Preexisting cerebral microbleeds on susceptibility-weighted magnetic resonance imaging and post-thrombolysis bleeding risk in 392 patients.

BACKGROUND AND PURPOSE: The question whether cerebral microbleeds (CMBs) visible on MRI in acute stroke increase the risk for intracerebral hemorrhages (ICHs) or worse outcome after thrombolysis is unresolved. The aim of this study was to analyze the impact of CMB detected with pretreatment susceptibility-weighted MRI on ICH occurrence and outcome. METHODS: From 2010 to 2013 we treated 724 patients with intravenous thrombolysis, endovascular therapy, or intravenous thrombolysis followed by endovascular therapy. A total of 392 of the 724 patients were examined with susceptibility-weighted MRI before treatment. CMBs were rated retrospectively. Multivariable regression analysis was used to determine the impact of CMB on ICH and outcome. RESULTS: Of 392 patients, 174 were treated with intravenous thrombolysis, 150 with endovascular therapy, and 68 with intravenous thrombolysis followed by endovascular therapy. CMBs were detected in 79 (20.2%) patients. Symptomatic ICH occurred in 21 (5.4%) and asymptomatic in 75 (19.1%) patients, thereof 61 (15.6%) bleedings within and 35 (8.9%) outside the infarct. Neither the existence of CMB, their burden, predominant location nor their presumed pathogenesis influenced the risk for symptomatic or asymptomatic ICH. A higher CMB burden marginally increased the risk for ICH outside the infarct (P=0.048; odds ratio, 1.004; 95% confidence interval, 1.000-1.008). CONCLUSIONS: CMB detected on pretreatment susceptibility-weighted MRI did not increase the risk for ICH or worsen outcome, even when CMB burden, predominant location, or presumed pathogenesis was considered. There was only a small increased risk for ICH outside the infarct with increasing CMB burden that does not advise against thrombolysis in such patients.

Theta burst stimulation reduces disability during the activities of daily living in spatial neglect.

Left-sided spatial neglect is a common neurological syndrome following right-hemispheric stroke. The presence of spatial neglect is a powerful predictor of poor rehabilitation outcome. In one influential account of spatial neglect, interhemispheric inhibition is impaired and leads to a pathological hyperactivity in the contralesional hemisphere, resulting in a biased attentional allocation towards the right hemifield. Inhibitory transcranial magnetic stimulation can reduce the hyperactivity of the contralesional, intact hemisphere and thereby improve spatial neglect symptoms. However, it is not known whether this improvement is also relevant to the activities of daily living during spontaneous behaviour. The primary aim of the present study was to investigate whether the repeated application of continuous theta burst stimulation trains could ameliorate spatial neglect on a quantitative measure of the activities of daily living during spontaneous behaviour. We applied the Catherine Bergego Scale, a standardized observation questionnaire that can validly and reliably detect the presence and severity of spatial neglect during the activities of daily living. Eight trains of continuous theta burst stimulation were applied over two consecutive days on the contralesional, left posterior parietal cortex in patients suffering from subacute left spatial neglect, in a randomized, double-blind, sham-controlled design, which also included a control group of neglect patients without stimulation. The results showed a 37% improvement in the spontaneous everyday behaviour of the neglect patients after the repeated application of continuous theta burst stimulation. Remarkably, the improvement persisted for at least 3 weeks after stimulation. The amelioration of spatial neglect symptoms in the activities of daily living was also generally accompanied by significantly better performance in the neuropsychological tests. No significant amelioration in symptoms was observed after sham stimulation or in the control group without stimulation. These results provide Class I evidence that continuous theta burst stimulation is a viable add-on therapy in neglect rehabilitation that facilitates recovery of normal everyday behaviour.

Glutathione peroxidase overexpression causes aberrant ERK activation in neonatal mouse cortex after hypoxic preconditioning.

BACKGROUND: Preconditioning of neonatal mice with nonlethal hypoxia (HPC) protects the brain from hypoxic-ischemic (HI) injury. Overexpression of human glutathione peroxidase 1 (GPx1), which normally protects the developing murine brain from HI injury, reverses HPC protection, suggesting that a certain threshold of hydrogen peroxide concentration is required for activation of HPC signaling. METHODS: Activation (phosphorylation) of extracellular-regulated kinase (ERK) 1/2 and Akt, and induction of hypoxia-inducible factor (HIF)-1α were assessed in the cortex, one of the main structures affected by HI and protected by HPC, at different time points after reoxygenation in wild-type (WT) and GPx1-overexpressing animals. RESULTS: GPx1 overexpression prevented both the global and nuclear increase in activated ERK at 0.5 h after HPC and caused a significant decrease in phospho-ERK (pERK)/ERK levels at 24 h after HPC. In contrast, HIF-1α induction at the end of hypoxia was unaffected by GPx1 overexpression. In the cortex of preconditioned WT animals, enhanced pERK staining was primarily observed in neurons and to a lower extent in astrocytes and endothelial cells, with a nuclear prominence. CONCLUSION: Aberrant activation of ERK probably explains the paradoxical reversal of HPC protection by GPx1 overexpression. The results identify hydrogen peroxide as an important mediator of neuroprotective ERK signaling.

Pure optic ataxia and visual hemiagnosia - extending the dual visual hypothesis.

Goodale and Milner's two visual system hypothesis is an influential model for the understanding of the primate visual system. Lesions of either the ventral (occipito-temporal) or the dorsal (occipito-parietal) stream produce distinct and dissociated syndromes in humans: visual agnosia is typical for ventral damage, whereas optic ataxia (OA) for dorsal damage. We studied the case of a 59-year-old left-handed woman with a circumscribed lesion around the left posterior occipital sulcus, extending to the underlying white matter. Initially, she presented with a central visual field OA, which regressed to an OA to the right visual hemifield during the 3 months observation period. In addition, tachistoscopic experiments showed visual hemiagnosia to the right visual hemifield. In line with the findings of the neuropsychological experiments, the analysis of the structural MR data by means of a trackwise hodologic probabilistic approach revealed damage to the left superior longitudinal fasciculus and to the left inferior longitudinal fasciculus, indicating an impairment of both the dorsal and the ventral stream. The combination of OA and visual hemiagnosia in the same patient has never been previously described. The present case study thus provides further insights for the understanding of visual processing.

The influence of reading direction on hemianopic reading disorders.

UNLABELLED: Hemianopic reading impairment is a consequence of a visual field defect to either the right or the left side and is characterized by an increased reading time and reduced reading performance. Depending on the side of the visual field defect, reading will be affected differently: Patients suffering from a visual field defect to the right side have noticeable difficulties in reading fluently with slowing. Patients suffering from a visual field defect to the left usually struggle to find the beginning of a line and read more fluently. It was suggested in the literature that changing the reading direction from horizontal to vertical may be a training strategy to reduce reading problems in patients with hemianopia. The aim of the study was to investigate the influence of reading direction on reading speed in patients with left- or right-sided visual field defects and in healthy controls. METHOD: In 13 patients with hemianopia and in 13 age-matched controls, reading speed was calculated for texts in standard as well as in clockwise rotated orientation of 90, 180, and 270°. RESULTS: In both groups, text rotation reduced reading speed compared to standard reading. Patients with left-sided hemianopia had the greatest reduction after text rotation. Patients with right-sided hemianopia had the smallest speed reduction in 90° vertically rotated texts. CONCLUSIONS: Text rotation has different effects in left- or right-sided hemianopia patients. For patients with left-sided heminanopia, rotation of the text may not be a helpful training strategy, for right-sided hemianopia vertical rotation of the text of 90° may be a beneficial training strategy to reduce reading deficits.

Anosognosia for cerebral achromatopsia--a longitudinal case study.

Cerebral achromatopsia is a rare disorder of colour vision caused by bilateral damage to the occipito-temporal cortex. Patients with cerebral achromatopsia are commonly said to suffer due to their disturbed colour sense. Here, we report the case of a patient with cerebral achromatopsia who was initially unaware of his deficit, although three experiments with eye movement recordings demonstrated his severe inability to use colour information in everyday tasks. During two months, the evolution of his colour vision deficit was followed with repeated standardized colour vision tests and eye movement recordings. While his performance continuously improved, he became more and more aware of the deficit. Only after colour vision had almost normalized, his subjective colour sensation was inconspicuous again. The simultaneous occurrence of achromatopsia and the corresponding anosognosia and their parallel recovery suggest that both deficits were due to dysfunction of the same brain region. Consequently, the subjective experience of colour loss in achromatopsia may depend on the residual function of the damaged colour centre.

Linking physiology with behaviour: Functional specialisation of the visual field is reflected in gaze patterns during visual search.

Based on neurophysiological findings and a grid to score binocular visual field function, two hypotheses concerning the spatial distribution of fixations during visual search were tested and confirmed in healthy participants and patients with homonymous visual field defects. Both groups showed significant biases of fixations and viewing time towards the centre of the screen and the upper screen half. Patients displayed a third bias towards the side of their field defect, which represents oculomotor compensation. Moreover, significant correlations between the extent of these three biases and search performance were found. Our findings suggest a new, more dynamic view of how functional specialisation of the visual field influences behaviour.