Case Report
Diffusion Tensor Imaging and Neuropsychologic Assessment in Aphasic Stroke Domenica Nunnari, PSyD,* Lilla Bonanno, MSc, PhD,* Placido Bramanti, MD,* and Silvia Marino, MD, PhD*†
With the recent advances in neuroimaging it has become possible to characterize the cerebral reorganization that occurs in response to therapy and the conditions under which this reorganization occurs. Diffusion tensor imaging (DTI) is a neuroimaging technique that allows us to visualize white matter tracts and potential changes associated with different treatments. To date, only few data on structural neuroplasticity related to the recovery of poststroke aphasia were reported. We describe a case of aphasic stroke patient, who was studied before and after the intense rehabilitative treatment by using neuropsychologic evaluation and DTI examination, to assess the integrity of the arcuate fasciculus related to motor, language, and cognitive recovery. Key Words: Aphasia—diffusion tensor imaging—neuropsychological evaluation—rehabilitation—stroke. Ó 2014 by National Stroke Association
Introduction Diffusion tensor imaging (DTI) provides a noninvasive assessment of cerebral white matter tracts in vivo. Only few DTI studies showed the correlates of language recovery and outcome in stroke aphasic patients.1-3 We described an aphasic stroke patient regarding changes in the integrity of the arcuate fasciculus (AF), known to be involved in language function, after intense rehabilitative treatment, by using neuropsychologic and DTI evaluation.
From the *IRCCS Centro Neurolesi ‘‘Bonino-Pulejo’’, Messina; and †Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy. Received March 14, 2014; revision received July 21, 2014; accepted July 27, 2014. Address correspondence to Silvia Marino, MD, PhD, Neurobioimaging Laboratory, IRCCS Centro Neurolesi ‘‘Bonino-Pulejo’’, S.S. 113, Via Palermo, Cntr Casazza, 98124 Messina, Italy. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2014 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.07.047
Case Report We report a case of a 49-year-old right-handed female patient affected by a right hemiparesis as result of ischemic stroke in the left temporoparietal area. She underwent clinical, neuropsychologic, and DTI examination at baseline (T0) and 1 month after rehabilitative treatment (T1). The physical therapy improved balance coordination, gait, and fine motor right hand movement. The speech therapy improved verbal and written communication. The neuropsychologic assessment (T0) presented a cognitive profile compatible with a diagnosis of motor aphasia: the patient showed relatively preserved auditory comprehension (Fig 1, A). The ‘‘Neuropsychological Examination of Aphasia Battery’’4 scoring indicated the presence of deficits in different subtests (Fig 1, A). At T1, we found a global cognitive recovery (Fig 1, A). Furthermore, the patient and 5 sex- and age- matched normal controls agreed to undergo a DTI examination on system operating at 3.0 T (Achieva, Philips, Best, The Netherlands) using a 32-channel SENSE head coil. DTI data were analyzed using the FMRIB Software Library (www.fmrib.ox.ac.uk/fsl/).5
Journal of Stroke and Cerebrovascular Diseases, Vol. 23, No. 10 (November-December), 2014: pp e477-e478
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Figure 1. (A) Histogram of Cognitive Assessment Scores at T0 and T1. The figure shows the more significant improvements in cognitive performances. In particular auditory comprehension, visuospatial research and selective attention, capacity of inhibitory control, and ideomotor praxis abilities. Regarding language outcomes, we observed a consistent improvement in repetition, reading, and writing words and nonwords, in nouns oral naming, and in numeric processing, especially about the addition operations. (B) Seed region of interest (I). DTT for the AF (right AF, yellow; left AF, red) for normal controls (II), for patient before rehabilitative treatment (III), and for patient after rehabilitative treatment (IV). There was evidence that the right AF fibers were more represented on the left AF immediately after therapy. In addition, these parameters were calculated for patient (left AF FA and left AF fiber number prerehabilitative treatment .33 and 81, respectively; left AF FA and left AF fiber number postrehabilitative treatment .37 and 102, respectively; right AF FA and right AF fiber number prerehabilitative treatment .40 and 196, respectively; right AF FA and right AF fiber number postrehabilitative treatment .41 and 198, respectively) and for normal controls (left AF FA and left AF fiber number .42 and 215 6 35.02, respectively; right AF FA and right AF fiber number .41 and 208 6 28.6, respectively). Abbreviations: AF, arcuate fasciculus; DTT, diffusion tensor tractography; ENPA, Neuropsychological Examination for Aphasia Battery; FA, fractional anisotropy; TMT, Trail Making Test (*the highest score indicates a worse performance).
DTI tractography indicated an increase of the integrity (higher fractional anisotropy and number fiber values) in the left AF after rehabilitative treatment (P , .05, Fig 1, B). In contrast, fractional anisotropy and number fiber values in the right AF remained stable including compared with normal controls. (Fig 1, B).
Discussion We observed an improvement in language function after logopedic and motor treatment with evidence of an increase in integrity of the fibers of the left AF. Our patient, with a left temporoparietal stroke, had measures which demonstrate the degree to which temporoparietal regions are structurally and functionally connected as well as how the AF mediates specific aspects of language comprehension. Few DTI studies addressing aphasia and stroke have been reported compared with deficits in motor or cognitive functions.6,7 Further DTI studies may provide useful information about the severity of AF injury and recovery process in stroke-related aphasia.
References 1. Schlaug G, Marchina S, Norton A. Evidence for plasticity in white-matter tracts of patients with chronic Broca’s aphasia undergoing intense intonationbased speech therapy. Ann NY Acad Sci 2009;1169: 385-394. 2. Berthier ML, Garcıa-Casares N, Walsh SF, et al. Recovery from post-stroke aphasia: lessons from brain imaging and implications for rehabilitation and biological treatments. Discov Med 2011;12:275-289. 3. Jang SH. Diffusion tensor imaging studies on arcuate fasciculus in stroke patients: a review. Front Hum Neurosci 2013;7:749. 4. Capasso R, Miceli G. Esame neuropsicologico per l’afasia (E.N.P.A.). Milano: Springer-Verlag Italia 2001. 5. Smith SM, Jenkinson M, Johansen-Berg H, et al. Tract-based spatial statistics: voxelwise analysis of multi-subject diffusion data. Neuroimage 2006;31: 1487-1505. 6. Song F, Zhang F, Yin DZ, et al. Diffusion tensor imaging for predicting hand motor outcome in chronic stroke patients. J Int Med Res 2012;40:126-133. 7. Wang J, Marchina S, Norton AC, et al. Predicting speech fluency and naming abilities in aphasic patients. Front Hum Neurosci 2013;7:831.
Diffusion Tensor Imaging and Neuropsychologic Assessment in Aphasic Stroke Domenica Nunnari, PSyD,* Lilla Bonanno, MSc, PhD,* Placido Bramanti, MD,* and Silvia Marino, MD, PhD*†
With the recent advances in neuroimaging it has become possible to characterize the cerebral reorganization that occurs in response to therapy and the conditions under which this reorganization occurs. Diffusion tensor imaging (DTI) is a neuroimaging technique that allows us to visualize white matter tracts and potential changes associated with different treatments. To date, only few data on structural neuroplasticity related to the recovery of poststroke aphasia were reported. We describe a case of aphasic stroke patient, who was studied before and after the intense rehabilitative treatment by using neuropsychologic evaluation and DTI examination, to assess the integrity of the arcuate fasciculus related to motor, language, and cognitive recovery. Key Words: Aphasia—diffusion tensor imaging—neuropsychological evaluation—rehabilitation—stroke. Ó 2014 by National Stroke Association
Introduction Diffusion tensor imaging (DTI) provides a noninvasive assessment of cerebral white matter tracts in vivo. Only few DTI studies showed the correlates of language recovery and outcome in stroke aphasic patients.1-3 We described an aphasic stroke patient regarding changes in the integrity of the arcuate fasciculus (AF), known to be involved in language function, after intense rehabilitative treatment, by using neuropsychologic and DTI evaluation.
From the *IRCCS Centro Neurolesi ‘‘Bonino-Pulejo’’, Messina; and †Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy. Received March 14, 2014; revision received July 21, 2014; accepted July 27, 2014. Address correspondence to Silvia Marino, MD, PhD, Neurobioimaging Laboratory, IRCCS Centro Neurolesi ‘‘Bonino-Pulejo’’, S.S. 113, Via Palermo, Cntr Casazza, 98124 Messina, Italy. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2014 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.07.047
Case Report We report a case of a 49-year-old right-handed female patient affected by a right hemiparesis as result of ischemic stroke in the left temporoparietal area. She underwent clinical, neuropsychologic, and DTI examination at baseline (T0) and 1 month after rehabilitative treatment (T1). The physical therapy improved balance coordination, gait, and fine motor right hand movement. The speech therapy improved verbal and written communication. The neuropsychologic assessment (T0) presented a cognitive profile compatible with a diagnosis of motor aphasia: the patient showed relatively preserved auditory comprehension (Fig 1, A). The ‘‘Neuropsychological Examination of Aphasia Battery’’4 scoring indicated the presence of deficits in different subtests (Fig 1, A). At T1, we found a global cognitive recovery (Fig 1, A). Furthermore, the patient and 5 sex- and age- matched normal controls agreed to undergo a DTI examination on system operating at 3.0 T (Achieva, Philips, Best, The Netherlands) using a 32-channel SENSE head coil. DTI data were analyzed using the FMRIB Software Library (www.fmrib.ox.ac.uk/fsl/).5
Journal of Stroke and Cerebrovascular Diseases, Vol. 23, No. 10 (November-December), 2014: pp e477-e478
e477
D. NUNNARI ET AL.
e478
Figure 1. (A) Histogram of Cognitive Assessment Scores at T0 and T1. The figure shows the more significant improvements in cognitive performances. In particular auditory comprehension, visuospatial research and selective attention, capacity of inhibitory control, and ideomotor praxis abilities. Regarding language outcomes, we observed a consistent improvement in repetition, reading, and writing words and nonwords, in nouns oral naming, and in numeric processing, especially about the addition operations. (B) Seed region of interest (I). DTT for the AF (right AF, yellow; left AF, red) for normal controls (II), for patient before rehabilitative treatment (III), and for patient after rehabilitative treatment (IV). There was evidence that the right AF fibers were more represented on the left AF immediately after therapy. In addition, these parameters were calculated for patient (left AF FA and left AF fiber number prerehabilitative treatment .33 and 81, respectively; left AF FA and left AF fiber number postrehabilitative treatment .37 and 102, respectively; right AF FA and right AF fiber number prerehabilitative treatment .40 and 196, respectively; right AF FA and right AF fiber number postrehabilitative treatment .41 and 198, respectively) and for normal controls (left AF FA and left AF fiber number .42 and 215 6 35.02, respectively; right AF FA and right AF fiber number .41 and 208 6 28.6, respectively). Abbreviations: AF, arcuate fasciculus; DTT, diffusion tensor tractography; ENPA, Neuropsychological Examination for Aphasia Battery; FA, fractional anisotropy; TMT, Trail Making Test (*the highest score indicates a worse performance).
DTI tractography indicated an increase of the integrity (higher fractional anisotropy and number fiber values) in the left AF after rehabilitative treatment (P , .05, Fig 1, B). In contrast, fractional anisotropy and number fiber values in the right AF remained stable including compared with normal controls. (Fig 1, B).
Discussion We observed an improvement in language function after logopedic and motor treatment with evidence of an increase in integrity of the fibers of the left AF. Our patient, with a left temporoparietal stroke, had measures which demonstrate the degree to which temporoparietal regions are structurally and functionally connected as well as how the AF mediates specific aspects of language comprehension. Few DTI studies addressing aphasia and stroke have been reported compared with deficits in motor or cognitive functions.6,7 Further DTI studies may provide useful information about the severity of AF injury and recovery process in stroke-related aphasia.
References 1. Schlaug G, Marchina S, Norton A. Evidence for plasticity in white-matter tracts of patients with chronic Broca’s aphasia undergoing intense intonationbased speech therapy. Ann NY Acad Sci 2009;1169: 385-394. 2. Berthier ML, Garcıa-Casares N, Walsh SF, et al. Recovery from post-stroke aphasia: lessons from brain imaging and implications for rehabilitation and biological treatments. Discov Med 2011;12:275-289. 3. Jang SH. Diffusion tensor imaging studies on arcuate fasciculus in stroke patients: a review. Front Hum Neurosci 2013;7:749. 4. Capasso R, Miceli G. Esame neuropsicologico per l’afasia (E.N.P.A.). Milano: Springer-Verlag Italia 2001. 5. Smith SM, Jenkinson M, Johansen-Berg H, et al. Tract-based spatial statistics: voxelwise analysis of multi-subject diffusion data. Neuroimage 2006;31: 1487-1505. 6. Song F, Zhang F, Yin DZ, et al. Diffusion tensor imaging for predicting hand motor outcome in chronic stroke patients. J Int Med Res 2012;40:126-133. 7. Wang J, Marchina S, Norton AC, et al. Predicting speech fluency and naming abilities in aphasic patients. Front Hum Neurosci 2013;7:831.
