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Introduction: Stroke survivors usually present physical and neuropsychiatric complications. Post-stroke psychosis (PSPsy) is a particularly neglected sequel despite its disruptive nature. Objectives: To present a case of early emerging neuropsychiatric symptoms following a left posterior cerebral artery (PCA) stroke. To review and discuss PSPsy clinical manifestations, pathophysiology, and clinical outcomes. Clinical Case: A previously autonomous 68-year-old woman with vascular risk factors and depressive disorder presented to the emergency department with a 5-day history of disorientation, motor aphasia, and right hypoesthesia. Computer tomography revealed a left PCA stroke. She was started on acetylsalicylic acid and rosuvastatin and discharged the next day. Afterward, the patient developed a depressive mood, emotional lability, periods of confusion, delusions of persecution, guilt and unworthiness, auditory hallucinations, and suicide ideation. She was admitted to a psychiatric hospital and started on risperidone with a good response, being discharged after 15 days with the resolution of psychiatric symptoms. Conclusions: PSPsy is more common after right hemisphere lesions and usually develops after some months. Nevertheless, our patient presented PSPsy following an ischemic event of the left PCA, with neuropsychiatric symptomatology dominating the clinic since the beginning. The involvement of the retrosplenial cortex or its connections was likely important for this atypical presentation. Due to the lack of guidelines on approaching PSPsy, most patients are treated with the same strategies used for non-stroke patients. A better comprehension of the anatomical basis underlining the symptomatology in these patients could deepen the understanding of psychosis and psychotic disorders. (AU)
Asunto(s)
Humanos , Femenino , Anciano , Trastornos Psicóticos/diagnóstico , Trastornos Psicóticos/fisiopatología , Accidente Cerebrovascular , Arteria Cerebral Posterior , Correlación de DatosRESUMEN
Attention, working memory, and executive control are commonly considered distinct cognitive functions with important reciprocal interactions. Yet, longstanding evidence from lesion studies has demonstrated both overlap and dissociation in their behavioural expression and anatomical underpinnings, suggesting that a lower dimensional framework could be employed to further identify processes supporting goal-directed behaviour. Here, we describe the anatomical and functional correspondence between attention, working memory, and executive control by providing an overview of cognitive models, as well as recent data from lesion studies, invasive and non-invasive multimodal neuroimaging and brain stimulation. We emphasize the benefits of considering converging evidence from multiple methodologies centred on the identification of brain mechanisms supporting goal-driven behaviour. We propose that expanding on this approach should enable the construction of a comprehensive anatomo-functional framework with testable new hypotheses, and aid clinical neuroscience to intervene on impairments of executive functions.
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White matter bundles linking gray matter nodes are key anatomical players to fully characterize associations between brain systems and cognitive functions. Here we used a multivariate lesion inference approach grounded in coalitional game theory (multiperturbation Shapley value analysis, MSA) to infer causal contributions of white matter bundles to visuospatial orienting of attention. Our work is based on the characterization of the lesion patterns of 25 right hemisphere stroke patients and the causal analysis of their impact on three neuropsychological tasks: line bisection, letter cancellation, and bells cancellation. We report that, out of the 11 white matter bundles included in our MSA coalitions, the optic radiations, the inferior fronto-occipital fasciculus and the anterior cingulum were the only tracts to display task-invariant contributions (positive, positive, and negative, respectively) to the tasks. We also report task-dependent influences for the branches of the superior longitudinal fasciculus and the posterior cingulum. By extending prior findings to white matter tracts linking key gray matter nodes, we further characterize from a network perspective the anatomical basis of visual and attentional orienting processes. The knowledge about interactions patterns mediated by white matter tracts linking cortical nodes of attention orienting networks, consolidated by further studies, may help develop and customize brain stimulation approaches for the rehabilitation of visuospatial neglect.
Asunto(s)
Atención/fisiología , Corteza Cerebral/patología , Sustancia Gris/patología , Accidente Cerebrovascular Hemorrágico , Accidente Cerebrovascular Isquémico , Red Nerviosa/patología , Neuroimagen , Trastornos de la Percepción , Percepción Espacial/fisiología , Percepción Visual/fisiología , Sustancia Blanca/patología , Adulto , Anciano , Corteza Cerebral/diagnóstico por imagen , Femenino , Teoría del Juego , Sustancia Gris/diagnóstico por imagen , Accidente Cerebrovascular Hemorrágico/complicaciones , Accidente Cerebrovascular Hemorrágico/diagnóstico por imagen , Accidente Cerebrovascular Hemorrágico/patología , Accidente Cerebrovascular Hemorrágico/fisiopatología , Humanos , Accidente Cerebrovascular Isquémico/complicaciones , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/patología , Accidente Cerebrovascular Isquémico/fisiopatología , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Red Nerviosa/diagnóstico por imagen , Neuroimagen/métodos , Trastornos de la Percepción/diagnóstico por imagen , Trastornos de la Percepción/etiología , Trastornos de la Percepción/patología , Trastornos de la Percepción/fisiopatología , Sustancia Blanca/diagnóstico por imagenRESUMEN
Visual neglect is a disabling consequence of right hemisphere damage, whereby patients fail to detect left-sided objects. Its precise mechanisms are debated, but there is some consensus that distinct component deficits may variously associate and interact in different patients. Here we used a touch-screen based procedure to study two putative component deficits of neglect, rightward "magnetic" attraction of attention and impaired spatial working memory, in a group of 47 right brain-damaged patients, of whom 33 had signs of left neglect. Patients performed a visual search task on three distinct conditions, whereby touched targets could (1) be tagged, (2) disappear or (3) show no change. Magnetic attraction of attention was defined as more left neglect on the tag condition than on the disappear condition, where right-sided disappeared targets could not capture patients' attention. Impaired spatial working memory should instead produce more neglect on the no change condition, where no external cue indicated that a target had already been explored, than on the tag condition. Using a specifically developed analysis algorithm, we identified significant differences of performance between the critical conditions. Neglect patients as a group performed better on the disappear condition than on the no change condition and also better in the tag condition comparing with the no change condition. No difference was found between the tag condition and the disappear condition. Some of our neglect patients had dissociated patterns of performance, with predominant magnetic attraction or impaired spatial working memory. Anatomical results issued from both grey matter analysis and fiber tracking were consistent with the typical patterns of fronto-parietal and occipito-frontal disconnection in neglect, but did not identify lesional patterns specifically associated with one or another deficit, thus suggesting the possible co-localization of attentional and working memory processes in fronto-parietal networks. These findings give support to the hypothesis of the co-occurrence of distinct cognitive deficits in visual neglect and stress the necessity of multi-component models of visuospatial disorders.