Caudate hemorrhage: clinical features, neuropsychological assessments and radiological findings

Decreased Functional Connectivities of Low-Degree Level Rich Club Organization and Caudate in Post-stroke Cognitive Impairment Based on Resting-State fMRI and Radiomics Features

Background

Stroke is an important cause of cognitive impairment. Rich club organization, a highly interconnected network brain core region, is closely related to cognition. We hypothesized that the disturbance of rich club organization exists in patients with post-stroke cognitive impairment (PSCI).

Methods

We collected data on resting-state functional magnetic resonance imaging (rs-fMRI) with 21 healthy controls (HC), 16 hemorrhagic stroke (hPSCI), and 21 infarct stroke (iPSCI). 3D shape features and first-order statistics of stroke lesions were extracted using 3D slicer software. Additionally, we assessed cognitive function using the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE).

Results

Normalized rich club coefficients were higher in hPSCI and iPSCI than HC at low-degree k-levels (k = 1–8 in iPSCI, k = 2–8 in hPSCI). Feeder and local connections were significantly decreased in PSCI patients versus HC, mainly distributed in salience network (SN), default-mode network (DMN), cerebellum network (CN), and orbitofrontal cortex (ORB), especially involving the right and left caudate with changed nodal efficiency. The feeder and local connections of significantly between-group difference were positively related to MMSE and MoCA scores, primarily distributed in the sensorimotor network (SMN) and visual network (VN) in hPSCI, SN, and DMN in iPSCI. Additionally, decreased local connections and low-degree ϕnorm(k) were correlated to 3D shape features and first-order statistics of stroke lesions.

Conclusion

This study reveals the disrupted low-degree level rich club organization and relatively preserved functional core network in PSCI patients. Decreased feeder and local connections in cognition-related networks (DMN, SN, CN, and ORB), particularly involving the caudate nucleus, may offer insight into pathological mechanism of PSCI patients. The shape and signal features of stroke lesions may provide an essential clue for the damage of functional connectivity and the whole brain networks.

Subcortical Aphasia

PURPOSE OF REVIEW

Subcortical structures have long been thought to play a role in language processing. Increasingly spirited debates on language studies, arising from as early as the nineteenth century, grew remarkably sophisticated as the years pass. In the context of non-thalamic aphasia, a few theoretical frameworks have been laid out. The disconnection hypothesis postulates that basal ganglia insults result in aphasia due to a rupture of connectivity between Broca and Wernicke's areas. A second viewpoint conjectures that the basal ganglia would more directly partake in language processing, and a third stream proclaims that aphasia would stem from cortical deafferentation. On the other hand, thalamic aphasia is more predominantly deemed as a resultant of diaschisis. This article reviews the above topics with recent findings on deep brain stimulation, neurophysiology, and aphasiology.

RECENT FINDINGS

The more recent approach conceptualizes non-thalamic aphasias as the offspring of unpredictable cortical hypoperfusion. Regarding the thalamus, there is mounting evidence now pointing to leading contributions of the pulvinar/lateral posterior nucleus and the anterior/ventral anterior thalamus to language disturbances. While the former appears to relate to lexical-semantic indiscrimination, the latter seems to bring about a severe breakdown in word selection and/or spontaneous top-down lexical-semantic operations. The characterization of subcortical aphasias and the role of the basal ganglia and thalamus in language processing continues to pose a challenge. Neuroimaging studies have pointed a path forward, and we believe that more recent methods such as tractography and connectivity studies will significantly expand our knowledge in this particular area of aphasiology.

Aphasia in vascular lesions of the basal ganglia: A comprehensive review

Between 1970 and 1990, the study of aphasia secondary to subcortical lesions (including the basal ganglia - BG) was largely driven by the advent of modern neuroimaging techniques such as MRI and PET. However, attempts to characterize a pattern of language abnormalities in patients with basal ganglia lesions proved unfruitful. We conducted a comprehensive review of language disturbances after vascular lesions in the BG. Literature search in Medline and LILACS (1966-2016) and PsychINFO (last 25years) was conducted, and returned 145 articles, with 57 eligible for the review yielding data on 303 patients. We report the clinical and neuroimaging features of these cases. Results showed that aphasias caused by BG lesions are heterogeneous with weak clinicoanatomical correlations. Data derived from follow-up and flow/metabolism studies suggest that subcortical aphasia caused by BG lesions involves hypoperfusion in the cortical territories of the middle cerebral/internal carotid arteries (MCA/ICA) and their branches.

Impact of spontaneous intracerebral hemorrhage on cognitive functioning: An update

Intracerebral hemorrhage (ICH) accounts for 15% of all strokes and approximately 50% of stroke-related mortality and disability worldwide. Patients who have experienced ICH are at high risk of negative outcome, including stroke and cognitive disorders. Vascular cognitive impairment are frequently seen after brain hemorrhage, yet little is known about them, as most studies have focused on neuropsychological outcome in ischemic stroke survivors, using well-documented acute and chronic cognitive scores. However, recent evidence supports the notion that ICH and dementia are closely related and each increases the risk of the other. The location of the lesion also plays a significant role as regards the neuropsychological profile, while the pathophysiology of ICH can indicate a specific pattern of dysfunction. Several cognitive domains may be affected, such as language, memory, executive function, processing speed and gnosis.

High prevalence of cognitive impairment after intracerebral hemorrhage

Background

Cognitive impairment seems to be frequent in intracerebral hemorrhage (ICH) survivors, but remains widely understudied. In this study, we investigated the frequency and patterns of vascular cognitive disorders (VCDs) in patients with cerebral amyloid angiopathy (CAA)-related and deep ICH compared to patients with mild cognitive impairment due to Alzheimer’s disease (MCI-AD) and healthy controls.

Methods

We prospectively recruited 20 patients with CAA-related lobar ICH, 20 with deep ICH, 20 with MCI-AD and 17 healthy controls. Patients with cognitive decline pre-ICH were excluded from the analysis. Each participant underwent a comprehensive neuropsychological assessment and a structural brain MRI. Cognitive assessment was performed at a median delay of 4 months after the acute phase in ICH patients, and more than 6 months after the first complaint in MCI-AD patients. Cognitive profiles were compared between groups. The prevalence of VCDs in the ICH groups was estimated using the recent VASCOG criteria.

Results

“Mild” and “major VCDs” were respectively observed in 87.5% and 2.5% of all ICH patients. Every patient in the CAA group had mild VCDs. No significant difference was observed in cognitive functioning between CAA-related and deep ICH patients. The most impaired process in the CAA group was naming, with a mean (±standard deviation) z-score of -5.2 ±5.5, followed by processing speed (-4.1±3.3), executive functioning (-2.6 ±2.5), memory (-2.4 ±3.5) and attention (-0.9 ±1.3). This cognitive pattern was different from the MCI-AD patients, but the groups were only different in gestural praxis, and by construction, in memory processes.

Conclusions

VCDs are frequent after ICH. Cognitive patterns of patients with deep or CAA-related ICH did not differ, but there was impaired performance in specific domains distinct from the effects of Alzheimer’s disease.

Clinical trial registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01619709.

Long-term brain structural magnetic resonance imaging and cognitive functioning in children treated for acute lymphoblastic leukemia with high-dose methotrexate chemotherapy alone or combined with CNS radiotherapy at reduced total dose to 12 Gy

INTRODUCTION

The aim of this study was to assess the long-term side effects of central nervous system prophylaxis (high-dose chemotherapy alone vs chemotherapy and CNS radiotherapy) according to the ALL IC-BFM 2002.

METHODS

Thirty-tree children aged 6.7-19.9 years have been studied. The control group consisted of 12 children newly diagnosed with acute lymphoblastic leukemia. We assessed subcortical gray matter volume using automatic MRI segmentation and cognitive performance to identify differences between two therapeutic schemes and patients prior to treatment.

RESULTS

Patients treated with chemotherapy and CNS radiotherapy had smaller hippocampi than two other subgroups and lower IQ score than patients treated with chemotherapy alone. Both treated groups, whether with chemotherapy only or in combination with CNS radiotherapy, had significantly lower volumes of caudate nucleus and performed significantly worse on measures of verbal fluency in comparison with patients prior to treatment. There were no differences in the mean volumes of total white matter, total gray matter, thalamus, putamen, and amygdala between the studied groups.

CONCLUSION

In all children treated according to the ALL IC-BFM 2002 with high-dose chemotherapy, both decreased volume of selected subcortical structures and cognitive impairment was observed, especially in children who received chemotherapy in combination with reduced dose CNS radiotherapy. In all children treated according to the ALL IC-BFM 2002 with high-dose chemotherapy, both decreased volume of selected subcortical structures and cognitive impairment were observed, especially in children who received chemotherapy in combination with CNS radiotherapy.

Reduced neuroanatomic volumes in long-term survivors of childhood acute lymphoblastic leukemia

PURPOSE

To compare regional brain volumes in adult long-term survivors of childhood acute lymphoblastic leukemia (ALL) and healthy controls.

PATIENTS AND METHODS

We investigated 130 survivors of childhood ALL diagnosed between 1970 and 2002 with magnetic resonance imaging (MRI) and neuropsychological testing at a median of 22.5 years after diagnosis. Morphometric analyses including whole-brain segmentation were performed using a validated automated procedure; 130 healthy adults served as controls.

RESULTS

Compared with healthy controls, ALL survivors showed significantly smaller volumes of cortical gray matter, cerebral white matter, amygdala, caudate, hippocampus, thalamus, and estimated intracranial volume. Effect sizes ranged from small to medium. The strongest effect was found for the caudate, which on average was 5.2% smaller in ALL survivors. Caudate volumes were also smaller when controlling for intracranial volume, suggesting a specific effect. Neither age at diagnosis nor treatment variables such as radiation therapy or drug dose had a major impact on neuroanatomic volumes. Neuropsychological assessment revealed reduced processing speed, executive function, and verbal learning/memory in survivors compared with controls but no difference in estimated general intellectual ability. In ALL survivors, but not in controls, neuropsychological test results correlated with volumes of cortical gray matter, caudate, and thalamus as well as intracranial volume.

CONCLUSION

Structural MRI of long-term survivors of childhood ALL demonstrated smaller volumes of multiple brain structures compared with healthy controls. Because of possible selection biases, these results must be interpreted with caution. Future studies are required to clarify the significance of these findings and the neurobiologic mechanisms involved.

The neuropathology of autism: defects of neurogenesis and neuronal migration, and dysplastic changes

Autism is characterized by a broad spectrum of clinical manifestations including qualitative impairments in social interactions and communication, and repetitive and stereotyped patterns of behavior. Abnormal acceleration of brain growth in early childhood, signs of slower growth of neurons, and minicolumn developmental abnormalities suggest multiregional alterations. The aim of this study was to detect the patterns of focal qualitative developmental defects and to identify brain regions that are prone to developmental alterations in autism. Formalin-fixed brain hemispheres of 13 autistic (4–60 years of age) and 14 age-matched control subjects were embedded in celloidin and cut into 200-μm-thick coronal sections, which were stained with cresyl violet and used for neuropathological evaluation. Thickening of the subependymal cell layer in two brains and subependymal nodular dysplasia in one brain is indicative of active neurogenesis in two autistic children. Subcortical, periventricular, hippocampal and cerebellar heterotopias detected in the brains of four autistic subjects (31%) reflect abnormal neuronal migration. Multifocal cerebral dysplasia resulted in local distortion of the cytoarchitecture of the neocortex in four brains (31%), of the entorhinal cortex in two brains (15%), of the cornu Ammonis in four brains and of the dentate gyrus in two brains. Cerebellar flocculonodular dysplasia detected in six subjects (46%), focal dysplasia in the vermis in one case, and hypoplasia in one subject indicate local failure of cerebellar development in 62% of autistic subjects. Detection of flocculonodular dysplasia in only one control subject and of a broad spectrum of focal qualitative neuropathological developmental changes in 12 of 13 examined brains of autistic subjects (92%) reflects multiregional dysregulation of neurogenesis, neuronal migration and maturation in autism, which may contribute to the heterogeneity of the clinical phenotype.

Reduced caudate nuclei volumes in patients with congenital central hypoventilation syndrome

Congenital central hypoventilation syndrome (CCHS) children show cognitive and affective deficits, in addition to state-specific loss of respiratory drive. The caudate nuclei serve motor, cognitive, and affective roles, and show structural deficits in CCHS patients, based on gross voxel-based analytic procedures. However, the magnitude and regional sites of caudate injury in CCHS are unclear. We assessed global caudate nuclei volumes with manual volumetric procedures, and regional volume differences with three-dimensional surface morphometry in 14 CCHS (mean age+/-SD: 15.1+/-2.3 years; 8 male) and 31 control children (15.1+/-2.4 years; 17 male) using brain magnetic resonance imaging (MRI). Two high-resolution T1-weighted image series were collected using a 3.0 Tesla MRI scanner; images were averaged and reoriented (rigid-body transformation) to common space. Both left and right caudate nuclei were outlined in the reoriented images, and global volumes calculated; surface models were derived from manually-outlined caudate structures. Global caudate nuclei volume differences between groups were evaluated using a multivariate analysis of covariance (covariates: age, gender, and total intracranial volume). Both left and right caudate nuclei volumes were significantly reduced in CCHS over control subjects (left, 4293.45+/-549.05 vs. 4626.87+/-593.41 mm(3), P<0.006; right, 4376.29+/-565.42 vs. 4747.81+/-578.13 mm(3), P<0.004). Regional deficits in CCHS caudate volume appeared bilaterally, in the rostral head, ventrolateral mid, and caudal body. Damaged caudate nuclei may contribute to CCHS neuropsychological and motor deficits; hypoxic processes, or maldevelopment in the condition may underlie the injury.

Caudate nucleus volume and cognitive performance: Are they related in childhood psychopathology?

BACKGROUND

Impaired neuropsychological test performance, especially on tests of executive function and attention, is often seen in children diagnosed with autism spectrum disorders (ASD). Structures involved in fronto-striatal circuitry, such as the caudate nucleus, may support these cognitive abilities. However, few studies have examined caudate volumes specifically in children with ASD, or correlated caudate volumes to cognitive ability.

METHODS

Neuropsychological test scores and caudate volumes of children with ASD were compared to those of children with bipolar disorder (BD) and of typically developing (TD) children. The relationship between test performance and caudate volumes was analyzed.

RESULTS

The ASD group displayed larger right and left caudate volumes, and modest executive deficits, compared to TD controls. While caudate volume inversely predicted performance on the Wisconsin Card Sorting Test in all participants, it differentially predicted performance on measures of attention across the ASD, BD and TD groups.

CONCLUSIONS

Larger caudate volumes were related to impaired problem solving. On a test of attention, larger left caudate volumes predicted increased impulsivity and more omission errors in the ASD group as compared to the TD group, however smaller volume predicted poorer discriminant responding as compared to the BD group.

Prevalence of executive impairment in patients seen by a psychiatry consultation service

The prevalence of impairment of executive function among 50 medical inpatients referred for psychiatric consultation was assessed by using the Executive Interview (EXIT25) and an executive clock-drawing task (CLOX). The Mini-Mental Status Examination (MMSE) was also administered to assess general cognition. The percentage of patients who failed each test was calculated. Seventy-two percent failed at least one measure of executive function, whereas only 30% failed the MMSE. The results suggest that impairment of executive function is common among inpatients referred for psychiatric consultation. Because impairment of executive function has been specifically associated with behavioral and functional disability, routine assessment of executive function should be integrated into psychiatric case management.

Executive control function in psychiatric and medical illness

Executive Control Function (ECF) is the ability to plan, sequence, and monitor one's behavior in order to accomplish a given goal while simultaneously exercising cognitive flexibility to adapt to changing task requirements. Multiple studies demonstrate that ECF predicts functional outcome, level of care required, and work potential for both well and ill populations. However, clinicians often do not routinely assess ECF during mental status evaluations because of the perceived lack of practical bedside tests. This review article discusses the major neuropsychological measures used to probe for impairment, with special emphasis on those that are easily administered at the patient's bedside. The current literature on executive dysfunction in psychiatric and medical illness is reviewed. The neuroanatomy and neurochemistry of ECF is also reviewed, with emphasis on structural dysfunction in specific illnesses. Finally, various treatment options, both pharmacological and psychotherapeutic, are discussed.

Hypertensive caudate hemorrhage prognostic predictor, outcome, and role of external ventricular drainage

BACKGROUND AND PURPOSE

The purpose of the present study was to analyze the outcome and outcome predictors of caudate hemorrhage and role of external ventricular drainage in acute hydrocephalus.

METHODS

Clinical data from 36 consecutive patients with hypertensive caudate hemorrhage was used in the present study. Age, gender, volume of parenchymal hematoma, hematoma in the internal capsule, initial Glasgow Coma Scale (GCS), hydrocephalus, severity of intraventricular hemorrhage, and hemorrhagic dilatation of the fourth ventricle were analyzed for effect on outcome. Effect of external ventricle drainage for hydrocephalus was evaluated by comparing preoperative and postoperative GCS scores.

RESULTS

By univariate analyses, poor outcome was associated with a poor initial GCS score (P=0.016), hydrocephalus (P<0.001), intraventricular hemorrhage severity (P<0.01), and hemorrhagic dilatation of the fourth ventricle (P=0.02). By multivariate analysis, stepwise logistic regression revealed that hydrocephalus was the only independent prognostic factor for poor outcome (P<0.001). Postoperative 48-hour GCS score was better than the preoperative score by use of paired-sample t test (P<0.001).

CONCLUSIONS

Hydrocephalus is the most important predictor of poor outcome. External ventricular drainage response for hydrocephalus was good in the present study, whereas an early decision should be made regarding preoperative neurological condition.

Perceptual differences between stroke patients with cerebral infarction and intracerebral hemorrhage

OBJECTIVE

To assess perceptual performances of patients with intracerebral hemorrhage (ICH) compared with those of ischemic patients early after stroke and to analyze the psychometric properties of three perceptual tests used in the study.

DESIGN

Cross-sectional study.

SETTING

A rehabilitation unit at a teaching hospital.

PATIENTS

Twenty-two stroke patients with ICH and 22 demographically matched stroke patients with infarction.

MAIN OUTCOME MEASURES

Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), Rivermead Perceptual Assessment Battery (RPAB), and Motor-Free Visual Perception Test (MVPT).

RESULTS

Stroke patients with ICH had significantly more severe deficits on a task of thinking operations than did patients with infarction. A significant lateralized effect of stroke existed in the ICH group, with patients with right-hemisphere strokes scoring lower than patients with left-hemisphere strokes on the figure-ground discrimination subtest of the RPAB. A considerable overlap among the three instruments was found. Yet, the observed correlations between supposedly similar subtests from the tests proved to be moderate, indicating that to a certain extent these test measures tap different perceptual processes. Four factors were generated from a joint LOTCA-RPAB-MVPT factor analysis. They assessed different facets of perceptual functioning, including higher-level and lower-level perceptual skills, part/whole conceptual integration, and color perception. This factor pattern accounted for 75.5% of the variance.

CONCLUSIONS

Higher-level perceptual functions tend to be relatively susceptible to ICH stroke pathology early in the course of the disease. This information has important clinical implications in the early treatment planning for the stroke patients with ICH, such that specific compensatory strategies for these deficiencies should be devised to facilitate a successful rehabilitation. Knowledge regarding the influences of specific deficits on the performance of daily activities may also be useful to the patients' family.