Telemedicine-Based Cognitive Examinations During COVID-19 and Beyond: Perspective of the Massachusetts General Hospital Behavioral Neurology & Neuropsychiatry Group.

Telehealth and telemedicine have encountered explosive growth since the beginning of the COVID-19 pandemic, resulting in increased access to care for patients located far from medical centers and clinics. Subspecialty clinicians in behavioral neurology & neuropsychiatry (BNNP) have implemented the use of telemedicine platforms to perform cognitive examinations that were previously office based. In this perspective article, BNNP clinicians at Massachusetts General Hospital (MGH) describe their experience performing cognitive examinations via telemedicine. The article reviews the goals, prerequisites, advantages, and potential limitations of performing a video- or telephone-based telemedicine cognitive examination. The article shares the approaches used by MGH BNNP clinicians to examine cognitive and behavioral areas, such as orientation, attention and executive functions, language, verbal learning and memory, visual learning and memory, visuospatial function, praxis, and abstract abilities, as well as to survey for neuropsychiatric symptoms and assess activities of daily living. Limitations of telemedicine-based cognitive examinations include limited access to and familiarity with telecommunication technologies on the patient side, limitations of the technology itself on the clinician side, and the limited psychometric validation of virtual assessments. Therefore, an in-person examination with a BNNP clinician or a formal in-person neuropsychological examination with a neuropsychologist may be recommended. Overall, this article emphasizes the use of standardized cognitive and behavioral assessment instruments that are either in the public domain or, if copyrighted, are nonproprietary and do not require a fee to be used by the practicing BNNP clinician.

Treatment-induced neural reorganization in aphasia is language-domain specific: Evidence from a large-scale fMRI study.

Studies investigating the effects of language intervention on the re-organization of language networks in chronic aphasia have resulted in mixed findings, likely related to-among other factors-the language function targeted during treatment. The present study investigated the effects of the type of treatment provided on neural reorganization. Seventy individuals with chronic stroke-induced aphasia, recruited from three research laboratories and meeting criteria for agrammatism, anomia or dysgraphia were assigned to either treatment (N = 51) or control (N = 19) groups. Participants in the treatment group received 12-weeks of language intervention targeting sentence comprehension/production, naming, or spelling. At baseline and post-testing, all participants performed an fMRI story comprehension task, with blocks of auditorily-presented stories alternated with blocks of reversed speech. Participants in the treatment, but not control, group significantly improved in the treated language domain. FMRI region-of-interest (ROI) analyses, conducted within regions that were either active (or homologous to active) regions in a group of 22 healthy participants on the story comprehension task, revealed a significant increase in activation from pre-to post-treatment in right-hemisphere homologues of these regions for participants in the sentence and spelling, but not naming, treatment groups, not predicted by left-hemisphere lesion size. For the sentence (but not the spelling) treatment group, activation changes within right-hemisphere homologues of language regions were positively associated with changes in measures of verb and sentence comprehension. These findings support previous research pointing to recruitment of right hemisphere tissue as a viable route for language recovery and suggest that sentence-level treatment may promote greater neuroplasticity on naturalistic, language comprehension tasks, compared to word-level treatment.

Social Work Education & Support of Gender Expansive People: A Qualitative Analysis of MSW Student Experiences.

This study examined Master of Social Work (MSW) student experiences with social work education related to support of transgender, nonbinary, queer or other gender expansive people. Sixty-seven students from a sample of thirty-four MSW programs in the United States provided brief qualitative reflections on their educational experiences related to gender identity or expression. Thematic content analysis of these data revealed five primary emergent themes related to; MSW program capacity, persistent bias/tension, safety issues, emotional and academic burden, and lived-experiences external to social work education. Findings suggest there remains a disconnect between the stated intent of social work to support gender expansive communities and the reality of social work education. Specifically, although most students appear to want more from their schools of social work regarding trans-affirming education, most programs reflect persistent discomfort with this domain, or a hesitance or inability to address the topic appropriately and consistently. Examples of how social work education might work to improve its capacity to reflect support of gender expansive people and communities are discussed.

The Role of Working Memory, Short-Term Memory, Speed of Processing, Education, and Locality in Verb-Related Morphosyntactic Production: Evidence From Greek.

This study investigates the relationship between verb-related morphosyntactic production (VRMP) and locality (i.e., critical cue being adjacent to the target or not), verbal Working Memory (vWM), nonverbal/visuospatial WM (nvWM), verbal short-term memory (vSTM), nonverbal/visuospatial STM (nvSTM), speed of processing, and education. Eighty healthy middle-aged and older Greek-speaking participants were administered a sentence completion task tapping into production of subject-verb Agreement, Time Reference/Tense, and grammatical Aspect in local and nonlocal configurations, and cognitive tasks tapping into vSTM, nvSTM, vWM, nvWM, and speed of processing. Aspect elicited worse performance than Time Reference and Agreement, and Time Reference elicited worse performance than Agreement. There were main effects of vSTM, vWM, education, and locality: the greater the participants' vSTM/vWM capacity, and the higher their educational level, the better their VRMP; nonlocal configurations elicited worse performance on VRMP than local configurations. Moreover, vWM affected Aspect and Time Reference/Tense more than Agreement, and education affected VRMP more in local than in nonlocal configurations. Lastly, locality affected Agreement and Aspect (with nonlocal configurations eliciting more agreement and aspect errors than local configurations) but not Time Reference. That vSTM/vWM (but not nvSTM/nvWM) were found to subserve VRMP suggests that VRMP is predominantly supported by domain-specific, not by domain-general, memory resources. The main effects of vWM and vSTM suggest that both the processing and storage components of WM are relevant to VRMP. That vWM (but not vSTM) interacts with production of Aspect, Time Reference, and Agreement suggests that Aspect and Time Reference are computationally more demanding than Agreement. These findings are consistent with earlier findings that, in individuals with aphasia, vWM interacts with production of Aspect, Time Reference, and Agreement. The differential effect of education on VRMP in local vs. nonlocal configurations could be accounted for by assuming that education is a proxy for an assumed procedural memory system that is sensitive to frequency patterns in language and better supports VRMP in more frequent than in less frequent configurations. In the same vein, the interaction between locality and the three morphosyntactic categories might reflect the statistical distribution of local vs. nonlocal Aspect, Agreement, and Time Reference/Tense in Greek.

Structural disconnections associated with language impairments in chronic post-stroke aphasia using disconnectome maps.

Inconsistent findings have been reported about the impact of structural disconnections on language function in post-stroke aphasia. This study investigated patterns of structural disconnections associated with chronic language impairments using disconnectome maps. Seventy-six individuals with post-stroke aphasia underwent a battery of language assessments and a structural MRI scan. Support-vector regression disconnectome-symptom mapping analyses were performed to examine the correlations between disconnectome maps, representing the probability of disconnection at each white matter voxel and different language scores. To further understand whether significant disconnections were primarily representing focal damage or a more extended network of seemingly preserved but disconnected areas beyond the lesion site, results were qualitatively compared to support-vector regression lesion-symptom mapping analyses. Part of the left white matter perisylvian network was similarly disconnected in 90% of the individuals with aphasia. Surrounding this common left perisylvian disconnectome, specific structural disconnections in the left fronto-temporo-parietal network were significantly associated with aphasia severity and with lower performance in auditory comprehension, syntactic comprehension, syntactic production, repetition and naming tasks. Auditory comprehension, repetition and syntactic processing deficits were related to disconnections in areas that overlapped with and extended beyond lesion sites significant in SVR-LSM analyses. In contrast, overall language abilities as measured by aphasia severity and naming seemed to be mostly explained by focal damage at the level of the insular and central opercular cortices, given the high overlap between SVR-DSM and SVR-LSM results for these scores. While focal damage seems to be sufficient to explain broad measures of language performance, the structural disconnections between language areas provide additional information on the neural basis of specific and persistent language impairments at the chronic stage beyond lesion volume. Leveraging routinely available clinical data, disconnectome mapping furthers our understanding of anatomical connectivity constraints that may limit the recovery of some language abilities in chronic post-stroke aphasia.

Perilesional Perfusion in Chronic Stroke-Induced Aphasia and Its Response to Behavioral Treatment Interventions.

Stroke-induced alterations in cerebral blood flow (perfusion) may contribute to functional language impairments in chronic aphasia, particularly in perilesional tissue. Abnormal perfusion in this region may also serve as a biomarker for predicting functional improvements with behavioral treatment interventions. Using pseudo-continuous arterial spin labeling in magnetic resonance imaging (MRI), we examined perfusion in chronic aphasia, in perilesional rings in the left hemisphere and their right hemisphere homologues. In the left hemisphere we found a gradient pattern of decreasing perfusion closer to the lesion. The opposite pattern was found in the right hemisphere, with significantly increased perfusion close to the lesion homologue. Perfusion was also increased in the right hemisphere lesion homologue region relative to the surrounding tissue. We next examined changes in perfusion in two groups: one group who underwent MRI scanning before and after three months of a behavioral treatment intervention that led to significant language gains, and a second group who was scanned twice at a three-month interval without a treatment intervention. For both groups, there was no difference in perfusion over time in either the left or the right hemisphere. Moreover, within the treatment group pre-treatment perfusion scores did not predict treatment response; neither did pre-treatment perfusion predict post-treatment language performance. These results indicate that perfusion is chronically abnormal in both hemispheres, but chronically abnormal perfusion did not change in response to our behavioral treatment interventions, and did not predict responsiveness to language treatment.

Multimodal Neural and Behavioral Data Predict Response to Rehabilitation in Chronic Poststroke Aphasia.

BACKGROUND: Poststroke recovery depends on multiple factors and varies greatly across individuals. Using machine learning models, this study investigated the independent and complementary prognostic role of different patient-related factors in predicting response to language rehabilitation after a stroke. METHODS: Fifty-five individuals with chronic poststroke aphasia underwent a battery of standardized assessments and structural and functional magnetic resonance imaging scans, and received 12 weeks of language treatment. Support vector machine and random forest models were constructed to predict responsiveness to treatment using pretreatment behavioral, demographic, and structural and functional neuroimaging data. RESULTS: The best prediction performance was achieved by a support vector machine model trained on aphasia severity, demographics, measures of anatomic integrity and resting-state functional connectivity (F1=0.94). This model resulted in a significantly superior prediction performance compared with support vector machine models trained on all feature sets (F1=0.82, P<0.001) or a single feature set (F1 range=0.68-0.84, P<0.001). Across random forest models, training on resting-state functional magnetic resonance imaging connectivity data yielded the best F1 score (F1=0.87). CONCLUSIONS: While behavioral, multimodal neuroimaging data and demographic information carry complementary information in predicting response to rehabilitation in chronic poststroke aphasia, functional connectivity of the brain at rest after stroke is a particularly important predictor of responsiveness to treatment, both alone and combined with other patient-related factors.

Predicting language recovery in post-stroke aphasia using behavior and functional MRI.

Language outcomes after speech and language therapy in post-stroke aphasia are challenging to predict. This study examines behavioral language measures and resting state fMRI (rsfMRI) as predictors of treatment outcome. Fifty-seven patients with chronic aphasia were recruited and treated for one of three aphasia impairments: anomia, agrammatism, or dysgraphia. Treatment effect was measured by performance on a treatment-specific language measure, assessed before and after three months of language therapy. Each patient also underwent an additional 27 language assessments and a rsfMRI scan at baseline. Patient scans were decomposed into 20 components by group independent component analysis, and the fractional amplitude of low-frequency fluctuations (fALFF) was calculated for each component time series. Post-treatment performance was modelled with elastic net regression, using pre-treatment performance and either behavioral language measures or fALFF imaging predictors. Analysis showed strong performance for behavioral measures in anomia (R2 = 0.948, n = 28) and for fALFF predictors in agrammatism (R2 = 0.876, n = 11) and dysgraphia (R2 = 0.822, n = 18). Models of language outcomes after treatment trained using rsfMRI features may outperform models trained using behavioral language measures in some patient populations. This suggests that rsfMRI may have prognostic value for aphasia therapy outcomes.

A Computational Evaluation of Two Models of Retrieval Processes in Sentence Processing in Aphasia.

Can sentence comprehension impairments in aphasia be explained by difficulties arising from dependency completion processes in parsing? Two distinct models of dependency completion difficulty are investigated, the Lewis and Vasishth (2005) activation-based model and the direct-access model (DA; McElree, 2000). These models' predictive performance is compared using data from individuals with aphasia (IWAs) and control participants. The data are from a self-paced listening task involving subject and object relative clauses. The relative predictive performance of the models is evaluated using k-fold cross-validation. For both IWAs and controls, the activation-based model furnishes a somewhat better quantitative fit to the data than the DA. Model comparisons using Bayes factors show that, assuming an activation-based model, intermittent deficiencies may be the best explanation for the cause of impairments in IWAs, although slowed syntax and lexical delayed access may also play a role. This is the first computational evaluation of different models of dependency completion using data from impaired and unimpaired individuals. This evaluation develops a systematic approach that can be used to quantitatively compare the predictions of competing models of language processing.

Common and distinct neural substrates of sentence production and comprehension.

Functional neuroimaging and lesion-symptom mapping investigations implicate a left frontal-temporal-parietal network for sentence processing. The majority of studies have focused on sentence comprehension, with fewer in the domain of sentence production, which have not fully elucidated overlapping and/or unique brain structures associated with the two domains, particularly for sentences with noncanonical word order. Using voxel-based lesion symptom mapping (VLSM) we examined the relationship between lesions within the left hemisphere language network and both sentence comprehension and production of simple and complex syntactic structures in 76 participants with chronic stroke-induced aphasia. Results revealed shared regions across domains in the anterior and posterior superior temporal gyri (aSTG, pSTG), and the temporal pole (adjusted for verb production/comprehension). Additionally, comprehension was associated with lesions in the anterior and posterior middle temporal gyri (aMTG, pMTG), the MTG temporooccipital regions, SMG/AG, central and parietal operculum, and the insula. Subsequent VLSM analyses (production versus comprehension) revealed critical regions associated with each domain: anterior temporal lesions were associated with production; posterior temporo-parietal lesions were associated with comprehension, implicating important roles for regions within the ventral and dorsal stream processing routes, respectively. Processing of syntactically complex, noncanonical (adjusted for canonical), sentences was associated with damage to the pSTG across domains, with additional damage to the pMTG and IPL associated with impaired sentence comprehension, suggesting that the pSTG is crucial for computing noncanonical sentences across domains and that the pMTG, and IPL are necessary for re-analysis of thematic roles as required for resolution of long-distance dependencies. These findings converge with previous studies and extend our knowledge of the neural mechanisms of sentence comprehension to production, highlighting critical regions associated with both domains, and further address the mechanism engaged for syntactic computation, controlled for the contribution of verb processing.

Transgender-Competence in Social Work Education: The Relationship of School Contexts to Student Affirmation of Gender Expansive People.

This study examined the relationship between Master of Social Work program's (MSW) support of lesbian, gay, bisexual, and transgender people (LGBT-competence), and social work student's self-perceived competence to support transgender people (transgender-competence). Thirty-four accredited MSW programs in the United States provided a sample of program directors, faculty members, and students (N = 1385). Hierarchical linear models revealed an MSW program's LGBT-competence was associated with the transgender-competence of its students, and that significant differences exist between organizational LGBT-competence and individual transgender-competence within schools of social work. Specifically, programs with greater LGBT-competence also had students who felt more competent to work with gender minorities. These findings suggest schools of social work provide different levels of support for gender minorities, and that such programs can take substantive action at an organizational level to improve the professional competence of future social workers to serve transgender populations. Implications for social work education are discussed.

White Matter Hyperintensities Predict Response to Language Treatment in Poststroke Aphasia.

BACKGROUND: White matter hyperintensities (WMH) are a radiological marker of brain health that has been associated with language status in poststroke aphasia; however, its association with language treatment outcomes remains unknown. OBJECTIVE: To determine whether WMH in the right hemisphere (RH) predict response to language therapy independently from demographics and stroke lesion-related factors in poststroke aphasia. METHODS: We used the Fazekas scale to rate WMH in the RH in 30 patients with poststroke aphasia who received language treatment. We developed ordinal regression models to examine language treatment effects as a function of WMH severity after controlling for aphasia severity, stroke lesion volume, time post onset, age, and education level. We also evaluated associations between WMH severity and both pre-treatment naming ability and executive function. RESULTS: The severity of WMH in the RH predicted treatment response independently from demographic and stroke-related factors such that patients with less severe WMH exhibited better treatment outcome. WMH scores were not significantly correlated with pretreatment language scores, but they were significantly correlated with pretreatment scores of executive function. CONCLUSION: We suggest that the severity of WMH in the RH is a clinically relevant predictor of treatment response in this population.

Telemedicine in Behavioral Neurology-Neuropsychiatry: Opportunities and Challenges Catalyzed by COVID-19.

Coronavirus 2019 (COVID-19) has profoundly impacted the well-being of society and the practice of medicine across health care systems worldwide. As with many other subspecialties, the clinical paradigm in behavioral neurology and neuropsychiatry (BN-NP) was transformed abruptly, transitioning to real-time telemedicine for the assessment and management of the vast majorities of patient populations served by our subspecialty. In this commentary, we outline themes from the BN-NP perspective that reflect the emerging lessons we learned using telemedicine during the COVID-19 pandemic. Positive developments include the ability to extend consultations and management to patients in our high-demand field, maintenance of continuity of care, enhanced ecological validity, greater access to a variety of well-reimbursed telemedicine options (telephone and video) that help bridge the digital divide, and educational and research opportunities. Challenges include the need to adapt the mental state examination to the telemedicine environment, the ability to perform detailed motor neurologic examinations in patients where motor features are important diagnostic considerations, appreciating nonverbal cues, managing acute safety and behavioral concerns in less controlled environments, and navigating intervention-based (neuromodulation) clinics requiring in-person contact. We hope that our reflections help to catalyze discussions that should take place within the Society for Behavioral and Cognitive Neurology, the American Neuropsychiatric Association, and allied organizations regarding how to optimize real-time telemedicine practices for our subspecialty now and into the future.

Reliability of BOLD signals in chronic stroke-induced aphasia.

Investigating the neurobiology of language impairment and treatment in chronic stroke aphasia using fMRI requires an understanding of measurement variability within and between participants. In this multicenter study, we evaluated the scan-rescan reliability of an auditory and visual (written) story comprehension paradigm in stroke participants with aphasia (N = 65) and healthy controls (N = 22). The multi-modal task was conducted twice (~1 week apart) on separate visits upon study enrolment and twice again at completion three months later. A non-language visuomotor task was studied in the aphasia group only, which was conducted once per time point (3 months apart). While participants were asked to make responses during the comprehension task, these in-scanner responses were not recorded. Reliability was assessed using intraclass correlation coefficient (ICC) at both group and individual participant levels. The visual story comprehension condition had higher reliability than the auditory condition in both groups, with participants with aphasia exhibiting lower reliability than controls in both conditions (stroke ICC = .43, healthy ICC = .81). Differences in reliability within the group of participants with aphasia were found to be partially explained by overall language impairment as well as greater head motion. In the participants with aphasia, the visuomotor paradigm was found to have greater reliability than the story comprehension task at equivalent interscan intervals (visuomotor = 0.50, comprehension = 0.34), and its reliability was not associated with language impairment. This work highlights the importance of considering the reliability of fMRI tasks in aphasia research, provides strategies to improve reliability and has potential implications for the field of clinical neuroimaging in general.

Cautionary notes on diagnosing functional neurologic disorder as a neurologist-in-training.

Functional neurologic disorder (FND), although neglected for much of the 20th century, is among the most common conditions encountered by neurologists across clinical settings. High prevalence rates and limited provider expertise in FND have created a considerable need to develop educational initiatives and practical suggestions to guide neurologists in training working with this population. To help avoid diagnostic errors, trainees should keep in mind that (1) marginally positive functional examination signs have low specificity; (2) FND can coexist with other neurologic comorbidities; and (3) bizarre, not previously encountered, neurologic presentations should not be mistakenly diagnosed as FND. Furthermore, trainees should be encouraged to longitudinally follow in their clinics a subset of patients with FND to develop the interview, diagnostic, and neuropsychiatric skills needed to effectively care for this population. As the landscape of neurologic care evolves, neurologists with expertise in FND should advise on shaping elements of the educational curriculum for neurology residents.

Pain Catastrophizing and Limiting Behavior Mediate the Association Between Anxiety and Postconcussion Symptoms.

BACKGROUND: Despite growing evidence that anxiety is critical in the development and maintenance of postconcussion symptoms after mild traumatic brain injury (mTBI), little is known about potential mechanisms through which anxiety may affect these symptoms. OBJECTIVE: To test the strength and reliability of cognitive (pain catastrophizing) and behavioral (limiting behaviors) pathways mediating the relationship between anxiety and postconcussion symptoms among patients with mTBI. METHOD: Patients with mTBI (N = 57) completed self-report measures of anxiety, postconcussion symptoms, pain catastrophizing, and limiting behavior. After preliminary simple-mediation models (for pain catastrophizing and limiting behavior separately), we ran a multiple-mediation model (pathways modeled simultaneously). Bootstrapping with 10,000 resampling iterations assessed mediation reliability. RESULTS: In preliminary simple mediation models, both pain catastrophizing (ß = 0.24, 95% confidence interval [CI] = 0.03-0.44, P = 0.02) and limiting behaviors (ß = 0.14, 95% CI = 0.03-0.26, P = 0.01) partially mediated the relationship between anxiety and postconcussion symptoms. In the multiple mediation model, pain catastrophizing was a less reliable but numerically stronger mediator (ß = 0.19, 95% CI = -0.01 to 0.38; P = 0.05) and explained more variance in postconcussion symptoms (R2 = 0.41) than limiting behavior (ß = 0.10, 95% CI = 0.02-0.21, P = 0.03; R2 = 0.22), although mediators did not significantly differ in strength (ß = 0.08, 95% CI = -0.16 to 0.32; P = 0.49). Results provide novel evidence for the role of pain catastrophizing and limiting behaviors in explaining the association between anxiety and postconcussion symptoms. Addressing both factors may improve the recovery trajectory of individuals with mTBI. Emphasizing limiting behavior may yield more consistent and reliable effects. CONCLUSION: Results support developing interventions to directly target anxiety, for pain catastrophizing, and for activity engagement despite symptoms, to decrease symptom severity among patients with mTBI.

Comparison of Measures to Predict Mortality and Length of Stay in Hospitalized Patients.

BACKGROUND: Patient risk adjustment is critical for hospital benchmarking and allocation of healthcare resources. However, considerable heterogeneity exists among measures. OBJECTIVES: The performance of five measures was compared to predict mortality and length of stay (LOS) in hospitalized adults using claims data; these include three comorbidity composite scores (Charlson/Deyo age-comorbidity score, V W Elixhauser comorbidity score, and V W Elixhauser age-comorbidity score), 3 M risk of mortality (3 M ROM), and 3 M severity of illness (3 M SOI) subclasses. METHODS: Binary logistic and zero-truncated negative binomial regression models were applied to a 2-year retrospective dataset (2013-2014) with 123,641 adult inpatient admissions from a large hospital system in New York City. RESULTS: All five measures demonstrated good to strong model fit for predicting in-hospital mortality, with C-statistics of 0.74 (95% confidence interval [CI] [0.74, 0.75]), 0.80 (95% CI [0.80, 0.81]), 0.81(95% CI [0.81, 0.82]), 0.94 (95% CI [0.93, 0.94]), and 0.90 (95% CI [0.90, 0.91]) for Charlson/Deyo age-comorbidity score, V W Elixhauser comorbidity score, V W Elixhauser age-comorbidity score, 3 M ROM, and 3 M SOI, respectively. The model fit statistics to predict hospital LOS measured by the likelihood ratio index were 0.3%, 1.2%, 1.1%, 6.2%, and 4.3%, respectively. DISCUSSION: The measures tested in this study can guide nurse managers in the assignment of nursing care and coordination of needed patient services and administrators to effectively and efficiently support optimal nursing care.

Neural networks for sentence comprehension and production: An ALE-based meta-analysis of neuroimaging studies.

Comprehending and producing sentences is a complex endeavor requiring the coordinated activity of multiple brain regions. We examined three issues related to the brain networks underlying sentence comprehension and production in healthy individuals: First, which regions are recruited for sentence comprehension and sentence production? Second, are there differences for auditory sentence comprehension vs. visual sentence comprehension? Third, which regions are specifically recruited for the comprehension of syntactically complex sentences? Results from activation likelihood estimation (ALE) analyses (from 45 studies) implicated a sentence comprehension network occupying bilateral frontal and temporal lobe regions. Regions implicated in production (from 15 studies) overlapped with the set of regions associated with sentence comprehension in the left hemisphere, but did not include inferior frontal cortex, and did not extend to the right hemisphere. Modality differences between auditory and visual sentence comprehension were found principally in the temporal lobes. Results from the analysis of complex syntax (from 37 studies) showed engagement of left inferior frontal and posterior temporal regions, as well as the right insula. The involvement of the right hemisphere in the comprehension of these structures has potentially important implications for language treatment and recovery in individuals with agrammatic aphasia following left hemisphere brain damage.