Case Report: True Motor Recovery of Upper Limb Beyond 5 Years Post-stroke

 Lots of big words used so I couldn't figure out how to apply this to my case, 16 years.

Case Report: True Motor Recovery of Upper Limb Beyond 5 Years Post-stroke

 

Carine Ciceron^1,2*, Dominique Sappey-Marinier^3,4, Paola Riffo^1†, Soline Bellaiche^1†, Gabriel Kocevar^3‡, Salem Hannoun^3,5‡, Claudio Stamile^3‡, Jérôme Redoute⁴, Francois Cotton^3,6, Patrice Revol^1,2, Nathalie Andre-Obadia^7,8, Jacques Luaute^1,2 and Gilles Rode^1,2

• ¹Service de Médecine Physique et Réadaptation, Plateforme Mouvement et Handicap, Hôpital Henry Gabrielle, Hospices Civils de Lyon, Pierre-Bénite, France
• ²CRNL (Lyon Neuroscience Research Center, Trajectoires Team), INSERM U1028 & CNRS UMR 5292, Université Claude Bernard-Lyon 1, Bron, France
• ³CREATIS, CNRS UMR 5220 & INSERM U1294, Université Claude Bernard-Lyon1, INSA de Lyon, Université de Lyon, Villeurbanne, France
• ⁴CERMEP-Imagerie du Vivant, Université de Lyon, Bron, France
• ⁵Medical Imaging Sciences Program, Division of Health Professions, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
• ⁶Service de Radiologie, Center Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
• ⁷Service de Neurologie Fonctionnelle et Epileptologie, Hôpital Pierre Wertheimer, Hospices Civils de Lyon, Bron, France
• ⁸CRNL (Lyon Neuroscience Research Center, NeuroPain Team), INSERM U1028 & CNRS UMR 5292, University Claude Bernard-Lyon 1, Bron, France

Most of motor recovery usually occurs within the first 3 months after stroke. Herein is reported a remarkable late recovery of the right upper-limb motor function after a left middle cerebral artery stroke. This recovery happened progressively, from two to 12 years post-stroke onset, and along a proximo-distal gradient, including dissociated finger movements after 5 years. Standardized clinical assessment and quantified analysis of the reach-to-grasp movement were repeated over time to characterize the recovery. Twelve years after stroke onset, diffusion tensor imaging (DTI), functional magnetic resonance imaging (fMRI), and transcranial magnetic stimulation (TMS) analyses of the corticospinal tracts were carried out to investigate the plasticity mechanisms and efferent pathways underlying motor control of the paretic hand. Clinical evaluations and quantified movement analysis argue for a true neurological recovery rather than a compensation mechanism. DTI showed a significant decrease of fractional anisotropy, associated with a severe atrophy, only in the upper part of the left corticospinal tract (CST), suggesting an alteration of the CST at the level of the infarction that is not propagated downstream. The finger opposition movement of the right paretic hand was associated with fMRI activations of a broad network including predominantly the contralateral sensorimotor areas. Motor evoked potentials were normal and the selective stimulation of the right hemisphere did not elicit any response of the ipsilateral upper limb. These findings support the idea that the motor control of the paretic hand is mediated mainly by the contralateral sensorimotor cortex and the corresponding CST, but also by a plasticity of motor-related areas in both hemispheres. To our knowledge, this is the first report of a high quality upper-limb recovery occurring more than 2 years after stroke with a genuine insight of brain plasticity mechanisms.

Introduction

Motor recovery usually occurs within the first 3 months after stroke and is more limited for upper limbs than lower limbs (1–6). Similarly, recent modeling showed that the probability to recover upper limb motor function is extremely limited after the first 12 weeks post-stroke onset (7), which can be explained by the damage sustained by the contralateral corticospinal tract (CST) and the limited vicarious capacities of the motor system to compensate for this complex and lateralized function, especially for the individual finger movement and manual dexterity (8). A patient with a complete motor deficit of the right upper limb after stroke was followed for 12 years. He presented a remarkable late recovery of the upper-limb motility, in terms of strength, individual finger movement, and manual dexterity, 5 years after stroke onset.

The aim of the present study was to assess objectively the upper-limb recovery of this patient over a long-time period and to explore the potential mechanisms underlying this unusually delayed recovery. For this purpose, 3D kinematic analysis were carried out as well as a neuro-anatomo-functional study of the CST, using diffusion tensor imaging (DTI), functional magnetic resonance imaging (fMRI), and transcranial magnetic stimulation (TMS) techniques.

Case Description

The patient was a 53-year-old male, right-handed according to the Edinburgh laterality questionnaire. He underwent a stroke of cardio-embolic origin in the territory of the left superficial middle cerebral artery. He had an initial complete right hemiplegia and a severe mixed aphasia. He experienced intravascular thrombolysis 6 h after the onset of symptoms. His affected inferior limb recovered quite fast, and he was able to walk without limitation 3 months after the stroke, while he was unable to initiate movement in the right upper limb. He never had somato-sensory impairment nor spasticity. After 3 months of inpatient rehabilitation, he was discharged home and kept up with a standard physiotherapy of 30 min, 3 times a week. A home self-training program was monitored by the physiotherapist, including finger tapping exercises as soon as it was possible. The aphasia progressed, and he recovered oral comprehension, but a moderate expressive aphasia persisted. In the affected upper limb, the recovery was delayed and happened very gradually, along a proximal-distal gradient. Slight proximal movements, at the shoulder and elbow, re-appeared 6 months after the stroke onset. Slight global movements of the fingers were observed in the second year. A thumb-index finger grip was possible 4 years after the stroke, and gross prehension the following year. Six years after stroke onset, the movements were dissociated on the whole upper limb comprising the fingers. Nine years after the stroke, all kinds of prehension, gross, and fine, were functional. A brain MRI, performed 10 years after stroke onset, showed a single large infarction in the left superficial middle cerebral artery territory, sparing the cranial part of the precentral gyrus.

More at link.