Post-stroke Movement Disorders: The Clinical, Neuroanatomic, and Demographic Portrait of 284 Published Cases

Movement disorders following mechanical thrombectomy resulting in ischemic lesions of the basal ganglia: An emerging clinical entity

BACKGROUND AND PURPOSE

Post-stroke movement disorders (PMDs) following ischemic lesions of the basal ganglia (BG) are a known entity, but data regarding their incidence are lacking. Ischemic strokes secondary to proximal middle cerebral artery (MCA) occlusion treated with thrombectomy represent a model of selective damage to the BG. The aim of this study was to assess the prevalence and features of movement disorders after selective BG ischemia in patients with successfully reperfused acute ischemic stroke (AIS).

METHODS

We enrolled 64 consecutive subjects with AIS due to proximal MCA occlusion treated with thrombectomy. Patients were clinically evaluated by a movement disorders specialist for PMDs onset at baseline, and after 6 and 12 months.

RESULTS

None of the patients showed an identifiable movement disorder in the subacute phase of the stroke. At 6 and 12 months, respectively, 7/25 (28%) and 7/13 (53.8%) evaluated patients developed PMDs. The clinical spectrum of PMDs encompassed parkinsonism, dystonia and chorea, either isolated or combined. In most patients, symptoms were contralateral to the lesion, although a subset of patients presented with bilateral involvement and prominent axial signs.

CONCLUSION

Post-stroke movement disorders are not uncommon in long-term follow-up of successfully reperfused AIS. Follow-up conducted by a multidisciplinary team is strongly advisable in patients with selective lesions of the BG after AIS, even if asymptomatic at discharge.

Qingda granule alleviates cerebral ischemia/reperfusion injury by inhibiting TLR4/NF-κB/NLRP3 signaling in microglia

ETHNOPHARMACOLOGICAL RELEVANCE

Qingda granule (QDG) is effective for treating hypertension and neuronal damage after cerebral ischemia/reperfusion. However, the anti-neuroinflammatory effect of QDG on injury due to cerebral ischemia/reperfusion is unclear.

AIM OF THE STUDY

The objective was to evaluate the effectiveness and action of QDG in treating neuroinflammation resulting from cerebral ischemia/reperfusion-induced injury.

MATERIALS AND METHODS

Network pharmacology was used to predict targets and pathways of QDG. An in vivo rat model of middle cerebral artery occlusion/reperfusion (MCAO/R) as well as an in vitro model of LPS-stimulated BV-2 cells were established. Magnetic resonance imaging (MRI) was used to quantify the area of cerebral infarction, with morphological changes in the brain being assessed by histology. Immunohistochemistry (IHC) was used to assess levels of the microglial marker IBA-1 in brain tissue. Bioplex analysis was used to measure TNF-α, IL-1β, IL-6, and MCP-1 in sera and in BV-2 cell culture supernatants. Simultaneously, mRNA levels of these factors were examined using RT-qPCR analysis. Proteins of the TLR4/NF-κB/NLRP3 axis were examined using IHC in vivo and Western blot in vitro, respectively. While NF-κB translocation was assessed using immunofluorescence.

RESULTS

The core targets of QDG included TNF, NF-κB1, MAPK1, MAPK3, JUN, and TLR4. QDG suppressed inflammation via modulation of TLR4/NF-κB signaling. In addition, our in vivo experiments using MCAO/R rats demonstrated the therapeutic effect of QDG in reducing brain tissue infarction, improving neurological function, and ameliorating cerebral histopathological damage. Furthermore, QDG reduced the levels of TNF-α, IL-1β, IL-6, and MCP-1 in both sera from MCAO/R rats and supernatants from LPS-induced BV-2 cells, along with a reduction in the expression of the microglia biomarker IBA-1, as well as that of TLR4, MyD88, p-IKK, p-IκBα, p-P65, and NLRP3 in MCAO/R rats. In LPS-treated BV-2 cells, QDG downregulated the expression of proinflammatory factors and TLR4/NF-κB/NLRP3 signaling-related proteins. Additionally, QDG reduced translocation of NF-κB to the nucleus in both brains of MCAO/R rats and LPS-induced BV-2 cells. Moreover, the combined treatment of the TLR4 inhibitor TAK242 and QDG significantly reduced the levels of p-P65, NLRP3, and IL-6.

CONCLUSIONS

QDG significantly suppressed neuroinflammation by inhibiting the TLR4/NF-κB/NLRP3 axis in microglia. This suggests potential for QDG in treating ischemia stroke.

Delayed levodopa-responsive parkinsonism following acute midbrain injury

Acute midbrain injury may cause both hyperkinetic movement disorders and parkinsonism. The temporal interval between the insult and the emergence of hyperkinetic disorders can last years. A delayed appearance of parkinsonism, on the other hand, was rarely described. We present three cases of male patients (50-, 58- and 28-year-old) who developed levodopa-responsive parkinsonism 20, 8 and two years, respectively, after acute brain insult involving the midbrain. Insults included subcortical intracerebral hemorrhage dissecting into the midbrain, embolic basilar occlusion and trauma. A fluorodopa scan, performed in two cases, revealed reduced striatal uptake. All individuals improved on low doses of levodopa and developed motor fluctuations shortly after levodopa was introduced. We conclude that delayed, levodopa-responsive parkinsonism following midbrain injury should be recognized in the relevant clinical setup. Possible mechanisms include age-related loss of dopaminergic neurons superimposed on acute injury and secondary neurodegeneration.

Clinical approaches for poststroke seizure: a review

Poststroke seizure is a potential complication of stroke, which is the most frequent acute symptomatic seizure in adults. Patients with stroke may present with an abnormal or aggressive behavior accompanied by altered mental status and symptoms, such as hemiparesis, dysarthria, and sensory deficits. Although stroke manifestations that mimic seizures are rare, diagnosing poststroke seizures can be challenging when accompanied with negative postictal symptoms. Differential diagnoses of poststroke seizures include movement disorders, syncope, and functional (nonepileptic) seizures, which may present with symptoms similar to seizures. Furthermore, it is important to determine whether poststroke seizures occur early or late. Seizures occurring within and after 7 d of stroke onset were classified as early and late seizures, respectively. Early seizures have the same clinical course as acute symptomatic seizures; they rarely recur or require long-term antiseizure medication. Conversely, late seizures are associated with a risk of recurrence similar to that of unprovoked seizures in a patient with a focal lesion, thereby requiring long-term administration of antiseizure medication. After diagnosis, concerns regarding treatment strategies, treatment duration, and administration of primary and secondary prophylaxis often arise. Antiseizure medication decisions for the initiation of short-term primary and long-term secondary seizure prophylaxis should be considered for patients with stroke. Antiseizure drugs such as lamotrigine, carbamazepine, lacosamide, levetiracetam, phenytoin, and valproate may be administered. Poststroke seizures should be diagnosed systematically through history with differential diagnosis; in addition, classifying them as early or late seizures can help to determine treatment strategies.

Current opinions and practices in post-stroke movement disorders: Survey of movement disorders society members

BACKGROUND

Post-stroke movement disorders (PSMD) encompass a wide array of presentations, which vary in mode of onset, phenomenology, response to treatment, and natural history. There are no evidence-based guidelines on the diagnosis and treatment of PSMD.

OBJECTIVES

To survey current opinions and practices on the diagnosis and treatment of PSMD.

METHODS

A survey was developed by the PSMD Study Group, commissioned by the International Parkinson's and Movement Disorders Society (MDS). The survey, distributed to all members, yielded a total of 529 responses, 395 (74.7%) of which came from clinicians with experience with PSMD.

RESULTS

Parkinsonism (68%), hemiballismus/hemichorea (61%), tremor (58%), and dystonia (54%) were by far the most commonly endorsed presentation of PSMD, although this varied by region. Basal ganglia stroke (76% of responders), symptoms contralateral to stroke (75%), and a temporal relationship (59%) were considered important factors for the diagnosis of PSMD. Oral medication use depended on the phenomenology of the PSMD. Almost 50% of respondents considered deep brain stimulation and ablative surgeries as options for treatment. The lack of guidelines for the diagnosis and treatment was considered the most important gap to address.

CONCLUSIONS

Regionally varying opinions and practices on PSMD highlight gaps in (and mistranslation of) epidemiologic and therapeutic knowledge. Multicenter registries and prospective community-based studies are needed for the creation of evidence-based guidelines to inform the diagnosis and treatment of patients with PSMD.

Rehabilitation effect of core muscle training combined with functional electrical stimulation on lower limb motor and balance functions in stroke patients

BACKGROUND

Studies have shown that core muscle training can accelerate the recovery of motor function in stroke patients. However, there are no relevant reports to show the effect of core muscle training combined with functional electrical stimulation (FES) on the rehabilitation of stroke patients.

OBJECTIVE

This study aimed to observe the efficacy of core muscle training combined with FES on motor and balance functions of lower limbs in stroke patients.

METHODS

This study selected and divided 120 stroke patients with hemiplegia admitted to our hospital into the control and observation groups. Patients in the control group just received core muscle training; while patients in the observation group were treated by core muscle training combined with FES. Both groups were treated for 8 weeks. Subsequently, the clinical data and information of all patients were collected and counted. Muscle strength changes were observed by detecting paralytic dorsiflexor (pDF), plantar flexor (pPF), knee extensor (pKE), and knee flexor (pKF) before and after treatment. Motor and balance abilities of both groups were scored through the 10-meter walking test (10 MWT), Berg balance scale (BBS), functional ambulation category (FAC) scale, timed up and go (TUG) test, and lower extremity motricity index (MI-Lower).

RESULTS

No significant difference was found in clinical data between the two groups. The intensity of pDF, pPF, pKE, and pKF significantly increased in both groups after treatment, and the intensity of these parameters was higher in the observation group relative to the control group. Additionally, 10 MWT and TUG test scores of patients in the observation group were notably decreased while the BBS and MI-Lower scores were significantly increased after treatment compared with those in the control group.

CONCLUSION

Core muscle training combined with FES can significantly improve the rehabilitation effect of lower limb motor and balance functions in stroke patients.

Post-stroke Everything

PURPOSE OF REVIEW

This review aims at providing updates on selected post-stroke complications. We examined recent advances in diagnosing and treating the following post-stroke complications: cognitive impairment, epilepsy, depression, fatigue, tremors, dysphagia, and pain.

RECENT FINDINGS

Advances in understanding the mechanisms of post-stroke complications, in general, are needed despite advances made in understanding, treating, and preventing these complications. There are growing progresses in integrating new tools to diagnose post-stroke cognitive impairment. The potential role of acute stroke reperfusion treatment in post-stroke epilepsy and its impact on other stroke complications is getting more transparent. Post-stroke depression remains underestimated and new tools to diagnose depression after stroke are being developed. New promising pharmacological approaches to treating post-stroke pain are emerging. Tremors related to stroke are poorly understood and under-evaluated, while treatment towards post-stroke dysphagia has benefited from new non-pharmacological to pharmacological approaches.

CONCLUSIONS

An integrative approach to stroke complications and collaborations between providers across specialties are more likely to improve stroke outcomes.

Oxidative stress as a bridge between age and stroke: A narrative review

Stroke is the third most common cause of death globally and a leading cause of disability. The cellular and molecular changes following stroke and causes of neuronal death are not fully understood, and there are few effective treatments currently available. A rapid increase in the levels of reactive oxygen species (ROS) post stroke can overwhelm antioxidant defenses and trigger a series of pathophysiologic events including the inflammatory response, blood-brain barrier (BBB) disruption, apoptosis, and autophagy, ultimately leading to neuron degeneration and apoptosis. It is thought that beyond a certain age, the ROS accumulation resulting from stroke increases the risk of morbidity and mortality. In the present review, we summarize the role of oxidative stress (OS) as a link between aging and stroke pathogenesis. We also discuss how antioxidants can play a beneficial role in the prevention and treatment of stroke by eliminating harmful ROS, delaying aging, and alleviating damage to neurons.

Integrative Approaches in Acute Ischemic Stroke: From Symptom Recognition to Future Innovations

Among the high prevalence of cerebrovascular diseases nowadays, acute ischemic stroke stands out, representing a significant worldwide health issue with important socio-economic implications. Prompt diagnosis and intervention are important milestones for the management of this multifaceted pathology, making understanding the various stroke-onset symptoms crucial. A key role in acute ischemic stroke management is emphasizing the essential role of a multi-disciplinary team, therefore, increasing the efficiency of recognition and treatment. Neuroimaging and neuroradiology have evolved dramatically over the years, with multiple approaches that provide a higher understanding of the morphological aspects as well as timely recognition of cerebral artery occlusions for effective therapy planning. Regarding the treatment matter, the pharmacological approach, particularly fibrinolytic therapy, has its merits and challenges. Endovascular thrombectomy, a game-changer in stroke management, has witnessed significant advances, with technologies like stent retrievers and aspiration catheters playing pivotal roles. For select patients, combining pharmacological and endovascular strategies offers evidence-backed benefits. The aim of our comprehensive study on acute ischemic stroke is to efficiently compare the current therapies, recognize novel possibilities from the literature, and describe the state of the art in the interdisciplinary approach to acute ischemic stroke. As we aspire for holistic patient management, the emphasis is not just on medical intervention but also on physical therapy, mental health, and community engagement. The future holds promising innovations, with artificial intelligence poised to reshape stroke diagnostics and treatments. Bridging the gap between groundbreaking research and clinical practice remains a challenge, urging continuous collaboration and research.

The enduring enigma of sporadic chorea: A single center case series

Chorea can have a wide variety of causes including neurodegenerative, pharmacological, structural, metabolic, infectious, immunologic and paraneoplastic processes. We reviewed the clinical records of patients with apparently sporadic choreic movements and no relevant family history, who presented to our neurology department (Hospital Fundación Jimenez Diaz) between 1991 and 2022. We detected 38 cases of apparent sporadic chorea (ASC); Our analysis revealed 5 cases of genetic chorea (including 3 cases with Huntington's disease) while 6 cases were autoimmune/hematological; 6 drug-related chorea, 5 metabolic-vascular, 5 due to miscellaneous conditions and 4 were of mixed etiology. No clear etiology was identified in 8 cases. The differential diagnosis of ASC is extensive and challenging.

Highlights

Chorea can have a wide variety of genetic and sporadic causesWe reviewed the clinical records of patients with apparently sporadic chorea (ASC), who presented to our neurology department over the last 30 yearsWe detected 38 cases of apparent ASC; Our analysis revealed a wide array of different sporadic conditions and 5 cases of genetic choreaThe differential diagnosis of ASC is extensive and challenging.

[Frontal-subcortical syndrome: When the network fails, about a case]

Depression and parkinsonism are direct consequences of a lesion, usually vascular, that affects some structure of the frontal-subcortical circuit. Their detection represents a diagnostic challenge and has important repercussions in therapeutic management. The case is presented of a 79-year-old male patient with good overall baseline status, who was admitted to a Psychogeriatric Unit after an autolytic attempt. Initially, a non-psychotic frank depression is observed, and an increase in the base of support for walking and bradykinesia is noted. After adjustment of antidepressant treatment, a notable improvement in affective symptoms is evidenced but not in motor symptoms, so it is decided to request a magnetic resonance imaging that shows ischemic lesions in the basal ganglia. This case provides clear support for the frontal-subcortical circuit model, in which the clinical presentation, neuropsychiatric evaluation, neuroimaging data and therapeutic response contribute to understanding the deficits following these types of lesions. We believe that this article will provide brief and accurate information on the pathophysiological mechanisms, evaluation, diagnostic approach, and treatment of the frontal-subcortical syndrome.

Acute Onset of Movement Disorders Accompanying Common Emergency Room Neurologic Disease Processes

Emergency departments (EDs) of hospitals accredited for trauma and/or comprehensive stroke care treat a large volume of high-acuity patients. In this fast-paced environment, the primary focus is appropriate triage, rapid stabilization, diagnosis, and acute intervention for life-threatening conditions such as cerebral vascular accident (CVA). However, this approach may result in subtle or atypical neurologic signs and symptoms being overlooked. Often, these oversights are innocuous in terms of their influence on overall patient outcomes. They are, in the vernacular, "of academic interest only". These cases provide ED clinicians with a unique opportunity to witness signs and symptoms not classically associated with common neurologic maladies. These unusual manifestations may be fleeting as they often either resolve with intervention or are overshadowed by progressive clinical decline. If such findings are recognized, they can at a minimum provide fascinating insights into neuroanatomic function. At a maximum, early recognition can influence immediate treatments and long-term outcomes. We report three ED patient presentations that shed light on functional neuroanatomical pathways and, in one case, significantly affected a patient's immediate algorithmic care. Two such cases involved acute middle cerebral artery distribution ischemic strokes, which typically present with focal contralateral sensorimotor and potential language deficits. Such events less commonly initially present with involuntary motor movements (dyskinesias). Failure to recognize these less common ictal signs may delay appropriate ED intervention or yield etiologic misdiagnoses. A third case involved a loss of consciousness ictal event secondary to a frontotemporal lobe tumor. This case presented with aphasic stroke-like symptoms along with new acute orofacial dyskinesias. Imaging before and after medical, surgical, and endovascular intervention provided important clinico-anatomic lessons. Furthermore, proposed neurophysiologic mechanisms and review of pertinent literature are provided.

Hemiballism and chorea with acute/subacute onset: a retrospective series

INTRODUCTION

Chorea is a hyperkinetic movement disorder with sudden, irregular, random, dance-like involuntary movements, and ballism is usually one-sided, high-amplitude movements at the proximal of the extremities. In the etiology of acute chorea/hemiballismus, it is necessary to distinguish drugs first and then focus on metabolic causes. The most important etiological causes that may provoke acute/subacute onset chorea/hemiballismus are hypo-hyperglycemia and electrolyte disorders. In this study, we aim to present 19 patients who were admitted to our clinic with movement disorder with acute/subacute onset and diagnosed with chorea/hemiballismus.

METHODS

The study was completed with 19 patients. Routine biochemistry, HbA1c level, hemogram, sedimentation, CRP, hepatitis panels, detailed infective parameters, HIV, vitamin B12 level, folate levels, and thyroid function tests were studied. All patients underwent neuro-imaging.

RESULTS

16(84.2%) were female and 3(15.8%) were male. The lowest age of the patients was 48 years, the highest age was 89 years, and the mean age was 72.21 years. Thirteen (68.42%) patients had a diagnosis of diabetes mellitus in their history. The blood glucose levels of these patients at the time of admission: the lowest was 99 mg/dl and the highest was 1200 mg/dl. HbA1c values of 11(84.61%) of the 13 patients were also found elevated. Thirteen (68.4%) patients had hemiballismus, 4(21.1%) patients had bilateral choreoathetosis in the four extremities, and 2(10.2%) patients had ballism limited to one upper extremity.

CONCLUSIONS

Chorea/hemiballismus is a movement disorder that is rare and can occur due to a wide range of etiologies. The most common metabolic cause is NKHHS.

Preoperative risk model for perioperative stroke after intracranial tumor resection: ACS NSQIP analysis of 30,951 cases

OBJECTIVE

Perioperative and/or postoperative cerebrovascular accidents (PCVAs) after intracranial tumor resection (ITR) are serious complications with devastating effects on quality of life and survival. Here, the authors retrospectively analyzed a prospectively maintained, multicenter surgical registry to design a risk model for PCVA after ITR to support efforts in neurosurgical personalized medicine to risk stratify patients and potentially mitigate poor outcomes.

METHODS

The National Surgical Quality Improvement Program database was queried for ITR cases (2015-2019, n = 30,951). Patients with and without PCVAs were compared on baseline demographics, preoperative clinical characteristics, and outcomes. Frailty (physiological reserve for surgery) was measured by the Revised Risk Analysis Index (RAI-rev). Logistic regression analysis was performed to identify independent associations between preoperative covariates and PCVA occurrence. The ITR-PCVA risk model was generated based on logit effect sizes and assessed in area under the receiver operating characteristic curve (AUROC) analysis.

RESULTS

The rate of PCVA was 1.7% (n = 532). Patients with PCVAs, on average, were older and frailer, and had increased rates of nonelective surgery, interhospital transfer status, diabetes, hypertension, unintentional weight loss, and elevated BUN. PCVA was associated with higher rates of postoperative reintubation, infection, thromboembolic events, prolonged length of stay, readmission, reoperation, nonhome discharge destination, and 30-day mortality (all p < 0.001). In multivariable analysis, predictors of PCVAs included RAI "frail" category (OR 1.7, 95% CI 1.2-2.4; p = 0.006), Black (vs White) race (OR 1.5, 95% CI 1.1-2.1; p = 0.009), nonelective surgery (OR 1.4, 95% CI 1.1-1.7; p = 0.003), diabetes mellitus (OR 1.5, 95% CI 1.1-1.9; p = 0.002), hypertension (OR 1.4, 95% CI 1.1-1.7; p = 0.006), and preoperative elevated blood urea nitrogen (OR 1.4, 95% CI 1.1-1.8; p = 0.014). The ITR-PCVA predictive model was proposed from the resultant multivariable analysis and performed with a modest C-statistic in AUROC analysis of 0.64 (95% CI 0.61-0.66). Multicollinearity diagnostics did not detect any correlation between RAI-rev parameters and other covariates (variance inflation factor = 1).

CONCLUSIONS

The current study proposes a novel preoperative risk model for PCVA in patients undergoing ITR. Patients with poor physiological reserve (measured by frailty), multiple comorbidities, abnormal preoperative laboratory values, and those admitted under high acuity were at highest risk. The ITR-PCVA risk model may support patient-centered counseling striving to respect goals of care and maximize quality of life. Future prospective studies are warranted to validate the ITR-PCVA risk model and evaluate its utility as a bedside clinical tool.

Effect of Salvia Miltiorrhiza Polyphenolic Acid Injection on Improving Limb Use and Cognitive Impairment in Patients with Acute Stroke

Aims. To investigate the effect of injectable salvia polyphenolic acid on the improvement of limb movement and cognitive dysfunction in acute stroke patients. Materials and Methods. The clinical data of 90 acute stroke patients were collected for retrospective study and divided into 45 cases each in the comparison group and the observation group according to the different treatment methods; using basic treatment + salvianolic acid, the comparison group implemented conventional alteplase and butalbital treatment, and the observation group used injectable salvianolic acid treatment, to observe and compare the clinical efficacy, changes in neurological deficits, cognitive function, and motor function scores before and after treatment in the two groups. Results. The NIHSS (National Institute of Health stroke scale) score, cerebral infarct volume, NSE (neuron-specific enolase), and S100β (A neurotrophic factor) levels were reduced after treatment compared with those before treatment in this group, and the NIHSS score, cerebral infarct volume, NSE, and S100β levels in the observation group were lower than those in the comparison group after treatment, and the difference was statistically significant ( $P<0.05$ ). Compared with the clinical efficacy of the comparison group and the observation group, the treatment effect of the observation group was better than that of the comparison group, and the difference was statistically significant ( $P<0.05$ ). After treatment, the cognitive function and motor function scores of both groups were significantly improved compared with those before treatment, and the degree of improvement of each score in the observation group was significantly better than that in the comparison group ( $P<0.05$ ). During the trial, two patients in the comparison group developed a generalized rash and withdrew from the experiment, and the rash subsided after anti-allergic treatment, and no significant adverse events were observed in the remaining participants. There was no statistically significant difference in liver and kidney function and cardiac enzyme test indexes between the two groups of patients at 14 days of treatment ( $P>0.05$ ). Conclusion. Danshen polyphenolic acid for injection has definite clinical efficacy in the treatment of acute ischemic stroke, and it can effectively improve cognitive and motor functions and promote neurological recovery in patients with high safety.

Diagnostic Value of Image Features of Magnetic Resonance Imaging in Intracranial Hemorrhage and Cerebral Infarction

This study aimed to investigate the differential diagnosis value of routine magnetic resonance imaging (MRI) and magnetic resonance diffusion-weighted imaging (DWI) in hyperacute intracranial hemorrhage (HICH) and hyperacute cerebral infarction (HCI). Fifty-five patients with HICH were set as group A, and 55 patients with HCI were selected as group B. All the patients underwent routine MRI and DWI examinations. The morphological distribution and signal characteristics (low, high, or mixed) of the lesions in the two groups were recorded. The diagnostic accuracy, sensitivity, and specificity of routine MRI and DWI were compared for distinguishing HICH and HCI. The results suggested that the lesions in patients with HICH were mainly manifested as mixed signals (40 cases), while those in patients with HCI showed high signals (48 cases). HICH occurred in the basal ganglia in 44 cases, in the brain stem in 6 cases, in the cerebellum in 4 cases, in the cerebral cortex in 0 cases, and in the corpus callosum in 1 case. HCI occurred in the basal ganglia area, brain stem, cerebellum, cerebral cortex, and corpus callosum in 5, 3, 35, 12, and 0 cases, respectively. The diagnostic accuracy, specificity, and sensitivity of DWI for HICH and HCI were significantly higher than those of routine MRI (P < 0.05). It was indicated that compared with routine MRI, DWI was more effective in the diagnosis of HICH and HCI, with clearer and more accurate images and better diagnostic performance.

Blood Th17 cells and IL-17A as candidate biomarkers estimating the progression of cognitive impairment in stroke patients

Background

T helper (Th) cells regulate immunity and inflammation to engage in cognitive impairment in several neurological diseases, while their clinical relevance in stroke patients is not clear. The current study intended to assess the relationship of Th1 cells, Th17 cells, interferon‐gamma (IFN‐γ), and interleukin (IL)‐17A with cognitive function in stroke patients.

Methods

One hundred twenty stroke patients and 40 controls were enrolled in this muticenter study. Th1 and Th17 cells in peripheral blood were assessed by flow cytometry; meanwhile, IFN‐γ and IL‐17A in serum were detected by enzyme‐linked immunosorbent assay. Cognitive function of stroke patients was evaluated by Mini‐Mental State Examination (MMSE) score at enrollment (baseline), year 1, year 2, and year 3.

Results

Th1 cells (p = 0.037) and IFN‐γ (p = 0.048) were slightly increased, while Th17 cells (p < 0.001) and IL‐17A (p < 0.001) were greatly elevated in stroke patients compared with controls. Th17 cells (r_s = −0.374, p < 0.001) and IL‐17A (r_s = −0.267, p = 0.003) were negatively correlated with MMSE score at baseline, but Th1 cells and IFN‐γ were not. Meanwhile, Th17 cells (p = 0.001) and IL‐17A (p = 0.024) were increased in patients with cognitive impairment compared to those without cognitive impairment. Notably, Th17 cells were positively associated with 1‐year (r_s = 0.331, p < 0.001), 2‐year (r_s = 0.261, p = 0.006), and 3‐year (r_s = 0.256, p = 0.011) MMSE decline; IL‐17A was positively correlated with 1‐year (r_s = 0.262, p = 0.005), 2‐year (r_s = 0.193, p = 0.045), but not 3‐year MMSE decline. However, both Th1 cells and IFN‐γ were not linked with MMSE decline.

Conclusion

Th17 cells and IL‐17A estimate the progression of cognitive impairment in stroke patients.

Intervention Effect of Rehabilitation Robotic Bed Under Machine Learning Combined With Intensive Motor Training on Stroke Patients With Hemiplegia

It was aimed to discuss the effect of bed-type rehabilitation robots under machine learning combined with intensive motor training on the motor function of lower limbs of stroke patients with hemiplegia. A total of 80 patients with stroke hemiplegia were taken as the subjects, who all had a course of treatment for less than 6 months in the Rehabilitation Medicine Department of Ganzhou Hospital. These patients were divided into the experimental group (40 cases) and the control group (40 cases) by random number method. For patients in the control group, conventional intensive motor training was adopted, whereas the conventional intensive motor training combined with the bed-type rehabilitation robot under machine learning was applied for patients in the experimental group. Fugl-Meyer Assessment of Lower Extremity (FMA-LE), Rivermead Mobility Index (RMI), and Modified Barthel Index (MBI) were used to evaluate the motor function and mobility of patients. The human–machine collaboration experiment system was constructed, and the software and hardware of the control system were designed. Then, the experimental platform for lower limb rehabilitation training robots was built, and the rehabilitation training methods for stroke patients with hemiplegia were determined by completing the contact force experiment. The results showed that the prediction effect of back-propagation neural network (BPNN) was better than that of the radial basis neural network (RBNN). The bed-type rehabilitation robot under machine learning combined with intensive motor training could significantly improve the motor function and mobility of the lower limbs of stroke patients with hemiplegia.

Biomechanical Assessment of Post-Stroke Patients' Upper Limb before and after Rehabilitation Therapy Based on FES and VR

Stroke is a medical condition characterized by the rapid loss of focal brain function. Post-stroke patients attend rehabilitation training to prevent the degeneration of physical function and improve upper limb movements and functional status after stroke. Promising rehabilitation therapies include functional electrical stimulation (FES), exergaming, and virtual reality (VR). This work presents a biomechanical assessment of 13 post-stroke patients with hemiparesis before and after rehabilitation therapy for two months with these three methods. Patients performed two tests (Maximum Forward Reach and Apley Scratching) where maximum angles, range of motion, angular velocities, and execution times were measured. A Wilcoxon test was performed (p = 0.05) to compare the variables before and after the therapy for paretic and non-paretic limbs. Significant differences were found in range of motion in flexion–extension, adduction–abduction, and internal–external rotation of the shoulder. Increases were found in flexion–extension, 17.98%, and internal–external rotation, 18.12%, after therapy in the Maximum Forward Reach Test. For shoulder adduction–abduction, the increase found was 20.23% in the Apley Scratching Test, supporting the benefits of rehabilitation therapy that combines FES, exergaming, and VR in the literature.

Telerehabilitation for balance rehabilitation in the subacute stage of stroke: A pilot controlled trial

BACKGROUND

Telerehabilitation has been proposed as an effective strategy to deliver post-stroke specific exercise.

OBJECTIVE

To assess the effectiveness and feasibility of core stability exercises guided by a telerehabilitation App after hospital discharge.

METHODS

Extension of a prospective controlled trial. Subacute stage stroke survivors were included at the time of hospital discharge where they had participated in a previous 5-week randomized controlled trial comparing conventional physiotherapy versus core stability exercises. After discharge, patients from the experimental group were offered access to telerehabilitation to perform core stability exercises at home (AppG), while those from the control group were subject to usual care (CG). The Spanish-version of the Trunk Impairment Scale 2.0 (S-TIS 2.0), Function in Sitting Test (S-FIST), Berg Balance Scale (BBS), Spanish-version of Postural Assessment for Stroke Patients (S-PASS), the number of falls, Brunel Balance Assessment (BBA) and Gait were assessed before and after 3 months intervention.

RESULTS

A total of 49 subjects were recruited. AppG showed greater improvement in balance in both sitting and standing position and gait compared with CG, although no statistically significant differences were obtained.

CONCLUSION

Core stability exercises Telerehabilitation as a home-based guide appears to improve balance in post-stroke stage. Future studies are necessary to confirm the effects as well as identifying strategies to increase telerehabilitation adherence.

Effect of Acupuncture and Rehabilitation Therapy on the Recovery of Neurological Function and Prognosis of Stroke Patients

BACKGROUND

Stroke is a common cerebrovascular disease among the middle-aged and elderly, which can lead to a series of neurological disorders. Acupuncture is an important part of traditional Chinese medicine, with great value in improving the neurological deficits of stroke patients. In addition, rehabilitation therapy is also of great significance for alleviating the neurological deficits of patients and improving their activities of daily living.

OBJECTIVE

To explore the effect of acupuncture and moxibustion combined with rehabilitation therapy on the recovery of neurological function and prognosis of stroke patients.

METHODS

The case data of 100 stroke patients treated in the Wuhan Hospital of Traditional Chinese Medicine from January 2019 to July 2021 were analyzed retrospectively. According to the treatment plan patients received, they were divided into the following two groups: an observation group (n = 52) treated with acupuncture combined with rehabilitation therapy and a control group (n = 48) treated with rehabilitation therapy alone. The two groups were compared in terms of the following items: therapeutic efficacy, plasma levels of cortisol (Cor) and neuropeptide Y (NPY), nerve function, motor function, balance ability, self-care ability, swallowing function, negative emotions, and quality of life.

RESULTS

The therapeutic effect of the observation group was significantly higher than that of the control group (P < 0.05). The levels of Cor and NPY, as well as the neurological function, motor function, balance ability, self-care ability, swallowing function, and negative emotions, were not significantly different between the two groups before treatment (P > 0.05). While after intervention, all the above indexes improved in both groups, with better improvements in the observation group compared with the control group (P < 0.05). And the various dimensions concerning the quality of life of patients were also significantly better in the observation group when compared with the control group.

CONCLUSION

Acupuncture of traditional Chinese medicine combined with rehabilitation therapy has outstanding effects in stroke treatment and can effectively improve the neurological function, prognosis, and quality of life of patients, which is worthy of clinical promotion.

Efficiency of Leg Exoskeleton Use in Rehabilitation of Cerebral Stroke Patients

The study aimed to evaluate the effectiveness of functional and motor activity restoration, including the walking function, in patients after an ischemic stroke using the ExoAtlet lower limb exoskeleton.

Patients and methods. A clinical study was carried out on 42 patients who had undergone a cerebral infarction in the mid cerebral artery system with a post-stroke paresis of the leg, and who had undergone a rehabilitation course in a round-theclock hospital during the early recovery period. Patients were randomized into two equal groups comparable in terms of the stroke severity: the patients in group 1 were receiving a standard rehabilitation program (control group), the patients in group 2 were additionally receiving a course of gait rehabilitation using the ExoAtlet exoskeleton - 10 sessions, 5 sessions per week for 14 days.

Results. The study demonstrated the effectiveness of the ExoAtlet exoskeleton used in the rehabilitation of stroke patients over the standard course of rehabilitation. The advantages include a decrease in the hemiparesis degree, an increase in the muscle strength of the paretic limb, an improvement in balance, an improvement and acceleration of the walking process. The obtained results of the instrumental study confirmed the benefits of physical training on the Exoskeleton, which was demonstrated through an increase in stability and balance, as well as through a decrease in the energy consumption index for maintaining the stable verticalization.

Conclusion. The usage of the ExoAtlet exoskeleton increases the effectiveness of rehabilitation measures and improves motor and functional activities of patients who have suffered a cerebral stroke.

Parkinsonism and cerebrovascular disease

The relationship between cerebrovascular disease and parkinsonism is commonly seen in everyday clinical practice but remains ill-defined and under-recognised with little guidance for the practising neurologist. We attempt to define this association and to illustrate key clinical, radiological and pathological features of the syndrome of Vascular Parkinsonism (VaP). VaP is a major cause of morbidity in the elderly associated with falls, hip fractures and cognitive impairment. Although acute parkinsonism is reported in the context of an acute cerebrovascular event, the vast majority of VaP presents as an insidious syndrome usually in the context of vascular risk factors and radiological evidence of small vessel disease. There may be an anatomic impact on basal ganglia neuronal networks, however the effect of small vessel disease (SVD) on these pathways is not clear. There are now established reporting standards for radiological features of SVD on MRI. White matter hyperintensities and lacunes have been thought to be the representative radiological features of SVD but other features such as the perivascular space are gaining more importance, especially in context of the glymphatic system. It is important to consider VaP in the differential diagnosis of Parkinson disease (PD) and in these situations, neuroimaging may offer diagnostic benefit especially in those patients with atypical presentations or refractoriness to levodopa. Proactive management of vascular risk factors, monitoring of bone density and an exercise program may offer easily attainable therapeutic targets in PD and VaP. Levodopa therapy should be considered in patients with VaP, however the dose and effect may be different from use in PD. This article is part of the Special Issue "Parkinsonism across the spectrum of movement disorders and beyond" edited by Joseph Jankovic, Daniel D. Truong and Matteo Bologna.

Functional Disability After Ischemic Stroke: A Community-Based Cross-Sectional Study in Shanghai, China

Objective: This study aimed to understand the demographics, functional disabilities, cognitive impairment, and depressive mood among stroke patients and to explore the correlation between functional disability and the other health conditions so as to provide some data for community rehabilitation among stroke patients. Methods: A cross-sectional study was conducted to investigate the functional status of ischemic stroke patients with stroke history between 1 month and 2 years by applying the modified Rankin Scale (mRS). Data were collected during October 2016 and January 2017 from 11 communities in two districts of Shanghai, China. We used face-to-face questionnaire interviews to collect information on sociodemographics, vascular risks associated with stroke, cognitive function [Mini-Mental State Examination (MMSE)], and depression [Patient Health Questionnaire-9 (PHQ-9)]; and we applied SPSS 24.0 for data analysis. Results: In this study, 305 patients with ischemic stroke were finally recruited, including 189 (61.97%) men, with an average age of 67 years. According to the mRS score, ischemic stroke patients were divided into patients without symptoms (controls, mRS = 0), patients without obvious disability (mRS = 1), and patients with mild to severe disability (mRS = 2-5). Ischemic stroke patients with different mRS levels demonstrated significant differences in age, tobacco smoke exposure, previous stroke history, cognitive function, and depression status. Compared with patients without symptoms (mRS = 0), patients with mRS = 1 had a lower MMSE score [odds ratio (OR): 0.48, 95% confidence interval (CI): 0.26-0.90]; and patients with mRS = 2-5 had a lower MMSE score [OR = 0.16, 95% CI: 0.08-0.33], had a higher PHQ-9 score [OR = 5.36, 95% CI: 2.19-13.11], and were more likely to have previous stroke history [OR = 2.18, 95% CI: 1.01-4.79]. Conclusion: Lower degrees of functional independence are related to cognitive impairment, as well as the previous stroke history and depression status.

[A case of hemichorea due to insular and parietal cortical infarctions]

A 70-year-old man visited our hospital with a chief complaint of involuntary movements, diagnosed as chorea, involving the right upper and lower limbs. Brain MRI showed acute cerebral infarctions involving the left insular and parietal cortices. Chorea is usually due to dysfunction of components of the basal ganglia pathways, such as the caudate nucleus or subthalamic nucleus, and is rarely caused by lesions of the insular or parietal cortex. Here, we describe a case of cerebral infarctions in the left insular and parietal cortices and chorea of the right limbs, and discuss the relationship between the mechanism of chorea and insular and parietal cortical lesions.

Negative Myoclonus Secondary to Thalamic Infarction: Case Report

Background

Movement disorders are an infrequent presentation to stroke, and in this context, negative myoclonus is not among the most common movement disorders, hence we present a case of negative myoclonus secondary to thalamic stroke.

Case

A 75 year old male presented with left central facial palsy and negative myoclonus on his left upper limb. He was submitted to a diagnostic workup, with evidence of a right thalamic stroke. He was started on Phenobarbital 50 mg and the movement disorder resolved.

Conclusion

Given the relevance of cerebrovascular disease as a cause of morbidity and mortality, it is important to the clinician to be aware of the less typical presentations such as the observed in our case, in order to provide adequate care to the patient.

Post-stroke Movement Disorders: Clinical Spectrum, Pathogenesis, and Management

Involuntary movements develop after 1-4% of strokes and they have been reported in patients with ischemic and hemorrhagic strokes affecting the basal ganglia, thalamus, and/or their connections. Hemichorea-hemiballism is the most common movement disorder following a stroke in adults while dystonia is most common in children. Tremor, myoclonus, asterixis, stereotypies, and vascular parkinsonism are other movement disorders seen following stroke. Some of them occur immediately after acute stroke, some can develop later, and others may have delayed onset progressive course. Proposed pathophysiological mechanisms include neuronal plasticity, functional diaschisis, and age-related differences in brain metabolism. There are no guidelines regarding the management of post-stroke movement disorders, mainly because of their heterogeneity.

Effects of Motor Imagery as a Complementary Resource on the Rehabilitation of Stroke Patients: A Meta-Analysis of Randomized Trials

BACKGROUND

Stroke is the second leading cause of death and a leading cause of disability worldwide. Motor imagery is a technique that can be utilized in the rehabilitation process to improve the lives of patients with a functional disability acquired by this pathology.

AIM

To evaluate the effects of motor imagery as a complementary intervention for the rehabilitation of stroke patients.

METHODS

We conducted a systematic review in MEDLINE/PubMed, Scopus, Web of Science, and PEDro databases. We included randomized controlled trials (RCTs) that used motor imagery as a complementary resource for the rehabilitation of patients affected by stroke, who had motor function and functional independence as outcomes.

RESULTS

Of the 1,473 studies found, ten RCTs were included. Regarding the interventions, motor imagery was associated with traditional rehabilitation, virtual reality, physical practice, structured progressive circuit class therapy, and electromyography. The upper and lower extremity performance were accessed through the Fugl-Meyer Assessment (FMA) and gait speed, respectively. Although the practice of motor imagery at least twice a week during three weeks showed to be effective in improving the motor performance of post-stroke patients, the studies' protocols present a high heterogeneity, with training session times lasting between 30 to 180 minutes and a post-stroke invention window of one to 12 months.

CONCLUSIONS

Motor imagery has been shown to be an efficacious technique in the treatment of post-stroke patients when used as a complement to traditional rehabilitation techniques. However, greater standardization of interventions and studies with higher methodological quality are required to determine further conclusions.

Acute chorea: case series from the emergency room of a Brazilian tertiary-level center

BACKGROUND

Chorea is a movement disorder characterized by random, brief and migratory involuntary muscle contractions. It is defined as acute when present within hours to days. Three main causes for this scenario have emerged as most likely: vascular, toxic-metabolic and inflammatory.

OBJECTIVES

To identify the prevalence of the main etiologies and major clinical findings of acute chorea in the emergency room of a tertiary-level referral center; and to suggest an approach for guiding the diagnostic workup and clinical management.

METHODS

We retrospectively reviewed the clinical aspects and neuroimaging data of 10 patients presenting with acute chorea at the neurological emergency room of our hospital from 2015 to 2019.

RESULTS

Stroke was the most common etiology (50% of the cases). All of them were ischemic. It was noteworthy that only one case demonstrated the classical ischemic topographic lesion at the contralateral subthalamic nuclei. Regarding nonvascular etiologies, nonketotic hyperglycemia was the major cause, followed by drug-related chorea. One patient showed inflammatory etiology, which was probably Sydenham chorea reactivation.

CONCLUSION

Acute chorea is an uncommon and challenging problem at the emergency room, often associated with potentially treatable causes. We suggest that use of the acronym DANCE (Diagnosis of chorea, Acute stroke protocol, Normal glucose levels, Check neuroimaging, Exposure to drugs) could form a potential initial approach in the evaluation, in order to emphasize causes that require prompt proper management (e.g. thrombolysis).

Dietary docosahexaenoic acid inhibits neurodegeneration and prevents stroke

Stroke severely impairs quality of life and has a high mortality rate. On the other hand, dietary docosahexaenoic acid (DHA) prevents neuronal damage. In this review, we describe the effects of dietary DHA on ischemic stroke-associated neuronal damage and its role in stroke prevention. Recent epidemiological studies have been conducted to analyze stroke prevention through DHA intake. The effects of dietary intake and supply of DHA to neuronal cells, DHA-mediated inhibition of neuronal damage, and its mechanism, including the effects of the DHA metabolite, neuroprotectin D1 (NPD1), were investigated. These studies revealed that DHA intake was associated with a reduced risk of stroke. Moreover, studies have shown that DHA intake may reduce stroke mortality rates. DHA, which is abundant in fish oil, passes through the blood-brain barrier to accumulate as a constituent of phospholipids in the cell membranes of neuronal cells and astrocytes. Astrocytes supply DHA to neuronal cells, and neuronal DHA, in turn, activates Akt and Raf-1 to prevent neuronal death or damage. Therefore, DHA indirectly prevents neuronal damage. Furthermore, NDP1 blocks neuronal apoptosis. DHA, together with NPD1, may block neuronal damage and prevent stroke. The inhibitory effect on neuronal damage is achieved through the antioxidant (via inducing the Nrf2/HO-1 system) and anti-inflammatory effects (via promoting JNK/AP-1 signaling) of DHA.

Metabolomics coupled with integrative pharmacology reveals the therapeutic effect of l-borneolum against cerebral ischaemia in rats

Objectives

This study aimed to investigate metabolic biomarker changes and related metabolic pathways before and after treatment with l-borneolum in cerebral ischaemic rats.

Methods

Rats were subjected to pMCAO surgery. The Zea-Longa scoring method was used to evaluate neurological deficits. TTC staining was used to observe cerebral infarction. HE staining was used to observe the pathological changes in brain tissue. The metabolomics method was used to analyse the changes in metabolism.

Results

The pharmacology changes of the H-B group were significantly different from those of the vehicle group. Moreover, according to the metabolomics method, identification of potential biomarkers in cerebral ischaemia treatment showed that the levels of l-valine and l-arginine were increased while the levels of N-succinyl-L,L-2,6-diaminopimelate and LysoPC (18 : 1(9Z)) were reduced, which were related to energy metabolism. Simultaneously, thermogenesis and bile secretion levels were inhibited by l-borneolum. Furthermore, elevated level of methotrexate might be related to an anti-inflammatory effect.

Conclusions

The therapeutic effect of l-borneolum on cerebral ischaemia might be associated with the regulation of energy metabolism, thermogenesis and bile secretion. These metabolic changes and the core target changes, as well as the metabolic-target pathway network, help to elucidate the mechanisms governing the effect of l-borneolum on cerebral ischaemia.

The large-scale structural connectome of task-specific focal dystonia

The emerging view of dystonia is that of a large‐scale functional network disorder, in which the communication is disrupted between sensorimotor cortical areas, basal ganglia, thalamus, and cerebellum. The structural underpinnings of functional alterations in dystonia are, however, poorly understood. Notably, it is unclear whether structural changes form a larger‐scale dystonic network or rather remain focal to isolated brain regions, merely underlying their functional abnormalities. Using diffusion‐weighted imaging and graph theoretical analysis, we examined inter‐regional white matter connectivity of the whole‐brain structural network in two different forms of task‐specific focal dystonia, writer's cramp and laryngeal dystonia, compared to healthy individuals. We show that, in addition to profoundly altered functional network in focal dystonia, its structural connectome is characterized by large‐scale aberrations due to abnormal transfer of prefrontal and parietal nodes between neural communities and the reorganization of normal hub architecture, commonly involving the insula and superior frontal gyrus in patients compared to controls. Other prominent common changes involved the basal ganglia, parietal and cingulate cortical regions, whereas premotor and occipital abnormalities distinctly characterized the two forms of dystonia. We propose a revised pathophysiological model of focal dystonia as a disorder of both functional and structural connectomes, where dystonia form‐specific abnormalities underlie the divergent mechanisms in the development of distinct clinical symptomatology. These findings may guide the development of novel therapeutic strategies directed at targeted neuromodulation of pathophysiological brain regions for the restoration of their structural and functional connectivity.

Mirror movements induced by hemiballism due to putamen infarction: a case report and literature review

Mirror movements (MMs), which are involuntary movements of one limb that synchronously mirror voluntary movements of the contralateral limb, are a relatively uncommon complication of strokes. Here we report what appears to be the first case of putamen infarction manifesting as MMs in one side of the body induced by contralateral hemiballism. MMs and hemiballism were nearly entirely eliminated after one week of clonazepam and haloperidol therapy. During the subsequent one year of standard ischemic stroke prevention measures, no further episodes of involuntary movement occurred. Our case and literature review highlight that acute stroke can manifest as hemiballism and MMs, which should be recognized as soon as possible to ensure timely management.

Dystonia and levodopa-induced dyskinesias in Parkinson's disease: Is there a connection?

Dystonia and levodopa-induced dyskinesia (LID) are both hyperkinetic movement disorders. Dystonia arises most often spontaneously, although it may be seen after stroke, injury, or as a result of genetic causes. LID is associated with Parkinson's disease (PD), emerging as a consequence of chronic therapy with levodopa, and may be either dystonic or choreiform. LID and dystonia share important phenomenological properties and mechanisms. Both LID and dystonia are generated by an integrated circuit involving the cortex, basal ganglia, thalamus and cerebellum. They also share dysregulation of striatal cholinergic signaling and abnormalities of striatal synaptic plasticity. The long duration nature of both LID and dystonia suggests that there may be underlying epigenetic dysregulation as a proximate cause. While both may improve after interventions such as deep brain stimulation (DBS), neither currently has a satisfactory medical therapy, and many people are disabled by the symptoms of dystonia and LID. Further study of the fundamental mechanisms connecting these two disorders may lead to novel approaches to treatment or prevention.

Association of Extrapyramidal Tracts' Integrity With Performance in Fine Motor Skills After Stroke

Background and Purpose- Tractography by diffusion tensor imaging has extended our knowledge on the contribution of damage to different pathways to residual motor function after stroke. Integrity of the corticospinal tract (CST), for example, has been identified to characterize and predict its course. Yet there is only scarce data that allow a judgment on the impact of extrapyramidal pathways between the basal ganglia on motor function poststroke. We aimed at studying their association with performance in fine motor skills after stroke. Methods- We performed probabilistic tractography and reconstructed nigro-pallidal tracts connecting substantia nigra and globus pallidus, as well as the CST in 26 healthy subjects. Resulting tracts were registered to the individual images of 20 patients 3 months after stroke, and their microstructural integrity was measured by fractional anisotropy. Clinical examination of the patients' gross (grip force) and fine (nine-hole peg test) motor skills was performed 1 year after stroke. For assessment of factors influencing nine-hole peg test, we used a multivariate model. Results- Nigro-pallidal tracts were traceable in all participants, had no overlap to the CST and passed the nucleus subthalamicus. In stroke patients, nigro-pallidal tracts ipsilateral to the stroke lesion showed a significantly reduced fractional anisotropy (ratio, 0.96±0.02; P=0.021). One year after stroke, nine-hole peg test values were significantly slower for the affected hand, while grip force was comparable between both hands. Reduced integrity of the nigro-pallidal tracts was associated with worse performance in the nine-hole peg test ( P=0.040), as was reduced integrity of the CST ( P<0.001) and younger age ( P<0.001). Conclusions- Nigro-pallidal tracts with containing connections of the nucleus subthalamicus represent a relevant part of the extrapyramidal system and specifically contribute to residual fine motor skills after stroke beyond the well-known contribution of the CST. They may deliver supportive information for prediction of motor recovery after stroke.

Neural substrates of reduced walking activity after supratentorial stroke: A voxel-based lesion symptom mapping study

BACKGROUND

Most stroke patients exhibit low levels of walking activity, a key component of secondary stroke prevention. The predictors of walking activity may be multifactorial and are thus far partially understood. We aimed to study the neuroanatomic correlates of low levels of daily walking activity following hemispheric stroke.

METHODS

In this cross-sectional study, 33 community-dwelling stroke survivors (age: 63.9 ± 12.9 years; % female: 36.4%; NIHSS at admission: 3.3 ± 4.0) were prospectively recruited at least 3 months after a first ever, unilateral, supratentorial stroke confirmed by brain magnetic resonance imaging. Walking activity was measured by daily step counts (steps∙day^-1), recorded using an Actigraph GT3x+ triaxial accelerometer over 7 consecutive days. Voxel-based lesion-symptom mapping was performed to identify brain areas associated with walking activity following stroke.

RESULTS

Participants presented 4491.9 ± 2473.7 steps∙day^-1. Lower levels of walking activity were related to lesions of the posterior part of the putamen, of the posterior limb of the internal capsule and of the anterior part of the corona radiata. No cortical region was associated with walking activity.

CONCLUSIONS

Our preliminary results identify subcortical neuroanatomical correlates for reduced walking activity following stroke. If confirmed, these results could serve as a rationale for the development of targeted rehabilitative strategy to improve mobility after stroke.