Noradrenergic enhancement improves motor network connectivity in stroke patients

Dopaminergic modulation of motor network dynamics in Parkinson's disease

Using connectivity analyses based on functional MRI, Michely et al. investigate dopaminergic modulation of neural network dynamics involved in motor control in Parkinson’s disease. The findings provide insights into the pathophysiology underlying bradykinesia and deficits in executive function, and help to explain why dopaminergic treatments have a greater effect on the former.

Although characteristic motor symptoms of Parkinson’s disease such as bradykinesia typically improve under dopaminergic medication, deficits in higher motor control are less responsive. We here investigated the dopaminergic modulation of network dynamics underlying basic motor performance, i.e. finger tapping, and higher motor control, i.e. internally and externally cued movement preparation and selection. Twelve patients, assessed ON and OFF medication, and 12 age-matched healthy subjects underwent functional magnetic resonance imaging. Dynamic causal modelling was used to assess effective connectivity in a motor network comprising cortical and subcortical regions. In particular, we investigated whether impairments in basic and higher motor control, and the effects induced by dopaminergic treatment are due to connectivity changes in (i) the mesial premotor loop comprising the supplementary motor area; (ii) the lateral premotor loop comprising lateral premotor cortex; and (iii) cortico-subcortical interactions. At the behavioural level, we observed a marked slowing of movement preparation and selection when patients were internally as opposed to externally cued. Preserved performance during external cueing was associated with enhanced connectivity between prefrontal cortex and lateral premotor cortex OFF medication, compatible with a context-dependent compensatory role of the lateral premotor loop in the hypodopaminergic state. Dopaminergic medication significantly improved finger tapping speed in patients, which correlated with a drug-induced coupling increase of prefrontal cortex with the supplementary motor area, i.e. the mesial premotor loop. In addition, only in the finger tapping condition, patients ON medication showed enhanced excitatory influences exerted by cortical premotor regions and the thalamus upon the putamen. In conclusion, the amelioration of bradykinesia by dopaminergic medication seems to be driven by enhanced connectivity within the mesial premotor loop and cortico-striatal interactions. In contrast, medication did not improve internal motor control deficits concurrent to missing effects at the connectivity level. This differential effect of dopaminergic medication on the network dynamics underlying motor control provides new insights into the clinical finding that in Parkinson’s disease dopaminergic drugs especially impact on bradykinesia but less on executive functions.

The promotion of recovery through rehabilitation after acquired brain injury in children

A degree of motor recovery is typically seen after acquired brain injury in children. The extent to which rehabilitation efforts can claim credit for this is disputed. Strong correlations between late impairment outcomes and early severity and impairment indices are seen both in adults and children. These correlations have been interpreted by some as evidence that recovery is largely intrinsic and that any additional rehabilitation effects are small. Such views are belied by published animal studies demonstrating the possibility of large rehabilitation effects. Animal models suggest that to achieve similar rehabilitation treatment effect sizes in clinical practice, rehabilitation 'doses' should be greater, rehabilitation efforts should start sooner, and premature accommodation of impairment should be avoided.

Handedness and effective connectivity of the motor system

Handedness denotes the individual predisposition to consistently use the left or right hand for most types of skilled movements. A putative neurobiological mechanism for handedness consists in hemisphere-specific differences in network dynamics that govern unimanual movements. We, therefore, used functional magnetic resonance imaging and dynamic causal modeling to investigate effective connectivity between key motor areas during fist closures of the dominant or non-dominant hand performed by 18 right- and 18 left-handers. Handedness was assessed employing the Edinburgh-Handedness-Inventory (EHI). The network of interest consisted of key motor regions in both hemispheres including the primary motor cortex (M1), supplementary motor area (SMA), ventral premotor cortex (PMv), motor putamen (Put) and motor cerebellum (Cb). The connectivity analysis revealed that in right-handed subjects movements of the dominant hand were associated with significantly stronger coupling of contralateral (left, i.e., dominant) SMA with ipsilateral SMA, ipsilateral PMv, contralateral motor putamen and contralateral M1 compared to equivalent connections in left-handers. The degree of handedness as indexed by the individual EHI scores also correlated with coupling parameters of these connections. In contrast, we found no differences between right- and left-handers when testing for the effect of movement speed on effective connectivity. In conclusion, the data show that handedness is associated with differences in effective connectivity within the human motor network with a prominent role of SMA in right-handers. Left-handers featured less asymmetry in effective connectivity implying different hemispheric mechanisms underlying hand motor control compared to right-handers.

Identifying Neuroimaging Markers of Motor Disability in Acute Stroke by Machine Learning Techniques

Conventional mass-univariate analyses have been previously used to test for group differences in neural signals. However, machine learning algorithms represent a multivariate decoding approach that may help to identify neuroimaging patterns associated with functional impairment in "individual" patients. We investigated whether fMRI allows classification of individual motor impairment after stroke using support vector machines (SVMs). Forty acute stroke patients and 20 control subjects underwent resting-state fMRI. Half of the patients showed significant impairment in hand motor function. Resting-state connectivity was computed by means of whole-brain correlations of seed time-courses in ipsilesional primary motor cortex (M1). Lesion location was identified using diffusion-weighted images. These features were used for linear SVM classification of unseen patients with respect to motor impairment. SVM results were compared with conventional mass-univariate analyses. Resting-state connectivity classified patients with hand motor deficits compared with controls and nonimpaired patients with 82.6-87.6% accuracy. Classification was driven by reduced interhemispheric M1 connectivity and enhanced connectivity between ipsilesional M1 and premotor areas. In contrast, lesion location provided only 50% sensitivity to classify impaired patients. Hence, resting-state fMRI reflects behavioral deficits more accurately than structural MRI. In conclusion, multivariate fMRI analyses offer the potential to serve as markers for endophenotypes of functional impairment.

Connectivity-based approaches in stroke and recovery of function

After focal damage, cerebral networks reorganise their structural and functional anatomy to compensate for both the lesion itself and remote effects. Novel developments in the analysis of functional neuroimaging data enable us to assess in vivo the specific contributions of individual brain areas to recovery of function and the effect of treatment on cortical reorganisation. Connectivity analyses can be used to investigate the effect of stroke on cerebral networks, and help us to understand why some patients make a better recovery than others. This systems-level view also provides insights into how neuromodulatory interventions might target pathological network configurations associated with incomplete recovery. In the future, such analyses of connectivity could help to optimise treatment regimens based on the individual network pathology underlying a particular neurological deficit, thereby opening the way for stratification of patients based on the possible response to an intervention.

Acupuncture Enhances Effective Connectivity between Cerebellum and Primary Sensorimotor Cortex in Patients with Stable Recovery Stroke

Recent neuroimaging studies have demonstrated that stimulation of acupuncture at motor-implicated acupoints modulates activities of brain areas relevant to the processing of motor functions. This study aims to investigate acupuncture-induced changes in effective connectivity among motor areas in hemiparetic stroke patients by using the multivariate Granger causal analysis. A total of 9 stable recovery stroke patients and 8 healthy controls were recruited and underwent three runs of fMRI scan: passive finger movements and resting state before and after manual acupuncture stimuli. Stroke patients showed significantly attenuated effective connectivity between cortical and subcortical areas during passive motor task, which indicates inefficient information transmissions between cortical and subcortical motor-related regions. Acupuncture at motor-implicated acupoints showed specific modulations of motor-related network in stroke patients relative to healthy control subjects. This specific modulation enhanced bidirectionally effective connectivity between the cerebellum and primary sensorimotor cortex in stroke patients, which may compensate for the attenuated effective connectivity between cortical and subcortical areas during passive motor task and, consequently, contribute to improvement of movement coordination and motor learning in subacute stroke patients. Our results suggested that further efficacy studies of acupuncture in motor recovery can focus on the improvement of movement coordination and motor learning during motor rehabilitation.

Upper limb recovery after stroke is associated with ipsilesional primary motor cortical activity: a meta-analysis

BACKGROUND AND PURPOSE

Although neuroimaging studies have revealed specific patterns of reorganization in the sensorimotor control network after stroke, their role in recovery remains unsettled. To review the existing evidence systematically, we performed activation likelihood estimation meta-analysis of functional neuroimaging studies investigating upper limb movement-related brain activity after stroke.

METHODS

Twenty-four studies using sensorimotor tasks in standardized coordinates were included, totaling 255 patients and 145 healthy controls. Across the entire brain, we compared task-related activity patterns in good and poor recovery and assessed the magnitude of spatial shifts in sensorimotor activity in cortical motor areas after stroke.

RESULTS

When compared with healthy controls, patients showed higher activation likelihood estimation values in contralesional primary motor soon after stroke that abated with time, but were not related to motor outcome. The observed activity changes were consistent with restoration of typical interhemispheric balance. In contrast, activation likelihood estimation values in ipsilesional medial-premotor and primary motor cortex were associated with good outcome, reorganization that may reflect vicarious processes associated with ventral activity shifts from BA4a to 4p. In the anterior cerebellum, a novel finding was the association of poor recovery with increased vermal activity, possibly reflecting behaviorally inadequate compensatory strategies engaging the fastigio-thalamo-cortical and corticoreticulospinal systems.

CONCLUSIONS

Activity in ipsilesional primary motor and medial-premotor cortices in chronic stroke signals good motor recovery, whereas cerebellar vermis activity signals poor recovery. Functional MRI may be useful in identifying recovery biomarkers.

Intrinsic coupling modes: multiscale interactions in ongoing brain activity

Intrinsic coupling constitutes a key feature of ongoing brain activity, which exhibits rich spatiotemporal patterning and contains information that influences cognitive processing. We discuss evidence for two distinct types of intrinsic coupling modes which seem to reflect the operation of different coupling mechanisms. One type arises from phase coupling of band-limited oscillatory signals, whereas the other results from coupled aperiodic fluctuations of signal envelopes. The two coupling modes differ in their dynamics, their origins, and their putative functions and with respect to their alteration in neuropsychiatric disorders. We propose that the concept of intrinsic coupling modes can provide a unifying framework for capturing the dynamics of intrinsically generated neuronal interactions at multiple spatial and temporal scales.

The role of citicoline in neuroprotection and neurorepair in ischemic stroke

Advances in acute stroke therapy resulting from thrombolytic treatment, endovascular procedures, and stroke units have improved significantly stroke survival and prognosis; however, for the large majority of patients lacking access to advanced therapies stroke mortality and residual morbidity remain high and many patients become incapacitated by motor and cognitive deficits, with loss of independence in activities of daily living. Therefore, over the past several years, research has been directed to limit the brain lesions produced by acute ischemia (neuroprotection) and to increase the recovery, plasticity and neuroregenerative processes that complement rehabilitation and enhance the possibility of recovery and return to normal functions (neurorepair). Citicoline has therapeutic effects at several stages of the ischemic cascade in acute ischemic stroke and has demonstrated efficiency in a multiplicity of animal models of acute stroke. Long-term treatment with citicoline is safe and effective, improving post-stroke cognitive decline and enhancing patients' functional recovery. Prolonged citicoline administration at optimal doses has been demonstrated to be remarkably well tolerated and to enhance endogenous mechanisms of neurogenesis and neurorepair contributing to physical therapy and rehabilitation.

Beyond the lesion: neuroimaging foundations for post-stroke recovery

A shift is emerging in the way in which we view post-stroke recovery. This shift, supported by evidence from neuroimaging studies, encourages us to look beyond the lesion and to identify viable brain networks with capacity for plasticity. In this article, the authors review current advances in neuroimaging techniques and the new insights that they have contributed. The ability to quantify salvageable tissue, evidence of changes in remote networks, changes of functional and structural connectivity, and alterations in cortical thickness are reviewed in the context of their impact on post-stroke recovery. The value of monitoring spared structural connections and functional connectivity of brain networks within and across hemispheres is highlighted.

Management of patients with stroke: is it time to expand treatment options?

Approximately 700,000 people in the United States have an ischemic stroke annually. Substantial research has tested therapies for the very early treatment of ischemic stroke but, to date, only intravenous thrombolysis and intra-arterial measures to restore perfusion have shown success. Despite a 15-year effort to increase the use of these therapies, only approximately 5% of patients with stroke are currently being treated. Although most patients with stroke have some neurological recovery, more than half of stroke survivors have residual impairments that lead to disability or long-term institutionalized care. Laboratory research has demonstrated several mechanisms that help the brain to recover after a stroke. New pharmacological and cell-based approaches that are known to promote brain plasticity are emerging from laboratory studies and may soon expand the window for stroke treatment to restore function. It is time to build on this knowledge and to translate the understanding of recovery after stroke into the clinical setting. Measures that might augment recovery should become a major focus of clinical research in stroke in the 21st century.

Biomarkers and predictors of restorative therapy effects after stroke

Many restorative therapies that promote brain repair are under development. Stroke is very heterogeneous, highlighting the need to identify target populations and to understand intersubject differences in treatment response. Several neuroimaging measures have shown promise as biomarkers and predictors, including measures of structure and function, in gray matter and white matter. The choice of biomarker and predictor can differ with the content of therapy and with the population under study, for example, contralesional hemisphere measures may be of particular importance in patients with more severe injury. Studies of training effects in healthy subjects provide insights useful to brain repair. Limitations of published studies include a focus on chronic stroke, however the brain is most galvanized to respond to restorative therapies in the early days after stroke. Multimodal approaches might be the most robust approach for stratifying patients and so for optimizing prescription of restorative therapies after stroke.

Network dynamics engaged in the modulation of motor behavior in healthy subjects

Motor skills are mediated by a dynamic and finely regulated interplay of the primary motor cortex (M1) with various cortical and subcortical regions engaged in movement preparation and execution. To date, data elucidating the dynamics in the motor network that enable movements at different levels of behavioral performance remain scarce. We here used functional magnetic resonance imaging (fMRI) and dynamic causal modeling (DCM) to investigate effective connectivity of key motor areas at different movement frequencies performed by right-handed subjects (n=36) with the left or right hand. The network of interest consisted of motor regions in both hemispheres including M1, supplementary motor area (SMA), ventral premotor cortex (PMv), motor putamen, and motor cerebellum. The connectivity analysis showed that performing hand movements at higher frequencies was associated with a linear increase in neural coupling strength from premotor areas (SMA, PMv) contralateral to the moving hand and ipsilateral cerebellum towards contralateral, active M1. In addition, we found hemispheric differences in the amount by which the coupling of premotor areas and M1 was modulated, depending on which hand was moved. Other connections were not modulated by changes in motor performance. The results suggest that a stronger coupling, especially between contralateral premotor areas and M1, enables increased motor performance of simple unilateral hand movements.

Brain connectivity plasticity in the motor network after ischemic stroke

The motor function is controlled by the motor system that comprises a series of cortical and subcortical areas interacting via anatomical connections. The motor function will be disturbed when the stroke lesion impairs either any of these areas or their connections. More and more evidence indicates that the reorganization of the motor network including both areas and their anatomical and functional connectivity might contribute to the motor recovery after stroke. Here, we review recent studies employing models of anatomical, functional, and effective connectivity on neuroimaging data to investigate how ischemic stroke influences the connectivity of motor areas and how changes in connectivity relate to impaired function and functional recovery. We suggest that connectivity changes constitute an important pathophysiological aspect of motor impairment after stroke and important mechanisms of motor recovery. We also demonstrate that therapeutic interventions may facilitate motor recovery after stroke by modulating the connectivity among the motor areas. In conclusion, connectivity analyses improved our understanding of the mechanisms of motor recovery after stroke and may help to design hypothesis-driven treatment strategies and sensitive measures for outcome prediction in stroke patients.

Interregional compensatory mechanisms of motor functioning in progressing preclinical neurodegeneration

Understanding brain reserve in preclinical stages of neurodegenerative disorders allows determination of which brain regions contribute to normal functioning despite accelerated neuronal loss. Besides the recruitment of additional regions, a reorganisation and shift of relevance between normally engaged regions are a suggested key mechanism. Thus, network analysis methods seem critical for investigation of changes in directed causal interactions between such candidate brain regions. To identify core compensatory regions, fifteen preclinical patients carrying the genetic mutation leading to Huntington's disease and twelve controls underwent fMRI scanning. They accomplished an auditory paced finger sequence tapping task, which challenged cognitive as well as executive aspects of motor functioning by varying speed and complexity of movements. To investigate causal interactions among brain regions a single Dynamic Causal Model (DCM) was constructed and fitted to the data from each subject. The DCM parameters were analysed using statistical methods to assess group differences in connectivity, and the relationship between connectivity patterns and predicted years to clinical onset was assessed in gene carriers.

In preclinical patients, we found indications for neural reserve mechanisms predominantly driven by bilateral dorsal premotor cortex, which increasingly activated superior parietal cortices the closer individuals were to estimated clinical onset. This compensatory mechanism was restricted to complex movements characterised by high cognitive demand. Additionally, we identified task-induced connectivity changes in both groups of subjects towards pre- and caudal supplementary motor areas, which were linked to either faster or more complex task conditions. Interestingly, coupling of dorsal premotor cortex and supplementary motor area was more negative in controls compared to gene mutation carriers. Furthermore, changes in the connectivity pattern of gene carriers allowed prediction of the years to estimated disease onset in individuals.

Our study characterises the connectivity pattern of core cortical regions maintaining motor function in relation to varying task demand. We identified connections of bilateral dorsal premotor cortex as critical for compensation as well as task-dependent recruitment of pre- and caudal supplementary motor area. The latter finding nicely mirrors a previously published general linear model-based analysis of the same data. Such knowledge about disease specific inter-regional effective connectivity may help identify foci for interventions based on transcranial magnetic stimulation designed to stimulate functioning and also to predict their impact on other regions in motor-associated networks.

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Connectivity of a motor network is altered in preclinical neurodegeneration.

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Dynamic Causal Modelling reveals task-dependent recruitment of pre- and caudal SMA.

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Connectivity of the dorsal premotor cortex reveals compensatory mechanisms.

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DCM allows prediction of years to clinical onset in preclinical patients.

Stroke rehabilitation: recent advances and future therapies

Despite advances in the acute management of stroke, a large proportion of stroke patients are left with significant impairments. Over the coming decades the prevalence of stroke-related disability is expected to increase worldwide and this will impact greatly on families, healthcare systems and economies. Effective neuro-rehabilitation is a key factor in reducing disability after stroke. In this review, we discuss the effects of stroke, principles of stroke rehabilitative care and predictors of recovery. We also discuss novel therapies in stroke rehabilitation, including non-invasive brain stimulation, robotics and pharmacological augmentation. Many trials are currently underway, which, in time, may impact on future rehabilitative practice.

Cerebral network disorders after stroke: evidence from imaging-based connectivity analyses of active and resting brain states in humans

Stroke causes a sudden disruption of physiological brain function which leads to impairments of functional brain networks involved in voluntary movements. In some cases, the brain has the intrinsic capacity to reorganize itself, thereby compensating for the disruption of motor networks. In humans, such reorganization can be investigated in vivo using neuroimaging. Recent developments in connectivity analyses based on functional neuroimaging data have provided new insights into the network pathophysiology underlying neurological symptoms. Here we review recent neuroimaging studies using functional resting-state correlations, effective connectivity models or graph theoretical analyses to investigate changes in neural motor networks and recovery after stroke. The data demonstrate that network disturbances after stroke occur not only in the vicinity of the lesion but also between remote cortical areas in the affected and unaffected hemisphere. The reorganization of motor networks encompasses a restoration of interhemispheric functional coherence in the resting state, particularly between the primary motor cortices. Furthermore, reorganized neural networks feature strong excitatory interactions between fronto-parietal areas and primary motor cortex in the affected hemisphere, suggesting that greater top-down control over primary motor areas facilitates motor execution in the lesioned brain. In addition, there is evidence that motor recovery is accompanied by a more random network topology with reduced local information processing. In conclusion, Stroke induces changes in functional and effective connectivity within and across hemispheres which relate to motor impairments and recovery thereof. Connectivity analyses may hence provide new insights into the pathophysiology underlying neurological deficits and may be further used to develop novel, neurobiologically informed treatment strategies.

Pro-cognitive drug effects modulate functional brain network organization

Previous studies document that cholinergic and noradrenergic drugs improve attention, memory and cognitive control in healthy subjects and patients with neuropsychiatric disorders. In humans neural mechanisms of cholinergic and noradrenergic modulation have mainly been analyzed by investigating drug-induced changes of task-related neural activity measured with functional magnetic resonance imaging (fMRI). Endogenous neural activity has often been neglected. Further, although drugs affect the coupling between neurons, only a few human studies have explicitly addressed how drugs modulate the functional connectome, i.e., the functional neural interactions within the brain. These studies have mainly focused on synchronization or correlation of brain activations. Recently, there are some drug studies using graph theory and other new mathematical approaches to model the brain as a complex network of interconnected processing nodes. Using such measures it is possible to detect not only focal, but also subtle, widely distributed drug effects on functional network topology. Most important, graph theoretical measures also quantify whether drug-induced changes in topology or network organization facilitate or hinder information processing. Several studies could show that functional brain integration is highly correlated with behavioral performance suggesting that cholinergic and noradrenergic drugs which improve measures of cognitive performance should increase functional network integration. The purpose of this paper is to show that graph theory provides a mathematical tool to develop theory-driven biomarkers of pro-cognitive drug effects, and also to discuss how these approaches can contribute to the understanding of the role of cholinergic and noradrenergic modulation in the human brain. Finally we discuss the "global workspace" theory as a theoretical framework of pro-cognitive drug effects and argue that pro-cognitive effects of cholinergic and noradrenergic drugs might be related to higher network integration.

Differential effects of dopaminergic medication on basic motor performance and executive functions in Parkinson's disease

BACKGROUND

Patients with Parkinson's disease (PD) often show deficits in the self-initiation and selection of movements, which can be partly compensated for by external cues. We here investigated impairments in the initiation and selection of self-initiated or externally cued movements in PD. Specifically, we assessed how behavioral changes relate to medication, disease severity, and basic motor or cognitive deficits.

METHODS

Seventeen akinetic-rigid PD patients and 16 healthy controls (HC) performed a computerized motor task assessing differences between internally and externally triggered movements and reaction times. Patients performed the task twice in a randomized fashion, once with their regular dopaminergic medication and once 12h after withdrawal of medication. Additionally, all subjects underwent comprehensive neuropsychological and motor assessments.

RESULTS

Compared to HC, patients showed a significant slowing across all tasks. Furthermore, patients showed a selective deficit of movement initiation as indexed by longer reaction times when movement lateralization was internally chosen as opposed to being externally cued. This deficit correlated significantly with motor scores of the Unified Parkinson's Disease Rating Scale (UPDRS). Notably, there was no main effect of dopaminergic medication ("ON"/"OFF") on internally and externally triggered movements despite significant improvement of UPDRS and maximum finger tapping frequency in the "ON" state.

DISCUSSION

Our results suggest that disease severity in PD patients is related to disturbances in internal action initiation, selection and simple decision processes. Moreover, the data add further support to the notion that dopaminergic medication differentially affects motor and cognitive performance in PD. These findings imply that disturbances in executive functions in PD are also influenced by factors other than reduced dopaminergic activity.

Parietofrontal integrity determines neural modulation associated with grasping imagery after stroke

Chronic stroke patients with heterogeneous lesions, but no direct damage to the primary sensorimotor cortex, are capable of longitudinally acquiring the ability to modulate sensorimotor rhythms using grasping imagery of the affected hand. Volitional modulation of neural activity can be used to drive grasping functions of the paralyzed hand through a brain-computer interface. The neural substrates underlying this skill are not known. Here, we investigated the impact of individual patient's lesion pathology on functional and structural network integrity related to this volitional skill. Magnetoencephalography data acquired throughout training was used to derive functional networks. Structural network models and local estimates of extralesional white matter microstructure were constructed using T(1)-weighted and diffusion-weighted magnetic resonance imaging data. We employed a graph theoretical approach to characterize emergent properties of distributed interactions between nodal brain regions of these networks. We report that interindividual variability in patients' lesions led to differential impairment of functional and structural network characteristics related to successful post-training sensorimotor rhythm modulation skill. Patients displaying greater magnetoencephalography global cost-efficiency, a measure of information integration within the distributed functional network, achieved greater levels of skill. Analysis of lesion damage to structural network connectivity revealed that the impact on nodal betweenness centrality of the ipsilesional primary motor cortex, a measure that characterizes the importance of a brain region for integrating visuomotor information between frontal and parietal cortical regions and related thalamic nuclei, correlated with skill. Edge betweenness centrality, an analogous measure, which assesses the role of specific white matter fibre pathways in network integration, showed a similar relationship between skill and a portion of the ipsilesional superior longitudinal fascicle connecting premotor and posterior parietal visuomotor regions known to be crucially involved in normal grasping behaviour. Finally, estimated white matter microstructure integrity in regions of the contralesional superior longitudinal fascicle adjacent to primary sensorimotor and posterior parietal cortex, as well as grey matter volume co-localized to these specific regions, positively correlated with sensorimotor rhythm modulation leading to successful brain-computer interface control. Thus, volitional modulation of ipsilesional neural activity leading to control of paralyzed hand grasping function through a brain-computer interface after longitudinal training relies on structural and functional connectivity in both ipsilesional and contralesional parietofrontal pathways involved in visuomotor information processing. Extant integrity of this structural network may serve as a future predictor of response to longitudinal therapeutic interventions geared towards training sensorimotor rhythms in the lesioned brain, secondarily improving grasping function through brain-computer interface applications.

The motor system and its disorders

The motor system has been intensively studied using the emerging neuroimaging technologies over the last twenty years. These include early applications of positron emission tomography of brain perfusion, metabolic rate and receptor function, as well as functional magnetic resonance imaging, tractography from diffusion weighted imaging, and transcranial magnetic stimulation. Motor system research has the advantage of the existence of extensive electrophysiological and anatomical information from comparative studies which enables cross-validation of new methods. We review the impact of neuroimaging on the understanding of diverse motor functions, including motor learning, decision making, inhibition and the mirror neuron system. In addition, we show how imaging of the motor system has supported a powerful platform for bidirectional translational neuroscience. In one direction, it has provided the opportunity to study safely the processes of neuroplasticity, neural networks and neuropharmacology in stroke and movement disorders and offers a sensitive tool to assess novel therapeutics. In the reverse direction, imaging of clinical populations has promoted innovations in cognitive theory, experimental design and analysis. We highlight recent developments in the analysis of structural and functional connectivity in the motor system; the advantages of integration of multiple methodologies; and new approaches to experimental design using formal models of cognitive-motor processes.

State-dependent and timing-dependent bidirectional associative plasticity in the human SMA-M1 network

The supplementary motor area (SMA-proper) plays a key role in the preparation and execution of voluntary movements. Anatomically, SMA-proper is densely reciprocally connected to primary motor cortex (M1), but neuronal coordination within the SMA-M1 network and its modification by external perturbation are not well understood. Here we modulated the SMA-M1 network using MR-navigated multicoil associative transcranial magnetic stimulation in healthy subjects. Changes in corticospinal excitability were assessed by recording motor evoked potential (MEP) amplitude bilaterally in a hand muscle. We found timing-dependent bidirectional Hebbian-like MEP changes during and for at least 30 min after paired associative SMA-M1 stimulation. MEP amplitude increased if SMA stimulation preceded M1 stimulation by 6 ms, but decreased if SMA stimulation lagged M1 stimulation by 15 ms. This associative plasticity in the SMA-M1 network was highly topographically specific because paired associative stimulation of pre-SMA and M1 did not result in any significant MEP change. Furthermore, associative plasticity in the SMA-M1 network was strongly state-dependent because it required priming by near-simultaneous M1 stimulation to occur. We conclude that timing-dependent bidirectional associative plasticity is demonstrated for the first time at the systems level of a human corticocortical neuronal network. The properties of this form of plasticity are fully compatible with spike-timing-dependent plasticity as defined at the cellular level. The necessity of priming may reflect the strong interhemispheric connectivity of the SMA-M1 network. Findings are relevant for better understanding reorganization and potentially therapeutic modification of neuronal coordination in the SMA-M1 network after cerebral lesions such as stroke.

Crossmodal interactions in audiovisual emotion processing

Emotion in daily life is often expressed in a multimodal fashion. Consequently emotional information from one modality can influence processing in another. In a previous fMRI study we assessed the neural correlates of audio-visual integration and found that activity in the left amygdala is significantly attenuated when a neutral stimulus is paired with an emotional one compared to conditions where emotional stimuli were present in both channels. Here we used dynamic causal modelling to investigate the effective connectivity in the neuronal network underlying this emotion presence congruence effect. Our results provided strong evidence in favor of a model family, differing only in the interhemispheric interactions. All winning models share a connection from the bilateral fusiform gyrus (FFG) into the left amygdala and a non-linear modulatory influence of bilateral posterior superior temporal sulcus (pSTS) on these connections. This result indicates that the pSTS not only integrates multi-modal information from visual and auditory regions (as reflected in our model by significant feed-forward connections) but also gates the influence of the sensory information on the left amygdala, leading to attenuation of amygdala activity when a neutral stimulus is integrated. Moreover, we found a significant lateralization of the FFG due to stronger driving input by the stimuli (faces) into the right hemisphere, whereas such lateralization was not present for sound-driven input into the superior temporal gyrus. In summary, our data provides further evidence for a rightward lateralization of the FFG and in particular for a key role of the pSTS in the integration and gating of audio-visual emotional information.

Degeneration of corpus callosum and recovery of motor function after stroke: a multimodal magnetic resonance imaging study

Animal models of stroke demonstrated that white matter ischemia may cause both axonal damage and myelin degradation distant from the core lesion, thereby impacting on behavior and functional outcome after stroke. We here used parameters derived from diffusion magnetic resonance imaging (MRI) to investigate the effect of focal white matter ischemia on functional reorganization within the motor system. Patients (n = 18) suffering from hand motor deficits in the subacute or chronic stage after subcortical stroke and healthy controls (n = 12) were scanned with both diffusion MRI and functional MRI while performing a motor task with the left or right hand. A laterality index was employed on activated voxels to assess functional reorganization across hemispheres. Regression analyses revealed that diffusion MRI parameters of both the ipsilesional corticospinal tract (CST) and corpus callosum (CC) predicted increased activation of the unaffected hemisphere during movements of the stroke-affected hand. Changes in diffusion MRI parameters possibly reflecting axonal damage and/or destruction of myelin sheath correlated with a stronger bilateral recruitment of motor areas and poorer motor performance. Probabilistic fiber tracking analyses revealed that the region in the CC correlating with the fMRI laterality index and motor deficits connected to sensorimotor cortex, supplementary motor area, ventral premotor cortex, superior parietal lobule, and temporoparietal junction. The results suggest that degeneration of transcallosal fibers connecting higher order sensorimotor regions constitute a relevant factor influencing cortical reorganization and motor outcome after subcortical stroke.

Neurorehabilitation of stroke

Despite ongoing improvements in the acute treatment of cerebrovascular diseases and organization of stroke services, many stroke survivors are in need of neurorehabilitation, as more than two-thirds show persisting neurologic deficits. While early elements of neurorehabilitation are already taking place on the stroke unit, after the acute treatment, the patient with relevant neurologic deficits usually takes part in an organized inpatient multidisciplinary rehabilitation program and eventually continues with therapies in an ambulatory setting afterwards. A specialized multidisciplinary neurorehabilitation team with structured organization and processes provides a multimodal, intense treatment program for stroke patients which is adapted in detail to the individual goals of rehabilitation. There are many parallels between postlesional neuroplasticity (relearning) and learning in the development of individuals as well as task learning of healthy persons. One key principle of neurorehabilitation is the repetitive creation of specific learning situations to promote mechanisms of neural plasticity in stroke recovery. There is evidence of achieving a better outcome of neurorehabilitation with early initiation of treatment, high intensity, with specific goals and active therapies, and the coordinated work and multimodality of a specialized team. In this context, interdisciplinary goal-setting and regular assessments of the patient are important. Furthermore, several further potential enhancers of neural plasticity, e.g., peripheral and brain stimulation techniques, pharmacological augmentation, and use of robotics, are under evaluation.

Rewiring the brain: potential role of the premotor cortex in motor control, learning, and recovery of function following brain injury

The brain is a plastic organ with a capability to reorganize in response to behavior and/or injury. Following injury to the motor cortex or emergent corticospinal pathways, recovery of function depends on the capacity of surviving anatomical resources to recover and repair in response to task-specific training. One such area implicated in poststroke reorganization to promote recovery of upper extremity recovery is the premotor cortex (PMC). This study reviews the role of distinct subdivisions of PMC: dorsal (PMd) and ventral (PMv) premotor cortices as critical anatomical and physiological nodes within the neural networks for the control and learning of goal-oriented reach and grasp actions in healthy individuals and individuals with stroke. Based on evidence emerging from studies of intrinsic and extrinsic connectivity, transcranial magnetic stimulation, functional neuroimaging, and experimental studies in animals and humans, the authors propose 2 distinct patterns of reorganization that differentially engage ipsilesional and contralesional PMC. Research directions that may offer further insights into the role of PMC in motor control, learning, and poststroke recovery are also proposed. This research may facilitate neuroplasticity for maximal recovery of function following brain injury.

Approaches for the integrated analysis of structure, function and connectivity of the human brain

Understanding the organization of the human brain is the fundamental prerequisite for appreciating the neural dysfunctions underlying neurological or psychiatric disorders. One major challenge in this context is the presence of multiple organizational aspects, in particular the regional differentiation in structure and function on one hand and the integration by inter-regional connectivity on the other. We here review these fundamental distinctions and introduce current methods for mapping regional specialization. The main focus of this review is to provide an overview over the different concepts and methods for assessing connections and interactions in the brain, in particular anatomical, functional and effective connectivity. In this context, we focus less on technical details and more on the comparative description of strengths and weaknesses of different aspects of connectivity as well as different methods for examining a particular aspect. This overview closes by raising several open questions on the conceptual and empirical relationship between different approaches towards understanding brain structure, function and connectivity.