LHD Patients Research Articles

A Model of Reverse Vascular Remodeling in Pulmonary Hypertension Due to Left Heart Disease by Aortic Debanding in Rats.

Pulmonary hypertension due to left heart disease (PH-LHD) is the most common form of PH, yet its pathophysiology is poorly characterized than pulmonary arterial hypertension (PAH). As a result, approved therapeutic interventions for the treatment or prevention of PH-LHD are missing. Medications used to treat PH in PAH patients are not recommended for treatment of PH-LHD, as reduced pulmonary vascular resistance (PVR) and increased pulmonary blood flow in the presence of increased left-sided filling pressures may cause left heart decompensation and pulmonary edema. New strategies need to be developed to reverse PH in LHD patients. In contrast to PAH, PH-LHD develops due to increased mechanical load caused by congestion of blood into the lung circulation during left heart failure. Clinically, mechanical unloading of the left ventricle (LV) by aortic valve replacement in aortic stenosis patients or by implantation of LV assist devices in end-stage heart failure patients normalizes not only pulmonary arterial and right ventricular (RV) pressures but also PVR, thus providing indirect evidence for reverse remodeling in the pulmonary vasculature. Using an established rat model of PH-LHD due to left heart failure triggered by pressure overload with subsequent development of PH, a model is developed to study the molecular and cellular mechanisms of this physiological reverse remodeling process. Specifically, an aortic debanding surgery was performed, which resulted in reverse remodeling of the LV myocardium and its unloading. In parallel, complete normalization of RV systolic pressure and significant but incomplete reversal of RV hypertrophy was detectable. This model may present a valuable tool to study the mechanisms of physiological reverse remodeling in the pulmonary circulation and the RV, aiming to develop therapeutic strategies for treating PH-LHD and other forms of PH.

In Search for the Meaning of Illness: Content of Narrative Discourse Is Related to Cognitive Deficits in Stroke Patients.

Stroke survivors undergo a thorough cognitive diagnosis that often involves administration of multiple standardized tests. However, patient’s narrative discourse can provide clinicians with additional knowledge on patient’s subjective experience of illness, attitude toward current situation, and motivation for treatment. We evaluated the methods of analyzing thematic content and story types in relationship to cognitive impairment in stroke survivors with no aphasia (including 9 left hemisphere damage – LHD patients, and 16 right hemisphere damage – RHD patients). Cognitive impairment was evaluated in comparison to a group of 25 patients with orthopaedic injury not involving the brain. Our findings primarily show that higher elaboration on own cognitive problems, physical ailments or coping strategies in LHD patients and cognitive problems, emotional issues and circumstances of illness onset in RHD patients is related to deficits in executive functions and retrieval of information from memory. Furthermore, RHD patients who use more chaos story type show lower executive functioning. However, these results did not survive the significance threshold of p < 0.05 after Bonferroni adjustment for multiple comparisons. In conclusion, this study provides preliminary evidence that stroke survivor’s narrative can constitute an additional source of clinically-relevant information regarding patient’s experience of illness and attitude toward recovery. This knowledge can aid clinicians and nurses in everyday interactions with the patients and support individualized strategy to treatment. Still, the current results need be confirmed with future studies in a larger cohort of stroke patients.

Poem Versus Laparoscopic Heller Myotomy in the Treatment of Esophageal Achalasia: A Case-Control Study from Two High Volume Centers Using the Propensity Score

BackgroundPOEM has recently had a widespread diffusion, aiming at being the treatment of choice for esophageal achalasia. The results of ongoing RCTs against laparoscopic myotomy are not available, yet. We, therefore, designed this propensity score (PS) case-control study with the aim of evaluating how POEM compares to the long-standing laparoscopic Heller myotomy + Dor fundoplication (LHD) and verifying if it may really replace the latter as the first-line treatment for achalasia. MethodsTwo groups of consecutive patients undergoing treatment for primary achalasia from January 2014 to November 2017 were recruited in two high-volume centers, one with extensive experience with POEM and one with LHD. Patients with previous endoscopic treatment were included, whereas patients with previous LHD or POEM were excluded. A total of 140 patients in both centers were thus matched. LHD and POEM were performed following established techniques. The patients were followed with clinical (Eckardt score), endoscopic, and pH-manometry evaluations. ResultsThe procedure was successfully completed in all the patients. POEM required a shorter operation time and postoperative stay compared to LHD (p < 0.001). No mortality was recorded in either group. Seven complications were recorded in the POEM group (five mucosal perforations) and 3 in the LHD group (3 mucosal perforations)(p = 0.33). Two patients in the POEM group and one in the LHD were lost to follow-up. One patient in both groups died during the follow-up for unrelated causes. At a median follow-up of 24 months [15–30] for POEM and 31 months [15–41] for LHD (p < 0.05), 99.3% of the POEM patients and 97.7% of the LHD patients showed an Eckardt score ≤ 3 (p < 0.12). Four years after the treatment, the probability to have symptoms adequately controlled was > 90% for both groups (p = 0.2, Log-rank test). HR-Manometry showed a similar reduction in the LES pressure and 4sIRP; 24-h pH-monitoring showed however an abnormal exposure to acid in 38.4% of POEM patients, as compared to 17.1% of LHD patients (p < 0.01) and esophagitis was found in 37.4% of the POEM and 15.2% of LHD patients (p < 0.05). ConclusionPOEM provides the same midterm results as LHD. This study confirms, however, a higher incidence of postoperative GERD with the former, even if its real significance needs to be further evaluated.

O17 A PROPENSITY SCORE-MATCHED CASE-CONTROL STUDY TO COMPARE POEM AND LAPAROSCOPIC HELLER MYOTOMY IN THE TREATMENT OF ESOPHAGEAL ACHALASIA

Abstract Background We designed this study with the aim of comparing POEM and laparoscopic Heller myotomy+Dor fundoplication (LHD) by matching 2 groups of consecutive patients, treated in 2 high-volume Centers, with the propensity score (PS). Methods Patients undergoing treatment for achalasia from 2014 to 2017 were selected: by applying the PS, 140 patients in both centers were matched. LHD and POEM were performed following established techniques. Patients were followed with clinical, endoscopic and pH-manometry evaluations. Results POEM required a shorter operation time (47 min [35-57]) and postoperative stay (2 days [2-2]) compared to LHD (95 min [85-105] and 3 days [3-3], respectively, p&lt;0.001). No mortality was recorded in either group. Seven complications were recorded in the POEM group (5 mucosal perforations) and 3 in the LHD group (3 mucosal perforations)(p=0.33). At a median follow up of 24 mos. [15-30] for POEM and 31 mos. [15-41] for LHD (p&lt;0.05), the median Eckardt score did not differ: moreover, 99.3% of the POEM patients and 97.7% of the LHD patients showed an Eckardt score ≤ 3 (p &lt;0.12). Four years after the treatment, the probability to be symptom free was &gt; 90% for both groups (98.2% for POEM and 93.9% for LHD, p=0.2, Log-rank test). HR-Manometry showed a similar reduction in the LES pressure and 4sIRP; however, 24-h pH-monitoring showed an abnormal exposure to acid in 38.4% of POEM patients, as compared to 17.1% of LHD patients (p&lt;0.01) and esophagitis was found in 37.4% of the POEM and 15.2% of LHD patients (p&lt;0.05). Finally, the need for PPI therapy was higher in the POEM group (38.8%) compared to the LHD group (15.1%), p&lt;0.001.

Lesion location impact on functional recovery of the hemiparetic upper limb.

The effect of stroke topography on the recovery of hemiparetic upper limb (HUL) function is unclear due to limitations in previous studies–examination of lesion effects only in one point of time, or grouping together patients with left and right hemispheric damage (LHD, RHD), or disregard to different lesion impact on proximal and distal operations. Here we used voxel-based lesion symptom mapping (VLSM) to investigate the impact of stroke topography on HUL function taking into consideration the effects of (a) assessment time (subacute, chronic phases), (b) side of damaged hemisphere (left, right), (c) HUL part (proximal, distal). HUL function was examined in 3 groups of patients—Subacute (n = 130), Chronic (n = 66), and Delta (n = 49; patients examined both in the subacute and chronic phases)–using the proximal and distal sub-divisions of the Fugl-Meyer (FM) and the Box and Blocks (B&B) tests. HUL function following LHD tended to be affected in the subacute phase mainly by damage to white matter tracts, the putamen and the insula. In the chronic phase, a similar pattern was shown for B&B performance, whereas FM performance was affected by damage only to the white matter tracts. HUL function following RHD was affected in both phases, mainly by damage to the basal ganglia, white matter tracts and the insula, along with a restricted effect of damage to other cortical structures. In the chronic phase HUL function following RHD was affected also by damage to the thalamus. In the small Delta groups the following trends were found: In LHD patients, delayed motor recovery, captured by the B&B test, was affected by damage to the sensory-motor cortex, white matter association fibers and parts of the perisilvian cortex. In the RHD patients of the Delta group, delayed motor recovery was affected by damage to white matter projection fibers. Proximal and distal HUL functions examined in LHD patients (both in the subacute and chronic phases) tended to be affected by similar structures—mainly white matter projection tracts. In RHD patients, a distinction between proximal and distal HUL functions was found in the subacute but not in the chronic phase, with proximal and distal HUL functions affected by similar subcortical and cortical structures, except for an additional impact of damage to the superior temporal cortex and the retro-lenticular internal capsule only on proximal HUL function. The current study suggests the existence of important differences between the functional neuroanatomy underlying motor recovery following left and right hemisphere damage. A trend for different lesion effects was shown for residual proximal and distal HUL motor control. The study corroborates earlier findings showing an effect of the time after stroke onset (subacute, chronic) on the results of VLSM analyses. Further studies with larger sample size are required for the validation of these results.

Analysis of Brain Lesion Impact on Balance and Gait Following Stroke.

Falls are a leading cause of serious injury and restricted participation among persons with stroke (PwS). Reactive balance control is essential for fall prevention, however, only a few studies have explored the effects of lesion characteristics (location and extent) on balance control in PwS. We aimed to assess the impact of lesion characteristics on reactive and anticipatory balance capacity, gait, and hemiparetic lower limb function, in PwS. Forty-six subacute PwS were exposed to forward, backward, right and left unannounced horizontal surface translations in six increasing intensities while standing. Fall threshold (i.e., perturbation intensity that results in a fall into the harness system) was measured. In addition, the Berg Balance Scale (BBS), 6 Minute Walk Test (6MWT) and Lower Extremity Fugl-Meyer (LEFM) were measured. Lesion effects were analyzed separately for left and right hemisphere damaged (LHD, RHD) patients, using voxel-based lesion-symptom mapping (VLSM). Our results show that voxel clusters where damage exerted a significant impact on balance, gait and lower-limb function were found in the corticospinal tract (CST), in its passage in the corona radiata and in the posterior limb of the internal capsule. An additional significant impact was found to lesions affecting the putamen and the external capsule (EC). Balance, gait, and hemiparetic lower limb function showed much overlap of the corresponding “significant” voxel clusters. Test scores of RHD and LHD patients were affected largely by damage to homologous regions, with the LHD group showing a wider distribution of “significant” voxels. The study corroborates and extends previous findings by demonstrating that balance control, gait, and lower limb function are all affected mainly by damage to essentially the same brain structures, namely—the CST and adjacent structures in the capsular-putaminal region.

Audiovisual Lexical Retrieval Deficits Following Left Hemisphere Stroke.

Binding sensory features of multiple modalities of what we hear and see allows formation of a coherent percept to access semantics. Previous work on object naming has focused on visual confrontation naming with limited research in nonverbal auditory or multisensory processing. To investigate neural substrates and sensory effects of lexical retrieval, we evaluated healthy adults (n = 118) and left hemisphere stroke patients (LHD, n = 42) in naming manipulable objects across auditory (sound), visual (picture), and multisensory (audiovisual) conditions. LHD patients were divided into cortical, cortical–subcortical, or subcortical lesions (CO, CO–SC, SC), and specific lesion location investigated in a predictive model. Subjects produced lower accuracy in auditory naming relative to other conditions. Controls demonstrated greater naming accuracy and faster reaction times across all conditions compared to LHD patients. Naming across conditions was most severely impaired in CO patients. Both auditory and visual naming accuracy were impacted by temporal lobe involvement, although auditory naming was sensitive to lesions extending subcortically. Only controls demonstrated significant improvement over visual naming with the addition of auditory cues (i.e., multisensory condition). Results support overlapping neural networks for visual and auditory modalities related to semantic integration in lexical retrieval and temporal lobe involvement, while multisensory integration was impacted by both occipital and temporal lobe lesion involvement. The findings support modality specificity in naming and suggest that auditory naming is mediated by a distributed cortical–subcortical network overlapping with networks mediating spatiotemporal aspects of skilled movements producing sound.

The neural substrate of residual motor function after stroke: Comparison of left and right hemisphere damage

Lesion characteristics exert a dominant effect on the severity of motor impairment following stroke and on the likelihood of obtaining natural and treatment-induced recovery. Here we aimed to assess the relationship between location of brain damage and residual motor function using voxel-based lesion-symptom mapping (VLSM). Residual motor function of the hemiparetic upper limb (HUL) was examined in 3 groups of patients — Subacute ( n = 72), Chronic ( n = 31), and Delta ( n = 20; patients examined both in the subacute and chronic stages) — using the proximal and distal sub-divisions of the Upper Extremity module of the Fugl-Meyer test and the Box and Blocks test. Normalized lesion data were used for VLSM analyses of lesion impact on motor function, separately for left and right hemisphere damage (LHD, RHD). HUL function following LHD was affected in the subacute phase mainly by damage to the sensory-motor and premotor cortices, with an additional impact of damage to white matter tracts. In the chronic phase, the impact of damage to cortical structures was restricted to a smaller part of the sensory-motor cortex, whereas damage to white matter tracts maintained a dominant impact on HUL function. The RHD group revealed a less salient effect of assessment time and in both phases the major impact on HUL function was attributed to damage to the insular cortex, the basal ganglia and the adjacent white matter tracts. Proximal and distal HUL functions were affected mainly by lesions to dorsal and ventral cortical regions, respectively. The functional neuroanatomy underlying motor recovery is different in LHD and RHD patients. Proximal and distal HUL motor control is affected by different lesion patterns. Time after stroke onset (subacute, chronic) affects significantly the results of VLSM analyses.

The Circulating MicroRNA-206 Level Predicts the Severity of Pulmonary Hypertension in Patients with Left Heart Diseases

Background: MicroRNA-206 (miR-206), a muscle-specific miRNA, regulates the growth of cardiac myocytes and pulmonary artery smooth muscle cells. However, it remains unknown whether miR-206 is involved in pulmonary hypertension (PH) due to left heart diseases (PH-LHD). This study was designed to investigate the correlation between miR-206 and PH in patients with LHD. Methods: In 82 consecutively enrolled LHD patients, we examined the serum levels of miR-206 and analyzed its correlations with pulmonary artery systolic pressure (PASP) and cardiac function. Another 36 age- and sex-matched subjects served as healthy controls. Results: The patients were divided into the LHD group (n=47, PASP<50 mmHg) and the PH-LHD group (n=35, PASP≥50 mmHg). The level of miR-206 was significantly decreased in the PH-LHD group compared with that of the LHD and healthy control groups. In addition, the miR-206 level was correlated with PASP (r=-0.305, p<0.001) but not with systemic blood pressure. Univariate analyses showed that miR-206, brain natriuretic peptide (BNP), left ventricular ejection fraction and left atrial longitudinal diameter (LAD) were significantly related to PASP. Multivariate regression analysis identified miR-206 as an independent predictive factor for PH. MiR-206 alone (cut-off <0.66) demonstrated a sensitivity of 68.60% and a specificity of 65.80% in predicting PH. Moreover, the combination of miR-206, BNP and LAD (cut-off 0.21) showed a sensitivity of 97.10% and a specificity of 80.30% in predicting PH in LHD patients. Conclusion: A decreased circulating miR-206 level was associated with increased PASP in LHD patients. Thus, the level of miR-206, especially combined with BNP and LAD, might be helpful in the detection of PH in LHD patients.

Beyond stroke: Impact of the lesion side on the recovery of between-hands coordination

One-fit-all post-stroke rehabilitation has limited plausibility. Better understanding the effects of the lesion location on the recovery process may help to develop new tailored therapeutic strategies to individuals. The purpose of this study was to assess the natural evolution of bimanual coordination over standard rehabilitation according to the lesion side, aiming to identify a potential responder-profile for bimanual-oriented therapy. Twelve hemiparetic, moderately impaired patients were included within 30 days after a first unilateral stroke. The kinematic and clinical assessments were performed once a week for 6 weeks and at 3 months after inclusion. The patients performed a reach-to-grasp task in unimanual condition followed by a synchronous bimanual condition. The clinical evaluation included the Fugl-Meyer Assessment, Box and Block Test, 9-Hole Peg Test and Barthel Index. The clinical scores indicated no difference in motor function between left- (LHD) and right-hemispheric damaged (RHD) patients over time. Interestingly, the LHD patients produced smoother bimanual reaching movements than the RHD patients while we found no effect of the lesion side on reaching kinematics of the paretic UL in unimanual condition. These inter-group differences disappeared after 5 weeks of standard therapy, likely indicating a time lag in motor recovery. Because the RHD patients were less prematurely coordinated again during bimanual movements than the LHD patients, they may benefit differently from a bimanual rehabilitation, and especially from the simultaneous involvement of the ipsilesional UL. It becomes necessary to investigate to what extent this difference due to lesion side may be integrated into the design of rehabilitation protocols.

Lateralization of motor cortex excitability in stroke patients during action observation: a TMS study.

Action observation activates the same motor areas as those involved in the performance of the observed actions and promotes functional recovery following stroke. Movement observation is now considered a promising tool for motor rehabilitation, by allowing patients to train their motor functions when voluntary movement is partially impaired. We asked chronic-stroke patients, affected by either left (LHD) or right hemisphere (RHD) lesions, to observe either a left or right hand, while grasping a small target (eliciting a precision grip) or a large target (eliciting a whole hand grasp directed towards a target object). To better understand the effects of action observation on damaged motor circuits, we used transcranial magnetic stimulation (TMS) to induce motor evoked potentials (MEP) from two muscles of the unaffected hand in 10 completely hemiplegic participants. Results revealed that LHD patients showed MEP facilitation on the right (contralesional) M1 during action observation of hand-object interactions. In contrast, results showed no facilitation of the left (contralesional) M1 in RHD patients. Our results confirm that action observation might have a positive influence on the recovery of motor functions after stroke. Activating the motor system by means of action observation might provide a mechanism for improving function, at least in LHD patients.

Clinical Utility of the Neuropsychological Assessment Battery (NAB) after Unilateral Stroke

The NAB is a comprehensive battery assessing five cognitive domains (Attention, Language, Memory, Spatial, Executive Function). Despite the advantage of co-normative domain data, its clinical utility is not well established because few studies have reported full-battery findings. The aim of this study was to determine if the NAB was sensitive to well documented hemispheric differences in language and spatial skills after unilateral stroke. We compared demographically matched control participants (n = 52) and individuals after left (LHD, n = 36) or right (RHD, n = 33) hemisphere damage due to stroke on the NAB, parts of the Western Aphasia Battery, and traditional visuospatial tasks. Both stroke groups showed impaired NAB Attention, Spatial, and Executive Functions relative to controls, while the LHD group was more impaired than control and RHD groups on Language and Memory modules. LHD patients with aphasia on traditional measures performed worse than control and non-aphasic LHD patients on all NAB domains. RHD patients with spatial impairment on traditional measures performed worse than controls, but not RHD patients without spatial impairment, on the NAB Spatial domain. Findings suggest the NAB is generally comparable to traditional language and visuospatial measures, and it sufficiently detects attention and executive deficits.

Effects of left and right hemisphere damage on sensitivity to global context during lexical ambiguity resolution

Background: A great deal of research suggests that both the left hemisphere (LH) and right hemisphere (RH) contribute to the resolution of lexically ambiguous words. If this is indeed the case, then patients with left (LHD) or right hemisphere brain damage (RHD) should exhibit deficits in ambiguity resolution. Although several studies have explored this issue, there is still little consensus regarding the exact nature of the patients' deficits. Moreover, the focus of most studies has been on ambiguity resolution in short, single-sentence contexts, so less is known about the impact of LH and RH damage on ambiguity resolution in larger contexts. Aims: The goal of the present study was to investigate sensitivity to a global (i.e., two-sentence) context during lexical ambiguity resolution in LHD and RHD patients relative to a group of control participants with no neurological impairment. Control participants were expected to activate only contextually appropriate meanings. In contrast, LHD patients were expected to have difficulty activating ambiguous word meanings or selecting contextually appropriate meanings. RHD patients were expected to have difficulty using context or suppressing contextually inappropriate meanings. Methods & Procedures: Three groups of participants took part in this study: 10 LHD patients with nonfluent aphasia, 8 RHD patients, and 9 age-matched control participants. A cross-modal sentence priming task was employed where participants first listened to a biased two-sentence passage ending in an ambiguous word. After each passage a visual target word, related to either the first or second meaning of the ambiguous word, was presented for lexical decision. Reaction time data were analysed using a repeated-measures ANOVA. Priming effects were tested by way of planned comparisons. Outcomes & Results: The performance of both patient groups differed markedly from that of the control group, who only showed priming for contextually appropriate meanings. The LHD patients did not exhibit any significant priming of ambiguous word meanings, whereas the RHD patients only showed priming for the most frequent or dominant meaning of ambiguous words (e.g., the “animal” meaning as opposed to the “emblem” meaning of seal) regardless of context. Conclusions: Both LH and RH damage can disrupt the process of ambiguity resolution in a global context. Specifically, LH damage is argued to impair the degree of activation of ambiguous word meanings or the time course of meaning activation, while RH damage seems to impair the use of context, leading to frequency-based meaning activation.

Influence of the side of brain damage on postural upper-limb control including the scapula in stroke patients

Following stroke, control of both the contralesional (paretic) and ipsilesional (less affected) arms is altered. The purpose of this study was to analyse the consequences of stroke on joint rotations of both shoulder girdles, that is, glenohumeral (GH) and scapula motion. Because of hemispheric specialization, we hypothesized that changes would relate to the side of hemisphere damage. Nine stroke patients with left, and 9 with right hemisphere damage (LHD and RHD) and 9 healthy subjects were included. Reaching movements to targets positioned close, far and high in three directions were recorded using an electromagnetic system. Initial and final postures of the scapula, GH and elbow joint were evaluated. Inter-joint rotations throughout the movements were analysed using principal component analysis (PCA). The main finding was that initial and final postures of the contralesional and ipsilesional shoulders differed depending on the side of brain lesion. On the contralesional side, there was less scapula protraction and GH lateral rotation for both groups. Scapula tilt was less anterior in LHD patients, and GH elevation was greater in RHD patients. On the ipsilesional side, GH lateral rotation was reduced in both groups, and scapula protraction was reduced only for LHD patients. PCA confirmed that postures of both shoulders of the LHD group were substantially different to the healthy subjects, while only the contralesional arm of the RHD subjects differed. These results add to existing knowledge of hemispheric specialization, suggesting that the left hemisphere plays a greater role in bilateral joint postures than the right hemisphere.

Associations and dissociations of transitive and intransitive gestures in left and right hemisphere stroke patients

The study investigated performance on pantomime and imitation of transitive and intransitive gestures in 80 stroke patients, 42 with left (LHD) and 38 with right (RHD) hemisphere damage. Patients were also categorized in two groups based on the time that has elapsed between their stroke and the apraxia assessment: acute–subacute ( n = 42) and chronic ( n = 38). In addition, patterns of performance in apraxia were examined. We expected that acute–subacute patients would be more impaired than chronic patients and that LHD patients would be more impaired than RHD patients, relative to controls. The hemisphere prediction was confirmed, replicating previous findings. The frequency of apraxia was also higher in all LHD time post-stroke groups. The most common impairment after LHD was impairment in both pantomime and imitation in both transitive and intransitive gestures. Selective deficits in imitation were more frequent after RHD for transitive gestures but for intransitive gestures they were more frequent after LHD. Patients were more impaired on imitation than pantomime, relative to controls. In addition, after looking at both gesture types concurrently, we have described cases of patients who suffered deficits in pantomime of intransitive gestures with preserved performance on transitive gestures. Such cases show that the right hemisphere may be in some cases critical for the successful pantomime of intransitive gestures and the neural networks subserving them may be distinct. Chronic patients were also less impaired than acute–subacute patients, even though the difference did not reach significance. A longitudinal study is needed to examine the recovery patterns in both LHD and RHD patients.

Relevance of Subcortical Stroke in Dysphagia

Unilateral cortical lesions are associated with dysphagia in ischemic stroke. It is unclear, however, whether acute subcortical stroke is associated with a similar risk of dysphagia. The aim of this study was to determine the occurrence of dysphagia in purely subcortical stroke and identify dysphagia characteristics. Between 2003 and 2005, videofluoroscopic swallow studies (VFSSs) were completed in 20 consecutive ischemic stroke patients with purely subcortical lesions (right hemisphere damage [RHD]=10, left hemisphere damage [LHD]=10) and 25 age-matched controls. Individuals were classified with dysphagia when at least 2 swallowing measures were 2 standard deviations above mean scores for the control group. Lesion volume, hemisphere, and location were determined from diffusion-weighted magnetic resonance imaging scans. Seven subcortical stroke patients (35%) met VFSS criteria for dysphagia (LHD=5, RHD=2); 4 patients presented with clinically significant dysphagia. A significant interaction between hemisphere and lesion location was identified. Whereas 3 of 5 patients with dysphagia (60%) had lesions to the left periventricular white matter (PVWM), LHD patients without dysphagia did not have PVWM lesions. In contrast, no RHD patients with PVWM lesions had dysphagia, and 6 of 8 patients without dysphagia (75%) had PVWM lesions. Oral transfer was significantly slower in patients with subcortical stroke compared with the healthy adults. Lesions to the left PVWM may be more disruptive to swallowing behavior than similar lesions to the right PVWM. Swallowing deficits involving oral control and transfer may be a marker of subcortical neural axis involvement.

Use of prosodic cues in the production of idiomatic and literal sentences by individuals with right- and left-hemisphere damage

The neural bases of prosody during the production of literal and idiomatic interpretations of literally plausible idioms was investigated. Left- and right-hemisphere-damaged participants and normal controls produced literal and idiomatic versions of idioms ( He hit the books.) All groups modulated duration to distinguish the interpretations. LHD patients, however, showed typical speech timing difficulties. RHD patients did not differ from the normal controls. The results partially support a differential lateralization of prosodic cues in the two cerebral hemispheres [Van Lancker, D., & Sidtis, J. J. (1992). The identification of affective-prosodic stimuli by left- and right-hemisphere-damaged subjects: All errors are not created equal. Journal of Speech and Hearing Research, 35, 963–970]. Furthermore, extended final word lengthening appears to mark idiomaticity.

Acoustic correlates to idiomatic interpretations in brain-damaged populations

McGill University, Montre´al, CanadaAccepted 8 July 2005Available online 22 August 2005IntroductionAlthough much is known about idiom processing in normal in-dividuals (e.g., Titone & Connine, 1999), some controversial findingshave emerged for brain-damaged patients (e.g., Papagno, Tabossi,Colombo, & Zampetti, 2004), and very few studies have examined therole of prosody in spoken idiom production. In normal subjects, VanLancker, Canter, and Terbeek (1981) have shown that literal produc-tions of potentially idiomatic phrases are longer in duration, exhibitlonger pauses between words, and demonstrate more rapid changes inF0 within words and phrases relative to the same phrases producedwith an idiomatic reading. However, idioms differ with respect to di-mensions like familiarity and compositionality (not heretofore con-trolled) that may influence production, and may be manifest differentlyin productions by brain-damaged populations.With respect to the ability of left- (LHD) and right-hemispherebrain-damaged (RHD) patients to signal idiomatic relative to literalinterpretations through prosodic cues, current theories concerning theneural bases of prosody yield somewhat different predictions (seeBaum & Pell, 1999 for review). According to one perspective, thelinguistic relevance of prosodic cues is critical and intimately linkedwith the prosodic domain or size of prosodic unit, with smaller-sizedunits processed by LH mechanisms and larger units mediated by RHmechanisms (Gandour, et al., 2003). Although idioms are phrase-length units, some studies have suggested that they are initially ac-cessed and stored as lexical units (Titone, Libben, & Romero, 2004;but cf. Papagno et al., 2004). Under this view, it could be hypothesizedthat LHD patients may have difficulty producing the prosodic con-trasts that disambiguate literal from figurative interpretations of idi-oms (assuming a lexical prosodic domain). Further support for thisprediction is based on the suggestion that much of the idiomatic/literalprosodic distinction is carried by temporal cues, with which LHDpatients are known to have difficulty. In contrast, because idioms andtheir literal counterparts are, in fact, phrasal units, one might predictthat RHD patients may be unable to successfully produce the requiredcontrast. To assess these possibilities, following Van Lancker andcolleagues (1981), a set of literally plausible idiomatic expressions (e.g.,‘he kicked the bucket’, but not ‘he was on cloud nine’) were embedded inbiasing contexts that disambiguated the intended meaning as literal oridiomatic. Speakers were instructed to explicitly contrast the targetsentences as clearly as possible to convey the intended interpretation.MethodsSubjectsParticipants included LHD patients, RHD patients, age-matchednon-brain-damaged individuals, and young normal speakers.StimuliThirty-two idioms, following the ‘‘(s)he verbed the noun’’ form,were included as stimuli; these idioms were subgrouped with respectto the semantic decomposability of the verb and the noun (Libben,Borovay, & Titone, 2005) and controlled for dimensions such asfamiliarity and predictability of the idiom-final word. The noun wasrated as highly related to the idiomatic meaning for 8 idioms (Nhigh), the verb was rated as highly related for eight idioms (V high),both the noun and the verb were rated as highly related for eightidioms (NV high), and neither the noun nor the verb was rated asrelated for the final eight idioms (NV low). All idioms were embed-ded in an idiomatic and a literal biasing context and presented tospeakers in a manner such that the interpretive contrast was high-lighted. Subjects were required to read the context sentence silentlyand then produce the idiomatic or literal target sentence for re-cording on digital media.Acoustic analysesMeasures of total utterance duration, number, and length of pausesbetween words within the phrase, and durations of individual wordswithin the phrase were computed, as was mean F0 across the phrase,and the pattern of F0 rises and falls within the phrase.Brain and Language 95 (2005) 223–224www.elsevier.com/locate/b&l

Functional implications of ipsilesional motor deficits after unilateral stroke

Wetter S, Poole JL, Haaland KY. Functional implications of ipsilesional motor deficits after unilateral stroke. Arch Phys Med Rehabil 2005;86:776–81. Objective To investigate the functional impact of ipsilesional motor deficits after unilateral stroke and the best predictors of those deficits. Design Observational cohort. Setting Primary care Veterans Affairs and private medical center. Participants Volunteer right-handed sample; stroke patients with left (LHD) or right hemisphere damage (RHD) a mean of 3.9 to 5.2 years poststroke and able-bodied participants who were tested using their left (LAB) or right hand. Interventions Not applicable. Main outcome measure The Jebsen-Taylor Hand Function Test (JHFT). Results Ipsilesional JHFT performance was impaired to the same extent in the LHD and RHD groups. LHD patients with apraxia had poorer scores on the JHFT than LHD patients without apraxia and the LAB group. Regression analyses showed that severity of apraxia was the best predictor of JHFT performance for the LHD group and that right (ipsilesional) motor performance (grip strength, finger tapping) was the best predictor of JHFT performance for the RHD group. Conclusions Ipsilesional deficits are present on simulated activities of daily living after LHD or RHD, suggesting that rehabilitation after stroke should include the ipsilesional arm and that ipsilesional limb apraxia is a better predictor of ipsilesional functional motor skills after LHD than aphasia or simple motor skills (grip strength, finger tapping). These findings suggest that limb apraxia should be assessed more routinely after stroke of the left hemisphere.

Temporal parameters as cues to phrasal boundaries: A comparison of processing by left- and right-hemisphere brain-damaged individuals

Two experiments were conducted to examine the ability of left- (LHD) and right-hemisphere-damaged (RHD) patients and normal controls to use temporal cues in rendering phrase grouping decisions. The phrase “pink and black and green” was manipulated to signal a boundary after “pink” or after “black” by altering pre-boundary word durations and pause durations at the boundary in a stepwise fashion. Stimuli were presented to listeners auditorily along with a card with three alternative groupings of colored squares from which to select the presented alternative. Results revealed that normal controls were able to use both temporal cues to identify the intended grouping. In contrast, LHD patients required longer than normal pause durations to consistently identify the intended grouping, suggesting a higher than normal threshold for perception of temporal prosodic cues. Surprisingly, the RHD patients exhibited great difficulty with the task, perhaps due to the limited acoustic cues available in the stimuli.