BackgroundAn emerging hypothesis from cognitive neuroscience is that the ventromedial prefrontal cortex (vmPFC) is central to the evaluation and expectation of reward. However, there is scant evidence that lesions in this region alter reward processing. Rather, patients with damage in vmPFC have shown many conflicting effects with respect to motivation and affect. We aimed to specifically examine incentivisation by reward after damage to human vmPFC. MethodsWe selected a group of 19 patients with highly focal medial frontal lesions, from a database of 453 patients with subarachnoid haemorrhage, and 32 age-matched healthy controls. We directly tested for sensitivity to incentives using eye movements. Lesions included anterior cingulate, vmPFC, and medial orbitofrontal cortex. The task required participants to make saccadic eye movements to a target while avoiding a distractor, to obtain speed-related rewards. Crucially, before each eye movement, participants heard a reward cue indicating the maximum reward available. We examined the effect of the incentive cue on subsequent saccade velocity, and how this motivational effect was altered by medial frontal damage. FindingsIn healthy people, mean peak saccadic velocity was modulated by the incentive (from 458 degrees per s [SE 15] to 489 [17], p=0·0011), allowing a parametric measure of reward sensitivity. As a group, patients with medial frontal damage had significantly reduced effects of reward on invigorating saccadic velocity (from 443 degrees per s [SE 16] to 459 [19], p=0·038) and autonomic (pupil) responses (z-score traces significantly differed after 653 ms, p<0·05) compared with controls. However at the individual level, some patients showed the opposite effect, with abnormally strong incentivisation effects (3 SD above controls). Voxel-based lesion mapping demonstrated that within the lesion group, increased sensitivity to rewards correlated with damage to vmPFC subregions (144 voxels=1·15 cm3 whole-brain corrected). Lesions to vmPFC were also associated with clinical apathy (p=0·027 in region of interest) suggesting that apathy associated with prefrontal damage is reduced by vmPFC damage. InterpretationThis study found that, although medial frontal lesions could generally reduce reward sensitivity, damage to key subregions paradoxically were protective of this effect. Changes in reward sensitivity caused by altered representation of reward value might be a central link between various facets of behavioural changes seen after medial frontal damage. The results suggest a direct, mechanistic role for prefrontal reward computation in clinical motivation syndromes. FundingWellcome Trust.
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