O comprometimento da comunicação é uma das principais sequelas dos vitimados de acidente vascular encefálico. No Brasil, há extrema carência de instrumentos de avaliação da linguagem e comunicação de afásicos em beira de leito. A avaliação em beira de leito permite a obtenção de benefícios em relação a informações sobre prognóstico e reabilitação e constitui base na qual família, profissionais e serviços de saúde poderão se amparar. Neste estudo, buscou-se verificar a aplicabilidade de um teste de rastreio para detecção de alterações de linguagem decorrentes de acidentes vasculares encefálicos em duas unidades de cuidados específicos, geriatria e neurologia, em hospital destinado a atendimento de alta complexidade. Dessa forma, 108 participantes, divididos em dois grupos, controle (n= 32) e pesquisa (n= 76) foram submetidos à investigação de comunicação por meio da versão em Português do Brasil do Bedside Evaluation Screening Test -2a versão (BEST-2). Foi possível obter o ponto de corte para discriminar sujeitos com desempenho normal e alterado em comunicação. Ademais, este estudo disponibilizou um instrumento que cumpriu a função de ser abrangente incluindo a análise de aspectos preservados e comprometidos em vários subitens linguísticos. A versão em língua portuguesa do BEST-2 mostrou-se útil como rastreio de alterações comunicativas em pacientes com lesão neurológica. Dessa forma, contribuiu para preencher a lacuna de carência de instrumentos formais de avaliação de comunicação em fase aguda, a entender os pressupostos de cada cultura e incentivar o desenvolvimento procedimentos de avaliação corretamente modelados para cada uma delas. / The impairment of communication is one of the main sequelae in victims of stroke. In Brazil there is a vast shortage of instruments to do bedside evaluation of language and communication to aphasics. Bedside evaluation makes it possible to obtain the benefits related to prognosis and rehabilitation data and it constitutes a base in which the family, professionals and health services can rely. The aim of this study was to verify the suitability of a screening test to detect the language alterations resulting from encephalic vascular accidents, in two-specific care-units, geriatrics and neurology, in a hospital for highcomplexity attendance. Therefore, 108 individuals divided into two groups, control (n=32) and research (n=76) were subjected to communication tests through the Brazilian-Portuguese translation of the Bedside Evaluation Screening Test 2nd version (BEST 2). It was possible to attain a cut-off point to discriminate the subjects with normal or altered performance communication. Furthermore, this study provided an instrument that fulfilled the function of being comprehensive including the analysis of preserved and impaired aspects in various linguistic sub-items. The Portuguese language version of BEST 2 proved to be useful to screen communication alterations in patients with neurological lesion. Therefore, it contributed to fill the gap caused by the lack of formal instruments to assess acute-phase communication, to understand the underlying assumptions of each culture and to encourage the development of evaluation procedures correctly modeled for each of them.

Inferências são representações mentais, formadas mediante a interação entre informações linguísticas explícitas e o conhecimento de mundo que um indivíduo tem. É sabido que indivíduos com lesões cerebrais em hemisfério direito (HD) frequentemente falham nesse tipo de tarefa e que esta falha pode interferir na elaboração do discurso oral destes indivíduos. A literatura sobre esse tema é escassa e não são conhecidos os efeitos do local da lesão cerebral no processamento inferencial desses indivíduos. Esta pesquisa teve como objetivos comparar o desempenho de indivíduos normais e indivíduos com lesão de HD em uma tarefa de realização de inferências a partir de estímulos visuais, comparar a elaboração do discurso oral desses sujeitos neste mesmo teste, e verificar o impacto da escolaridade e do local da lesão cerebral nestas tarefas. Para isso, foram avaliados 75 indivíduos normais, com média de idade de 60,3 anos (± 8,5) e escolaridade média de 9,6 anos (± 4,2) e 50 indivíduos com lesão de HD, com média de idade de 58,1 anos (± 12) e escolaridade média de 8,9 anos (± 3,2). Os sujeitos foram avaliados individualmente, através do instrumento 300 exercices de compréhension dinferences logique et pragmatique et de chaînes causales, que requer a realização de inferências lógicas e pragmáticas. Os indivíduos foram orientados a descrever o que estava acontecendo em uma figura determinada (estímulo-alvo) e, em seguida, escolher uma única alternativa (também em forma de figura) que completava a cena anterior. A análise deste teste foi realizada através de pontuações atribuídas (estipuladas pelas pesquisadoras) de acordo com as respostas dos sujeitos. Para a análise do discurso, foram computados o número total de palavras, a quantidade de componentes principais e de proposições incorretas emitidas pelos sujeitos. O desempenho dos grupos foi comparado de acordo com a escolaridade (de quatro a oito anos e acima de nove anos). O desempenho dos pacientes também foi comparado de acordo com o local da lesão (anterior, posterior e ântero-posterior). Verificou-se que: sujeitos com lesão de HD apresentaram pior desempenho nas tarefas de geração de inferência visual, comparados ao grupo controle; na elaboração do discurso, os sujeitos com lesão de HD obtiveram pior desempenho do que o grupo controle, gerando um número elevado de proposições incorretas e um número rebaixado de componentes principais; a escolaridade afetou a habilidade inferencial de pacientes e controles; pacientes com lesões posteriores apresentaram piores resultados nos testes inferenciais e na elaboração do discurso, comparados aos outros locais de lesão / Inferences are mental representations, formed through the interaction between explicit linguistic information and the subjects world knowledge. It is well known that individuals with brain damage in the right hemisphere (RH) often fail in this task and, that this failure can interfere in the elaboration of discourse in these subjects. The literature on this issue is scarce and the effects of the brain injury site in the inferential processing in these individuals are not fully known. This study aimed to compare the performance of normal individuals and individuals with RH lesion in a task of visual inferences, to compare the discourse elaboration of these subjects in this test and to verify the impact of schooling level and the cerebral injury site in the same tasks. We evaluated 75 normal individuals, with an average age of 60.3 years (± 8.5) and schooling average of 9.6 years (± 4.2) and 50 individuals with RH lesion, with an average age of 58.1 years (± 12) and schooling average of 8.9 years (± 3.2). The subjects were individually assessed through the instrument 300 exercices de compréhension dinferences logique et pragmatique et de chaînes causales, which requires the realization of logical and pragmatic inferences. The individuals have been instructed to describe what was happening in a determined picture (target-stimulus) and, then, to choose only one alternative (also a picture) which completes the previous stage. The analysis of this test was carried out through scores (attributed by the researchers) according to the subjects answers. For the discourse analysis, the total numbers of words, the quantity of principal components and of incorrect assertions emitted by the subjects were computed. The performance of the groups was compared according to the schooling level (four to eight years and above nine years). The performance of patients also was compared according to the lesion site. We concluded that: subjects with RH lesion performed poorer in the tasks of visual inference generation when compared to the control group; in the discourse elaboration, subjects with RH lesion also performance worse than the control group, generating an elevated number of incorrect propositions and a low number of principal components; the level of schooling had influence on the inference skills for both groups; patients with posterior lesions had the worst performance in the inferential tests and discourse elaboration, when compared to other lesion sites

Nas últimas décadas houve o aumento da ocorrência de doenças crônicas no Brasil, dentre elas o Acidente Vascular Encefálico (AVE) se destaca. O AVE frequentemente acarreta perdas funcionais e a dependência por cuidadores. A compreensão da percepção da Qualidade de Vida (QV) e o impacto do AVE sobre os acometidos e seus cuidadores torna-se muito importante, uma vez que se apresenta como um problema de saúde pública no país. Este estudo teve como objetivo avaliar a QV dos indivíduos acometidos por AVE e a de seus cuidadores e também descrever o perfil sociodemográfico e clínico. Tratou-se de um estudo observacional do tipo inquérito transversal, desenvolvido em um município do Triângulo Mineiro envolvendo 83 indivíduos que sofreram um AVE sendo todos assistidos pela Estratégia Saúde da Família (EsSF). Os indivíduos participantes foram separados em 4 grupos, sendo o grupo dos indivíduos com AVE que possuem cuidadores (44), grupo dos indivíduos com AVE sem cuidadores (39), grupo dos cuidadores (44) e um grupo de referência (83) no período de março a maio de 2010. Foi utilizado um questionário contendo dados sociodemográficos e clínicos para os indivíduos com AVE e cuidadores. Para avaliação da QV o instrumento WHOQOL-bref (World Health Organization Quality of Life-bref) foi aplicado à todos os grupos. Para os dois grupos de indivíduos com AVE ainda foi aplicado um instrumento específico denominado SSQOL (Stroke-specific of Quality of Life). Os indivíduos com AVE tinham idade média de 61,93 anos, a maioria do sexo masculino, casados, religião católica, aposentados/pensionistas, baixa renda e responsáveis por ela, baixa escolaridade e 53% possuíam cuidador. Os cuidadores tinham idade média de 49,25 anos, maioria do sexo feminino, filhos (as), casados, religião católica, exerciam outra atividade, baixa renda e escolaridade, longo tempo de cuidado e não tinham dificuldade para o cuidado. O AVE do tipo isquêmico foi o mais encontrado, tempo de diagnóstico de 5 ou mais anos, presença de antecedentes familiares (41%), recidivas (20%) e 51% dos indivíduos possuíam algum grau de dependência. Estavam presentes o tabagismo (54%), etilismo (27%) e a hipertensão arterial (94%). Em relação à QV geral o grupo de AVE com cuidadores apresentou o menor escore. Podemos observar que nos domínios físico, psicológico e meio ambiente o escore médio foi menor para o grupo de AVE com cuidadores. Os maiores escores para estes três domínios foram observados de forma crescente no grupo de AVE sem cuidadores seguido pelo grupo de cuidadores e pelo grupo de referência. No domínio relações sociais observamos que o escore para o grupo de AVE com cuidadores (71,02) foi um pouco maior que o escore médio do grupo de AVE sem cuidadores (70,94). A comparação dos escores em todos os grupos evidenciou que a presença do AVE e o fato de ser cuidador afeta a QV em todos os domínios do WHOQOL-bref. A QV avaliada pelo SSQOL evidenciou que os domínios mais afetados foram o da personalidade, papéis sociais e energia. Ao compararmos os dois grupos com AVE observamos que 6 dos 12 domínios apresentaram diferenças significativas. Esta pesquisa pode ajudar a entender o impacto que o AVE causa na vida dos acometidos e na de seus cuidadores, assim como melhor orientar políticas públicas destinadas a esta população. / There was a raise of chronic diseases occurrence in Brazil in the last decades, among them the stroke detaches itself. The stroke, frequently leads to functional losses and dependency for caregivers. The awareness comprehension of the Quality of Life (QOL) and the stroke impact to the patients and their caregivers become very important, once it shows itself as a healthy problem in the country. This research aimed to evaluate the QOL of patients suffering from strokes and their caregivers and describe the sociodemographic and clinical profile. It was a transversal inquire observational research developed in a city of Triangulo Mineiro involving 83 people who suffered a stroke are all assisted by the Family Health Strategy (EsSF). The participants were separated in 4 different groups: the ones with stroke who had caregivers (44); the ones with stroke without caregivers (39); caregivers group (44) and a reference group (83) from March to May 2010. It was used a questionnaire with the social demographic and clinic dates to the people with stroke and caregivers. To evaluate the QOL it was used the tool WHOQOL-bref (World Health Organization Quality of Life-bref) in all the groups. For both groups with of individuals with stroke has been applied another specific tool called SSQOL (Stroke-specific of Quality of Life). The average age of stroke people was 61,93 years old, most of them male, married, catholic, retired, underpaid and responsible for it, not properly educated and 53% had a caregiver. The caregivers were 49,25 years old, most of them females, daughters and sons, married, catholic, had another activity, underpaid and not properly educated, long care period and had no problems for this activity. The skemical stroke was the most common to be found, 5 or more years of diagnosis time, previous familiar case (41%), repetitions (20%) and 51% 51% of subjects had some degree of dependence. Among them we found, smoking (54%), drinking (27%) and high blood pressure (94%). About general QOL the strokes group with caregivers showed a lower score. We observe that the physical, psychological and environmental domain, the average score was inferior to the strokes groups with caregivers. The highest scores for those three groups were observed increasingly in the strokes group without caregivers followed by caregivers group and the reference group. About the social relation domain, we could see that the strokes group with caregivers score (71,02) was similar the average score from the strokes group without caregivers (70,94). The scores comparison showed that the strokes presence and the fact of being taken care affects QOL in all the domain of the WHOQOL-bref. The QOL evaluated by SSQOL showed the most affected domain were: the personality, social chores and energy. When we compare both groups with stroke we can see that 6 of 12 domains showed significant differences. This research can help o understand the strokes impact in the victims and caregivers lives as well better guidance at public polices for this population.

Introdução: Apesar da relevância epidemiológica da doença cerebrovascular, há poucos estudos sobre o tema no Brasil e nenhum em populações amazônicas, especialmente entre os ribeirinhos. Os objetivos deste estudo foram: estimar incidência, letalidade e desfechos funcionais de casos hospitalares após 28 dias do evento no município de Coari, estado do Amazonas (Brasil); conhecer a prevalência e mortalidade associada à doença cerebrovascular em população urbana e ribeirinha na cidade, e comparar distribuições desta doença entre as duas populações urbana e ribeirinha neste município da Amazônia brasileira. Métodos: O estudo envolveu população ribeirinha e urbana com idade igual ou superior a 35 anos com residência na cidade de Coari, e, baseado na estratégia The WHO STEPwise approach to Stroke Surveillance, foi dividido em três etapas. A etapa 1, realizada de outubro de 2010 a outubro de 2011, coletou dados sociodemográficos, relativos à manifestação clínica e funcional de pacientes com acidente vascular cerebral admitidos no Hospital Regional de Coari em até 28 dias após o evento. A etapa 2 analisou dados secundários de óbitos associados ao evento cerebrovascular no município no período de 2003 a 2010 por área de residência. A etapa 3 tratou-se de um estudo de prevalência de casos não fatais desta doença na área rural e urbana da cidade, com rastreamento realizado pelos agentes comunitários de saúde entre maio e outubro de 2011 por meio da aplicação do questionário de sintomas de doença vascular cerebral. Resultados: A amostra hospitalar apresentou maioria de idosos, homens, pardos e com baixo nível socioeconômico. Verificou-se, na admissão, maioria com grave comprometimento neurológico (73,4%). Em 28 dias, A letalidade foi de 34,8% (intervalo de confiança, IC95% 15,3 54,3) e houve baixo nível de independência funcional. De um total de 1.059 mortes em indivíduos acima de 35 anos no período, 14% foram associadas ao acidente vascular cerebral. No total, as taxas brutas de mortalidade associada à doença cerebrovascular nas populações rural e urbana foram, respectivamente: 55,6 (IC95% 37,0 83,7) e 139,6 (IC95% 117,0 166,6) por 100.000 habitantes. O risco relativo desta mortalidade na área urbana em relação à rural foi de 2,17 (IC95% 1,39 3,39). No estudo transversal, houve um total de 4.897 respondentes na área urbana e 1.028 na rural. As prevalências brutas foram 6,3% entre os ribeirinhos e 3,7% entre os citadinos, com diferenças mantidas após ajuste por sexo e idade. Dentre os casos, os ribeirinhos tiveram menos acesso a tratamento de saúde que os da área urbana (razão de prevalência de 1,37; IC95% 1,02 1,85), independente de idade, sexo, educação e prejuízo funcional. Conclusões: Houve alta letalidade, graves comprometimentos neurológicos e prejuízos funcionais entre os casos hospitalares de doença cerebrovascular, não sendo possível estimar incidência hospitalar. Os indivíduos da área urbana apresentaram maior mortalidade associada à doença cerebrovascular no período de 2003 a 2010 e menor prevalência por esta doença em comparação aos ribeirinhos, além de altas prevalências nas duas populações. A urbanização recente, baixo nível socioeconômico da região e carência de cuidado e acesso a serviços de saúde, principalmente entre os ribeirinhos, podem ter influência nas mortalidades e, consequentes, prevalências nas populações amazônicas investigadas / Introduction: Despite the public health relevance of cerebrovascular disease, there are few studies addressing stroke epidemiology in Brazil and none in populations in the Amazon forest, especially among ribeirinhos. The objectives of this study were: to estimate incidence, case-fatality and functional outcomes of hospital cases after 28 days of the event in the municipality of Coari, state of Amazonas (Brazil); to know the prevalence and mortality associated to cerebrovascular disease in urban population and ribeirinha in the town, and compare distributions of this disease in two populations in this town of the Brazilian Amazon. Methods: The study involved ribeirinha and urban populations aged 35 years or older with residence in the town of Coari and, based on The WHO STEPwise approach to Stroke Surveillance, was divided into three steps. The Step 1, performed from October 2010 to October 2011, collected sociodemographic data, relating to clinical and functional manifestation of stroke patients admitted to the Hospital Regional de Coari up to 28 days after the event. The Step 2 examined secondary data on deaths associated to stroke in the municipality in the period from 2003 to 2010 by area of residence. The Step 3 it was a study of prevalence of non-fatal stroke cases in the rural and in the urban areas of the town, with screening conducted by community health workers between May and October 2011 by using the questionnaire of symptoms of stroke. Results: The hospital sample showed a majority of elderly, men, mixed and with low socioeconomic status. It was found majority with severe neurological impairment at admission (73.4%). At 28 days, the case-fatality was 34.8% (95% CI 15.3 to 54.3) and there was a low level of functional independence. From a total of 1,059 deaths in individuals over 35 years in the period, 14% were associated to stroke. Overall, rates crude mortality associated to stroke in rural and urban populations were, respectively: 55.6 (95% CI 37.0 to 83.7) and 139.6 (95% CI 117.0 to 166.6) per 100,000 inhabitants. The relative risk of this mortality in the urban area compared to the rural was 2.17 (95% CI 1.39 to 3.39). In a cross-sectional study, there were a total of 4,897 respondents in the urban area and 1,028 in the rural area. The crude prevalences of stroke were 6.3% among the ribeirinhos and 3.7% among the urban dwellers, with differences maintained after age- and sex-adjustment. Among the cases, the ribeirinhos had less access to health treatment than those of the urban area (prevalence ratio of 1.37; 95% CI 1.02 to 1.85), independent of age, sex, education and functional impairment. Conclusions: There was high case-fatality, severe neurological damage and functional impairment among the hospital stroke cases, it was not possible to estimate hospital incidence. The individuals of the urban area had higher mortality associated to stroke in the period 2003 to 2010 and lower prevalence of stroke in comparison to the ribeirinhos, and high prevalence rates in both populations. The recent urbanization, low socioeconomic status of the region and lack of care and access to health services, especially among the ribeirinhos, may have influence on mortalities and, consequent, prevalences in Amazonian populations investigated

As disfonias neurológicas são distúrbios vocais que acompanham lesões ou alterações no sistema nervoso. O Acidente Vascular Encefálico (AVE) é a segunda causa de morte no mundo e os danos cerebrais causados podem afetar a comunicação do indivíduo em diversos aspectos. As alterações de voz características dessas lesões são pouco descritas quanto à localização e extensão do acometimento cerebral. Desta forma, torna-se importante compreender a interferência das alterações no Sistema Nervoso Central (SNC) na produção da voz, visando maior substrato para reabilitação. Os objetivos do trabalho foram caracterizar a população de pacientes acometidos por AVE conforme a topografia da lesão observada ao exame de Tomografia Computadorizada (TC) e relacionar tais achados com as características fonatórias encontradas. Participaram do estudo 10 idosos acometidos por AVE. Foram realizadas avaliação perceptivo-auditiva da voz por meio d o protocolo CAPE-V, análise do Tempo Máximo de Fonação e avaliação da diadococinesia (DDC) laríngea, por meio do programa Motor Speech Profile Advanced, da KayPentax. Os exames de neuroimagem foram classificados quanto a localização, extensão, lateralidade e território de vascularização da lesão cerebral. Foi observado um grupo homogêneo de cinco sujeitos que apresentaram AVEs extensos de acometimento da artéria cerebral média e outros cinco sujeitos que apresentaram AVEs de menor extensão e com localização variada no cérebro. Os resultados da avaliação de voz foram relacionados com os achados dos exames de imagem e foi observado que não houve relação entre a localização e extensão da lesão cerebral com as alterações vocais dos indivíduos. As vozes dos sujeitos mostraram predominantemente presença de rugosidade, instabilidade e pastosidade, além de velocidade reduzida e instabilidade na repetição de vogais, indicativas de alteração no controle motor laríngeo, bem como redução dos tempos máximos de fonação, indicativos de alteração no controle do fluxo aéreo. / Neurological dysphonias are vocal disorders accompanying injuries or changes in the nervous system. The Cerebrovascular accident is the second leading cause of death worldwide and the brain damage caused by it can affect an individual\'s communication in several aspects. The voice changes characteristical of these lesions are poorly described as location and extent of cerebral involvement. Thus, it becomes important to understand the influence of changes in central nervous system on voice production, aiming to increase the substrate for rehabilitation. The objectives were to characterize the population of patients who had stroke according to the topography of the lesion to the cerebral computed tomography and correlate these findings with the phonatory characteristics found. The study included 10 elderly patients whit stroke. The perceptual voice analysis through the CAPE-V protocol, the Maximum Phonation Time and larynx diadochosinesis (DDK), through the program Advanced Motor Speech Profile of Kay Pentax, were evaluated. Neuroimaging studies were classified according to location, extent and laterality of the vascular territory of brain injury. Were observed imaging studies from a homogeneous group of five patients who had strokes extensive involvement of the middle cerebral artery and another five patients who had less extensive strokes and varied location in the brain. The results of the voice analysis were related to the fidings of imaging studies. It was found no relationship between the location and extent of brain injury with individuals vocal changes. The voices of the subjects showed presence of roughness, instability and pastiness, changes in larynx motor control and air flow control.

Gao Shan. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2002. / Includes bibliographical references (leaves 191-194). / Abstracts in English and Chinese. / Abstract in English --- p.i / Abstract in Chinese --- p.iii / Acknowledgement --- p.v / Introduction --- p.vi / Contents --- p.viii / List of tables --- p.xiv / List of figures --- p.xv / Chapter Chapter One --- Literature Review / Chapter 1.1 --- Middle Cerebral Artery (MCA) Stenos --- p.is / Chapter 1.1.1 --- Prevalence of atherosclerotic MCA stenosis --- p.2 / Chapter 1.1.2 --- Methods for diagnosis of MCA stenosis --- p.3 / Chapter 1.1.3 --- Possible mechanism and course of stroke with MCA stenosis --- p.4 / Chapter 1.1.4 --- Treatment and prevention of stroke in patients with MCA stenosis --- p.5 / Chapter 1.2 --- Microembolic Signal (MES) Detection / Chapter 1.2.1 --- Introduction --- p.9 / Chapter 1.2.2 --- Technology --- p.9 / Characteristics of MES / Factors that affect MES detection / Problems of technology / Chapter 1.2.3 --- Clinical application --- p.15 / MES originating from atherosclerotic carotid artery stenosis / MES detection in internal carotid endarterectomy (CEA) / MES detection in patients with MCA stenosis / Predicting value and application in therapeutic trial / References --- p.19 / Chapter Chapter Two --- General Methodology / Chapter 2.1 --- Transcranial Doppler (TCD) Diagnosis for Intracranial Artery Stenosis / Chapter 2.1.1 --- TCD spectrum and common parameters --- p.29 / Chapter 2.1.2 --- Emitting and receiving transducers --- p.29 / Chapter 2.1.3 --- Pulsitility index (PI) --- p.31 / Chapter 2.1.4 --- Insonation depth and flow direction --- p.31 / Chapter 2.1.5 --- Continuous wave (CW) and pulsed wave (PW) --- p.33 / Chapter 2.1.6 --- Normal intracranial arteries through temporal and suboccipital window --- p.33 / Chapter 2.1.7 --- Normal intracranial arteries through orbital window --- p.36 / Chapter 2.1.8 --- Normal extracranial arteries --- p.36 / Chapter 2.1.9 --- TCD diagnosis for intracranial artery stenosis --- p.39 / Chapter 2.1.10 --- Example of multiple intracranial arteries stenosis --- p.39 / Chapter 2.2 --- Microembolic Signal (MES) Detection / Chapter 2.2.1 --- Device of MES monitoring --- p.41 / Chapter 2.2.2 --- Insonated artery and depth --- p.41 / Chapter 2.2.3 --- Axis length of the sample volume --- p.43 / Chapter 2.2.4 --- Fast Fourier Transform (FFT) time window overlap --- p.43 / Chapter 2.2.5 --- Distinguishing embolic signal and artifact with two-gate transducer --- p.45 / Chapter 2.2.6 --- Measurements of embolic signal and threshold --- p.47 / References --- p.45 / Chapter Chapter Three --- Prevalence and Clinical Significance of Microembolic Signal (MES) in Patients with Middle Cerebral Artery (MCA) Stenosis / Chapter 3.1 --- Abstract --- p.50 / Chapter 3.2 --- Introduction --- p.51 / Chapter 3.3 --- Methodology --- p.51 / Patients / Severity of stroke and clinical course / Diagnosis for middle cerebral artery (MCA) stenosis / Microembolic signal (MES) detection / Statistical analysis / Chapter 3.4 --- Results --- p.55 / Baseline information of patients / Prevalence of MES / Relationship between presence of MES and severity of MCA stenosis / Correlation between presence of MES and clinical course in 85 symptomatic patients / Correlation between the count of MES and clinical course in 85 symptomatic patients / Correlation between the presence of MES and further ischemic stroke / Chapter 3.5 --- Discussion --- p.63 / Prevalence of MES / Association between severity of stroke and presence or the number of MES / Predictive value of MES for further stroke / References --- p.66 / Chapter Chapter Four --- Mechanisms of Acute Cerebral Infarction in Patients with Cerebral Artery Stenosis: a Diffusion-weighted Imaging and Microemboli Monitoring study / Chapter 4.1 --- Abstract / Chapter 4.2 --- Introduction --- p.72 / Chapter 4.3 --- Methodology --- p.73 / Patients / Microembolic signal (MES) detection by transcranial Doppler (TCD) / "Magnetic resonance imaging (DWI, MRI and MRA)" / Statistical analysis / Chapter 4.4 --- Results --- p.77 / Severity of MCA stenosis on MRA and pattern of infarct on DWI / Frequency and count of MES and its relationship with multiple and borderzone infarction on DWI / Chapter 4.5 --- Discussion --- p.79 / Frequency of MES / Pattern of cerebral infarcts on DWI / Relationship between MES and multiple infarcts on DWI / References --- p.83 / Chapter Chapter Five / Chapter Chapter Five-I --- Novel Observations of the Characteristics of Real Time Genesis of Thromboembolism in Middle Cerebral Artery Stenosis Detected by Transcranial Doppler / Chapter 5.1.1 --- Abstract --- p.90 / Chapter 5.1.2 --- Introduction --- p.91 / Chapter 5.1.3 --- Methodology --- p.91 / Characteristics of patients / "MRA, DWI and conventional TCD data" / MES monitoring method and overall data / Neuroimaging and MES monitoring data in all five patients / Signal analysis in off-line / Confirmation test for the origin of MES / Chapter 5.1.4 --- Results --- p.104 / Frequency of three special phenomena / Characteristics of three special phenomena / Results of confirmation test for embolic source / Chapter 5.1.5 --- Discussion --- p.133 / Occurrence of MES with flow velocity change simultaneously / MES splatter / Bi-directional low frequency (S-velocity) vibration / Testing for source of MES detected from MCA stenosis / References --- p.139 / Chapter Chapter Five-II --- Characteristics of Microembolic Signals Detected near Its Origin from the Middle Cerebral Artery Stenosis / Chapter 5.2.1 --- Abstract --- p.143 / Chapter 5.2.2 --- Introduction --- p.144 / Chapter 5.2.3 --- Methodology --- p.144 / Patients / Microembolic signal (MES) detection / Classification of MES / Chapter 5.2.4 --- Results --- p.145 / Types of MES detected from MCA stenosis / Characteristics of three types of MES / Chapter 5.2.5 --- Discussion --- p.157 / Emboli moving from vessel wall to the center / Emboli vibration / About calculating the time delay between two channels / References --- p.160 / Chapter Chapter Five-III --- "Hemodynamic change,microembolic signal counts and use of antithrombotic treatments" / Chapter 5.3.1 --- Abstract --- p.163 / Chapter 5.3.2 --- Introduction --- p.164 / Chapter 5.3.3 --- Methodology --- p.164 / Chapter 5.3.4 --- Results / "The relationship among flow velocity, the number of MES and time since symptom onset" --- p.165 / Patient one / Patient two / Patient three / Chapter 5.3.5 --- Discussion / Association between flow velocity or MES change and different anticoagulants in acute stage / Progression of MCA stenosis after acute stage / Stability of MCA atherosclerotic stenosis / References --- p.173 / Chapter Chapter Six --- The Optimal Values of Flow Velocity on Transcranial Dopplerin Grading Severity of Middle Cerebral Artery Stenosis in Comparison With Magnetic Resonance Angiography / Chapter 6.1 --- Abstract --- p.179 / Chapter 6.2 --- Introduction --- p.180 / Chapter 6.3 --- Methodology --- p.180 / Patients / TCD examination / Grading of MCA stenosis on MRA / Statistical analysis / Chapter 6.4 --- Results --- p.182 / Detection of >50% MCA stenosis according to flow velocity / Grading severity of MCA stenosis by flow velocity / Chapter 6.5 --- Discussion --- p.186 / Reliability of TCD diagnosis for MCA stenosis / Grading MCA stenosis according to flow velocity on TCD / References / Abbreviations --- p.189 / Publications --- p.191

OBJECTIVE: Determine if complex singular value decomposition (cSVD) used as preprocessing in the maximum slope algorithm reduces image noise of resultant physiologic parametric images. Noise will be decreased in the parametric maps of cerebral blood flow (CBF), cerebral blood volume (CBV) as compared to the same algorithm and data set with no cSVD applied. MATERIALS AND METHODS: A set of 10 patients (n=15) underwent a total combined 15 CT perfusion studies upon presenting with stroke symptoms. It was determined these patients suffered from occlusions resulting in a prolonged arrival time of blood to the brain. DICOM data files of these patients scans were selected based on this increased arrival delay. We compared the output of estimation calculations for cerebral blood flow (CBF), and cerebral blood volume (CBV), using preprocessing cSVD against the same scan data with no preprocessing cSVD. Image noise was assessed through the calculation of the standard deviation within specific regions of interest copied to specific areas of grey and white matter as well as CSF space. A decrease in the standard deviation values will indicate improvement in the noise level of the resultant images.. Results for the mean value within the regions of interest are expected to be similar between the groups calculated using cSVD and those calculated under the standard method. This will indicate the presence of minimal bias. RESULTS: Between groups of the standard processing method and the cSVD method standard deviation (SD) reductions were seen in both CBF and CBV values across all three ROIs. In grey matter measures of CBV, SD was reduced an average of 0.0034 mL/100g while measures of CBF saw SD reduced by an average of 0.073 mL/100g/min. In samples of white matter, standard deviations of CBV values were reduced on average by 0.0041mL/100g while CBF SD's were reduced by 0.073 mL/100g/min. CSF ROIs in CBV calculations saw SD reductions averaging 0.0047 mL/100g and reductions of 0.074 mL/100g/min in measures of CBF. Bias within CBV calculations was at most minimal as determined by no significant changes in mean calculated values. Calculations of CBF saw large downward bias in the mean values. CONCLUSIONS: The application of the cSVD method to preprocessing of CT perfusion imaging studies produces an effective method of noise reduction. In calculations of CBV, cSVD noise reduction results in overall improvement. In calculations of CBF, cSVD, while effective in noise reduction, caused mean values to be statistically lower than the standard method. It should be noted that there is currently no evaluation of which values can be considered more accurate physiologically. Simulations of the effect of noise on CBF showed a positive correlation suggesting that the CBF algorithm itself is sensitive to the level of noise.

Auditory comprehension, the ability to understand spoken language, consists of a number of different auditory processing skills. In the five studies presented in this thesis I investigated both intact and impaired auditory comprehension at different levels: voice versus phoneme perception, as well as single word auditory comprehension in terms of phonemic and semantic content. In the first study, using sounds from different continua of ‘male’-/pæ/ to ‘female’-/tæ/ and ‘male’-/tæ/ to ‘female’-/pæ/, healthy participants (n=18) showed that phonemes are categorised faster than voice, in contradistinction with the common hypothesis that voice information is stripped away (or normalised) to access phonemic content. Furthermore, reverse correlation analysis suggests that gender and phoneme are processed on the basis of different perceptual representations. A follow-up study (same paradigm) in stroke patients (n=25, right or left hemispheric brain lesions, both with and without aphasia) showed that lesions of the right frontal cortex (likely ventral inferior frontal gyrus) leads to systematic voice perception deficits while left hemispheric lesions can elicit both voice and phoneme deficits. Together these results show that phoneme processing is lateralized while voice information processing requires both hemispheres. Furthermore, this suggests that commencing Speech and Language Therapy at a low level of acoustic processing/voice perception may be an appropriate method in the treatment of phoneme perception impairments. A longitudinal case study (CF) of crossed aphasia (rare acquired communication impairment secondary to lesion ipsilateral to the dominant hand) is then presented alongside a mini-review of the literature. Extensive clinical investigation showed that CF presented with word-finding difficulties related to impaired auditory phonological analysis, while functional Magnetic Resonance Imaging (fMRI) analyses showed right hemispheric lateralization of language functions (reading, repetition and verb generation). These results, together with the co-morbidity analysis from the mini-review, suggest that crossed aphasia can be explained by developmental disorders which cause partial right lateralization shift of language processes. Interestingly, in CF this process did not affect voice lateralization and information processing, suggesting partial segregation of voice and speech processing. In the last two studies, auditory comprehension was examined at the single word level using a word-picture matching task with congruent (correct target) and incongruent (semantic, phonological and unrelated foils) conditions. fMRI in healthy participants (n=16) revealed a key role of the pars triangularis (phonological processing), the left angular gyrus (semantic incongruency) and the left precuneus (semantic relatedness) in this task – regions typically associated via the arcuate fasciculus and often impaired in aphasia. Further investigation of stroke patients on the same task (n=15) suggested that the connections between the angular gyrus and the pars triangularis serve a fundamental role in semantic processing. The quality of a published word-picture matching task was also investigated, with results questioning the clinical relevance of this task as an assessment tool. Finally, a pilot study looking at the effect of a computer-assisted auditory comprehension therapy (React2©) in 6 stroke patients (vs. 6 healthy controls and 6 stroke patients without therapy) is presented. Results show that the more therapy patients carry out the more improvement is seen in the semantic processing of single nouns. However, these results need to be reproduced on a larger scale in order to generalise any outcomes. Overall, the findings from these studies present new insight into, as well as extending on, current cognitive and neuroanatomical models of voice perception, speech perception and single word auditory comprehension. A combinatorial approach to cognitive and neuroanatomical models is proposed in order to further research, and thus improve clinical care, into impaired auditory comprehension.

Background: Fatigue is common and distressing after stroke. Many stroke survivors say it is their worst or one of their worst symptoms. The frequency of clinically significant fatigue, whether fatigue is likely to be more or less problematic over time, and its aetiology are unknown. There are currently no known treatments. One hypothesis is that fatigue after stroke is triggered by physical deconditioning which sets up a self-perpetuating cycle of fatigue, avoidance of physical activity, further deconditioning and more fatigue. Another theory is that low mood may contribute to fatigue. Aims: This thesis therefore aims to investigate the frequency and natural history of fatigue after stroke and to explore its associations with mood, physical activity and/or fitness. Method: These aims were addressed by carrying out: 1) a systematic review of all longitudinal observational studies which have assessed fatigue on at least two separate time points and reported its frequency, 2) a systematic review of all observational studies which have measured both fatigue poststroke and one or more measures of physical activity and/or fitness at the same time point and 3) a longitudinal cohort study which assessed clinically significant fatigue, mood and physical activity and fitness at one, six and 12 months after stroke. Results: Frequency of fatigue ranged from 30% to 92% at first time point and frequency of fatigue decreased over time in seven of the ten studies identified in the systematic review of longitudinal studies. The second systematic review found that only two of the eight studies identified found a significant direct relationship between fatigue and physical activity and/or fitness poststroke. In the longtidudinal cohort study, clinically significant fatigue was identified in 32.6% of 132 participants at one month and was still present in a fifth of 91 participants at 12 months, two-thirds of participants who had clinically significant fatigue at one month did not have it by six months and that most (60.4%) individuals either reported fatigue at all three time points or that they did not have fatigue at any time point. There were significant associations between daily step count and fatigue at each time point (p= < 0.0001, 0.011, 0.006). Physical activity (p=0.002, 0.006) and anxiety (p= < 0.0001, 0.001) at one month were independent significant predictors of fatigue severity at six and 12 months after stroke. Age, gender, fatigue before stroke, step count and anxiety at one month accounted for 22% and 27% of the variance in fatigue severity at six and 12 months respectively. No significant associations were found between fatigue and measures of physical fitness. Discussion and conclusion: The findings suggest that although fatigue is common and persistent after stroke, it is more likely to become less problematic over time. They also suggest that the de-conditioning hypothesis of the aetiology of fatigue may be too simplistic and that other factors are involved in the development and perpetuation of fatigue after stroke. Implications are that patients should be assessed for fatigue early after stroke and that the development of an intervention which increases activity and/or reduces anxiety may be beneficial.

Le but de cette étude était d'évaluer les limitations fonctionnelles chez les adultes avec antécédent d’AVC et de décrire le devenir fonctionnel des patients admis en rééducation en France, suite à un AVC aigu, en fonction du type de structure (spécialisée ou non). Les données de l’enquête Handicap-Santé et les bases PMSI 2009 (Programme de Médicalisation du Système d'Information) ont été utilisé. La prévalence globale de l'AVC était de 1,6% de la population française adulte (dont 34,4% dépendants). Les difficultés pour l’autonomie augmentent avec l'âge, mais le risque relatif de dépendance diminuait avec l’âge (17 à 25 avant 60 ans ; 1,5 à 2,2 après 85 ans). 10,3% des participants ont déclaré raideur articulaire liée à l'AVC mais son impact fonctionnel n'était pas significatif lorsqu’était inclus dans le modèle le niveau de déficience motrice (OR = 1,18; IC = 0,60-2,29). Enfin suite à un AVC, parmi les 83 505 survivants, 28 201 ont été admis pour la réhabilitation (33,8%). Après ajustement, la rééducation en centre spécialisé était liée à une plus grande probabilité d'amélioration fonctionnelle (OR = 1,75, p <0,001) / The aim of this study was to evaluate functional limitations in adults with and without self-reported stroke and to describe the functional outcome of post-stroke patients admitted for rehabilitation in France as a function of the rehabilitation setting (specialized or not). Data from a survey named “the Disability Health survey” and from the French Hospital Discharge Diagnosis databases were used. The overall prevalence of stroke was 1.6%. The mRS was over 2 for 34.4% of participants with stroke. Difficulty with activity of daily living increased with age but the relative risk was higher below the age of 60 (17 to 25) than over 85 years (1.5 to 2.2). 10.3 % of the participants reported stroke-related stiffness. When included motor impairment, multivariate analysis of the functional impact of the joint stiffness was not significant (OR= 1.18; CI = 0.60-2.29). Among the 83 505 survivors of acute stroke in 2009, 28 201 were admitted for rehabilitation (33.8%). After adjustment, rehabilitation in specialized center lead to a greater probability of functional improvement (OR=1.75, p<0.001)