Control of hand movements after striatocapsular stroke: high-resolution temporal analysis of the function of ipsilateral activation

Upper extremity asymmetry due to nerve injuries or central neurologic conditions: a scoping review

BACKGROUND

Peripheral nerve injuries and central neurologic conditions can result in extensive disabilities. In cases with unilateral impairment, assessing the asymmetry between the upper extremity has been used to assess outcomes of treatment and severity of injury. A wide variety of validated and novel tests and sensors have been utilized to determine the upper extremity asymmetry. The purpose of this article is to review the literature and define the current state of the art for describing upper extremity asymmetry in patients with peripheral nerve injuries or central neurologic conditions.

METHOD

An electronic literature search of PubMed, Scopus, Web of Science, OVID was performed for publications between 2000 to 2022. Eligibility criteria were subjects with neurological conditions/injuries who were analyzed for dissimilarities in use between the upper extremities. Data related to study population, target condition/injury, types of tests performed, sensors used, real-world data collection, outcome measures of interest, and results of the study were extracted. Sackett's Level of Evidence was used to judge the quality of the articles.

RESULTS

Of the 7281 unique articles, 112 articles met the inclusion criteria for the review. Eight target conditions/injuries were identified (Brachial Plexus Injury, Cerebral Palsy, Multiple Sclerosis, Parkinson's Disease, Peripheral Nerve Injury, Spinal Cord Injury, Schizophrenia, and stroke). The tests performed were classified into thirteen categories based on the nature of the test and data collected. The general results related to upper extremity asymmetry were listed for all the reviewed articles. Stroke was the most studied condition, followed by cerebral palsy, with kinematics and strength measurement tests being the most frequently used tests. Studies with a level of evidence level II and III increased between 2000 and 2021. The use of real-world evidence-based data, and objective data collection tests also increased in the same period.

CONCLUSION

Adequately powered randomized controlled trials should be used to study upper extremity asymmetry. Neurological conditions other than stroke should be studied further. Upper extremity asymmetry should be measured using objective outcome measures like motion tracking and activity monitoring in the patient's daily living environment.

An fMRI, DTI and Neurophysiological Examination of Atypical Organization of Motor Cortex in Ipsilesional Hemisphere Following Post-Stroke Recovery

OBJECTIVES

We report a 61-year-old woman who developed left hemiparesis following a right frontal stroke. She underwent rehabilitation and regained function of the left side of her body. Three years after her first stroke, she developed a large left subdural hematoma and again presented with left hemiparesis.

MATERIALS AND METHODS

Prior to the cranioplasty, an fMRI scan involving left and right hand movement, arm movement, and foot peddling were conducted in order to determine whether the patient showed ipsilateral activation for the motor tasks, thus explaining the left hemiparesis following the left subdural hematoma. Diffusion tensor imaging (DTI) tractography was also collected to visualize the motor and sensory tracts.

RESULTS

The fMRI results revealed activation in the expected contralateral left primary motor cortex (M1) for the right-sided motor tasks, and bilateral M1 activation for the left-sided motor tasks. Intraoperative neurophysiology confirmed these findings, whereby electromyography revealed left-sided (i.e., ipsilateral) responses for four of the five electrode locations. The DTI results indicated that the corticospinal tracts and spinothalamic tracts were within normal limits and showed no displacement or disorganization.

CONCLUSIONS

These results suggest that there may have been reorganization of the M1 following her initial stroke, and that the left hemisphere may have become involved in moving the left side of the body thereby leading to left hemiparesis following the left subdural hematoma. The findings suggest that cortical reorganization may occur in stroke patients recovering from hemiparesis, and specifically, that components of motor processing subserved by M1 may be taken over by ipsilateral regions.

Assessing the Relationship Between Motor Anticipation and Cortical Excitability in Subacute Stroke Patients With Movement-Related Potentials

Background: Stroke survivors may lack the cognitive ability to anticipate the required control for palmar grasp execution. The cortical mechanisms involved in motor anticipation of palmar grasp movement and its association with post-stroke hand function remains unknown. Aims: To investigate the cognitive anticipation process during a palmar grasp task in subacute stroke survivors and to compare with healthy individuals. The association between cortical excitability and hand function was also explored. Methods: Twenty-five participants with hemiparesis within 1-6 months after first unilateral stroke were recruited. Twenty-five matched healthy individuals were recruited as control. Contingent negative variation (CNV) was measured using electroencephalography recordings (EEG). Event related potentials were elicited by cue triggered hand movement paradigm. CNV onset time and amplitude between pre-cue and before movement execution were recorded. Results: The differences in CNV onset time and peak amplitude were statistically significant between the subacute stroke and control groups, with patients showing earlier onset time with increased amplitudes. However, there was no statistically significant difference in CNV onset time and peak amplitude between lesioned and non-lesioned hemisphere in the subacute stroke group. Low to moderate linear associations were observed between cortical excitability and hand function. Conclusions: The earlier CNV onset time and higher peak amplitude observed in the subacute stroke group suggest increased brain computational demand during palmar grasp task. The lack of difference in CNV amplitude between the lesioned and non-lesioned hemisphere within the subacute stroke group may suggest that the non-lesioned hemisphere plays a role in the motor anticipatory process. The moderate correlations suggested that hand function may be associated with cortical processing of motor anticipation.

Preclinical and Clinical Evidence on Ipsilateral Corticospinal Projections: Implication for Motor Recovery

Motor impairment is the most common complication after stroke, and recovery of motor function has been shown to be dependent on the extent of lesion in the ipsilesional corticospinal tract (iCST) and activity within ipsilesional primary and secondary motor cortices. However, work from neuroimaging research has suggested a role of the contralesional hemisphere in promoting recovery after stroke potentially through the ipsilateral uncrossed CST fibers descending to ipsilateral spinal segments. These ipsilateral fibers, sometimes referred to as "latent" projections, are thought to contribute to motor recovery independent of the crossed CST. The aim of this paper is to evaluate using cumulative evidence from animal models and human patients on whether an uncrossed CST component is present in mammals and conserved through primates and humans, and whether iCST fibers have a functional role in hemiparetic/hemiplegic human conditions. This review highlights that an ipsilateral uncrossed CST exists in human during development, but the evidence on a functionally relevant iCST component in adult humans is still elusive. In addition, this review argues that whereas activity within the ipsilesional cortex is essential for enhancing motor recovery after stroke, the role of iCST projections specifically is still controversial. Finally, conclusions from current literature emphasize the importance of activity in the ipsilesional cortex and the integrity of crossed CST fibers as major determinants of motor recovery after brain injury.

Neurophysiology of Grasping Actions: Evidence from ERPs

We use our hands very frequently to interact with our environment. Neuropsychology together with lesion models and intracranial recordings and imaging work yielded important insights into the functional neuroanatomical correlates of grasping, one important function of our hands, pointing toward a functional parietofrontal brain network. Event-related potentials (ERPs) register directly electrical brain activity and are endowed with high temporal resolution but have long been assumed to be susceptible to movement artifacts. Recent work has shown that reliable ERPs can be obtained during movement execution. Here, we review the available ERP work on (uni) manual grasping actions. We discuss various ERP components and how they may be related to functional components of grasping according to traditional distinctions of manual actions such as planning and control phases. The ERP results are largely in line with the assumption of a parietofrontal network. But other questions remain, in particular regarding the temporal succession of frontal and parietal ERP effects. With the low number of ERP studies on grasping, not all ERP effects appear to be coherent with one another. Understanding the control of our hands may help to develop further neurocognitive theories of grasping and to make progress in prosthetics, rehabilitation or development of technical systems for support of human actions.

Downregulating Aberrant Motor Evoked Potential Synergies of the Lower Extremity Post Stroke During TMS of the Contralesional Hemisphere

BACKGROUND

Growing evidence demonstrates unique synergistic signatures in the lower limb (LL) post-stroke, with specific across-plane and across-joint representations. While the inhibitory role of the ipsilateral hemisphere in the upper limb (UL) has been widely reported, examination of the contralesional hemisphere (CON-H) in modulating LL expressions of synergies following stroke is lacking.

OBJECTIVE

We hypothesize that stimulation of lesioned and contralesional motor cortices will differentially regulate paretic LL motor outflow. We propose a novel TMS paradigm to identify synergistic motor evoked potential (MEP) patterns across multiple muscles.

METHODS

Amplitude and background activation matched adductor MEPs were elicited using single pulse TMS of L-H and CON-H (control ipsilateral) during an adductor torque matching task from 11 stroke and 10 control participants. Associated MEPs of key synergistic muscles were simultaneously observed.

RESULTS

By quantifying CON-H/L-H MEP ratios, we characterized a significant targeted inhibition of aberrant MEP coupling between ADD and VM (p = 0.0078) and VL (p = 0.047) exclusive to the stroke group (p = 0.028) that was muscle dependent (p = 0.039). We find TA inhibition in both groups following ipsilateral hemisphere stimulation (p = 0.0014; p = 0.015).

CONCLUSION

We argue that ipsilaterally mediated attenuation of abnormal synergistic activations post stroke may reflect an adaptive intracortical inhibition. The predominance of sub 3ms interhemispheric MEP latency differences implicates LL ipsilateral corticomotor projections. These findings provide insight into the association between CON-H reorganization and post-stroke LL recovery. While a prevailing view of driving L-H disinhibition for UL recovery seems expedient, presuming analogous LL neuromodulation may require further examination for rehabilitation. This study provides a step toward this goal.

Movement related cortical potentials in severe chronic stroke

Movement related cortical potentials (MRCPs) have been studied for many years and controlled using brain computer interfaces (BCIs). Furthermore, MRCPs have been proposed as reliable and immediate indicators of cortical reorganizations in motor learning and after stroke. In this study MRCPs preceding and during hand movements in severe chronic stroke were investigated. Eight severely impaired (no residual finger extension) chronic stoke patients underwent EEG and EMG recordings during a cue triggered hand movement paradigm. Four patients presented subcortical lesions only while the other four presented mixed (cortical and subcortical) lesions. MRCPs were measured before (slow cortical potentials SCPs) and at movement onset (motor potentials MPs). SCPs were observed during paretic hand movements only. Latencies were longer and reached their negativity peak earlier during paretic hand movement. When dividing the patients in subcortical only and mixed lesion patients, we observed significantly bigger MP peak amplitudes over the lesioned hemisphere during paretic and healthy hand movements in subcortical stroke patients. Furthermore, we observed a significant difference in MP peak latency between subcortical and mixed stroke patients during paretic hand movements. We demonstrated for the first time significant differences between subcortical only and mixed (cortical and subcortical) stroke patients' MRCPs during motor preparation and execution. Furthermore, we demonstrated how stroke produces a longer MRCP and that lesion location affects MP peak amplitude and latency. Finally, we propose the use MRCP based BCIs to reduce their duration (towards normal) and induce motor function recovery.

Evidence for a role of the reticulospinal system in recovery of skilled reaching after cortical stroke: initial results from a model of ischemic cortical injury

The purposes of this pilot study were to create a model of focal cortical ischemia in Macaca fascicularis and to explore contributions of the reticulospinal system in recovery of reaching. Endothelin-1 was used to create a focal lesion in the shoulder/elbow representation of left primary motor cortex (M1) of two adult female macaques. Repetitive microstimulation was used to map upper limb motor outputs from right and left cortical motor areas and from the pontomedullary reticular formation (PMRF). In subject 1 with a small lesion and spontaneous recovery, reaching was mildly impaired. Changes were evident in the shoulder/elbow representations of both the lesioned and contralesional M1, and there appeared to be fewer than expected upper limb responses from the left (ipsilesional) PMRF. In subject 2 with a substantial lesion, reaching was severely impaired immediately after the lesion. After 12 weeks of intensive rehabilitative training, reach performance recovered to near-baseline levels, but movement times remained about 50% slower. Surprisingly, the shoulder/elbow representation in the lesioned M1 remained completely absent after recovery, and there was a little change in the contralesional M1. There was a definite difference in motor output patterns for left versus right PMRF for this subject, with an increase in right arm responses from right PMRF and a paucity of left arm responses from left PMRF. The results are consistent with increased reliance on PMRF motor outputs for recovery of voluntary upper limb motor control after significant cortical ischemic injury.

Movement related slow cortical potentials in severely paralyzed chronic stroke patients

Movement-related slow cortical potentials (SCPs) are proposed as reliable and immediate indicators of cortical reorganization in motor learning. SCP amplitude and latency have been reported as markers for the brain's computational effort, attention and movement planning. SCPs have been used as an EEG signature of motor control and as a main feature in Brain-Machine-Interfaces (BMIs). Some reports suggest SCPs are modified following stroke. In this study, we investigated movement-related SCPs in severe chronic stroke patients with no residual paretic hand movements preceding and during paretic (when they try to move) and healthy hand movements. The aim was to identify SCP signatures related to cortex integrity and complete paralysis due to stroke in the chronic stage. Twenty severely impaired (no residual finger extension) chronic stoke patients, of whom ten presented subcortical and ten cortical and subcortical lesions, underwent EEG and EMG recordings during a cue triggered hand movement (open/close) paradigm. SCP onset appeared and peaked significantly earlier during paretic hand movements than during healthy hand movements. Amplitudes were significantly larger over the midline (Cz, Fz) for paretic hand movements while contralateral (C4, F4) and midline (Cz, Fz) amplitudes were significantly larger than ipsilateral activity for healthy hand movements. Dividing the participants into subcortical only and mixed lesioned patient groups, no significant differences observed in SCP amplitude and latency between groups. This suggests lesions in the thalamocortical loop as the main factor in SCP changes after stroke. Furthermore, we demonstrated how, after long-term complete paralysis, post-stroke intention to move a paralyzed hand resulted in longer and larger SCPs originating in the frontal areas. These results suggest SCP are a valuable feature that should be incorporated in the design of new neurofeedback strategies for motor neurorehabilitation.

Motor planning in chronic upper-limb hemiparesis: evidence from movement-related potentials

Background

Chronic hemiplegia is a common long-term consequence of stroke, and subsequent motor recovery is often incomplete. Neurophysiological studies have focused on motor execution deficits in relatively high functioning patients. Much less is known about the influence exerted by processes related to motor preparation, particularly in patients with poor motor recovery.

Methodology/Principal Findings

The current study investigates motor preparation using a modified response-priming experiment in a large sample of patients (n = 50) with moderate-to-severe chronic hemiparesis. The behavioural results revealed that hemiparetic patients had an increased response-priming effect compared to controls, but that their response times were markedly slower for both hands. Patients also demonstrated significantly enhanced midline late contingent negative variation (CNV) during paretic hand preparation, despite the absence of overall group differences when compared to controls. Furthermore, increased amplitude of the midline CNV correlated with a greater response-priming effect. We propose that these changes might reflect greater anticipated effort to respond in patients, and consequently that advance cueing of motor responses may be of benefit in these individuals. We further observed significantly reduced CNV amplitudes over the lesioned hemisphere in hemiparetic patients compared to controls during non-paretic hand preparation, preparation of both hands and no hand preparation. Two potential explanations for these CNV reductions are discussed: alterations in anticipatory attention or state changes in motor processing, for example an imbalance in inter-hemispheric inhibition.

Conclusions/Significance

Overall, this study provides evidence that movement preparation could play a crucial role in hemiparetic motor deficits, and that advance motor cueing may be of benefit in future therapeutic interventions. In addition, it demonstrates the importance of monitoring both the non-paretic and paretic hand after stroke and during therapeutic intervention.

Plasticity of adult sensorimotor system in severe brain infarcts: challenges and opportunities

Functional reorganization forms the critical mechanism for the recovery of function after brain damage. These processes are driven by inherent changes within the central nervous system (CNS) triggered by the insult and further depend on the neural input the recovering system is processing. Therefore these processes interact with not only the interventions a patient receives, but also the activities and behaviors a patient engages in. In recent years, a wide range of research programs has addressed the association between functional reorganization and the spontaneous and treatment-induced recovery. The bulk of this work has focused on upper-limb and hand function, and today there are new treatments available that capitalize on the neuroplasticity of the brain. However, this is only true for patients with mild to moderated impairments; for those with very limited hand function, the basic understanding is much poorer and directly translates into limited treatment opportunities for these patients. The present paper aims to highlight the knowledge gap on severe stroke with a brief summary of the literature followed by a discussion of the challenges involved in the study and treatment of severe stroke and poor long-term outcome.

Event-related desynchronization of sensorimotor EEG rhythms in hemiparetic patients with acute stroke

Previous neuroimaging studies based on neurovascular coupling have shown that stroke affects both, strength and spatial extent of brain activation during upper limb movements. Here, we investigated the sub-second amplitude dynamics of a direct neuronal measure, i.e., event-related desynchronization (ERD) of EEG oscillations during finger movements, in patients with acute cortical and subcortical stroke. Acute cortical strokes were found to decrease the ERD of alpha oscillations for the affected pericentral sensorimotor areas compared to a control group. Within the cortical stroke group, the affected hemisphere showed a smaller alpha-ERD compared to the unaffected hemisphere when each was contralateral to the acting hand. Furthermore, when cortical stroke patients moved their paretic hand, the ipsilateral (i.e., contralesional) alpha-ERD was stronger than the contralateral (ipsilesional) ERD. Interestingly, the alpha-ERD amplitude in a hemisphere with a cortical stroke was relatively well preserved for non-paretic hand movements compared to alpha-ERD amplitude for paretic hand movements. This finding provides a new perspective for assessing the rehabilitative potential, which could be utilized through training of the still responsive cortical network, e.g., via enforced use of the paretic hand.

Reorganization of brain function during force production after stroke: a systematic review of the literature

BACKGROUND AND PURPOSE

Damage to motor areas of the brain caused by stroke can produce devastating motor deficits, including aberrant control of force. Reorganization of brain function is a fundamental mechanism involved in recovery of motor control after stroke, and recent advances in neuroimaging have enabled study of this reorganization. This review focuses on neuroimaging studies that have examined reorganization of brain function during force production and force modulation after stroke.

METHODS

The type and extent of reorganization after stroke were characterized by three factors: severity of injury, time after stroke, and impact of therapeutic interventions on brain activation during force production. Twenty-six studies meeting the inclusion criteria could be identified in MEDLINE (1980-2007).

RESULTS

Relevant characteristics of studies (lesion location, chronicity of stroke, and motor task) and mapping techniques varied. During force production, increased activation in secondary motor areas occurred in persons with more severe strokes. Reduced recruitment of secondary motor areas during force production was found as a function of increased time since stroke. During force modulation, increased activation in motor areas occurred with greater force generation. Persons with more severe stroke showed greater activation with increasing force compared with persons with less severe stroke. Alteration of brain activation during and after rehabilitative interventions was identified in some studies.

DISCUSSION AND CONCLUSION

This systematic review establishes that reorganization of brain function during force production and force modulation can occur after stroke. These findings imply that therapeutic strategies may target brain reorganization to improve force control and functional recovery after stroke.

Ipsilateral versus contralateral cortical motor projections to a shoulder adductor in chronic hemiparetic stroke: implications for the expression of arm synergies

An increase in ipsilateral descending motor pathway activity has been reported following hemiparetic stroke. In axial muscles, increased ipsilateral cortical activity has been correlated with good recovery whereas in distal arm muscles it is correlated with poor recovery. Currently, little is known about the control of proximal upper limb muscles following stroke. This muscle group is less impaired than the distal arm muscles following stroke, yet contributes to the abnormal motor coordination patterns associated with movements of the arm which can severely impair reaching ability. This study used transcranial magnetic stimulation (TMS) to evaluate the presence and magnitude of ipsilateral and contralateral projections to the pectoralis major (PMJ) muscle in stroke survivors. A laterality index (LI) was used to investigate the relationship between ipsilateral and contralateral projections and strength, clinical impairment level, and the degree of abnormal coordination expressed in the arm. The ipsilateral and contralateral hemispheres were stimulated using 90% TMS intensity while the subject generated shoulder adduction torques in both arms. Motor evoked potentials (MEPs) were measured in the paretic and non-paretic PMJ. The secondary torque at the elbow was measured during maximal adduction as an indicator of the degree of extensor synergy. Ipsilateral MEPs were most common in stroke survivors with moderate to severe motor deficits. The LI was correlated with clinical impairment level (P = 0.05) and the degree of extension synergy expressed in the arm (P = 0.03). The LI was not correlated with strength. These results suggest that increased excitability of ipsilateral pathways projecting to the proximal upper arm may contribute to the expression of the extension synergy following stroke. These findings are discussed in relation to a possible unmasking or upregulation of oligosynaptic cortico-bulbospinal pathways following stroke.

Crossed cortico-spinal motor control after capsular stroke

While it is widely accepted that multiple nonprimary motor areas such as the dorsal premotor cortex contribute to recovery from stroke, the contribution of the ipsilesional and contralesional primary motor cortex (M1) is controversial. It has been suggested that re-instating 'near normal' activation patterns is a good strategy for recovery of function [Baron et al., (2004) Cerebrovasc. Dis., 18, 260-267; Ward & Cohen, (2004) Arch. Neurol., 61, 1844-1848]. The present study addressed this aspect of stroke recovery by combining transcranial magnetic stimulation (TMS) and magnetoencephalography (MEG) in a cross-sectional design on nine patients with well-recovered motor function 17.6 +/- 5.5 months (mean +/- SD) after subcortical stroke. While TMS was applied to probe the integrity of the cortico-spinal tract (CST) at rest, MEG was used to test for recruitment of CST pathways during a motor challenge [cortico-muscular coherence (CMC) in a precision grip task]. With both techniques, crossed cortico-spinal connectivity could be demonstrated. A significant correlation (r = 0.85) of CMC magnitude and recovered muscle strength underlined the functional relevance of crossed CST integrity for successful recovery. In conclusion, at the descriptive level, crossed CST connectivity is a common finding in well-recovered patients with capsular stroke. This renders it likely that maintaining or regaining use of crossed CST fibers is one way to achieve effective recovery.

Bereitschaftspotential and movement-related potentials: Origin, significance, and application in disorders of human movement

The existence of a slow negative wave, the Bereitschaftspotential ("BP"), preceding voluntary movement by 1 second or more was first reported more than 40 years ago. There appears to be considerable interindividual differences, but there is general agreement that the initial negativity actually consists of two distinct phases. Uncertainty remains about many other properties and features of the response, including nomenclature, which makes the existing literature difficult to synthesize. The duration of the premovement negativity raises questions about how and when voluntary movement is initiated. Premovement negativities can also be seen before (predictably) externally paced movement, and these have similarities to the BP. Although lateralized generators exist, it is likely that the majority of the early component of the BP (BP1 or early BP), arises from the anterior supplementary motor area (SMA) and more rostral pre-SMA. The late phase of the BP (BP2 or late BP) is probably generated by activity in both the SMA proper and the contralateral motor cortex. Changes in the BP occur in several movement disorders, notably Parkinson's disease, in which the pattern is consistent with a failure of pre-SMA activation. The presence (or absence) of a clear preceding negativity can also have diagnostic importance for certain movement disorders.

The Neural Substrates of Motor Recovery After Focal Damage to the Central Nervous System

OBJECTIVE

To discuss how reorganization of the surviving central nervous system tissue might subserve the improvements in function that are commonly seen over weeks, months, and sometimes years after stroke.

DATA SOURCES

Original scientific studies.

STUDY SELECTION

The studies reviewed all used noninvasive techniques such as functional magnetic resonance imaging, electroencephalography, magnetoencephalography, and transcranial magnetic stimulation. Only studies using motor paradigms in stroke patients were reviewed.

DATA EXTRACTION

Data were reviewed and assessed by the author.

DATA SYNTHESIS

Currently, results suggest that functionally relevant changes do occur in cerebral networks in human stroke patients. For example, it is apparent that initial attempts to move a paretic limb after stroke are associated with widespread activity within the distributed motor system in both cerebral hemispheres. This reliance on nonprimary motor output pathways is unlikely to support full recovery, but improved efficiency of the surviving networks is associated with behavioral gains.

CONCLUSIONS

This review discusses how a better understanding of the relation between these changes and recovery will facilitate the development of novel therapeutic techniques that are based on neurobiologic principles and that are designed to minimize impairment in appropriately targeted patients suffering from stroke.

Symmetry of post-movement beta-ERS and motor recovery from stroke: a low-resolution EEG pilot study

The inter-hemispheric symmetry of electroencephalographic (EEG) post-movement beta-event-related synchronization (PMBS) after movements on a drawing board was studied in eight acute stroke subjects with mild hemiparesis and eight normal subjects. A follow-up testing was conducted 3 months after the initial recordings with a twofold purpose: (1) to validate the reproducibility of the experimental protocol in normal subjects; and (2) to study changes of inter-hemispheric PMBS-symmetry as a response to recovery of motor function. PMBS values were calculated and their topographic distributions illustrated at various time instances following movement offset. Significant PMBS patterns were present in all normal subjects, with only minor differences within consecutive recordings. The side of hemiparesis in acute stroke subjects could be distinguished (P = 0.04) on the basis of the signed symmetry index, a quantitative measure of lateralization. The follow-up testing on three recovered stroke subjects revealed a trend of changes in the lateralization towards the contralateral side of movement, an indication that the cortical organization of movement following recovery turned out as reported for normal subjects. Further clinical investigations need to be carried out to evaluate the relationship between recovery and PMBS symmetry on a large number of subjects, using the method presented here.

Recovery from ischemic stroke: a translational research perspective for neurology

Ischemic stroke is the most frequent neurological disease, characterized by an age-related incidence and chronic disability in the majority of patients. A great challenge in acute stroke is to predict the degree to which a patient will eventually recover. Magnetic resonance imaging has revealed that treatment-induced reperfusion limits the extent of ischemic brain damage, thereby enabling rapid and profound recovery. Nevertheless, patients may retain deficits in motor, sensory or cognitive functions due to the residual lesion. Functional neuroimaging and transcranial magnetic stimulation have shown that recovery is associated with abnormal activation in the perilesional vicinity and in brain areas remote from the lesion. This is likely related to altered functional properties or morphological changes in both cerebral hemispheres. Recent neurorehabilitative strategies, including forced use, mental imagery and peripheral nerve or cortex stimulation, aim at modulating these functional networks. Accordingly, translational research has provided new vistas on the neurobiological mechanisms of recovery and opened future avenues for science-based pharmacological and neurophysiological training strategies in stroke.

Multimodal imaging of brain reorganization in motor areas of the contralesional hemisphere of well recovered patients after capsular stroke

Clinical recovery after stroke can be significant and has been attributed to plastic reorganization and recruitment of novel areas previously not engaged in a given task. As equivocal results have been reported in studies using single imaging or electrophysiological methods, here we applied an integrative multimodal approach to a group of well-recovered chronic stroke patients (n = 11; aged 50-81 years) with left capsular lesions. Focal activation during recovered hand movements was assessed with EEG spectral analysis and H2(15)O-PET with EMG monitoring, cortico-cortical connectivity with EEG coherence analysis (cortico-cortical coherence) and corticospinal connectivity with transcranial magnetic stimulation (TMS). As seen from comparisons with age-matched controls, our patients showed enhanced recruitment of the lateral premotor cortex of the lesioned hemisphere [Brodmann area (BA) 6], lateral premotor and to a lesser extent primary sensorimotor and parietal cortex of the contralesional hemisphere (CON-H; BA 4 and superior parietal lobule) and left cerebellum (patients versus controls, Z > 3.09). EEG coherence analysis showed that after stroke cortico-cortical connections were reduced in the stroke hemisphere but relatively increased in the CON-H (ANOVA, contrast analysis, P < 0.05), suggesting a shift of functional connectivity towards the CON-H. Nevertheless, fast conducting corticospinal transmission originated exclusively from the lesioned hemisphere. No direct ipsilateral motor evoked potentials (MEPs) could be elicited with TMS over the contralesional primary motor cortex (iM1) in stroke patients. We conclude that (i) effective recovery is based on enhanced utilization of ipsi- and contralesional resources, (ii) basic corticospinal commands arise from the lesioned hemisphere without recruitment of ('latent') uncrossed corticospinal tract fibres and (iii) increased contralesional activity probably facilitates control of recovered motor function by operating at a higher-order processing level, similar to but not identical with the extended network concerned with complex movements in healthy subjects.

Patterns of impairment in digit independence after subcortical stroke

The nature of impairment in hand motor control after stroke and its relationship to hand function are still not well understood. In this study, we investigated digit independence in patients with subcortical stroke (n = 8) and moderate hand impairment, defined by wrist and hand Fugl-Meyer scale scores < or =25/33, and age-matched controls (n = 8). Subjects made cyclical flexion-extension movements of an instructed digit while keeping the other digits as still as possible. Movements of the metacarpo-phalangeal (MCP) joints of the five digits were measured using an instrumented glove. The ability to move an instructed digit individually (individuation index), and the ability to keep a noninstructed digit as still as possible (stationarity index) were determined for each digit. Contrary to the finding of normal thumb individuation in a recent study of patients with variable hand motor impairment after stroke, we found that independent movement for all digits was significantly impaired, although individuation and stationarity were differentially affected for each digit. All the digits, including the thumb, showed a similar impairment in individuation. In contrast, stationarity was affected in a digit-dependent pattern: the thumb was affected least, and the middle finger was most impaired. Stroke subjects did not extend their digits fully to the baseline position, and the angular displacement at maximum digit extension correlated significantly with digit individuation. Contrary to expectation, digit independence correlated weakly with clinical tests of hand function, which emphasize grasp. This suggests that corticospinal projections might be separated with respect to function rather than finger topography.

Qualitative differences between conscious and nonconscious processing? On inverse priming induced by masked arrows

In general, both consciously and unconsciously perceived stimuli facilitate responses to following similar stimuli. However, masked arrows delay responses to following arrows. This inverse priming has been ascribed to inhibition of premature motor activation, more recently even to special processing of nonconsciously perceived material. Here, inverse priming depended on particular masks, was insensitive to contextual requirements for increased inhibition, and was constant across response speeds. Putative signs of motor inhibition in the electroencephalogram may as well reflect activation of the opposite response. Consequently, rather than profiting from inhibition of primed responses, the alternative response is directly primed by perceptual interactions of primes and masks. Thus there is no need to assume separate pathways for nonconscious and conscious processing.

Functional reorganization of the cerebral motor system after stroke

PURPOSE OF REVIEW

Recovery of function after stroke is now widely considered to be a consequence of central nervous system reorganization. Non-invasive techniques such as functional magnetic resonance imaging, transcranial magnetic stimulation, electroencephalography and magnetoencephalography now allow the study of the working human brain. Studies in stroke patients can now address how cerebral networks in the human brain respond to focal injury and whether these changes are related to functional recovery. This understanding may in turn lead to the development of techniques that will drive cerebral reorganization in a way that promotes functional improvement.

RECENT FINDINGS

The relationship between cerebral reorganization and functional recovery has been examined in both cross-sectional and longitudinal studies. It appears that the motor system reacts to damage in a way that attempts to generate motor output through surviving brain regions and networks. There are changes in cortical excitability after stroke that may provide the substrate whereby the effects of motor practice or experience can be more effective in driving long lasting changes in motor networks. This will be particularly important in intact portions of neural networks subserving motor skills learning.

SUMMARY

Functionally relevant adaptive changes occur in the human brain following focal damage. A greater understanding of how these changes are related to the recovery process will allow the development of novel therapeutic techniques that are based on neurobiological principles and which are designed to minimize impairment in appropriately targeted patients suffering from stroke.

Malfunctions of Central Control of Movement Studied with Slow Brain Potentials in Neurological Patients

Abstract Studies are reviewed that used movement-related EEG potentials to investigate impairments of movement control in neurological patients. The EEG potentials reviewed are the Bereitschaftspotential (BP), Contingent Negative Variation (CNV), and components of the lateralized readiness potential (LRP). Patient groups included in this review are patients with infarction of the middle cerebral artery, Parkinson's disease, cerebellar disease, and amyotrophic lateral sclerosis. A rich body of evidence has been collected on Parkinson's disease, and somewhat less on cerebellar atrophy, contributing to an understanding of the impairments caused by these diseases. In contrast, not much research has been done in amyotrophic lateral sclerosis and in infarction patients. The latter is particularly striking since utility of this method for assessing residual capacities of affected motor areas seems rather obvious.