Visual attention in posterior stroke and relations to alexia

Predictors of post stroke cognitive impairment: VITATOPS cognition substudy

INTRODUCTION

Post stroke cognitive impairment (PSCI) is a common complication of ischemic stroke. PSCI can involve different depending on clinical and stroke related characteristics. The aim of this study is to determine the factors associated with impairments in specific cognitive domains.

METHODS

The Vitamins to Prevent Stroke (VITATOPS) trial is a large, multinational randomised controlled trial. In this substudy, consecutive patients admitted for ischaemic stroke or transient ischaemic attack (TIA) at a tertiary hospital in Singapore were included. PSCI was defined as impairment of any of the six cognitive subgroups - visuoconstruction, attention, verbal memory, language, visual memory and visuomotor function - that were assessed annually for up to five years. Univariate and multivariate Cox proportional hazard models were used to determine factors associated with impairments in each of these cognitive domains.

RESULTS

A total of 736 patients were included in this study, of which 173 (23.5 %) developed cognitive impairment. Out of the six cognitive domains, the greatest proportion of patients had an impairment in visuoconstruction (26.4 %) followed by attention (19.8 %), verbal memory (18.3 %), language (17.5 %), visual memory (17.3 %) and visuomotor function (14.8 %). Patients with posterior circulation cerebral infarction (POCI) as the index stroke subtype had higher rates of cognitive impairment. Further subgroup analyses show that Indian race and advanced age were predictive of language impairment, whilst fewer years of education and POCI were predictive of verbal memory impairment. POCI was predictive of visual memory impairment, and advanced age and POCI were predictive of visuomotor function impairment.

CONCLUSION

We identified visuoconstruction and attention domains to be the most affected in our Asian cohort of PSCI. Advanced age, lower levels of education, posterior circulation strokes and concomitant comorbidities such as peripheral artery disease are independent predictors of PSCI.

Neuropsychiatric symptoms in a occipito-temporal infarction with remarkable long-term functional recovery

Posterior circulation infarctions (PCI) constitute 5-25% of ischemic strokes. PCI of the occipital lobe present with a panoply of symptoms including quadrantanopsia, topographical disorientation, and executive dysfunction. Long-term cognitive recovery after PCI is not well described. However, the adult brain is remarkably plastic, capable of adapting and remodeling. We describe a 43-year-old right-handed woman who complained of black spots in both eyes, headaches, photophobia, and a feeling she would faint. Initial neurological exam and a CT scan were normal; she was diagnosed with ocular migraine. A second neurological exam a week later showed left superior quadrantopsia; an MRI scan suggested right occipito-temporal infarct. In subsequent months, the patient complained of fatigue, quadrantanopsia, memory problems, and topographical disorientation. The patient participated in multi-modality treatment, and in self-directed arts projects and physical activities. Six years later, she reported noticeable improvements in cognition and daily functioning, which were documented on neurocognitive testing. Comparison between initial and subsequent MRIs using FreeSurfer 5.3 identified neuroplastic brain changes in areas serving similar functions to the areas injured from the stroke. The case illustrates the neuropsychiatric presentation after right occipito-temporal stroke, the value of formal and self-directed cognitive rehabilitation, the extended time to cognitive recovery, and the ability of the brain to undergo neuroplastic changes.

Empirical Evidence for Intraspecific Multiple Realization?

Despite the remarkable advances in behavioral and brain sciences over the last decades, the mind-body (brain) problem is still an open debate and one of the most intriguing questions for both cognitive neuroscience and philosophy of mind. Traditional approaches have conceived this problem in terms of a contrast between physicalist monism and Cartesian dualism. However, since the late sixties, the landscape of philosophical views on the problem has become more varied and complex. The Multiple Realization Thesis (MRT) claims that mental properties can be (or are) realized, and mental processes can be (or are) implemented by neural correlates of different kinds. Thus, MRT challenges the psychoneural type-identity theory and the corresponding reductionism. Many philosophers have acknowledged the a priori plausibility of MRT. However, the existence of empirical evidence in favor of intraspecific, human multiple realizations of mental processes and properties is still controversial. Here, we illustrate some cases that provide empirical evidence in support of MRT. Recently, it has been proposed that foveal agnosic vision, like peripheral vision, can be restored by increasing object parts’ spacing (Crutch and Warrington, 2007; Strappini et al., 2017b). Agnosic fovea and normal periphery are both limited by crowding, which impairs object recognition, and provides the signature of visual integration. Here, we define a psychological property of restored object identification, and we cross-reference the data of visually impaired patients with different etiologies. In particular, we compare the data of two stroke patients, two patients with posterior cortical atrophy, six cases of strabismic amblyopia, and one case with restored sight. We also compare these patients with unimpaired subjects tested in the periphery. We show that integration (i.e., restored recognition) seems to describe quite accurately the visual performance in all these cases. Whereas the patients have different etiologies and different neural correlates, the unimpaired subjects have no neural damage. Thus, similarity in the psychological property given the differences in the neural substrate can be interpreted in relation to MRT and provide evidence in its support. Finally, we will frame our contribution within the current debate concerning MRT providing new and compelling empirical evidence.