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Basal ganglia accounts to most common site of hemorrhagic stroke (50%). Right hemisphere lesions that are restricted to basal ganglia are responsible for perceptual disorders such as unilateral neglect. Unilateral Neglect is a very common perceptual disorder that occurs after stroke. Unilateral neglect when compared to the stroke severity results in poor overall recovery. It may involve longer hospitalization period, functional dependency, long term disability in ADLs as well as increased risk of falls. Postural imbalance is more prevalent with right hemisphere lesions. Stroke survivors with right hemisphere damage have less ability to ambulate. As the stroke patient’s balance is impaired and can lead to serious consequences like falls. So, if we know the questions related to balance and gait in stroke patients then it would be very important for us to understand these two physical capabilities among the hemiparetic subjects. It is therefore believed that it will lead to a better direction regarding the rehabilitation of these stroke patients. The case report presented here describes the clinical presentation of a right basal ganglia bleed patient who had unilateral neglect.
Amity Institute of Physiotherapy, Amity University, Noida, Uttar Pradesh, India
Meena Gupta*
Amity Institute of Physiotherapy, Amity University, Noida, Uttar Pradesh, India
*Address all correspondence to: mgupta9@amity.edu
1. Introduction
Stroke is the 3rd major cause of morbidity and mortality in many countries. It is basically of three types: ischemic, thrombotic & hemorrhagic. Ischemic stroke results from reduced blood supply, thrombotic stroke results from clot formation in a blood vessel whereas hemorrhagic stroke results from rupture of blood vessel. The latter is of following two types: intracerebral and subarachnoid [1]. Among the intracerebral hemorrhage, basal ganglia bleed is most common. It usually results from poorly controlled or long-standing hypertension [2]. Cigarette smoking and alcohol consumption further adds on to the risk of developing such stroke. Basal ganglia accounts to most common site of hemorrhagic stroke (50%). Other sites are cerebral lobes (10%), pons & brainstem (10–20%), thalamus (15%) and cerebellum (10%) [2, 3]. Right side cortical stroke is closely related to perceptual disorders. Many studies suggests that right hemisphere lesions that are restricted to basal ganglia are responsible for perceptual disorders such as unilateral neglect [4]. Unilateral Neglect is a very common perceptual disorder that occurs after stroke. It can be defined as the inability to respond, report or orient to stimuli on contralateral side to brain lesion [5]. ULN is of different types. On the basis of behavior that is elicited it is classified into sensory, motor, and representational type and on the basis of abnormal behavior distribution ULN is of personal & spatial type [6]. Unilateral neglect can be assessed by many qualitative as well as quantitative tools such as Behavioral Inattention Test, Cancelation test, Line bisection test, Copying & drawing test, Catherine Bergego Scale etc. Unilateral neglect when compared to the stroke severity results in poor overall recovery. It may involve longer hospitalization period, functional dependency, long term disability in ADLs as well as increased risk of falls [7]. Postural imbalance is more prevalent with right hemisphere lesions. Stroke survivors with right hemisphere damage have less ability to ambulate. This is because they have lesser ability to shift weight on the non-paretic leg [8]. Acquiring independence of gait is one of the prime goals in rehabilitation of stroke subjects. Unilateral Neglect leads to poor gait recovery of activity of daily living as well as gait [9, 10]. Unilateral neglect when clubbed with cognitive impairment has a negative impact on independent gait recovery. Thus, this indicates that the unilateral neglect when combined with cognitive impairments is a strong negative predictor for independent gait [11]. Postural instability is the main cause of falls & limited functional independence among the stroke patients. Posture deficits as well as balance deficits is very common. This is because the good limb has to bear a greater proportion of the body weight. The correlations of parameters of balance and gait is utmost important for thorough assessment of stroke subjects as well as for their proper rehabilitation. This is because a reliable correlation means that resources used to improve balance could also influence gait. As the stroke patient’s balance is impaired and can lead to serious consequences like falls. So, if we know the questions related to balance and gait in stroke patients then it would be very important for us to understand these two physical capabilities among the hemiparetic subjects. It is therefore believed that it will lead to a better direction regarding the rehabilitation of these stroke patients. The case report presented here describes the clinical presentation of a right basal ganglia bleed patient who had unilateral neglect.
A 40-year male presented with weakness in left arm & and leg along with difficulties in doing ADLs as well as walking since last 2 years. He also complained of occasional headaches. It is a known Follow up case of right basal ganglia bleed with Left Complete Hemiplegia. 2 years prior to episode of stroke, the patient had gone to pick up his elder son from school. He suddenly felt weakness on left side of his body while he was talking to some other parent on the street. He lost control of his body and fell on the ground. He was then immediately taken to Safdarjung hospital where CT Scan of brain was done which revealed intracranial bleed. His family members then took LAMA from there and admitted the patient to Max Super-Speciality Hospital for further management. NCCT head was done which showed a large hematoma in right basal ganglia region with intraventricular extension and midline shift to the left. The doctors then performed right sided decompressive craniectomy with evacuation of hematoma on 1st Feb 2019. He was managed in ICU on ventilator & necessary support. His condition gradually improved and he was then discharged from the hospital. He received regular physiotherapy sessions during his stay in the hospital. He was advised for cranioplasty after 1 month. He was then admitted in Vimhans hospital on 19th July 2019 for cranioplasty. He underwent regular physiotherapy sessions again during his stay at the hospital. After being discharged from the hospital he did exercises at home but since there was not much improvement even after 2 years so his neurologist referred him for regular PT sessions at hospital’s Physiotherapy OPD. Patient has history of hypertension since last 5 years and the medicines he was currently taking for that included Tab levesam 500 mg BD, tab Serta 25 mg OD, tab tryptomer 10 mg BD, tab Napra D 250 mg BD and Pantocid 40 mg OD and anti-hypertensive drugs. Patient has habit cigarette smoking (2–3 cigarettes/week). He lives with his wife and 4 kids who help the patient with his activity of daily living. He lives on first floor of the building which has no lift facility. The staircase has proper railings. So, the patient moves up & down through stairs with support of his family members.
On observation the patient was found to be ectomorphic with left side facial asymmetry. He was wearing a shoulder sling. He had circumductory gait but was using quadripod cane for ambulation. On examination he was alert, attentive & oriented with intact short term & long-term memory but impaired immediate memory. He had slurred speech. He was depressed and had MMSE score 20/30 along-with presence of unilateral neglect. All the cranial nerves were intact except left facial nerve. He had left facial nerve palsy with jaw deviated towards right side. Superficial and deep sensations were impaired. Babinski sign was positive on left side. All the DTRs had grade 3+ except supinator jerk which was normal. Tone was remarkedly increased in left upper & lower limb. PROM was within normal ROM but patient had no AROM. Voluntary Control grading for synergy pattern had grade 0 initially with brunnstorm stage 3. Tremors were present in left hand whenever patient did any activity with concentration. Limb girth for both upper & lower limb was remarkedly reduced. Posture assessment in anterior view revealed lt. shoulder drop, rt. side torso shift, lt side pelvic shift, lt hip hike, foot planterflexion & inversion whereas posture assessment in lateral view showed forward head, posterior pelvic tilt and knee hyperextension.
Balance Assessment was done according to Functional Balance Grade: sitting balance (static & dynamic) had grade 2 score and standing balance (static & dynamic) had grade 1 & 0 respectively. Other outcomes measures used were Modified Rankin Scale (Grade 4), Catherine Bergego Scale (Score 17/30), Fugl Meyer Assessment Scale for stroke (UL = 38, LL = 52; total = 90/226). NCCT Head revealed evidence of gliosis noted in right basal ganglia, adjacent fronto-temporo-parietal region with resulting ex-vacuo changes. Mild herniation of brain parenchyma noted at the site of craniectomy defect. Small gliotic focus noted in left basal ganglia region. (20/07/21). Physiotherapy goals were established for the rehabilitation protocol which continued for the duration of 6 weeks (4 times/week). After completion of the rehabilitation, the outcome measures were re-assessed and the prognosis of the patient was reported (Tables 1 and 2).
PT Goals
Short term goals
Reduce muscle tone to score 1 (acc. to MAS)
Left extremity VC for synergy pattern will improve by at least grade (0/6 advances to 2/6) through all joints within 6 weeks.
Hold a proper posture (trunk control) for at least one full treatment session with no more than 5 cues within 6 weeks.
Achieve good sitting balance on the Functional Balance Grade
Independently perform all transfers (logrolling, supine to sit, sit to stand, stand to sit) for at least 5 repetitions within 6 weeks.
Improve unilateral neglect with score difference of 10 within 6 weeks.
Independently ambulate for at least 10 minutes on even/uneven terrain with his quad cane within 6 weeks
Long term goals
Improve fine motor skills
Left extremity VC for synergy pattern will improve to at least a grade 3 through all joints within 12 weeks.
Independently perform all transfers (logrolling, supine to sit, sit to stand, stand to sit) for at least 10 repetitions within 12 weeks.
Hold a proper posture (trunk control) for at least one full treatment session with no cueing within 12 weeks.
Independently ambulate for 20 minutes on even/uneven terrain with his quad cane within 12 weeks.
Promote functional independence with a finalized home exercise program for long- term carryover within 12 weeks.
Table 1.
Physiotherapy goals for intervention.
Week 1
PROM Lt UL & LL (5 reps)
Rocking movement in sitting position (antero-posterior & medio-lateral 5 reps)
Bridging exercise with support (5 reps)
Table polishing exercises (5 reps)
Table top exercises (5 reps)
Compensatory strategies to work on unilateral neglect
MRP approach: getting up from supine position from affected side
Week 2
PROM Lt UL & LL (10 reps)
Rocking movement in sitting position (antero-posterior & medio-lateral 10 reps)
Bridging exercise with support (10 reps)
Table polishing exercises (7 reps) and Table top exercises (7 reps)
Compensatory strategies to work on unilateral neglect
MRP approach: sitting up from supine position from unaffected side
Week 3
Single leg bridging exercise with unaffected leg (5 reps)
Table polishing exercises (10 reps)
Table top exercises (10 reps)
Compensatory strategies to work on unilateral neglect
Stretching of wrist flexors, finger flexors and plantarflexors (3 reps, 10s hold)
Ball kicking with support unaffected limb (5 reps)
MRP approach:
Balanced sitting with reaching activities from upper limb (10 reps)
Sit to stand (5 reps)
Functional Electrical Stimulation: for shoulder elevators (Frequency- 40 Hz, Pulse width- 700 ms and Intensity- 3 mA in channel 1, duration-15 min)
Week 4
Weight bearing exercise in modified plantigrade position. (5 reps)
Single leg bridging exercise with unaffected leg (10 reps)
Table polishing exercises (12 reps)
Table top exercises (12 reps)
Compensatory strategies to work on unilateral neglect
Stretching of wrist flexors, finger flexors and plantarflexors (5 reps, 15 s hold)
Ball kicking with support of unaffected limb (10 reps)
Obstacle crossing (5 reps)
MRP approach: Sit to stand (10 reps)
Stimulate correct standing alignment (by stimulating hip extension, maintaining knee extension and stimulating ankle dorsiflexors) – 5 reps
Functional Electrical Stimulation: for shoulder elevators & wrist extensors (Frequency- 40 Hz, Pulse width- 700 ms and Intensity- 3 mA in channel 1, duration-15 min)
Week 5
Bridging exercise with affected leg (5 reps)
Peg board activities
Ball kicking with affected limb (5 reps)
Obstacle crossing (7 reps)
Weight bearing exercise in modified plantigrade position. (7 reps)
Single leg standing with support (5 reps)
MRP approach: To prepare for stance phase (stimulate hip extension, train knee control, train for lateral horizontal pelvic shift) – 5 reps
Functional Electrical Stimulation: for shoulder elevators and wrist extensors (Frequency- 40 Hz, Pulse width- 700 ms and Intensity- 3 mA in channel 1 & 4 mA in channel 2, Mode- Alternate and FES rise SNS- 100 ms & FES extension period- 20 ms)
Week 6
Week 6
Bridging exercise with affected leg (10 reps)
Peg board activities
Ball kicking with affected limb (10 reps)
Obstacle crossing (10 reps)
Weight bearing exercise in modified plantigrade position (10 reps)
Single leg standing with support (10 reps)
MRP approach: To prepare for swing phase (train knee flexion, to stimulate knee extension and foot dorsiflexion at heel strike) – 5 reps
Functional Electrical Stimulation: for shoulder elevators and wrist extensors (Frequency- 40 Hz, Pulse width- 700 ms and Intensity- 3 mA in channel 1 & 4 mA in channel 2, Mode- Alternate and FES rise SNS- 100 ms & FES extension period- 20 ms and duration-15 min)
The pre and post assessment score of CBS and FMA have been shown in Table 3. After the treatment protocol followed, there was marked improvement in unilateral neglect and sensory-motor recovery following stroke. Overall percentage improvement in FMA score was more for lower extremity (24.44%) than that for upper extremity (11.11%). Percentage improvement for overall FMA score was 14.6%. There was remarkedly more improvement in unilateral neglect (30%) (Figures 1–3). There was even significant improvement seen in voluntary control grading for synergy pattern, brunnstorm stages, functional balance grade and modified rankin scale as mentioned in Table 4.
Outcome Measures
Pre
Post
Percentage Improvement
Catherine Bergego Scale
17/30
8/30
30%
FMA
UL–38 LL–52 Total–90/226
UL–52(126) LL–74(90) Total–123/226
11.11% 24.44% 14.6%
Table 3.
Pre & post score of CBS and FMA along with percentage improvement.
Figure 1.
Pre & post score of CBS (percentage improvement 30%).
Figure 2.
Pre & post score of FMA for UL & LL (percentage improvement 11.1% & 24.44% respectively).
Figure 3.
Pre & post score of FMA (percentage improvement 14.6%).
Outcome Measures
Components
Pre
Post
Voluntary Control Grading for Synergy pattern (Extension Synergy)
The purpose of this study was to find out the effect of unilateral neglect with basal ganglia bleed in stroke survivors. In this study, a stroke survivor with right BG bleed was administered to a six-week intervention protocol following the episode of stroke that occurred 2 years ago. A complete neurological assessment was carried out including certain outcome measures such as MMSE, Voluntary control grading for synergy pattern, Brunnstorm stages of stroke recovery, Functional balance grading, Modified rankin scale, Catherine begego scale and Fugl meyr assessment of sensory & motion functions.
Unilateral Neglect is a very common perceptual disorder that occurs after stroke. It can be defined as the inability to respond, report or orient to stimuli on contralateral side to brain lesion [5]. It is the inability to understand and integrate stimulus and perception from side of body (body neglect) & environment (spatial neglect) [12]. Left sided unilateral neglect which occurs following the episode of right cerebral stroke is more common than the right sided unilateral neglect which occurs following the episode of left cerebral stroke [13]. The prevalence rate of unilateral neglect is 12–100% in case of right hemisphere stroke whereas in case of left hemisphere stroke the prevalence rate ranges between 0 and 76% [14].
Unilateral neglect is more common in acute as well as sub-acute phase. Left hemisphere stroke causes more severe unilateral neglect as compared right hemisphere stroke [15]. Unilateral neglect is mainly caused by right hemisphere damage resulting from stroke which leads to difficulties in attending to stimuli in the left perceptual hemifield. The brain damage that leads to neglect usually involves infarcts in the inferior parietal lobe, temporo-parietal junction & the superior temporal lobe. Unilateral neglect is most common & severe and it occurs following the episode of right cerebral hemisphere infarct [16]. ULN is of different types. On the basis of behavior that is elicited it is classified into sensory, motor, and representational type and on the basis of abnormal behavior distribution ULN is of personal & spatial type [6].
Unilateral neglect can be assessed by many qualitative as well as quantitative tools such as Behavioral Inattention Test, Cancelation test, Line bisection test, Copying & drawing test, Catherine Bergego Scale etc. [6] Out of these tests, in this study CBS has been used to assess the presence as well as the severity of unilateral neglect in stroke subjects. CBS tool has a high sensitivity in evaluating hemi-neglect, and its inter-researcher reliability was highly reliable as r = 0.93 [17]. Unilateral neglect when compared to the stroke severity results in poor overall recovery. It may involve longer hospitalization period, functional dependency, long term disability in ADLs as well as increased risk of falls [18].
Basal ganglia bleed is most common among all types of intracerebral hemorrhages. Long-standing hypertension is one of the major cause responsible for BG bleed. Cigarette smoking and alcohol consumption further adds on to the risk of developing this stroke. Basal ganglia accounts to most common site of hemorrhagic stroke (50%) [2]. Due to the uncommon nature of BG bleed, stroke cases having lesions confined to globus pallidus, caudate & putamen, only limited number of cases have been reported [19]. Neuropsychological problems such as depression occurs very commonly when there are large lesions in basal ganglia [20].
Balance related issues are most commonly seen in stroke survivors. Issues related to balance are often associated risk of falls and mobility problems. Maintenance of balance involves complex interaction of musculoskeletal and neural systems. Out of these, neural components involve motor system, sensory system and higher level cognitive & perceptual processes. Perception and cognition play a very important role in balance control [8]. Postural imbalance is more prevalent with right hemisphere lesions. Stroke survivors with right hemisphere damage have less ability to ambulate. This is because they have lesser ability to shift weight on the non-paretic leg [8]. Perceptual deficit is one of the contributing factors to balance issues which is more commonly seen in right hemisphere stroke lesions. Inappropriate body perception affects the alignment of the body [8].
Acquiring independence of gait is one of the prime goals in rehabilitation of stroke subjects. Unilateral Neglect leads to poor gait recovery of activity of daily living as well as gait [9, 10]. Unilateral neglect when clubbed with cognitive impairment has a negative impact on independent gait recovery. Thus, this indicates that the unilateral neglect when combined with cognitive impairments is a strong negative predictor for independent gait [11].
Postural instability is the main cause of falls & limited functional independence among the stroke patients. Posture deficits as well as balance deficits is very common. This is because the good limb has to bear a greater proportion of the body weight. The correlations of parameters of balance and gait is utmost important for thorough assessment of stroke subjects as well as for their proper rehabilitation. This is because a reliable correlation means that resources used to improve balance could also influence gait. As the stroke patient’s balance is impaired and can lead to serious consequences like falls. So, if we know the questions related to balance and gait in stroke patients then it would be very important for us to understand these two physical capabilities among the hemiparetic subjects. It is therefore believed that it will lead to a better direction regarding the rehabilitation of these stroke patients.
Basal ganglia bleed patients are prone to have cognitive impairments [19]. According to a study done by Hochstenbach et al. [21], it is stated that striatum of brain receives inputs from mostly all the cortical regions, thalamus, and limbic system thus playing an integrative role in processing the cognitive information processing. Thus, impairment in cognitive domains occurs following BG patients. Such deficits in BG may lead to deficits in other domain. Aphasia and dysarthria type of speech disorders have a prevalence of about 13% of 240 BG bleed cases. This also occurs due to large lesions in basal ganglia. Damasio et al. 1998 explained about speech disorder having reduced fluency in addition to mild defects of repetition, comprehension & dysarthria [20].
Unilateral neglect is also associated with basal ganglia disorders. Visuospatial functions or hemineglect helps to discriminate between stroke patients and healthy subjects [19]. From a global point of view, destruction of the cortex-striata circuits involving the temporal & parietal lobe leads to difficulties with hemispatial analysis, visual organization and even organization of behavior. Damage of striata impairs performance of striata with respect to spatial cues [22]. According to Harris et al., BG bleed patients have problems of mental rotation of the objects into spatial framework thereby leading to problem of perceptual disorders such as unilateral neglect [23]. Coughlan 1979 explained that with regard to lesion laterality, right BG bleed patients have poorer performance in visuospatial domain whereas left BG bleed patients have more problem in language domain [24]. Thus, rehabilitation of BG bleed patients should always include interventional strategies to work cognitive impairments, unilateral neglect in addition to the basic stroke rehabilitation.
This study sheds light upon the effect of unilateral neglect with basal ganglia bleed in stroke survivors. According to the study conducted it was found that perceptual disorders are predominant in right hemisphere lesions. Unilateral neglect being common among the perceptual disorders. Cognitive impairments following the episode of stroke is closely related to such condition depending upon the size of lesion. Neuropsychological dysfunctions such as depression and speech abnormalities such as dysarthria & aphasia are also commonly seen in BG bleed cases. Thus, planning a rehabilitation protocol for such patients should include interventions to work upon unilateral neglect, neuropsychological dysfunctions and speech disorders in addition to improvement in sensory & motor functions for early recovery of stroke survivors. The patient in this study underwent 6 weeks rehabilitation program in the OPD. He was referred to neuro-psychiatrist for medications & counseling for his neuropsychological problems. Referral was also made to speech therapist for his speech problems. He regularly performed home exercise program which was designed by the physical therapist under the supervision of his caregivers. Thus, after following the six-week intervention protocol the patient responded well in terms of sensory-motor recovery and as well showed significant improvement in unilateral neglect.
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Written By
Ashna Sinha and Meena Gupta
Submitted: 04 March 2022Reviewed: 07 March 2022Published: 07 June 2022
Open access peer-reviewed chapter
