Bertrand Glize

Language features in the acute phase of post-stroke severe aphasia could predict the outcome.

BACKGROUND Aphasia recovery remains difficult to predict initially in particular for the most severe cases. The features of impaired verbal communication which are the basis for cognitive-linguistic diagnosis and treatment could be part of prediction of recovery from aphasia. AIM This study investigated whether some components of language screening in the acute phase of stroke are reliable prognostic factors for language recovery in the post-acute phase. DESIGN Monocentric prospective study. SETTING University hospital stroke unit. POPULATION Eighty-six patients aged between 21 and 92 years (mean=67.4, SD=15.3) were admitted after a first left hemisphere stroke with aphasia and were consecutively included. METHODS Language assessment was performed in the acute phase and 3 months post-stroke with the LAnguage Screening Test (LAST) and the Aphasia Severity Rating Scale (ASRS) of the Boston Diagnostic Aphasia Examination (BDAE). Severe aphasia was defined as ASRS<3. Good recovery was defined as an ASRS≥4. Language scores and other potential predictors of recovery were analysed by comparing groups of patients with good versus poor recovery and as predictors of change with multiple regression approaches. RESULTS LAST Total score as well as all the individual items of LAST, NIHSS and ASRS measured in the acute phase significantly differentiated good and poor recovery from aphasia at three months for all aphasic patients and for the most severe cases. In multivariable analyses the repetition score of LAST at the acute phase was significantly associated with the delta of ASRS between the acute phase and 3 months after the stroke reflecting changes in symptom severity. CONCLUSIONS For patients with initial severe aphasia, word repetition from a language screening task seems to be a more relevant predictor of recovery than initial severity to enrich the prognosis of poststroke aphasia recovery three month after a stroke. These findings show the importance of phonological perception and production as well as speech motor components in the recovery of language. These linguistic aspects of the assessment seem more relevant than severity for prediction in the acute phase. CLINICAL REHABILITATION IMPACT These findings could improve aphasia management pathway for people with severe aphasia and their families and minimize the evidence-practice gap for speech pathologists.

Seizure induced by repetitive transcranial magnetic stimulation for central pain: Adapted guidelines for post-stroke patients

The patient was a 65-year-old woman who had a righthemispheric ischemic stroke (middle cerebral artery territory, see Fig. 1) in September 2015. The etiology of the stroke is still undetermined to this day. Except for the brain lesion, the patient had no risk factor for epilepsy. She had no previous seizure history even during the acute post-stroke phase, nor did she have a family history of epilepsy. Her daily treatment was composed of: fluoxetin 20mg, atorvastatin 40mg, acetylsalicylic acid 160mg, gabapentin 800mg. She was referred for rTMS because she suffered from pharmacoresistent neuropathic pain in her left arm for a year. Indeed, tramadol, pregabaline, gabapentin, lidocaine patches and transcutaneous electric stimulation had been unsuccessful. Past medical history did not contain any rTMS contraindications and no additional risk factors, i.e. sleep deprivation, change in medication, illegal drug use, or doses of caffeine, were noticed the day of rTMS.

Improvement of Navigation and Representation in Virtual Reality after Prism Adaptation in Neglect Patients

Prism adaptation (PA) is responsible for an expansion of sensori-motor after-effects to cognitive domains for patients with spatial neglect. One important question is whether the cognitive after-effects induced by PA may also concern higher aspects of spatial cognition, such as navigation and topographic memory, which are critical in everyday life. The aim of this study was to assess whether multiple sessions of right PA can affect navigation and topographic memory. Seven right brain-damaged (RBD) patients with chronic neglect were included. We used a virtual supermarket named VAP-S which is an original paradigm, similar to the “shopping list test” during which patients had to purchase items from a list of eight products. Furthermore, in order to assess generalization of PA effects on constructing a spatial map from virtual information, each participant was then asked to draw the map of the virtual supermarket from memory. Regarding navigation performance, significant results were obtained: session duration reduction, fewer numbers of pauses and omissions, more items purchased on the left side and more items purchased over all. A long-lasting effect was noted, up to one month after PA. The representational task performance was also significantly increased for map drawing, with a reduction of the right shift of the symmetry axis of the map, more items drawn on the left side of maps and over all, and more items correctly located on the map. Some of these effects lasted for at least 7 days. These results suggest an expansion of PA benefit to a virtual environment. Crucially, the cognitive benefits induced by PA were noted for complex spatial cognition tasks required in everyday life such as navigation and topographic memory and this improvement was maintained for up to 1 month.

Motor evoked potential of upper-limbs is predictive of aphasia recovery

ABSTRACT Background: Recovery from aphasia impacts the quality of life in stroke patients but remains difficult to predict. Some neuroanatomical factors combined with anagraphical factors contribute to the prediction of longitudinal outcomes, but still fail to predict changes in severity of symptoms. Among the language features predicting recovery from aphasia, production scores such as repetition or phonology seem to be more relevant predictors than only severity. As motor cortex is strongly involved in language processes, both production and perception, the present study builds on the hypothesis that assessment of the anatomo-functional motor pathways could improve predictive models on top of factors based on neuroanatomy. Aim: In this prospective longitudinal study, we aimed to determine whether the integration of an electrophysiological measure of the motor network using Motor Evoked Potentials (MEPs) with an anatomical approach—diffusion-weighted MRI— in the acute phase of stroke can improve the prediction of recovery from post-stroke aphasia. Methods and Procedures: Fifteen aphasic patients were included in the post-stroke acute phase. Electrophysiological assessment exploring resting motor threshold ratio (rMTr) of the two upper-limbs and neuroanatomy exploration using MRI and diffusion tensor imaging were performed in the acute phase. Language impairment was assessed at the same stage and six months after the stroke. Multivariate regression analyses were carried out on aphasia severity score at M6, on recovery rates (change of severity) and on speech and language features as the dependent variables. Outcomes and Results: A first-level model, including only clinical variables (i.e., the initial severity) predicted severity at six months. When the rMTr of upper limbs was added in a second-level model, the predictive power significantly increased from 51% to 79%, as well as adding in a third-level model rMTr of upper limbs and the initial fibers number ratio (iFNr) of the corticospinal tracts (51% to 80%). With the changes in severity as the dependent variable, the same factors made a significant contribution and the predictive power of a second-level model increased from 23% to 50% to the same extent as in a third-level model (23% to 51%). A similar improvement when adding MEPs was noted for the prediction of articulatory agility and naming skills. Conclusions: Our results suggest that MEPs of upper limbs measured within 15days post-stroke are strong determinants of the prediction of longitudinal severity of post-stroke aphasia as well as of changes in symptoms and that the combination of electrophysiological and anatomical biomarkers improve this prediction.

Need for updating safety recommendations on repetitive transcranial magnetic stimulation in stroke patients

http://dx.doi.org/10.1016/j.clinph.2017.04.031 1388-2457/ 2017 International Federation of Clinical Neurophysiology. A paper entitled ‘‘Inhibition versus facilitation of contralesional motor cortices in stroke: Deriving a model to tailor brain stimulation” was published by Sankarasubramanian et al. in Clinical Neurophysiology in March 2017 (Sankarasubramanian et al., 2017). That article reported the results of a study that aimed at investigating whether facilitation of contralesional dorsal premotor cortex by repetitive transcranial magnetic stimulation (rTMS) permitted to improve upper-limb function in severely affected post-stroke patients. The authors proposed criteria for patients who are likely to respond to this facilitation of contralesional dorsal premotor cortex, in contrast to responders to a standard approach aiming at inhibiting contralesional motor cortex. Hence, the use of highfrequency rTMS to provide cortex facilitation could be a new rehabilitation approach for post-stroke patients with severe motor impairment. This method seems to be a new promising approach for the use of rTMS in stroke rehabilitation. It could be the basis for future studies, and future investigators might be tempted to apply a similar procedure of neuromodulation. Nevertheless, we would like to draw attention to some safety aspects of high-frequency rTMS for patients who have had a stroke. Non-invasive brain stimulation, and particularly high-frequency rTMS has some adverse effects, among which seizure is the most severe (see review by Kubis, 2016). Faced with this risk, guidelines are constantly being updated. Safety guidelines also published in this journal were suggested for stimulation parameters based on previous seizure cases (Rossi et al., 2009). However, in this manuscript the procedure used by Authors was based on old recommendations and old studies, with the following parameters: 5 Hz rTMS, 5 trains of 300 pulses each in 10 min, 90% of the active motor threshold. The duration of each train was 60 s, like the inter-train interval, for a total of 1500 pulses. This number of pulses by train seems to be rather high taking into consideration the latest safety recommendations (Rossi et al., 2009; Lefaucheur et al., 2014), that recommended a maximum duration of individual pulse trains at 5 Hz rTMS and 90% resting motor threshold of 10 s (i.e., 50 pulses). Even if 90% of the active motor threshold is less than 90% resting motor threshold, the pulse train duration exceeded the recommended maximum pulse train duration by a factor of 6. This could potentially lower the seizure threshold. Even if no adverse effect occurred in this small sample of 15 patients, it appears crucial that practices using non-invasive brain stimulation on stroke patients become harmonized. Indeed, a seizure induced by high-frequency rTMS for central pain, despite compliance with these latest recommendations, was recently reported in a post-stroke patient (Cogné et al., 2017). This raises the issue of a new update of guidelines, particularly for stroke

Affective Prosody and Depression After Stroke: A Pilot Study.

Background and Purpose— Poststroke depression (PSD) is a frequent complication of stroke with detrimental consequences in terms of quality of life and functional outcomes. In individuals with major depression, several studies have demonstrated an alteration of affective prosody. The aim of this study is to identify prosodic markers that may be predictive of PSD. Methods— Patient voices were recorded at baseline and 3 months after stroke. We extracted prosodic parameters, including fundamental frequency, percentage of voice breaks, and shimmer. Depression and anxiety symptoms were assessed 3 months later. Results— Among the 49 patients included in the study, 22.5% developed PSD 3 months after stroke. A significant decrease was observed concerning the fundamental frequency among patients who developed PSD. Discriminant analysis demonstrated that initial voice breaks coupled with shimmer are strongly predictive of subsequent PSD. Conclusions— Early alterations of affective prosody are associated with a higher risk of PSD 3 months after a stroke. This new physiological approach overcomes traditional barriers associated with clinical instruments and contributes to the prediction of this disorder.

Autochthonous strongyloidiasis, Bordeaux area, South-Western France.

Strongyloidiasis is a ubiquitous parasitic infection mostly endemic in tropical and subtropical regions, although sporadic autochthonous cases or sparse pockets have been reported in some areas of temperate regions. We report here the first, to our knowledge, autochthonous case diagnosed in the Arcachon basin in the coastal Aquitaine region of South-Western France. We failed to identify any recognized risk factor for transmission in this case of autochthonous infection occurring in a wealthy major tourist destination.

The lexical or sub-lexical locus of facilitation by phonemic cueing in aphasic speakers: the effect of onset cohort size

ABSTRACT Background: While the facilitation of word production by phonological cueing is used in clinical practice to evaluate the integrity of the lexical representations in anomia, the mechanisms by which phonological cueing facilitates oral production remain poorly understood. Most interpretations in psycholinguistic studies favor the phonological (sub-lexical) hypothesis, whereas results from studies on aphasia report evidence suggesting a lexical locus. Aims: This study aims to directly test the impact of phonological cues on lexical retrieval in participants with aphasia by manipulating the size of the cohort of nouns sharing the onset provided by the cue. Methods & Procedure: Fourteen aphasic participants presenting either a lexico-semantic or a phonological anomic profile performed a noun/object picture-naming task preceded by congruent or incongruent phonological cues. We manipulated the size of the lexical cohort of the words starting with the cue, reasoning that if phonological cues facilitate at the lexical level, a cue corresponding to a small number of words should be more effective than a cue compatible with a larger cohort. Outcomes & Results: The cue only improved accuracy in participants with lexico-semantic impairment, with a reduction of errors as a function of the cohort size (facilitation restricted to cues associated with a small onset cohort). In contrast, the cue onset cohort size only affects production latencies in participants with phonological impairment (shorter latencies for cues related to a small noun-onset cohort size). Conclusions: The observed effect of the cohort size associated with the cue favors a lexical locus of facilitation by phonological cueing. The fact that this effect is observed in different groups corresponding to different underlying impairments in error and in latencies suggests that the analyses of latencies reflect spared processes, whereas the analyses of errors tap into the impaired process.

Post-stroke coordination team to support non specialized rehabilitation hospital in French setting

Objective Access to a specialized rehabilitation is limited for most of post stroke patients who are often transferred in non-specialized rehabilitation hospitals. We have set up a multidisciplinary mobile team working in these hospitals. The aim of this pilot study was to describe the contribution of our mobile team specialized in post acute care of stroke. Materials/patients and methods We collected the changes in the management of rehabilitation for 31 patients hospitalized in non-specialized rehabilitation hospital referred to our mobile team. We assessed the training of healthcare workers that we provided and the impact on the care pathway. Results Our team permitted for almost all patients a specialized assessment (occupational therapy, referred for a psychological or neuropsychological assessment, a social evaluation, further evaluation, including specific neurovascular investigations). Therapeutic was changed, including learning self-rehabilitation methods, physiotherapy, and speech therapy. An adaptation of the care pathway has been done (neurovascular consultations, change of place of life project, accompanying a return home and reorientation in specialized rehabilitation unit). The team also permitted a training of the paramedical crew. All the doctors who requested the team declared this intervention as facilitator for admission of post-stroke patients in their hospital. Discussion/Conclusion These results show that our rehabilitation mobile team provides a large and diverse contribution to the non-specialized hospitals. This support covers all medical and social aspects. Beyond the individual impact, it helps, with training, to improve overall care and quality of care for non-specialized hospitals. Our results also suggest our mobile team is a facilitator for admission in post acute post-stroke unit.

Small bowel obstruction by superior mesenteric artery syndrome: A diagnosis to know after intensive care stay

P082-e Small bowel obstruction by superior mesenteric artery syndrome: A diagnosis to know after intensive care stay S. Chapeau *, B. Glize , M. Barsan , L. Tell , G. Rode c a Service de médecine physique et de réadaptation, hospices civils de Lyon, hôpital Henry-Gabrielle, 20, route de Vourles, 69230 Saint-Genis-Laval, France b Équipe ImpAct, Inserm U1028, CNRS UMR 5292, centre de recherche en neurosciences de Lyon, université Claude-Bernard Lyon I, 69000 Lyon, France c Service de médecine physique et réadaptation, hospices civils de Lyon, hôpital Henry-Gabrielle, Saint-Genis-Laval, France d Service de radiologie, centre hospitalier Lyon Sud, France *Corresponding author. E-mail address: sara.chapeau@chu-lyon.fr.