Large-scale changes in network interactions as a physiological signature of spatial neglect

Severity-Dependent Interhemispheric White Matter Connectivity Predicts Poststroke Neglect Recovery

Left-sided spatial neglect is a very common and challenging issue after right-hemispheric stroke, which strongly and negatively affects daily living behavior and recovery of stroke survivors. The mechanisms underlying recovery of spatial neglect remain controversial, particularly regarding the involvement of the intact, contralesional hemisphere, with potential contributions ranging from maladaptive to compensatory. In the present prospective, observational study, we assessed neglect severity in 54 right-hemispheric stroke patients (32 male; 22 female) at admission to and discharge from inpatient neurorehabilitation. We demonstrate that the interaction of initial neglect severity and spared white matter (dis)connectivity resulting from individual lesions (as assessed by diffusion tensor imaging, DTI) explains a significant portion of the variability of poststroke neglect recovery. In mildly impaired patients, spared structural connectivity within the lesioned hemisphere is sufficient to attain good recovery. Conversely, in patients with severe impairment, successful recovery critically depends on structural connectivity within the intact hemisphere and between hemispheres. These distinct patterns, mediated by their respective white matter connections, may help to reconcile the dichotomous perspectives regarding the role of the contralesional hemisphere as exclusively compensatory or not. Instead, they suggest a unified viewpoint wherein the contralesional hemisphere can - but must not necessarily - assume a compensatory role. This would depend on initial impairment severity and on the available, spared structural connectivity. In the future, our findings could serve as a prognostic biomarker for neglect recovery and guide patient-tailored therapeutic approaches.

Disengagement of attention with spatial neglect: A systematic review of behavioral and anatomical findings

The present review examined the consequences of focal brain injury on spatial attention studied with cueing paradigms, with a particular focus on the disengagement deficit, which refers to the abnormal slowing of reactions following an ipsilesional cue. Our review supports the established notion that the disengagement deficit is a functional marker of spatial neglect and is particularly pronounced when elicited by peripheral cues. Recent research has revealed that this deficit critically depends on cues that have task-relevant characteristics or are associated with negative reinforcement. Attentional capture by task-relevant cues is contingent on damage to the right temporo-parietal junction (TPJ) and is modulated by functional connections between the TPJ and the right insular cortex. Furthermore, damage to the dorsal premotor or prefrontal cortex (dPMC/dPFC) reduces the effect of task-relevant cues. These findings support an interactive model of the disengagement deficit, involving the right TPJ, the insula, and the dPMC/dPFC. These interconnected regions play a crucial role in regulating and adapting spatial attention to changing intrinsic values of stimuli in the environment.

The emergence of multiscale connectomics-based approaches in stroke recovery

Stroke is a leading cause of adult disability. Understanding stroke damage and recovery requires deciphering changes in complex brain networks across different spatiotemporal scales. While recent developments in brain readout technologies and progress in complex network modeling have revolutionized current understanding of the effects of stroke on brain networks at a macroscale, reorganization of smaller scale brain networks remains incompletely understood. In this review, we use a conceptual framework of graph theory to define brain networks from nano- to macroscales. Highlighting stroke-related brain connectivity studies at multiple scales, we argue that multiscale connectomics-based approaches may provide new routes to better evaluate brain structural and functional remapping after stroke and during recovery.

High-density transcranial direct current stimulation to improve upper limb motor function following stroke: study protocol for a double-blind randomized clinical trial targeting prefrontal and/or cerebellar cognitive contributions to voluntary motion

BACKGROUND

Focal brain lesions following a stroke of the middle cerebral artery induce large-scale network disarray with a potential to impact multiple cognitive and behavioral domains. Over the last 20 years, non-invasive brain neuromodulation via electrical (tCS) stimulation has shown promise to modulate motor deficits and contribute to recovery. However, weak, inconsistent, or at times heterogeneous outcomes using these techniques have also highlighted the need for novel strategies and the assessment of their efficacy in ad hoc controlled clinical trials.

METHODS

We here present a double-blind, sham-controlled, single-center, randomized pilot clinical trial involving participants having suffered a unilateral middle cerebral artery (MCA) stroke resulting in motor paralysis of the contralateral upper limb. Patients will undergo a 10-day regime (5 days a week for 2 consecutive weeks) of a newly designed high-definition transcranial direct current stimulation (HD-tDCS) protocol. Clinical evaluations (e.g., Fugl Meyer, NIHSS), computer-based cognitive assessments (visuo-motor adaptation and AX-CPT attention tasks), and electroencephalography (resting-state and task-evoked EEG) will be carried out at 3 time points: (I) Baseline, (II) Post-tDCS, and (III) Follow-up. The study consists of a four-arm trial comparing the impact on motor recovery of three active anodal tDCS conditions: ipsilesional DLPFC tDCS, contralesional cerebellar tDCS or combined DLPFC + contralesional cerebellar tDCS, and a sham tDCS intervention. The Fugl-Meyer Assessment for the upper extremity (FMA-UE) is selected as the primary outcome measure to quantify motor recovery. In every stimulation session, participants will receive 20 min of high-density tDCS stimulation (HD-tDCS) (up to 0.63 mA/[Formula: see text]) with [Formula: see text] electrodes. Electrode scalp positioning relative to the cortical surface (anodes and cathodes) and intensities are based on a biophysical optimization model of current distribution ensuring a 0.25 V/m impact at each of the chosen targets.

DISCUSSION

Our trial will gauge the therapeutic potential of accumulative sessions of HD-tDCS to improve upper limb motor and cognitive dysfunctions presented by middle cerebral artery stroke patients. In parallel, we aim at characterizing changes in electroencephalographic (EEG) activity as biomarkers of clinical effects and at identifying potential interactions between tDCS impact and motor performance outcomes. Our work will enrich our mechanistic understanding on prefrontal and cerebellar contributions to motor function and its rehabilitation following brain damage.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05329818. April 15, 2022.

Influence of frontal-to-parietal connectivity in pseudoneglect: A cortico-cortical paired associative stimulation study

Pseudoneglect is a set of visuospatial biases that entails a behavioral advantage for stimuli appearing in the left hemifield compared to the right one. Although right hemisphere dominance for visuospatial processing has been invoked to explain this phenomenon, its neurophysiological mechanisms are still debated, and the role of intra- and inter-hemispheric connectivity is yet to be defined. The present study explored the possibility of modulating pseudoneglect in healthy participants through a cortico-cortical paired associative stimulation protocol (ccPAS): a non-invasive brain stimulation protocol that manipulates the interplay between brain regions through the repeated, time-locked coupling of two transcranial magnetic stimulation (TMS) pulses. In the first experiment, healthy participants underwent a frontal-to-parietal (FP) and a parietal-to-frontal (PF) ccPAS. In the FP protocol, the first TMS pulse targeted the right frontal eye field (FEF), and the second pulse the right inferior parietal lobule (IPL), two critical areas for visuospatial and attentional processing. In the PF condition, the order of the pulses was reversed. In both protocols, the inter-stimulus interval (ISI) was 10 ms. Before and after stimulation, pseudoneglect was assessed with a landmark task and a manual line bisection task. A second experiment controlled for ccPAS timing dependency by testing FP-ccPAS with a longer ISI of 100 ms. Results showed that after administering the FP-ccPAS with the ISI of 10 ms, participants' leftward bias in the landmark task increased significantly, with no effects in the manual line bisection task. The other two protocols tested were ineffective. Our findings showed that ccPAS could be used to modulate pseudoneglect by exploiting frontal-to-parietal connectivity, possibly through increased top-down attentional control. FP-ccPAS could represent a promising tool to investigate connectivity properties within visuospatial and attentional networks in the healthy and as a potential rehabilitation protocol in patients suffering from severe visuospatial pathologies.

Brain Topological Reorganization Associated with Visual Neglect After Stroke

Background/Purpose: To identify brain hubs that are behaviorally relevant for neglect after stroke as well as to characterize their functional architecture of communication. Methods: Twenty acute right hemisphere damaged patients underwent neuropsychological and resting-state functional magnetic resonance imaging sessions. Spatial neglect was assessed by means of the Center of Cancellation on the Bells Cancellation Test. For each patient, resting-state functional connectivity matrices were derived by adopting a brain parcellation scheme consisting of 153 nodes. For every node, we extracted its betweenness centrality (BC) defined as the portion of all shortest paths in the connectome involving such node. Then, neglect hubs were identified as those regions showing a high correlation between their BC and neglect scores. Results: A first set of neglect hubs was identified in multiple systems including dorsal attention and ventral attention, default mode, and frontoparietal executive-control networks within the damaged hemisphere as well as in the posterior and anterior cingulate cortex. Such cortical regions exhibited a loss of BC and increased (i.e., less efficient) weighted shortest path length (WSPL) related to severe neglect. Conversely, a second group of neglect hubs found in visual and motor networks, in the undamaged hemisphere, exhibited a pathological increase of BC and reduction of WSPL associated with severe neglect. Conclusion: The topological reorganization of the brain in neglect patients might reflect a maladaptive shift in processing spatial information from higher level associative-control systems to lower level visual and sensory-motor processing areas after a right hemisphere lesion.

Neuroimaging evidence supporting a dual-network architecture for the control of visuospatial attention in the human brain: a mini review

Neuroimaging studies conducted in the last three decades have distinguished two frontoparietal networks responsible for the control of visuospatial attention. The present review summarizes recent findings on the neurophysiological mechanisms implemented in both networks and describes the evolution from a model centered on the distinction between top-down and bottom-up attention to a model that emphasizes the dynamic interplay between the two networks based on attentional demands. The role of the dorsal attention network (DAN) in attentional orienting, by boosting behavioral performance, has been investigated with multiple experimental approaches. This research effort allowed us to trace a distinction between DAN regions involved in shifting vs. maintenance of attention, gather evidence for the modulatory influence exerted by the DAN over sensory cortices, and identify the electrophysiological correlates of the orienting function. Simultaneously, other studies have contributed to reframing our understanding of the functions of the ventral attention network (VAN) and its relevance for behavior. The VAN is not simply involved in bottom-up attentional capture but interacts with the DAN during reorienting to behaviorally relevant targets, exhibiting a general resetting function. Further studies have confirmed the selective rightward asymmetry of the VAN, proposed a functional dissociation along the anteroposterior axis, and suggested hypotheses about its emergence during the evolution of the primate brain. Finally, novel models of network interactions explain the expression of complex attentional functions and the emergence and restorations of symptoms characterizing unilateral spatial neglect. These latter studies emphasize the importance of considering patterns of network interactions for understanding the consequences of brain lesions.

Association of delirium and spatial neglect in patients with right-hemisphere stroke

BACKGROUND

Delirium, an acute and fluctuating decline in cognitive functioning, increases mortality and length of hospital stays (LOS) and adversely affects functional outcomes. Previous studies suggested that the incidence of delirium may be increased in right-hemisphere strokes. Similarly, spatial neglect, a disabling deficit in unilateral spatial processing, is more common and more severe following a right-sided stroke. Spatial neglect has been established as a risk factor for delirium.

OBJECTIVE

It was hypothesized that functionally relevant spatial neglect and delirium are associated in patients with right-hemisphere stroke during acute inpatient rehabilitation. Data were examined from consecutive unilateral stroke patients evaluated with the 3-minute diagnostic interview for confusion assessment method (3D-CAM) and the Catherine Bergego Scale (CBS) via the Kessler Foundation Neglect Assessment Process (KF-NAP).

DESIGN

A retrospective, cohort study.

SETTING

Data collected in an acute inpatient rehabilitation facility.

PARTICIPANTS

Six hundred twenty six patients with stroke were included.

MAIN OUTCOME MEASURES

The measures were the relative risk of patients with right-hemisphere stroke having delirium when also positive for spatial neglect compared to patients with right-hemisphere stroke without spatial neglect, the incidence of 3D-CAM positive results by stroke hemisphere, and the effect of spatial neglect and delirium on functional outcomes for patients with right-brain stroke patients.

RESULTS

There was a significantly higher risk of delirium in patients with right-hemisphere stroke with spatial neglect compared to patients with right-hemisphere stroke without spatial neglect. The rates of 3D-CAM positive results were not statistically different for left- compared to right-hemisphere strokes. Both delirium and spatial neglect had significant adverse effects on right-hemisphere stroke patients' functional independence.

CONCLUSIONS

The results demonstrate an association between spatial neglect and delirium in patients with right hemisphere stroke in the acute inpatient rehabilitation setting. Because of the negative effect of these impairments on functional outcomes after stroke, prevention, early detection, and targeted treatments should be prioritized for these patients.

Recombination of the right cerebral cortex in patients with left side USN after stroke: fNIRS evidence from resting state

Objective

Unilateral spatial neglect (USN) is an impaired contralesional stimulus detection, response, or action, causing functional disability. After a stroke, the right hemisphere experiences USN more noticeably, severely, and persistently than the left. However, few studies using fNIRS have been reported in cases of USN. This study aimed to confirm weaker RSFC in USN and investigate the potential inherent features in hemodynamic fluctuations that may be associated with USN. Furthermore, these features were combined into a mathematical model for more accurate classification.

Methods

A total of 33 stroke patients with right-sided brain damage were chosen, of whom 12 had non-USN after stroke, and 21 had USN after stroke (the USN group). Graph theory was used to evaluate the hemodynamic signals of the brain's right cerebral cortex during rest. Furthermore, a support vector machine model was built to categorize the subjects into two groups based on the chosen network properties.

Results

First, mean functional connectivity was lower in the USN group (0.745 ± 0.239) than in the non-USN group (0.843 ± 0.254) (t = -4.300, p < 0.001). Second, compared with the non-USN group, USN patients had a larger clustering coefficient (C) (t = 3.145, p < 0.001), local efficiency (LE) (t = 3.189, p < 0.001), and smaller global efficiency (GE) (t = 3.047, p < 0.001). Notably, there were differences in characteristic path length (L) and small worldness (σ) values between the two groups at certain thresholds, mainly as higher L (t = 3.074, p < 0.001) and lower small worldness (σ) values (t = 2.998, p < 0.001) in USN patients compared with non-USN patients. Finally, the classification accuracy of the SVM model based on AUC aC (t = -2.259, p = 0.031) and AUC aLE (t = -2.063, p = 0.048) was 85%, the sensitivity was 75%, and the specificity was 89%.

Conclusion

The functional network architecture of the right cerebral cortex exhibits significant topological alterations in individuals with USN following stroke, and the sensitivity index based on the small-world property AUC may be utilized to identify these patients accurately.

Multiscale effects of excitatory-inhibitory homeostasis in lesioned cortical networks: A computational study

Stroke-related disruptions in functional connectivity (FC) often spread beyond lesioned areas and, given the localized nature of lesions, it is unclear how the recovery of FC is orchestrated on a global scale. Since recovery is accompanied by long-term changes in excitability, we propose excitatory-inhibitory (E-I) homeostasis as a driving mechanism. We present a large-scale model of the neocortex, with synaptic scaling of local inhibition, showing how E-I homeostasis can drive the post-lesion restoration of FC and linking it to changes in excitability. We show that functional networks could reorganize to recover disrupted modularity and small-worldness, but not network dynamics, suggesting the need to consider forms of plasticity beyond synaptic scaling of inhibition. On average, we observed widespread increases in excitability, with the emergence of complex lesion-dependent patterns related to biomarkers of relevant side effects of stroke, such as epilepsy, depression and chronic pain. In summary, our results show that the effects of E-I homeostasis extend beyond local E-I balance, driving the restoration of global properties of FC, and relating to post-stroke symptomatology. Therefore, we suggest the framework of E-I homeostasis as a relevant theoretical foundation for the study of stroke recovery and for understanding the emergence of meaningful features of FC from local dynamics.

Functional Connectivity Pattern Using Resting-state fMRI as an Assessment Tool for Spatial Neglect during the Recovery Stage of Stroke: A Pilot Study

PURPOSE

To determine if functional connectivity measured with resting-state functional MRI could be used as a tool to assess unilateral spatial neglect during stroke recovery.

METHODS

Resting-state functional MRI was performed on 13 stroke patients with lesions in the right cerebral hemisphere and 31 healthy subjects. The functional connectivity score was defined as a correlation of a target region with the right inferior parietal lobule. Spatial neglect was measured with a behavioral inattention test.

RESULTS

First, the functional connectivity scores between the right inferior parietal lobule and right inferior frontal gyrus, including the opercular and triangular parts, were significantly decreased in stroke patients with unilateral spatial neglect compared with patients without unilateral spatial neglect and were significantly correlated with the behavioral inattention test score. Second, the functional connectivity scores between the bilateral inferior parietal lobules were also significantly decreased in patients with unilateral spatial neglect compared with patients without unilateral spatial neglect and were significantly correlated with the behavioral inattention test score. Third, negative functional connectivity scores between the right inferior parietal lobule and bilateral medial orbitofrontal cortexes, which are related to the default mode network, were detected in patients without unilateral spatial neglect in contrast to a reduction of this negative tendency in patients with unilateral spatial neglect. The functional connectivity scores between these regions were significantly different between patients with and without unilateral spatial neglect and were negatively correlated with the behavioral inattention test score.

CONCLUSION

Though still in the pilot research stage and using a small number of cases, our findings are consistent with the hypothesis that functional connectivity maps generated with resting-state functional MRI may be used as a tool to evaluate unilateral spatial neglect during stroke recovery.

Functional and structural lesion network mapping in neurological and psychiatric disorders: a systematic review

Background

The traditional approach to studying the neurobiological mechanisms of brain disorders and localizing brain function involves identifying brain abnormalities and comparing them to matched controls. This method has been instrumental in clinical neurology, providing insight into the functional roles of different brain regions. However, it becomes challenging when lesions in diverse regions produce similar symptoms. To address this, researchers have begun mapping brain lesions to functional or structural networks, a process known as lesion network mapping (LNM). This approach seeks to identify common brain circuits associated with lesions in various areas. In this review, we focus on recent studies that have utilized LNM to map neurological and psychiatric symptoms, shedding light on how this method enhances our understanding of brain network functions.

Methods

We conducted a systematic search of four databases: PubMed, Scopus, and Web of Science, using the term "Lesion network mapping." Our focus was on observational studies that applied lesion network mapping in the context of neurological and psychiatric disorders.

Results

Following our screening process, we included 52 studies, comprising a total of 6,814 subjects, in our systematic review. These studies, which utilized functional connectivity, revealed several regions and network overlaps across various movement and psychiatric disorders. For instance, the cerebellum was found to be part of a common network for conditions such as essential tremor relief, parkinsonism, Holmes tremor, freezing of gait, cervical dystonia, infantile spasms, and tics. Additionally, the thalamus was identified as part of a common network for essential tremor relief, Holmes tremor, and executive function deficits. The dorsal attention network was significantly associated with fall risk in elderly individuals and parkinsonism.

Conclusion

LNM has proven to be a powerful tool in localizing a broad range of neuropsychiatric, behavioral, and movement disorders. It holds promise in identifying new treatment targets through symptom mapping. Nonetheless, the validity of these approaches should be confirmed by more comprehensive prospective studies.

Longitudinal investigation of changes in resting-state co-activation patterns and their predictive ability in the zQ175 DN mouse model of Huntington's disease

Huntington's disease (HD) is a neurodegenerative disorder caused by expanded (≥ 40) glutamine-encoding CAG repeats in the huntingtin gene, which leads to dysfunction and death of predominantly striatal and cortical neurons. While the genetic profile and clinical signs and symptoms of the disease are better known, changes in the functional architecture of the brain, especially before the clinical expression becomes apparent, are not fully and consistently characterized. In this study, we sought to uncover functional changes in the brain in the heterozygous (HET) zQ175 delta-neo (DN) mouse model at 3, 6, and 10 months of age, using resting-state functional magnetic resonance imaging (RS-fMRI). This mouse model shows molecular, cellular and circuitry alterations that worsen through age. Motor function disturbances are manifested in this model at 6 and 10 months of age. Specifically, we investigated, longitudinally, changes in co-activation patterns (CAPs) that are the transient states of brain activity constituting the resting-state networks (RSNs). Most robust changes in the temporal properties of CAPs occurred at the 10-months time point; the durations of two anti-correlated CAPs, characterized by simultaneous co-activation of default-mode like network (DMLN) and co-deactivation of lateral-cortical network (LCN) and vice-versa, were reduced in the zQ175 DN HET animals compared to the wild-type mice. Changes in the spatial properties, measured in terms of activation levels of different brain regions, during CAPs were found at all three ages and became progressively more pronounced at 6-, and 10 months of age. We then assessed the cross-validated predictive power of CAP metrics to distinguish HET animals from controls. Spatial properties of CAPs performed significantly better than the chance level at all three ages with 80% classification accuracy at 6 and 10 months of age.

Language Network Connectivity of Euthymic Bipolar Patients Is Altered at Rest and during a Verbal Fluency Task

Abnormalities of the Language Network (LN) have been found in different psychiatric conditions (e.g., schizophrenia and bipolar disorder), supporting the hypothesis that language plays a central role in a high-level integration/connectivity of second-level cognitive processes and the underlying cortical regions. This view implies a continuum of shared neural alterations along the psychotic disorder spectrum. In particular, bipolar disorder (BD) patients were recently documented to have an altered LN asymmetry during resting state. The extent to which the LN architecture is altered and stable also during a language task has yet to be investigated. To address this question, we analyzed fMRI data recorded during an open-eyes resting state session and a silent verbal fluency task in 16 euthymic BD patients and 16 matched healthy controls (HC). Functional connectivity in the LN of both groups was computed using spatial independent component analysis, and group comparisons were carried out to assess the network organization during both rest and active linguistic task conditions. The LN of BD patients involved left and right brain areas during both resting state and linguistic task. Compared to the left-lateralized network found in HC, the BD group was characterized by two anterior clusters (in left frontal and right temporo-insular regions) and the disengagement of the posterior language areas, especially during the verbal fluency task. Our findings support the hypothesis that reduced language lateralization may represent a biological marker across different psychotic disorders and that the altered language network connectivity found at rest in bipolar patients is stable and pervasive as it is also impaired during a verbal fluency task.

The analysis of brain functional connectivity of post-stroke cognitive impairment patients: an fNIRS study

Background

Post-stroke cognitive impairment (PSCI) is a considerable risk factor for developing dementia and reoccurrence of stroke. Understanding the neural mechanisms of cognitive impairment after stroke can facilitate early identification and intervention.

Objectives

Using functional near-infrared spectroscopy (fNRIS), the present study aimed to examine whether resting-state functional connectivity (FC) of brain networks differs in patients with PSCI, patients with Non-PSCI (NPSCI), and healthy controls (HCs), and whether these features could be used for clinical diagnosis of PSCI.

Methods

The present study recruited 16 HCs and 32 post-stroke patients. Based on the diagnostic criteria of PSCI, post-stroke patients were divided to the PSCI or NPSCI group. All participants underwent a 6-min resting-state fNRIS test to measure the hemodynamic responses from regions of interests (ROIs) that were primarily distributed in the prefrontal, somatosensory, and motor cortices.

Results

The results showed that, when compared to the HC group, the PSCI group exhibited significantly decreased interhemispheric FC and intra-right hemispheric FC. ROI analyses showed significantly decreased FC among the regions of somatosensory cortex, dorsolateral prefrontal cortex, and medial prefrontal cortex for the PSCI group than for the HC group. However, no significant difference was found in the FC between the PSCI and the NPSCI groups.

Conclusion

Our findings provide evidence for compromised interhemispheric and intra-right hemispheric functional connectivity in patients with PSCI, suggesting that fNIRS is a promising approach to investigate the effects of stroke on functional connectivity of brain networks.

Hierarchical psychophysiological pathways subtend perceptual asymmetries in Neglect

Stroke patients with left Hemispatial Neglect (LHN) show deficits in perceiving left contralesional stimuli with biased visuospatial perception towards the right hemifield. However, very little is known about the functional organization of the visuospatial perceptual neural network and how this can account for the profound reorganization of space representation in LHN. In the present work, we aimed at (1) identifying EEG measures that discriminate LHN patients against controls and (2) devise a causative neurophysiological model between the discriminative EEG measures. To these aims, EEG was recorded during exposure to lateralized visual stimuli which allowed for pre-and post-stimulus activity investigation across three groups: LHN patients, lesioned controls, and healthy individuals. Moreover, all participants performed a standard behavioral test assessing the perceptual asymmetry index in detecting lateralized stimuli. The between-groups discriminative EEG patterns were entered into a Structural Equation Model for the identification of causative hierarchical associations (i.e., pathways) between EEG measures and the perceptual asymmetry index. The model identified two pathways. A first pathway showed that the combined contribution of pre-stimulus frontoparietal connectivity and individual-alpha-frequency predicts post-stimulus processing, as measured by visual-evoked N100, which, in turn, predicts the perceptual asymmetry index. A second pathway directly links the inter-hemispheric distribution of alpha-amplitude with the perceptual asymmetry index. The two pathways can collectively explain 83.1% of the variance in the perceptual asymmetry index. Using causative modeling, the present study identified how psychophysiological correlates of visuospatial perception are organized and predict the degree of behavioral asymmetry in LHN patients and controls.

Case report: Multiple disconnection patterns revealed by a multi-modal analysis explained behavior after a focal frontal damage

Introduction

There is overwhelming evidence that focal lesions cause structural, metabolic, functional, and electrical disconnection of regions directly and indirectly connected with the site of injury. Unfortunately, methods to study disconnection (positron emission tomography, structural and functional magnetic resonance imaging, electroencephalography) have been applied primarily in isolation without capturing their interaction. Moreover, multi-modal imaging studies applied to focal lesions are rare.

Case report

We analyzed with a multi-modal approach the case of a patient presenting with borderline cognitive deficits across multiple domains and recurrent delirium. A post-surgical focal frontal lesion was evident based on the brain anatomical MRI. However, we were able to acquire also simultaneous MRI (structural and functional) and [18F]FDG using a hybrid PET/MRI scan along with EEG recordings. Despite the focality of the primary anatomical lesion, structural disconnection in the white matter bundles extended far beyond the lesion and showed a topographical match with the cortical glucose hypometabolism seen both locally and remotely, in posterior cortices. Similarly, a right frontal delta activity near/at the region of structural damage was associated with alterations of distant occipital alpha power. Moreover, functional MRI revealed even more widespread local and distant synchronization, involving also regions not affected by the structural/metabolic/electrical impairment.

Conclusion

Overall, this exemplary multi-modal case study illustrates how a focal brain lesion causes a multiplicity of disconnection and functional impairments that extend beyond the borders of the anatomical irrecoverable damage. These effects were relevant to explain patient’s behavior and may be potential targets of neuro-modulation strategies.

Is recovery from left-sided neglect based on changes in automatic attention? An auditory event related potentials study

An automatic spatial attention deficit is the primary deficit in neglect. However, the cognitive processes enabling recovery from neglect have rarely been studied. We used event-related potentials (ERP) to analyze if recovery is based on changes in automatic attention components. Twelve sub-acute patients with left visuospatial neglect were included. They received 3 weeks of intensive treatment. ERPs were recorded using two auditory paradigms: either a tone was presented randomly to the right or left ear (ATP) or as a Posner paradigm (PP) with left to right and vice versa moving cue tones and validly and invalidly cued target tones. Patients improved significantly on neuropsychological tests and neurological scales. For the ATP, no differences were observed related to the side of stimulation, but the auditory PP showed characteristic results, that is, smaller amplitudes for left-sided targets and higher amplitudes for invalid trials. Both paradigms revealed a treatment effect, but no changes were found in the amplitudes for the two target sides, which would be expected if the treatment would affect the automatic attention bias. Recovery from neglect seems not to be associated with changes in the automatic spatial attention bias, arguing that recovery might be due to higher cognitive compensatory processes.

Dynamic brain states in spatial neglect after stroke

Previous studies indicated that spatial neglect is characterized by widespread alteration of resting-state functional connectivity and changes in the functional topology of large-scale brain systems. However, whether such network modulations exhibit temporal fluctuations related to spatial neglect is still largely unknown. This study investigated the association between brain states and spatial neglect after the onset of focal brain lesions. A cohort of right-hemisphere stroke patients (n = 20) underwent neuropsychological assessment of neglect as well as structural and resting-state functional MRI sessions within 2 weeks from stroke onset. Brain states were identified using dynamic functional connectivity as estimated by the sliding window approach followed by clustering of seven resting state networks. The networks included visual, dorsal attention, sensorimotor, cingulo-opercular, language, fronto-parietal, and default mode networks. The analyses on the whole cohort of patients, i.e., with and without neglect, identified two distinct brain states characterized by different degrees of brain modularity and system segregation. Compared to non-neglect patients, neglect subjects spent more time in less modular and segregated state characterized by weak intra-network coupling and sparse inter-network interactions. By contrast, patients without neglect dwelt mainly in more modular and segregated states, which displayed robust intra-network connectivity and anti-correlations among task-positive and task-negative systems. Notably, correlational analyses indicated that patients exhibiting more severe neglect spent more time and dwelt more often in the state featuring low brain modularity and system segregation and vice versa. Furthermore, separate analyses on neglect vs. non-neglect patients yielded two distinct brain states for each sub-cohort. A state featuring widespread strong connections within and between networks and low modularity and system segregation was detected only in the neglect group. Such a connectivity profile blurred the distinction among functional systems. Finally, a state exhibiting a clear separation among modules with strong positive intra-network and negative inter-network connectivity was found only in the non-neglect group. Overall, our results indicate that stroke yielding spatial attention deficits affects the time-varying properties of functional interactions among large-scale networks. These findings provide further insights into the pathophysiology of spatial neglect and its treatment.

Unilateral Spatial Neglect Recovery Poststroke

Unilateral spatial neglect (USN) is a common and disabling cognitive consequence of stroke wherein individuals demonstrate decreased response to contralesional information. Here, we provide an updated narrative review of studies that shed light on the neural mechanisms and predictors of recovery of USN. Additionally, we report a rapid review of randomized controlled trials focusing on USN intervention, both nonpharmacological and pharmacological, published in the last 5 years. Randomized controlled trials are reviewed within the context of systematic reviews and meta-analyses of USN interventions published within the same time frame. The quality of randomized controlled trials of treatment is higher compared to quality reported in previous reviews and meta-analyses. However, remaining weaknesses in participant demographic reporting, as well as small, heterogenous samples, render generalizability and cross-study interpretation a challenge. Nevertheless, evidence regarding neural mechanisms underlying USN recovery and regarding the effectiveness of targeted USN interventions is accumulating and strengthening, setting the foundation for future investigations into patient-specific factors that may influence treatment response. We identify gaps and provide suggestions for future USN intervention research.

The subcortical and neurochemical organization of the ventral and dorsal attention networks

Attention is a core cognitive function that filters and selects behaviourally relevant information in the environment. The cortical mapping of attentional systems identified two segregated networks that mediate stimulus-driven and goal-driven processes, the Ventral and the Dorsal Attention Networks (VAN, DAN). Deep brain electrophysiological recordings, behavioral data from phylogenetic distant species, and observations from human brain pathologies challenge purely corticocentric models. Here, we used advanced methods of functional alignment applied to resting-state functional connectivity analyses to map the subcortical architecture of the Ventral and Dorsal Attention Networks. Our investigations revealed the involvement of the pulvinar, the superior colliculi, the head of caudate nuclei, and a cluster of brainstem nuclei relevant to both networks. These nuclei are densely connected structural network hubs, as revealed by diffusion-weighted imaging tractography. Their projections establish interrelations with the acetylcholine nicotinic receptor as well as dopamine and serotonin transporters, as demonstrated in a spatial correlation analysis with a normative atlas of neurotransmitter systems. This convergence of functional, structural, and neurochemical evidence provides a comprehensive framework to understand the neural basis of attention across different species and brain diseases.

Advancing brain network models to reconcile functional neuroimaging and clinical research

Functional magnetic resonance imaging (fMRI) captures information on brain function beyond the anatomical alterations that are traditionally visually examined by neuroradiologists. However, the fMRI signals are complex in addition to being noisy, so fMRI still faces limitations for clinical applications. Here we review methods that have been proposed as potential solutions so far, namely statistical, biophysical and decoding models, with their strengths and weaknesses. We especially evaluate the ability of these models to directly predict clinical variables from their parameters (predictability) and to extract clinically relevant information regarding biological mechanisms and relevant features for classification and prediction (interpretability). We then provide guidelines for useful applications and pitfalls of such fMRI-based models in a clinical research context, looking beyond the current state of the art. In particular, we argue that the clinical relevance of fMRI calls for a new generation of models for fMRI data, which combine the strengths of both biophysical and decoding models. This leads to reliable and biologically meaningful model parameters, which thus fulfills the need for simultaneous interpretability and predictability. In our view, this synergy is fundamental for the discovery of new pharmacological and interventional targets, as well as the use of models as biomarkers in neurology and psychiatry.

Virtual reality-based sensorimotor adaptation shapes subsequent spontaneous and naturalistic stimulus-driven brain activity

Our everyday life summons numerous novel sensorimotor experiences, to which our brain needs to adapt in order to function properly. However, tracking plasticity of naturalistic behavior and associated brain modulations is challenging. Here, we tackled this question implementing a prism adaptation-like training in virtual reality (VRPA) in combination with functional neuroimaging. Three groups of healthy participants (N = 45) underwent VRPA (with a shift either to the left/right side, or with no shift), and performed functional magnetic resonance imaging (fMRI) sessions before and after training. To capture modulations in free-flowing, task-free brain activity, the fMRI sessions included resting-state and free-viewing of naturalistic videos. We found significant decreases in spontaneous functional connectivity between attentional and default mode (DMN)/fronto-parietal networks, only for the adaptation groups, more pronouncedly in the hemisphere contralateral to the induced shift. In addition, VRPA was found to bias visual responses to naturalistic videos: Following rightward adaptation, we found upregulation of visual response in an area in the parieto-occipital sulcus (POS) only in the right hemisphere. Notably, the extent of POS upregulation correlated with the size of the VRPA-induced after-effect measured in behavioral tests. This study demonstrates that a brief VRPA exposure can change large-scale cortical connectivity and correspondingly bias visual responses to naturalistic sensory inputs.

Computer-based assessment of unilateral spatial neglect: A systematic review

Background

To date, no gold standard exists for the assessment of unilateral spatial neglect (USN), a common post-stroke cognitive impairment, with limited sensitivity provided by currently used clinical assessments. Extensive research has shown that computer-based (CB) assessment can be more sensitive, but these have not been adopted by stroke services yet.

Objective

We conducted a systematic review providing an overview of existing CB tests for USN to identify knowledge gaps and positive/negative aspects of different methods. This review also investigated the benefits and barriers of introducing CB assessment tasks to clinical settings and explored practical implications for optimizing future designs.

Methodology

We included studies that investigated the efficacy of CB neglect assessment tasks compared to conventional methods in detecting USN for adults with brain damage. Study identification was conducted through electronic database searches (e.g., Scopus), using keywords and standardized terms combinations, without date limitation (last search: 08/06/2022). Literature review and study selection were based on prespecified inclusion criteria. The quality of studies was assessed with the quality assessment of diagnostic accuracy studies tool (Quadas-2). Data synthesis included a narrative synthesis, a table summarizing the evidence, and vote counting analysis based on a direction of effect plot.

Results

A total of 28 studies met the eligibility criteria and were included in the review. According to our results, 13/28 studies explored CB versions of conventional tasks, 11/28 involved visual search tasks, and 5/28 other types of tasks. The vote counting analysis revealed that 17/28 studies found CB tasks had either equal or higher sensitivity than conventional methods and positive correlation with conventional methods (15/28 studies). Finally, 20/28 studies showed CB tasks effectively detected patients with USN within different patient groups and control groups (17/28).

Conclusions

The findings of this review provide practical implications for the implementation of CB assessment in the future, offering important information to enhance a variety of methodological issues. The study adds to our understanding of using CB tasks for USN assessment, exploring their efficacy and benefits compared to conventional methods, and considers their adoption in clinical environments.

Neural substrates in patients with visual-spatial neglect recovering from right-hemispheric stroke

Visual-spatial attention disorder after stroke seriously affects recovery and quality of life in stroke patients. Previous studies have shown that some patients recovery rapidly from visual-spatial neglect (VSN), but the brain networks underlying this recovery are not well understood. Using functional magnetic resonance imaging, we aimed to identify network differences between patients who rapidly recovered from VSN and those with persistent VSN. The study included 30 patients with VSN who suffered subacute stroke. Patients were examined 2–4 weeks after stroke onset and 4 weeks after the initial assessment. At the last evaluation, patients in the persistent VSN (n = 15) and rapid recovery (n = 15) groups underwent paper-and-pencil tests. We defined the bilateral frontal eye fields, bilateral intraparietal sulcus in the dorsal attention network, and right temporoparietal junction and ventral frontal cortex areas in the ventral attention network as regions of interest (ROI) and measured whole-brain ROI-based functional connectivity (FC) and amplitude of low-frequency fluctuations (ALFF) in subacute right-hemisphere stroke patients. VSN recovery was associated with changes in the activation of multiple bilateral attentional brain regions. Specifically, persistent VSN was associated with lower FC in the right superior frontal gyrus, right inferior temporal gyrus, right medial orbitofrontal cortex, left precuneus, right inferior parietal gyrus, right medial frontal gyrus, right rectus gyrus, left superior frontal gyrus, left middle cingulate gyrus, right superior temporal pole, right postcentral gyrus, and right posterior cingulate gyrus compared to that in those with rapid recovery, whereas ALFF in the left cerebellum were decreased in patients with persistent VSN. Our results demonstrate that the DAN rather than the VAN, plays a more important role in recovery from VSN, and that the cerebellum is involved in recovery. We believe that our results supplement those of previous studies on recovery from VSN.

Visuomotor misalignment induced through immersive virtual reality to improve spatial neglect: a case-series study

One evidence-based treatment for spatial neglect is prism adaptation (PA) treatment. PA after-effects, i.e., the implicit shifts in the arm reaching position toward the neglected side of space after prism removal, are considered fundamental to PA treatment effects. In the present study, the arm reaching position was shifted through a visuomotor misalignment procedure using immersive virtual reality (VR). To examine whether this procedure might have a beneficial impact on spatial neglect, we conducted a multi-baseline experiment in three individuals with chronic left-sided neglect post stroke. Improved spatial neglect was observed in all participants immediately after 5 sessions with two rounds in each. Two participants demonstrated lasting or continuous improvement two weeks later. Participants' pattern of brain lesions did not appear to clearly explain performance differences. The findings suggest that VR-induced visuomotor misalignment may improve spatial neglect immediately after a multi-session treatment course. The optimal number of sessions will be determined by future studies with a larger sample size, which may also elucidate the number of sessions sufficient for sustained improvement in most patients. Further investigations will identify the neural mechanisms underlying VR-induced visuomotor misalignment, which may or may not be identical to PA after-effects.

Mapping correlated neurological deficits after stroke to distributed brain networks

Understanding the relationships between brain organization and behavior is a central goal of neuroscience. Traditional teaching emphasizes that the human cerebrum includes many distinct areas for which damage or dysfunction would lead to a unique and specific behavioral syndrome. This teaching implies that brain areas correspond to encapsulated modules that are specialized for specific cognitive operations. However, empirically, local damage from stroke more often produces one of a small number of clusters of deficits and disrupts brain-wide connectivity in a small number of predictable ways (relative to the vast complexity of behavior and brain connectivity). Behaviors that involve shared operations show correlated deficits following a stroke, consistent with a low-dimensional behavioral space. Because of the networked organization of the brain, local damage from a stroke can result in widespread functional abnormalities, matching the low dimensionality of behavioral deficit. In alignment with this, neurological disease, psychiatric disease, and altered brain states produce behavioral changes that are highly correlated across a range of behaviors. We discuss how known structural and functional network priors in addition to graph theoretical concepts such as modularity and entropy have provided inroads to understanding this more complex relationship between brain and behavior. This model for brain disease has important implications for normal brain-behavior relationships and the treatment of neurological and psychiatric diseases.

Detection of Stroke-Induced Visual Neglect and Target Response Prediction Using Augmented Reality and Electroencephalography

We aim to build a system incorporating electroencephalography (EEG) and augmented reality (AR) that is capable of identifying the presence of visual spatial neglect (SN) and mapping the estimated neglected visual field. An EEG-based brain-computer interface (BCI) was used to identify those spatiospectral features that best detect participants with SN among stroke survivors using their EEG responses to ipsilesional and contralesional visual stimuli. Frontal-central delta and alpha, frontal-parietal theta, Fp1 beta, and left frontal gamma were found to be important features for neglect detection. Additionally, temporal analysis of the responses shows that the proposed model is accurate in detecting potentially neglected targets. These targets were predicted using common spatial patterns as the feature extraction algorithm and regularized discriminant analysis combined with kernel density estimation for classification. With our preliminary results, our system shows promise for reliably detecting the presence of SN and predicting visual target responses in stroke patients with SN.

Recovery of neural dynamics criticality in personalized whole-brain models of stroke

The critical brain hypothesis states that biological neuronal networks, because of their structural and functional architecture, work near phase transitions for optimal response to internal and external inputs. Criticality thus provides optimal function and behavioral capabilities. We test this hypothesis by examining the influence of brain injury (strokes) on the criticality of neural dynamics estimated at the level of single participants using directly measured individual structural connectomes and whole-brain models. Lesions engender a sub-critical state that recovers over time in parallel with behavior. The improvement of criticality is associated with the re-modeling of specific white-matter connections. We show that personalized whole-brain dynamical models poised at criticality track neural dynamics, alteration post-stroke, and behavior at the level of single participants.

The authors investigate the influence of brain injury (strokes) on the criticality of neural dynamics using directly measured connectomes and whole-brain models. They show that lesions engender a sub-critical state that recovers over time in parallel with behavior.

Alpha rhythm modulations in the intraparietal sulcus reflect decision signals during item recognition

Theoretical work and empirical observations suggest a contribution of regions along the intraparietal sulcus to the process of evidence accumulation during episodic memory retrieval. In the present study, we recorded magnetoencephalographic signals in a group of healthy human participants to test whether the pattern of oscillatory modulations in the lateral parietal lobe is consistent with the mnemonic accumulator hypothesis. To this aim, the dynamic properties and the spatial distribution of MEG oscillatory power modulations were investigated during an item recognition task in which the amount of evidence for old vs. new memory decisions was manipulated across three levels. A data-driven approach was employed to identify brain nodes where oscillatory activity was sensitive to both retrieval success and the amount of evidence for old decisions. The analysis identified three nodes in the left lateral parietal lobe where the event-related desynchronization (ERD) in the alpha frequency band showed both effects. Further analyses revealed that the alpha ERD in the intraparietal sulcus, but not in other parietal nodes: i. showed modulation of duration in response to the amount of evidence for both old and new decisions, ii. was behaviorally significant, and iii. more accurately tracked the subjective memory judgment rather than the objective memory status. The present findings provide support for a recent anatomical-functional model of the parietal involvement in episodic memory retrieval and suggest that the alpha ERD in the intraparietal sulcus might represent a neural signature of the evidence accumulation process during simple memory-based decisions.

Functional Connectivity Changes in Multiple-Frequency Bands in Acute Basal Ganglia Ischemic Stroke Patients: A Machine Learning Approach

Purpose

Several functional magnetic resonance imaging (fMRI) studies have investigated the resting-state functional connectivity (rs-FC) changes in the primary motor cortex (M1) in patients with acute basal ganglia ischemic stroke (BGIS). However, the frequency-specific FC changes of M1 in acute BGIS patients are still unclear. Our study was aimed at exploring the altered FC of M1 in three frequency bands and the potential features as biomarkers for the identification by using a support vector machine (SVM).

Methods

We included 28 acute BGIS patients and 42 healthy controls (HCs). Seed-based FC of two regions of interest (ROI, bilateral M1s) were calculated in conventional, slow-5, and slow-4 frequency bands. The abnormal voxel-wise FC values were defined as the features for SVM in different frequency bands.

Results

In the ipsilesional M1, the acute BGIS patients exhibited decreased FC with the right lingual gyrus in the conventional and slow-4 frequency band. Besides, the acute BGIS patients showed increased FC with the right medial superior frontal gyrus (SFGmed) in the conventional and slow-5 frequency band and decreased FC with the left lingual gyrus in the slow-5 frequency band. In the contralesional M1, the BGIS patients showed lower FC with the right SFGmed in the conventional frequency band. The higher FC values with the right lingual gyrus and left SFGmed were detected in the slow-4 frequency band. In the slow-5 frequency band, the BGIS patients showed decreased FC with the left calcarine sulcus. SVM results showed that the combined features (slow-4+slow-5) had the highest accuracy in classification prediction of acute BGIS patients, with an area under curve (AUC) of 0.86.

Conclusion

Acute BGIS patients had frequency-specific alterations in FC; SVM is a promising method for exploring these frequency-dependent FC alterations. The abnormal brain regions might be potential targets for future researchers in the rehabilitation and treatment of stroke patients.

Disruption of large-scale electrophysiological networks in stroke patients with visuospatial neglect

Stroke frequently produces attentional dysfunctions including symptoms of hemispatial neglect, which is characterized by a breakdown of awareness for the contralesional hemispace. Recent studies with functional MRI (fMRI) suggest that hemineglect patients display abnormal intra- and interhemispheric functional connectivity. However, since stroke is a vascular disorder and fMRI signals remain sensitive to nonneuronal (i.e., vascular) coupling, more direct demonstrations of neural network dysfunction in hemispatial neglect are warranted. Here, we utilize electroencephalogram (EEG) source imaging to uncover differences in resting-state network organization between patients with right hemispheric stroke (N = 15) and age-matched, healthy controls (N = 27), and determine the relationship between hemineglect symptoms and brain network organization. We estimated intra- and interregional differences in cortical communication by calculating the spectral power and amplitude envelope correlations of narrow-band EEG oscillations. We first observed focal frequency-slowing within the right posterior cortical regions, reflected in relative delta/theta power increases and alpha/beta/gamma decreases. Secondly, nodes within the right temporal and parietal cortex consistently displayed anomalous intra- and interhemispheric coupling, stronger in delta and gamma bands, and weaker in theta, alpha, and beta bands. Finally, a significant association was observed between the severity of left-hemispace search deficits (e.g., cancellation test omissions) and reduced functional connectivity within the alpha and beta bands. In sum, our novel results validate the hypothesis of large-scale cortical network disruption following stroke and reinforce the proposal that abnormal brain oscillations may be intimately involved in the pathophysiology of visuospatial neglect.

Stroke patients often exhibit a disabling deficit of visual awareness in the hemifield opposite to their brain lesion, known as hemineglect. Recent studies with functional MRI (fMRI) suggest that hemineglect patients display abnormal functional coupling (i.e., connectivity) within and between brain hemispheres. However, since stroke is a vascular disorder and fMRI measures nonneuronal (i.e., vascular) coupling, we here provide direct evidence of neural network dysfunction in hemineglect by using electroencephalogram (EEG) source imaging, which measures the electrical fluctuations of large neuronal populations. Overall, we observed a breakdown of interhemispheric network connectivity within alpha/beta rhythms, which specifically correlated with the degree of patients’ hemispatial errors. The high temporal resolution and frequency content of EEG signals could lead to more sensitive markers and targeted rehabilitation approaches of hemineglect.

Contribution of the medial eye field network to the voluntary deployment of visuospatial attention

Historically, the study of patients with spatial neglect has provided fundamental insights into the neural basis of spatial attention. However, lesion mapping studies have been unsuccessful in establishing the potential role of associative networks spreading on the dorsal-medial axis, mainly because they are uncommonly targeted by vascular injuries. Here we combine machine learning-based lesion-symptom mapping, disconnection analyses and the longitudinal behavioral data of 128 patients with well-delineated surgical resections. The analyses show that surgical resections in a location compatible with both the supplementary and the cingulate eye fields, and disrupting the dorsal-medial fiber network, are specifically associated with severely diminished performance on a visual search task (i.e., visuo-motor exploratory neglect) with intact performance on a task probing the perceptual component of neglect. This general finding provides causal evidence for a role of the frontal-medial network in the voluntary deployment of visuo-spatial attention.

Excitatory-Inhibitory Homeostasis and Diaschisis: Tying the Local and Global Scales in the Post-stroke Cortex

Maintaining a balance between excitatory and inhibitory activity is an essential feature of neural networks of the neocortex. In the face of perturbations in the levels of excitation to cortical neurons, synapses adjust to maintain excitatory-inhibitory (EI) balance. In this review, we summarize research on this EI homeostasis in the neocortex, using stroke as our case study, and in particular the loss of excitation to distant cortical regions after focal lesions. Widespread changes following a localized lesion, a phenomenon known as diaschisis, are not only related to excitability, but also observed with respect to functional connectivity. Here, we highlight the main findings regarding the evolution of excitability and functional cortical networks during the process of post-stroke recovery, and how both are related to functional recovery. We show that cortical reorganization at a global scale can be explained from the perspective of EI homeostasis. Indeed, recovery of functional networks is paralleled by increases in excitability across the cortex. These adaptive changes likely result from plasticity mechanisms such as synaptic scaling and are linked to EI homeostasis, providing a possible target for future therapeutic strategies in the process of rehabilitation. In addition, we address the difficulty of simultaneously studying these multiscale processes by presenting recent advances in large-scale modeling of the human cortex in the contexts of stroke and EI homeostasis, suggesting computational modeling as a powerful tool to tie the meso- and macro-scale processes of recovery in stroke patients.

Resting-state Functional Connectivity After Occipital Stroke

BACKGROUND

Resting-state functional magnetic resonance imaging (rsfMRI) reflects spontaneous activation of cortical networks. After stroke, these networks reorganize, both due to structural lesion and reorganization of functional connectivity (FC).

OBJECTIVE

We studied FC in chronic phase occipital stroke patients with homonymous visual field defects before and after repetitive transorbital alternating current stimulation (rtACS).

METHODS

This spin-off study, embedded in the randomized, sham-controlled REVIS trial, comprised 16 chronic occipital stroke patients with visual field defect and 12 healthy control subjects. The patients underwent rsfMRI at baseline, after two weeks of rtACS or sham treatment, and after two months of treatment-free follow-up, whereas the control subjects were measured once. We used a multivariate regression connectivity model to determine mutual prediction accuracy between 74 cortical regions of interest. Additionally, the model parameters were included into a graph to analyze average path length, centrality eigenvector, centrality degree, and clustering of the network. The patients and controls at baseline and the two treatment groups were compared with multilevel modeling.

RESULTS

Before treatment, the patients and controls had similar whole-network prediction accuracy and network parameters, whereas centrality eigenvector differed in perilesional regions, indicating local modification in connectivity. In line with behavioral results, neither prediction accuracy nor any network parameter changed systematically as a result of rtACS rehabilitation compared to sham.

CONCLUSIONS

Whole-network FC showed no difference between occipital stroke patients and healthy population, congruent with the peripheral location of the visual network in relation to the high-density cortical core. rtACS treatment in the given setting did not affect FC.

Functional connectivity drives stroke recovery: shifting the paradigm from correlation to causation

Stroke is a leading cause of disability, with deficits encompassing multiple functional domains. The heterogeneity underlying stroke poses significant challenges in the prediction of post-stroke recovery, prompting the development of neuroimaging-based biomarkers. Structural neuroimaging measurements, particularly those reflecting corticospinal tract injury, are well-documented in the literature as potential biomarker candidates of post-stroke motor recovery. Consistent with the view of stroke as a 'circuitopathy', functional neuroimaging measures probing functional connectivity may also prove informative in post-stroke recovery. An important step in the development of biomarkers based on functional neural network connectivity is the establishment of causality between connectivity and post-stroke recovery. Current evidence predominantly involves statistical correlations between connectivity measures and post-stroke behavioral status, either cross-sectionally or serially over time. However, the advancement of functional connectivity application in stroke depends on devising experiments that infer causality. In 1965, Sir Austin Bradford Hill introduced nine viewpoints to consider when determining the causality of an association: [1] Strength, [2] Consistency [3] Specificity, [4] Temporality, [5] Biological gradient, [6] Plausibility, [7] Coherence, [8] Experiment, and [9] Analogy. Collectively referred to as the Bradford Hill Criteria, these points have been widely adopted in epidemiology. In this review, we assert the value of implementing Bradford Hill's framework to stroke rehabilitation and neuroimaging. We focus on the role of neural network connectivity measurements acquired from task-oriented and resting-state functional magnetic resonance imaging, electroencephalography, magnetoencephalography, and functional near-infrared spectroscopy in describing and predicting post-stroke behavioral status and recovery. We also identify research opportunities within each Bradford Hill tenet to shift the experimental paradigm from correlation to causation.

Cortical Hyper-Connectivity in a Stroke Patient with Rotated Drawing

In the present case report, we investigated the cortical networks of a patient (DDA) affected by right parietal stroke who showed a constructional phenomenon, in which when coping and recalling from memory a complex figure, the model was reproduced rotated of 90° along the vertical axis. Previous studies suggested that rotation on copy is associated with visuospatial impairments and abnormalities in parietal cortex, whereas rotation on recall might be related to executive deficits and dysfunction of frontal regions. Here, we computed the DDA's resting-state functional connectivity (FC) derived from cortical regions of the dorsal attention (DAN) and the frontal portion of the executive-control network (fECN), which are involved in the control of visuospatial attention and multiple executive functions, respectively. We observed that, as compared to a control group of right stroke patients without drawing rotation, DDA exhibited selective increased FC of the DAN and fECN, but not of task-irrelevant language network, within the undamaged hemisphere. These patterns might reflect a pathological communication in such networks leading to impaired attentional and executive operations required to reproduce the model in the correct orientation. Notably, such enhancement of FC was not detected in a patient with a comparable neuropsychological profile as DDA, yet without rotated drawing, suggesting that network-specific modulations in DDA might be ascribed to the constructional phenomenon of rotated drawing.

Theta-burst transcranial magnetic stimulation for the treatment of unilateral neglect in stroke patients: A systematic review and best evidence synthesis

BACKGROUND

Unilateral neglect (UN) is a common and disabling disorder after stroke. UN is a strong and negative predictor of functional rehabilitative outcome. Non-invasive brain stimulation, such as theta-burst transcranial magnetic stimulation (TBS), is a promising rehabilitation technique for treating stroke-induced UN.

OBJECTIVE

To systematically review the available literature, researching whether TBS of the contra-lesional hemisphere is more effective than standard rehabilitation in improving symptoms of UN in patients with right hemisphere stroke.

REVIEW METHODS

A systematic review was conducted to retrieve randomized controlled trials (RCTs) that were relevant to the objective of this review. PubMed, Ovid and Cochrane Library electronic databases were comprehensively searched from inception up to February 2021. Of the included studies, methodological quality was assessed using the PEDro scale, whereafter a best evidence synthesis (BES) was conducted to summarize the results.

RESULTS

Nine RCTs investigating the effects of TBS on stroke-induced UN symptoms were included in this review. Seven studies assessing continuous TBS (cTBS) found significantly greater amelioration of UN symptoms in the TBS intervention group when compared to the control group; one study assessing cTBS found no such significant difference. One study assessing intermittent TBS (iTBS) found significant between-group differences in favor of the intervention. The BES yielded strong evidence in favor of cTBS, and limited evidence in favor of iTBS.

CONCLUSIONS

The included studies in the present review allow the conclusion that TBS can have favorable effects on UN recovery in stroke patients. Its clinical use is recommended in conjunction with cognitive rehabilitation and occupational or physical rehabilitation as needed. However, many aspects for optimal usage of TBS therapy in clinical settings, such as exact TBS protocols, number of sessions, and treatment duration, are not clear.

A novel stroke lesion network mapping approach: improved accuracy yet still low deficit prediction

Lesion network mapping estimates functional network abnormalities caused by a focal brain lesion. The method requires embedding the volume of the lesion into a normative functional connectome and using the average functional magnetic resonance imaging signal from that volume to compute the temporal correlation with all other brain locations. Lesion network mapping yields a map of potentially functionally disconnected regions. Although promising, this approach does not predict behavioural deficits well. We modified lesion network mapping by using the first principal component of the functional magnetic resonance imaging signal computed from the voxels within the lesioned area for temporal correlation. We measured potential improvements in connectivity strength, anatomical specificity of the lesioned network and behavioural prediction in a large cohort of first-time stroke patients at 2-weeks post-injury (n = 123). This principal component functional disconnection approach localized mainly cortical voxels of high signal-to-noise; and it yielded networks with higher anatomical specificity, and stronger behavioural correlation than the standard method. However, when examined with a rigorous leave-one-out machine learning approach, principal component functional disconnection approach did not perform better than the standard lesion network mapping in predicting neurological deficits. In summary, even though our novel method improves the specificity of disconnected networks and correlates with behavioural deficits post-stroke, it does not improve clinical prediction. Further work is needed to capture the complex adjustment of functional networks produced by focal damage in relation to behaviour.

Spectral signature of attentional reorienting in the human brain

As we move in the environment, attention shifts to novel objects of interest based on either their sensory salience or behavioral value (reorienting). This study measures with magnetoencephalography (MEG) different properties (amplitude, onset-to-peak duration) of event-related desynchronization/synchronization (ERD/ERS) of oscillatory activity during a visuospatial attention task designed to separate activity related to reorienting vs. maintaining attention to the same location, controlling for target detection and response processes. The oscillatory activity was measured both in fMRI-defined regions of interest (ROIs) of the dorsal attention (DAN) and visual (VIS) networks, previously defined as task-relevant in the same subjects, or whole-brain in a pre-defined set of cortical ROIs encompassing the main brain networks. Reorienting attention (shift cues) as compared to maintaining attention (stay cues) produced a temporal sequence of ERD/ERS modulations at multiple frequencies in specific anatomical regions/networks. An early (∼330 ms), stronger, transient theta ERS occurred in task-relevant (DAN, VIS) and control networks (VAN, CON, FPN), possibly reflecting an alert/reset signal in response to the cue. A more sustained, behaviorally relevant, low-beta band ERD peaking ∼450 ms following shift cues (∼410 for stay cues) localized in frontal and parietal regions of the DAN. This modulation is consistent with a control signal re-routing information across visual hemifields. Contralateral vs. ipsilateral shift cues produced in occipital visual regions a stronger, sustained alpha ERD (peak ∼470 ms) and a longer, transient high beta/gamma ERS (peak ∼490 ms) related to preparatory visual modulations in advance of target occurrence. This is the first description of a cascade of oscillatory processes during attentional reorienting in specific anatomical regions and networks. Among these processes, a behaviorally relevant beta desynchronization in the FEF is likely associated with the control of attention shifts.

Neural Mechanisms of Prism Adaptation in Healthy Adults and Individuals with Spatial Neglect after Unilateral Stroke: A Review of fMRI Studies

Functional disability due to spatial neglect hinders recovery in up to 30% of stroke survivors. Prism adaptation treatment (PAT) may alleviate the disabling consequences of spatial neglect, but we do not yet know why some individuals show much better outcomes following PAT than others. The goal of this scoping review and meta-analysis was to investigate the neural mechanisms underlying prism adaptation (PA). We conducted both quantitative and qualitative analyses across fMRI studies investigating brain activity before, during, and after PA, in healthy individuals and patients with right or left brain damage (RBD or LBD) due to stroke. In healthy adults, PA was linked with activity in posterior parietal and cerebellar clusters, reduced bilateral parieto-frontal connectivity, and increased fronto-limbic and sensorimotor network connectivity. In contrast, RBD individuals with spatial neglect relied on different circuits, including an activity cluster in the intact left occipital cortex. This finding is consistent with a shift in hemispheric dominance in spatial processing to the left hemisphere. However, more studies are needed to clarify the contribution of lesion location and load on the circuits involved in PA after unilateral brain damage. Future studies are also needed to clarify the relationship of decreasing resting state functional connectivity (rsFC) to visuomotor function.

Effective connectivity extracts clinically relevant prognostic information from resting state activity in stroke

Recent resting-state functional MRI studies in stroke patients have identified two robust biomarkers of acute brain dysfunction: a reduction of inter-hemispheric functional connectivity between homotopic regions of the same network, and an abnormal increase of ipsi-lesional functional connectivity between task-negative and task-positive resting-state networks. Whole-brain computational modelling studies, at the individual subject level, using undirected effective connectivity derived from empirically measured functional connectivity, have shown a reduction of measures of integration and segregation in stroke as compared to healthy brains. Here we employ a novel method, first, to infer whole-brain directional effective connectivity from zero-lagged and lagged covariance matrices, then, to compare it to empirically measured functional connectivity for predicting stroke versus healthy status, and patient performance (zero, one, multiple deficits) across neuropsychological tests. We also investigated the accuracy of functional connectivity versus model effective connectivity in predicting the long-term outcome from acute measures. Both functional and effective connectivity predicted healthy from stroke individuals significantly better than the chance-level; however, accuracy for the effective connectivity was significantly higher than for functional connectivity at 1- to 2-week, 3-month and 1-year post-stroke. Predictive functional connections mainly included those reported in previous studies (within-network inter-hemispheric and between task-positive and -negative networks intra-hemispherically). Predictive effective connections included additional between-network links. Effective connectivity was a better predictor than functional connectivity of the number of behavioural domains in which patients suffered deficits, both at 2-week and 1-year post-onset of stroke. Interestingly, patient deficits at 1-year time-point were better predicted by effective connectivity values at 2 weeks rather than at 1-year time-point. Our results thus demonstrate that the second-order statistics of functional MRI resting-state activity at an early stage of stroke, derived from a whole-brain effective connectivity, estimated in a model fitted to reproduce the propagation of neuronal activity, has pertinent information for clinical prognosis.

Frontal and parietal background connectivity and their dynamic changes account for individual differences in the multisensory representation of peripersonal space

Functional connectivity (FC) of brain networks dynamically fluctuates during both rest and task execution. Individual differences in dynamic FC have been associated with several cognitive and behavioral traits. However, whether dynamic FC also contributes to sensorimotor representations guiding body-environment interactions, such as the representation of peripersonal space (PPS), is currently unknown. PPS is the space immediately surrounding the body and acts as a multisensory interface between the individual and the environment. We used an audio-tactile task with approaching sounds to map the individual PPS extension, and fMRI to estimate the background FC. Specifically, we analyzed FC values for each stimulus type (near and far space) and its across-trial variability. FC was evaluated between task-relevant nodes of two fronto-parietal networks (the Dorsal Attention Network, DAN, and the Fronto-Parietal Network, FPN) and a key PPS region in the premotor cortex (PM). PM was significantly connected to specific task-relevant nodes of the DAN and the FPN during the audio-tactile task, and FC was stronger while processing near space, as compared to far space. At the individual level, less PPS extension was associated with stronger premotor-parietal FC during processing of near space, while the across-trial variability of premotor-parietal and premotor-frontal FC was higher during the processing of far space. Notably, only across-trial FC variability captured the near-far modulation of space processing. Our findings indicate that PM connectivity with task-relevant frontal and parietal regions and its dynamic changes participate in the mechanisms that enable PPS representation, in agreement with the idea that neural variability plays a crucial role in plastic and dynamic sensorimotor representations.

Stroke-related alterations in inter-areal communication

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We used covariance-based Granger Causality on resting-state fMRI of stroke patients.

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Stroke determines an overall decrease of homotopic Granger causality (GC)

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Stroke determines a decrease of GC from and within the lesioned hemisphere.

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Stroke causes imbalances in GC between the lesioned and the healthy hemisphere.

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GC anomalies correlate with impaired performance in several behavioral domains.

Beyond causing local ischemia and cell damage at the site of injury, stroke strongly affects long-range anatomical connections, perturbing the functional organization of brain networks. Several studies reported functional connectivity abnormalities parallelling both behavioral deficits and functional recovery across different cognitive domains. FC alterations suggest that long-range communication in the brain is altered after stroke. However, standard FC analyses cannot reveal the directionality and time scale of inter-areal information transfer. We used resting-state fMRI and covariance-based Granger causality analysis to quantify network-level information transfer and its alteration in stroke. Two main large-scale anomalies were observed in stroke patients. First, inter-hemispheric information transfer was significantly decreased with respect to healthy controls. Second, stroke caused inter-hemispheric asymmetries, as information transfer within the affected hemisphere and from the affected to the intact hemisphere was significantly reduced. Both anomalies were more prominent in resting-state networks related to attention and language, and they correlated with impaired performance in several behavioral domains. Overall, our findings support the hypothesis that stroke provokes asymmetries between the affected and spared hemisphere, with different functional consequences depending on which hemisphere is lesioned.

Migraine in Multiple Sclerosis Patients Affects Functional Connectivity of the Brain Circuitry Involved in Pain Processing

Migraine is particularly common in patients with multiple sclerosis (MS) and has been linked to the dysfunction of the brain circuitry modulating the peripheral nociceptive stimuli. Using MRI, we explored whether changes in the resting state-functional connectivity (RS-FC) may characterize the occurrence of migraine in patients with MS. The RS-FC characteristics in concerned brain regions were explored in 20 MS patients with migraine (MS+M) during the interictal phase, and compared with 19 MS patients without migraine (MS-M), which served as a control group. Functional differences were correlated to the frequency and severity of previous migraine attacks, and with the resulting impact on daily activities. In MS+M, the loss of periaqueductal gray matter (PAG) positive connectivity with the default mode network and the left posterior cranial pons was associated with an increase of migraine attacks frequency. In contrast, the loss of PAG negative connectivity with sensorimotor and visual network was linked to migraine symptom severity and related daily activities impact. Finally, a PAG negative connection was established with the prefrontal executive control network. Migraine in MS+M patients and its impact on daily activities, underlies RS-FC rearrangements between brain regions involved in pain perception and modulation.

Effect of Stroke on Contralateral Functional Connectivity

Introduction: Stroke can induce large-scale functional reorganization of the brain; however, the spatial patterns of this reorganization remain largely unknown. Methods: Using a large (N = 116) sample of participants who were in the chronic stages of stroke, we present a systematic study of the association between brain damage and functional connectivity (FC) within the intact hemisphere. We computed correlations between regional cortical damage and contralateral FC. Results: We identified left-hemisphere regions that had the most pronounced effect on the right-hemisphere FC, and, conversely, right-hemisphere connections where the effect of damage was particularly strong. Notably, the vast majority of significant correlations were positive: damage was associated with an increase in regional contralateral connectivity. Discussion: These findings lend evidence of the reorganization of contralateral cortical networks as a response to brain damage, which is more pronounced in a set of well-connected regions where connectivity increases with the amount of damage.

Distinct effects of prematurity on MRI metrics of brain functional connectivity, activity, and structure: Univariate and multivariate analyses

Premature birth affects the developmental trajectory of the brain during a period of intense maturation with possible lifelong consequences. To better understand the effect of prematurity on brain structure and function, we performed blood‐oxygen‐level dependent (BOLD) and anatomical magnetic resonance imaging (MRI) at 40 weeks of postmenstrual age on 88 newborns with variable gestational age (GA) at birth and no evident radiological alterations. We extracted measures of resting‐state functional connectivity and activity in a set of 90 cortical and subcortical brain regions through the evaluation of BOLD correlations between regions and of fractional amplitude of low‐frequency fluctuation (fALFF) within regions, respectively. Anatomical information was acquired through the assessment of regional volumes. We performed univariate analyses on each metric to examine the association with GA at birth, the spatial distribution of the effects, and the consistency across metrics. Moreover, a data‐driven multivariate analysis (i.e., Machine Learning) framework exploited the high dimensionality of the data to assess the sensitivity of each metric to the effect of premature birth. Prematurity was associated with bidirectional alterations of functional connectivity and regional volume and, to a lesser extent, of fALFF. Notably, the effects of prematurity on functional connectivity were spatially diffuse, mainly within cortical regions, whereas effects on regional volume and fALFF were more focal, involving subcortical structures. While the two analytical approaches delivered consistent results, the multivariate analysis was more sensitive in capturing the complex pattern of prematurity effects. Future studies might apply multivariate frameworks to identify premature infants at risk of a negative neurodevelopmental outcome.

Early parietofrontal network upregulation relates to future persistent deficits after severe stroke-a prospective cohort study

Recent brain imaging has evidenced that parietofrontal networks show alterations after stroke which also relate to motor recovery processes. There is converging evidence for an upregulation of parietofrontal coupling between parietal brain regions and frontal motor cortices. The majority of studies though have included only moderately to mildly affected patients, particularly in the subacute or chronic stage. Whether these network alterations will also be present in severely affected patients and early after stroke and whether such information can improve correlative models to infer motor recovery remains unclear. In this prospective cohort study, 19 severely affected first-ever stroke patients (mean age 74 years, 12 females) were analysed which underwent resting-state functional MRI and clinical testing during the initial week after the event. Clinical evaluation of neurological and motor impairment as well as global disability was repeated after three and six months. Nineteen healthy participants of similar age and gender were also recruited. MRI data were used to calculate functional connectivity values between the ipsilesional primary motor cortex, the ventral premotor cortex, the supplementary motor area and the anterior and caudal intraparietal sulcus of the ipsilesional hemisphere. Linear regression models were estimated to compare parietofrontal functional connectivity between stroke patients and healthy controls and to relate them to motor recovery. The main finding was a significant increase in ipsilesional parietofrontal coupling between anterior intraparietal sulcus and the primary motor cortex in severely affected stroke patients (P < 0.003). This upregulation significantly contributed to correlative models explaining variability in subsequent neurological and global disability as quantified by National Institute of Health Stroke Scale and modified Rankin Scale, respectively. Patients with increased parietofrontal coupling in the acute stage showed higher levels of persistent deficits in the late subacute stage of recovery (P < 0.05). This study provides novel insights that parietofrontal networks of the ipsilesional hemisphere undergo neuroplastic alteration already very early after severe motor stroke. The association between early parietofrontal upregulation and future levels of persistent functional deficits and dependence from help in daily living might be useful in models to enhance clinical neurorehabilitative decision making.

Temporal modes of hub synchronization at rest

The brain is a dynamic system that generates a broad repertoire of perceptual, motor, and cognitive states by the integration and segregation of different functional domains represented in large-scale brain networks. However, the fundamental mechanisms underlying brain network integration remain elusive. Here, for the first time to our knowledge, we found that in the resting state the brain visits few synchronization modes defined as clusters of temporally aligned functional hubs. These modes alternate over time and their probability of switching leads to specific temporal loops among them. Notably, although each mode involves a small set of nodes, the brain integration seems highly vulnerable to a simulated attack on this temporal synchronization mechanism. In line with the hypothesis that the resting state represents a prior sculpted by the task activity, the observed synchronization modes might be interpreted as a temporal brain template needed to respond to task/environmental demands .