stroke. a Case Report

Neglect phenomena may occur in both extrapersonal and personal space. Whereas extrapersonal neglect has been found associated with both right- and left-sided brain lesions, no case of right personal neglect following a left-sided lesion has been so far reported. We describe a right-handed female patient who, after two left-hemisphere strokes, exhibited a florid personal neglect, but no extrapersonal neglect, anosognosia or somatoparaphrenia. The symptom persisted for a few weeks and then gradually disappeared. At least in the early phase of disease, a personal neglect can also be observed in patients with left brain damage.

Acute Confusional State (Delirium) Soon after Stroke is Associated with Hypercortisolism

Acute confusional state (ACS), or delirium according to DSM-III-R, and the function of the hypothalamic-pituitary-adrenal-axis were studied in 83 patients soon after an ischemic supratentorial stroke. ACS was common (35/83 = 42%). Patients with stroke had higher cortisol levels after dexamethasone than an elderly healthy control population (median = 75 and 31 nmol/l, respectively; p < 0.001). The stroke patients with ACS had higher post-dexamethasone cortisol levels than stroke patients without ACS (median = 98 vs. 59 nmol/l; p < 0.001). A logistic regression analysis revealed that ACS in stroke patients was independently associated with high cortisol levels after dexamethasone, extensive motor impairment and left-sided brain lesion. There is a close association between ACS and hypercortisolism in stroke patients, not explained by other known determinants of ACS. The possibility that hypercortisolism is involved in the pathophysiology of confusion caused by an acute stroke should be considered.