Attention,Memory, and Language after Pediatric Ischemic Stroke

A previous study evaluating receptive language after unilateral brain damage in childhood hypothesized lateralized attention and memory deficits without direct measurement. Our study directly measured attention, memory, and language in order to evaluate empirically the severity and laterality of sequelae. The performances of 11 individuals with a unilateral ischemic-lesion (7 right and 4 left hemisphere) were compared to controls matched on age, sex, and socioeconomic status. Results suggest subtle but persistent deficits in verbal memory, functional memory, and speed of processing after a lesion to either hemisphere. Lesions sustained before two years of age were associated with the lowest IQ scores. Our findings provide support for a configural representation of language that can to some extent compensate for inefficient or damaged components (Bates, 1994), and the middle-ground lateralization position (Thal et al., 1991) that asserts initial hemispheric specialization with the potential for reorganization.     

Visual span of apprehension in patients with unilateral cerebral lesions

The visual span of apprehension for random letter and digit sequences, approximations to English sequences and non-symbolic line stimuli was measured in patients with unilateral cerebral lesions. The left hemisphere group was significantly impaired relative to the right hemisphere group and a control group on all three types of visual span task. The deficit was most marked in patients with left posterior lesions. The visual span deficits were not related to other language deficits. The findings are discussed in terms of a modality-specific defect of visual short-term memory.     

Involvement of the insular cortex in retention of conditioned taste aversion is not time dependent

In fear-associated learning paradigms, hippocampal lesions induce memory deficits of recent but not remote memories, while amygdala lesions produce retention deficits irrespective of the age of the memory. In conditioned taste aversion (CTA), non-hippocampal mediated learning paradigm, the insular vortex (IC) has shown to have a crucial role in consolidation and storage of CTA memory. Due to the functional and anatomical similarities to the hippocampus, a time dependent role of the IC in CTA retention cannot be ruled out. To test whether the IC shows a time dependent role in CTA memory retention, male Wistar rats were CTA trained on saccharin 0.1% (LiCl 0.15M, 2% b/w, 40 min after drinking) and lesioned with ibotenic acid (200-300 nL, 5mg/mL) unilaterally into the IC 1 week or bilaterally 1 or 6 weeks after CTA. CTA memory was completely disrupted in both bilateral lesion groups but unaffected in the unilateral lesioned group. The resulting preference was comparable to that of the bilaterally IC lesioned animals exposed to the taste for the first time, proving that in these animals a complete amnesic state was achieved. Bilaterally IC lesioned rats showed normal discrimination between preferred (sucrose 5%) and non-preferred (quinone) tastes. Our data indicates that the involvement of the IC in CTA is not time dependent and that CTA memories are stored in each hemisphere separately.     

Testing conclusions from functional imaging of working memory with data from acute stroke

Functional imaging studies indicate that the left hemisphere mediates verbal working memory, while the right hemisphere mediates both verbal and spatial working memory. We evaluated acute stroke patients with working memory tests and imaging to identify whether unilateral dysfunction causes deficits in spatial and/or verbal working memory deficits. While left cortical stroke patients had verbal working memory impairments (p<0.003), right cortical stroke patients had both verbal p<0.007) and spatial working memory (p<0.03) impairments, confirming functional imaging results. Patients with transient ischemic stroke and patients with non-cortical stroke did not have significant deficits in working memory in either modality.     

Unilateral brain lesions in childhood: performance on the Revised Token Test

Comprehension of connected language as assessed by the Revised Token Test (RTT) was studied in 17 children with left hemisphere lesions (LL) and 11 with right hemisphere lesions (RL). LL children's significantly lower performance on several subtests than left controls (LC) matched by age, sex, race, and social class appeared to be related to the memory demands of these subtests rather than the limited syntactic elements assessed by the RTT. LL subjects requested significantly more command repetitions than control or RL subjects and when a repetition was not requested LL subjects often responded with immediacy. Although RL children tended to perform lower than right matched controls (RC), these differences were not significant nor readily related to either the memory or specific linguistic structures assessed. RL subjects required fewer command repetitions than LL subjects and exhibited a significantly greater frequency of immediate responses than controls or LL subjects. While based on few children, a trend for LL children with retrorolandic lesions to perform more poorly than those with left prerolandic lesions was suggested. No systematic difference in performance was apparent for children with left cortical vs. left subcortical lesions or among discrete sites of lesions within the right hemisphere. Children with left lesions prior to 1 year of age performed no better and, in several instances, significantly poorer than LL patients sustaining lesions after 1 year of age. Among RL subjects, those sustaining lesions after 1 year of age had greater difficulty than those with lesion onset before 1 year of age, especially on linguistic elements which seemed to be dependent upon visual spatial properties. Further studies are needed to evaluate the comprehension of more complex linguistic structures among children with unilateral brain lesions as well as to study the role of more basic factors such as memory and attention in explaining the present findings.     

Neuropsychological Profile of Duchenne Muscular Dystrophy

In this study, subjects with Duchenne Muscular Dystrophy (DMD) were matched for age, verbal intelligence, and depression with a group of healthy control subjects. Neuropsychological testing was conducted to assess complex attention, language fluency, receptive language, and visuospatial cognition using tests that would not be affected by impaired motor skill. The subjects with DMD demonstrated poorer functioning on tests of complex attention, verbal fluency, and nonverbal memory functions, suggesting that the cognitive deficits in the DMD population may be specific rather than global in nature. Methodological issues salient to the assessment of intellectual functioning among subjects with DMD and the implications of these data for the further study of cognitive deficits in DMD are discussed.     

Validating age-related functional imaging changes in verbal working memory with acute stroke

Functional imaging studies consistently find that older adults recruit bilateral brain regions in cognitive tasks that are strongly lateralized in younger adults, a characterization known as the Hemispheric Asymmetry Reduction in Older Adults model. While functional imaging displays what brain areas are active during tasks, it cannot demonstrate what brain regions are necessary for task performance. We used behavioral data from acute stroke patients to test the hypothesis that older adults need both hemispheres for a verbal working memory task that is predominantly left-lateralized in younger adults. Right-handed younger (age ? 50, n = 7) and older adults (age > 50, n =21) with acute unilateral stroke, as well as younger (n =6) and older (n =13) transient ischemic attack (TIA) patients, performed a self-paced verbal item-recognition task. Older patients with stroke to either hemisphere had a higher frequency of deficits in the verbal working memory task compared to older TIA patients. Additionally, the deficits in older stroke patients were mainly in retrieval time while the deficits in younger stroke patients were mainly in accuracy. These data suggest that bihemispheric activity is necessary for older adults to successfully perform a verbal working memory task.     

Use of the dichotic listening technique with learning disabilities

Dichotic listening (DL) techniques have been used extensively as a non-invasive procedure to assess language lateralization among children with and without learning disabilities (LD), and with individuals who have other auditory system related brain disorders. Results of studies using DL have indicated that language is lateralized in children with LD and that the lateralized language asymmetries do not develop after age 6 nor are they affected by gender. Observed differences in lateralized language processes between control children and those with LD were found not due to delayed cerebral dominance, but rather to deficits in selective attention. In addition, attention factors have a greater influence on auditory processing of verbal than nonverbal stimuli for children with LD, and children with LD exhibit a general processing bias to the same hemisphere unlike control children. Furthermore, employing directed attention conditions in DL experiments has played an important role in explaining learning disabled children's performance on DL tasks. We conclude that auditory perceptual asymmetries as assessed by DL with children who experience LD are the result of the interaction of hemispheric capability and attention factors.     

Pattern of Neuropsychological Deficit at Age Five Years Following Neonatal Unilateral Brain Injury

The pattern of language deficit following left-hemisphere brain injury and visual/spatial deficit following right-hemisphere injury in an adult or older child is well recognized, but has been inconsistently reported following presumed neonatal brain injury. Our prospective study of 24 children at age 5 with documented neonatal unilateral brain injury lends support to the theory of hemisphere specialization at the time of birth. Twelve children who had unilateral left-hemisphere lesion were compared to 12 children with unilateral right-hemisphere lesion of similar timing and severity. Relative visual/spatial deficit following right-hemisphere lesion and receptive language deficit following left-hemisphere lesion were identified. Lateralized measures of grip strength, fine motor speed, and fine motor dexterity were not significantly different between the groups for either hand in this nonhemiparetic study sample. Only one child with a left-hemisphere lesion was left-handed, and only one child (right-lesion) had a hemiparesis.     

Short-term and long-term memory deficit following intracarotid Amytal injection: Further support for the memory consolidation hypothesis

To test the three main hypotheses of the human amnesic syndrome (encoding, consolidation, retrieval), we designed an original protocol for memory assessment under Amytal that included, in addition to a retrograde memory measure, both short-term and long-term anterograde memory measures. Twenty epileptic patients with SEEG-confirmed unilateral temporal lobe foci were given right and left injections on successive days. Only the long-term memory measure for material presented under Amytal was significantly related to the presence of a temporal contralateral epileptogenic focus, even if it was assessed when the hemisphere had completely recovered from the effect of Amytal. Short-term memory deficits were observed equally often after injections ipsilateral and contralateral to the epileptogenic focus, and no retrograde amnesia was observed. These results are consistent with the consolidation hypothesis.     

Spoken language correlates of reading impairments acquired in childhood

This study reports the reading difficulties of five children following unilateral left hemisphere stroke sustained either before or during the early stages of literacy acquisition. Although each of the children experienced a period of disturbed language processing in the initial stages postonset, at the time of testing none of the children were considered to be clinically aphasic. Yet, on a standardized test of oral reading each of the children achieved a reading age that lagged behind chronological age and marked reading impairments were disclosed in four of the five children. A set of standardized and nonstandardized tests, aimed at measuring aspects of cognitive and spoken language processing that are considered to be important for normal reading acquisition, was administered. Where nonstandardized tests were used, performance of each of the stroke children was compared to that of groups of normally developing control children, closely matched for chronological age. A range of residual deficits in cognitive and spoken language processing was disclosed among the five brain-damaged children that appeared to be associated with their reading impairments. Two children had expectedly poor reading due to a selective impairment in verbal IQ; a specific phonological reading disorder was revealed in two children, each of which had a residual impairment to phonological awareness; and delayed reading acquisition was observed in one child with a general language deficit. It is suggested that when a child suffers damage to the left hemisphere in the early stages of reading acquisition, difficulties with learning to read are likely to ensue and may arise as a consequence of an underlying cognitive or linguistic deficit.     

Neurology of affective prosody and its functional-anatomic organization in right hemisphere

Unlike the aphasic syndromes, the organization of affective prosody in brain has remained controversial because affective-prosodic deficits may occur after left or right brain damage. However, different patterns of deficits are observed following left and right brain damage that suggest affective prosody is a dominant and lateralized function of the right hemisphere. Using the Aprosodia Battery, which was developed to differentiate left and right hemisphere patterns of affective-prosodic deficits, functional-anatomic evidence is presented in patients with focal ischemic strokes to support the concepts that (1) affective prosody is a dominant and lateralized function of the right hemisphere, (2) the intrahemispheric organization of affective prosody in the right hemisphere, with the partial exception of Repetition, is analogous to the organization of propositional language in the left hemisphere and (3) the aprosodic syndromes are cortically based as part of evolutionary adaptations underlying human language and communication.     

Language development after unilateral brain injury.

This longitudinal study describes the growth of syntactic abilities and vocabulary size in nine children with unilateral antepartum or perinatal brain injury. Five children with left hemisphere damage (LHD) and four with right hemisphere damage (RHD), ages 15 to 48 months, were evaluated on three or more occasions. Language samples generated from parent-child interaction were transcribed, coded, and analyzed using the Child Language Data Exchange System. Individual growth trajectories were constructed by graphing three dependent variables--MLU, scores on the Index of Productive Syntax (IPSYN), and number of different words--as a function of the child's age. One subject remained in a prelinguistic stage throughout the study. Simple linear functions best described the growth of MLU, IPSYN scores, and vocabulary in the other eight children. The slopes of the individual growth trajectories, the graphic representations of rates of progress, were comparable in the eight children. Seven children showed developmental delays in initial word use and five in the onset of multiword utterances. However, by age 24 months, four children with LHD and two children with RHD had syntactic capabilities comparable to those of children without brain injuries. The developmental patterns suggested that both cerebral hemispheres may play critical roles in the very earliest stages of language acquisition. Some unilateral lesions caused little discernible effect on language outcome in the toddler-preschool years after the initial developmental delays.     

Bilateral language: Is the left hemisphere still dominant?

A 13-year-old left-handed boy with a left fronto-parietal vascular malformation evidenced bilateral symmetrical language representation at intracarotid amytal testing. Surgical resection of the parietal motor and frontal premotor area (sparing classical perisylvian language regions) for seizure control resulted in an acute aphasia. Language deficits were still apparent 3 months and to a lesser degree 1 year after surgery. This suggests that when language is bilateral and symmetrical, the left hemisphere may still be dominant or both hemispheres may be necessary to sustain full language competence. Explanations for atypical language localization within the left hemisphere are also discussed.     

Hemisphere Inactivation and Mood-State Changes

Mood-state changes were studied during a sodium Amytal testing procedure in epilepsy patients with unilateral temporal lobe foci. The results showed that inactivation of the left hemisphere, but not the right hemisphere, produced a negative mood state. This decline in mood was not specifically related to side of focus or sex. As expected, the inactivation of either hemisphere also lead to an impairment in memory performance. This impairment was somewhat worse during a left than a right hemisphere inactivation. Furthermore, patients with left hemisphere foci showed a lower memory performance than patients with a right-hemisphere lesion. These results suggest (a) a hemispheric specialization for emotion that underlie changes in mood and (b) a discrepancy between mood states at encoding (during inactivation) and retrieval (after inactivation).     

Spatial and emotional aspects of language inferencing in nonverbal learning disabilities.

Although subtle linguistic deficits have been postulated for children identified with nonverbal learning disabilities (NLD), there is little empirical evidence to support this contention. Two experimental language inferencing measures that have been demonstrated to be problematic for individuals with right hemisphere brain damage (RHBD) and one norm-referenced inferencing task were examined in three groups of children aged 9-13: (1) children with NLD (n = 14), (2) children with verbal impairments (VI) (n = 14), and (3) children without learning disabilities who served as controls (n = 19). The NLD and VI groups did not differ from one another on any of the three measures, indicating a generalized language inferencing deficit in the NLD group. Relative to the control group, however, the NLD group experienced specific difficulties with spatial and emotional inferencing. The implications for right hemisphere involvement in the NLD profile are examined in relation to the effects of working memory on inferential abilities.     

LATERALIZATION FOR FACIAL EMOTIONAL BEHAVIOR: A METHODOLOGICAL PERSPECTIVE*

Recent attention has focused upon the neuropsychological mechanisms underlying facial emotional expression. The greater intensity of expression and more extensive muscular involvement of the left hemiface have suggested right hemisphere dominance in the expression of emotion. This interpretation is based on the fact that the lower portion of the face is predominantly innervated by the contralateral cerebral hemisphere. The current paper reviews a series of studies on (a) facial asymmetry in normal subjects, (b) facial emotional expression in brain-damaged subjects with unilateral lesions, and (c) peripheral factors mediating facial expression findings. Neuropsychological mechanisms underlying emotional processing are also discussed. Our finding of left-sided facial asymmetries in normals is underscored by our finding that right brain-damaged patients are impaired in the expression of facial emotion. Finally, our studies have demonstrated that the asymmetries in normals and the deficits in patient populations are not artifacts of hemiface size and mobility or facial paralysis and apraxia. Taken together, these studies provide evidence that the right hemisphere is specialized for the expression of facial emotion.     

No strong evidence for lateralisation of word reading and face recognition deficits following posterior brain injury

Face recognition and word reading are thought to be mediated by relatively independent cognitive systems lateralised to the right and left hemispheres, respectively. In this case, we should expect a higher incidence of face recognition problems in patients with right hemisphere injury and a higher incidence of reading problems in patients with left hemisphere injury. We tested this hypothesis in a group of 31 patients with unilateral right or left hemisphere infarcts in the territory of the posterior cerebral arteries. In most domains tested (e.g., visual attention, object recognition, visuo-construction, motion perception), we found that both patient groups performed significantly worse than a matched control group. In particular, we found a significant number of face recognition deficits in patients with left hemisphere injury and a significant number of patients with word reading deficits following right hemisphere injury. This suggests that face recognition and word reading may be mediated by more bilaterally distributed neural systems than is commonly assumed.     

Linguistic and neuropsychological deficits in crossed conduction aphasia. Report of three cases

This study describes the linguistic and neuropsychological findings in three right-handed patients with crossed conduction aphasia. Despite the location of the lesion in the right hemisphere, all patients displayed a combination of linguistic deficits typically found in conduction aphasia following analogous damage to the left hemisphere. Associated cognitive deficits varied across the three patients. In addition, all cases showed deficits classically attributed to non-dominant hemisphere damage (visuoperceptual deficits and reduced figural memory). As a result, lesion-behaviour relationships in our study sample indicate both dominant and non-dominant qualities of the right hemisphere.     

Spatial neglect, Balint-Homes' and Gerstmann's syndrome, and other spatial disorders

Brain-damaged patients with lesion or dysfunction involving the parietal cortex may show a variety of neuropsychological impairments involving spatial cognition. The more frequent and disabling deficit is the syndrome of unilateral spatial neglect that, in a nutshell, consists in a bias of spatial representation and attention ipsilateral to of extrapersonal, personal (ie, the body) space, or both, toward the side of the hemispheric lesion. The deficit is more frequent and severe after damage to the right hemisphere, involving particularly the posterior-inferior parietal cortex at the temporo-parietal junction. Damage to these posterior parietal regions may also impair visuospatial short-term memory, which may be associated with and worsen spatial neglect. The neural network supporting spatial representation, attention and short-term memory is, however, more extensive, including the right premotor cortex. Also disorders of drawing and building objects (traditionally termed constructional apraxia) are a frequent indicator of posterior parietal damage in the left and in the right hemispheres. Other less frequent deficits, which, however, have a relevant localizing value, include optic ataxia (namely, the defective reaching of visual objects, in the absence of elementary visuo-motor impairments), which is typically brought about by damage to the superior parietal lobule. Optic ataxia, together with deficits of visual attention, of estimating distances and depth, and with apraxia of gaze, constitutes the severely disabling Balint-Holmes' syndrome, which is typically associated with bilateral posterior parietal and occipital damage. Finally, lesions of the posterior parietal lobule (angular gyrus) in the left hemisphere may bring about a tetrad of symptoms (left-right disorientation, acalculia, finger agnosia, and agraphia) termed Gerstmann's syndrome, that also exists in a developmental form.