Contributions of bilateral white matter to chronic aphasia symptoms as assessed by diffusion tensor MRI

The role of the right hemispheric homologous language pathways in recovery from post-stroke aphasia: A systematic review

The involvement of the right hemisphere, mainly the activation of the right cerebral regions, in recovery from post-stroke aphasia has been widely recognized. In contrast, the role of the right white matter pathways in the recovery from post-stroke aphasia is rarely understood. In this study, we aimed to provide a primary overview of the correlation between the structural integrity of the right hemispheric neural tracts based on the dual-stream model of language organization and recovery from post-stroke aphasia by systematically reviewing prior longitudinal interventional studies. By searching electronic databases for relevant studies according to a standard protocol, a total of 10 records (seven group studies and three case studies) including 79 participants were finally included. After comprehensively analyzing these studies and reviewing the literature, although no definite correlation was found between the right hemispheric neural tracts and recovery from post-stroke aphasia, our review provideds a new perspective for investigating the linguistic role of the right hemispheric neural tracts. This suggests that the involvement of the right hemispheric neural tracts in recovery from post-stroke aphasia may be mediated by multiple factors; thus, this topic should be comprehensively investigated in the future.

Application of diffusion tensor imaging in the diagnosis of post-stroke aphasia: a meta-analysis and systematic review

Introduction

Diffusion Tensor Imaging (DTI) indicators of different white matter (WM) fibers and brain region lesions for post-stroke aphasia (PSA) are inconsistent in existing studies. Our study examines the consistency and differences between PSA tests performed with DTI. In addition, obtaining consistent and independent conclusions between studies was made possible by utilizing DTI in PSA assessment.

Methods

In order to gather relevant studies using DTI for diagnosing PSA, we searched the Web of Science, PubMed, Embase, and CNKI databases. Based on the screening and evaluation of the included studies, the meta-analysis was used to conduct a quantitative analysis. Narrative descriptions were provided for studies that met the inclusion criteria but lacked data.

Results

First, we reported on the left hemisphere. The meta-analysis showed that fractional anisotropy (FA) of the arcuate fasciculus (AF) and superior longitudinal fasciculus (SLF), inferior frontal-occipital fasciculus (IFOF), inferior longitudinal fasciculus (ILF), and uncinate fasciculus (UF) were decreased in the PSA group in comparison with the healthy controls (p < 0.00001). However, in the comparison of axial diffusivity (AD), there was no statistically significant difference in white matter fiber tracts in the dual-stream language model of the PSA group. Elevated radial diffusivity (RD) was seen only in the IFOF and ILF (PIFOF = 0.01; PILF = 0.05). In the classic Broca's area, the FA of the PSA group was decreased (p < 0.00001) while the apparent diffusion coefficient was elevated (p = 0.03). Secondly, we evaluated the white matter fiber tracts in the dual-stream language model of the right hemisphere. The FA of the PSA group was decreased only in the IFOF (p = 0.001). AD was elevated in the AF and UF (PAF < 0.00001; PUF = 0.009). RD was elevated in the AF and UF (PAF = 0.01; PUF = 0.003). The other fiber tracts did not undergo similar alterations.

Conclusion

In conclusion, DTI is vital for diagnosing PSA because it detects WM changes effectively, but it still has some limitations. Due to a lack of relevant language scales and clinical manifestations, diagnosing and differentiating PSA independently remain challenging.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=365897.

The arcuate fasciculus: Combining structure and function into surgical considerations

BACKGROUND

Two Centuries from today, Karl Friedrich Burdach attributed the nomenclature "arcuate fasciculus" to a white matter (WM) pathway connecting the frontal to the temporal cortices by arching around the Sylvian fissure. Although this label remained essentially unvaried, the concepts related to it and the characterization of the structural properties of this bundle evolved along with the methodological progress of the past years. Concurrently, the functional relevance of the arcuate fasciculus (AF) classically restricted to the linguistic domain has extended to further cognitive abilities. These features make it a relevant structure to consider in a large variety of neurosurgical procedures.

OBJECTIVE

Herein, we build on our previous review uncovering the connectivity provided by the Superior Longitudinal System, including the AF, and provide a handy representation of the structural organization of the AF by considering the frequency of defined reports in the literature. By adopting the same approach, we implement an account of which functions are mediated by this WM bundle. We highlight how this information can be transferred to the neurosurgical field by presenting four surgical cases of glioma resection requiring the evaluation of the relationship between the AF and the nearby structures, and the safest approaches to adopt.

CONCLUSIONS

Our cumulative overview reports the most common wiring patterns and functional implications to be expected when approaching the study of the AF, while still considering seldom descriptions as an account of interindividual variability. Given its extension and the variety of cortical territories it reaches, the AF is a pivotal structure for different cognitive functions, and thorough understanding of its structural wiring and the functions it mediates is necessary for preserving the patient's cognitive abilities during glioma resection.

Neural correlates of verbal fluency revealed by longitudinal T1, T2 and FLAIR imaging in stroke

Diffusion-weighted imaging has been widely used in the research on post-stroke verbal fluency but acquiring diffusion data is not always clinically feasible. Achieving comparable reliability for detecting brain variables associated with verbal fluency impairments, based on more readily available anatomical, non-diffusion images (T1, T2 and FLAIR), enables clinical practitioners to have complementary neurophysiological information at hand to facilitate diagnosis and treatment of language impairment. Meanwhile, although the predominant focus in the stroke recovery literature has been on cortical contributions to verbal fluency, it remains unclear how subcortical regions and white matter disconnection are related to verbal fluency. Our study thus utilized anatomical scans of ischaemic stroke survivors (n = 121) to identify longitudinal relationships between subcortical volume, white matter tract disconnection, and verbal fluency performance at 3- and 12-months post-stroke. Subcortical grey matter volume was derived from FreeSurfer. We used an indirect probabilistic approach to quantify white matter disconnection in terms of disconnection severity, the proportion of lesioned voxel volume to the total volume of a tract, and disconnection probability, the probability of the overlap between the stroke lesion and a tract. These disconnection variables of each subject were identified based on the disconnectome map of the BCBToolkit. Using a linear mixed multiple regression method with 5-fold cross-validations, we correlated the semantic and phonemic fluency scores with longitudinal measurements of subcortical grey matter volume and 22 bilateral white matter tracts, while controlling for demographic variables (age, sex, handedness and education), total brain volume, lesion volume, and cortical thickness. The results showed that the right subcortical grey matter volume was positively correlated with phonemic fluency averaged over 3 months and 12 months. The finding generalized well on the test data. The disconnection probability of left superior longitudinal fasciculus II and left posterior arcuate fasciculus was negatively associated with semantic fluency only on the training data, but the result aligned with our previous study using diffusion scans in the same clinical population. In sum, our results presented evidence that routinely acquired anatomical scans can serve as a reliable source for deriving neural variables of post-stroke verbal fluency performance. The use of this method might provide an ecologically valid and more readily implementable analysis tool.

Constrained spherical deconvolution -based tractography of major language tracts reveals post-stroke bilateral white matter changes correlated to aphasia

PURPOSE

Using constrained spherical deconvolution (CSD)-based tractography, we aimed to obtain conjoint analysis of diffusion measures of major language white matter (WM) tracts in post-stroke aphasic patients bilaterally, and to correlate the measures of each tract to the different language deficits.

MATERIAL AND METHODS

17 aphasic patients with left hemispheric stroke, at the subacute stage, and ten age- matched controls underwent diffusion MRI examination. CSD-based tractography was performed. Diffusion measures [fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), axial diffusivity (AD)] were extracted after dissection of major language tracts bilaterally. Aphasia was assessed using language subset of hemispheric stroke scale. Comparisons of diffusion measures, for all tracts, between the two groups were performed. Partial correlations between the diffusion measures and different language components were obtained.

RESULTS

In the left hemisphere, significant lower FA and or higher MD with higher RD of patients' WM tracts compared to the control group. Significant differences of diffusion measures were also evident in the right hemisphere yet, less prominent. All changes reflected damage of the tracts' integrity. Significant correlations were found between comprehension and FA of the left arcuate fasciculus (AF) and left inferior longitudinal fasciculus. Additionally, a significant correlation was found between MD of the right AF and repetition.

CONCLUSION

Conjoint analysis of diffusion measures, based on CSD tractography, can provide important markers for the underlying WM changes bilaterally. Moreover, our findings emphasize that language processing can be mediated by both ventral and dorsal streams and further highlight the contribution of the right AF in repetition.

Early white matter connectivity and plasticity in post stroke aphasia recovery

A disruption of white matter connectivity is negatively associated with language (recovery) in patients with aphasia after stroke, and behavioral gains have been shown to coincide with white matter neuroplasticity. However, most brain-behavior studies have been carried out in the chronic phase after stroke, with limited generalizability to earlier phases. Furthermore, few studies have investigated neuroplasticity patterns during spontaneous recovery (i.e., not related to a specific treatment) in the first months after stroke, hindering the investigation of potential early compensatory mechanisms. Finally, the majority of previous research has focused on damaged left hemisphere pathways, while neglecting the potential protective value of their right hemisphere counterparts for language recovery. To address these outstanding issues, we present a longitudinal study of thirty-two patients with aphasia (21 males and 11 females, M = 69.47 years, SD = 10.60 years) who were followed up for a period of 1 year with test moments in the acute (1-2 weeks), subacute (3-6 months) and chronic phase (9-12 months) after stroke. Constrained Spherical Deconvolution-based tractography was performed in the acute and subacute phase to measure Fiber Bundle Capacity (FBC), a quantitative connectivity measure that is valid in crossing fiber regions, in the bilateral dorsal arcuate fasciculus (AF) and the bilateral ventral inferior fronto-occipital fasciculus (IFOF). First, concurrent analyses revealed positive associations between the left AF and phonology, and between the bilateral IFOF and semantics in the acute - but not subacute - phase, supporting the dual-stream language model. Second, neuroplasticity analyses revealed a decrease in connection density of the bilateral AF - but not the IFOF - from the acute to the subacute phase, possibly reflecting post stroke white matter degeneration in areas adjacent to the lesion. Third, predictive analyses revealed no contribution of acute FBC measures to the prediction of later language outcomes over and above the initial language scores, suggesting no added value ofthe diffusion measures for languageprediction. Our study provides new insights on (changes in) connectivity of damaged and undamaged language pathways in patients with aphasia in the first months after stroke, as well as if/how such measures are related to language outcomes at different stages of recovery. Individual results are discussed in the light of current frameworks of language processing and aphasia recovery.

Poor Spontaneous Recovery of Aphemia Accompanied by Damage to the Anterior Segment of the Left Arcuate Fasciculus: A Case Report

Aphemia is a rare and special type of speech disorder, and the mechanisms underlying the occurrence and recovery remain unclear. Here, we present a clinical case of poor spontaneous recovery of aphemia, with the anterior segment of the left arcuate fasciculus server damaged and the posterior segment intact, as detected by diffusion tensor imaging. Aphemia could be caused by the disruption of the cortical and subcortical language circuits. In particular, our data support the view that damage to the anterior segment of the left arcuate fasciculus may result in poor spontaneous recovery from speech production deficits and that an intact posterior segment seems to be crucial for supporting residual language comprehension ability in patients with post-stroke aphasia. Collectively, these data imply the importance of the left arcuate fasciculus during recovery from the language disorder in the subacute stage of stroke.

White matter microstructural integrity pre- and post-treatment in individuals with chronic post-stroke aphasia

While previous studies have found that white matter damage relates to impairment severity in individuals with aphasia, further study is required to understand the relationship between white matter integrity and treatment response. In this study, 34 individuals with chronic post-stroke aphasia underwent behavioral testing and structural magnetic resonance imaging at two timepoints. Thirty participants within this sample completed typicality-based semantic feature treatment for anomia. Tractography of bi-hemispheric white matter tracts was completed via Automated Fiber Quantification. Associations between microstructural integrity metrics and behavioral measures were evaluated at the tract level and in nodes along the tract. Diffusion measures of the left inferior longitudinal, superior longitudinal, and arcuate fasciculi were related to aphasia severity and diffusion measures of the left inferior longitudinal fasciculus were related to naming and treatment response. This study also found preliminary evidence of left inferior longitudinal fasciculus microstructural changes following treatment.

Structural Changes in the Arcuate Fasciculus and Recovery of Post-stroke Aphasia: A 6-Month Follow-up Study using Diffusion Tensor Imaging

BACKGROUND

Temporal changes in the structural connectivity of major language tracts after stroke and their contribution to aphasia recovery are unclear.

OBJECTIVE

To investigate longitudinal arcuate fasciculus (AF) integrity changes and their relationship with post-stroke aphasia recovery using diffusion tensor imaging (DTI).

METHODS

Thirty-five patients with aphasia due to first-ever left hemispheric stroke underwent the Korean version of the Western Aphasia Battery and DTI at 1- and 6-month post stroke onset. Fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD) of both AF tracts were analyzed to evaluate the temporal changes in tract integrity and determine the correlation between changes (Δ; follow-up - initial) in DTI parameters and language scores.

RESULTS

At 6 months post-stroke, the mean FA decreased, and mean MD and RD increased in both hemispheres; however, compared with mean AD observed after 1 month, the mean observed at 6 months increased only in the left hemisphere (P < .05). ΔFA of the left AF and proportional change in the aphasia quotient showed a significant positive correlation (r = 0.365, P = .031). No correlation was found between changes in the right AF parameters and language score. The group with increased FA in the left AF showed more significant language improvement than the group with decreased FA.

CONCLUSIONS

During the subacute stage, the integrity of AF decreased in both hemispheres in patients with aphasia, and the change in structural connectivity of the left AF was associated with language improvement.

Integrity of the Left Arcuate Fasciculus Segments Significantly Affects Language Performance in Individuals with Acute/Subacute Post-Stroke Aphasia: A Cross-Sectional Diffusion Tensor Imaging Study

Objective: To investigate the correlation between the left arcuate fasciculus (AF) segments and acute/subacute post-stroke aphasia (PSA). Methods: Twenty-six patients underwent language assessment and MRI scanning. The integrity of the AF based on a three-segment model was evaluated using diffusion tensor imaging. All patients were classified into three groups according to the reconstruction of the left AF: completely reconstructed (group A, 8 cases), non-reconstructed (group B, 6 cases), and partially reconstructed (group C, 12 cases). The correlations and intergroup differences in language performance and diffusion indices were comprehensively estimated. Results: A correlation analyses showed that the lesion load of the language areas and diffusion indices on the left AF posterior and long segments was significantly related to some language subsets, respectively. When controlled lesion load was variable, significant correlations between diffusion indices on the posterior and long segments and comprehension, repetition, naming, and aphasia quotient were retained. Multiple comparison tests revealed intergroup differences in diffusion indices on the left AF posterior and long segments, as well as these language subsets. No significant correlation was found between the anterior segment and language performance. Conclusions: The integrity of the left AF segments, particularly the posterior segment, is crucial for the residual comprehension and repetition abilities in individuals with acute/subacute PSA, and lesion load in cortical language areas is an important factor that should be taken into account when illustrating the contributions of damage to special fiber tracts to language impairments.

Functional Contributions of the Arcuate Fasciculus to Language Processing

Current evidence strongly suggests that the arcuate fasciculus (AF) is critical for language, from spontaneous speech and word retrieval to repetition and comprehension abilities. However, to further pinpoint its unique and differential role in language, its anatomy needs to be explored in greater detail and its contribution to language processing beyond that of known cortical language areas must be established. We address this in a comprehensive evaluation of the specific functional role of the AF in a well-characterized cohort of individuals with chronic aphasia (n = 33) following left hemisphere stroke. To evaluate macro- and microstructural integrity of the AF, tractography based on the constrained spherical deconvolution model was performed. The AF in the left and right hemispheres were then manually reconstructed using a modified 3-segment model (Catani et al., 2005), and a modified 2-segment model (Glasser and Rilling, 2008). The normalized volume and a measure of microstructural integrity of the long and the posterior segments of the AF were significantly correlated with language indices while controlling for gender and lesion volume. Specific contributions of AF segments to language while accounting for the role of specific cortical language areas – inferior frontal, inferior parietal, and posterior temporal – were tested using multiple regression analyses. Involvement of the following tract segments in the left hemisphere in language processing beyond the contribution of cortical areas was demonstrated: the long segment of the AF contributed to naming abilities; anterior segment – to fluency and naming; the posterior segment – to comprehension. The results highlight the important contributions of the AF fiber pathways to language impairments beyond that of known cortical language areas. At the same time, no clear role of the right hemisphere AF tracts in language processing could be ascertained. In sum, our findings lend support to the broader role of the left AF in language processing, with particular emphasis on comprehension and naming, and point to the posterior segment of this tract as being most crucial for supporting residual language abilities.

The Role of the Right Hemisphere White Matter Tracts in Chronic Aphasic Patients After Damage of the Language Tracts in the Left Hemisphere

The involvement of the right hemisphere (RH) in language, and especially after aphasia resulting from left hemisphere (LH) lesions, has been recently highlighted. The present study investigates white matter structure in the right hemisphere of 25 chronic post-stroke aphasic patients after LH lesions in comparison with 24 healthy controls, focusing on the four cortico-cortical tracts that link posterior parietal and temporal language-related areas with Broca’s region in the inferior frontal gyrus of the LH: the Superior Longitudinal Fasciculi II and III (SLF II and SLF III), the Arcuate Fasciculus (AF), and the Temporo-Frontal extreme capsule Fasciculus (TFexcF). Additionally, the relationship of these RH white matter tracts to language performance was examined. The patients with post-stroke aphasia in the chronic phase and the healthy control participants underwent diffusion tensor imaging (DTI) examination. The aphasic patients were assessed with standard aphasia tests. The results demonstrated increased axial diffusivity in the RH tracts of the aphasic patients. Patients were then divided according to the extent of the left hemisphere white matter loss. Correlations of language performance with radial diffusivity (RD) in the right hemisphere homologs of the tracts examined were demonstrated for the TFexcF, SLF III, and AF in the subgroup with limited damage to the LH language networks and only with the TFexcF in the subgroup with extensive damage. The results argue in favor of compensatory roles of the right hemisphere tracts in language functions when the LH networks are disrupted.

Prediction of Aphasia Severity in Patients with Stroke Using Diffusion Tensor Imaging

This study classified the severity of aphasia through the Western Aphasia Battery and determined the optimal cut-off value for each Language-Related White Matter fiber and their combinations, we further examined the correlations between Language-Related White Matter and Western Aphasia Battery subscores. This retrospective study recruited 64 patients with aphasia. Mild/moderate and severe aphasia were classified according to cut-off Aphasia Quotient score of 51 points. Diffusion tensor imaging and fractional anisotropy reconstructed Language-Related White Matter in multiple fasciculi. We determined the area under the covariate-adjusted receiver operating characteristic curve to evaluate the accuracy of predicting aphasia severity. The optimal fractional-anisotropy cut-off values for the individual fibers of the Language-Related White Matter and their combinations were determined. Their correlations with Western Aphasia Battery subscores were analyzed. The arcuate and superior longitudinal fasciculi showed fair accuracy, the inferior frontal occipital fasciculus poor accuracy, and their combinations fair accuracy. Correlations between Language-Related White Matter parameters and Western Aphasia Battery subscores were found between the arcuate, superior longitudinal, and inferior frontal occipital fasciculi and spontaneous speech, auditory verbal comprehension, repetition, and naming. Diffusion-tensor-imaging-based language-Related White Matter analysis may help predict the severity of language impairment in patients with aphasia following stroke.

The role of microstructural integrity of major language pathways in narrative speech in the first year after stroke

BACKGROUND AND PURPOSE

Left hemisphere stroke often results in a variety of language deficits due to varying patterns of damage to language networks. The Cookie Theft picture description task, a classic, quick bedside assessment, has been shown to quantify narrative speech reliably. In this study, we utilized diffusion tensor imaging (DTI) to assess language network white matter tract correlates of lexical-semantic and syntactic impairments longitudinally.

METHODS

Twenty-eight patients with mild to severe language impairments after left hemispheric lobar and/or subcortical ischemic stroke underwent the Cookie Theft picture description test and DTI up to three different time points: within the first three months, six months and twelve months after stroke. Dorsal and ventral stream language pathways were segmented to obtain DTI integrity metrics of both hemispheres. Multivariable regression models and partial correlation analyses adjusted for age, education, and lesion load were conducted to evaluate the temporal DTI profile of the white matter microstructural integrity of the language tracts as neural correlates of narrative speech within the first year after stroke.

RESULTS

Among all the major language white matter pathways, the integrity of the left arcuate (AF), inferior fronto-occipital, and inferior longitudinal fasciculi (ILF) were related to picture description performance. After FDR correction, left ILF fractional anisotropy correlated with syntactic cohesiveness (r=0.85,p=0.00087) within the first three months after stroke, whereas at one year post-stroke, the strongest correlations were found between lexical-semantic performance and left AF radial diffusivity (r = -0.71, p = 0.00065).

CONCLUSION

Our study provides a temporal profile of associations between the integrity of the main language pathways and lexical semantics and syntactic impairments in left hemispheric strokes.

The utility of lesion classification in predicting language and treatment outcomes in chronic stroke-induced aphasia

Stroke recovery models can improve prognostication of therapy response in patients with chronic aphasia, yet quantifying the effect of lesion on recovery is challenging. This study aimed to evaluate the utility of lesion classification via gray matter (GM)-only versus combined GM plus white matter (WM) metrics and to determine structural measures associated with aphasia severity, naming skills, and treatment outcomes. Thirty-four patients with chronic aphasia due to left hemisphere infarct completed T1-weighted and DTI scans and language assessments prior to receiving a 12-week naming treatment. GM metrics included the amount of spared tissue within five cortical masks. WM integrity was indexed by spared tissue and fractional anisotropy (FA) from four homologous left and right association tracts. Clustering of GM-only and GM + WM metrics via k-medoids yielded four patient clusters that captured two lesion characteristics, size and location. Linear regression models revealed that both GM-only and GM + WM clustering predicted baseline aphasia severity and naming skills, but only GM + WM clustering predicted treatment outcomes. Spearman correlations revealed that without controlling for lesion volume, the majority of left hemisphere metrics were related to language measures. However, adjusting for lesion volume, no relationships with aphasia severity remained significant. FA from two ventral left WM tracts was related to naming and treatment success, independent of lesion size. In sum, lesion volume and GM metrics are sufficient predictors of overall aphasia severity in patients with chronic stroke, whereas diffusion metrics reflecting WM tract integrity may add predictive power to language recovery outcomes after rehabilitation.

WORD LEARNING IN APHASIA: TREATMENT IMPLICATIONS AND STRUCTURAL CONNECTIVITY ANALYSES

OBJECTIVE

Of current interest in aphasia research is the relevance of what we can learn from studying word learning ability in aphasia. In a preliminary study, we addressed two issues related to the novel word learning ability of individuals with aphasia. First, as word learning engages large-scale cognitive-linguistic systems (language skills, verbal short-term memory (STM), other memory and executive functions), we probed whether novel word learning practice in three people with aphasia could stimulate these language-related systems. Second, as lesion correlates affecting word learning in aphasia remain unclear, we examined whether the structural integrity of the left arcuate fasciculus (AF) in the same three individuals is related to outcomes of novel word learning practice.

METHOD

To stimulate word learning systems, our three participants practiced for 4 weeks with an explicit novel word - novel referent word learning task, adopted from the Ancient Farming Equipment learning paradigm (Laine & Salmelin, 2010). The participants' progress on receptive and expressive novel word learning was followed up, and their language and verbal STM abilities as well as single-session novel word learning (Learning to Name Aliens by Gupta, Martin, Abbs, Schwartz & Lipinski, 2006) were tested before and after the practice period. To address the second question, we analyzed the participants' structural MRI scans with respect to the integrity of the left AF and its overlap with the lesion areas.

RESULTS

All participants showed some receptive word learning in the trained task, as well as improvements in verbal STM span at posttest. Two of the three participants also showed improved performance on some of the language outcome measures. One participant with partially spared left AF, especially temporo-parietal connections, exhibited better word learning performance than the other two who had larger damage and disconnection of the AF.

CONCLUSIONS

While the present results are preliminary, they open the possibility that novel word learning practice in aphasia may stimulate remaining word learning mechanisms in aphasia, and thereby influence language and verbal STM abilities. These results also suggest that preservation of novel word learning ability in aphasia in part depends on the integrity of the left arcuate track.

Acute Diffusivity Biomarkers for Prediction of Motor and Language Outcome in Mild-to-Severe Stroke Patients

Background and Purpose—

Early severity of stroke symptoms—especially in mild-to-severe stroke patients—are imperfect predictors of long-term motor and aphasia outcome. Motor function and language processing heavily rely on the preservation of important white matter fasciculi in the brain. Axial diffusivity (AD) from the diffusion tensor imaging model has repeatedly shown to accurately reflect acute axonal damage and is thus optimal to probe the integrity of important white matter bundles and their relationship with long-term outcome. Our aim was to investigate the independent prognostic value of the AD of white matter tracts in the motor and language network evaluated at 24 hours poststroke for motor and aphasia outcome at 3 months poststroke.

Methods—

Seventeen (motor cohort) and 28 (aphasia cohort) thrombolyzed patients with initial mild-to-severe stroke underwent a diffusion tensor imaging sequence at 24 hours poststroke. Motor and language outcome were evaluated at 3 months poststroke with a composite motor score and the aphasia handicap scale. We first used stepwise regression to determine which classic (age, initial motor or aphasia severity, and lesion volume) and imaging (ratio of affected/unaffected AD of motor and language fasciculi) factors were related to outcome. Second, to determine the specificity of our a priori choices of fasciculi, we performed voxel-based analyses to determine if the same, additional, or altogether new regions were associated with long-term outcome.

Results—

The ratio of AD in the corticospinal tract was the sole predictor of long-term motor outcome, and the ratio of AD in the arcuate fasciculus—along with age and initial aphasia severity—was an independent predictor of 3-month aphasia outcome. White matter regions overlapping with these fasciculi naturally emerged in the corresponding voxel-based analyses.

Conclusions—

AD of the corticospinal tract and arcuate fasciculus are effective biomarkers of long-term motor and aphasia outcome, respectively.

Repetitive verbal behaviors are not always harmful signs: Compensatory plasticity within the language network in aphasia

Repetitive verbal behaviors such as conduite d'approche (CdA) and mitigated echolalia (ME) are well-known phenomena since early descriptions of aphasia. Nevertheless, there is no substantial fresh knowledge on their clinical features, neural correlates and treatment interventions. In the present study we take advantage of three index cases of chronic fluent aphasia showing CdA, ME or both symptoms to dissect their clinical and neural signatures. Using multimodal neuroimaging (structural magnetic resonance imaging and [18]-fluorodeoxyglucose positron emission tomography during resting state), we found that despite of the heterogeneous lesions in terms of etiology (stroke, traumatic brain injury), volume and location, CdA was present when the lesion affected in greater extent the left dorsal language pathway, while ME resulted from preferential damage to the left ventral stream. The coexistence of CdA and ME was associated with involvement of areas overlapping with the structural lesions and metabolic derangements described in the subjects who showed one of these symptoms (CdA or ME). These findings suggest that CdA and ME represent the clinical expression of plastic changes that occur within the spared language network and its interconnected areas in order to compensate for the linguistic functions that previously relied on the activity of the damaged pathway. We discuss the results in the light of this idea and consider alternative undamaged neural networks that may support CdA and ME.

Lesion mapping in acute stroke aphasia and its implications for recovery

Patients with stroke offer a unique window into understanding human brain function. Mapping stroke lesions poses several challenges due to the complexity of the lesion anatomy and the mechanisms causing local and remote disruption on brain networks. In this prospective longitudinal study, we compare standard and advanced approaches to white matter lesion mapping applied to acute stroke patients with aphasia. Eighteen patients with acute left hemisphere stroke were recruited and scanned within two weeks from symptom onset. Aphasia assessment was performed at baseline and six-month follow-up. Structural and diffusion MRI contrasts indicated an area of maximum overlap in the anterior external/extreme capsule with diffusion images showing a larger overlap extending into posterior perisylvian regions. Anatomical predictors of recovery included damage to ipsilesional tracts (as shown by both structural and diffusion images) and contralesional tracts (as shown by diffusion images only). These findings indicate converging results from structural and diffusion lesion mapping methods but also clear differences between the two approaches in their ability to identify predictors of recovery outside the lesioned regions.

Behavioral Effects of Chronic Gray and White Matter Stroke Lesions in a Functionally Defined Connectome for Naming

BACKGROUND

In functional magnetic resonance imaging studies, picture naming engages widely distributed brain regions in the parietal, frontal, and temporal cortices. However, it remains unknown whether those activated areas, along with white matter pathways between them, are actually crucial for naming.

OBJECTIVE

We aimed to identify nodes and pathways implicated in naming in healthy older adults and test the impact of lesions to the connectome on naming ability.

METHODS

We first identified 24 cortical nodes activated by a naming task and reconstructed anatomical connections between these nodes using probabilistic tractography in healthy adults. We then used structural scans and fractional anisotropy (FA) maps in 45 patients with left hemisphere stroke to assess the relationships of node and pathway integrity to naming, phonology, and nonverbal semantic ability.

RESULTS

We found that mean FA values in 13 left hemisphere white matter tracts within the dorsal and ventral streams and 1 interhemispheric tract significantly related to naming scores after controlling for lesion size and demographic factors. In contrast, lesion loads in the cortical nodes were not related to naming performance after controlling for the same variables. Among the identified tracts, the integrity of 4 left hemisphere ventral stream tracts related to nonverbal semantic processing and 1 left hemisphere dorsal stream tract related to phonological processing.

CONCLUSIONS

Our findings reveal white matter structures vital for naming and its subprocesses. These findings demonstrate the value of multimodal methods that integrate functional imaging, structural connectivity, and lesion data to understand relationships between brain networks and behavior.

Multifunctional Roles of the Ventral Stream in Language Models: Advanced Segmental Quantification in Post-Stroke Aphasic Patients

In the dual-route language model, the dorsal pathway is known for sound-to-motor mapping, but the role of the ventral stream is controversial. With the goal of enhancing our understanding of language models, this study investigated the diffusion characteristics of candidate tracts in aphasic patients. We evaluated 14 subacute aphasic patients post-stroke and 11 healthy controls with language assessment and diffusion magnetic resonance imaging. Voxel-based lesion-symptom mapping found multiple linguistic associations for the ventral stream, while automated fiber quantification (AFQ) showed, via reduced fractional anisotropy (FA) and axial diffusivity with increased radial diffusivity (all corrected p < 0.05), that the integrity of both the left dorsal and ventral streams was compromised. The average diffusion metrics of each fascicle provided by AFQ also confirmed that voxels with significant FA-language correlations were located in the ventral tracts, including the left inferior fronto-occipital fascicle (IFOF) (comprehension: r = 0.839, p = 0.001; repetition: r = 0.845, p = 0.001; naming: r = 0.813, p = 0.002; aphasia quotient: r = 0.847, p = 0.001) and uncinate fascicle (naming: r = 0.948, p = 0.001). Furthermore, point-wise AFQ revealed that the segment of the left IFOF with the strongest correlations was its narrow stem. The temporal segment of the left inferior longitudinal fascicle was also found to correlate significantly with comprehension (r = 0.663, p = 0.03) and repetition (r = 0.742, p = 0.009). This preliminary study suggests that white matter integrity analysis of the ventral stream may have the potential to reveal aphasic severity and guide individualized rehabilitation. The left IFOF, specifically its narrow stem segment, associates with multiple aspects of language, indicating an important role in semantic processing and multimodal linguistic functions.

Neuroplasticity of language in left-hemisphere stroke: Evidence linking subsecond electrophysiology and structural connections

The understanding of neuroplasticity following stroke is predominantly based on neuroimaging measures that cannot address the subsecond neurodynamics of impaired language processing. We combined behavioral and electrophysiological measures and structural-connectivity estimates to characterize neuroplasticity underlying successful compensation of language abilities after left-hemispheric stroke. We recorded the electroencephalogram from patients with stroke lesions to the left temporal lobe and from matched controls during context-driven word retrieval. Participants heard lead-in sentences that either constrained the final word ("He locked the door with the") or not ("She walked in here with the"). The last word was shown as a picture to be named. Individual-participant analyses were conducted, focusing on oscillatory power as a subsecond indicator of a brain region's functional neurophysiological computations. All participants named pictures faster following constrained than unconstrained sentences, except for two patients, who had extensive damage to the left temporal lobe. Left-lateralized alpha-beta oscillatory power decreased in controls pre-picture presentation for constrained relative to unconstrained contexts. In patients, the alpha-beta power decreases were observed with the same time course as in controls but were lateralized to the intact right hemisphere. The right lateralization depended on the probability of white-matter connections between the bilateral temporal lobes. The two patients who performed poorly behaviorally showed no alpha-beta power decreases. Our findings suggest that incorporating direct measures of neural activity into investigations of neuroplasticity can provide important neural markers to help predict language recovery, assess the progress of neurorehabilitation, and delineate targets for therapeutic neuromodulation. Hum Brain Mapp 38:3151-3162, 2017. © 2017 Wiley Periodicals, Inc.

Hypoconnectivity of Resting-State Networks in Persons with Aphasia Compared with Healthy Age-Matched Adults

Aphasia is a language disorder affecting more than one million people in the US. While language function has traditionally been the focus of neuroimaging research, other cognitive functions are affected in this population, which has implications not only for those specific processes but also for the interaction of language and other cognitive functions. Resting state fMRI (rs-fMRI) is a practical and informative way to explore and characterize general cognitive engagement and/or health in this population, but it is currently underutilized. The aim of this study was to explore the functional connectivity in resting state networks (RSNs) and in the semantic network in seven persons with aphasia (PWA) who were at least 6 months post onset compared with 11 neurologically healthy adults (NHA) in order to gain a more comprehensive understanding of general cognitive engagement in aphasia. These preliminary results show that PWA exhibit hypoconnectivity in the semantic network and all RSNs except the visual network. Compared with NHA, PWA appear to have fewer cross- and left-hemispheric connections. However, PWA exhibit some stronger connections than NHA within the semantic network, which could indicate compensatory mechanisms. Importantly, connectivity for RSNs appear to increase with decreasing aphasia severity and decrease with increasing lesion size. This knowledge has the potential to improve aphasia therapy by furthering the understanding of lesion effects on the cognitive system as a whole, which can guide treatment target selection and promotion of favorable neural reorganization for optimal recovery of function.

Damage to white matter bottlenecks contributes to language impairments after left hemispheric stroke

Damage to the white matter underlying the left posterior temporal lobe leads to deficits in multiple language functions. The posterior temporal white matter may correspond to a bottleneck where both dorsal and ventral language pathways are vulnerable to simultaneous damage. Damage to a second putative white matter bottleneck in the left deep prefrontal white matter involving projections associated with ventral language pathways and thalamo-cortical projections has recently been proposed as a source of semantic deficits after stroke. Here, we first used white matter atlases to identify the previously described white matter bottlenecks in the posterior temporal and deep prefrontal white matter. We then assessed the effects of damage to each region on measures of verbal fluency, picture naming, and auditory semantic decision-making in 43 chronic left hemispheric stroke patients. Damage to the posterior temporal bottleneck predicted deficits on all tasks, while damage to the anterior bottleneck only significantly predicted deficits in verbal fluency. Importantly, the effects of damage to the bottleneck regions were not attributable to lesion volume, lesion loads on the tracts traversing the bottlenecks, or damage to nearby cortical language areas. Multivariate lesion-symptom mapping revealed additional lesion predictors of deficits. Post-hoc fiber tracking of the peak white matter lesion predictors using a publicly available tractography atlas revealed evidence consistent with the results of the bottleneck analyses. Together, our results provide support for the proposal that spatially specific white matter damage affecting bottleneck regions, particularly in the posterior temporal lobe, contributes to chronic language deficits after left hemispheric stroke. This may reflect the simultaneous disruption of signaling in dorsal and ventral language processing streams.

White Matter Correlates of Auditory Comprehension Outcomes in Chronic Post-Stroke Aphasia

Neuroimaging studies have shown that speech comprehension involves a number of widely distributed regions within the frontal and temporal lobes. We aimed to examine the differential contributions of white matter connectivity to auditory word and sentence comprehension in chronic post-stroke aphasia. Structural and diffusion MRI data were acquired on 40 patients with chronic post-stroke aphasia. A battery of auditory word and sentence comprehension tests were administered to all the patients. Tract-based spatial statistics were used to identify areas in which white matter integrity related to specific comprehension deficits. Relevant tracts were reconstructed using probabilistic tractography in healthy older participants, and the mean values of fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) of the entire tracts were examined in relation to comprehension scores. Anterior temporal white matter integrity loss and involvement of the uncinate fasciculus related to word-level comprehension deficits (R_FA = 0.408, P = 0.012; R_MD = −0.429, P = 0.008; R_AD = −0.424, P = 0.009; R_RD = −0.439, P = 0.007). Posterior temporal white matter integrity loss and involvement of the inferior longitudinal fasciculus related to sentence-level comprehension deficits (R_FA = 0.382, P = 0.02; R_MD = −0.461, P = 0.004; R_AD = −0.457, P = 0.004; R_RD = −0.453, P = 0.005). Loss of white matter integrity in the inferior fronto-occipital fasciculus related to both word- and sentence-level comprehension (word-level scores: R_FA = 0.41, P = 0.012; R_MD = −0.447, P = 0.006; R_AD = −0.489, P = 0.002; R_RD = −0.432, P = 0.008; sentence-level scores: R_FA = 0.409, P = 0.012; R_MD = −0.413, P = 0.011; R_AD = −0.408, P = 0.012; R_RD = −0.413, P = 0.011). Lesion overlap, but not white matter integrity, in the arcuate fasciculus related to sentence-level comprehension deficits. These findings suggest that word-level comprehension outcomes in chronic post-stroke aphasia rely primarily on anterior temporal lobe pathways, whereas sentence-level comprehension relies on more widespread pathways including the posterior temporal lobe.

Reduced Diffusion Tensor Fractional Anisotropy in the Left Arcuate Fasciculus of Patients with Aphasia Caused by Acute Cerebral Infarct

Background

Magnetic resonance diffusion tensor imaging (DTI) is a new technique that evaluates neural fiber integrity within the brain. We conducted DTI in patients exhibiting aphasia during the acute stage post-infarct and investigated the neural tracts responsible by comparison with DTI data from age-matched controls.

Methods

Fractional anisotropy (FA) maps were generated from diffusion tensor brain images obtained from aphasic patients 14-21 days following their first infarct. Tract-based spatial statistics (TBSS) analysis was then applied. In addition, regions of interest (ROIs) were set within the right and left arcuate fasciculus, and mean FA values were extracted from individual TBSS data. The ratios between FA values in the left and right hemispheres were compared with those of the control group.

Results

The study examined 10 aphasic patients and 21 age-matched controls. Brain maps from TBSS analysis revealed significantly reduced FA in the left arcuate fasciculus of the patient group compared with that in the control group. Further ROI analyses confirmed significantly lower left/right arcuate fasciculus FA ratios in aphasic patients versus controls (median [range]: 0.955 [0.739-1.023] vs. 1.006 [0.982-1.088]; P = 0.0001 by Wilcoxon rank sum test).

Conclusions

These results suggest that FA in the left arcuate fasciculus decreased in association with aphasia after cerebral infarct. Because patients in the acute stage have not yet experienced the neural recovery that occurs in the chronic stage, the findings indicate that the left arcuate fasciculus is a crucial neural structure in aphasia.