RECOVERY FROM NEGLECT

AFTER RIGHT HEMISPHERE

STROKE
Estanislao, Nuena Y.
BS PSYCHOLOGY 3A
Luukkainen-Markkula and Tarkka, Int J
Year: 2014
Source:
https://www.researchgate.net/publication/267756611_Recovery_from_neglect_after_righ
t_hemisphere_stroke

Abstract

Favourable outcome after cerebrovascular stroke is associated with early admission to

rehabilitation, small lesion size and minor cognitive impairment. The aim of the present
study was to explore factors associated with the amelioration of neglect after right
hemisphere stroke. Twenty-one consecutive eligible right hemisphere stroke patients in
one rehabilitation center were assessed and followed for 6 months. The neglect syndrome
was assessed by the conventional subtests of the Behavioural Inattention Test (BIT) and
by the Catherine Bergego Scale (CBS) before and after the 3-week rehabilitation and at 6-
month follow-up. The manifestations of extinction, pusher syndrome and depression were
evaluated. Recovery from neglect was strongly associated with early rehabilitation and the
initial severity of neglect. Intensive treatment yielded recovery in severe or moderate visual
neglect long after the first two to three months after stroke. Even chronic patients with
sufficient cognitive and psychological capacity improved with intensive rehabilitation.
Tactile extinction was common in these patients but was not associated with recovery.
Manifestations of pusher syndrome hampered amelioration of visual neglect in acute and
sub-acute stroke patients, whereas depression did not prevent recovery from neglect.
Intensive rehabilitation promotes recovery from neglect in the acute phase after right
hemisphere stroke. A comprehensive program later, in sub-acute or chronic phase, may
also be effective especially in those patients who have not received intensive multi-
professional rehabilitation soon after the stroke.
ARTICLE ANALYSIS

I. INTRODUCTION

Stroke is today and will continue to be the most frequent cause of chronic
disability in adults in the western world. Nearly half of the stroke survivors display
neuropsychological deficits acutely after stroke and one in every three stroke patients
is diagnosed with neglect. Although many patients recover from neglect spontaneously
within the first months, ten percent of these individuals still show neglect three months
after right hemisphere cerebral accident. Neglect often predicts a poor functional
outcome.

Neglect has a negative effect on long-term outcome: these patients take longer to
recover and they are left with more functional disabilities than patients with right
hemisphere lesions without neglect. Less than half of neglect patients recover
spontaneously during the first weeks after stroke and less than 10% show complete
recovery. Severe disabilities often lead to lack of co-operation acutely after stroke and
dementia and attention deficits increase the probability of late failure in recovery. Early
admission to rehabilitation decreases long-term adverse outcomes. Hemispatial neglect
and depression are associated with an increased risk of low recovery as assessed in
activities of daily living (ADL), but not on mobility. Previously stroke patients who
improved most at one year follow-up were those with larger lesions and generalized
cognitive impairment at baseline, however, aphasia and neglect were not influencing
the long term recovery.

In the present study, neurological deficits, the amount and quality of

rehabilitation and neuropsychological deficits in patients with neglect during the course
of recovery were assessed. The role of hemianopia, extinction, pusher syndrome and
depression were also analysed in the recovery from neglect. We searched for
determinants of excellent or poor recovery from neglect.

II. OBJECTIVES

The aim of the present study was to search for the factors associated with
recovery from neglect yet considering the heterogeneity of the syndrome.
III. DESIGN

All 21 patients were followed up at 6 months. The neglect syndrome was assessed
by the conventional subtests of the Behavioural Inattention Test (BIT) and by the
Catherine Bergego Scale (CBS) before and after the 3-week rehabilitation and at 6-
month follow-up.

IV. POTENTIAL IMPACT TO SELF, SOCIETY AND THE FUTURE

GENERATION

In the present study, patients entered the rehabilitation at a minimum of 18 days

after the stroke, when the most rapid spontaneous recovery had already passed, but their
neglect still ameliorated significantly due to the rehabilitation though spontaneous
recovery may still occur for several weeks. Our study confirms the previous findings
that early admission to rehabilitation increases the likelihood for better outcome. We
also confirm that significant recovery in visual neglect is possible during 3-6 months
or even later after the stroke especially in patients with severe neglect and insufficient
acute rehabilitation.

Intensive multiprofessional acute rehabilitation is essential, even though

comprehensive program also later can be effective in rehabilitation of neglect,
especially in patients who have not received proper rehabilitation in the acute phase.
Recovery from neglect is strongly associated with the severity of neglect and with early
rehabilitation. Intensive treatment can induce recovery in severe or moderate visual
neglect also long after the first two or three months after stroke. Even chronic patients
with visual neglect improve after intensive rehabilitation, if they have sufficient
compensatory cognitive and psychological capacities. Behavioural neglect is often
found when visual neglect has already ameliorated and it may be associated with
hemianopia. The combination of neglect and hemianopia needs to receive special
attention in the rehabilitation program. The presence of pusher syndrome hampers
recovery of neglect acutely after stroke, whereas tactile extinction is not associated with
recovery from neglect. Depression may be associated with more extensive lesions and
severe neurological losses in chronic neglect patients and should be diagnosed and
treated even years after the stroke to enhance recovery.
NEUROPLASTICITY IN Estanislao, Nuena Y.
HEMISPHERIC SYNDROME: AN
BS PSYCHOLOGY- 3A
INTERESTING CASE REPORT

ShyamSundar Krishnan, Manas Panigrahi, Sita Jayalakshmi, Dandu R Varma

Year : 2011

Source: http://www.neurologyindia.com/article.asp?issn=0028-
3886;year=2011;volume=59;issue=4;spage=601;epage=604;aulast=Krishnan

» Abstract

Functional hemispherectomy is an accepted treatment in hemispherical intractable

epilepsy syndromes. We report a patient who had functional hemispherectomy for
intractable seizures secondary to right hemispheric cortical dysplasia. Preoperatively, the
patient had mild left hemiparesis and functional magnetic resonance imaging (fMRI)
showed bilateral motor function lateralization to normal left hemisphere. The patient
remains seizure free at 1-year follow-up, with no deterioration of motor power on left
side. This report reviews physiology of neural plasticity for motor function lateralization
and also reliability of fMRI in determining the functional shift.

Keywords: Epilepsy surgery, focal cortical dysplasia, functional hemispherectomy,

functional magnetic resonance imaging, neuroplasticity

» Introduction

Functional hemispherectomy is an effective treatment for intractable epilepsy in patients

with hemispherical epilepsy syndromes. The principle of epilepsy surgery is to render the
patient seizure free without causing an unacceptable neurological deficit. In functional
hemispherectomy, disconnection would require a certain innate capacity of plasticity to
be harnessed preoperatively and/or postoperatively.

» Case Report

A 21-year-old male presented with intractable seizures since the age of 8 months. He had
infantile spasms at the onset and used to have disabling multiple seizure types: Left focal
seizures with secondary generalization, sudden head and trunk flexion associated with
falls and injuries, and atonic seizures since the age of 2 years. The preoperative seizure
frequency was two to three times per week, mostly in clusters at any time of the day. He
had delayed motor milestones and attained walking at 2 years and language at 3 years.
Left hemiparesis was noted at 2 years of age. However, the patient was independent for
activities of daily living.

On neurological examination, he had left hemiparesis (4/5) with mild hand grip weakness
and was ambulant. Neuropsychological evaluation showed below average IQ of 48 and a
Social Quotient of 52 with behavioral problems. Ictal EEG showed epileptiform
discharges with right hemisphere hemispherical onset. Magnetic resonance imaging
(MRI) of brain showed an extensive right hemispheric polymicrogyria [Figure 1] and
[Figure 2]. Blood oxygen level dependent (BOLD) functional MRI (fMRI) with self-
paced sequential finger tapping and ankle dorsiflexion paradigms revealed lateralization
of bilateral upper and lower limb motor functions to the normal left hemisphere [Figure
3] and [Figure 4]. The patient underwent a right frontoparietal craniotomy and vertical
parasagittal functional hemispherectomy as described by Delalande. Postoperatively, the
patient did not have any worsening of his pre-existing deficits and has been seizure free
(Engels Class I outcome) for more than 1 year.
» Discussion

Functional hemispherectomy is indicated in certain congenital or acquired hemispheric

epilepsy syndromes with intractable seizures: Infantile hemiplegic seizure syndrome,
hemimegalencephaly, SturgeWeber syndrome More Details, non-hypertrophic
migrational disorders, Rasmussen's encephalitis, trauma, hemorrhage, and
meningoencephaliticsequelae. Prerequisite for functional hemispherectomy is complete
hemispheric syndrome as defined by the presence of hemiplegia, hemianopsia and
cerebral hemiatrophy. However, for a patient with intractable seizures and near-normal
limb power, functional hemispherectomy can still be performed if the affected
hemisphere has diffuse abnormality and the contralateral hemisphere is radiologically
normal. The possibility of neurological deterioration following surgery and extent of
subsequent recovery depends on the extent of functional shift between the hemispheres.
Our patient had a clear functional shift to the normal hemisphere seen on fMRI; probably
this may explain his good motor outcome.

For a functional motor shift to the normal hemisphere to happen, the innate capacity of
neural plasticity would be the key. Neural plasticity is a change in functional destination
of the existing neurons, that is, a reorganization of the remaining cortical-subcortical
networks and their descending projections and does not involve the generation of new
neurons. The basis of neural plasticity derives from synaptic plasticity. Synaptic plasticity
refers to changes in the strength of neurotransmission induced by activity experienced by
the synapse in the past. Changes in the frequency or strength of activation across
synapses can result in long-term increases or decreases in their strength, referred to as
either long-term potentiation (LTP) or long-term depression (LTD), respectively. Neural
plasticity entails increase in new synapses besides strengthening and expansion of
influence by dendritic arborization. For a given neuronal function, there are far more
pathways than actually in use, which become available for the organism by opening up of
dormant synapses by decrease in inhibition, increased excitability or decreased threshold
of synaptic transmission. Damage to a functional area of the brain also causes loss of
suppression to an associated/dormant remote area of the brain as per the theory of
Diaschesis. After hemispherectomy the inhibition of the corpus callosum is stopped,
hence the ipsilateral pathways can open up. Also existent is an overall hyperexcitability
(also increase in neuromodulators and neurotrophins) noted after such cortical insult. This
overall hyperexcitability helps neuroplasticity.

The theory of vacariation proposes relocalization of damaged area function by

reorganization of another area of the brain. The premotor cortex, supplementary motor
cortex or motor cortex along with abnormal corticospinal projections on the unaffected
side are areas of learned motor activity and can act as substrates to take on motor function
of the affected hemisphere. For this recruitment to take place, cerebral cortical horizontal
fibers play a pivotal role. By extending several millimeters, its modulating capacity
extends across several columns of neurons, providing prexistant information for the
emergent functional area. There may be a difference in neural plasticity recruitment as it
is seen more often that the premotor and hence the cortico-reticulospinal pathway is
recruited in acquired disorders, whereas in developmental disorders it is the ipsilateral
motor cortex that is recruited.

This capacity of plasticity has a limiting window of opportunity which is to do with the
end point of plasticity. Plasticity is postulated to occur till 7 years for language, between
5 and 16 years for frontal lobe functions and between 1and 11 years for occipital
functions. The corpus callosum suppressive nature on the ipsilateralcorticalspinal
projections is maximally completed by 10 years of age. This means delay would close the
capacity of plasticity which is needed to reverse postoperative weakness. Early surgery
results in better cognitive outcome by reducing the seizure-induced damage of normal
hemispheric development. Also, in certain hemispheric epilepsy syndromes like
Rasmussen's encephalitis and extensive Sturge Weber syndrome, progressive extensive
hemispheric deficits occur; hence, early hemispherotomy is indicated before maximal
deficit with gains in neurocognitive outcomes. Having said this, gains in neurocognitive
status are possible following hemispherotomy for late onset seizures andin patients with
worsening focal motor deficits as a wide age range has been noted for interhemispheric
transfer of language and motor function. Post hemispherectomy re-organization begins
soon after surgery but can continue for as long as 1 year. Our patient presented with mild
left-sided weakness with intact gross motor and fine motor activity much later than the
stipulated time for plasticity capacity. Such patients are known to be more susceptible to
have significant postoperative weakness. An fMRI, however, showed a complete shift of
the motor function to normal hemisphere. This precluded his chances of postoperative
deterioration.

The exact prevalence of shift of motor and language functions in response to congenital
and acquired insults is not known. Several techniques such as intracarotidamobarbital test
(Wada test), positron emission tomography, fMRI, diffusion tensor imaging (DTI),
transcranial magnetic stimulation (TMS) and near infrared spectroscopy have been used
to assess such shifts in individual patients. Among these, fMRI is the most popular,
considering its wider availability and non-invasive nature. Till the results of careful
longitudinal studies in patients with well-defined lesions and specific deficits are
available, results of fMRI should be interpreted in light of other studies. Specifically, a
combination of fMRI information with DTI fiber tracking or TMS may prove more
accurate for this purpose.

Seizure outcome and cognitive performance appear to be related to the underlying

pathology, being most favorable in those with acquired or progressive pathology when
compared to those with developmental pathology. This is especially true with
hemimegalencephaly where the outcomes are poor due to abnormality in the near-normal
looking hemisphere impairing plasticity. This also seems to be the reason for better motor
outcomes in perinatal strokes as compared to cortical dysplasias. Functional
reorganization following developmental or early acquired hemispheric epileptogenic
lesions may lead to transfer of eloquent (including motor) functions to the normal
hemisphere. Preoperative identification of this element of neuroplasticity using functional
imaging represents an exciting modality in selection of candidates for major hemispheric
procedures.
CASE ANALYSIS

1. What happen to the case?

The patient underwent a right frontoparietal craniotomy and vertical

parasagittal functional hemispherectomy as described by Delalande. Postoperatively,
the patient did not have any worsening of his pre-existing deficits and has been
seizure free for more than a year. Post hemispherectomy re-organization begins soon
after surgery but can continue for as long as 1 year. Our patient had a clear functional
shift to the normal hemisphere seen on fMRI; probably this may explain his good
motor outcome.

2. Declare the signs and symptoms

Intractable seizures since the age of 8 months. He had infantile spasms at the
onset and used to have disabling multiple seizure types: Left focal seizures with
secondary generalization, sudden head and trunk flexion associated with falls and
injuries, and atonic seizures since the age of 2 years. The preoperative seizure
frequency was two to three times per week, mostly in clusters at any time of the day.
He had delayed motor milestones and attained walking at 2 years and language at 3
years. Left hemiparesis was noted at 2 years of age.

3. How was the family affected by what happen or who was affected?
It was the 21 year old male, other than that there was none specified.
4. What kind of treatment was given?

Several techniques such as intracarotidamobarbital test (Wada test),

Functional hemispherectomy, positron emission tomography, diffusion tensor
imaging (DTI), transcranial magnetic stimulation (TMS) and near infrared
spectroscopy have been used to assess such shifts in individual patients. Among
these, fMRI is the most popular, considering its wider availability and non-invasive
nature. Specifically, a combination of fMRI information with DTI fiber tracking or
TMS may prove more accurate for this purpose.