Head-Mounted Displays for Clinical Virtual Reality Applications: Pitfalls in Understanding User Behavior while Using Technology

The use of virtual environments with head-mounted displays (HMDs) offers unique assets to the evaluation and therapy of clinical populations. However, research examining the effects of this technology on clinical populations is sparse. Understanding how wearers interact with the HMD is vital. Discomfort leads to altered use of the HMD that could confound performance measures; the very measures which might be used as tools for clinical decision making. The current study is a post-hoc analysis of the relationship between HMD use and HMD comfort. The analysis was conducted to examine contributing factors for a high incidence of simulator sickness observed in an HMD-based driving simulator. Pearson correlation analysis was used to evaluate objective and subjective measures of HMD performance and self-reported user comfort ratings. The results indicated weak correlations between these variables, indicating the complexity of quantifying user discomfort and HMD performance. Comparison of two case studies detailing user behavior in the virtual environment demonstrates that selected variables may not capture how individuals use the HMD. The validity and usefulness of the HMD-based virtual environments must be understood to fully reap the benefits of virtual reality (VR) in rehabilitation medicine.

Musical alexia with recovery: a personal account

I describe the experience of an acute loss of ability to read music and play the piano accurately and expressively following an embolic infarct of the right angular and supramarginal gyri in a setting of chronic migraine. Other parietal deficits included a small visual field defect, visual hallucinations, prosopagnosia, topographical disorientation, disturbance of perception of velocity of moving objects and dyscalculia. Recovery began within a month of the ictus after instituting a regular practice routine. The ability to read and play polyphony recovered before the ability to read homophonic music. A substantial degree of recovery of musical function occurred within 6 months and of the other parietal deficits over a year. Failure to maintain regular practice led to marked though recoverable deterioration. An increased frequency of migraine persisted for some 18 months.

A study of humour and communicative intention following right hemisphere stroke

This research provides further data regarding non-literal language comprehension following right hemisphere damage (RHD). To assess the impact of RHD on the processing of non-literal language, ten participants presenting with RHD and ten matched healthy control participants were administered tasks tapping humour appreciation and pragmatic interpretation of non-literal language. Although the RHD participants exhibited a relatively intact ability to interpret humour from jokes, their use of pragmatic knowledge about interpersonal relationships in discourse was significantly reduced, leading to abnormalities in their understanding of communicative intentions (CI). Results imply that explicitly detailing CI in discourse facilitates RHD participants' comprehension of non-literal language.

Thalassemia and learning: Neurocognitive functioning in children

As more effective management and even cure of thalassemia become possible, attention is beginning to be directed to the potential neurologic and resulting neurocognitive effects of this illness on adults and children. Recent studies indicate that for adults with beta-thalassemia major and intermedia, and for children with sickle beta-thalassemia (Sbeta-thalassemia), there is a substantial risk for silent brain infarcts that may be associated with neurocognitive impairment similar to that reported for children with sickle cell anemia. Here the available literature in this area is reviewed and the limited outcomes are compared with those available from large, multicenter longitudinal studies of sickle cell anemia. On the basis of these comparisons, it is recommend that children with thalassemia be screened for specific neuropsychological impairments and that they be provided early intervention and special education access as available under the Individuals with Disabilities Education Act (IDEA) or the 504 Regulations of the Rehabilitation Act of 1973.

Impact of frontal white matter lesions on performance monitoring: ERP evidence for cortical disconnection

We examined the impact of discrete white matter lesions in the frontal lobes on event-related potential (ERP) correlates of performance monitoring. We tested the hypothesis that abnormal performance monitoring may result from injury to white matter without evidence of injury to grey matter in the frontal lobes. It was predicted that such lesions may result in disconnection of the lateral and medial frontal cortices. The close interaction of these two areas has been implicated in performance monitoring. Two fast-choice response tasks were administered to patients with MRI-confirmed frontal white matter lesions due to sickle cell disease (SCD) vasculopathy (n = 11; age = 11-23 years; 6 unilateral left lesions and 5 bilateral lesions) and two control groups: SCD patients without brain lesions and non-sickle cell sibling controls (n = 11 each). Stimulus-locked ERP components N2 and P3 were not significantly affected by presence of lesions. The difference between response-locked components to correct trials (correct-response negativity--CRN) and erroneous trials (error-related negativity--ERN) was diminished in patients with unilateral and bilateral frontal white matter lesions. This finding was due to a significantly attenuated ERN amplitude in lesion patients compared with both sibling and non-lesion control groups. These ERP findings were not due to performance differences between groups and hence reflect a compromised neural substrate underlying performance monitoring. The latter may also contribute to the deficits in executive function tasks observed in these patients. As disruption to ERP markers of error processing was found in the absence of lesions to the lateral or medial frontal cortex, we conclude that a functional connection between these areas facilitates performance monitoring, possibly implemented via tracts traversing the deep frontal white matter.

Changes in Mini Mental State Examination score after stroke: lacunar infarction predicts cognitive decline

Stroke and cognitive impairment are inter-related. The purpose of this study was to show the natural evolution of cognitive performance during the first year after a stroke, and to show which factors that predict cognitive decline. Subjects were patients with a first-ever stroke who were treated in a stroke unit. A total of 160 patients were included. At baseline patients were evaluated with regard to stroke type, stroke severity, pre-stroke dementia and other risk factors. Mini Mental State Examinations (MMSE) were performed after 1 week and after 1 year. Patients had a median increase of 1 point (range -8 to +9) on the MMSE. Thirty-two pre cent of the patients deteriorated, 13% were unchanged, and 55% improved. Lacunar infarction (LI) and left-sided stroke were associated with a failure to exhibit improvement. Patients with LI had an average decline of 1.7 points, whilst patients with other stroke types had an average increase of 1.8 points. Most stroke survivors improve cognitively during the first year after the event. The outcome for LI patients is worse, which suggests that LI may serve as a marker for concomitant processes that cause cognitive decline.

Gene Transfer of Hepatocyte Growth Factor Gene Improves Learning and Memory in the Chronic Stage of Cerebral Infarction

There is no specific treatment to improve the functional recovery in the chronic stage of ischemic stroke. To provide the new therapeutic options, we examined the effect of overexpression of hepatocyte growth factor (HGF) in the chronic stage of cerebral infarction by transferring the HGF gene into the brain using hemagglutinating virus of Japan envelope vector. Sixty rats were exposed to permanent middle cerebral artery occlusion (day 1). Based on the sensorimotor deficits at day 7, the rats were divided equally into control vector or HGF-treated rats. At day 56, rats transfected with the HGF gene showed a significant recovery of learning and memory in Morris water maze tests (control vector 50±4 s; HGF 33±5 s; P <0.05) and passive avoidance task (control vector 132.4±37.5 s; HGF 214.8±26.5 s; P <0.05). Although the total volume of cerebral infarction was not related to the outcome, immunohistochemical analysis for Cdc42 and synaptophysin in the peri-infarct region revealed that HGF enhanced the neurite extension and increased synapses. Immunohistochemistry for glial fibriary acidic protein revealed that the formation of glial scar was also prevented by HGF gene treatment. Additionally, the number of the arteries was increased in the HGF group at day 56. These data demonstrated that HGF has a pivotal role for the functional recovery after cerebral infarction through neuritogenesis, improved microcirculation, and the prevention of gliosis. Our results also provide evidence for the feasibility of gene therapy in the chronic stage of cerebral infarction.

Cognitive profile in CADASIL

BACKGROUND

The spectrum of cognitive alterations associated with CADASIL, a model of pure vascular dementia, has not been thoroughly evaluated.

OBJECTIVES

The aims of this study were: (i) to describe the cognitive profile in CADASIL patients according to age; (ii) to compare the profile of patients with dementia with that of patients without dementia; and (iii) to determine the association between alterations in performance in different cognitive domains.

METHODS

Forty two consecutive individuals with CADASIL (35-73 years old) were investigated. Cognitive skills were analysed in five domains (executive functions, reasoning, attention, memory, visuospatial abilities) according to age and compared between patients with and without dementia. Associations between cognitive performance and stroke were tested.

RESULTS

The youngest patients presented with attention (69%), memory (70%), and executive disturbances (100%). Visuospatial abilities and reasoning deteriorated with age, mainly after the age of 60. About one quarter of patients had dementia, and 75% of these were >60 years of age. Age >60 years was associated with a Rankin score >3 and a significant deficit in all cognitive domains. No association was found between dementia and the number of ischaemic attacks. Episodic memory disorder was characterised by difficulties in retrieval rather than impairment of the encoding process.

CONCLUSION

Cognitive decline in CADASIL is dominated by early impairment of executive functions. Skills in other cognitive domains deteriorate with age and are found to be diffusely impaired in patients with dementia. The relative preservation of the encoding process in episodic memory impairment, even in individuals with dementia, is noteworthy.

Behavioral and histological evaluation of a focal cerebral infarction rat model transplanted with neurons induced from bone marrow stromal cells

Neurons can be specifically induced from bone marrow stromal cells (MSCs) with extremely high efficiency using gene transfection of the Notch intracellular domain and subsequent treatment with basic-fibroblast growth factor, forskolin, and ciliary neurotrophic factor. We investigated the behavioral and histologic efficacy of such bone marrow stromal cell-derived neuronal cell (MSDNC) transplantation into a focal cerebral infarction model in rats. A left middle cerebral artery occlusion (MCAO) was performed on adult Wistar rats. MSDNC transplantation into the ipsilateral hemisphere was performed on day 7 after MCAO. The behavioral analyses were conducted on days 14, 21, 28, 35, and 36-40, and a histologic evaluation was performed on day 41. MSDNC-transplanted rats showed significant recovery compared with controls (MCAO without cell transplantation) in beam balance, limb placing, and Morris water maze tests. Histologically, transplanted cells migrated from the injection site into the ischemic boundary area, including the cortex, corpus callosum, striatum, and hippocampus. Transplanted MSDNCs were positive for MAP-2 (84% +/- 8.11%), whereas only a small number of cells were positive for GFAP (1.0% +/- 0.23%). The survival rates of MSDNCs and MSCs 1 month after transplantation were approximately 45% and 10%, respectively. These results suggest that use of MSDNCs may be a promising therapeutic strategy for cerebral infarction.

[Determining the support needs of patients who live at home following a stroke]

The study "determining the support needs of patients who live at home following a stroke" was chosen because stroke is (one of) the most significant causes of permanent handicap in the elderly. (This project was developed as part of the studies for the degree of Nurse Manager/Teacher:) The results are based on qualitative and quantitative data collected from focus groups and a standardised questionnaire. Due to the small number of participants (57) the study cannot be regarded as representative. Typical key issues such as "going out of the house" were highlighted in the standard questionnaires. The interviews which were evaluated using the Mayring technique give an impression of themes, such as reduced tolerance levels and (greater) increased anxiety, which together with the physical burden dominate their daily life. It was apparent that the persons concerned have a general lack of understanding of their condition. The most significant results of the study are presented together with life enhancing recommendations.

Decreased corpus callosum size in sickle cell disease: relationship with cerebral infarcts and cognitive functioning

We assessed midsagittal corpus callosum size in sickle cell disease (SCD) and its relationship to lesion volume, lesion location, and cognitive functioning. Twenty-eight children with SCD and 16 demographic controls completed magnetic resonance imaging (MRI) and neuropsychological testing. Corpus callosum (CC) size was smaller for children with silent infarcts (n = 8) or overt stroke (n = 8) than for those without visible infarcts (n = 12) or control participants. Lesion volume was a robust predictor of IQ and other cognitive scores; total CC size did not typically add explanatory power for these measures. The size of the rostral body of the CC, however, independently predicted measures of distractibility, speeded production, and working memory. Posterior CC size was also decreased among many of the children with SCD, even in the absence of visible infarcts in this region. Brain morphology appears to provide additional information about SCD-related effects on the brain above and beyond visible infarcts.

What does recovery from anomia tell us about the underlying impairment: The case of similar anomic patterns and different recovery

Although word-finding difficulties have been largely studied from a theoretical and a rehabilitation point of view, recovery mechanisms and especially the fact that patients with similar anomic patterns may exhibit different recovery, are still not fully understood. In the first part of the present study we investigated the word retrieval curve during therapy and the psycholinguistic variables affecting word-finding recovery patterns in three anomic subjects (PG, AH and TM). Despite the fact that all patients had similar anomia at baseline, they presented different recovery patterns during an identical therapy program. The progress during therapy and the number of sessions necessary to reach satisfactory improvement was similar in two patients (AH and TM), but differed in the third patient (PG), who needed more treatment sessions. Moreover, these two different patterns were affected by different psycholinguistic variables: words age of acquisition predicted improvement in AH and TM, whereas phonological neighbourhood predicted improvement in PG. Following the observation that phonological neighbourhood density affected the slower progress during therapy, in the second study we analysed whether this variable also predicts pseudo-word learning in healthy controls and in anomic subjects. Indeed, phonological neighbourhood predicted pseudo-word learning speed in controls and in some anomic patients. We suggest that the analysis of progress during therapy for anomia and the comparison of the variables affecting learning and recovery may provide information about the underlying nature of the anomic deficit that is not available through the simple assessment of performance.

Frequency of attendance at religious services, cardiovascular disease, metabolic risk factors and dietary intake in Americans: an age-stratified exploratory analysis

BACKGROUND

Few data have been published on the association of attendance at religious services with cardiovascular morbidity and dietary and metabolic risk factors in representative samples of populations despite a known inverse association with mortality and smoking.

OBJECTIVE

To test the null hypothesis that frequency of attendance at religious services is unrelated to prevalence or levels of cardiovascular disease, dietary and metabolic risk factors.

DESIGN

Cross-sectional survey of a large national sample.

PARTICIPANTS

American men and women aged 20 years and over with complete data in the Third National Health and Nutrition Examination Survey (N = 14,192).

MEASUREMENTS

Self-reported frequency of attendance at religious services, history of doctor-diagnosed diseases, food intake frequency, 24-hour dietary intake, health status, socio-demographic variables and measured serum lipids and body mass index.

RESULTS

Weekly attenders were significantly less likely to report stroke, even after adjusting for multiple variables only in African American women OR = 0.35, 95% CI 0.19-0.66, p < 0.01. No association was seen for heart attack or diabetes. Fish intake at least weekly was more common in weekly attenders, significantly so only in African American women (odds ratio 1.24, 95% CI 1.01-1.58, p < 0.05) and in older Mexican American men (odds ratio 2.57, 95% CI 1.45-2.57, p < 0.01). In linear regression analyses, no significant independent associations were seen between attendance frequency and serum lipid levels or dietary intake of energy, or fat in g and % of kcal.

CONCLUSION

Hypotheses generated by these analyses are that in African American women stroke is less prevalent and weekly fish intake more prevalent among weekly attenders than others and that there are no significant independent associations of serum lipids, dietary intake, prevalent CHD, or diabetes with frequency of attendance of religious services. Independent testing of these hypotheses in other samples is needed.

Goal-driven selective attention in patients with right hemisphere lesions: how intact is the ipsilesional field?

Patients with right hemisphere (RH) lesions often display a spatial bias in attention towards the ipsilesional hemifield. The behavioural manifestations of this spatial bias are typically interpreted as reflecting increased or enhanced attention for stimuli within the 'intact' ipsilesional field, and impaired attentional functioning within the contralesional field. In the healthy brain, goal-driven and stimulus-driven attentional processes interact to determine which stimuli should be prioritized for selection. Although unilateral brain damage increases the relative attentional salience of stimuli within the ipsilesional field, it might also cause problems in filtering or attenuating task-irrelevant information. We examined whether goal-driven attention modulates the processing of ipsilesional and contralesional information in 6 patients with unilateral brain damage following RH stroke (5 male, 1 female; mean age 60.8 years) and a group of age and sex-matched controls. We used a flanker task in which participants made speeded judgements on a central target item (a coloured letter). On each trial the target was flanked by a coloured letter in the left and right hemifields. In separate blocks, participants were instructed to judge either the identity or the colour of the central target and to ignore the flankers. The flanker on one side could be congruent, incongruent or neutral with respect to the target, on either the letter or the colour dimension, whereas the flanker on the other side was always neutral on both dimensions. Healthy controls showed significant interference from incongruent flankers on either side. Crucially, however, this effect only occurred for the task-relevant dimension [F(2,10) = 24.60; P < 0.001]. For patients, however, both the task-relevant and task-irrelevant dimensions of ipsilesional flankers interfered with response times [task-relevant: F(2,10) = 7.50, P < 0.05; task-irrelevant: F(1,5) = 6.20, P < 0.05]. Conversely, contralesional flankers influenced response times only when the target and distractor were incongruent on the task-relevant dimension [F(2,10) = 4.85; P < 0.05]. Our findings demonstrate that following RH damage, goal-driven biases cannot constrain the processing of task-irrelevant features of ipsilesional stimuli. We speculate that a lateralized bias in spatial attention leads to unselective prioritization of all feature-based attributes of stimuli appearing within the ipsilesional hemifield, whether or not they are relevant to performance. Attentional selection for ipsilesional stimuli in disorders such as spatial neglect and extinction may not therefore be entirely normal, as previously assumed.

Isolated continuous rhythmic involuntary tongue movements following a pontine infarct

Isolated involuntary tongue movements are rare and poorly understood. The anatomical substrate and pathogenesis underlying involuntary tongue movements remain elusive. We describe a patient who developed isolated continuous rhythmic involuntary tongue movements after pontine infarct without evidence of hypertrophy of inferior olivary nucleus on follow-up magnetic resonance image. We discuss the rhythmic involuntary tongue movements as a prototype of involuntary hyperkinetic movement released by a central pacemaker.

The alien hand syndrome: report of a case and review of the literature

The term "alien hand syndrome (AHS)" comprises many clinical signs of which the common features are the involuntary motor movement of the affected limb and the denial of limb ownership. It can result from several diseases involving corpus callosum or medial frontal cortex. Two major types of AHS were previously classified, callosal and frontal types. Moreover posterior subtype of which the lesions do not involve corpus callosum have been reported. In the present report, the authors describe a 57-year-old man with AHS, aggressive behavior and hemispatial neglect which are the rare manifestations of callosal damage. Neuroimaging demonstrated subacute infarction of entire corpus callosum from the rostrum to splenium. A review of the literature on these abnormalities is included in the present paper.

Impaired concentration due to frontal lobe damage from two distinct lesion sites

BACKGROUND

Investigations of cognitive deficits after frontal lobe damage have commonly relied on multidimensional tests and relatively coarse specification of lesion anatomy. Some form of impairment in attention is often asserted to cause the revealed deficits.

OBJECTIVE

To describe a disorder of attention in patients with frontal damage using a theoretical model of the fundamental cognitive processes that underlie attention.

METHODS

The ability to perform a task of concentrated responding was studied in 43 patients with well-defined chronic frontal lesions and 38 control subjects using a continuous reaction time (RT) test. Performance measures were mean RT, RT across blocks of the test, and errors. Lesion measures were coarse localization and a hot-spot analysis to detect finer grained lesion effects.

RESULTS

Only patients with lesions in the right superomedial (SM) frontal regions had significantly prolonged RT consistently across the entire test. The critical lesion was in Brodmann's areas 24, 32, 9, and 46 days and in the adjacent corpus callosum. Patients with lesions in left lateral frontal (LL) regions made significantly more errors on the 20% of trials in the first block. The critical lesion was in areas 44, 45, and 47/12.

CONCLUSION

Concentrating attention to respond is affected by lesions in two different frontal regions for reasons that reflect impairments in different cognitive processes. Right superomedial lesions cause an insufficient energizing of attention to respond. Left lateral lesions cause defective setting of specific stimulus-response contingencies. Constrained tests of attention can demonstrate impairments in specific cognitive operations following lesions to different regions of the frontal lobes.

Fatigue at long-term follow-up in young adults with cerebral infarction

BACKGROUND

To study the impact of fatigue in young ischaemic stroke patients.

METHODS

The Fatigue Severity Scale score was obtained in 192 patients (mean time 6.0 years after the stroke) and 212 controls.

RESULTS

Fatigue was associated with cerebral infarction in a multivariate analysis of patients and controls (p = 0.002). Fatigue was independently associated with unfavourable functional outcome (p = 0.001), depression (p < 0.001), and basilar artery infarction through interaction with the modified Rankin Scale score (p = 0.047) in patients.

CONCLUSION

Fatigue is frequent in young adults with cerebral infarction. Stroke-related factors independently associated with fatigue include functional outcome. Stroke location may influence fatigue.

Cerebellar lesions in the PICA but not SCA territory impair cognition

The authors sought to clarify whether lesions in different parts of the cerebellum result in differential cognitive and affective impairment. Six subjects with cerebellar lesions due to posterior inferior cerebellar artery (PICA) infarction, five subjects with lesions in the SCA vascular territory, and 11 matched controls were administered a battery of standard neuropsychological tests. PICA lesions but not SCA lesions resulted in cognitive and affective deficits pointing to a dominant role of posterior cerebellar regions in cognitive and affective processing.

Characteristics of Mini-Mental State Examination 1 year after stroke

OBJECTIVES

The Mini-Mental State Examination (MMSE) is commonly used to evaluate cognition after stroke. The purpose of this study was to describe the properties of MMSE in relation to different stroke characteristics.

MATERIALS AND METHODS

Subjects were survivors (n = 253) of a population-based cohort who had had a first-ever stroke 1 year earlier. At baseline, patients were evaluated with regard to stroke type, stroke severity, unilateral neglect, and prestroke dementia. The 1-year follow-up included an MMSE, a functional evaluation according to the modified Rankin Scale (MRS) and a question regarding subjective memory problems.

RESULTS

The mean MMSE was 24.9. Patients with lacunar infarction scored 26.6. Impact of hemisphere localization was insignificant. Twenty-nine percent of the patients had cognitive impairment (cut-off <24). After adjustment for age and education, 16% had cognitive impairment; 41% of the patients had subjective memory problems. The kappa-value between subjective memory problems and dichotomized MMSE was 0.21. Patients with cognitive impairment scored at average 1.8 higher on the MRS.

CONCLUSIONS

If cut-off is used, the MMSE should be adjusted for age and education; otherwise the prevalence of cognitive impairment may be overestimated. Cognitive impairment heavily influences functional outcome. Subjective memory problems correlate poorly with MMSE. The impact of hemisphere location may previously have been overestimated.

Directed and divided attention during hierarchical processing in patients with visuo-spatial neglect and matched healthy volunteers

Hierarchically organized figures (for example, a large E made up of smaller N's) are frequently used to investigate directed and divided attention. Investigations of neurological and psychiatric patients, and also tachistoscopic and functional neuroimaging studies on healthy subjects, typically find the right hemisphere to be specialized for the processing of global stimuli and the left hemisphere to be specialized for the processing of local stimuli. In the current study, a group of 12 patients with visuo-spatial neglect (NP) after right hemisphere lesions and 12 age and sex-matched control subjects (CO) performed a directed and a divided attention task with hierarchically organized letters. As expected, faster reaction times were found for control subjects than for neglect patients, especially for the directed global attention task. Lower error rates were found for CO and NP for local than for global targets during the divided attention condition. Local on global interference was found for both groups in reaction times. These local processing advantages for older healthy adults have been reported previously. Additionally, an impairment in the divided attention task was found in both groups, but especially for global targets in NP. This impairment is consistent with other evidence of difficulty in disengaging attention shown by patients with visuo-spatial neglect.

Deficits of motion integration and segregation in patients with unilateral extrastriate lesions

Functional neuroimaging in human subjects and single cell recordings in monkeys show that several extra-striate visual areas are activated by visual motion. However, the extent to which different types of motion are processed in different regions remains unclear, although neuropsychological studies of patients with circumscribed lesions hint at regional specialization. We, therefore, studied four patients with unilateral damage to different regions of extrastriate visual cortex on a series of visual discrimination tasks that required them, to a different extent, to integrate local motion signals in order to correctly perceive the direction of global motion. Performance was assessed psychophysically and compared with that of control subjects and with the patients' performance with stimuli presented in the visual field ipsilateral to the lesion. The results indicate considerable regional specialization in extra-striate regions for different aspects of motion processing, namely the largest displacement from frame to frame (D-max) that can sustain perception of coherent motion; perception of relative speed; the amount of coherent motion needed to sustain a percept of global motion in a particular direction; the detection of discontinuities within a moving display; the extraction of form from motion. It was also clear that a defect in local motion, i.e. D-max, can be overcome by integrating local motion signals over a longer period of time. Although no patient suffered from only one defect, the overall pattern of results strongly supports the notion of regional specialization for different aspects of motion processing.

Cerebral small-vessel disease and decline in information processing speed, executive function and memory

Cerebral small-vessel disease is common in older people and may contribute to the development of dementia. The objective of the present study was to evaluate the relationship between measures of cerebral small-vessel disease on MRI and the rate of decline in specific cognitive domains in participants from the prospective, population-based Rotterdam Scan Study. Participants were 60-90 years of age and free from dementia at baseline in 1995-1996. White matter lesions (WML), cerebral infarcts and generalized brain atrophy were assessed on the baseline MRI. We performed neuropsychological testing at baseline and repeatedly in 1999-2000 and in 2001-2003. We used random-effects models for repeated measures to examine the association between quantitative MRI measures and rate of decline in measures of global cognitive function, information processing speed, executive function and memory. There were a total of 2266 assessments for the 832 participants in the study, with an average time from the initial to last assessment of 5.2 years. Increasing severity of periventricular WML and generalized brain atrophy and the presence of brain infarcts on MRI were associated with a steeper decline in cognitive function. These structural brain changes were specifically associated with decline in information processing speed and executive function. The associations between MRI measures of cerebral small-vessel disease and cognitive decline did not change after additional adjustment for vascular risk factors or depressed mood. After exclusion of participants with an incident stroke, some of the associations of periventricular WML, brain infarcts and generalized brain atrophy with measures of information processing speed and executive function were no longer significant. This may indicate that stroke plays an intermediate role in the relationship between cerebral small-vessel disease and cognitive decline. Our results suggest that in older people cerebral small-vessel disease may contribute to cognitive decline by affecting information processing speed and executive function.