Segregating Semantic from Phonological Processes during Reading

A number of previous functional neuroimaging studies have linked activation of the left inferior frontal gyms with semantic processing, yet damage to the frontal lobes does not critically impair semantic knowledge. This study distinguishes between semantic knowledge and the strategic processes required to make verbal decisions. Using positron emission tomography (PET), we identify the neural correlates of semantic knowledge by contrasting semantic decision on visually presented words to phonological decision on the same words. Both tasks involve identical stimuli and a verbal decision on central lingual codes (semantics and phonology), but the explicit task demands directed attention either to meaning or to the segmentation of phonology. Relative to the phonological task, the semantic task was associated with activations in left extrasylvian temporal cortex with the highest activity in the left temporal pole and a posterior region of the left middle temporal cortex (BA 39) close to the angular gyrus. The reverse contrast showed increased activity in both supramarginal gyri, the left precentral sulcus, and the cuneus with a trend toward enhanced activation in the inferior frontal cortex. These results fit well with neuropsychological evidence, associating semantic knowledge with the extrasylvian left temporal cortex and the segmentation of phonology with the perisylvian cortex.

The planning and guiding of reading saccades: a repetitive transcranial magnetic stimulation study

A previous positron emission tomography study that investigated the cortical areas involved in directing eye movements during text reading showed two areas of extra-occipital asymmetry: left > right posterior parietal cortex (PPC), and right > left frontal eye-field (FEF). We used the temporal resolution of repetitive TMS (rTMS) to isolate the contributions of the left and right PPC and FEF to the planning and execution of rightward reading saccades. We present eye-movement data collected during text reading, which involves the initiation and maintenance of a series of saccades (scanpath). rTMS over the left but not right PPC slowed reading speeds for the whole array of words, indicating that this area is involved throughout the scanpath. rTMS over the right but not the left FEF slowed the time to make the first saccade, but only when triggered before the stimuli appeared, demonstrating that the role of this region is in the preparation of the scanpath. Our results are compatible with the hypotheses that the left PPC maintains reading saccades along a line of text while the right FEF is involved in the preparation of the motor plan for the scanpath at the start of each new line of text.

The functional anatomy of single-word reading in patients with hemianopic and pure alexia

We investigated single-word reading in normal subjects and patients with alexia following a left occipital infarct, using PET. The most posterior brain region to show a lateralized response was at the left occipitotemporal junction, in the inferior temporal gyrus. This region was activated when normal subjects, patients with hemianopic alexia and patients with an incomplete right homonymous hemianopia, but no reading deficit, viewed single words presented at increasing rates. This same area was damaged in a patient with pure alexia ("alexia without agraphia") and no hemianopia, who read words slowly using a letter-by-letter strategy. Although the exact level of the functional deficit is controversial, pure alexia is the result of an inability to map a percept of all the letters in a familiar letter string on to the mental representation of the whole word form. However, the commonest deficit associated with "pure" alexia is a right homonymous field defect; an impairment that may, by itself, interfere with single-word reading because of inability to see the letters towards the end of a word. The relative contributions of pure and hemianopic alexia in individual patients needs to be assessed, as the latter has been shown to respond well to specific rehabilitation programmes.

Separate neural subsystems within 'Wernicke's area'

Over time, both the functional and anatomical boundaries of 'Wernicke's area' have become so broad as to be meaningless. We have re-analysed four functional neuroimaging (PET) studies, three previously published and one unpublished, to identify anatomically separable, functional subsystems in the left superior temporal cortex posterior to primary auditory cortex. From the results we identified a posterior stream of auditory processing. One part, directed along the supratemporal cortical plane, responded to both non-speech and speech sounds, including the sound of the speaker's own voice. Activity in its most posterior and medial part, at the junction with the inferior parietal lobe, was linked to speech production rather than perception. The second, more lateral and ventral part lay in the posterior left superior temporal sulcus, a region that responded to an external source of speech. In addition, this region was activated by the recall of lists of words during verbal fluency tasks. The results are compatible with an hypothesis that the posterior superior temporal cortex is specialized for processes involved in the mimicry of sounds, including repetition, the specific role of the posterior left superior temporal sulcus being to transiently represent phonetic sequences, whether heard or internally generated and rehearsed. These processes are central to the acquisition of long- term lexical memories of novel words.

Identification of a pathway for intelligible speech in the left temporal lobe

It has been proposed that the identification of sounds, including species-specific vocalizations, by primates depends on anterior projections from the primary auditory cortex, an auditory pathway analogous to the ventral route proposed for the visual identification of objects. We have identified a similar route in the human for understanding intelligible speech. Using PET imaging to identify separable neural subsystems within the human auditory cortex, we used a variety of speech and speech-like stimuli with equivalent acoustic complexity but varying intelligibility. We have demonstrated that the left superior temporal sulcus responds to the presence of phonetic information, but its anterior part only responds if the stimulus is also intelligible. This novel observation demonstrates a left anterior temporal pathway for speech comprehension.

Statistical modeling of positron emission tomography images in wavelet space

A new method is introduced for the analysis of multiple studies measured with emission tomography. Traditional models of statistical analysis (ANOVA, ANCOVA and other linear models) are applied not directly on images but on their correspondent wavelet transforms. Maps of model effects estimated from these models are filtered using a thresholding procedure based on a simple Bonferroni correction and then reconstructed. This procedure inherently represents a complete modeling approach and therefore obtains estimates of the effects of interest (condition effect, difference between conditions, covariate of interest, and so on) under the specified statistical risk. By performing the statistical modeling step in wavelet space. the procedure allows the direct estimation of the error for each wavelet coefficient; hence, the local noise characteristics are accounted for in the subsequent filtering. The method was validated by use of a null dataset and then applied to typical examples of neuroimaging studies to highlight conceptual and practical differences from existing statistical parametric mapping approaches.

Noun imageability and the temporal lobes

We used positron emission tomography to investigate brain activity in response to hearing or reading nouns of varying imageability. Three experiments were performed. Activity increased with noun imageability in the left mid-fusiform gyrus, the lateral parahippocampal area in humans, and in the rostral medial temporal lobes close to or within perirhinal cortex. The left mid-fusiform activation has been observed in previous imaging studies of single word processing. Its functional significance was variously attributed to semantic processing, visual imagery, encoding episodic memories, or the integration of lexical inputs from different sensory modalities. These hypotheses are not mutually exclusive. The more rostral medial lobe response to noun imageability has not been observed previously. However, lesions in perirhinal cortex impair knowledge about objects in non-human primates, and bilateral rostral ventromedial temporal lobe potentials in response to object nouns were observed with human intracranial recordings. Imageable (object) nouns are learnt with reference to sensory experiences of living and non-living objects, whereas acquisition of the meaning of low imageable (abstract) nouns is more dependent on their context within sentences. Parahippocampal and perirhinal cortices are reciprocally connected with, respectively, second and third order sensory association cortices. We conclude that access to the representations of word meaning is dependent on heteromodal temporal lobe cortex, and that during the acquisition of object nouns one route is established through ventromedial temporal cortical regions that have reciprocal connections with all sensory association cortices.

Breathlessness in humans activates insular cortex

Dyspnea (shortness of breath, breathlessness) is a major and disabling symptom of heart and lung disease. The representation of dyspnea in the cerebral cortex is unknown. In the first study designed to explore the central neural structures underlying perception of dyspnea, we evoked the perception of severe 'air hunger' in healthy subjects by restraining ventilation below spontaneous levels while holding arterial oxygen and carbon dioxide levels constant. PET revealed that air hunger activated the insular cortex. The insula is a limbic structure also activated by visceral stimuli, temperature, taste, nausea and pain. Like dyspnea, such perceptions underlie behaviors essential to homeostasis and survival.

First report of an intravenous and oral glycoprotein IIb/IIIa inhibitor (RPR 109891) in patients with recent acute coronary syndromes: results of the TIMI 15A and 15B trials

BACKGROUND

RPR 109891 is a modified tetrapeptide glycoprotein IIb/IIIa inhibitor available in intravenous and oral formulations. Two phase II dose-ranging studies were performed to investigate pharmacodynamics and safety in acute coronary syndromes.

METHODS

The Thrombolysis In Myocardial Infarction (TIMI) 15A trial was a randomized, open-label, study of RPR 109891 administered intravenously for 24 to 96 hours in 91 patients. TIMI 15B was a randomized, double-blind comparison of intravenous RPR 109891 plus 4 weeks of oral RPR 109891 (n = 142) compared with placebo (n = 50).

RESULTS

Intravenous RPR 109891 exhibited a dose-response inhibition of platelet aggregation; mean inhibition after a bolus ranged from 53% to 92%, and at steady state 49% to 98%. Oral RPR 109891 demonstrated less platelet inhibition (peaks, range 48% to 59%; troughs, range 18% to 39%). Mean glycoprotein IIb/IIIa receptor occupancy and platelet inhibition were highly correlated (r = 0.82, 95% confidence interval 0.74-0.88). There were trends for increased major hemorrhage (10% vs 6%, P =.57), thrombocytopenia <90,000 cells/mm(3) (13% vs 4%, P =.11), and profound thrombocytopenia <20, 000 (3.5% vs 0%, P =.33) with intravenous plus oral RPR 109891 compared with placebo. In 3 of 5 cases of profound thrombocytopenia, RPR 109891 had been interrupted because of bypass surgery, and a precipitous fall in platelet count occurred after the first postoperative oral dose.

CONCLUSIONS

Intravenous RPR 109891 is a potent, predictable, dose-related platelet inhibitor. Oral RPR 109891 (</=600 mg/d) achieves moderate platelet inhibition. Interrupted glycoprotein IIb/IIIa blockade may be associated with a higher risk of profound thrombocytopenia and deserves closer examination in future studies.

A thalamo-prefrontal system for representation in executive response choice

This study demonstrates the neural system potentially involved in the representation of, and choice between, stimulus classifications in an ambiguous, novel, decision-making task. This difficult choice behaviour is taken as an example of a basic executive processing task. Subjects heard sounds that were consonant-vowel combinations that had been distorted and were required to categorize each stimulus as speech-like or not-speech-like. Cerebral activity was measured with positron emission tomography. A neural system (thalamic and medial prefrontal cortical regions) was demonstrated; there was greater activity involved in assigning the sound to the larger class of not-speech-like sounds than to the more restricted category of speech-like sounds. We interpret this activity as reflecting process and representation in a simple central executive task.

Impaired reading in patients with right hemianopia

A left occipital stroke may result in alexia for two reasons, which may coexist depending on the distribution of the lesion. A lesion of the left lateroventral prestriate cortex or its afferents impairs word recognition ("pure" alexia). If the left primary visual cortex or its afferents are destroyed, resulting in a complete right homonymous hemianopia, rightward saccades during text reading are disrupted ("hemianopic" alexia). By using functional imaging, we showed two separate but interdependent systems involved in reading. The first, subserving word recognition, involved the representation of foveal vision in the left and right primary visual cortex and the ventral prestriate cortex. The second system, responsible for the planning and execution of reading saccades, consisted of the representation of right parafoveal vision in the left visual cortex, the bilateral posterior parietal cortex (left > right), and the frontal eye fields (right > left). Disruption of this distributed neural system was demonstrated in patients with severe right homonymous hemianopia, commensurate with their inability to perform normal reading eye movements. Text reading, before processes involved in comprehension, requires the integration of perceptual and motor processes. We have demonstrated these distributed neural systems in normal readers and have shown how a right homonymous hemianopia disrupts the motor preparation of reading saccades during text reading.

Functional neuroimaging of speech perception in six normal and two aphasic subjects

This positron emission tomography study used a correlational design to investigate neural activity during speech perception in six normal subjects and two aphasic patients. The normal subjects listened either to speech or to signal-correlated noise equivalents; the latter were nonspeech stimuli, similar to speech in complexity but not perceived as speechlike. Regions common to the auditory processing of both types of stimuli were dissociated from those specific to spoken words. Increasing rates of presentation of both speech and nonspeech correlated with cerebral activity in bilateral transverse gyri and adjacent superior temporal cortex. Correlations specific to speech stimuli were located more anteriorly in both superior temporal sulci. The only asymmetry in normal subjects was a left lateralized response to speech in the posterior superior temporal sulcus, corresponding closely to structural asymmetry on the subjects' magnetic resonance images. Two patients, who had left temporal infarction but performed well on single word comprehension tasks, were also scanned while listening to speech. These cases showed right superior temporal activity correlating with increasing rates of hearing speech, but no significant left temporal activation. These findings together suggest that the dorsolateral temporal cortex of both hemispheres can be involved in prelexical processing of speech.

Long-term cure of the photosensitivity of murine erythropoietic protoporphyria by preselective gene therapy

Definitive cure of an animal model of a human disease by gene transfer into hematopoietic stem cells has not yet been accomplished in the absence of spontaneous in vivo selection for transduced cells. Erythropoietic protoporphyria is a genetic disease in which ferrochelatase is defective. Protoporphyrin accumulates in erythrocytes, leaks into the plasma and results in severe skin photosensitivity. Using a mouse model of erythropoietic protoporphyria, we demonstrate here that ex vivo preselection of hematopoietic stem cells transduced with a polycistronic retrovirus expressing both human ferrochelatase and green fluorescent protein results in complete and long-term correction of skin photosensitivity in all transplanted mice.

Collagen-bound von Willebrand factor has reduced affinity for factor VIII

von Willebrand factor (vWf) is a multimeric adhesive glycoprotein that serves as a carrier for factor VIII in plasma. Although each vWf subunit displays a high affinity binding site for factor VIII in vitro, in plasma, only 2% of the vWf sites for factor VIII are occupied. We investigated whether interaction of plasma proteins with vWf or adhesion of vWf to collagen may alter the affinity or availability of factor VIII-binding sites on vWf. When vWf was immobilized on agarose-linked monoclonal antibody, factor VIII bound to vWf with high affinity, and neither the affinity nor binding site availability was influenced by the presence of 50% plasma. Therefore, plasma proteins do not alter the affinity or availability of factor VIII-binding sites. In contrast, when vWf was immobilized on agarose-linked collagen, its affinity for factor VIII was reduced 4-fold, with KD increasing from 0.9 to 3.8 nM. However, one factor VIII-binding site remained available on each vWf subunit. A comparable reduction in affinity for factor VIII was observed when vWf was a constituent of the subendothelial cell matrix and when it was bound to purified type VI collagen. In parallel with the decreased affinity for factor VIII, collagen-bound vWf displayed a 6-fold lower affinity for monoclonal antibody W5-6A, with an epitope composed of residues 78-96 within the factor VIII-binding motif of vWf. We conclude that collagen induces a conformational change within the factor VIII-binding motif of vWf that lowers the affinity for factor VIII.

Beyond JCAHO: using competency models to improve healthcare organizations. Part I

In 1996 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) required hospitals to assess, prove, track, and improve the competence of all employees. Part 1 of this two-part series discusses competencies, their assessment, and the implications of meeting and going beyond JCAHO's requirements. Part 2, which will appear in the next issue of Hospital Topics, provides specific guidelines for the development of a competence assessment system and its practical application.

Beyond JCAHO: using competency models to change healthcare organizations. Part 2: Developing competence assessment systems

In 1996, JCAHO required hospitals to assess, prove, track, and improve the competence of all employees. This article is the second part of a review of the concept of competency assessment and the implications of meeting and exceeding the JCAHO standards. Part 1 (in the previous issue of Hospital Topics) provided the theory of competence assessment, the current situation in JCAHO surveys, and an overview of the problems inherent in competency assessment. This part puts competence assessment in the context of quality improvement and provides the details of developing competence assessment systems.

Brain regions involved in articulation

BACKGROUND

The left inferior frontal gyrus (Broca's area) is generally believed to be critical for the motor act of speech. A lesion-based analysis has, however, shown that the left anterior insula is necessary for accurate articulation. We used functional imaging in normal people to show the neural systems involved in speech during different speech tasks.

METHODS

12 normal people underwent positron emission tomography with oxygen-15-labelled water as tracer. We measured cerebral activity while participants performed three different tasks: repetition of heard nouns at different rates; listening to single nouns at different rates; and anticipation of listening or repetition. We analysed the data with imaging software.

FINDINGS

Repetition of single words did not activate Broca's area but activity in three left-lateralised regions was seen: the anterior insula, a localised region in the lateral premotor cortex, and the posterior pallidum. The left anterior insula and lateral premotor cortex showed a conjunction of activity for hearing and articulation. In addition, articulation modulated the response to hearing words in the left dorsolateral temporal cortex, the physiological expression of the speaker's auditory attention being directed towards the stimuli and not his or her articulated responses.

INTERPRETATION

The formulation of an articulatory plan is a function of the left anterior insula and lateral premotor cortex and not of Broca's area. The left basal ganglia seem to be dominant for speech, although the axial muscles involved receive their motor output from both cerebral hemispheres.

Mechanisms of recovery from aphasia: evidence from positron emission tomography studies

OBJECTIVES

Language functions comprise a distributed neural system, largely lateralised to the left cerebral hemisphere. Late recovery from aphasia after a focal lesion, other than by behavioural strategies, has been attributed to one of two changes at a systems level: a laterality shift, with mirror region cortex in the contralateral cortex assuming the function(s) of the damaged region; or a partial lesion effect, with recovery of perilesional tissue to support impaired language functions. Functional neuroimaging with PET allows direct observations of brain functions at systems level. This study used PET to compare regional brain activations in response to a word retrieval task in normal subjects and in aphasic patients who had shown at least some recovery and were able to attempt the task. Emphasis has been placed on single subject analysis of the results as there is no reason to assume that the mechanisms of recovery are necessarily uniform among aphasic patients.

METHODS

Six right handed aphasic patients, each with a left cerebral hemispheric lesion (five strokes and one glioma), were studied. Criteria for inclusion were symptomatic or formal test evidence of at least some recovery and an ability to attempt word retrieval in response to heard word cues. Each patient underwent 12 PET scans using oxygen-15 labelled water (H2(15)O) as tracer to index regional cerebral blood flow (rCBF). The task, repeated six times, required the patient to think of verbs appropriate to different lists of heard noun cues. The six scans obtained during word retrieval were contrasted with six made while the subject was "at rest". The patients' individual results were compared with those of nine right handed normal volunteers undergoing the same activation study. The data were analysed using statistical parametric mapping (SPM96, Wellcome Department of Cognitive Neurology, London, UK).

RESULTS

Perception of the noun cues would be expected to result in bilateral dorsolateral temporal cortical activations, but as the rate of presentation was only four per minute the auditory perceptual activations were not evident in all people. Anterior cingulate, medial premotor (supplementary speech area) and dorsolateral frontal activations were evident in all normal subjects and patients. There were limited right dorsolateral frontal activations in three of the six patients, but a similar pattern was also found in four of the nine normal subjects. In the left inferolateral temporal cortex, activation was found for the normal subjects and five of the six patients, including two of the three subjects with lesions involving the left temporal lobe. The only patient who showed subthreshold activation in the left inferolateral temporal activation had a very high error rate when performing the verb retrieval task.

CONCLUSIONS

The normal subjects showed a left lateralised inferolateral temporal activation, reflecting retrieval of words appropriate in meaning to the cue from the semantic system. Lateralisation of frontal activations to the left was only relative, with right prefrontal involvement in half of the normal subjects. Frontal activations are associated with parallel psychological processes involved in word retrieval, including task initiation, short term (working) memory for the cue and responses, and prearticulatory processes (even though no overt articulation was required). There was little evidence of a laterality shift of word retrieval functions to the right temporal lobe after a left hemispheric lesion. In particular, left inferolateral temporal activation was seen in all patients except one, and he proved to be very inefficient at the task. The results provide indirect evidence that even limited salvage of peri-infarct tissue with acute stroke treatments will have an important impact on the rehabilitation of cognitive functions.

Disrupted temporal lobe connections in semantic dementia

Semantic dementia refers to the variant of frontotemporal dementia in which there is progressive semantic deterioration and anomia in the face of relative preservation of other language and cognitive functions. Structural imaging and SPECT studies of such patients have suggested that the site of damage, and by inference the region critical to semantic processing, is the anterolateral temporal lobe, especially on the left. Recent functional imaging studies of normal participants have revealed a network of areas involved in semantic tasks. The present study used PET to examine the consequences of focal damage to the anterolateral temporal cortex for the operation of this semantic network. We measured PET activation associated with a semantic decision task relative to a visual decision task in four patients with semantic dementia compared with six age-matched normal controls. Normals activated a network of regions consistent with previous studies. The patients activated some areas consistently with the normals, including some regions of significant atrophy, but showed substantially reduced activity particularly in the left posterior inferior temporal gyrus (iTG) (Brodmann area 37/19). Voxel-based morphometry, used to identify the regions of structural deficit, revealed significant anterolateral temporal atrophy (especially on the left), but no significant structural damage to the posterior inferior temporal lobe. Other evidence suggests that the left posterior iTG is critically involved in lexical-phonological retrieval: the lack of activation here is consistent with the observation that these patients are all anomic. We conclude that changes in activity in regions distant from the patients' structural damage support the argument that their prominent anomia is due to disrupted temporal lobe connections.

Binding of factor VIII to von willebrand factor is enabled by cleavage of the von Willebrand factor propeptide and enhanced by formation of disulfide-linked multimers

von Willebrand factor (vWF) is a multimeric adhesive glycoprotein with one factor VIII binding site/subunit. Prior reports suggest that posttranslational modifications of vWF, including formation of N-terminal intersubunit disulfide bonds and subsequent cleavage of the propeptide, influence availability and/or affinity of factor VIII binding sites. We found that deletion of the vWF propeptide produced a dimeric vWF molecule lacking N-terminal intersubunit disulfide bonds. This molecule bound fluorescein-labeled factor VIII with sixfold lower affinity than multimeric vWF in an equilibrium flow cytometry assay (approximate KDs, 5 nmol/L v 0.9 nmol/L). Coexpression of propeptide-deleted vWF with the vWF propeptide in trans yielded multimeric vWF that displayed increased affinity for factor VIII. Insertion of an alanine residue at the N-terminus of the mature vWF subunit destroyed binding to factor VIII, indicating that the native mature N-terminus is required for factor VIII binding. The requirement for vWF propeptide cleavage was shown by (1) a point mutation of the vWF propeptide cleavage site yielding pro-vWF that was defective in factor VIII binding and (2) correlation between efficiency of intracellular propeptide cleavage and factor VIII binding. Furthermore, in a cell-free system, addition of the propeptide-cleaving enzyme PACE/furin enabled factor VIII binding in parallel with propeptide cleavage. Our results indicate that high-affinity factor VIII binding sites are located on N-terminal disulfide-linked vWF subunits from which the propeptide has been cleaved.

Molecular chaperone GRP94 binds to the Fanconi anemia group C protein and regulates its intracellular expression

The FAC protein encoded by the gene defective in Fanconi anemia (FA) complementation group C binds to at least three ubiquitous cytoplasmic proteins in vitro. We used here the complete coding sequence of FAC in a yeast two-hybrid screen to identify interacting proteins. The molecular chaperone GRP94 was isolated twice from a B-lymphocyte cDNA library. Binding was confirmed by coimmunoprecipitation of FAC and GRP94 from cytosolic, but not nuclear, lysates of transfected COS-1 cells, as well as from mouse liver cytoplasmic extracts. Deletion mutants of FAC showed that residues 103-308 were required for interaction with GRP94, and a natural splicing mutation within the IVS-4 of FAC that removes residues 111-148 failed to bind GRP94. Ribozyme-mediated inactivation of GRP94 in the rat NRK cell line led to significantly reduced levels of immunoreactive FAC and concomitant hypersensitivity to mitomycin C, similar to the cellular phenotype of FA. Our results demonstrate that GRP94 interacts with FAC both in vitro and in vivo and regulates its intracellular level in a cell culture model. In addition, the pathogenicity of the IVS-4 splicing mutation in the FAC gene may be mediated in part by its inability to bind to GRP94.

Cerebral areas associated with motor control of speech in humans

We have defined areas in the brain activated during speaking, utilizing positron emission tomography. Six normal subjects continuously repeated the phrase "Buy Bobby a poppy" (requiring minimal language processing) in four ways: A) spoken aloud, B) mouthed silently, C) without articulation, and D) thought silently. Statistical comparison of images from conditions A with C and B with D highlighted areas associated with articulation alone, because control of breathing for speech was controlled for; we found bilateral activations in sensorimotor cortex and cerebellum with right-sided activation in the thalamus/caudate nucleus. Contrasting images from conditions A with B and C with D highlighted areas associated with the control of breathing for speech, vocalization, and hearing, because articulation was controlled for; we found bilateral activations in sensorimotor and motor cortex, close to but distinct from the activations in the preceding contrast, together with activations in thalamus, cerebellum, and supplementary motor area. In neither subtraction was there activation in Broca's area. These results emphasize the bilaterality of the cerebral control of "speaking" without language processing.

Inhibition of sickle erythrocyte adhesion to immobilized thrombospondin by von Willebrand factor under dynamic flow conditions

Sickle red blood cell (RBC) adhesion to the blood vessel wall is hypothesized to be the initiating event in the periodic vaso-occlusive episodes that characterize sickle cell disease (SCD). Thrombospondin-1 (TSP) and von Willebrand factor (vWF) have each been implicated in the adhesion of sickle RBC to vascular endothelial cells (EC) and subendothelial matrices. To better understand the contributions of each of these adhesive glycoproteins, we examined the adhesion of sickle RBC to immobilized TSP and vWF using a parallel plate flow chamber. Under postcapillary venular shear stress (1 dyne/cm2), sickle RBC adhered preferentially to TSP. To explore potential interactive effects of vWF and TSP, we examined sickle RBC adhesion to mixtures of these proteins. Whether the proteins were first combined in solution or sequentially applied to the slide, the presence of vWF inhibited the binding of sickle RBC to TSP. The inhibition of adhesion by vWF was shown to be the result of specific and saturable binding of vWF to TSP. Furthermore, vWF in solution at normal plasma levels also inhibited RBC adhesion to immobilized TSP. These data indicate that sickle RBC adhesion in vivo may be significantly influenced by the relative concentrations of TSP and vWF in the vascular wall.

Generating 'tiger' as an animal name or a word beginning with T: differences in brain activation

Positron emission tomography was used to investigate differences in regional cerebral activity during word retrieval in response to different prompts. The contrast of semantic category fluency and initial letter fluency resulted in selective activation of left temporal regions; the reverse contrast yielded activation in left frontal regions (BA44/6). A further comparison between types of category fluency demonstrated a more anterior temporal response for natural kinds and more posterior activation for manipulable manmade objects. These results support behavioural data suggesting that category fluency is relatively more dependent on temporal-lobe regions, and initial letter fluency on frontal structures; and that categorical word retrieval is not a uniformly distributed function within the brain. This is compatible with the category-specific deficits observed after some focal lesions.

Nonlinear regression in parametric activation studies

Parametric study designs can reveal information about the relationship between a study parameter (e.g., word presentation rate) and regional cerebral blood flow (rCBF) in functional imaging. The brain's responses in relation to study parameters might be nonlinear, therefore the (linear) correlation coefficient as often used in the analysis of parametric studies might not be a proper characterization. We present a noninteractive method, which fits nonlinear functions of stimulus or task parameters to rCBF responses, using second-order polynomial expansions. This technique is implemented in the context of the general linear model and statistical parametric mapping. We also consider the usefulness of statistical inferences, based on F fields, about similarities and differences of these nonlinear responses in different groups. This approach is illustrated with a 12-run H215O PET activation study using an auditory paradigm of increasing word presentation rates. A patient who had recovered from severe aphasia and a normal control were studied. We demonstrate the ability of this new technique to identify brain regions where rCBF is closely related to increasing word presentation rate in both subjects without constraining the nature of this relationship and where these nonlinear responses differ.

Hearing and saying. The functional neuro-anatomy of auditory word processing

The neural systems involved in hearing and repeating single words were investigated in a series of experiments using PET. Neuropsychological and psycholinguistic studies implicate the involvement of posterior and anterior left perisylvian regions (Wernicke's and Broca's areas). Although previous functional neuroimaging studies have consistently shown activation of Wernicke's area, there has been only variable implication of Broca's area. This study demonstrates that Broca's area is involved in both auditory word perception and repetition but activation is dependent on task (greater during repetition than hearing) and stimulus presentation (greater when hearing words at a slow rate). The peak of frontal activation in response to hearing words is anterior to that associated with repeating words; the former is probably located in Brodmann's area 45, the latter in Brodmann's area 44 and the adjacent precentral sulcus. As Broca's area activation is more subtle and complex than that in Wernicke's area during these tasks, the likelihood of observing it is influenced by both the study design and the image analysis technique employed. As a secondary outcome from the study, the response of bilateral auditory association cortex to 'own voice' during repetition was shown to be the same as when listening to "other voice' from a prerecorded tape.

Platelet adhesion to multimeric and dimeric von Willebrand factor and to collagen type III preincubated with von Willebrand factor

As part of a systematic study of platelet interaction with adhesive proteins under flow conditions, we studied platelet adhesion to multimeric and dimeric von Willebrand factor (vWF) coated to glass. vWF-dependent adhesion to collagen type III was studied for comparison. Adhesion to glass-coated vWF and vWF-mediated adhesion to collagen type III were in many respects similar. Both showed no decrease at increasing shear rates and a decline to 50% of maximum with a low-molecular-weight multimeric fraction. Adhesion to glass-coated vWF was partially inhibited by heparin and completely inhibited by prostaglandin I(2) and anti-glycoprotein (GP) Ib and anti-GPIIb-IIIa antibodies. vWF-dependent adhesion to collagen was not inhibited by heparin, was partially inhibited by anti-GPIIb-IIIa, and was completely inhibited by prostaglandin I(2) and anti-GPIb. Recombinant dimeric vWF was made by deletion of the propeptide and expression in Chinese hamster ovary cells. Adhesion was 50% of that with plasma vWF, and larger concentrations of dimeric vWF were required. Adhesion to dimeric vWF was optimal at 1500 s(-1), with a gradual decrease at higher shear rates. We conclude that adhesion to collagen type III is strongly but not completely determined by the adhesive properties of vWF.

Noun and verb retrieval by normal subjects. Studies with PET

PET activation studies identify significant local changes in regional cerebral blood flow (rCBF) in contrasts of behavioural tasks with control states, and these local changes identify net changes in local synaptic activity. A number of studies on word retrieval have all demonstrated left frontal (dorsolateral and medial) involvement in the task. However, there have been differences in the responses observed in the left temporal lobe, with variously a deactivation (significant decrease in rCBF), no response and an activation (significant increase in rCBF). In the four studies described here, we have examined word (verbs and nouns) retrieval contrasted with a number of different control states. The studies confirmed extensive activation of the left dorsolateral prefrontal cortex and, medially, the anterior cingulate cortex and the supplementary motor area (SMA). Activations of the left posterior temporal lobe and the inferior parietal lobe were consistently demonstrated when word retrieval was contrasted with a rest state. Contrasts with other single word tasks controlled out the activation in the perisylvian part of the left posterior temporal lobe, suggesting a role for this region in lexical processing. The left inferolateral temporal cortex and the posterior part of the inferior parietal lobe were only activated by word retrieval, particularly verbs. It is proposed that these activated regions reflect access to semantic fields.

Demonstrating the implicit processing of visually presented words and pseudowords

This study demonstrates that even when subjects are instructed to perform a nonlinguistic visual feature detection task, the mere presence of words or pseudowords in the visual field activates a widespread neuronal network that is congruent with classical language areas. The implication of this result is that subjects will process words beyond the functional demands of the task. Therefore, contrasting brain activity in a word task that explicitly requires a cognitive function with a word task in which the function is activated implicitly will not necessarily isolate the brain area of interest. Furthermore, in most brain regions, we found that pseudowords, which have unfamiliar phonological associations and no associated semantic association, produce greater activation than words. Greater brain activity associated with pseudowords illustrates that unfamiliar stimuli that are unable to access word associations may activate the neuronal network more strongly than familiar words for which access occurs with ease.

Modulation of conscious experience by peripheral sensory stimuli

Lack of awareness of touch associated with brain damage may transiently recover after stimulation of the vestibular system. We used positron emission tomographic regional cerebral blood flow measurements to study the neurophysiological effect of vestibular stimulation on touch imperception in a subject with a right brain lesion. We tested the hypothesis that the vestibular system aids conscious tactile perception by introducing a bias in the neural system subserving body representation. We show that in normal subjects touch and vestibular signals share projections to the putamen, insula, somatosensory area II, premotor cortex and supramarginal gyrus. In our patient a subset of these regions (right putamen and insula) was spared by the lesion and was maximally active when touch and vestibular stimulations were combined. These results support the suggestion that our phenomenological consciousness is associated with activation in circumscribed brain areas specific to the particular sensation of which we are aware.

Interaction of the von Willebrand factor (vWF) with collagen. Localization of the primary collagen-binding site by analysis of recombinant vWF a domain polypeptides

The von Willebrand factor (vWF) mediates platelet adhesion to the vascular subendothelium by binding to collagen, other matrix constituents, and the platelet receptor glycoproteins Ib/IX and IIb/IIIa. Although substantial progress has been made in defining vWF structure-function relationships, there are conflicting data regarding the location of its collagen-binding site(s). Possible collagen-binding sites have been localized in the A1 and A3 domains of vWF. To study the proposed binding sites, we have expressed cDNA sequences encoding the A1 and A3 domains of vWF in Escherichia coli and purified the resulting proteins from bacterial inclusion bodies. In addition, a chimeric molecule containing residues 465-598 of the vWF A1 domain polypeptide (vWF-A1) fused in frame to residues 1018-1114 of the vWF A3 domain polypeptide (vWF-A3) was also expressed. Each of the three recombinant proteins purified as a monomer and contained a single disulfide bond. As previously reported (Cruz, M. A., Handin, R. I., and Wise, R. J. (1993) J. Biol. Chem. 268, 21238-21245), recombinant vWF-A1 inhibited ristocetin-induced platelet agglutination, but did not compete with vWF multimers for collagen binding. In contrast, vWF-A3 inhibited the binding of multimeric vWF to immobilized collagen, but did not inhibit ristocetin-induced platelet agglutination. Metabolically labeled vWF-A3 bound to immobilized collagen in a saturable and reversible manner with a Kd of 1.8 x 10(-6) M. The vWF-A1/A3 chimera was bifunctional. It inhibited vWF binding to platelet glycoprotein Ib/IX with an IC50 of 0.6 x 10(-6) M and inhibited vWF binding to collagen with an IC50 of 0.5-1.0 x 10(-6) M. These results, taken together, provide firm evidence that the major collagen-binding site in vWF resides in the A3 domain.

Amelioration of the metabolic defect in erythropoietic protoporphyria by expression of human ferrochelatase in cultured cells

The cDNA for human ferrochelatase, the enzyme that is defective in the rare genetic disease erythropoietic protoporphyria (EPP), was tested for its ability to allow the expression of ferrochelatase in mammalian cells. The cDNA was ligated to the plasmid expression vectors pCD and pED6 and transfected into COS-1 and CHO-DUKX cells, respectively. In each case, ferrochelatase activity increased. The cDNA was also ligated into the retroviral vector pLXSN, and virus-packaging cells were produced. Supernatants from these cells were used to infect fibroblasts in vitro from a patient with EPP. We found that the infected cells containing the ferrochelatase cDNA had enzyme levels in the range of normal fibroblasts and that they did not accumulate protoporphyrin when grown in the presence of delta-aminolevulinic acid. We conclude that introducing the cDNA for normal ferrochelatase into fibroblasts from an EPP patient restores ferrochelatase enzyme activity to the normal range. These experiments suggest potential for genetic therapy in EPP.

Brain activity during reading. The effects of exposure duration and task

Brain activity during reading tasks was investigated using PET. The aim was to account for differences in the results of two previous studies [those of Petersen et al. (Science 1990; 249: 1041-4) and Howard et al. (Brain 1992; 115: 1769-82)] by systematically varying the type of reading task and the exposure duration of the word stimuli. Both variables strongly influenced patterns of brain activity. There were three types of task: (i) reading aloud; (ii) reading silently; and (iii) lexical decision on visually presented words and pseudowords. Reading aloud and reading silently engaged the left middle and superior temporal regions, confirming the important role of these areas in visual word processing. The areas principally engaged during lexical decision were the left inferior and middle frontal cortices and the supplementary motor area; activity in these areas suggests that the subjects were using a phonological strategy to perform the task. There was also a significant effect of exposure duration, with activity being greater for short (150 ms) exposure durations than for long (1000 ms or 981 ms) exposure durations. We conclude that until we understand how subtle variations in experimental design influence brain activity during reading tasks, the association of specific processing functions with individual anatomical areas activated during reading is premature.

Identification of individual tyrosine sulfation sites within factor VIII required for optimal activity and efficient thrombin cleavage

Factor VIII functions as an essential cofactor in the blood coagulation cascade for the factor IXa-mediated activation of factor X. Factor VIII contains 6 tyrosine residues at positions 346, 718, 719, 723, 1664, and 1680 that are modified by post-translational sulfation. This modification is required for full factor VIII procoagulant activity. We have employed site-directed mutagenesis to identify the individual sulfated tyrosines within factor VIII that influence activity. The molecules were expressed in COS-1 monkey cells by transient transfection, and the resultant proteins were characterized. Metabolic incorporation of [35S]sulfate demonstrated that all 6 tyrosine residues are sulfated in factor VIII. Sulfation at residues 346 and 1664 was required for full activity in a factor VIII clotting assay but did not affect factor VIII activity monitored by a factor Xa generation assay. The Tyr346-->Phe and Tyr1664-->Phe mutants displayed delayed thrombin activation that correlated with delayed cleavage at residues 372 and 1689, respectively. In contrast, these mutants were efficiently activated by factor Xa. A triple Tyr to Phe mutant at residues 718, 719, and 723 displayed both reduced factor VIII clotting activity and factor Xa generation activity. Finally, a Tyr1680-->Phe mutant factor VIII displayed a 5-fold reduced affinity for von Willebrand factor. The results demonstrate that 1) sulfation at tyrosine residues 346 and 1664 increases factor VIII activity by increasing the rate of thrombin activation and cleavage; 2) sulfation at tyrosine residues 718, 719, and 723 increases the intrinsic activity of factor VIIIa; and 3) sulfation at tyrosine residue 1680 increases the affinity for vWF. In addition, the results implicate that thrombin interacts with three distinct sites within factor VIII, two of which are required for proteolytic activation. The results demonstrate that the six sites of tyrosine sulfation modulate factor VIII activity through different mechanisms.

The interaction of the von Willebrand factor-A1 domain with platelet glycoprotein Ib/IX. The role of glycosylation and disulfide bonding in a monomeric recombinant A1 domain protein

The interaction of von Willebrand factor (vWF) with platelet glycoprotein Ib/IX plays an important role in primary hemostasis. Previous studies have localized the GpIb alpha binding domain of vWF to amino acid residues 449-728, a region containing the vWF-A1 domain. In order to assess the role of A1 domain structure in vWF binding functions, a cDNA encoding residues 475-709 of vWF was expressed in Escherichia coli (non-glycosylated) and in Chinese hamster ovary (CHO) cells (glycosylated). These recombinant proteins contain a single intrachain disulfide bond between C509 and C695 and were purified as monomers with apparent molecular weights of 36,000 (E. coli) and 39,000 (CHO). 35S-Labeled-vWF-A1 proteins bound directly to GpIb/IX receptors on platelets. The non-glycosylated form had a slightly higher affinity (Kd = 1.4 +/- 0.4 microM) than the glycosylated vWF-A1 protein (Kd = 4.5 +/- 0.9 microM) but had similar binding capacity of 28,000 GpIb/IX-specific binding sites per platelet. Additionally, both recombinant vWF-A1 proteins bound to heparin but neither bound to immobilized type I and III collagen. Both E. coli- and CHO-derived vWF-A1 proteins inhibited ristocetin-induced platelet agglutination with IC50 values of 300 and 700 nM, respectively. Reduction of the only disulfide bond between C509 and C695 abolished platelet binding activity at concentration up to 2 microM of protein. Confirmation of the importance of the 509-695 disulfide bond was obtained from a full-length vWF mutant containing substitutions at C509 and C695 (C509/695S) which failed to bind to the platelet GpIb/IX receptor. These studies document that vWF-A1 domain can bind to GpIb/IX and heparin but not collagen, and that binding to GpIb/IX requires an intact disulfide bond between C509 and C695. Furthermore, glycosylation increases the solubility but reduces binding affinity of recombinant vWF A1.

Ramifications of the Family and Medical Leave Act of 1993

Six months ago, the Family and Medical Leave Act of 1993 was signed into law, and key provisions of the act became effective on August 5, 1993. This article examines the main provisions of the act, explains how employee leaves will be granted in compliance with the act, outlines the consequences of noncompliance with the act, analyzes the operational ramifications of the act, quantifies the financial implications of the act, and discusses the role of the healthcare financial manager in assisting with the formulation of a hospital policy to comply with the act.

Autosomal recessive transmission of hemophilia A due to a von Willebrand factor mutation

The differential diagnosis of the genetic bleeding disorders, hemophilia A and von Willebrand disease, is occasionally confounded by the close molecular relationship of coagulation factor VIII and von Willebrand factor (vWF). This report describes the autosomal inheritance of a hemophilia A phenotype due to a mutation of vWF that results in defective factor VIII binding. The proband was a female patient with low levels of factor VIII activity. Polymerase chain reaction (PCR) amplification and DNA sequencing were employed to examine exons encoding the putative factor VIII binding domain of vWF. The patient was found to be homozygous for a single point mutation causing a Thr-->Met substitution at amino acid position 28 in the mature vWF subunit. The phenotypic expression of the mutation was determined to be recessive because heterozygous family members were clinically unaffected. Recombinant vWF containing the observed amino acid substitution was expressed in COS-1 cells. The mutant vWF was processed and secreted normally, and was functionally equivalent to wild-type vWF in its ability to bind to platelets. However, the mutant failed to bind factor VIII, demonstrating that the mutation was functionally related to the observed hemophilia phenotype. The family we describe demonstrates the recessive inheritance of a recently recognized class of genetic bleeding disorders, we call "autosomal hemophilia." We conclude that vWF mutation may be an under recognized cause of hemophilia, especially in cases where the inheritance pattern is not consistent with X-linked transmission.

Migraine madness: recurrent psychosis after migraine

A 69 year old man with longstanding migraine with aura had four episodes of psychosis lasting 7-28 days during a 17 year period. During attacks he had formed visual hallucination and delusions, including reduplicative paramnesia. His mother was similarly affected. His EEG showed symmetrical frontal delta waves. The time course and EEG changes are similar to acute confusional migraine. The reduplicative paramnesia suggests a focal non-dominant hemisphere dysfunction.

Individual patterns of functional reorganization in the human cerebral cortex after capsular infarction

We have previously shown bilateral activation of motor pathways and the recruitment of additional motor areas in studies of groups of patients with recovery from motor stroke. We have now developed a new positron emission tomographic technique to measure the changes in regional cerebral blood flow elicited during a motor task in individual patients, relative to the cerebral activation found in normal subjects. The patterns of cerebral activation in each of 8 individual patients with capsular lesions of the pyramidal tract and complete recovery from hemiplegia are described by comparison with the pattern found in a representative sample of 10 normal subjects. We found a large ventral extension of the hand field of the contralateral (sensori)motor cortex in all patients with lesions of the posterior limb of the internal capsule. Greater activation than in normal subjects was found in variable combinations of the supplementary motor areas, the insula, the frontal operculum, and the parietal cortex. Structures belonging to motor pathways ipsilateral to the recovered limb were also more activated in the patients than in normal subjects. However, additional activation of the ipsilateral (sensori)motor cortex was only found in the 4 patients who exhibited associated movements of the unaffected hand when the recovered hand performed the motor task. We conclude that recovery from motor stroke due to striatocapsular damage is associated with individually different patterns of functional reorganization of the brain. These patterns are dependent on the site of the subcortical lesion and the somatotopic organization of the pyramidal tract, both of which may determine the precise potential for recovery of limb function following this type of brain injury.

Functional reorganization of the brain in recovery from striatocapsular infarction in man

We used positron emission tomography (PET) to study organizational changes in the functional anatomy of the brain in 10 patients following recovery from striatocapsular motor strokes. Comparisons of regional cerebral blood flow maps at rest between the patients and 10 normal subjects revealed significantly lower regional cerebral blood flow in the basal ganglia, thalamus, sensorimotor, insular, and dorsolateral prefrontal cortices, in the brainstem, and in the ipsilateral cerebellum in patients, contralateral to the side of the recovered hand. These deficits reflect the distribution of dysfunction caused by the ischemic lesion. Regional cerebral blood flow was significantly increased in the contralateral posterior cingulate and premotor cortices, and in the caudate nucleus ipsilateral to the recovered hand. During the performance of a motor task by the recovered hand, patients activated the contralateral cortical motor areas and ipsilateral cerebellum to the same extent as did normal subjects. However, activation was greater than in normal subjects in both insulae; in the inferior parietal (area 40), prefrontal and anterior cingulate cortices; in the ipsilateral premotor cortex and basal ganglia; and in the contralateral cerebellum. The pattern of cortical activation was also abnormal when the unaffected hand, contralateral to the hemiplegia, performed the task. We showed that bilateral activation of motor pathways and the recruitment of additional sensorimotor areas and of other specific cortical areas are associated with recovery from motor stroke due to striatocapsular infarction. Activation of anterior and posterior cingulate and prefrontal cortices suggests that selective attentional and intentional mechanisms may be important in the recovery process. Our findings suggest that there is considerable scope for functional plasticity in the adult human cerebral cortex.

Selective inactivation of the Arg-Gly-Asp-Ser (RGDS) binding site in von Willebrand factor by site-directed mutagenesis

In order to assess the requirement for the Arg-Gly-Asp-Ser (RGDS) consensus adhesion sequence in von Willebrand factor (vWF) for vWF binding to platelets and endothelial cells, point mutations were introduced into this sequence by site-directed mutagenesis. A glycine to alanine substitution yielded RADS-vWF, while an aspartate to glutamate substitution resulted in RGES-vWF. Recombinant RADS-vWF and RGES-vWF, purified from transformed Chinese hamster ovary cells, were compared with recombinant wild type vWF (WT-vWF) in functional assays with platelets and human umbilical vein endothelial cells (HU-VECs). High molecular weight RADS-vWF and RGES-vWF multimers inhibited binding of 125I-vWF to a mixture of insolubilized native type I and III collagen and competed effectively with 125I-vWF for binding to formalin-fixed platelets in the presence of ristocetin, indicating functional collagen and platelet glycoprotein Ib binding. However, RADS-vWF and RGES-vWF were unable to displace the binding of 125I-vWF to thrombin or ADP-activated platelets. The attachment of HUVECs to either RADS-vWF or RGES-vWF coated surfaces was reduced and spreading was almost completely inhibited, compared with WT-vWF. We conclude that point mutations of the RGDS sequence in vWF selectively impair binding to platelet glycoprotein IIb/IIIa and the HUVEC vitronectin receptor.

The role of von Willebrand factor multimers and propeptide cleavage in binding and stabilization of factor VIII

von Willebrand factor (vWF) is a multimeric glycoprotein that promotes platelet aggregation and stabilizes coagulation factor VIII in the plasma. vWF is also required for the stable accumulation of recombinant factor VIII secreted from cells in a heterologous expression system. In this report, we show that vWF can promote the in vitro reconstitution of factor VIII activity from dissociated heavy and light chains of factor VIII, suggesting that vWF may act to promote stable assembly of factor VIII subunits at the site of secretion. The structural requirements for vWF propeptide cleavage and for vWF multimerization in its binding and stabilization of factor VIII was examined using specifically altered recombinant vWF. The mutant vWF molecules were also assayed for their function in ristocetin-induced platelet agglutination mediated through the platelet receptor GPIb. Deletion of the vWF propeptide produced a dimeric vWF molecule that failed to mediate platelet agglutination, suggesting that multimerization is required for vWF to attain functional GPIb binding. This mature dimeric form of vWF, however, was fully capable of binding to and supporting stable secretion of factor VIII. A vWF mutant with an altered propeptide cleavage site formed large multimers of uncleaved pro-vWF that functioned in platelet agglutination. However, this noncleavage mutant neither bound to or supported stable accumulation of factor VIII. Analysis of the vWF propeptide, expressed independently, demonstrated that it could not bind factor VIII or stabilize its secretion. These results show that the dimeric mature vWF subunit is sufficient to bind and stabilize factor VIII and that the presence of uncleaved vWF propeptide inhibits both factor VIII binding and stabilization.

The functional anatomy of motor recovery after stroke in humans: a study with positron emission tomography

We have studied regional cerebral blood flow changes in 6 patients after their recovery from a first hemiplegic stroke. All had a single well-defined hemispheric lesion and at least a brachial monoparesis that subsequently recovered. Each patient had 6 measurements of cerebral blood flow by positron tomography with 2 scans at rest, 2 during movement of fingers of the recovered hand, and 2 during movement of fingers of the normal hand. When the normal fingers were moved, regional cerebral blood flow increased significantly in contralateral primary sensorimotor cortex and in the ipsilateral cerebellar hemisphere. When the fingers of the recovered hand were moved, significant regional cerebral blood flow increases were observed in both contralateral and ipsilateral primary sensorimotor cortex and in both cerebellar hemispheres. Other regions, namely, insula, inferior parietal, and premotor cortex, were also bilaterally activated with movement of the recovered hand. We have also demonstrated, by using a new technique of image analysis, different functional connections between the thalamic nuclei and specific cortical and cerebellar regions during these movements. Our results suggest that ipsilateral motor pathways may play a role in the recovery of motor function after ischemic stroke.