There is startling individual variability in the degree to which people recover from stroke and the duration of time over which recovery of some symptoms occurs. There are a variety of mechanisms of recovery from stroke which take place at distinct time points after stroke and are influenced by different variables. We review recent studies from our laboratory that unveil some surprising findings, such as the role of education in chronic recovery. We also report data showing that the consequences that most plague survivors of stroke and their caregivers are loss of high level cortical functions, such as empathy or written language. These results have implications for rehabilitation and management of stroke. 1. Introduction Stroke is among the leading causes of serious, long-term disability worldwide; 15 million people suffer a stroke each year. Almost six million people die of stroke annually, and another five million people have permanent disability due to stroke (http://www.world-heart-federation.org/cardiovascular-health/stroke). Yet, physicians are notoriously weak in predicting who will recover from stroke, how much they will recover, and when they will recover. It is widely recognized that there is a great deal of individual variability in stroke recovery. Even two individuals with very similar appearing ischemic strokes may show very different outcomes one year later. In this paper, we review recent studies from our research group, the Stroke Cognitive Outcomes and Recovery (SCORE) Lab, revealing new insights into sequelae of stroke that are most important to survivors and caregivers and the variables that influence cognitive recovery after stroke. These data have implications for both acute management of stroke and the need to explore new avenues of rehabilitation. 1.1. Why Focus on Cognitive Recovery? The human brain is responsible for all of the functions that define who we are and how we relate to one another—our talents, our intellect, our creativity, our ability to participate in sports, our ability to communicate, and our ability to understand and share in the emotions of others. Stroke can interfere with any or all of these functions. Most of the brain, in fact, supports cognitive and integrative processes underlying complex systems, such as attention, working memory, cognitive control, and language that are critical for these activities. Yet, stroke outcomes research traditionally has focused on recovery of very basic activities of daily living, such as feeding oneself and walking. Consider the most commonly used outcome measures for
References
[1]
B. Farrell, J. Godwin, S. Richards, and C. Warlow, “The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results,” Journal of Neurology Neurosurgery and Psychiatry, vol. 54, no. 12, pp. 1044–1054, 1991.
[2]
D. Wade and C. Collin, “The Barthel ADL index: a standard measure of physical disability?” Disability & Rehabilitation, vol. 10, no. 2, pp. 64–67, 1988.
[3]
J. I. Cameron, D. E. Stewart, D. L. Streiner, P. C. Coyte, and A. M. Cheung, “What makes family caregivers happy during the first 2 years post stroke?” Stroke, vol. 45, no. 4, pp. 1084–1089, 2014.
[4]
M. Acler, E. Robol, A. Fiaschi, and P. Manganotti, “A double blind placebo RCT to investigate the effects of serotonergic modulation on brain excitability and motor recovery in stroke patients,” Journal of Neurology, vol. 256, no. 7, pp. 1152–1158, 2009.
[5]
G. Nys, M. Van Zandvoort, P. De Kort et al., “Domain-specific cognitive recovery after first-ever stroke: A follow-up study of 111 cases,” Journal of the International Neuropsychological Society, vol. 11, no. 7, pp. 795–806, 2005.
[6]
D. Woo, J. P. Broderick, R. U. Kothari et al., “Does the National Institutes of Health Stroke Scale favor left hemisphere strokes?” Stroke, vol. 30, no. 11, pp. 2355–2359, 1999.
[7]
P. Lyden, L. Claesson, S. Havstad, T. Ashwood, and M. Lu, “Factor analysis of the National Institutes of Health Stroke Scale in patients with large strokes,” Archives of Neurology, vol. 61, no. 11, pp. 1677–1680, 2004.
[8]
M. M. Glymour, L. F. Berkman, K. A. Ertel, M. E. Fay, T. A. Glass, and K. L. Furie, “Lesion characteristics, NIH stroke scale, and functional recovery after stroke,” The American Journal of Physical Medicine and Rehabilitation, vol. 86, no. 9, pp. 725–733, 2007.
[9]
A. E. Hillis, R. J. Wityk, P. B. Barker, J. A. Ulatowski, and M. A. Jacobs, “Change in perfusion in acute nondominant hemisphere stroke may be better estimated by tests of hemispatial neglect than by the national institutes of health stroke scale,” Stroke, vol. 34, no. 10, pp. 2392–2396, 2003.
[10]
R. F. Gottesman, J. T. Kleinman, C. Davis, J. Heidler-Gary, M. Newhart, and A. E. Hillis, “The NIHSS-plus: improving cognitive assessment with the NIHSS,” Behavioural Neurology, vol. 22, no. 1-2, pp. 11–15, 2010.
[11]
L. A. Pearce, L. A. McClure, D. C. Anderson, C. Jacova, M. Sharma, and O. R. Benavente, “Effects of long-term blood pressure lowering and dual antiplatelet therapy on cognition in patients with recent lacunar stroke: secondary prevention of small subcortical strokes (SPS3) trial,” Lancet Neurology. In press.
[12]
K. Hilari, J. J. Needle, and K. L. Harrison, “What are the important factors in health-related quality of life for people with aphasia? A systematic review,” Archives of Physical Medicine and Rehabilitation, vol. 93, no. 1, pp. S86–S95, 2012.
[13]
D. S. Nichols-Larsen, P. C. Clark, A. Zeringue, A. Greenspan, and S. Blanton, “Factors influencing stroke survivors' quality of life during subacute recovery,” Stroke, vol. 36, no. 7, pp. 1480–1484, 2005.
[14]
M.-L. Niemi, R. Laaksonen, M. Kotila, and O. Waltimo, “Quality of life 4 years after stroke,” Stroke, vol. 19, no. 9, pp. 1101–1107, 1988.
[15]
J. Carod-Artal, J. A. Egido, J. L. González, and E. V. Seijas, “Quality of life among stroke survivors evaluated 1 year after stroke: experience of a stroke unit,” Stroke, vol. 31, no. 12, pp. 2995–3000, 2000.
[16]
V. Urrutia, B. Johnson, and A. Hillis, “Relative importance of stroke sequelae according to patients and caregivers,” in Abstract Presented at the Annual Meeting of the American Academy of Neurology, Philadelphia, Pa, USA, April 2014.
[17]
P. J. Eslinger, K. Parkinson, and S. G. Shamay, “Empathy and social-emotional factors in recovery from stroke,” Current Opinion in Neurology, vol. 15, no. 1, pp. 91–97, 2002.
[18]
E. Zarahn, L. Alon, S. L. Ryan, et al., “Prediction of motor recovery using initial impairment and fMRI 48？h poststroke,” Cerebral Cortex, vol. 21, no. 12, pp. 2712–2721, 2011.
[19]
T. M. H. Hope, M. L. Seghier, A. P. Leff, and C. J. Price, “Predicting outcome and recovery after stroke with lesions extracted from MRI images,” NeuroImage: Clinical, vol. 2, no. 1, pp. 424–433, 2013.
[20]
S. Jarso, M. Li, A. Faria et al., “Distinct mechanisms and timing of language recovery after stroke,” Cognitive Neuropsychology, vol. 30, no. 7-8, pp. 454–475, 2013.
[21]
S. R. Zeiler and J. W. Krakauer, “The interaction between training and plasticity in the poststroke brain,” Current Opinion in Neurology, vol. 26, no. 6, pp. 609–616, 2013.
[22]
A. E. Hillis, J. A. Ulatowski, P. B. Barker et al., “A pilot randomized trial of induced blood pressure elevation: effects on function and focal perfusion in acute and subacute stroke,” Cerebrovascular Diseases, vol. 16, no. 3, pp. 236–246, 2003.
[23]
S. Khurshid, L. A. Trupe, M. Newhart et al., “Reperfusion of specific cortical areas is associated with improvement in distinct forms of hemispatial neglect,” Cortex, vol. 48, no. 5, pp. 530–539, 2012.
[24]
H. Ota, T. Fujii, K. Suzuki, R. Fukatsu, and A. Yamadori, “Dissociation of body-centered and stimulus-centered representations in unilateral neglect,” Neurology, vol. 57, no. 11, pp. 2064–2069, 2001.
[25]
A. E. Hillis, M. Newhart, J. Heidler, P. B. Barker, E. H. Herskovits, and M. Degaonkar, “Anatomy of spatial attention: insights from perfusion imaging and hemispatial neglect in acute stroke,” The Journal of Neuroscience, vol. 25, no. 12, pp. 3161–3167, 2005.
[26]
J. Medina, V. Kannan, M. A. Pawlak et al., “Neural substrates of visuospatial processing in distinct reference frames: evidence from unilateral spatial neglect,” Journal of Cognitive Neuroscience, vol. 21, no. 11, pp. 2073–2084, 2009.
[27]
A. E. Hillis, A. Kane, E. Tuffiash et al., “Reperfusion of specific brain regions by raising blood pressure restores selective language functions in subacute stroke,” Brain and Language, vol. 79, no. 3, pp. 495–510, 2001.
[28]
A. E. Hillis, J. T. Kleinman, M. Newhart et al., “Restoring cerebral blood flow reveals neural regions critical for naming,” Journal of Neuroscience, vol. 26, no. 31, pp. 8069–8073, 2006.
[29]
A. E. Hillis, R. J. Wityk, P. B. Barker, and A. Caramazza, “Neural regions essential for writing verbs,” Nature Neuroscience, vol. 6, no. 1, pp. 19–20, 2003.
[30]
E. Plowman, B. Hentz, and C. Ellis, “Post-stroke aphasia prognosis: a review of patient-related and stroke-related factors,” Journal of Evaluation in Clinical Practice, vol. 18, no. 3, pp. 689–694, 2012.
[31]
EClipSE Collaborative Members, C. Brayne, P. G. Ince et al., “Education, the brain and dementia: neuroprotection or compensation?” Brain, vol. 133, part 8, pp. 2210–2216, 2010.
[32]
C. M. Roe, C. Xiong, J. P. Miller, and J. C. Morris, “Education and Alzheimer disease without dementia: support for the cognitive reserve hypothesis,” Neurology, vol. 68, no. 3, pp. 223–228, 2007.
[33]
Y. Stern, S. Albert, M.-X. Tang, and W.-Y. Tsai, “Rate of memory decline in AD is related to education and occupation: cognitive reserve?” Neurology, vol. 53, no. 9, pp. 1942–1947, 1999.
[34]
Y. Stern, “Cognitive reserve and Alzheimer disease,” Alzheimer Disease & Associated Disorders, vol. 20, no. 2, pp. 112–117, 2006.
[35]
G. E. Alexander, M. L. Furey, C. L. Grady et al., “Association of premorbid intellectual function with cerebral metabolism in Alzheimer's disease: implications for the cognitive reserve hypothesis,” The American Journal of Psychiatry, vol. 154, no. 2, pp. 165–172, 1997.
[36]
J. Ojala-Oksala, H. Jokinen, V. Kopsi et al., “Educational history is an independent predictor of cognitive deficits and long-term survival in postacute patients with mild to moderate ischemic stroke,” Stroke, vol. 43, no. 11, pp. 2931–2935, 2012.
[37]
A. M. Suneja, M. Gonzalez-Fernandez, and A. E. Hillis, “Predictors of recovery of chronic aphasia,” in Proceedings of the Annual Meeting of the American Academy of Neurology, Philadelphia, Pa, USA, April 2014.
[38]
F. Chollet, J. Tardy, J.-F. Albucher, et al., “Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial,” The Lancet Neurology, vol. 10, no. 2, pp. 123–130, 2011.
[39]
G. E. Mead, C.-F. Hsieh, and M. Hackett, “Selective serotonin reuptake inhibitors for stroke recovery,” JAMA—Journal of the American Medical Association, vol. 310, no. 10, pp. 1066–1067, 2013.
[40]
M. González-Fernández, C. Davis, J. J. Molitoris, M. Newhart, R. Leigh, and A. E. Hillis, “Formal education, socioeconomic status, and the severity of aphasia after stroke,” Archives of Physical Medicine and Rehabilitation, vol. 92, no. 11, pp. 1809–1813, 2011.
[41]
J. Posner, L. A. Trupe, C. L. Davis, Y. Gomez, D. Tippett, and A. E. Hillis, “Predictors of recovery of allocentric and egocentric neglect: the role of education,” in Proceedings of the Annual Meeting of the American Academy of Neurology, Philadelphia, Pa, USA, April 2014.
