Rescue of Neglect and Language Impairment After Stroke Thrombectomy.

Background and Purpose: Although National Institutes of Health Stroke Scale scores provide an objective measure of clinical deficits, data regarding the impact of neglect or language impairment on outcomes after mechanical thrombectomy (MT) is lacking. We assessed the frequency of neglect and language impairment, rate of their rescue by MT, and impact of rescue on clinical outcomes. Methods: This is a retrospective analysis of a prospectively collected database from a comprehensive stroke center. We assessed right (RHS) and left hemispheric strokes (LHS) patients with anterior circulation large vessel occlusion undergoing MT to assess the impact of neglect and language impairment on clinical outcomes, respectively. Safety and efficacy outcomes were compared between patients with and without rescue of neglect or language impairment. Results: Among 324 RHS and 210 LHS patients, 71% of patients presented with neglect whereas 93% of patients had language impairment, respectively. Mean age was 71±15, 56% were females, and median National Institutes of Health Stroke Scale score was 16 (12­20). At 24 hours, MT resulted in rescue of neglect in 31% of RHS and rescue of language impairment in 23% of LHS patients, respectively. RHS patients with rescue of neglect (56% versus 34%, P<0.001) and LHS patients with rescue of language impairment (64 % versus 25%, P<0.01) were observed to have a higher rate of functional independence compared to patients without rescue. After adjusting for confounders including 24-hour National Institutes of Health Stroke Scale, rescue of neglect among RHS patients was associated with functional independence (P=0.01) and lower mortality (P=0.01). Similarly, rescue of language impairment among LHS patients was associated with functional independence (P=0.02) and lower mortality (P=0.001). Conclusions: Majority of LHS-anterior circulation large vessel occlusion and of RHS-anterior circulation large vessel occlusion patients present with the impairment of language and neglect, respectively. In comparison to 24-hour National Institutes of Health Stroke Scale, rescue of these deficits by MT is an independent and a better predictor of functional independence and lower mortality.

Plasticity in language cortex and white matter tracts after resection of dominant inferior parietal lobule arteriovenous malformations: a combined fMRI and DTI study.

OBJECTIVE: The dominant inferior parietal lobe (IPL) contains cortical and subcortical structures that serve language processing. A high incidence of postoperative short-term aphasia and good potential for language reorganization have been observed. The authors' goal was to study the plasticity of the language cortex and language-related fibers in patients with brain arteriovenous malformations (BAVMs) located in the IPL. METHODS: A total of 6 patients who underwent microsurgical treatment of an IPL BAVM were prospectively recruited between September 2016 and May 2018. Blood oxygen level-dependent functional MRI (BOLD-fMRI) and diffusion tensor imaging (DTI) were performed within 1 week before and 6 months after microsurgery. Language-related white matter (WM) eloquent fiber tracts and their contralateral homologous fiber tracts were tracked. The Western Aphasia Battery was administered to assess language function. The authors determined the total number of fibers and mean fractional anisotropy (FA) indices for each individual tract. In addition, they calculated the laterality index (LI) between the activated language cortex voxels in the lesional and contralesional hemispheres and compared these indices between the preoperative and postoperative fMR and DT images. RESULTS: Of the 6 patients with IPL BAVMs, all experienced postoperative short-term language deficits, and 5 (83.3%) recovered completely at 6 months after surgery. Five patients (83.3%) had right homologous reorganization of BOLD signal activations in both Broca's and Wernicke's areas. More fibers were observed in the arcuate fasciculus (AF) in the lesional hemisphere than in the contralesional hemisphere (1905 vs 254 fibers, p = 0.035). Six months after surgery, a significantly increased number of fibers was seen in the right hemispheric AF (249 fibers preoperatively vs 485 postoperatively, p = 0.026). There were significantly more nerve fibers in the postoperative left inferior frontooccipital fasciculus (IFOF) (874 fibers preoperatively vs 1186 postoperatively, p = 0.010). A statistically significant increase in right hemispheric dominance of Wernicke's area was observed. The overall functional LI showed functional lateralization of Wernicke's area in the right hemisphere (LI ≤ -0.20) in all patients. CONCLUSIONS: The authors' findings provide evidence for the functional reorganization by recruiting the right hemispheric homologous region of Broca's and Wernicke's areas, right hemispheric AFs, and left hemispheric IFOFs following resection of IPL BAVMs.Clinical trial registration no.: NCT02868008 (clinicaltrials.gov).

Successful embolisation of an intracranial meningioma via a right-sided aortic arch.

Right aortic arch is an unusual arch variation. Supra-aortic neurointervention in such cases has been sparingly reported. This case highlights the unusual association of a left hemispheric convexity meningioma with a right aortic arch which was successfully navigated. Particle embolisation of the meningioma produced good results followed by complete surgical excision and gratifying overall final outcome in this challenging scenario.

Repeated mapping of cortical language sites by preoperative navigated transcranial magnetic stimulation compared to repeated intraoperative DCS mapping in awake craniotomy.

BACKGROUND: Repetitive navigated transcranial magnetic stimulation (rTMS) was recently described for mapping of human language areas. However, its capability of detecting language plasticity in brain tumor patients was not proven up to now. Thus, this study was designed to evaluate such data in order to compare rTMS language mapping to language mapping during repeated awake surgery during follow-up in patients suffering from language-eloquent gliomas. METHODS: Three right-handed patients with left-sided gliomas (2 opercular glioblastomas, 1 astrocytoma WHO grade III of the angular gyrus) underwent preoperative language mapping by rTMS as well as intraoperative language mapping provided via direct cortical stimulation (DCS) for initial as well as for repeated Resection 7, 10, and 15 months later. RESULTS: Overall, preoperative rTMS was able to elicit clear language errors in all mappings. A good correlation between initial rTMS and DCS results was observed. As a consequence of brain plasticity, initial DCS and rTMS findings only corresponded with the results obtained during the second examination in one out of three patients thus suggesting changes of language organization in two of our three patients. CONCLUSIONS: This report points out the usefulness but also the limitations of preoperative rTMS language mapping to detect plastic changes in language function or for long-term follow-up prior to DCS even in recurrent gliomas. However, DCS still has to be regarded as gold standard.

Naming outcome after left or right temporal lobectomy in patients with bilateral language representation by Wada testing.

OBJECTIVE: This study aimed to examine language outcome after left or right anterior temporal lobectomy (ATL) in patients with epilepsy with bilateral language representation on intracarotid sodium amobarbital (Wada) testing. METHODS: Twenty-two patients with epilepsy with bilateral language (Wada laterality index between -50 and 50) underwent right ATL (RATL, n=10) or left ATL (LATL, n=12). All the patients were administered the Boston Naming Test preoperatively and six months postoperatively. RESULTS: Left anterior temporal lobectomy patients showed greater postoperative naming decline than RATL patients. Group differences were also observed on subtests of the Wada test. Performance on the Wada naming and comprehension subtests was better in the nonsurgical hemisphere than in the surgical hemisphere in the RATL group, but there was no difference between the nonsurgical and the surgical hemisphere naming and comprehension performance in the LATL group. CONCLUSIONS: Left anterior temporal lobectomy patients with bilateral language are at greater risk for naming decline than RATL patients with bilateral language. This difference may be due to relatively better naming and comprehension abilities in the nonsurgical hemisphere in the RATL group.

Operative and nonoperative linguistic outcomes in brain injury patients.

OBJECTIVE AND BACKGROUND: Linguistic function is one of vulnerable aspects of traumatic brain injury (TBI) which may have destructive effects on patients' communicative activities and daily life, years following trauma. This paper attempts to answer the controversy whether surgery affects increase and decrease of linguistic impairment or not. MATERIALS AND METHODS: Two hundred forty-one TBI patients aged 18-65 with abnormal CT findings and at least 20 minute post-trauma amnesia (PTA), who were conscious at discharge, participated in this study. Based on operative intervention, the samples were divided into two groups: operative and nonoperative. Cognitive and aphasic deficits were inspected formally and pragmatic disorder was informally appraised at discharge. RESULTS: The groups had no significant differences in aphasia incidence and language pragmatic impairment, though they were significantly distinctive in aphasia subcategories and cognitive deficit after trauma. Fluent aphasia was more common in both groups alike. In aphasia subcategories, however, transcortical sensory aphasia (TSA) in operative and anomia in nonoperative group were the most prevalent. Several variables appeared strikingly related to higher aphasia in operative groups as follows: moderate to severe injury, 18-35 and over 50 years of age, more than 1 week PTA, intracranial surgery of multiple lesions in left or bilateral hemisphere fronto-temporal cortex plus post-trauma cognitive and pragmatic impairments, and diffuse axonal injuries. DISCUSSION: Almost certainly, meaningful drop of cognitive function post surgery roots back in significant loss of initial consciousness level. Related factors to postoperative aphasia suggest taking policies through surgery intervention. Discerning the indispensable contributions of neurosurgeons, neurolinguists, and neuroscientists, results inspire more clinical future studies.

Functional MRI and neuropsychological evidence for language plasticity before and after surgery in one patient with left temporal lobe epilepsy.

This study explores the language reorganization before and after surgery in a 55-year-old right-handed female patient presenting with left temporal refractory epilepsy. Two aspects of language were explored, phonological and semantic, by using neuropsychological assessments and fMRI protocols. To assess the possible reorganization of language, fMRI results for B.L. were compared with results obtained in a group of healthy control subjects (results not presented in detail). According to our results and compared with healthy subjects, B.L. shows reorganization of temporal regions only. The reorganization had various patterns according to the task. Before surgery, neuropsychological testing in B.L. revealed impairment in phonological abilities and fMRI suggested right temporal involvement (interhemisphere reorganization) during the phonological task; semantic abilities were unaltered and fMRI showed bilateral activation of temporal regions during the semantic task. After surgery, the phonological deficit disappeared and fMRI showed left perilesional location of temporal activation (intrahemispheric reorganization); semantic abilities remain preserved and temporal activation remained located bilaterally but predominantly to the right during the semantic task. Our results suggest that cerebral reorganization of language depends on the language operation tested. Moreover, the results underline the importance of differential assessment of language operations and show functional reorganization after beneficial surgery in an older patient.

Language impairment associated with arachnoid cysts: recovery after surgical treatment.

Supporting data from the literature, we observe that large arachnoid cysts may affect cognitive function. Neuropsychologic assessment plus magnetic resonance imaging allowed for documentation of associations between left temporal arachnoid cysts, language impairment, and other cognitive dysfunctions. Significant cognitive improvements were evident soon after cysto-peritoneal shunting. These observations reinforce the rationale for neuropsychologic assessments of patients with developmental delay and arachnoid cysts, and support the potential benefit of surgical decompression for arachnoid cysts associated with neurologic deficits, even if surgery is performed well after the occurrence of neurologic deficits.

A comparison of seizure outcome after callosotomy in patients with Lennox-Gastaut syndrome and a positive or negative history for West syndrome.

PURPOSE: This retrospective study was designed to clarify the role of West syndrome in post-callosotomy seizure outcome in patients with Lennox-Gastaut syndrome. METHODS: From September 1989 to May 1999, 74 patients diagnosed with Lennox-Gastaut syndrome received anterior corpus callosotomy at Taipei Veterans General Hospital, Taiwan. All patients were followed for more than 4 years after surgery. Among them, 21 (28.4%) patients had a history of West syndrome (Group A) whereas 53 (71.6%) patients did not have a history of West syndrome (Group B). Postoperative seizure outcome was compared for these two patient groups. RESULTS: A total of 16 (76.2%) patients in Group A (positive history) and 29 (54.7%) patients in group B (negative history) achieved significant improvement in seizures after surgery (e.g., seizure reduction of more than 50%). There was no statistical significance (p=0.088) in the difference in outcome between the two groups. CONCLUSIONS: A history of West syndrome does not appear to influence post-callosotomy seizure outcome in patients with Lennox-Gastaut syndrome.

The role of the right superior temporal gyrus in visual search-insights from intraoperative electrical stimulation.

Intraoperative electrical stimulation in awake patients is a seminal technique during brain surgery allowing one to infer the function of brain areas by temporary inactivation. Using this technique, we found that inactivation of the middle portion of the superior temporal gyrus (STG) leads to disturbed serial exploratory visual search. The data supplement recent findings by Ellison et al. [Ellison, A., Schindler, I., Pattison, L. L., & Milner, A. D. (2004). An exploration of the role of the superior temporal gyrus in visual search and spatial perception using TMS. Brain, 127, 2307-2315] using repetitive transcranial magnetic stimulation over the STG in healthy subjects. Our data demonstrate that the STG is integral to human exploration behaviour and challenge the traditional view that only the right posterior parietal cortex is involved in the mediation of visual search processes.

Multiple subpial transection in Landau-Kleffner syndrome.

We have considered multiple subpial transection (MST) as a treatment option for Landau-Kleffner syndrome (LKS) for the past 6 years. The effect of this technique on language and cognitive ability, behaviour, seizures, and EEG abnormalities is analysed here. Five children (4 males, 1 female; aged 5.5 to 10 years) underwent MST with sufficiently detailed pre- and postoperative data for analysis. Behaviour and seizure frequency improved dramatically after surgery in all children. Improvement in language also occurred in all children, although none improved to an age-appropriate level. All five had electrical status epilepticus in sleep (ESES) before surgery, which was eliminated by the procedure. One child has had an extension of his MST due to the recurrence of ESES and accompanying clinical deterioration with good effect. An attempt is made to set the effect of MST against the natural history of the condition. MST is an important treatment modality in LKS, although the timing of this intervention and its effect on final language outcome remains to be defined.