Social Cognition Impairments in the Long Term Post Stroke

Hayling and stroop tests tap dissociable deficits and network-level neural correlates

Although many executive function screens have been developed, it is not yet clear whether these assessments are equally effective in detecting post-stroke deficits of initiation and inhibition. This study presents a comparative analysis of the Stroop and Hayling tests aiming to evaluate whether these tests measure the same underlying cognitive functions and to identify the neural correlates of the deficits detected by both tasks. Sixty six stroke survivors and 70 healthy ageing controls completed the Hayling and Stroop tests. Stroke patients were found to exhibit qualitative performance differences across analogous Stroop and Hayling Test metrics intended to tap initiation and inhibition. The Stroop test was found to have high specificity to abnormal performance, but low sensitivity relative to the Hayling Test. Minimal overlap was present between the network-level correlates of analogous Stroop and Hayling Test metrics. Hayling Task strategy use metrics were significantly associated with distinct patterns of disconnection in stroke survivors, providing novel insight into the neural correlates of fine-grained behavioural patterns. Overall, these findings strongly suggest that the functions tapped by the Stroop and Hayling Test are both behaviourally and anatomically dissociable. The Hayling Test was found to offer improved sensitivity and detail relative to the Stroop test. This novel demonstration of the Hayling Test within the stroke population suggests that this task represents an effective measure for quantifying post-stroke initiation and inhibition deficits.

Activity monitoring of stroke patients by physiotherapist and caregivers in a hospital setting: A pilot study

Background

Activity monitoring is a necessary technique to ensure stroke survivors' activity levels in the hospital are within optimal levels as this is important for enhanced motor recovery. However, this could be time-consuming for healthcare professionals like physiotherapists. Activity monitoring by caregivers could be an alternate option. Therefore, our aim was to compare the activity monitoring of stroke survivors by caregivers and physiotherapists during early phase in a hospital setting.

Methods

An observation study was carried out in the neuroscience ward in a tertiary care hospital among 17 stroke survivors. Physiotherapist and caregivers were instructed to use an activity log chart that was developed during previous research conducted by the same authors for observing the activities performed by the patients every 15 minutes from 8 AM to 5 PM across one day. Data collected were analysed using Stata 15. Kappa statistics were carried out to determine the agreement of the observations between the two raters.

Results

A total of 10 male and seven female caregivers of stroke survivors with a mean age of 40.11 ± 9.2 years and a trained physiotherapist participated in the study. A total of 272 observations of caregivers were in agreement with that of the physiotherapist. Inter-rater Kappa statistics showed 60% agreement between the physiotherapist and the caregivers (p<0.05).

Conclusions

There was moderate agreement between the physiotherapist and caregiver for activity monitoring of stroke survivors. This suggests behavioural mapping by caregivers may be a potential alternative solution in healthcare settings.

Exploring social cognition in individuals with neuropsychiatric symptoms following acquired brain injury

In this study, we explored the social cognitive skills of individuals with neuropsychiatric symptoms following acquired brain injury (ABI). To this end, a retrospective chart review was carried out. We examined scores on social cognition tests that were administered as part of routine neuropsychological assessment at a Dutch specialized care facility for patients with neuropsychiatric symptoms following ABI. In addition, correlations with time post injury were explored. Aspects of social cognition (emotion recognition, Theory of Mind (ToM) and empathy) were measured using the Emotion Recognition Task (n = 40), the Ekman 60-Faces Test of the Facial Expression of Emotion: Stimuli and Tests (n = 11) and the Faux Pas Test (n = 36). 72.5% to 81.8% of participants scored very low or low on emotion recognition. Participants' scores for ToM and empathy were lower than those reported recently for samples of Dutch stroke and traumatic brain injury patients. Correlations between social cognition scores and time since injury were non-significant or negative. While further research is necessary, our results indicate that social cognitive problems are prevalent and persistent in individuals who display neuropsychiatric symptoms after ABI. Future studies should employ a prospective approach in order to confirm our exploratory findings.

Multiplex array analysis of serum cytokines offers minimal predictive value for cognitive function in the subacute phase after stroke

OBJECTIVE

The effects of inflammation on post-stroke cognitive function are still unclear. This study investigated the correlation between the Th17-related cytokines in peripheral blood and post-stroke cognitive function after ischemic stroke in the subacute phase.

DESIGN

A retrospective cohort study.

SETTING

Academic acute inpatient rehabilitation facility.

PARTICIPANTS

One hundred and fourteen patients with first ischemic stroke were categorized as the poor cognitive recovery group (n = 58) or good cognitive recovery group (n = 56) based on their cognitive MRFS efficiency.

INTERVENTIONS

All subjects received routine physical, occupational, and speech-language pathology therapy.

MAIN OUTCOME MEASURES

Serum cytokines/chemokine (IL-1 β, IL-2, IL-4, IL-5, IL-6, IL-9, IL-10, IL-12p70, IL-13, IL-15, IL-17A, IL-17E, IL-17F, IL-21, IL-22, IL-23, IL-27, IL-28A, IL-31, IL-33, GM-CSF, IFN-γ, MIP-3 α, TNF-α, and TNF-β) levels were measured in duplicate using Human Th17 magnetic bead panel and multiplex array analysis (Luminex-200 system). The primary functional outcome was a gain in functional independence measure (FIM) cognitive subscore at discharge. The secondary outcome measures were FIM total score at discharge, length of stay in the hospital, and discharge destination. Cognitive Montebello Rehabilitation Factor Score (MRFS) and cognitive MRFS efficiency were calculated. Demographic and clinical characteristics were obtained from the medical record.

RESULTS

The good cognitive recovery group had an interesting trend of higher IL-13 than the poor cognitive recovery group (good cognitive recovery group 257.82 ± 268.76 vs. poor cognitive recovery group 191.67 ± 201.82, p = 0.049, unit: pg/ml). However, Pearson's correlation analysis showed no significant correlation between cytokine levels and gain of cognition, cognitive MRFS, or cognitive MRFS efficiency. Receiver operating characteristic (ROC) analysis of cytokines also suggested a low accuracy of prediction as a predictor for post-stroke cognitive recovery improvement.

CONCLUSION

Our preliminary findings suggested that the level of serum cytokines had minimal predictive value for the recovery of cognitive function during the subacute inpatient rehabilitation after stroke.

Right Cortical Infarction and a Reduction in Putamen Volume May Be Correlated with Empathy in Patients after Subacute Ischemic Stroke—A Multimodal Magnetic Resonance Imaging Study

Empathy has not been well studied in patients following ischemic stroke. We aimed to evaluate the relationships of multimodal neuroimaging parameters with the impairment of empathy in patients who had experienced subacute ischemic stroke. Patients who had experienced a first-event acute ischemic stroke were recruited, and we assessed their empathy using the Chinese version of the Empathy Quotient (EQ) 3 months after the index stroke. Multimodal magnetic resonance imaging (MRI) was conducted in all the participants to identify acute infarction and assess brain volumes, white matter integrity, and other preexisting abnormalities. We quantified the brain volumes of various subcortical structures, the ventricles, and cortical lobar atrophy. The microstructural integrity of the white matter was reflected in the mean fractional anisotropy (FA) and mean diffusivity (MD), and the regional mean values of FA and MD were quantified after mapping using the ICBM_DTI_81 Atlas. Twenty-three (56.1%) men and 18 (43.9%) women (mean age: 61.73 years, range: 41–77 years) were included. The median National Institutes of Health Stroke Scale (NIHSS) score at discharge was 1 (range: 0–4). On univariate analysis, the EQ was correlated with right cortical infarction (r = −0.39, p = 0.012), putamen volume (r = 0.382, p = 0.014), right putamen volume (r = 0.338, p = 0.031), and the FA value of the right sagittal stratum. EQ did not correlated with the MD value in any region of interest or pre-existing brain abnormalities. Multiple stepwise linear regression models were used to identify factors associated with EQ. After adjusting for age and the NIHSS score on admission, the frequency of right cortical infarcts negatively correlated with EQ (standardized β = −0.358, 95% confidence interval =−0.708 to −0.076, p = 0.016), and the putamen volume positively correlated with EQ (standardized β = 0.328, 95% confidence interval =0.044 to 0.676, p = 0.027). In conclusion, in patients who have experienced subacute ischemic stroke, right cortical infarction and a smaller putamen volume are associated with the impairment of empathy.

Social problem solving and trait socioemotional abilities in ambulatory stroke patients

INTRODUCTION

Stroke has been associated with sociocognitive impairment, so far well documented for emotion recognition and Theory of Mind. However, more complex abilities, such as social problem solving, which directly facilitate appropriate behavior in social situations have been neglected in previous research.

METHOD

The present study aimed to address this gap by focusing on performance-based social problem solving abilities and self-reported socioemotional abilities (i.e., empathy and alexithymia) in outpatient stroke patients (n = 36) compared to a group of healthy controls (n = 36) equivalent on age, gender, and education. In further analyses, potential lateralization effects and correlations between social problem solving/socioemotional functioning and demographic and clinical data were investigated.

RESULTS

In the main analyses, patients were impaired in their ability to freely generate appropriate solutions for challenging interpersonal situations depicted in written scenarios but performed on a comparable level as healthy controls when they had to choose the optimal solution presented amidst a range of less optimal options. While showing difficulty in identifying the awkward elements in the scenarios, the patient group nevertheless rated the degree of discomfort attributed to these elements on a level comparable to the control group. On the self-report measures, stroke patients reported overall higher degrees of alexithymia (i.e., an inability to describe and identify one's own and other persons´ emotions) and more personal distress in response to other individuals´ emotional suffering as assessed by self-report.

CONCLUSIONS

The present results suggest that stroke is associated with a broad impact on socioemotional and social problem solving abilities. As difficulties in social problem solving might be associated with increased psychosocial burden they ought to be addressed in stroke rehabilitation.

IMPAIRED VISUAL EMOTION RECOGNITION AFTER MINOR ISCHEMIC STROKE

OBJECTIVE

To assess the prevalence of impaired visual emotion recognition in patients who have suffered a minor ischemic stroke in the subacute phase and to determine associated factors of impaired visual emotion recognition.

DESIGN

A prospective observational study.

SETTING

Stroke-unit of a teaching hospital.

PARTICIPANTS

112 patients with minor ischemic stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patients with minor stroke underwent a neuropsychological assessment in the sub-acute phase for visual emotion recognition by the Ekman 60 Faces Test and for general cognition. Univariable linear regression analyses were performed to identify associated factors of emotion recognition impairment.

RESULTS

In 112 minor stroke patients we found a prevalence of 25% of impaired visual emotion recognition. This was significantly correlated with impaired general cognition. Nevertheless 10.9% of patients with normal general cognition still had impaired emotion recognition. Mood was negatively associated. Stroke localization, hemisphere side and gender were not associated.

CONCLUSION

Impaired visual emotion recognition is found in about a quarter of patients with minor ischemic stroke.

Psychiatric sequelae of stroke affecting the non-dominant cerebral hemisphere

There are a plethora of cognitive sequelae in addition to neglect and extinction that arise with unilateral right hemispheric stroke (RHS). Cognitive deficits following non-dominant (right) hemisphere stroke are common with unilateral neglect and extinction being the most recognized examples. The severity of RHS is usually underestimated by the National Institutes of Health Stroke Scale (NIHSS), which in terms of lateralized right hemisphere cognitive deficits, tests only for visual inattention/extinction. They account for 2 out of 42 total possible points. Additional neuropsychiatric sequelae include but are not limited to deficiencies in affective prosody comprehension and production (aprosodias), understanding and expressing facial emotions, empathy, recognition of familiar faces, anxiety, mania, apathy, and psychosis. These sequelae have a profound impact on patients' quality of life; affecting communication, interpersonal relationships, and the ability to fulfill social roles. They also pose additional challenges to recovery. There is presently a gap in the literature regarding a cohesive overview of the significant cognitive sequelae following RHS. This paper serves as a narrative survey of the current understanding of the subject, with particular emphasis on neuropsychiatric poststroke syndromes not predominantly associated with left hemisphere lesions (LHL), bilateral lesions, hemiplegia, or paralysis. A more comprehensive understanding of the neuropsychological consequences of RHS extending beyond the typical associations of unilateral neglect and extinction may have important implications for clinical practice, including the ways in which clinicians approach diagnostics, treatment, and rehabilitation.

The economic burden of stroke: a systematic review of cost of illness studies

Stroke is one of the leading causes of morbidity and mortality worldwide. As the number of stroke cases is rising from one year to another, policymakers require data on the amount spent on stroke to enforce better financing policies for prevention, hospital care, outpatient rehabilitation services and social services. We aimed to systematically assess the economic burden of stroke at global level. Cost of stroke studies were retrieved from five databases. We retrieved the average cost per patient, where specified, or estimated it using a top-down approach. Resulting costs were grouped in two main categories: per patient per year and per patient lifetime. We extracted information from forty-six cost of illness studies. Per patient per year costs are larger in high income countries and in studies conducted from the payer perspective. The highest average per patient per year cost by country was reported in the United States ($59,900), followed by Sweden ($52,725) and Spain ($41,950). The highest per patient lifetime costs were reported in Australia ($232,100) for all identified definitions of stroke. Existing literature regarding the economic burden of stroke is concentrated in high-income settings, with very few studies conducted in South America and Africa. Published manuscripts on this topic highlight substantial methodological heterogeneity, rendering comparisons difficult or impossible, even within the same country or among studies with similar costing perspectives.

Neuropsychological and socio-cognitive deficits in patients with obstructive sleep apnea

Introduction: Patients with obstructive sleep apnea (OSA) suffer from several neurocognitive deficits. We investigated the cognitive and socio-cognitive profiles of patients with severe OSA, controlling for potentially relevant mediating variables (i.e. age, body-mass index, cognitive reserve and depression). Moreover, we studied the neuropsychological profile of a high-risk OSA phenotype characterized by severe OSA and severe nocturnal hypoxemia.Method: We assessed 29 previously untreated severe OSA patients with a mean age of 55.6 (± 9.9 years) and a mean apnea-hypopnea index (AHI) of 53.1 (± 17.4). A control group of 34 healthy participants was also enrolled. Participants completed an extensive neuropsychological battery that included social cognition, a relatively new investigation area among OSA patients.Data analysis: Data were analyzed with a Bayesian approach. Specifically, Bayesian ANCOVA was used to investigate whether the grouping variable could predict test performance. Age, body-mass index, cognitive reserve and state of depression were added as covariates to the null model to weight the effects of these potential confounding factors. Three groups were analyzed: healthy controls (H), OSA with severe apnea and severe nocturnal oxygen desaturation (D⁺), and OSA with severe apnea non-desaturators (D^-). Performances on the various neuropsychological tests were treated as the dependent variables.Results: The results indicate that non-verbal reasoning, the theory of mind skills, and mental shifting ability were impaired in OSA patients. Patients with severe nocturnal hypoxemia underperformed compared to patients with the same severity of apnea but non-desaturators. Additionally, we observed a trend toward a worse performance among OSA desaturator patients in the following abilities: constructional ability, short term verbal memory, phonological fluency, and the ability to inhibit automatic and dominant responses.Conclusion: The data suggest a key role of hypoxemia in affecting cognitive functioning in OSA patients. Executive functions and the concomitant involvement of social cognition are particularly affected.

Emotion recognition impairments and social well-being following right-hemisphere stroke

Accurately recognizing and responding to the emotions of others is essential for proper social communication and helps bind strong relationships that are particularly important for stroke survivors. Emotion recognition typically engages cortical areas that are predominantly right-lateralized including superior temporal and inferior frontal gyri - regions frequently impacted by right-hemisphere stroke. Since prior work already links right-hemisphere stroke to deficits in emotion recognition, this research aims to extend these findings to determine whether impaired emotion recognition after right-hemisphere stroke is associated with worse social well-being outcomes. Eighteen right-hemisphere stroke patients (≥6 months post-stroke) and 21 neurologically healthy controls completed a multimodal emotion recognition test (Geneva Emotion Recognition Test - Short) and reported engagement in social/non-social activities and levels of social support. Right-hemisphere stroke was associated with worse emotion recognition accuracy, though not all patients exhibited impairment. In line with hypotheses, emotion recognition impairments were associated with greater loss of social activities after stroke, an effect that could not be attributed to stroke severity or loss of non-social activities. Impairments were also linked to reduced patient-reported social support. Results implicate emotion recognition difficulties as a potential antecedent of social withdrawal after stroke and warrant future research to test emotion recognition training post-stroke.

Frontotemporal dementia, music perception and social cognition share neurobiological circuits: A meta-analysis

Frontotemporal dementia (FTD) is a neurodegenerative disease that presents with profound changes in social cognition. Music might be a sensitive probe for social cognition abilities, but underlying neurobiological substrates are unclear. We performed a meta-analysis of voxel-based morphometry studies in FTD patients and functional MRI studies for music perception and social cognition tasks in cognitively normal controls to identify robust patterns of atrophy (FTD) or activation (music perception or social cognition). Conjunction analyses were performed to identify overlapping brain regions. In total 303 articles were included: 53 for FTD (n = 1153 patients, 42.5% female; 1337 controls, 53.8% female), 28 for music perception (n = 540, 51.8% female) and 222 for social cognition in controls (n = 5664, 50.2% female). We observed considerable overlap in atrophy patterns associated with FTD, and functional activation associated with music perception and social cognition, mostly encompassing the ventral language network. We further observed overlap across all three modalities in mesolimbic, basal forebrain and striatal regions. The results of our meta-analysis suggest that music perception and social cognition share neurobiological circuits that are affected in FTD. This supports the idea that music might be a sensitive probe for social cognition abilities with implications for diagnosis and monitoring.

Comparing static and dynamic emotion recognition tests: Performance of healthy participants

Facial expressions have a communicatory function and the ability to read them is a prerequisite for understanding feelings and thoughts of other individuals. Impairments in recognition of facial emotional expressions are frequently found in patients with neurological conditions (e.g. stroke, traumatic brain injury, frontotemporal dementia). Hence, a standard neuropsychological assessment should include measurement of emotion recognition. However, there is debate regarding which tests are most suitable. The current study evaluates and compares three different emotion recognition tests. 84 healthy participants were included and assessed with three tests, in varying order: a. Ekman 60 Faces Test (FEEST) b. Emotion Recognition Task (ERT) c. Emotion Evaluation Test (EET). The tests differ in type of stimuli from static photographs (FEEST) to more dynamic stimuli in the form of morphed photographs (ERT) to videos (EET). Comparing performances on the three tests, the lowest total scores (67.3% correct answers) were found for the ERT. Significant, but moderate correlations were found between the total scores of the three tests, but nearly all correlations between the same emotions across different tests were not significant. Furthermore, we found cross-over effects of the FEEST and EET to the ERT; participants attained higher total scores on the ERT when another emotion recognition test had been administered beforehand. Moreover, the ERT proved to be sensitive to the effects of age and education. The present findings indicate that despite some overlap, each emotion recognition test measures a unique part of the construct. The ERT seemed to be the most difficult test: performances were lowest and influenced by differences in age and education and it was the only test that showed a learning effect after practice with other tests. This highlights the importance of appropriate norms.

High occurrence of impaired emotion recognition after ischemic stroke

Introduction

Deficits of emotion recognition after ischemic stroke are often overlooked by clinicians, and are mostly not spontaneously reported by patients. However, impaired emotion recognition after stroke negatively affects the ability to return to work and the quality of life. It is still unknown how often impairments of emotion recognition occur shortly after ischemic stroke. We aimed to estimate the occurrence of impaired emotion recognition after ischemic stroke and to characterise these patients with impaired emotion recognition.

Patients and methods

Two hundred thirty patients were included, derived from a prospective study of cognitive recovery. Five weeks after ischemic stroke a neuropsychological assessment was performed, including an emotion recognition task (i.e. Ekman 60-faces test). Emotion recognition was regarded as impaired if the total score was below the fifth percentile for a large independent reference sample.

Results

Emotion recognition was impaired in 33.5% of patients. Patients with impaired emotion recognition were more likely to have an abnormal Montreal Cognitive Assessment during hospitalisation, and 5 weeks after their stroke, a higher proportion of them had a vascular cognitive disorder (VCD). Even 20% of patients without VCD had impaired emotion recognition.Discussion: Emotion recognition was often impaired after ischemic stroke. This is clinically relevant, since impaired emotion recognition negatively impacts social functioning.Conclusion: Even when there was no cognitive disorder in traditional cognitive domains, emotion recognition was impaired in 1 out of 5 patients. Clinicians should systematically ask patients and their caregivers about deficits in emotion recognition, and, if needed, test for these deficits.

Social cognition in patients with acquired brain lesions: An overview on an under-reported problem

Social cognition (SC) consists of mental representations of interpersonal relationships, which are used flexibly by the individual to promote functional social behaviors and achieve the goals. SC is a multidimensional construct and is supported by the activity of distributed neural networks in which different cortical and subcortical regions of the brain are involved. The review aims to evaluate the current literature on SC taking into account how it is compromised in acquired brain injury. Studies performed between 2010 and 2019 and fulfilling the selected criteria were searched on PubMed, Scopus, Cochrane and Web of Sciences databases. Impairment of SC is a neglected but common consequence of ABI, often leading to disordered interpersonal functioning and poor regulation of personal behavior with impaired social adaptation and quality of life of both the patient and his/her family. This review supports the idea that SC could have an important role in the management of neurological patients by both clinicians and caregivers.

The relationship between social cognition and participation in the long term after stroke

Social cognitive impairments may play a role in participation restrictions after stroke. Understanding their relationship could inform treatment approaches to improve participation. We investigated the relationship between social cognition and participation in the long term after stroke. Of 395 patients participating in a large prospective cohort study, cross-sectional data were available at 3-4 years post-stroke of 118 patients on tests for emotion recognition, theory of mind, empathy, and behaviour regulation. Participation was assessed with the Utrecht Scale for Evaluation of Rehabilitation - Participation (USER-P). Bivariate and multivariate regression analysis were used to examine the relationship between social cognitive domains and participation. The majority suffered from minor stroke (83.1% scored NIHSS 0-4). Only behaviour regulation was related to participation restrictions in bivariate analysis, but social cognitive impairments did not predict participation restrictions in multivariate regression in this group. To conclude, in a sample of minor stroke patients with mild impairments in theory of mind, emotion recognition and behavioural control, there were no associations with restrictions in participation. Research should examine whether a relationship is present in patients with more severe stroke. In addition, measuring social aspects of participation is necessary to further unravel this relationship, to determine treatment targets for improving participation.