A Neuropsychiatric and Neuroimaging Study of Unilateral and Bilateral Striatal Ischemic Lesions.

OBJECTIVE: Neuropsychiatric disorders after striatal territory stroke have not been studied systematically. The investigators aimed to study the spectrum of cognitive and behavioral disorders following striatal infarcts. METHODS: Different aspects of cognitive functions, including executive, frontal lobe, memory, visuospatial, language, and semantic processing, were assessed among patients with striatal infarct. Structural MRI data sets were obtained 3 months after stroke to delineate affected territories of the striatum. MRIcroGL software was used to acquire multiple layers of images, generate volume renderings, and draw volumes of interest. To determine the brain locus most frequently affected in patients with distinct cognitive disorders, ischemic area distributions in patients with cognitive dysfunction versus those without cognitive impairment were contrasted. RESULTS: Among 60 patients in this study, six different striatal infarction types were significantly associated with seven different cognitive categories (p<0.001). Unilateral caudate lesion was characterized by attention, planning, and executive disorders (38%), and unilateral lentiform infarct was characterized by executive (36%) and frontal (36%) dysfunctions. Bilateral caudate infarcts caused impairments in frontal and executive functions (75%), as well as in autobiographical (50%) and episodic (50%) memory. In those with bilateral caudate plus lentiform infarcts, all components of frontal and executive functions were dramatically impaired. The anteromedial striatum was affected more frequently in patients with language impairment compared with patients with other types of cognitive dysfunction (p<0.001). CONCLUSIONS: Following striatal stroke, a wide range of frontal-like cognitive impairments occurred, along with impaired working memory, declarative memory, executive function, speech fluency, and motor function.

Cognitive and Behavioral Disorders in Patients with Superior Parietal Lobule Infarcts.

BACKGROUND/OBJECTIVE: The superior parietal lobule (SPL) plays a strategic role in somatosensory and visuomotor integration. This study aims to evaluate the clinical, neurocognitive, and behavioral characteristics of isolated SPL stroke. METHODS: We assessed neuropsychological and behavioral findings in 14 patients with isolated SPL stroke among 4200 patients with ischemic stroke. All patients underwent neuroimaging, clinical and neuropsychological assessment after stroke. RESULTS: Of the 14 patients enrolled, the first complaints were tactile and visuospatial disorders at stroke onset. Except for 6 patients with only 1 cognitive impairment, the majority of patients (57%) experienced more than 1 cognitive impairment category. Functional hemispheric asymmetries have been found in different cognitive processes, such as between visuospatial and body image functions and language process. Among visuospatial abilities disorders, spatial disorientation, visuospatial neglect, and visual extinction were found in two-thirds (63%) of patients with right SPL lesion. Body schema and image disorders were observed in all patients with right-sided lesions, such as alien hand, autotopagnosia for body parts (36%), autotopagnosia for sensory sensations (36%), and fading limb (21%). Two-thirds (57%) of patients with left SPL had impairment in language abilities. CONCLUSION: Our findings after stroke suggest that SPL plays a pivotal role in the regulation of visuospatial abilities, body schema and body image processing, and language skills through bilateral frontoparietal networks and interhemispheric parietal networks.

Exploring Cognitive Impairment in Patients With Bilateral Capsular Genu Lesions.

OBJECTIVE: The authors investigated for presence of cognitive impairment after occurrence of bilateral lesions of the genu of the internal capsule (GIC). Clinical and neuropsychological features of unilateral GIC lesions have previously been studied, but the cognitive profile of bilateral lesions of the GIC has not been fully explored. METHODS: An investigation was conducted of neurocognitive deficits and computerized tomography MRI findings among 4,200 stroke patients with bilateral GIC involvement who were admitted to the hospital between January 2010 and October 2018. RESULTS: Eight patients with bilateral lesions of the capsular genu were identified and their data analyzed. Overall, behavioral and cognitive dysfunction were characterized by impairment of frontal, memory, and executive functions. Attention and abstraction were present among all eight patients (100%); apathy, abulia, and executive dysfunctions, among seven (87.5%); global mental dysfunction and planning deficits, among six (75.0%); short-term verbal memory deficits and language dysfunctions, among five (62.5%); long-term verbal memory deficits, among four (50.0%); and spatial memory deficits, reading, writing, counting dysfunctions, and anarthria, among two (25.0%). Four of the patients (50.0%) without a history of cognitive disorder showed severe mental deterioration compatible with the clinical picture of dementia. A clinical picture of dementia was still present in these patients 6 months after stroke. CONCLUSIONS: Bilateral lesions of the capsular genu appearing either simultaneously or at different times were significantly associated with executive dysfunctions.

The Clinical and Cognitive Spectrum of Artery of Percheron Infarction: 1-Year Follow-Up.

OBJECTIVE: Survivors of patients with artery of Percheron infarction (API) often have a prolonged and disabling form of cognitive impairment that remains insufficiently characterized. We aimed to examine the clinical and cognitive features of API in the short and long term after stroke. METHODS: We reviewed 6400 patients with a first-ever stroke included in the Stroke Registry between 2011 and 2021. The diagnosis of API was based on clinical diagnosis and imaging confirmation. All patients underwent neuropsychological assessment at hospital stay and 1 year after stroke. A z-score of each patients' cognitive test point was calculated, and a z-score inferior to 2 was considered as pathological. RESULTS: Of the 10 patients enrolled, all had cognitive impairment, consciousness, and behavioral disorders at stroke onset. Six patients had pure bilateral thalamic involvement while four had bilateral thalamic and rostral midbrain involvement. At 12 months, 50% of patients had global mental state scores 2 SD below the population mean (z-score mean ± SD, -2.17 ± 0.4). Most of the prefrontal cortex cognitive processes including executive functions such as planning and cognitive control (z-score mean ± SD, -3.92 ± 0.3), processing speed (-4.42 ± 0.5), working memory (-3.97 ± 0.3) were severely impaired at stroke onset. Especially in patients with thalamic and rostral midbrain involvement, deficiencies in executive function (z-score mean ± SD, -2.60 ± 0.4), processing speed (-2.22 ± 0.5), working (-3.76 ± 0.4), and episodic memory (-2.23 ± 0.3) continued 12 months after stroke. CONCLUSIONS: The occlusion of the artery of Percheron results in severe behavioral and cognitive disorders in the short and long term after stroke.

Associations Between Neuroanatomic Patterns of Cerebral Infarctions and Vascular Dementia.

OBJECTIVE: A history of multiple cerebral infarctions is generally regarded as an important risk factor for vascular dementia. The authors examined the risk of vascular dementia in patients with multiple acute ischemic lesions. METHODS: The authors conducted a hospital-based prospective study of 11,200 patients with first-time stroke who underwent 1.5 or 3-T MRI and a global cognitive assessment. Univariate and multivariate logistic regression analyses estimated the risk of dementia associated with multiple lesions versus a single lesion. RESULTS: Having multiple lesions, compared with having a single lesion, was significantly associated with dementia in patients with stroke (odds ratio=5.83, 95% CI=5.08, 6.70; p<0.001). The apoliproprotein ε4 allele was more frequent in patients with multiple lesions than in those with a single lesion (odds ratio=1.70, 95% CI=1.39, 2.07; p<0.001). Severe leukoaraiosis (odds ratio=15.77, 95% CI=8.38, 29.68; p<0.001) and microbleedings (odds ratio=1.31, 95% CI=1.06, 1.63; p<0.01) were strong confounders for dementia in the multivariate analysis. Multiple logistic regression analysis showed that multiple lesions in one hemisphere versus a single lesion (odds ratio=2.14, 95% CI=1.83, 2.51; p<0.001), involvement of strategic regions (odds ratio=4.73, 95% CI=4.07, 5.49; p<0.001), and stroke lesion volume (odds ratio=1.31, 95% CI=1.03, 1.66; p=0.03) were significantly associated with dementia. There was a preponderance of lesions on the left side in patients with dementia (odds ratio=2.56, 95% CI=2.11, 3.11; p<0.001). CONCLUSIONS: Multiple spontaneous anterior or posterior circulation lesions after stroke increase a patient's risk of developing dementia. Recognition of multiple ischemic lesions after stroke may allow targeted rapid therapeutic interventions to prevent subsequent cognitive deterioration.

Cognitive and Behavioral Disorders in Patients with Precuneal Infarcts.

OBJECTIVE: Ischemic stroke of the precuneal cortex (PC) alone is extremely rare. This study aimed to evaluate the clinical, neurocognitive, and behavioral characteristics of isolated PC infarcts. METHODS: We assessed neuropsychological and behavioral findings in 12 patients with isolated PC infarct among 3,800 patients with ischemic stroke. To determine the most frequently affected brain locus in patients, we first overlapped the ischemic area of patients with specific cognitive disorders and patients without specific cognitive disorders. Second, we compared both overlap maps using the "subtraction plot" function of MRIcroGL. RESULTS: Patients showed various types of cognitive disorders. All patients experienced more than 1 category of cognitive disorder, except for 2 patients with only 1 cognitive disorder. Lesion topographical analysis showed that damage within the anterior precuneal region might lead to consciousness disorders (25%), self-processing impairment (42%), visuospatial disorders (58%), and lesions in the posterior precuneal region caused episodic and semantic memory impairment (33%). The whole precuneus is involved in at least one body awareness disorder. The cause of stroke was cardioembolism in 5 patients (42%), large artery disease in 3 (25%), and unknown in 4 (33%). CONCLUSIONS: This study showed a wide variety of neuropsychological and behavioral disorders in patients with precuneal infarct. Future studies are needed to achieve a proper definition of the function of the precuneus in relation to the extended cortical areas. PC region infarcts have been found to predict a source of embolism from the large arteries or heart.

Predictors of Outcome in Patients with Medullary Hemorrhage.

BACKGROUND: Isolated medullary hemorrhage (MH) is an uncommon presentation of spontaneous intraparenchymal hemorrhage. The relationship between MH and neurological outcome is not well known. This study aims to assess predictive parameters for the outcome of medullary hemorrhage. METHODS: We conducted an extensive search of the literature for cases with spontaneous, isolated MH. The study was conducted according to the statement of Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA). Forty-three cases diagnosed by CT or MRI have been reported in the literature, to which we add three confirmed by MRI. The ventrodorsal size of hemorrhage was taken into account as a parameter of outcome. Early neurologic deterioration (END) was defined as an incremental increase in the National Institutes of Health Stroke Scale score by ≥1 point in motor power, or ≥2 points in the total score within the first week after admission. Modified Rankin Score (mRS) 0-2 was presumed as favorable outcome (FO) and mRS 3-6 score as unfavorable outcome (UO) at discharge and at 3 months after stroke. RESULTS: We enrolled 46 patients, and 17 (37%) patients were diagnosed with END. The cause of medullary hemorrhage was mostly vascular malformations, including cavernous malformation (33%) and arteriovenous malformation (11%). In univariate analyses, neither arteriovenous malformations (OR, 1.04; 95%CI, 0.10-10.53; P = 0.68) nor cavernomas (OR, 1.04; 95%CI, 0.22-4.89; P = 0.62) were associated with UO. Acute respiratory distress syndrome was higher in patients with UO group (44%) compared to those with FO group (16%), but this difference did not reach to a significant level (OR, 4.13; 95%CI, 0.85-20.04; P = 0.09). The diameter of hemorrhage was significantly larger (≥1 cm) in patients with UO compared to those with FO (OR, 16.67; 95%CI, 1.87-148.89; P = 0.003). Three months after stroke, 37 patients (80%) had FO and 9 (19.5%) had UO, and 5 (11%) died. Multiple logistic regression analysis using predetermined variables found to be significant in univariate analyses (END, consciousness disturbance at admission, hemorrhage size, and hypertension) showed that END at stroke onset was significantly associated with UO (OR, 4.97; CI95%, 1.13-21.94; P = 0.03). CONCLUSIONS: These results suggest that the END is a predictor for UO in patients with medullary hemorrhage. The extent of the medullary hemorrhage along the conduction tract may contribute to deterioration.

Association of Hyperhomocysteinemia with Stroke Recurrence after Initial Stroke.

BACKGROUND AND PURPOSE: Homocysteine (Hcy) is closely associated with stroke. Despite the fact that Hcy has consistently been shown to predict development of recurrent stroke, prior studies on the association of Hcy and stroke subtypes have been inconclusive. METHODS: Data from the Ege Stroke Registry were examined and 5-year follow-up data were analyzed. Multivariate survival analyses were undertaken using Cox proportional hazards models to determine the prognostic value of Hcy in different ischemic stroke subtypes. RESULTS: Of the 9522 patients with stroke, 307 (27%) with hyperhomocysteinemia (hHcy) had recurrent stroke. Univariate Cox regression model showed that hHcy group was associated with recurrent stroke (crude hazard ratio [HR] 1.16; 95% CI 1.02-1.30). But there was no such association in multivariate regression models (adjusted HR 1.11; 95% CI .97-1.26). hHcy was not associated with any ischemic stroke subtypes at 5 years. Univariate Cox regression model showed that hHcy group was associated with overall cardiovascular events (crude HR 1.44; 95% CI 1.32-1.57). However, this association no longer existed in multivariate regression models (adjusted HR 1.01; 95% CI .93-1.12). Higher plasma Hcy group was significantly associated with higher mortality compared with normal plasma Hcy group (OR 1.83; 95% CI .45-2.32). CONCLUSIONS: Our results showed that elevated Hcy is not associated independently with stroke recurrence and overall cardiovascular events in patients with ischemic stroke. There was no association between the hHcy and stroke recurrence in the stroke subtypes within 5 years.

Cognitive Decline in Patients with Leukoaraiosis Within 5 Years after Initial Stroke.

BACKGROUND: Leukoaraiosis (LA) is closely associated with cognitive deficits. The association between LA and cognitive disorders, such as mild cognitive impairment (MCI) and dementia, after initial stroke has not been systematically studied. In this study, we sought to identify whether LA contributes to the occurrence of certain type of cognitive disorders after initial stroke. METHODS: Data from our Stroke Registry were examined, and 5-year follow-up data for LA and cognitive disorders were analyzed. We performed Kaplan-Meier analysis and log-rank test to assess the predictive value of LA for risk of cognitive decline and the Cox proportional hazards model to test the risk factors studied as independent determinants of cognitive impairment. RESULTS: The frequency of patients with normal cognitive function decreased significantly at 5 years compared with initial stroke (78% vs 70%; odds ratio, 1.51; 95% confidence interval, 1.41-1.62). Of 8784 patients, 1659 (19%) had dementia and 964 (11%) had MCI at the final analysis. After 5 years of follow-up, survival analysis showed that all patients with LA had an increased probability of MCI compared with those without LA (P < .0001). Patients with LA had an increased chance of dementia compared with those without LA (P < .0001) at the end of follow-up. Cognitive decline probability was significantly higher in patients with severe LA compared with those with mild/moderate LA (P < .0001). Cox regression analyses showed that recurrence of stroke (hazard ratio [HR], 3.92 [95% CI, 3.26-4.72]), hypertension (HR, 1.11 [95% CI, 1.0-1.22]), LA (HR, 1.15 [95% CI, 1.05-1.25]), age (HR, 1.05 [95% CI, 1.04-1.06]), hypercholesterolemia (HR, .86 [95% CI, .77-.95]), higher LDL cholesterol (HR, 1.21 [95% CI, 1.11-1.32]), lower HDL cholesterol (HR, .90 [95% CI, .83-.98]), coronary heart disease (HR, .85 [95% CI, .77-.94]), and National Institutes of Health Stroke Scale score at admission (HR, .77 [95% CI, .72-.82]) were also significantly associated with cognitive impairments. CONCLUSIONS: Our findings suggest that patients with LA may be at risk of developing new cognitive impairments at long-term period after initial stroke. The evaluation of the concomitant risk factors, besides providing insights about the possible mechanisms behind the cognitive dysfunction present in LA, may be of help for the prevention of cognitive impairments.

Association of leukoaraiosis with stroke recurrence within 5 years after initial stroke.

BACKGROUND: Leukoaraiosis (LA) is closely associated with stroke. Despite the fact that LA has consistently been shown to predict development of recurrent stroke, prior studies on the association of LA and stroke subtypes have been unsatisfactory. In this study, we sought to identify whether LA contributes to the recurrence of certain subtypes of stroke at long term. METHODS: Data from the Ege Stroke Registry were examined, and 5 years follow-up data for LA and stroke recurrence were analyzed. We performed survival curves using the Kaplan-Meier method (unadjusted) and log-rank tests in patients with stroke to determine the relationship between LA and recurrent stroke by stroke subtypes within a time period of 5 years. Multivariate survival analyses were undertaken using Cox proportional hazards models to determine the prognostic value of LA, stroke subtypes, and other vascular risk factors before recurrent stroke. RESULTS: Of 9522 patients with stroke, 1280 (26%) with LA and 901 (19%) without LA experienced a stroke recurrence within 5 years of follow-up (odds ratio, 1.53; 95% confidence interval, 1.39-1.69). After stratification by stroke subtypes, multivariable analysis revealed a significant association between LA and large artery disease (LAD; odds ratio [OR], 1.39; 95% confidence interval [CI], 1.18-1.64), small artery disease (SAD; OR, 1.57; 95% CI, 1.27-1.94), and intracerebral hemorrhage (ICH; OR, 1.88; 95% CI, 1.32-2.66), except cardioembolic stroke and "other" stroke subtypes at 5 years after stroke onset. The survival analysis showed that stroke recurrence was significantly higher in patients with severe LA compared with those with mild/moderate LA (log-rank test [Mantel-Cox], P < .001). CONCLUSIONS: Our results showed that LA is related to the recurrent strokes in patients with stroke within 5 years after stroke, specifically to the LAD, SAD and ICH.

Post-stroke aggressive behavior in patients with first-ever ischemic stroke: underlying clinical and imaging factors.

BACKGROUND: Aggression is defined as a complex behavior consisting of a combination of sensory, emotional, cognitive and motor elements. We aimed to examine the relationships between post-stroke aggressive behavior (PSAB) and neuropsychological and neuroimaging findings. METHODS: 380 patients in the stroke unit were classified as aggressive or non-aggressive based on symptoms elicited by the Neuropsychiatric Inventory (NPI) and aggression screening questionnaire. RESULTS: Aggressive behavior was detected in 42 (11.1%) of 380 patients who had a first ischemic stroke. Patients with PSAB were older than those without (338 patients) (66.98 + 13.68 vs. 62.61 + 13.06, P = 0.043). Hamilton depression and anxiety scales showed significantly higher rates of depression and anxiety in the PSAB group compared to the non-PSAB group (47.6% vs. 16.3% and 57.1% vs. 15.4%, respectively; P = 0.001). Lesion mapping analysis showed that lesions in patients with PSAB mostly included the lower parietal lobe and lateral frontal gyrus. Multiple regression analysis showed that gender (OR, 2.81; CI%, 1.24-6.39), lateral prefrontal infarction (OR, 6.43; CI%, 1.51-27.44), parietal infarction (OR, 2.98; CI%, 1.15-7.76), occipital infarction (OR, 2.84; CI%, 1.00-8.06), multiple infarcts (OR, 5.62; CI%, 2.27-13.93), anxiety (OR, 2.06; CI%, 0.89-4.81) and verbal memory deficit (OR, 4.21; CI%, 1.37-12.93) were significant independent predictors of PSAB. CONCLUSION: The presence of PSAB may be related to neuropsychiatric symptoms such as high anxiety and verbal memory impairment, and neuroanatomical location of the lesions.

Impact of poststroke seizures on neurological deficits: magnetic resonance diffusion-weighted imaging study.

BACKGROUND: The impact of poststroke seizures on the neurological deficits related to ischemic stroke is not well known. It has been reported that following poststroke epilepsy, transient or long-lasting worsening of the poststroke sequelae may develop, but the underlying mechanism of deficit worsening has not been systematically studied by magnetic resonance diffusion-weighted imaging (MRI-DWI). METHODS: From 2008 to 2009, 1,010 ischemic stroke patients were admitted to our stroke unit at the Ege University Hospital with first-time strokes. Of these, 76 (7.5%) patients developed delayed seizures in a follow-up period of 18 months. We extracted the clinical and imaging data of the patients from our Stroke Registry databases and other medical records, and evaluated brain MRI, including spin-echo DWI with apparent diffusion coefficient (ADC) maps, FLAIR and T2-weighted images. RESULTS: There were 15 (20%) patients who had long-lasting worsening of the previous neurological sequelae, which we called long-lasting neurological worsening (LLW); 38 (50%) had transient neurological worsening (TNW) and 23 (30%) were without neurological worsening (WNW) after poststroke seizures. DWI findings were present in 3/23 (13%) patients with simple partial-type seizure, in 4/17 (29%) patients with complex partial-type seizure, and in 7/13 (54%) patients with generalized toni-clonic type seizure (p = 0.002). Patients with LLW showed more frequent changes on DWI than those with TNW (53 vs. 16%; p = 0.009). Forty percent of patients with LLW and 5% of those with TNW had ADC decrease (p = 0.004). Patients with LLW had DWI changes in the occipital region more frequently than those with TNW (57 vs. 18%; p = 0.05). Correlation analysis found a significant association between LLW and DWI changes, multiple DWI lesions, ADC decrease, and recurrent seizures. In the control MRI-DWI 1 month after the poststroke seizure, no signal abnormalities were detected in neuroimaging studies of all patients. Despite no functional outcome differences between the groups before the seizure, the functional scales 1 week after the seizure (National Institutes of Health Stroke Scale, Modified Rankin Scale and Barthel Index) showed significantly worse neurological functional statements in the patients with LLW than those with TNW and WNW (p = 0.001). CONCLUSIONS: Poststroke seizures may affect poststroke sequelae transiently, which we see more often, but some seizure types may prolong the duration of deficits. Multiple DWI changes and LLW following recurrent and longer poststroke seizures were strongly associated, and this may be due to the effect of seizures causing additional metabolical changes.

Prognostic Factors For Functional Outcome in Patients with Mesencephalic Hemorrhage.

Introduction: Mesencephalic hemorrhage (MH) is a rare presentation of spontaneous intraparenchymal hemorrhage. This study aims to evaluate prognostic parameters of the MH outcome. Methods: We conducted an extensive search in the literature for cases with spontaneous, isolated mesencephalic hemorrhage. The study was conducted according to the statement of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Sixty-two eligible cases have been reported in the literature as proven by CT or MRI, and to these, we added six cases confirmed by MRI. The modified Rankin Scale (mRS) was dichotomized into two groups as the favorable outcome (FO; score, 0-2) and unfavorable outcome (UO; score, 3-6). Results: Of the 68 patients studied, 26 (38%) presented with normal consciousness, 22 (32%) with lethargy , and 20 (29%) with stupor or coma. There was no cause of hemorrhage in 26 (65%) patients with FO and 12 (43%) with UO (p=0.059). In univariate analyses, neither arteriovenous malformations (p=0.33) nor cavernomas (p=0.19) were associated with outcome. Multiple logistic regression analysis revealed that hypertension (OR, 51.22; CI95%, 1.92-1370.24; P=0.019), consciousness (OR, 133.54; CI95%, 1.61-1113.3; P=0.03), NIHSS at admission (OR, 57.23; CI95%, 2.87-1141.2; p=0.008), and ventrodorsal hemorrhage size (≥1 cm) (OR, 61.83; CI95%, 2.15-1779.2; p=0.016) were significantly associated with UO. Three months after stroke, 40 patients (59%) had FO, 28 (41%) had UO, and 8 (12%) died. Conclusion: These results suggest that ventrodorsal size of hemorrhage and clinical severity at stroke onset are possible predictors of functional outcome after mesencephalic hemorrhage.

Hyposchematia without spatial neglect in 2 patients with lesions involving the insula.

BACKGROUND: : Hyposchematia is a rare variant of aschematia in which patients underestimate the size of part or all of their body. The term also describes an abnormality in drawing tasks, in which patients underestimate the size of 1 side of an image and draw it too small. Little is known about the neuroanatomy of the syndrome. CASE REPORTS: : We report 2 patients who developed contralateral hyposchematia without spatial neglect after suffering an ischemic lesion involving the right insula. Both patients felt that the left side of their face and their left arm and leg were disproportionately smaller than their right. On a drawing task, both patients drew the left sides of objects smaller than the right; they perseverated on the left sides of the images, for example, adding extra left-sided petals to a daisy. CONCLUSIONS: : In 2 reported patients, the cause of hyposchematia may be a lesion involving multiple insular circuits that affect the perception of extrapersonal space and self-related systems.

The clinical and cognitive spectrum of locked-in syndrome: 1-year follow-up of 100 patients.

In patients with locked-in syndrome (LIS), it is not known exactly to what extent cognitive functions are preserved and it is not known exactly how much it has improved. We aimed to examine the clinical and cognitive features of LIS 1 year after stroke. One hundred patients with locked-in syndrome (LIS) were recruited between January 2008 and May 2019 among 8200 patients with ischemic stroke. Patients were classified into two groups as single pontine infarcts (n = 72), and pontine plus multiple ischemic lesions (PMIL) (n = 28). Since the patients had limited motor and verbal response, the cognitive status of the patients in the early and late stages was evaluated with the Short Neuropsychological Questionnaire for Disabled Patients (SNQDP) test. At the onset of stroke, orientation to time and place was normal in 43% of patients with a single infarct compared with 18% of those with PMIL (OR 3.48; 95% CI 1.10-10.18; P = 0.015). There was no sustained visual fixation or tracking in 53% of patients with a single pontine infarct and 82% of those with PMIL (OR 4.12; 95% CI 1.41-12.02; P = 0.005). After 1-year follow-up, there was significant difference between patients with a single infarct and those with PMIL regarding to perception and execution, especially complex command follow (P = 0.042), attention span and concentration (P = 0.30), intelligible verbalization (P = 0.022). There was relatively high incidence (24%) of patients with a "good outcome" (mRS = 3) in those with single infarct. Given as in our study that many patients can show significant improvement in LIS, we recommend aggressive supportive measures, intense physical, speech and cognitive therapy to facilitate interaction with others and the environment.

Invisible doppelgänger and body image disorders in right superior parietal lobule stroke, a case series.

Autoscopic phenomena or an "invisible doppelgänger" refer to the illusory reduplication of one's own body. Body image disorder involves distorted perception or decreased body awareness. In the literature, feeling of presence (FOP) is rarely presented with a circumscribed cerebral pathology due to acute vascular lesions, and concomitant FOP and disorders of the body image or the body schema (BIBS) have rarely been reported. We present three cases of both FOP and BIBS disorders. All patients reported the two types of symptoms almost simultaneously: The first patient had the symptom of somatoparaphrenia characterized by deny ownership of the hand and feeling that it does not belong to her, the second patient had the sign of fading limb presented with misuse of his left hand when it was not under visual control and could not mentally represent and locate this part of the body in space, and the third patient had autotopagnosia; he was unable to localize any touched area below the elbow and knee. All patients had right parietal ischemic lesions involving the superior parietal lobule, and two patients had an adjacent additional precuneal involvement. Based on the cases presented here, it is plausible that BIBS may develop in addition to FOP, especially in lesions involving the superior parietal lobule and precuneus.

Efficacy of citalopram on stroke recurrence: A randomized clinical trial.

Post-stroke depression is one of the main causes of cerebrovascular and cardiovascular diseases. The aim of the present study was to investigate the efficacy of citalopram on stroke recurrence. A 52-week, randomized, double-blind, studyinvolved 440 ischemic stroke patients with depression. Patients with depression who met depression criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and V) and Hamilton Depression Rating Scale ≥ 8 (HAM-DRS) were dichotomized into patients receiving citalopram (225 patients), titrated according to clinical response, and patients with placebo (215 patients) for 52 weeks. The primary outcome measure was stroke recurrence and the secondary outcome measures were cardiovascular events and mortality. Stroke recurrence (66% vs 34%; P = 0.001) and cardiovascular events (76% vs. 24%; P = o.oo1) were significantly higher in the placebo group compared to those treated with citalopram. Multivariable analysis showed that hypertension, atrial fibrillation, and large-artery disease were significantly associated with stroke recurrence. Executive processing disorder was more associated with stroke recurrence than other neuropsychological disorders (OR, 1.74; CI95%, 1.04-2.89; P = 0.035). Survival analysis showed that treatment for depression interacted with time to reduce stroke recurrence by nearly half (39% vs. 61%; P = 0.05). The current study supports the importance of depression treatment in protecting the patients from recurrent strokes. This result warrants further studies to demonstrate the efficacy of depression treatment on stroke recurrence.

Acute respiratory failure due to unilateral dorsolateral bulbar infarction.

BACKGROUND: Previous clinicopathological studies have reported central hypoventilation alongside unilateral infarcts in the caudal brainstem. As already known, the respiratory centers are located in the medullary and pontine centers. METHODS: We sought patients with acute respiratory failure with brainstem involvement proved by MRI from 4,500 patients with first ischemic stroke consecutively admitted to our stroke unit over a period of 7 years. RESULTS: We report six patients with a unilateral dorsolateral medulla oblongata lesion, completely sparing the corticospinal tract, who presented impairments in automatic and voluntary respiratory movements. Topographical analysis showed involvement of the nucleus and tractus solitarius,nucleus ambiguus and retroambiguus,nucleus reticularis medulla oblongata, and nucleus tractus solitarius. CONCLUSIONS: Our findings provide insight into the central organization of respiratory control in the dorsolateral medulla oblongata in humans, and the importance of critical respiratory management in these patients.

Variants of Avellis Syndrome Due to Medulla Oblongata Infarction: A Case Series.

INTRODUCTION: Avellis syndrome is classically defined as a neurological disorder characterized by paralysis of the soft palate and vocal cords on one side, and a loss of sensation of pain and temperature sense on the other side. Between 2010 and 2020, 5400 patients with ischemic stroke were admitted to the Stroke Unit and prospectively entered in our Stroke Registry. CASE REPORT: A total of 216 patients with magnetic resonance imaging-proven ischemic lesions restricted to the medulla oblongata were identified. Among them, 5 patients had Avellis syndrome with a small medullary infarction. There was paralysis of the soft palate and vocal cords in all patients, but besides of loss of pain sensation and temperature sense, there were also partial disturbances in position and vibration senses in 3 patients. Different types of neuro-ophthalmologic findings were observed in 4 patients. In 5 patients, the cause of medulla oblongata infarct was microscopic polyangiitis vasculitis, neuro-Behçet disease, vertebral artery dissection, small vessel disease, and neurobrucellosis small vessel vasculitis. CONCLUSIONS: Avellis syndrome may present with additional neurological findings besides its classic definition. Apart from atherosclerotic disease, rare causes should be investigated in detail in small ischemic medullary lesions.