Prognostic Prediction of Dysphagia by Analyzing the Corticobulbar Tract in the Early Stage of Intracerebral Hemorrhage.

We investigated the predictive value of the corticobulbar tract (CBT) for dysphagia using diffusion tensor tractography in the early stage of intracerebral hemorrhage (ICH) for dysphagia. Forty-two patients with spontaneous ICH ± intraventricular hemorrhage (IVH) and 22 control subjects were recruited. The patients were classified into three groups: group A-could remove nasogastric tube (NGT) in the acute stage of ICH, group B-could remove NGT within 6 months after onset, and group C-could not remove NGT until 6 months after onset. The CBT were reconstructed, and fractional anisotropy (FA) and tract volume (TV) values were determined. The FA of the CBT in the affected hemisphere in group A was lower than in the control group (p < 0.05). The FA and TV of the CBT in the affected hemisphere in group B were lower than those in the control group (p < 0.05). In group C, the FA and TV in the affected hemisphere and unaffected hemispheres were lower than in the control group (p < 0.05). The TV of the CBT in the affected hemisphere in group B showed a moderate negative correlation with the length of time until NGT removal (r = 0.430, p < 0.05). We found that patients with CBT injuries in both hemispheres were not able to remove the NGT until 6 months after onset, whereas patients who were injured only in the affected hemisphere were able to remove NGT within 6 months of onset. The severity of injury to the CBT in the affected hemisphere appeared to be related to the length of time until NGT removal.

Relationship Between Impaired Consciousness and Injury of Ascending Reticular Activating System in Patients With Intracerebral Hemorrhage.

Background and Purpose- We investigated the relationship between impaired consciousness and ascending reticular activating system (ARAS) characteristics on diffusion tensor tractography during the early stage of spontaneous intracerebral hemorrhage confined to a unilateral supratentorial area. Methods- A total of 29 consecutive patients with impaired consciousness (the patient group A), 31 age- and sex-matched patients without impaired consciousness (the patient group B), and 20 age- and sex-matched healthy control subjects were recruited. The Glasgow Coma Scale was used to evaluate patients' conscious state in the early stage of intracerebral hemorrhage (within 30 days after onset). Three parts of the ARAS (lower dorsal, lower ventral, and upper) were reconstructed, and fractional anisotropy and tract volume values were determined. Results- The tract volume value of the lower dorsal ARAS in the patient group A was significantly lower than those of the patient group B and control group in the affected hemisphere (P<0.05). Among the diffusion tensor tractography parameters, only the tract volume of the lower dorsal ARAS in the affected hemispheres of the patient group A had a moderate positive correlation with Glasgow Coma Scale score (r=0.456; P<0.05). Conclusions- Impaired consciousness during the early stage of intracerebral hemorrhage was closely related to injury of the lower dorsal ARAS in the affected hemisphere. Clinical Trial Registration- URL: http://www.e-irb.com/index.jsp. Unique identifier: 2015-07-064.

Changes of the corticospinal tract in the unaffected hemisphere in stroke patients: A diffusion tensor imaging study.

We investigated changes of the corticospinal tract (CST) in the unaffected hemisphere according to severity of the CST injury, using diffusion tensor imaging (DTI). According to the severity of the CST injury in the affected hemisphere, the stroke patients showed different aspects of fiber volume increment of the CST in the unaffected hemisphere; the fiber volume was increased in the early phase in patients with mild injury of CST and later phase in patients with severe injury of CST.

Difference of injury of the corticospinal tract according to surgical or conservative treatment in patients with putaminal hemorrhage.

OBJECTIVE: We investigated difference of injury of the corticospinal tract (CST) according to surgical or conservative treatment in patients with putaminal hemorrhage (PH), using diffusion tensor tractography (DTT). METHODS: Forty-six patients with PH (hematoma volume on the brain CT: 20-40 ml) were recruited. Patients were classified as the surgical treatment group and the conservative treatment group. The hematoma volume on the initial brain CT (median 2 hours after onset; range 1-14 hours) and volumes of the hematoma, the total lesion and the peri-hematomal edema volume on the follow-up brain magnetic resonance imaging (MRI) (median 23.5 days after onset; range 12-46 days) were estimated. Diffusion tensor imaging was performed and we defined the injury of the CST in terms of the configuration or abnormal DTT parameters. RESULTS: In the conservative treatment group, the total lesion volume on the brain MRI was increased compared with the hematoma volume on the initial brain CT (p < 0.05). On brain MRI, the hematoma volume, peri-hematomal edema volume, and total lesion volume were larger in the conservative treatment group than in the surgical treatment group (p < 0.05). Twelve patients (60%) in the surgical treatment group and 24 patients (92%) in the conservative treatment group had injury of the CST. CONCLUSION: Injury of the CST was less prevalent in the surgical treatment group than in the conservative treatment group in patients with PH. Therefore, it appears that surgical treatment could be helpful in prevention of injury of the CST in patients with PH.

Characteristics of injury of the corticospinal tract and corticoreticular pathway in hemiparetic patients with putaminal hemorrhage.

BACKGROUND: No study on the characteristics of injury of the corticospinal tract (CST) or corticoreticular pathway (CRP) in patients with putaminal hemorrhage has been reported. In this study, using diffusion tensor tractography, we attempted to investigate the characteristics of injury of the CST and CRP in hemiparetic patients with putaminal hemorrhage. METHOD: Fifty seven consecutive patients with putaminal hemorrhage and 57 healthy control subjects were recruited for this study. Diffusion tensor imaging was performed during the early period (8 ~ 30 days) after onset. We defined injury of the CST or CRP in terms of the configuration (discontinuation of a neural tract) or abnormal DTT parameters (the fractional anisotrophy value or fiber number was more than two standard deviations lower than that of normal control subjects). The Motricity Index, the modified Brunnstrom Classification, and the Functional Ambulation Categories were used for evaluation of motor function. RESULTS: Among 57 patients, injury of the CST was found in 41 patients (71.9%) and injury of the CRP was found in 50 patients (87.8%), respectively, and 37 patients (64.9%) had injury of both the CST and CRP. All three motor functions of patients with injury of both the CST and CRP were significantly lower than those of patients with injury of either the CST or CRP (p < 0.05). CONCLUSION: Our results indicate that the putaminal hemorrhage frequently accompanies injury of both the CST and CRP, and the CRP appears to be more vulnerable to putaminal hemorrhage than the CST. These findings suggest the necessity for evaluation of both the CRP and the CST in patients with putaminal hemorrhage.

Imaging follow-up strategy after endovascular treatment of Intracranial aneurysms: A literature review and guideline recommendations.

OBJECTIVE: Endovascular coil embolization is the primary treatment modality for intracranial aneurysms. However, its long-term durability remains of concern, with a considerable proportion of cases requiring aneurysm reopening and retreatment. Therefore, establishing optimal follow-up imaging protocols is necessary to ensure a durable occlusion. This study aimed to develop guidelines for follow-up imaging strategies after endovascular treatment of intracranial aneurysms. METHODS: A committee comprising members of the Korean Neuroendovascular Society and other relevant societies was formed. A literature review and analyses of the major published guidelines were conducted to gather evidence. A panel of 40 experts convened to achieve a consensus on the recommendations using the modified Delphi method. RESULTS: The panel members reached the following consensus: 1. Schedule the initial follow-up imaging within 3-6 months of treatment. 2. Noninvasive imaging modalities, such as three-dimensional time-of-flight magnetic resonance angiography (MRA) or contrast-enhanced MRA, are alternatives to digital subtraction angiography (DSA) during the first follow-up. 3. Schedule mid-term follow-up imaging at 1, 2, 4, and 6 years after the initial treatment. 4. If noninvasive imaging reveals unstable changes in the treated aneurysms, DSA should be considered. 5. Consider late-term follow-up imaging every 3-5 years for lifelong monitoring of patients with unstable changes or at high risk of recurrence. CONCLUSIONS: The guidelines aim to provide physicians with the information to make informed decisions and provide patients with high-quality care. However, owing to a lack of specific recommendations and scientific data, these guidelines are based on expert consensus and should be considered in conjunction with individual patient characteristics and circumstances.

Functional role of the corticoreticular pathway in chronic stroke patients.

BACKGROUND AND PURPOSE: The corticoreticular pathway (CRP) is known to be an important extrapyramidal tract for walking ability. However, little is known about the functional role of the CRP in recovery of walking ability. We investigated relation between the CRP and walking ability in chronic hemiparetic stroke patients. METHODS: Among 209 consecutive patients, 54 patients, who showed complete injury of the corticospinal tract (CST) in the affected hemisphere on diffusion tensor tractography, and 20 normal subjects were recruited. Functional ambulation category was used in measurement of walking ability. The fractional anisotropy value, apparent diffusion coefficient value, and fiber volume of the CRP and CST were used for the diffusion tensor imaging parameters. RESULTS: In the affected hemisphere, no significant difference in diffusion tensor imaging parameters of the CRP was observed between patient subgroups. In the unaffected hemisphere, patients who were able to walk showed significantly increased fiber volume of the CRP, compared with patients who could not walk and normal control subjects (P<0.05), without significant difference in fractional anisotropy and apparent diffusion coefficient values. In addition, the fiber volume of the CRP in the unaffected hemisphere showed positive correlation with functional ambulation category (P<0.05). In contrast, diffusion tensor imaging parameters of the CST in the unaffected hemisphere showed no correlation with functional ambulation category (P>0.05). CONCLUSIONS: The increased fiber volume of the CRP in the unaffected hemisphere seems to be related to walking ability in patients with chronic stroke. Therefore, the compensation of the CRP in the unaffected hemisphere seems to be one of the mechanisms for recovery of walking ability after stroke.

Diffusion tensor imaging findings of optic radiation in patients with putaminal hemorrhage.

OBJECTIVES: Little is known about optic radiation (OR) injury in intracerebral hemorrhage (ICH). We attempted to investigate OR injury in patients with ICH by diffusion tensor imaging (DTI). METHODS: Forty-three consecutive patients with putaminal hemorrhage and 40 normal healthy control subjects were recruited. DTI data were acquired at the beginning of rehabilitation (average 34 days after onset). DTI-Studio software was used to reconstruct the OR. Fractional anisotropies (FA) and fiber numbers of the ORs were measured. FA values and fiber numbers of affected ORs were described as abnormal when they were more than 2.5 SD lower than those of normal controls. RESULTS: Thirty (70%) of the 43 patients showed an OR abnormality in the affected hemisphere. In 13 (30%) patients, the affected OR was disrupted or nonreconstructable. On the other hand, of the 20 patients with preserved OR integrity, 14 (33%) had a low FA value and 3 (7%) a low FA and fiber number. The other 13 (30%) of the 43 patients had no abnormal OR findings. CONCLUSION: Seventy percent of patients showed any abnormality of OR in the affected hemisphere on DTI. This result suggests that patients with putaminal hemorrhage are at high risk of OR injury.

Prediction of motor outcome based on diffusion tensor tractography findings in thalamic hemorrhage.

OBJECTIVES: Little is known about the usefulness of diffusion tensor tractography (DTT) findings of the corticospinal tract (CST) in terms of predicting motor outcome after thalamic hemorrhage. We investigated the predictive value of DTT for motor outcome in patients with thalamic hemorrhage. METHODS: Twenty-one patients were recruited; DTTs were obtained within 7-30 d of thalamic hemorrhage. We determined fractional anisotropies (FAs), tract numbers, and tract lengths of CSTs and calculated affected CST versus unaffected CST ratios for each value. In addition, patients were classified into two groups; a DTT type A group, in which the CST was preserved around the hematoma, and a DTT type B group, in which the CST was interrupted. Six months after thalamic hemorrhage, motor functions of affected sides were evaluated using upper Motricity Index (MI), lower MI, total MI, the modified Brunnstrom classification (MBC) and functional ambulation category (FAC). RESULTS: DTT parameters of CSTs, that is, FA ratios, tract number ratios and tract length ratios of affected/unaffected CSTs were found to be positively correlated with 6-month upper MIs, lower MIs, total MIs, MBCs and FACs. In addition, all motor function scores at 6 months after onset were higher in the DTT type A group than in the DTT type B group. CONCLUSIONS: Early DTT evaluation of CSTs appears to be useful for predicting motor outcomes of affected extremities at chronic stage in patients with thalamic hemorrhage.

The effects of hydrocephalus on the periventricular white matter in intracerebral hemorrhage: a diffuser tensor imaging study.

OBJECTIVES: Many diffusion tensor imaging (DTI) studies have described the effects of hydrocephalus on periventricular white matter in patients with normal pressure hydrocephalus. However, little is known about hydrocephalus following stroke. We investigated the effect of hydrocephalus on periventricular white matter in patients with hydrocephalus after an intracerebral hemorrhage (ICH) using DTI. METHODS: Fourteen patients with ICH and hydrocephalus, and 17 age- and sex-matched normal control subjects were recruited. DTI parameters were estimated in six regions of interest (ROIs) in periventricular white matter: the anterior corona radiata, the posterior corona radiata, the genu of the corpus callosum, the splenium of corpus callosum, the anterior limb of the internal capsule, and the posterior limb of the internal capsule. RESULTS: Mean fractional anisotropy of the anterior corona radiata in patients was significantly higher than in controls (p < 0.05), but apparent diffusion coefficient (ADC) was not different in the two groups (p > 0.05). No significant differences between fractional anisotropies and ADCs were observed in the other five ROIs (p > 0.05). CONCLUSIONS: The anterior corona radiata was found to be more compressed by hydrocephalus than the other five regions of periventricular white matter examined in patients with hydrocephalus following ICH. It is believed that the results of the present study will be useful for the diagnosis and management of hydrocephalus following stroke.

Treatment for subarachnoid hemorrhage due to ruptured posterior cerebral arterial dolichoectasia with aortic arch anomaly.

Subarachnoid hemorrhage (SAH) due to ruptured posterior cerebral artery (PCA) intracranial arterial dolichoectasia (IADE) is very rare. As these lesions are difficult to treat microsurgically, neurointervention is preferred because the dolichoectatic artery does not have a clear neck, and the surgical field of view was deep seated with the SAH. However, in some cases, neurointervention is difficult due to anatomical variation of the blood vessel to access the lesion. In this case, a 30-year-old male patient presented with a ruptured PCA IADE and an aortic arch anomaly. Aortic arch anomalies render it difficult to reach the ruptured PCA IADE via endovascular treatment. The orifice of the vertebral artery (VA) was different from the usual cases, so it was difficult to find the entrance. After only finding the VA and arriving at the lesion along the VA, trapping was performed. Herein, we report the PCA IADE with aortic arch anomaly endovascular treatment methods and results.

Tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms: a nationwide registry study.

BACKGROUND: Antiplatelet therapy, where regimens are tailored based on platelet function testing, has been introduced into neurointerventional surgery. This nationwide registry study evaluated the effect and safety of tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms compared with conventional therapy using a standard regimen. METHODS: This study enrolled 1686 patients in 44 participating centers who received stent assisted coiling for unruptured aneurysms between January 1, 2019 and December 31, 2019. The standard regimen (aspirin and clopidogrel) was used for all patients in the conventional group (924, 19 centers). The regimen was selected based on platelet function testing (standard regimen for clopidogrel responders; adding cilostazol or replacing clopidogrel with other thienopyridines (ticlopidine, prasugrel, or ticagrelor) for clopidogrel non-responders) in the tailored group (762, 25 centers). The primary outcome was thromboembolic events. Secondary outcomes were bleeding and poor outcomes (increase in modified Rankin Scale score). Outcomes within 30 days after coiling were compared using logistic regression analysis. RESULTS: The thromboembolic event rate was lower in the tailored group than in the conventional group (30/762 (3.9%) vs 63/924 (6.8%), adjusted OR 0.560, 95% CI 0.359 to 0.875, P=0.001). The bleeding event rate was not different between the study groups (62/762 (8.1%) vs 73/924 (7.9%), adjusted OR 0.790, 95% CI 0.469 to 1.331, P=0.376). Poor outcomes were less frequent in the tailored group (12/762 (1.6%) vs 34 (3.7%), adjusted OR 0.252, 95% CI 0.112 to 0.568, P=0.001). CONCLUSION: Tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms reduced thromboembolic events and poor outcomes without increasing bleeding.

Evidence of corticospinal tract injury at midbrain in patients with subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Clear elucidation of the exact pathophysiological mechanisms of motor weakness in patients with subarachnoid hemorrhage has not yet been achieved. We attempted to investigate injury to the corticospinal tract in patients with subarachnoid hemorrhage using diffusion tensor imaging. METHODS: Twenty-two patients with subarachnoid hemorrhage and 24 control subjects were recruited for this study. DTI-Studio software was used for reconstruction of the corticospinal tract. We measured fractional anisotropy and apparent diffusion coefficient values at 5 regions of interest along the corticospinal tract pathway including: the corona radiata, the posterior limb of the internal capsule, the upper midbrain, the midpons, and the upper medulla. RESULTS: Fractional anisotropy value for the midbrain region of interest was lower in the patient group compared with the control group without change of apparent diffusion coefficient value (P<0.05). By contrast, fractional anisotropy and apparent diffusion coefficient values of the other 4 regions of interest were not different between the patient and control groups. CONCLUSIONS: Injury of the corticospinal tract at the midbrain was observed in patients with subarachnoid hemorrhage. Injury of the corticospinal tract at the midbrain appears to be one of the various pathophysiological mechanisms for motor weakness after subarachnoid hemorrhage.

Neural connectivity of the pedunculopontine nucleus in relation to walking ability in chronic patients with intracerebral hemorrhage.

OBJECTIVES: As the mesencephalic locomotor center, the pedunculopontine nucleus (PPN) is known to be involved in control of locomotor function. We investigated neural connectivity of the PPN in relation to walking ability in chronic patients with spontaneous intracerebral hemorrhage. METHODS: Forty-three consecutive chronic patients with subcortical hemorrhage and 20 healthy control subjects were recruited. A seed region of interest was manually drawn on the PPN and connectivity of the PPN was measured. RESULTS: In the affected hemisphere, connectivity with the ipsilesional cerebellar locomotor center and connectivity with the contralesional pontine locomotor center were decreased in patients who could not walk, compared with patients who could walk and normal controls (p < 0.05). CONCLUSIONS: Connectivity between the PPN and ipsi-lesional cerebellum locomotor center and contralesional pontine locomotor center in the affected hemisphere appears to be related to walking ability.

The prevalence of central poststroke pain according to the integrity of the spino-thalamo-cortical pathway.

OBJECTIVES: Little is known about the prevalence of central poststroke pain (CPSP) according to the integrity of the spino-thalamo-cortical pathway (STP). Using diffusion tensor tractography, we investigated the prevalence of CPSP according to the integrity of the STP in patients with intracerebral hemorrhage. METHODS: We recruited 52 consecutive chronic patients and 10 normal control subjects. Patients were classified into two groups according to preservation of the integrity of the STP. Each group was divided into two subgroups according to the presence of CPSP. RESULTS: The preserved group included 34 patients [CPSP subgroup, 16 (47%) patients; non-CPSP subgroup, 18 (53%) patients], and 18 patients were enrolled into the disrupted group [CPSP subgroup, 3 (17%) patients; non-CPSP subgroup, 15 (83%) patients]. The fractional anisotropy and mean diffusivity values of the CPSP and non-CPSP subgroups of the preserved group were decreased and increased when compared with those of the control group, respectively (p < 0.05). CONCLUSIONS: We found that the prevalence of CPSP in patients with partial injury of the STP was higher than that of patients with complete injury of the STP. Partial injury of the STP appears to be more vulnerable to development of CPSP than complete injury of the STP in patients with intracerebral hemorrhage.

Injury of fornix in patients with intracerebral hemorrhage.

OBJECTIVES: Many diffusion tensor tractography (DTT) studies have reported on fornix injury in various diseases. However, there has been no DTT study on fornix injury by intracerebral hemorrhage (ICH). We attempted to investigate fornix body injury in patients with ICH, using DTT. METHODS: We identified 58 consecutive stroke patients using the following criteria: (1) first-ever stroke, (2) age: 45-65 years, (3) hemorrhage confined within the corona radiata and basal ganglion level, (4) an available DTT scan performed during the early stage of ICH (1-5 weeks after onset). Among 58 consecutive patients, we identified six patients who showed disruption at the fornix body. RESULTS: Following ICH, 10.7% of patients revealed complete disruption of the fornix body on DTT. Results from DTT of the fornix showed disruption in anterior and posterior portions of the fornix body in three patients, in the anterior portion of the fornix body in two patient, and in the posterior portion of the fornix body in one patient. CONCLUSIONS: We report on six patients who showed complete disruption of the fornix body following ICH. It is our belief that the fornix of patients with ICH could be evaluated using DTT.

Contribution of the pedunculopontine nucleus on walking in stroke patients.

OBJECTIVES: We attempted to investigate changes of the pedunculopontine nucleus (PPN) according to walking ability in chronic stroke patients, using diffusion tensor imaging (DTI). METHODS: 55 consecutive chronic stroke patients who were not able to walk due to injury of the corticospinal tract (CST) at stroke onset and 22 age-matched normal control subjects were recruited. We measured the values of fractional anisotropy (FA) and apparent diffusion coefficient (ADC) of the PPN and assessed the walking ability of each patient. RESULTS: In patients who were able to walk independently, the FA value of the PPN in the affected hemisphere was increased without change of the ADC value (p < 0.05). Increase of the FA value was positively correlated with the degree of walking ability (p < 0.05). In contrast, the ADC value was increased in the affected hemisphere of patients who could not walk, without change of the FA value (p < 0.05). This increase of the ADC value was negatively correlated with the degree of walking ability (p < 0.05). CONCLUSION: We found that the neuronal activity of the PPN in the affected hemisphere was increased in stroke patients who were able to walk independently. Therefore, we think that the PPN in the affected hemisphere contributed to walking ability in stroke patients with CST injury.

Periventricular white matter injury by primary intraventricular hemorrhage: a diffusion tensor imaging study.

OBJECTIVES: Intraventricular hemorrhage (IVH) in adult stroke patients is known to be an independent risk factor for poor functional outcome. Using diffusion tensor imaging (DTI), we attempted to investigate the effect of IVH on the white matter. METHODS: We recruited 10 consecutive patients with IVH and 18 age- and sex-matched control subjects. Using a 1.5-T Philips Gyroscan Intera system, DTI data was acquired at an average of 84 days (range: 38-149) after IVH onset. We measured fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values at the fornix, corpus callosum (CC), corona radiata (CR), and posterior limb of the internal capsule (PL). In addition, integrity and fiber number were measured for the fornix. RESULTS: DTI revealed disruption of the fornix in all patients. FA values showed a decrease in the fornix, CC, and CR; in contrast, the ADC value showed an increase in the CC, without changes in the fornix or CR. Fiber number of the fornix also decreased. However, no change was observed in the PL. CONCLUSIONS: We found periventricular white matter (fornix, CC, and CR) injury following IVH. We think that this result would be helpful in the establishment of management strategies for patients with IVH.

Changes in the prefronto-thalamic tract following cranioplasty: Case reports.

RATIONALE: The prefrontothalamic tract (PTT) injury is associated with various neuropsychological impairments including cognitive impairment. We report on three women with hemorrhagic stroke who showed changes in the PTT following cranioplasty (C/P) using diffusion tensor tractography (DTT) images. PATIENT CONCERNS: The 3 women with hemorrhagic stroke showed reductions of cognitive impairment following C/P. Mini-Mental State Examination scores (MMSE) were increased by 7-, 8-, and 5-point in patient 1, 2, and 3, respectively, after C/P compared with the patients' pre-C/P MMSE scores. DIAGNOSIS: Three patients were diagnosed with spontaneous intracerebral hemorrhage. Three patients underwent C/P using auto-bone at 7 (patient 1 and 3) and 13 (patient 2) weeks after onset. INTERVENTIONS: Diffusion tensor imaging data were acquired within 3 days before and 21 days after C/P. OUTCOMES: The pre-C/P DTT results showed non-reconstruction of the dorsolateral prefrontal cortex (DLPFC; patient 2 and 3) on the contralateral operation (contra-OP) side and orbitofrontal cortex (OFC; patient 3) on both sides, but those were reconstructed on post-C/P DTT. Except for the contra-OP side OFC of patient 2, all fractional anisotropy values decreased on post-C/P DTT compared with pre-C/P DTT. The mean diffusivity values of the VLPFC and OFC were higher on post-C/P DTT except for the contra-OP side VLPFC of patient 1 and contra-OP side OFC of patient 2. The voxel numbers also increased except for the contra-OP side VLPFC of patient 1. LESSONS: We demonstrated structural changes in the PTT along with concomitant reductions of cognitive impairments following C/P in 3 women with hemorrhagic stroke using DTT. The DTT changes suggest that C/P can affect the state of the PTT on both the OP and contra-OP sides. However, the limitation that DTT analysis may underestimate or overestimate fiber tract status due to regions of fiber complexity and crossing fiber should be considered.