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Longman RS, Schwartz FD. Acquired language disorders beyond aphasia: foreign accent syndrome as a neurological, speech, and psychiatric disorder. Front Psychol 2025; 16:1554104. [PMID: 40144038 PMCID: PMC11936979 DOI: 10.3389/fpsyg.2025.1554104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2025] [Accepted: 02/14/2025] [Indexed: 03/28/2025] Open
Abstract
This study examines historical conceptualizations of 'foreign accent syndrome' after brain trauma or as an aspect of psychiatric presentations, in addition to comparisons with current conceptualizations. Although classical understanding of aphasias as language disorders developed between 1861 and 1885, descriptions of non-aphasic speech disorders emerged later. Acquired accent following a stroke was first described in 1907 by Pierre Marie (1853-1940) in the context of the localizationist versus holistic debate. Early characterizations by Marie, Arnold Pick (1851-1924), and G.H. Monrad-Krohn (1884-1964) identified persisting speech changes following initial aphasia, which, from a contemporary viewpoint, provide insights into the dynamic nature of recovery after cerebral injury. These cases significantly contributed to the understanding of the neurological foundations of prosody and the non-linguistic aspects of speech. A deeper understanding of this disorder awaited contributions from various fields, including linguistics, speech-language pathology, psychiatry, and neuroimaging. Notably, there is an unusual gap in psychiatric causation reports prior to 1960, despite some intriguing indications from Josef Breuer's account of Anna O (1895). This study explores how historical perspectives continue to influence current conceptualizations of foreign accent syndrome.
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Affiliation(s)
- R. Stewart Longman
- Department of Psychology, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Health Department in Grande Prairie, AB, Canada
| | - Flint D. Schwartz
- Department of Psychology and Neuroscience, Dalhaousie University, Halifax, NS, Canada
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Miletic SP, Ahmed SRB. Analysis of events from sudden isolated dysarthria to diagnosis of myasthenic crisis: myasthenia gravis mimicking acute lacunar stroke-a case report. J Med Case Rep 2024; 18:319. [PMID: 38961428 PMCID: PMC11223319 DOI: 10.1186/s13256-024-04617-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 05/24/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND Myasthenic crisis (MC) is a life-threatening complication of myasthenia gravis (MG), necessitating ventilation. Achieving a safe and timely diagnosis of myasthenic crisis with atypical, isolated presentation is a considerable challenge particularly in elderly patients, where myasthenia gravis can present with isolated dysarthria in rare instances, giving a clinical impression of lacunar stroke. CASE PRESENTATION We present a compelling case of a 73-year-old Caucasian female presenting with abrupt onset of isolated dysarthria. Despite initial treatment for a presumed lacunar stroke, subsequent evaluations led to her diagnosis of a myasthenic crisis. Within 72 h of admission, the patient developed dysphagia and shortness of breath, requiring supplemental oxygen. The case highlights the sequential progression of events from the atypical presentation of isolated dysarthria and its course to the management of a myasthenic crisis. CONCLUSION Our reported case focuses on the discussion of myasthenia that mimicked a lacunar stroke and was finally diagnosed at a critical time of medical crisis. This case highlights the imperative notion that isolated dysarthria in elderly individuals warrants vigilant monitoring for possible myasthenia gravis, given the low incidence of lacunar stroke presenting with only dysarthria.
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Sung MF, Lim JH. Ataxic hemiparesis: a narrative review for clinical practice in rehabilitation. Top Stroke Rehabil 2024; 31:537-545. [PMID: 37965878 DOI: 10.1080/10749357.2023.2281722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 11/04/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Ataxic hemiparesis (AH) is a well-recognized clinical lacunar stroke syndrome, characterized by paresis with ataxia on the same side of the body. It affects patients with stroke involving the basal ganglia, pons, internal capsule, corona radiata, and thalamus. In the past, lacunar syndrome denotes good functional recovery with low mortality and morbidity rate. However, recent evidence suggests AH has an association with more debilitating outcomes in the long term. OBJECTIVE To provide a comprehensive narrative review of published literatures on the topics related with AH and update clinical practice including rehabilitation. METHODS Literature review was performed by using the keywords "Subcortical Ataxia," "Lacunar Stroke," "Diaschisis", and "Ataxic Hemiparesis" on PubMed and Google Scholar Engines from 1978 to 2022. All papers published in English were reviewed and manual search of references from retrieved literature was performed for other relevant articles. RESULTS A comprehensive review was carried out on the following topics: neuroanatomical localization, pathogenesis, clinical features and clinical assessment scales, pharmacological and non-pharmacological modalities for ataxia treatment, prognosis, and outcome. CONCLUSION AH imposes significant challenges on stroke survivors when it comes to remediation of balance and coordination. It is associated with increased risk of mortality, stroke recurrence, and dementia. Though application of the concept of neuroplasticity and the utilization of repetitive transcranial magnetic stimulation have shown early promising results, further research is needed to establish the practice guidelines for rehabilitation of patients with AH.
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Affiliation(s)
- Mei-Fen Sung
- Division of Rehabilitation Medicine, University Medicine Cluster, National University Hospital, Singapore
| | - Jeong Hoon Lim
- Division of Rehabilitation Medicine, University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Schön F, Wahl H, Grey A, Krukowski P, Müller A, Puetz V, Linn J, Kaiser DPO. Improved Visualization and Quantification of Net Water Uptake in Recent Small Subcortical Infarcts in the Thalamus Using Computed Tomography. Diagnostics (Basel) 2023; 13:3416. [PMID: 37998551 PMCID: PMC10670270 DOI: 10.3390/diagnostics13223416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/01/2023] [Accepted: 11/05/2023] [Indexed: 11/25/2023] Open
Abstract
Diagnosing recent small subcortical infarcts (RSSIs) via early computed tomography (CT) remains challenging. This study aimed to assess CT attenuation values (Hounsfield Units (HU)) and net water uptake (NWU) in RSSI and explore a postprocessing algorithm's potential to enhance thalamic RSSI detection. We examined non-contrast CT (NCCT) data from patients with confirmed thalamic RSSI on diffusion-weighted magnetic resonance imaging (DW-MRI) between January 2010 and October 2017. Co-registered DW-MRI and NCCT images enabled HU and NWU quantification in the infarct area compared to unaffected contralateral tissue. Results were categorized based on symptom onset to NCCT timing. Postprocessing using window optimization and frequency-selective non-linear blending (FSNLB) was applied, with interpretations by three blinded Neuroradiologists. The study included 34 patients (median age 70 years [IQR 63-76], 14 women). RSSI exhibited significantly reduced mean CT attenuation compared to unaffected thalamus (29.6 HU (±3.1) vs. 33.3 HU (±2.6); p < 0.01). Mean NWU in the infarct area increased from 6.4% (±7.2) at 0-6 h to 16.6% (±8.7) at 24-36 h post-symptom onset. Postprocessed NCCT using these HU values improved sensitivity for RSSI detection from 32% in unprocessed CT to 41% in FSNLB-optimized CT, with specificities ranging from 86% to 95%. In conclusion, CT attenuation values and NWU are discernible in thalamic RSSI up to 36 h post-symptom onset. Postprocessing techniques, particularly window optimization and FSNLB, moderately enhance RSSI detection.
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Affiliation(s)
- Felix Schön
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Institute and Polyclinic for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Hannes Wahl
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Arne Grey
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Pawel Krukowski
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Angela Müller
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Volker Puetz
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jennifer Linn
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Daniel P. O. Kaiser
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
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Fukuoka H, Nishita Y, Tange C, Otsuka R, Ando F, Shimokata H. Basal ganglia lesions may be a risk factor for characteristic features of a glaucomatous optic disc: population-based cohort study in Japan. BMJ Open Ophthalmol 2023. [DOI: 10.1136/bmjophth-2022-001077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
BackgroundWe conducted a study to investigate the relationship between optic nerve vertical cup-to-disc ratio (VCDR), body and ocular parameters, and brain lesions in middle-aged and above Japanese subjects, because although various risk factors for glaucoma have been previously characterised, it is theorised that there are unidentified neurological components.MethodsIn this population-based, age/gender-stratified, cross-sectional study that involved 2239 Japanese subjects (1127 men and 1112 women) aged 40 years and older (mean age: 59.3±11.7 years) living in the central geographical region of Japan who participated in the National Institute of Longevity Sciences–Longitudinal Study of Aging between 2002 and 2004, 4327 eyes and 2239 obtained MRIs of the head were evaluated. Multivariate mixed model and trend analyses were also performed.ResultsNo significant relationship between VCDR and brain lesions, other than basal ganglia lesions, was found. VCDR significantly increased with the high grade of basal ganglia infarct lesions (p=0.0193) and high intraocular pressure (p<0.0001) after adjustment for influential factors using a multivariate mixed model. A significant positive linear trend was observed between the predicted VCDR and the degrees of the basal ganglia lesions (p value trend=0.0096).ConclusionOur findings suggest that in subjects with higher grades of basal ganglia lesions, strict attention should be paid to elevated VCDR; however, further studies are needed to support/confirm our results.
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Younger DS. Motor sequela of adult and pediatric stroke: Imminent losses and ultimate gains. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:305-346. [PMID: 37620077 DOI: 10.1016/b978-0-323-98817-9.00025-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Stroke is the leading cause of neurological disability in the United States and worldwide. Remarkable advances have been made over the past 20 years in acute vascular treatments to reduce infarct size and improve neurological outcome. Substantially less progress has been made in the understanding and clinical approaches to neurological recovery after stroke. This chapter reviews the epidemiology, bedside examination, localization approaches, and classification of stroke, with an emphasis on motor stroke presentations and management, and promising research approaches to enhancing motor aspects of stroke recovery.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Summaka M, Hannoun S, Harati H, Daoud R, Zein H, Estephan E, Naim I, Nasser Z. Neuroanatomical regions associated with non-progressive dysarthria post-stroke: a systematic review. BMC Neurol 2022; 22:353. [PMID: 36114518 PMCID: PMC9479301 DOI: 10.1186/s12883-022-02877-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 09/02/2022] [Indexed: 11/15/2022] Open
Abstract
Background Dysarthria is a common and persisting sequela to stroke. It can have a negative influence on psychological wellbeing, and quality of life. This systematic review aimed to describe and identify the neuroanatomical regions associated with non-progressive dysarthria following stroke. Methods A systematic search of PubMed, Ovid Medline, CINAHL, Cochrane, Scopus, and ScienceDirect was conducted to identify all relevant articles published in peer-reviewed journals up to December 2021. Following data extraction, the National Institutes of Health (NIH) quality assessment tools were used to evaluate the methodological quality of the included studies. Results Out of 2186 papers found in the literature related to dysarthria post-stroke, 24 met the inclusion criteria. Eligible articles assessed 1150 post-stroke subjects. Out of them, 420 subjects had dysarthria from isolated lesions. Regarding dysarthric subjects with ischemic strokes, 153 sustained supratentorial infarctions, while 267 had infratentorial infarctions. The majority had pontine infarctions (n = 142), followed by infarctions in the corona radiata (n = 104), and the cerebellum (n = 64). Conclusion This systematic review is the first step toward establishing a neuroanatomical model of dysarthria throughout the whole brain. Our findings have many implications for clinical practice and provide a framework for implementing guidelines for early detection and management of dysarthria post-stroke. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02877-x.
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Shibagaki K, Shirasaka T, Sawada J, Saijo Y, Kunioka S, Kikuchi Y, Kamiya H. Silent cerebral ischemia detected by magnetic resonance imaging can predict postoperative delirium after total arch replacement for aneurysm. JTCVS OPEN 2022; 10:87-96. [PMID: 36004275 PMCID: PMC9390522 DOI: 10.1016/j.xjon.2022.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 02/17/2022] [Indexed: 11/17/2022]
Abstract
Objective To identify whether preoperative magnetic resonance imaging findings of the brain can predict postoperative delirium in patients who undergo arch replacement for aneurysms. Methods Overall, 193 patients who underwent aortic replacement for the first time at a single institution between April 2014 and September 2020 were enrolled in this retrospective study. After we excluded patients with acute aortic dissection, no preoperative magnetic resonance imaging findings of the brain, and postoperative cerebral infarction, 50 patients were included and divided into 2 groups, according to their confusion scale results: postoperative delirium (group D) and nonpostoperative delirium (group ND). Preoperative magnetic resonance imaging findings of the brain were classified into lacunar stroke, periventricular hyperintensity, and deep subcortical white matter hyperintensity groups; the latter 2 groups were further classified based on the Fazekas scale, grade 0 to 3. Results There were 23 patients (46%) in group D and 27 (54%) in group ND. The mean age was significantly greater in group D than in group ND (75 vs 70 years; P = .007). The mean operative time was significantly longer in group D than in group ND (447 vs 384 minutes; P = .024). As for preoperative magnetic resonance imaging findings of the brain, there were significantly more lacunar stroke cases in group D than in group ND (P = .027). In multivariable logistic regression with stepwise selection, high-grade periventricular hyperintensity was significantly related to postoperative delirium (odds ratio, 9.38; 95% confidence interval, 1.55-56.56; P = .015). Conclusions Silent cerebral ischemia detected by preoperative magnetic resonance imaging of the brain was a significant risk factor for postoperative delirium.
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Affiliation(s)
- Keisuke Shibagaki
- Department of Cardiac Surgery, Asahikawa Medical University, Hokkaido, Japan
| | - Tomonori Shirasaka
- Department of Cardiac Surgery, Asahikawa Medical University, Hokkaido, Japan
- Address for reprints: Tomonori Shirasaka, MD, PhD, Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan.
| | - Jun Sawada
- Division of Neurology, Department of Internal Medicine, Asahikawa Medical University, Hokkaido, Japan
| | - Yasuaki Saijo
- Division of Public Health and Epidemiology, Department of Social Medicine, Asahikawa Medical University, Hokkaido, Japan
| | - Shingo Kunioka
- Department of Cardiac Surgery, Asahikawa Medical University, Hokkaido, Japan
| | - Yuta Kikuchi
- Department of Cardiac Surgery, Asahikawa Medical University, Hokkaido, Japan
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Hokkaido, Japan
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Lacunar Syndromes, Lacunar Infarcts, and Cerebral Small-Vessel Disease. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00027-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Syros A, Kotlia P, Fotakopoulos G. Preliminary findings from an Acupuncture and experiential/traditional music therapy during the standard care of rehabilitation exercise program for Recovery on post-stroke upper limb dysfunction. Int J Neurosci 2021; 132:1110-1117. [PMID: 34143714 DOI: 10.1080/00207454.2020.1860972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Upper limb dysfunction is common damage after stroke posing an important challenge for post-stroke rehabilitation but little is known about the effects of combined therapy with acupuncture and experiential/traditional music during the standard care of rehabilitation exercise program. The aim of this study, therefore, was to systematically assess the effects of exercise rehabilitation program accompanied by experiential music or/+ acupuncture for clinical recovery on post-stroke upper limb dysfunction. This was a randomized controlled study with a total of 116 eligible subjects randomly divided into three groups, namely (1) MG group-(daily listening to experiential/traditional music), (2) AP/MG group (combined treatment with daily listening to experiential/traditional music and AP), and (3) CG group (with no experiential/traditional music therapy or AP (standard care only)), in a 1.3:1:1 ratio. The primary outcomes in this study were the changes between baseline score during the admission and after 6 months Fugl-Meyer Assessment for Upper Extremity (FMA/UE) and the recovery. The secondary outcomes are the mean change in the scores between baseline value during the admission and after 6 months on the Visual Analogue Scale, mini-mental test, Barthel index and Computer tomography Perfusion (CTP) findings- cerebral blood flow (CBF). The results of this study clarify the synergistic effects of AP and daily listening to experiential/traditional music during the standard care rehabilitation program on upper limb dysfunction after stroke.
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Affiliation(s)
- Apostolis Syros
- Department of Physiatria Scientific Director of Rehabilitation Center, Arwgi Thessalias S.A., Agnadero, Karditsa, Greece
| | - Polikceni Kotlia
- Department of Anesthesiology, General Hospital of Karditsa, Karditsa, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, Larissa, Greece
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Wray F, Clarke D, Forster A. How do stroke survivors with communication difficulties manage life after stroke in the first year? A qualitative study. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2019; 54:814-827. [PMID: 31273892 DOI: 10.1111/1460-6984.12487] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Interest in how stroke survivors might be better supported to manage life after stroke has grown rapidly in recent years, with a particular emphasis on enabling 'self-management'. Post-stroke communication difficulties may pose a unique barrier to longer term adaptation and adjustment. It is important to understand how stroke survivors with communication difficulties manage life after stroke and what support may be needed to facilitate this process. AIMS To explore how stroke survivors with communication difficulties manage life after stroke in the first year. METHODS & PROCEDURES A cross-sectional qualitative study involving in-depth semi-structured interviews with stroke survivors with communication difficulties (aphasia, dysarthria or apraxia of speech) and/or their family members at single time points during the first year post-stroke. A total of 21 participants (14 stroke survivors and seven family members) took part in interviews for the study. Interview data were analysed using thematic analysis. OUTCOME & RESULTS A total of six themes were identified: (1) strategies to manage changes to communication; (2) testing communication outside of the home; (3) balancing support and independence; (4) hope for recovery; (5) obtaining support from healthcare professionals; and (6) adapting activities and keeping busy. Stroke survivors with communication difficulties and their family members undertook significant work (practical, relational, emotional) to manage their condition. Adaptation and adjustment was often facilitated by 'doing'; testing out which activities could be managed independently and which required additional support. Some stroke survivors and their family members demonstrated considerable resourcefulness and creativity in developing strategies to manage their communication difficulties. Despite the work undertaken, many expressed a lack of confidence in their ability and feelings of powerlessness and abandonment at the point of discharge from community services. CONCLUSIONS & IMPLICATIONS Stroke survivors and their family members develop personally meaningful and context-specific strategies to adjust to and manage life after stroke. Future interventions should recognize, support and build upon the active work already undertaken by stroke survivors with communication difficulties and their families. Further support before and around the point of discharge from community services may be needed to help build confidence and skills to manage in the longer term. The benefit of a supported self-management approach for stroke survivors with communication difficulties should be further investigated.
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Affiliation(s)
- Faye Wray
- Academic Unit of Elderly Care and Rehabilitation, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - David Clarke
- Academic Unit of Elderly Care and Rehabilitation, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Anne Forster
- Academic Unit of Elderly Care and Rehabilitation, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Abstract
The analysis and interpretation of somatosensory information are performed by a complex network of brain areas located mainly in the parietal cortex. Somatosensory deficits are therefore a common impairment following lesions of the parietal lobe. This chapter summarizes the clinical presentation, examination, prognosis, and therapy of sensory deficits, along with current knowledge about the anatomy and function of the somatosensory system. We start by reviewing how somatosensory signals are transmitted to and processed by the parietal lobe, along with the anatomic and functional features of the somatosensory system. In this context, we highlight the importance of the thalamus for processing somatosensory information in the parietal lobe. We discuss typical patterns of somatosensory deficits, their clinical examination, and how they can be differentiated through a careful neurologic examination that allows the investigator to deduce the location and size of the underlying lesion. In the context of adaption and rehabilitation of somatosensory functions, we delineate the importance of somatosensory information for motor performance and the prognostic evaluation of somatosensory deficits. Finally, we review current rehabilitation approaches for directing cortical reorganization in the appropriate direction and highlight some challenging questions that are unexplored in the field.
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Affiliation(s)
- Carsten M Klingner
- Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany; Biomagnetic Center, Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany.
| | - Otto W Witte
- Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
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Wray F, Clarke D. Longer-term needs of stroke survivors with communication difficulties living in the community: a systematic review and thematic synthesis of qualitative studies. BMJ Open 2017; 7:e017944. [PMID: 28988185 PMCID: PMC5640038 DOI: 10.1136/bmjopen-2017-017944] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To review and synthesise qualitative literature relating to the longer-term needs of community dwelling stroke survivors with communication difficulties including aphasia, dysarthria and apraxia of speech. DESIGN Systematic review and thematic synthesis. METHOD We included studies employing qualitative methodology which focused on the perceived or expressed needs, views or experiences of stroke survivors with communication difficulties in relation to the day-to-day management of their condition following hospital discharge. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, The Cochrane Library, International Bibliography of the Social Sciences and AMED and undertook grey literature searches. Studies were assessed for methodological quality by two researchers independently and the findings were combined using thematic synthesis. RESULTS Thirty-two studies were included in the thematic synthesis. The synthesis reveals the ongoing difficulties stroke survivors can experience in coming to terms with the loss of communication and in adapting to life with a communication difficulty. While some were able to adjust, others struggled to maintain their social networks and to participate in activities which were meaningful to them. The challenges experienced by stroke survivors with communication difficulties persisted for many years poststroke. Four themes relating to longer-term need were developed: managing communication outside of the home, creating a meaningful role, creating or maintaining a support network and taking control and actively moving forward with life. CONCLUSIONS Understanding the experiences of stroke survivors with communication difficulties is vital for ensuring that longer-term care is designed according to their needs. Wider psychosocial factors must be considered in the rehabilitation of people with poststroke communication difficulties. Self-management interventions may be appropriate to help this subgroup of stroke survivors manage their condition in the longer-term; however, such approaches must be designed to help survivors to manage the unique psychosocial consequences of poststroke communication difficulties.
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Affiliation(s)
- Faye Wray
- Academic Unit of Elderly Care and Rehabilitation, Leeds Institute for Health Sciences, Bradford, UK
| | - David Clarke
- Academic Unit of Elderly Care and Rehabilitation, Leeds Institute for Health Sciences, Bradford, UK
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Nagaratnam N, Xavier C, Fabian R. Stroke Subtype—Ataxic Hemiparesis. Neurorehabil Neural Repair 2016. [DOI: 10.1177/154596839901300207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ataxic hemiparesis is a lacunar syndrome of ipsilateral corticospmal and cerebellar- like dysfunction due to supratentorial and brainstem lesions We studied 22 patients with ataxic hemiparesis resulting from brain lesions at three locations: capsular-corona radiata, thalamic, and pontine with regard to (1) their manifestations, (2) the degree and rate of recovery at 12 weeks as measured on the modified Rankm Scale, and (3) factors that may influence recovery The mean age was 67 years. Symptoms and signs were similar in all three groups except qualitative differences observed in the pontine subgroup and to a lesser extent in the thalamic group Age, gender, lateralization, and location were not associated with initial severity. and had no influence on recovery. Twenty (91%) of the 22 patients were in Rankm grades 3-5 at onset, and at 12 weeks only two remained. In this study initial severity and outcome were positively corre lated, and ataxic hemiparesis augurs well with recovery. Key Words: Ataxic hemi paresis— Capsular ataxic hemiparesis—Thalamic ataxic hemiparesis—Pontine ataxic hemiparesis—Rankm Scale—Lacunar syndromes
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Micieli G, Bosone D, Cavallini A, Bono G, Uggetti C, Rossi F, Nappi G. Carotid Plaques and Multiple Brain Infarctions. J Neuroimaging 2016. [DOI: 10.1111/jon199334220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Norrving B. Lacunar Syndromes, Lacunar Infarcts, and Cerebral Small-vessel Disease. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00027-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Rudilosso S, Urra X, San Román L, Laredo C, López-Rueda A, Amaro S, Oleaga L, Chamorro Á. Perfusion Deficits and Mismatch in Patients with Acute Lacunar Infarcts Studied with Whole-Brain CT Perfusion. AJNR Am J Neuroradiol 2015; 36:1407-12. [PMID: 25882287 DOI: 10.3174/ajnr.a4303] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 12/22/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The incidence and significance of perfusion abnormalities on brain imaging in patients with lacunar infarct are controversial. We studied the diagnostic yield of CTP and the type of perfusion abnormalities in patients presenting with a lacunar syndrome and in those with MR imaging-confirmed lacunar infarcts. MATERIALS AND METHODS A cohort of 33 patients with lacunar syndrome underwent whole-brain CTP on admission. Twenty-eight patients had an acute ischemic lesion at follow-up MR imaging; 16 were classified as lacunar infarcts. Two independent readers evaluated NCCT and CTP to compare their diagnostic yield. In patients with DWI-confirmed lacunar infarcts and visible deficits on CTP, the presence of mismatch tissue was measured by using different perfusion thresholds. RESULTS The symptomatic acute lesion was seen on CTP in 50% of patients presenting with a lacunar syndrome compared with only 17% on NCCT, and in 62% on CTP compared with 19% on NCCT, respectively, in patients with DWI-confirmed lacunar infarcts. CTP was more sensitive in supratentorial than in infratentorial lesions. In the nonblinded analysis, a perfusion deficit was observed in 12/16 patients with DWI-confirmed lacunar infarcts. The proportion of mismatch tissue was similar in patients with lacunar infarcts or nonlacunar strokes (32% versus 36%, P = .734). CONCLUSIONS Whole-brain CTP is superior to NCCT in identifying small ischemic lesions, including lacunar infarcts, in patients presenting with a lacunar syndrome. Perfusion deficits and mismatch are frequent in lacunar infarcts, but larger studies are warranted to elucidate the clinical significance of these CTP findings.
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Affiliation(s)
- S Rudilosso
- From the Functional Unit of Cerebrovascular Diseases (S.R., X.U., L.S.R., C.L., A.L.-R., S.A., L.O., Á.C.)
| | - X Urra
- From the Functional Unit of Cerebrovascular Diseases (S.R., X.U., L.S.R., C.L., A.L.-R., S.A., L.O., Á.C.) Institut d'Investigacions Biomèdiques August Pi i Sunyer (X.U., S.A., Á.C.), Barcelona, Spain
| | - L San Román
- From the Functional Unit of Cerebrovascular Diseases (S.R., X.U., L.S.R., C.L., A.L.-R., S.A., L.O., Á.C.) Department of Radiology (L.S.R., A.L.-R., L.O.), Hospital Clínic, Barcelona, Spain
| | - C Laredo
- From the Functional Unit of Cerebrovascular Diseases (S.R., X.U., L.S.R., C.L., A.L.-R., S.A., L.O., Á.C.)
| | - A López-Rueda
- From the Functional Unit of Cerebrovascular Diseases (S.R., X.U., L.S.R., C.L., A.L.-R., S.A., L.O., Á.C.) Department of Radiology (L.S.R., A.L.-R., L.O.), Hospital Clínic, Barcelona, Spain
| | - S Amaro
- From the Functional Unit of Cerebrovascular Diseases (S.R., X.U., L.S.R., C.L., A.L.-R., S.A., L.O., Á.C.) Institut d'Investigacions Biomèdiques August Pi i Sunyer (X.U., S.A., Á.C.), Barcelona, Spain
| | - L Oleaga
- From the Functional Unit of Cerebrovascular Diseases (S.R., X.U., L.S.R., C.L., A.L.-R., S.A., L.O., Á.C.) Department of Radiology (L.S.R., A.L.-R., L.O.), Hospital Clínic, Barcelona, Spain
| | - Á Chamorro
- From the Functional Unit of Cerebrovascular Diseases (S.R., X.U., L.S.R., C.L., A.L.-R., S.A., L.O., Á.C.) Institut d'Investigacions Biomèdiques August Pi i Sunyer (X.U., S.A., Á.C.), Barcelona, Spain Department of Medicine (Á.C.), School of Medicine, University of Barcelona, Barcelona. Spain
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Arboix A. Cardiovascular risk factors for acute stroke: Risk profiles in the different subtypes of ischemic stroke. World J Clin Cases 2015; 3:418-429. [PMID: 25984516 PMCID: PMC4419105 DOI: 10.12998/wjcc.v3.i5.418] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 01/14/2015] [Accepted: 02/12/2015] [Indexed: 02/05/2023] Open
Abstract
Timely diagnosis and control of cardiovascular risk factors is a priority objective for adequate primary and secondary prevention of acute stroke. Hypertension, atrial fibrillation and diabetes mellitus are the most common risk factors for acute cerebrovascular events, although novel risk factors, such as sleep-disordered breathing, inflammatory markers or carotid intima-media thickness have been identified. However, the cardiovascular risk factors profile differs according to the different subtypes of ischemic stroke. Atrial fibrillation and ischemic heart disease are more frequent in patients with cardioembolic infarction, hypertension and diabetes in patients with lacunar stroke, and vascular peripheral disease, hypertension, diabetes, previous transient ischemic attack and chronic obstructive pulmonary disease in patients with atherothrombotic infarction. This review aims to present updated data on risk factors for acute ischemic stroke as well as to describe the usefulness of new and emerging vascular risk factors in stroke patients.
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Djulejić V, Marinković S, Milić V, Georgievski B, Rašić M, Aksić M, Puškaš L. Common features of the cerebral perforating arteries and their clinical significance. Acta Neurochir (Wien) 2015; 157:743-54; discussion 754. [PMID: 25772345 DOI: 10.1007/s00701-015-2378-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 02/19/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND The perforating vessels supply very important regions of the brain stem and diencephalon, as well as the basal ganglia and internal capsule. Some of their micro-anatomical characteristics are still not well known. The aim of this study was to examine and evaluate the features of all the perforating vessels. METHODS The arteries of 24-32 cerebral hemispheres, diencephalons and halves of the brain stem were injected with India ink mixture or methylmethacrylate, and microdissection was performed or the vascular casts were produced and examined under the sterescopic microscope. RESULTS It was noticed that the perforators ranged from 0 to 14 in number, with the smallest mean value (1.1) for the diencephalic perforators and the largest one (8.1) for the lenticulostriate arteries. The smallest mean diameter (175 μm) was found in the group of the perforators of the anterior communicating artery, whereas the largest one is related to the Heubner's artery (668 μm), the diencephalic thalamoperforating vessels (562 μm), the premamillary vessel (489 μm) and the lenticulostriate arteries (469 μm). The perforators most frequently originated from the pial branches of the basilar artery (91.7 %) and of the posterior cerebral artery (59.4 %). The common stems were most often formed by the perforators of the basilar (79.2 %), posterior cerebral (75.0 %) and middle cerebral arteries (40.6 %). Some perforators arose close to or from the terminal divisions, the branching sites or the junctions of the parent arteries, where the saccular aneurysms most often develop. The anastomoses among the perforators were present in a range from 6.3 % to 53.2 %. CONCLUSIONS The micro-anatomical data obtained may be useful for neurosurgeons when operating at the base of the brain, as well as for a neurological and radiological evaluation of the perforators in the occlusive cerebrovascular disease, or in the cases of an aneurysm, arteriovenous malformation (AVM) or tumour presence.
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Affiliation(s)
- Vuk Djulejić
- Institute of Anatomy, Faculty of Medicine, University of Belgrade, Dr. Subotić 4/2, 11000,, Belgrade, Serbia
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Tremolizzo L, Giopato F, Piatti ML, Rigamonti A, Ferrarese C, Appollonio I. Myasthenia gravis mimicking stroke: a case series with sudden onset dysarthria. Neurol Sci 2015; 36:895-8. [DOI: 10.1007/s10072-015-2098-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 01/27/2015] [Indexed: 12/01/2022]
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Shi L, Pu J, Xu L, Malaguit J, Zhang J, Chen S. The efficacy and safety of cilostazol for the secondary prevention of ischemic stroke in acute and chronic phases in Asian population--an updated meta-analysis. BMC Neurol 2014; 14:251. [PMID: 25527141 PMCID: PMC4301843 DOI: 10.1186/s12883-014-0251-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 12/11/2014] [Indexed: 12/23/2022] Open
Abstract
Backgrounds While previous meta-analysis have investigated the efficacy of cilostazol in the secondary prevention of ischemic stroke, they were criticized for their methodology, which confused the acute and chronic phases of stroke. We present a new systematic review, which differs from previous meta-analysis by distinguishing between the different phases of stroke, and includes two new randomized, controlled trials (RCTs). Methods All RCTs investigating the effect of cilostazol on secondary prevention of ischemic stroke were obtained. Outcomes were analyzed by Review Manager, including recurrence of cerebral infarction (ROCI), hemorrhage stroke or subarachnoid hemorrhage (HSSH), all-cause death (ACD), and modified Rankin Scale score (mRS). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessed the quality of the evidence. Results 5491 patients from six studies were included in the current study. In secondary prevention of ischemic stroke in chronic phase, cilostazol was associated with a 47% reduction in ROCI (relative risk [RR] 0.53, 95% confidence interval [CI] 0.34 to 0.81, p = 0.003), while no significant difference in HSSH and ACD compared with placebo; and 71% reduction in HSSH (RR 0.29, 95% CI 0.15 to 0.56, p = 0.0002) compared with aspirin, but not in ROCI and ACD. In the secondary prevention of ischemic stroke in acute phase, cilostazol did not show any effect in the ROCI, HSSH, ACD and mRS compared to placebo or aspirin. The quality of the evidence from chronic phase was high or moderate, and those from acute phase were moderate or low when analyzed by GRADE approach. Conclusion Cilostazol provided a protective effect in the secondary prevention of the chronic phase of ischemic stroke.
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Affiliation(s)
- LiGen Shi
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
| | - JiaLi Pu
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Liang Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
| | - Jay Malaguit
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA.
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
| | - Sheng Chen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
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Elkind MSV, Luna JM, McClure LA, Zhang Y, Coffey CS, Roldan A, Del Brutto OH, Pretell EJ, Pettigrew LC, Meyer BC, Tapia J, White C, Benavente OR. C-reactive protein as a prognostic marker after lacunar stroke: levels of inflammatory markers in the treatment of stroke study. Stroke 2014; 45:707-16. [PMID: 24523037 DOI: 10.1161/strokeaha.113.004562] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Inflammatory biomarkers predict incident and recurrent cardiac events, but their relationship to stroke prognosis is uncertain. We hypothesized that high-sensitivity C-reactive protein (hsCRP) predicts recurrent ischemic stroke after recent lacunar stroke. METHODS Levels of Inflammatory Markers in the Treatment of Stroke (LIMITS) was an international, multicenter, prospective ancillary biomarker study nested within Secondary Prevention of Small Subcortical Strokes (SPS3), a phase III trial in patients with recent lacunar stroke. Patients were assigned in factorial design to aspirin versus aspirin plus clopidogrel, and higher versus lower blood pressure targets. Patients had blood samples collected at enrollment and hsCRP measured using nephelometry at a central laboratory. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for recurrence risks before and after adjusting for demographics, comorbidities, and statin use. RESULTS Among 1244 patients with lacunar stroke (mean age, 63.3±10.8 years), median hsCRP was 2.16 mg/L. There were 83 recurrent ischemic strokes (including 45 lacunes) and 115 major vascular events (stroke, myocardial infarction, and vascular death). Compared with the bottom quartile, those in the top quartile (hsCRP>4.86 mg/L) were at increased risk of recurrent ischemic stroke (unadjusted HR, 2.54; 95% CI, 1.30-4.96), even after adjusting for demographics and risk factors (adjusted HR, 2.32; 95% CI, 1.15-4.68). hsCRP predicted increased risk of major vascular events (top quartile adjusted HR, 2.04; 95% CI, 1.14-3.67). There was no interaction with randomized antiplatelet treatment. CONCLUSIONS Among recent lacunar stroke patients, hsCRP levels predict the risk of recurrent strokes and other vascular events. hsCRP did not predict the response to dual antiplatelets. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00059306.
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Affiliation(s)
- Mitchell S V Elkind
- From the Department of Neurology, College of Physicians and Surgeons (M.S.V.E., J.M.L.), Department of Epidemiology, Mailman School of Public Health (M.S.V.E., J.M.L.), and Gertrude H. Sergievsky Center (M.S.V.E.), Columbia University, New York, NY; Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL (L.A.M., Y.Z.); Department of Biostatistics, University of Iowa, Iowa City, IA (C.S.C.); Department of Neurology, University of Texas at Houston, Houston, TX (A.R.); School of Medicine, Universidad Espíritu Santo-Ecuador, Guayaquil, Ecuador (O.H.D.B.); Department of Neurology, Hospital Alberto Sabogal, Lima, Peru (E.J.P.); Department of Neurology, University of Kentucky, Lexington, KY (L.C.P.); Department of Neurology, University of San Diego, San Diego, CA (B.C.M.); Department of Neurology, Pontificia Universidad Católica de Chile, Santiago, Chile (J.T.); School of Nursing and Secondary Prevention of Small Subcortical Strokes (SPS3) Coordinating Center, University of Texas Health Science Center at San Antonio, San Antonio, TX (C.W.); and Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, BC, Canada (O.R.B.)
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Bal S, Goyal M, Smith E, Demchuk AM. Central nervous system imaging in diabetic cerebrovascular diseases and white matter hyperintensities. HANDBOOK OF CLINICAL NEUROLOGY 2014; 126:291-315. [PMID: 25410230 DOI: 10.1016/b978-0-444-53480-4.00021-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Diabetes mellitus is an important vascular risk factor for cerebrovascular disease. This occurs through pathophysiologic changes to the microcirculation as arteriolosclerosis and to the macrocirculation as large artery atherosclerosis. Imaging techniques can provide detailed visualization of the cerebrovasculature using CT (computed tomography) angiography and MR (magnetic resonance) angiography. Newer techniques focused on advanced parenchymal imaging include CT perfusion, quantitative MRI, and diffusion tensor imaging; each identifies brain lesion burden due to diabetes mellitus. These imaging approaches have provided insights into the diabetes mellitus brain and cerebral circulation pathophysiology. Imaging has taught us that diabetics develop cerebral atrophy, silent infarcts, and white matter disease more rapidly than other patient populations. Longitudinal studies are needed to quantify the rate and extent of such structural brain and blood vessel changes and how they relate to cognitive decline. Diabetes prevention and treatment strategies will then be possible to slow the development of such changes.
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Affiliation(s)
- Simerpreet Bal
- Department of Clinical Neurosciences and Radiology, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences and Radiology, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Eric Smith
- Department of Clinical Neurosciences and Radiology, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences and Radiology, Foothills Medical Centre, Calgary, Alberta, Canada.
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Arboix A, Sánchez MJ, Martí-Vilalta JL. Pure motor stroke as the most frequent lacunar syndrome: A clinical update. World J Neurol 2013; 3:129-132. [DOI: 10.5316/wjn.v3.i4.129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 09/30/2013] [Accepted: 10/12/2013] [Indexed: 02/06/2023] Open
Abstract
Pure motor stroke (PMS), also known as pure motor hemiparesis, is the most common of any lacunar form (between one half and two thirds of cases, depending on the series). In an acute stroke registry, 733 patients presented a lacunar infarct and PMS accounted for 12.7% (n = 342) of all first-ever stroke patients and for 48% of all lacunar syndromes. The posterior limb of the internal capsule, corona radiata, and pons are the most frequent brain topographies. Infarcts in the mesencephalus or medullary pyramid have been exceptionally reported. This present update is focused on the clinical evidence and mechanisms underlying the relationship between PMS and different stroke etiologies.
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European Stroke Prevention Study 2: A study of low-dose acetylsalicylic acid and of high dose dipyridamole in secondary prevention of cerebro-vascular accidents. Eur J Neurol 2013; 2:416-24. [PMID: 24283721 DOI: 10.1111/j.1468-1331.1995.tb00150.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In spite of some data being added to our knowledge of the effect of antiplatelets in secondary prevention of brain ischemic lesion in recent years, the main reasons to perform a second European Stroke Prevention Study (ESPS 2), which started in 1987-1988, were: (a) clarify the relative roles of aspirin (ASA) and dipyridamole (DP) alone or in combination; (b) confirm the efficacy of small doses of ASA and, so doing, decrease the number of drop-outs due to ASA side effects; (c) join information to the effect of antiplatelets in complete stroke. General characteristics of the sample of 6602 patients are presented and compared with other major trials and series. The patients in the four treatment arms (aspirin, dipyridamole, aspirin + dipyridamole and placebo) are compared. The more relevant features and risk factors known to influence long term prognosis are described and discussed. The small proportion of patients included with TIA (23.7%) and the comparability among treatment groups are stressed. No relevant differences have been found, among groups, on the sex or age distribution, prevalence of hypertension, diabetes, previous vascular events or atrial fibrillation, nor in the characteristics of the accident leading to the inclusion in trial.
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D'Olhaberriague L, Arboix A, Martí-Vilalta JL, Moral A, Massons J. Movement disorders in ischemic stroke: clinical study of 22 patients. Eur J Neurol 2013; 2:553-7. [PMID: 24283782 DOI: 10.1111/j.1468-1331.1995.tb00173.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Movement disorders (bemichorea-hemiballismus, hemidystonia and isolated tremor) are an uncommon clinical manifestation in ischemic stroke (IS), and their anatomical basis is poorly understood. We analyzed the clinical and neuroimaging characteristics of 22 consecutive patients who bad movement disorders associated with cerebral infarction (MDCI), studied at four institutions over 8 years. In one institution (from the La Alianza-Central Hospital of Barcelona Stroke Registry) nine patients with MDCI were identified among 1099 consecutive first ever stroke patients (0.8%) (908 with IS, 1%). Fifteen out of 22 patients (68%) had hemichorea-hemiballismus, five (23%) hemidystonia and two (9%) isolated tremor. MDCI were more often left sided (n = 15, 68%), being bilateral in one patient (4.5%). A lesion was found on neuroimaging (CT and/or MRI) in 15 patients (68%), in the territory of the posterior cerebral artery (n = 8) and middle cerebral artery (six deep and one superficial). The most commonly involved structure was the thalamus (n = 8, 36.5%). IS subtypes were; presumed lacunar infarcts in 14 patients (64%), atherothrombotic infarcts in two patients (9%), cardioembolic infarcts in two patients (9%) and infarcts of unknown etiology in four patients (18%). Hemichorea-hemiballismus was the most common type of MDCI in our study, usually being the result of a thalamic infarction. The thalamus was the most frequently damaged structure underlying all types of MDCI. There was a striking propensity of MDCI which resulted from nondominant deep hemispheric small vessel infarctions.
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Affiliation(s)
- L D'Olhaberriague
- Departments of Clinical Neurophysiology, Hospital del Mar, BarcelonaDepartment of Neurology (Acute Stroke Unit), La Alianza-Central Hospital, BarcelonaDepartment of Neurology, Hospital de la Santa Creu i Sant Pau, BarcelonaDepartment of Neurology, Hospital Sant Camil, Sant Pere de Ribes, Barcelona, Catalonia, Spain
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Kaski D, Domínguez R, Bronstein A. Motion diplopia in an isolated unilateral internuclear ophthalmoplegia: A new neurological symptom? Clin Neurol Neurosurg 2013; 115:636-7. [DOI: 10.1016/j.clineuro.2012.06.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 05/04/2012] [Accepted: 06/19/2012] [Indexed: 10/28/2022]
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Djulejić V, Marinković S, Maliković A, Jovanović I, Djordjević D, Ćetković M, Todorović V, Milisavljević M. Morphometric analysis, region of supply and microanatomy of the lenticulostriate arteries and their clinical significance. J Clin Neurosci 2012; 19:1416-21. [DOI: 10.1016/j.jocn.2011.10.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 10/29/2011] [Indexed: 11/30/2022]
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Mahler LA, Ramig LO. Intensive treatment of dysarthria secondary to stroke. CLINICAL LINGUISTICS & PHONETICS 2012; 26:681-694. [PMID: 22774928 DOI: 10.3109/02699206.2012.696173] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This study investigated the impact of a well-defined behavioral dysarthria treatment on acoustic and perceptual measures of speech in four adults with dysarthria secondary to stroke. A single-subject A-B-A experimental design was used to measure the effects of the Lee Silverman Voice Treatment (LSVT(®) LOUD) on the speech of individual participants. Dependent measures included vocal sound pressure level, phonatory stability, vowel space area, and listener ratings of speech, voice and intelligibility. Statistically significant improvements (p < 0.05) in vocal dB SPL and phonatory stability as well as larger vowel space area were present for all participants. Listener ratings suggested improved voice quality and more natural speech post-treatment. Speech intelligibility scores improved for one of four participants. These data suggest that people with dysarthria secondary to stroke can respond positively to intensive speech treatments such as LSVT. Further studies are needed to investigate speech treatments specific to stroke.
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Chen YC, Li MH, Li YH, Qiao RH. Analysis of correlation between the number of lenticulostriate arteries and hypertension based on high-resolution MR angiography findings. AJNR Am J Neuroradiol 2011; 32:1899-903. [PMID: 21885718 DOI: 10.3174/ajnr.a2667] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Hypertension, one of the most important risk factors for strokes, is associated with altered arterial anatomy and function. In this study, we compared the visualization of the LSAs by 3T 3D-TOF-MRA and DSA and quantitatively examined the LSAs in patients with hypertension by using 3D-TOF-MRA. MATERIALS AND METHODS We first examined 126 patients with 3D-TOF-MRA and DSA and determined the number of LSAs. In addition, we examined 60 patients with hypertension and 60 nonhypertensive volunteers with 3D-TOF-MRA and determined the quantitative differences between the LSAs of these 2 groups. RESULTS The mean number of LSA stems visualized by DSA and 3D-TOF-MRA on 1 side was 4.1 ± 0.74 and 3.9 ± 0.94, respectively (P = .0617). The average number of LSA stems on both sides was 4.7 ± 0.8 in patients with hypertension and 6.3 ± 1.9 in nonhypertensive volunteers (P < .0001). The mean number of LSAs in the young hypertensive group (<50 years of age) and its age-matched nonhypertensive group was 4.8 ± 1.1 and 7.6 ± 1.2, respectively (P < .0001) and that in the old hypertensive group (≥50 years of age) and its age-matched nonhypertensive group was 4.6 ± 0.9 and 5.0 ± 1.0, respectively (P = .1088). CONCLUSIONS LSA detection showed good correlation between 3T 3D-TOF-MRA and DSA. As determined by 3D-TOF-MRA, there was a significant decrease in the number of LSA stems in patients with hypertension compared with that in nonhypertensive volunteers; moreover, the difference in young subjects was more than that in the elderly.
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Affiliation(s)
- Y-c Chen
- Institute of Diagnostic and Interventional Radiology, Sixth People's Hospital, Shanghai Jiaotong University, China
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Mackenzie C. Dysarthria in stroke: a narrative review of its description and the outcome of intervention. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2011; 13:125-136. [PMID: 21480809 DOI: 10.3109/17549507.2011.524940] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Dysarthria is a frequent and persisting sequel to stroke and arises from varied lesion locations. Although the presence of dysarthria is well documented, for stroke there are scant data on presentation and intervention outcome. A literature search was undertaken to evaluate (a) the features of dysarthria in adult stroke populations relative to the conventional Mayo system for classification, which was developed from diverse pathological groups, and (b) the current status of evidence for the effectiveness of intervention in dysarthria caused by stroke. A narrative review of results is presented. The limited data available indicate that, regardless of stroke location, imprecise articulation and slow speaking rate are consistent features, and voice disturbances, especially harshness, and reduced prosodic variation are also common. Dysarthria is more prevalent in left than in right hemisphere lesions. There is a need for comprehensive, thorough analysis of dysarthria features, involving larger populations, with stroke and other variables controlled and with appropriate age-referenced control data. There is low level evidence for benefits arising from intervention in stroke-related dysarthria. Because studies involve few participants, without external control, and sometimes include stroke with other aetiologies, their results lack the required weight for confident evidence-based practice.
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Affiliation(s)
- Catherine Mackenzie
- School of Psychological Sciences and Health, University of Strathclyde, Southbrae Drive, Glasgow G13 1PP, UK.
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Cocho D, Martí-Fàbregas J, Baiget M, Gallardo E, Rio E, Arboix A, Ruscalleda J, Martí-Vilalta JL. Diagnosis of CADASIL disease in normotensive and non-diabetics with lacunar infarct. Neurologia 2011; 26:325-30. [PMID: 21345538 DOI: 10.1016/j.nrl.2010.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Revised: 11/09/2010] [Accepted: 12/01/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is characterized by recurrent cerebral ischemic episodes of the lacunar subtype usually without traditional vascular risk factors. We investigated the frequency of CADASIL among selected patients with cerebral ischemia of the lacunar subtype. METHODS we studied patients under 65 years old who presented cerebral ischemia of the lacunar subtype without hypertension, diabetes mellitus or other causes that explained the cerebral ischemia. On the skin biopsies, we performed immunostaining analysis on 5μm frozen sections with monoclonal antibody anti-Notch 3 (1E4). We also performed a genetic analysis of the Notch 3 gene (exons 3,4,5,6,11 and 19). RESULTS of 1.519 patients analyzed, only 57 (3.7%) fulfilled the selection criteria, and 30 of them accepted to participated in the study. We studied 30 patients, mean age was 53 years (range 34 to 65), 50% were men and all patients suffered a lacunar stroke. Immunostaining analysis was positive in two patients (6.6%) and the genetic analysis confirmed a mutation characteristic of CADASIL in exon 4 nt 622C/T (Arg 182 Cys) and 694 T/C (Cys206Arg) respectively. CONCLUSIONS CADASIL disease was present in 6.6% of patients younger than 65 years with a lacunar stroke and without hypertension or diabetes mellitus. Screening for CADASIL should be considered in these patients.
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Affiliation(s)
- D Cocho
- Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
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Cocho D, Martí-Fàbregas J, Baiget M, Gallardo E, Rio E, Arboix A, Ruscalleda J, Martí-Vilalta J. Diagnosis of CADASIL disease in normotensive and non-diabetics with lacunar infarct. NEUROLOGÍA (ENGLISH EDITION) 2011. [DOI: 10.1016/s2173-5808(11)70077-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Elkind MSV, Luna JM, Coffey CS, McClure LA, Liu KM, Spitalnik S, Paik MC, Roldan A, White C, Hart R, Benavente O. The Levels of Inflammatory Markers in the Treatment of Stroke study (LIMITS): inflammatory biomarkers as risk predictors after lacunar stroke. Int J Stroke 2010; 5:117-25. [PMID: 20446946 DOI: 10.1111/j.1747-4949.2010.00420.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Inflammation is increasingly recognised as playing a central role in atherosclerosis, and peripheral blood markers of inflammation have been associated with incident and recurrent cardiac events. The relationship of these potentially modifiable risk markers to prognosis after ischaemic stroke is less clear. The Levels of Inflammatory Markers in the Treatment of Stroke (LIMITS) study will address hypotheses related to the role of inflammatory markers in secondary stroke prevention in an efficient manner using the well-established framework of the Secondary Prevention of Small Subcortical Strokes (SPS3) trial (NCT00059306). METHODS SPS3 is an ongoing Phase III multicentre secondary prevention trial focused on preventing recurrent stroke in patients with small vessel ischaemic stroke, or lacunes. In SPS3, patients are assigned in a factorial design to aspirin vs. aspirin plus clopidogrel, and to usual vs. aggressive blood pressure targets. The purpose of LIMITS is to determine whether serum levels of inflammatory markers - including high-sensitivity C-reactive protein, serum amyloid A, CD40 ligand, and monocyte chemoattractant protein-1 - predict recurrent stroke and other vascular events among lacunar stroke patients. The project will also determine whether these markers predict which people will respond best to dual antiplatelet therapy with clopidogrel and aspirin, as well the relationship to cognitive function. ANALYSIS plan Multivariable Cox proportional hazard regression modeling will be used to estimate hazard ratios for the effect of marker levels on risk of recurrent stroke and other outcomes after adjusting for additional potential risk factors, including age, gender, ethnicity, treatment arm, and traditional stroke risk factors. Interactions between marker levels and treatment assignment for both arms of the SPS3 study will be assessed. Observations will be censored at the time of last follow-up visit. CONCLUSIONS LIMITS represents an efficient approach to the identification of novel inflammatory biomarkers for use in risk prediction and treatment selection in patients with small vessel disease.
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Affiliation(s)
- M S V Elkind
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA.
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Pure monoparesis of the leg due to cerebral infarctions: A diffusion-weighted imaging study. J Clin Neurosci 2009; 16:1414-6. [DOI: 10.1016/j.jocn.2009.01.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 01/18/2009] [Accepted: 01/24/2009] [Indexed: 11/18/2022]
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Wenke RJ, Theodoros D, Cornwell P. The short- and long-term effectiveness of the LSVT®for dysarthria following TBI and stroke. Brain Inj 2009; 22:339-52. [DOI: 10.1080/02699050801960987] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
Lacunar infarcts or small subcortical infarcts result from occlusion of a single penetrating artery and account for one quarter of cerebral infarctions. Patients with a lacunar infarct usually present with a classical lacunar syndrome (pure motor hemiparesis, pure sensory syndrome, sensorimotor stroke, ataxic hemiparesis or dysarthria-clumsy hand) and, less frequently, an atypical lacunar syndrome. Hypertension and diabetes mellitus are major risk factors for lacunar stroke. Lacunar infarcts show a paradoxical clinical course with a favorable prognosis in the short term, characterized by a low early mortality and reduced functional disability on hospital discharge, but with an increased risk of death, stroke recurrence and dementia in the mid- and long term. Asymptomatic progression of small-vessel disease is a typical feature of the lacunar infarcts. For this reason, lacunar infarction should be regarded as a potentially severe condition rather than a relatively benign disorder and, therefore, lacunar stroke patients require adequate and rigorous management and follow-up. Antiplatelet drugs, careful blood pressure control, the use of statins and modification of lifestyle risk factors are key elements in secondary prevention after lacunar stroke.
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Affiliation(s)
- Adrià Arboix
- Cerebrovascular Division, Department of Neurology, Hospital Universitari del Sagrat Cor, Universitat de Barcelona, C/ Viladomat 288, E-08029 Barcelona, Spain.
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Prodan CI, Joseph PM, Vincent AS, Dale GL. Coated-platelets in ischemic stroke: differences between lacunar and cortical stroke. J Thromb Haemost 2008; 6:609-14. [PMID: 18182039 DOI: 10.1111/j.1538-7836.2008.02890.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Coated-platelets are a subset of platelets with procoagulant potential observed upon dual agonist stimulation with collagen and thrombin. OBJECTIVE The goal was to investigate if coated-platelet production differs between patients with lacunar ischemic stroke and non-lacunar (cortical) ischemic stroke as compared with controls. PATIENTS AND METHODS Blood samples from 60 patients with ischemic stroke (20 lacunar and 40 cortical) and 70 controls were analyzed for coated-platelet production. RESULTS Coated-platelet production was significantly lower in patients with lacunar stroke (21.8 +/- 11.4%, mean +/- 1 SD) as compared with either controls (31.6 +/- 13.2%, P = 0.008) or patients with cortical stroke (39.4 +/- 12.7%, P < 0.001). The increase in coated-platelets for patients with cortical stroke as compared with controls was also significant (P = 0.008). CONCLUSIONS Our results indicate a marked difference in coated-platelet synthesis in lacunar vs. non-lacunar stroke, thereby providing additional support for the existence of distinct pathological processes underlying these two subtypes of ischemic stroke. Further investigation of the role of coated-platelets in stroke, taking into account these preliminary findings, is warranted.
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Affiliation(s)
- C I Prodan
- VA Medical Center, Oklahoma City, OK, USA.
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Micheli S, Agnelli G, Palmerini F, Caso V, Venti M, Alberti A, Biagini S, Paciaroni M. Need for extensive diagnostic work-up for patients with lacunar stroke. J Neurol 2008; 255:637-42. [PMID: 18283395 DOI: 10.1007/s00415-008-0762-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2007] [Revised: 09/16/2007] [Accepted: 09/21/2007] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Small-vessel disease is the most frequent cause of lacunar stroke. The aims of this study were to evaluate: 1) alternative causes of lacunar stroke other than small-vessel disease; 2) functional outcome of lacunar strokes due to small vessel disease compared to lacunar strokes due to alternative causes. METHODS Consecutive patients with first-ever ischemic lacunar stroke were prospectively followed-up for at least 3 months. At discharge patients were divided into 2 groups: lacunar stroke due to small vessel disease (L-SVD) and lacunar stroke due to possible other etiologies (L-non SVD) (e. g. cardioembolism, atherosclerosis or other causes). Main outcome measures were the combined end point of death or disability (mRS >or= 3) and recurrent stroke at the end of follow-up. RESULTS 535 patients with acute stroke were seen during the study period. Out of these, 196 patients (126 males) with a mean age of 71.6 years (SD = 10) had lacunar stroke. L-SVD was seen in 142 patients (72.4 %) and L-nonSVD in 54 patients (27.6 %). After 16.4 months, 12 patients had died (6.2%; annual mortality rate 4.4 %), 63 were disabled (32.5 %) and 27 had stroke recurrence (13.9%; annual recurrence rate 9.9 %). Forty-nine patients with L-SVD (34.7 %) and 26 with L-nonSVD (49%) had died or become disabled. Sixteen patients with L-SVD (11.3 %) and 11 with L-nonSVD (20.4 %) had stroke recurrence. On multivariate analysis, L-nonSVD (OR = 2.87, 95% CI 1.08-7.65; p = 0.034) and age (OR = 1.07, 95 % CI 1.02-1.12; p = 0.01) were associated to more severe outcome. L-nonSVD was independently associated with recurrence (OR = 5.03, 95% CI 1.54-16.44; p = 0.006). CONCLUSIONS Twenty-seven percent of patients with lacunar stroke have causes other than small vessel disease. These patients have a severe outcome in terms of recurrence,mortality or disability. These findings support the need for a comprehensive diagnostic work-up for patients with lacunar stroke.
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Affiliation(s)
- Sara Micheli
- Stroke Unit, Dept. of Cardiovascular Medicine, University of Perugia, Ospedale Santa Maria della Misericordia, Sant'Andrea delle Fratte, 06128 Perugia, Italy.
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Bradač GB, Daniele D, Bergui M, Cerrato P, Ferrio MF, Stura G, Coriasco M. Lacunes and other holes: diagnosis, pathogenesis, therapy. Neuroradiol J 2008; 21:35-52. [PMID: 24256748 DOI: 10.1177/197140090802100105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Accepted: 10/28/2007] [Indexed: 11/16/2022] Open
Abstract
Lacunar ischemic lesions are related to a pathology involving perforators, due to direct changes in the arteries or to an indirect mechanism, such as cardiac or artery to artery embolism, or to hypoperfusion in cases of cardiac failure, or proximal occlusion of large arteries. Changes involving the large intracranial arteries have progressively been taken into consideration as a cause of the disease. This latter aspect is interesting since possible endovascular treatment can be proposed in selected cases. In patients with lacunar syndrome an extended clinical and neuroradiological approach is indicated to choose the most appropriate therapy. Not all lesions recognizable on CT/MR are the expressions of ischemic lesions, this is another important aspect that should be considered in the differential diagnosis.
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Affiliation(s)
- G B Bradač
- Neuroscience-Neuroradiology Department, University of Turin; Turin, Italy -
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Cokar O, Ozturk O, Aydemir T, Tiras R, Ozer F, Hakyemez HA. Transoesophageal echocardiographic findings in patients with ischemic lacunar and nonlacunar stroke. J Clin Neurosci 2008; 15:246-52. [PMID: 18206376 DOI: 10.1016/j.jocn.2007.02.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Accepted: 02/21/2007] [Indexed: 11/17/2022]
Abstract
The aim of this study was to compare risk factors and concomitant potential cardioembolic sources detected by transthoracic (TTE) and transoesophageal echocardiography (TEE) in patients with lacunar and nonlacunar infarcts. Clinical data of 139 patients with a first episode of ischemic stroke who underwent both TTE and TEE were analysed. Patients were divided into two groups, lacunar (LACI=36), and nonlacunar infarcts (NLACI=103); then the latter group was divided into two subgroups, anterior (ACI=76) and posterior circulation infarct (POCI=27). Presence of hypertension and diabetes mellitus were not significantly different between LACI and NLACI groups. The rate of potential cardioembolic risk factors detected by echocardiography was similar in the NLACI groups. At least one potential cardiac source of embolism was identified in 44% (n=16) of LACI, 52.6% (n=40) of ACI and 55.5% (n=15) of POCI patients. Atrial fibrillation was significantly frequent in the ACI group. No significant differences were found between all groups regarding age, sex, hyperlipidemia, and smoking. Our findings demonstrate that hypertension and diabetes mellitus are equally important in the pathogenesis of both LACI and NLACI groups and there is a need for careful cardiac evaluation in cases even with lacunar infarct.
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Affiliation(s)
- Ozlem Cokar
- Department of Neurology, Haseki Educational and Research Hospital, Istanbul, Turkey.
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Arboix A, Altés E, García-Eroles L, Massons J. Clinical study of lacunar infarcts in non-hypertensive patients. J Stroke Cerebrovasc Dis 2007; 12:232-6. [PMID: 17903933 DOI: 10.1016/j.jstrokecerebrovasdis.2003.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2002] [Revised: 09/05/2003] [Accepted: 09/05/2003] [Indexed: 11/21/2022] Open
Abstract
Lacunar infarcts in non-hypertensive patients have been scantly assessed. The objective of this study was to determine clinical features of lacunar infarct in patients without hypertension (n = 91) in comparison with characteristics of lacunar infarcts occurring in patients with hypertension (n = 283) collected from a prospective hospital-based stroke registry in which 2000 patients with acute stroke are included. Predictors of lacunar infarct in patients without hypertension were assessed by multiple logistic regression analysis. The group of non-hypertensive patients with lacunar infarction showed a significantly higher frequency of male gender, age 85 years or older, history of atrial fibrillation, chronic obstructive pulmonary disease and diabetes mellitus, and a significantly lower frequency of female gender and absence of limitation at hospital discharge than hypertensive patients with lacunar infarct. Differences between hypertensive and non-hypertensive patients in relation to frequency of the different lacunar syndromes were not observed. After multivariate analysis, age 85 years or older (odds ratio 3.13), diabetes (odds ratio 2.57), and male gender (odds ratio 1.99) seemed to be independent factors associated with lacunar infarct in patients without hypertension. Lacunar infarct in non-hypertensive patients showed some differential clinical features compared to the remaining lacunar infarctions because it occurred more frequently in male patients aged 85 years or older. In this group, diabetes was the most important modifiable risk factor. These results suggest an earlier effect of arteriopathy caused by hypertension favoring lacunar brain ischemia, whereas in non-hypertensive patients, arteriopathy responsible for small vessel disease would take a more prolonged time in causing lacunar infarction.
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Affiliation(s)
- Adrià Arboix
- Acute Stroke Unit, Hospital del Sagrat Cor, Barcelona, Spain.
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Kruger E, Teasell R, Salter K, Foley N, Hellings C. The rehabilitation of patients recovering from brainstem strokes: case studies and clinical considerations. Top Stroke Rehabil 2007; 14:56-64. [PMID: 17901016 DOI: 10.1310/tsr1405-56] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An estimated 15% of all patients admitted to stroke rehabilitation units experience a brainstem stroke. Two case studies are presented to illustrate some of the difficulties encountered in the rehabilitation of these individuals. Unlike hemispheric stroke, the characteristic consequences of brainstem stroke include ataxia, dysarthria, and diplopia. Additionally, individuals with brainstem stroke may suffer from severe dysphagia and may require enteral feedings. Unlike the rehabilitation of patients with hemispheric stroke, where there is an impressive and relatively comprehensive research literature, there has been surprisingly little research published on the rehabilitation of patients with brainstem stroke despite the fact they represent a significant number of patients admitted to stroke rehabilitation units.
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Affiliation(s)
- Elizabeth Kruger
- Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research Institute, London, Ontario, Canada
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Rossmeisl JH, Rohleder JJ, Pickett JP, Duncan R, Herring IP. Presumed and confirmed striatocapsular brain infarctions in six dogs. Vet Ophthalmol 2007; 10:23-36. [PMID: 17204125 DOI: 10.1111/j.1463-5224.2007.00487.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe the clinical and diagnostic features of the canine sensorimotor syndrome caused by striatocapsular brain infarctions (SCI). ANIMALS STUDIED Six dogs with diagnostic imaging or postmortem evidence of SCI. PROCEDURES Medical records of dogs with SCI were retrospectively reviewed and the signalment, history, clinical signs, antemortem clinicopathologic test results, diagnostic imaging findings, case outcomes, and pathologic findings recorded. RESULTS All dogs had an acute onset of nonprogressive homonymous visual field deficits and contralateral general proprioceptive (GP) deficits. Contralateral hemiparesis and facial hypalgesia were noted in 5/6 dogs. CT scans were normal in 2/4 dogs, and revealed poorly defined hypoattenuating lesions in the subcortical white matter in two dogs. MRI exams were performed in 5/6 dogs and revealed unilateral, variably sized, striatocapsular lesions consistent with nonhemorrhagic infarctions. Diagnostic imaging (6/6) and postmortem examinations (2/6) suggested that SCI resulted from lesions in the vascular territories of the rostral choriodal (6/6) and lenticulostriate arteries (2/6). Diseases predisposing to infarction were not identified in 5/6 dogs. Improvements in mentation, behavior, proprioceptive deficits, and hemiparesis were seen in surviving dogs, but persistent, symptomatic sensory deficits were noted during the follow-up period. CONCLUSIONS SCI should be considered as a differential diagnosis for dogs with acute onset, nonprogressive homonymous hemianopia, contralateral GP deficits or hemiparesis, and facial hypalgesia. MRI is the preferred modality for the antemortem imaging diagnosis of SCI. Although partial recovery occurred in all surviving dogs, visual and facial sensory disturbances persisted.
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Affiliation(s)
- John H Rossmeisl
- Department of Small Animal Clinical Sciences, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA.
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Arboix A, López-Grau M, Casasnovas C, García-Eroles L, Massons J, Balcells M. Clinical study of 39 patients with atypical lacunar syndrome. J Neurol Neurosurg Psychiatry 2006; 77:381-4. [PMID: 16484649 PMCID: PMC2077681 DOI: 10.1136/jnnp.2005.071860] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The aim of this study was to describe the clinical characteristics of atypical lacunar syndrome (ALS) based on data collected from a prospective acute stroke registry. In total, 2500 acute stroke patients were included in a hospital based prospective stroke registry over a 12 year period, of whom 39 were identified as having ALS and radiologically proven (by computed tomography or magnetic resonance imaging) lacunes. ALS accounted for 1.8% of all acute stroke patients, 2.1% of acute ischaemic stroke, and 6.8% of lacunar syndromes. ALS included dysarthria facial paresis (n = 12) or isolate dysarthria (n = 9), isolated hemiataxia (n = 4), pure motor hemiparesis with transient internuclear ophthalmoplegia (n = 4), pure motor hemiparesis with transient subcortical aphasia (n = 3), unilateral (n = 2) or bilateral (n = 3) paramedian thalamic infarct syndrome, and hemichorea hemiballismus (n = 2). Atypical lacunar syndromes were due to small vessel disease in 96% of patients. Atherothrombotic infarction occurred in one patient and cardioembolic infarct in another, both presenting pure dysarthria. Outcome was good (in hospital mortality 0%, symptom free at discharge 28.2%). After multivariate analysis, the variables of speech disturbances, nausea/vomiting, ischaemic heart disease, and sensory symptoms were found to be significantly associated with ALS. In conclusion, atypical lacunar syndrome is an infrequent stroke subtype (one of each 14 lacunar strokes). ALS occurred in 6.8% of lacunar strokes. Isolated dysarthria or dysarthria facial paresis were the most frequent presenting forms. The prognosis of this infrequent non-classic lacunar syndrome is good.
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Affiliation(s)
- A Arboix
- Cerebrovascular Division, Department of Neurology, Hospital Universitari del Sagrat Cor, Universitat de Barcelona, Spain.
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Urban PP, Rolke R, Wicht S, Keilmann A, Stoeter P, Hopf HC, Dieterich M. Left-hemispheric dominance for articulation: a prospective study on acute ischaemic dysarthria at different localizations. Brain 2006; 129:767-77. [PMID: 16418180 DOI: 10.1093/brain/awh708] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Dysarthria is a frequent symptom in cerebral ischaemia. However, speech characteristics of these patients have not previously been investigated in relation to lesion site in a prospective study. We investigated the auditory perceptual features in 62 consecutive patients with dysarthria due to a single, non-space-occupying cerebral infarction confirmed by MRI. Standardized speech samples of all patients were stored within 72 h after stroke onset using a digital tape recorder. Speech samples were assessed independently by two experienced speech therapists, who were unaware of the clinical and neuroradiological findings, using an interval scale ranging from 0 to 6. Separately assessed were features of articulation, phonation, prosody, and the global severity for a total of 31 items. Extracerebellar infarctions (85.5%) were located in the lower motor cortex (14.5%), striatocapsular region (46.8%) and base of the pons (24.2%). Isolated cerebellar infarctions were present in 14.5% of patients. There was a strong correlation between the findings of both examiners, showing identical scores, or only minor differences (<1 on the assessment scale) for 80% of all items. The average severity of dysarthria was 2.9 +/- 1.3. Articulatory abnormalities were the predominant deviation characteristics, affecting in particular the production of consonants. However, phonatory and prosodic abnormalities were also frequently observed speech characteristics. As revealed by factor analysis of speech characteristics the total severity of dysarthria was mainly influenced by the impairment of articulation. Speech parameters describing characteristics of articulation and prosody showed significant side-to-side and area differences, while this effect was lacking for any voice parameter. Left cerebral lesions showed a more severe overall impairment of speech and articulation, independent of lesion topography. Thirty-eight of 62 patients were available for follow-up. Speech evaluation showed normal speech within weeks in 15 out of 38 patients (39.5%). In the other 23 patients overall severity of dysarthria was mild. This is the first prospective study which describes speech characteristics of dysarthria due to acute unilateral cerebral infarctions. We could demonstrate that dysarthria in extracerebellar infarctions was more frequently caused by left-sided lesions and that the severity of dysarthria was more pronounced in left-sided lesions independent from lesion topography. All extracerebellar lesions were located along the course of the cortico-bulbar tract fibres. Compatible with a common pathophysiological basis of dysarthria in these patients, none of the 31 speech items differed significantly between subcortical and brainstem lesions.
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Affiliation(s)
- P P Urban
- Department of Neurology, Johannes Gutenberg University, Mainz, Germany.
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Jung S, Hwang SH, Kwon SB, Yu KH, Lee BC. The clinico-radiologic properties of deep small basal ganglia infarction: Lacune or small striatocapsular infarction? J Neurol Sci 2005; 238:47-52. [PMID: 16126229 DOI: 10.1016/j.jns.2005.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2004] [Revised: 06/13/2005] [Accepted: 06/14/2005] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Deep small basal ganglia infarction (DSBI) cannot be clearly classified as either lacune or striatocapsular infarction by their sizes only. We tried to elucidate clinical and other properties of DSBI to understand better in pathophysiology of ischemic lesion of basal ganglia. METHODS We analyzed 36 patients with acute ischemic lesion of basal ganglia with the size varying from 1.5 to 3 cm in maximal diameters. We assessed clinical features, laboratory data, risk factors of stroke, and radiologic findings such as MRI and MR angiography. RESULTS Patients with DSBI could be largely divided into two distinctive groups, small infarction with cortical sign (SICS) and lacunar syndrome (LS) according to their presence of cortical manifestations. Total of 11 patients were in SICS group and they showed cortical manifestations such as eyeball deviation, visual field defect, aphasia and neglect. They also showed severer non-cortical neurologic deficit compared with LS group. Whereas LS group showed various MRA patterns, 7 patients of SICS group (63.6%) showed proximal MCA stenosis in MRA. CONCLUSIONS We found that many patients with DSBI could have the features of either lacune or striatocapsular infarction. Although they have similar morphologic characteristics but they are presumed to have different pathophysiologic mechanism.
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Affiliation(s)
- San Jung
- Department of Neurology, Hallym University College of Medicine, Seoul, South Korea.
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Sellars C, Hughes T, Langhorne P. Speech and language therapy for dysarthria due to non-progressive brain damage. Cochrane Database Syst Rev 2005:CD002088. [PMID: 16034872 DOI: 10.1002/14651858.cd002088.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Dysarthria is a common sequel of non-progressive brain damage (typically stroke and traumatic brain damage). Impairment-based therapy and a wide variety of compensatory management strategies are undertaken by speech and language therapists with this patient population. OBJECTIVES To determine the efficacy of speech and language therapy interventions for adults with dysarthria following non-progressive brain damage. SEARCH STRATEGY We searched the trials registers of the following Cochrane Groups: Stroke, Injuries, Movement Disorders and Infectious Diseases. We also searched the trials register of the Cochrane Rehabilitation and Related Therapies Field. The trials registers were last searched in September 2004. The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2004), MEDLINE (1966 to September 2004), EMBASE (1980 to September 2004), CINAHL (1983 to September 2004), PsycINFO (1974 to October 2004), and Linguistics and Language Behavior Abstracts (1983 to December 2004) were searched electronically. We handsearched the International Journal of Language and Communication Disorders (1966 to 2005, Issue 1) and selected conference proceedings, and scanned the reference lists of relevant articles. We approached colleagues and speech and language therapy training institutions to identify other possible published and unpublished studies. SELECTION CRITERIA Unconfounded randomised controlled trials (RCTs). DATA COLLECTION AND ANALYSIS One author assessed trial quality. Two co-authors were available to examine any potential trials for possible inclusion in the review. MAIN RESULTS No trials of the required standard were identified. AUTHORS' CONCLUSIONS There is no evidence of the quality required by this review to support or refute the effectiveness of speech and language therapy interventions for dysarthria following non-progressive brain damage. Despite the recent commencement of a RCT of optimised speech and language therapy for communication difficulties after stroke, there continues to be an urgent need for good quality research in this area.
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Affiliation(s)
- C Sellars
- Department of Speech and Language Therapy, Glasgow Royal Infirmary, Castle Street, Glasgow, UK, G4 0SF.
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Khedr EM, Abdel-Fadeil MR, El-Khilli F, Ibrahim MQ. Impaired corticolingual pathways in patients with or without dysarthria after acute monohemispheric stroke. Neurophysiol Clin 2005; 35:73-80. [PMID: 16087070 DOI: 10.1016/j.neucli.2005.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2004] [Accepted: 03/23/2005] [Indexed: 10/25/2022] Open
Abstract
The occurrence of dysarthria is not infrequent in stroke but little is known about its pathophysiology. The aims of the present study were to assess the central motor innervation of the tongue in normal adults using transcranial magnetic stimulation (TMS) and to compare this with that seen in stroke patients with or without dysarthria. The study included 46 patients with acute monohemispheric stroke due to occlusion of the territory of the middle cerebral artery as documented by CT brain scan (26 patients with dysarthria and 20 patients without dysarthria). Forty-five (age and sex matched) normal volunteers served as controls. Corticolingual pathways were assessed for each subject after TMS of each hemisphere. TMS over the motor cortex of healthy subjects elicited consistent ipsilateral and contralateral lingual responses. The ipsilateral response was usually smaller and approximately 73% of the amplitude of the contralateral response. The cross talk between the two halves of the tongue as estimated after unilateral electrical stimulation of hypoglossal nerve gave a contra/ipsi ratio of 36%, which was significantly smaller than the ratio seen after cortical stimulation (CL). For the patients, with or without dysarthria, motor evoked potential (MEP) latencies (ipsilateral and contralateral) were significantly prolonged after stimulation of affected hemisphere compared with the non-affected hemisphere or the control group (P< 0.001). MEP amplitudes were significantly smaller in hemiplegic patients with dysarthria compared to patients without dysarthria. In patients without dysarthria stimulation of the unaffected hemisphere tended to evoke responses that were of similar size on both sides. There were no significant associations between neurophysiological parameters and side of infarction. We conclude that interruption of the corticolingual pathways is frequent in stroke patients with or without dysarthria. The ability of unaffected hemisphere to evoke responses in the side contralateral to the lesion may relate to the absence or presence of dysarthria.
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Affiliation(s)
- E M Khedr
- Department of Neurology and Physiology, Assiut University Hospital, Assiut, Egypt.
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