Brain Advance Access originally published online on April 25, 2006
Brain 2006 129(6):1371-1384; doi:10.1093/brain/awl090
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Dynamics of language reorganization after stroke
1 Department of Neurology, University Freiburg Freiburg, Germany 2 NeuroImage Nord Germany 3 Department of Neurology, University Medical Centre Hamburg-Eppendorf Hamburg, Germany 4 Section Neuropsychology, Department of Neurology, RWTH Aachen University Aachen, Germany
*Correspondence to: Dr Dorothee Saur, MD, Department of Neurology, University Freiburg, Breisacher Strasse 64, 79106 Freiburg, Germany E-mail: dorothee.saur{at}uniklinik-freiburg.de
Previous functional imaging studies of chronic stroke patients with aphasia suggest that recovery of language occurs in a pre-existing, bilateral network with an upregulation of undamaged areas and a recruitment of perilesional tissue and homologue right language areas. The present study aimed at identifying the dynamics of reorganization in the language system by repeated functional MRI (fMRI) examinations with parallel language testing from the acute to the chronic stage. We examined 14 patients with aphasia due to an infarction of the left middle cerebral artery territory and an age-matched control group with an auditory comprehension task in an event-related design. Control subjects were scanned once, whereas patients were scanned repeatedly at three consecutive dates. All patients recovered clinically as shown by a set of aphasia tests. In the acute phase [mean: 1.8 days post-stroke (dps)], patients' group analysis showed little early activation of non-infarcted left-hemispheric language structures, while in the subacute phase (mean: 12.1 dps) a large increase of activation in the bilateral language network with peak activation in the right Broca-homologue (BHo) was observed. A direct comparison of both examinations revealed the strongest increase of activation in the right BHo and supplementary motor area (SMA). These upregulated areas also showed the strongest correlation between improved language function and increased activation (rBHo = 0.88, rSMA = 0.92). In the chronic phase (mean: 321 dps), a normalization of activation with a re-shift of peak activation to left-hemispheric language areas was observed, associated with further language improvement. The data suggest that brain reorganization during language recovery proceeds in three phases: a strongly reduced activation of remaining left language areas in the acute phase is followed by an upregulation with recruitment of homologue language zones, which correlates with language improvement. Thereafter, a normalization of activation is observed, possibly reflecting consolidation in the language system.
Key Words: stroke; aphasia; recovery of function; functional MRI; longitudinal studies
Abbreviations: AAT, Aachen Aphasia Test; AABT, Aachen Aphasia Bedside Test; C, controls; CETI, Communicative Effectiveness Index; fMRI, functional magnetic resonance imaging; IFG, inferior frontal gyrus; LRS, Language Recovery Score; MCA, middle cerebral artery; SMA, supplementary motor area; SPS, spontaneous speech; TT, Token Test
Received December 8, 2005. Revised February 3, 2006. Accepted March 16, 2006.
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