Why am I overwhelmed by bright lights? The behavioural mechanisms of post-stroke visual hypersensitivity.

After stroke, patients can experience visual hypersensitivity, an increase in their sensitivity for visual stimuli as compared to their state prior to the stroke. Candidate behavioural mechanisms for these subjective symptoms are atypical bottom-up sensory processing and impaired selective attention, but empirical evidence is currently lacking. In the current study, we aimed to investigate the relationship between post-stroke visual hypersensitivity and sensory thresholds, sensory processing speed, and selective attention using computational modelling of behavioural data. During a whole/partial report task, participants (51 stroke patients, 76 orthopedic patients, and 77 neurotypical adults) had to correctly identify a single target letter that was presented alone (for 17-100 ms) or along a distractor (for 83ms). Performance on this task was used to estimate the sensory threshold, sensory processing speed, and selective attention abilities of each participant. In the stroke population, both on a group and individual level, there was evidence for impaired selective attention and -to a lesser extent- lower sensory thresholds in patients with post-stroke visual hypersensitivity as compared to neurotypical adults, orthopedic patients, or stroke patients without post-stroke sensory hypersensitivity. These results provide a significant advancement in our comprehension of post-stroke visual hypersensitivity and can serve as a catalyst for further investigations into the underlying mechanisms of sensory hypersensitivity after other types of acquired brain injury as well as post-injury hypersensitivity for other sensory modalities.

Evaluation of different methods used to assess disease activity in rheumatoid arthritis: analyses of abatacept clinical trial data.

OBJECTIVES: To evaluate different methods of reporting response to treatment or disease status for their ability to discriminate between active therapy and placebo, or to reflect structural progression or patient satisfaction with treatment using an exploratory analysis of the Abatacept in Inadequate Responders to Methotrexate (AIM) trial. METHODS: 424 active (abatacept approximately 10 mg/kg) and 214 placebo-treated patients with rheumatoid arthritis (RA) were evaluated. METHOD: of reporting included: (1) response (American College of Rheumatology (ACR) criteria) versus state (disease activity score in 28 joints (DAS28) criteria); (2) stringency (ACR20 vs 50 vs 70; moderate disease activity state (MDAS; DAS28 <5.1) vs low disease activity state (LDAS; DAS28 or=2). More stringent criteria (at least ACR50/LDAS), faster onset (3 visits) of ACR50/LDAS best reflected patient satisfaction (positive LR >10). CONCLUSIONS: The optimal method for reporting a measure of disease activity may differ depending on the outcome of interest. Time to onset and sustainability can be important factors when evaluating treatment response and disease status in patients with RA.

Flemish Normative Data for the Buschke Selective Reminding Test.

The purpose of this study was to provide normative data for a Flemish version of the Buschke Selective Reminding Test (SRT). The SRT allows for the simultaneous analysis of several components of verbal memory, such as short and long term retrieval. The Flemish SRT was administered to 3257 neurologically healthy adults (1627 men and 1630 women, age range = 18-94 years). Effects of age, sex and education on SRT performance were assessed. Results indicate that SRT performance decreased with age and that this decline accelerated in men compared to women. Furthermore, an effect of education was found favoring participants who completed a higher education. Normative data quantified through percentile ranks and stratified by age, sex and education level are provided.

Attentional responses to unattended stimuli in human parietal cortex.

Right-sided parietal lesions lead to lateralized attentional deficits which are most prominent with bilateral stimulation. We determined how an irrelevant stimulus in the unattended hemifield alters attentional responses in parietal cortex during unilateral orienting. A trial consisted of a central spatial cue, a delay and a test phase during which a grating was presented at 9 degrees eccentricity. Subjects had to discriminate the orientation of the grating. The unattended hemifield was either empty or contained a second, irrelevant grating. We carried out a series of functional MRI (fMRI) studies in 35 healthy volunteers (13 men and 22 women, aged between 19 and 30 years) as well as a behavioural and structural lesion mapping study in 17 right-hemispheric lesion patients, 11 of whom had neglect. In the patients with but not in those without neglect, the addition of a distractor in the unattended hemifield significantly impaired performance if attention was directed contralesionally but not if it was directed ipsilesionally. In the healthy volunteers, we discerned two functionally distinct areas along the posterior-anterior axis of the intraparietal sulcus (IPS). The posterior, descending IPS segment in both hemispheres showed attentional enhancement of responses during contralateral attentional orienting and was unaffected by the presence of an irrelevant stimulus in the ignored hemifield. In contrast, the right-sided horizontal IPS segment showed a strong attentional response when subjects oriented to a stimulus in the relevant hemifield and an irrelevant stimulus was simultaneously present in the ignored hemifield, compared with unilateral stimulation. This effect was independent of the direction of attention. The symmetrical left-sided horizontal IPS segment showed the highest responses under the same circumstances, in combination with a contralateral bias during unilateral stimulation conditions. None of the six patients without neglect had a lesion of the horizontal IPS segment. In four of the 11 neglect patients, the lesion overlapped with the horizontal IPS activity cluster and lay in close proximity to it in another four. The remaining three patients had a lesion at a distance from the parietal cortex. Our findings reconcile the role of the IPS in endogenous attentional control with the clinically significant interaction between direction of attention and bilateral stimulation in right parietal lesion patients. Functional imaging in neglect patients will be necessary to assess IPS function in those cases where the structural lesion spares the middle IPS segment.

Temporal and spatial resolution in foveal vision of multiple sclerosis patients.

Deficits of spatial and temporal resolution were compared in a group of 49 definite multiple sclerosis(MS) patients showing no major evidence of previous optic neuritis attack but representative of the population of the Belgian National MS Centre as to age and the most important disease variables. Resolution in the two domains was measured foveally with forced-choice staircase psychophysical procedures using Landoldt C and double flash stimuli, respectively. The two measurements were equally sensitive to MS-induced deficits and did not exhibit cross-sensitivity. Since discrete deficits of either kind were equally prevalent and outnumbered combined deficits, this suggests a nonselective but nonuniform destruction of M and P visual pathway function in these patients.

Temporal resolution deficits in the visual fields of MS patients.

We assessed the relationship between temporal resolution and MS-induced neuropathy. A diagnostic strategy comprising assessments of temporal resolution at 16 points in the extra-foveal visual field up to 12 degrees from the fovea was first compared with foveal temporal resolution and with a standard VEP procedure in the same MS patients. At the group level, foveal temporal resolution was less sensitive to demyelination than the 16-point diagnostic strategy, the detection rate of which was comparable to that of the VEP procedure. Cross-sensitivity of the VEP and the 16-point diagnostic procedure was low. Subsequently, the average severity of MS-induced temporal resolution deficits was studied at three retinal loci of the same size but different eccentricities. Foveal deficits were not significantly greater than more peripheral deficits within the central 12 degrees.

Postural abnormalities and contraversive pushing following right hemisphere brain damage.

We investigated the presence of postural abnormalities in a consecutive sample of stroke patients, with either left or right brain damage, in relation to their perceived body position in space. The presence or absence of posture-related symptoms was judged by two trained therapists and subsequently analysed by hierarchical classes analysis (HICLAS). The subject classes resulting from the HICLAS model were further validated with respect to posture-related measurements, such as centre of gravity position and head position, as well as measurements related to the postural body scheme, such as the perception of postural and visual verticality. The results of the classification analysis clearly demonstrated a relation between the presence of right brain damage and abnormalities in body geometry. The HICLAS model revealed three classes of subjects: The first class contained almost all the patients without neglect and without any signs of contraversive pushing. They were mainly characterised by a normal body axis in any position. The second class were all neglect patients but predominantly without any contraversive pushing. The third class contained right brain damaged patients, all showing neglect and mostly exhibiting contraversive pushing. The patients in the third class showed a clear resistance to bringing the weight over to the ipsilesional side when the therapist attempted to make the subject achieve a vertical posture across the midline. The clear correspondence between abnormalities of the observed body geometry and the tilt of the subjective postural and visual vertical suggests that a patient's postural body geometry is characterised by leaning towards the side of space where he/she feels aligned with an altered postural body scheme. The presence of contraversive pushing after right brain damage points in to a spatial higher-order processing deficit underlying the higher frequency and severity of the axial postural abnormalities found after right brain lesions.

Contraversive pushing and inattention of the contralesional hemispace.

The aim of this study was to investigate, in 114 stroke patients, the frequency of occurrence of a largely unknown neurological disorder, characterized by a postural imbalance due to a 'pushing away' reaction of the body towards the contralesional side of space, in function of hemispheric lesion localization and gender. The study also investigate the relation of this contraversive pushing with active movement, somatosensory perception deficits and, in particular, inattention of contralesional hemispace and body. The similarity of the presence of contraversive pushing and the syndrome of spatial hemineglect together with a gender-related differentiation suggest the existence of a "pusher syndrome", in which the pathophysiology points in the direction of a spatial higher-order processing deficit, related to spatial inattention, underlying the higher frequency and severity of contraversive pushing after right brain lesions.

Upper limb exteroceptive somatosensory and proprioceptive sensory afferent modulation of hemispatial neglect.

In many paradigms of stimulation techniques aimed at reducing hemispatial neglect, somatosensory and proprioceptive stimulation are often interchanged, although the anatomical and functional pathways transmitting these signals are clearly different. Therefore, we have investigated the effects of one somatosensory stimulation technique, the cyclic pressure application (CPA), and have compared them with the effects of left transcutaneous electrical stimulation (TENS) on the expression of left hemispatial neglect in 13 stroke patients, as assessed by two visuospatial exploration tasks: the Star Cancellation task and Schenkenberg's Line Bisection task. In a first experiment, four treatment conditions were given: TENS, CPA, TENS + CPA, as well as a placebo condition. For each patient, the intensity of the TENS was determined, based on his/her conscious somatosensory threshold for the electrical impulses. In order to determine whether unconscious proprioceptive afferent information instead of exteroceptive somatosensory stimulation is a sufficient condition to improve hemispatial neglect, we carried out a second experiment, only with patients suffering from complete somatosensory loss. The effects of the different treatments were investigated, using the same sequence as for Experiment 1, but, this time, the applied intensity of TENS was manipulated over two conditions : (1) one in which the intensity of TENS stimulation was below the motor (proprioceptive) threshold and (2) one in which the intensity was determined following the degree of proprioceptive stimulation demonstrated by the point at which a visible muscle contraction during the stimulation could be elicited. The results demonstrated that proprioceptive-based TENS stimulation is a sufficient condition to reduce hemispatial neglect, even when a severe somatosensory loss was present.

Visuoperceptual impairment in MS patients: nature and possible neural origins.

Failures on visuoperceptual neuropsychological tasks (on neuropsychological tests of visuo-spatial perception or on tests concerning semantic properties of visual objects), may indicate focal deficits of visuoperceptual function, or could be the result of (an)other (peripheral) visual deficit(s), or be the effect of a more general cognitive decline. In multiple sclerosis (MS) patients exhibiting sufficient visual acuity and not showing severe cognitive deterioration, impairment on a comprehensive set of 31 visuoperceptual neuropsychological tasks was compared with spatial resolution deficits (SRD), temporal resolution deficits (TRD) for visual stimuli, abnormal pattern shift visual evoked potential (PSVEP) responses, and failing scores on neuropsychological tasks other than visuoperceptual tasks. Impairment on the visuoperceptual neuropsychological tasks was highly independent from the other abnormal visual and cognitive neurological impairments examined, suggesting that it mostly represented focal deficits. Only TRD in both eyes related to this impairment and this relationship was rather weak. Thus in some MS patients a slowed visual information processing may be one of the combined deficits underlying visuoperceptual neuropsychological task impairment. Given that SRD and TRD were not related to another stage of MS and reflect disturbances of a P (parvocellular channel and ventral stream projections) and M (magnocellular channel and dorsal stream projections) visual-system function respectively, demyelination of a certain M pathway may become a co-determinant of visuoperceptual neuropsychological task impairment more rapidly than damage to a certain P pathway.

Visuoperceptual impairment in multiple sclerosis patients diagnosed with neuropsychological tasks.

A comprehensive set of 31 binocular neuropsychological tasks assessing a series of spatial and non-spatial visuoperceptual abilities was used to study visuoperceptual impairment in a representative group of 49 MS-clinic patients exhibiting neither diagnosed ophthalmological afflictions nor major psychiatric diagnoses. Among these patients, true frequency rate of visuoperceptual impairment, i.e. of subjects failing four or more tasks, was estimated at 26%. The pattern of visuoperceptual impairment was non-uniform, non-selective, restricted and idiosyncratic. Only four tasks yielded significant rates of impairment. They concerned colour discrimination, the perception of the Müller-Lyer illusion and object recognition in two separate conditions. Each of the four factors identified by factor analysis had an important representative (with factor loading >0.35) among these four tasks. Failures on these tasks correlated poorly. Together, the four tasks satisfactorily predicted visuoperceptual impairment as defined by the comprehensive set of tasks (sensitivity 86.7%; specificity 81.3%), but with regard to an uncontaminated criterion, their aggregate sensitivity and specificity was only 75 and 56% respectively. Visuoperceptual neuropsychological task performance related significantly but weakly to cognitive status, physical disability and to pyramidal, cerebellar and brain stem neurological signs, and did not correlate with other clinical neurological signs, disease duration, type of MS, a history of optic neuritis, depression or medication status Multiple Sclerosis (2000) 6 241 - 254