You are on page 1of 6

2012 IEEE EMBS International Conference on Biomedical Engineering and Sciences | Langkawi | 17th - 19th December 2012

Post-stroke Brain Memory Assessment Framework

K Chellappan1, Noor K. Mohsin2, Sawal Hamid Bin MD Ali2, MD. Shabiul Islam2
1

Institute of Space Science (ANGKASA), Universiti Kebangsaan Malaysia


Faculty of Engineering & Built Environment,Universiti Kebangsaan Malaysia
kckalai@ukm.my

AbstractPost-stroke brain memory dysfunction is a


precondition for the diagnosis of vascular dementia. This
diagnosis in general made within months after a stroke, since
post-stroke brain memory assumed to be a common cause of
post-stroke. Clinical recovery and rehabilitation experience
added to research recommendation in literature urges that poststroke brain memory function perhaps reversible. The aim of the
study was to systematically review the available information on
the assessment of post-stroke brain memory function in stroke
survivors to establish a post-stroke brain memory assessment
framework. We performed systematic literature search of
published research findings in various scientific publication with
the following phrase: post-stroke brain memory assessment. The
studies reported that different types of memory dysfunction
resulted from stroke. The most commonly dysfunctional memory
types are working memory, episodic memory and procedural
memory. This finding was transformed into a post-stroke brain
memory assessment framework. Five different brain memory
assessment techniques are recommended for the proposed
framework assessment. The selection of the assessment
techniques based on the identified memory types. Both short
term and long term memory are effected by post-stroke brain
memory dysfunction. Standardized assessment of cognitive
function in each patient diagnosed with post-stroke vascular
dementia is crucial. Post-stroke vascular dementia may be
reversible in a considerable percentage of patients with stroke,
indirectly promising a healthier lifestyle.

II.

Brain has been structured from a soft jelly kind of material


floating in liquid cushion of cerebrospinal and sheltered by
skull. Cerebrum, cerebellum and brain stem are the main
functional player in the brain structure as in figure 1.

Figure 1. The cerebral cortex

Cerebrum contributes as the largest portion of the brain


and it divided into four lobes with specific functionality.
Frontal lobes, parietal lobes, temporal lobes and the occipital
lobes are occupying the cerebrum of the brain [4]. The roles of
frontal lobe are initiating voluntary movement, attention,
emotional, social and sexual control, verbal expression,
judgment, and decision making. Whereas parietal lobes
functions are awareness of body parts, academic skills, object
naming, right/left organization, and eye-hand coordination.
Functionality of temporal lobes is short-term memory,
language comprehension, face recognition, and behavior
(aggressive). Finally the occipital lobes functions are: visual
perception, visual processing and reading.

Keywords; Brain memory, Stroke, cognitive, knowledge framework

I.

INTRODUCTION

Memory loss is an incident commonly resulted from loss of


nerve cells in the brain. Dementia is a result of severe memory
loss that it obstructs the normal routine functionality of an
individual. Dementia patients are found to have difficulties in
capturing new things or recalling names of people they just met
[1]. Lost in familiar places and unable to recall words are the
common disabilities found in dementia patients [2]. There are
many leads to dementia. The two most significant case of
dementia are Alzheimer disease (AD), commonly present in
the elderly and vascular dementia or vascular cognitive
impairment, resulted from brain damage due to strokes [3].
This paper is going to focus on the second case, vascular
cognitive impairment and its current clinical assessment
techniques.

978-1-4673-1666-8/12/$31.00 2012 IEEE

THE BRAIN AND STROKE

189

2012 IEEE EMBS International Conference on Biomedical Engineering and Sciences | Langkawi | 17th - 19th December 2012

i.
Ischemic Stroke
Blood flow blockage to the brain by the presence of blood
clot in the arteries cause ischemic stroke. An ischemic stroke
can occur in two forms embolic and thrombotic strokes. In an
embolic stroke, a blood clot usually travels from the heart
through the bloodstream to the brain. In case of clot reach the
brain it eventually travels to a blood vessel small enough to
block its passage. The clot lodges there, blocking the blood
vessel and causing an embolic stroke.
Thrombotic stroke is the second type of ischemic stroke; blood
flow is impaired because of a deposit of fat on the wall of the
blood vessels case blockage to one or more of the arteries
supplying blood to the brain. The process leading to this
blockage is known as thrombosis. Strokes caused in this way
are called thrombotic strokes. Blood-clot strokes can also
happen as the result of unhealthy blood vessels clogged with a
buildup of fatty deposits and cholesterol [7].

The cerebellum is the second largest part of the brain the


functions is: coordination of voluntary movement, gross and
fine motor coordination, postural control, balance and
equilibrium, and eye movement.
The brain stem is the third part of the brain which play an
important role in: autonomic nervous system (heart rate,
breathing, etc.), arousal and sleep regulation, swallowing
food and fluid, and balance and movement [5].

ii. Hemorrhagic stroke


Hemorrhagic stroke is a result of bleeding into the brain
and other spaces within the central nervous system and
includes subarachnoid hemorrhage, intracerebral hemorrhage,
and subdural hematomas. Subarachnoid hemorrhage (SAH)
results from sudden bleeding into the space between the inner
layer and middle layer of the meninges. Most often is due to
the trauma or rupture of cerebral aneurysm or arteriovenous
malformation (AVM). Intracerebral hemorrhage (ICH) is
bleeding directly into the brain parenchyma, often as a result
of chronic, uncontrolled hypertension. A hemorrhagic stroke
covers 15 percent of all strokes and responsible for more than
30 percent of all stroke deaths [8].

Figure 2. Brain Stem

A. Types of stroke
High blood pressure, diabetes, and high cholesterol levels,
lack of exercise, and smoking are the established
cardiovascular risk leads to stroke. Stroke is a brain attack
normally caused by bleeding inside the head or disruption of
blood flow to the brain. The two main types of stroke are
ischemic (84%) and hemorrhagic (16%) [6]. Ischemic strokes,
a blood clot blocks or "plugs" a blood vessel in the brain.
Hemorrhagic strokes caused by a blood vessel rupture in the
brain. Figure 2 is featuring the stroke types and its statistical
summaries.

iii. Transient ischemic attacks (TIA)


Not all types of stroke leads to permanent brain damage.
Transient ischemic attacks (TIA) a type of stroke resulted
from temporary interruption in blood flow to brain segments.
TIAs has a rapid onset (5 minutes) and a short duration (1215 minute up to 24 hours). Compared to authentic strokes,
TIAs do not contribute to brain injury based on its nature for
not damaging any brain cells. On the other hand, they can be
warning signs of an upcoming stroke event [8].
B. Effects of stroke and Brain
Stroke effect varies widely depending on the type of
stroke, affected brain portion, and mode of stroke severity.
Stroke injury can affect the whole range of human learning
hierarchy (aphasia), vision, motor activity, sensory levels,
speech (dysarthria), chewing and swallowing food
(dysphagia), thinking, and emotions. Paralysis (hemiplegia)
or weakness (hemiparesis) on one side of the body may occur
as an outcome of the injuries [9]. Table 1 summaries brain
injuries and related brain segment due to stroke.

Figure 3. Types of Strokes

190

2012 IEEE EMBS International Conference on Biomedical Engineering and Sciences | Langkawi | 17th - 19th December 2012

TABLE 1: GUIDANCE TO BRAIN STROKE OUTCOME

Brain Segments

Frontal Lobe

Parietal Lobe

Control Action

Attention
Emotion, Social, Sexial control
Judgment, Decision making
Verbal expression
Vouluntary initiation of movement
Motor Strip
Smell

Academic skill
Objects name
Right (touch, smell) and left
(language) organization
Eye/hand coordination
Sensory strip

Stroke Outcome

Change of social behavior and personality


Loss of fine movement
Lack of strength in the arms, hands and fingers
Facial expression and speaking difficulties

Difficulty interpreting visual information such as length, size and depth


Hand-Eye In-coordination
Inability to visually scan ones surroundings
Sensory loss, inability to identify an object by the sense of touch
Right-left confusion: Profound inability to differentiate right from left.
Difficulty with reading, writing, and math
Hemineglect
Finger agnosia
Inability to understand spoken language, unable to find words and form
sentences
Hearing loss is mild after one temporal lobe is affected by a stroke, but when
both temporal lobes are affected the result might be complete deafness.
Difficulty in recognizing combinations of sounds such as songs, musical tones,
and complex conversations.
Word deafness
Feel unusual, strange, repeated, or loud sound
One hears sounds that are not there.
Loss of short or long term memory
Violent or aggressive behavior
Abnormally enhanced sexuality
Disturbance of smell and taste
Hemianopia
Quadrantanopia
Scotoma
Loss of feeling eye surface (blinking difficult, eye lid not close properly, droop
lid, blurred vission)
Agnosia
Blindness or partial blindness

lack of balance or coordination on the same side of the body


Balance problem
Dizzness
Nausea
Vomiting
Ataxia: irrigular and poorly coordinate of muscle movement

Decreased vital capacity in breathing, leads to speech difficulties


Environment organization / perception difficulties
Problems with balance and movement
Paralysis, hemiplagia, dysphagia

Temporal Lobe

Occipital Lobe

Cerebellum

Brain Stem

III.

Language comprehension
Hearing
Memory
Face recognition
Behavior

Visual

Balance and equilibrium


Postural control
Coordinate (voluntary, cross and fine, eye)
movement
Life-sustaining functions (ANS, arousal
and sleep regulation, swallowing food and
fluid)
Balance and movement

A. Types of Memory

BRAIN MEMORY STRUCTURE

Brain memory system is a mode in which the brain routes


available information for future usage, with or without
conscious awareness. Human brain memory system is a
complex structure with number of different functionality.
Diseases may attach a single memory function or multiple
functions [10]. Exercising found to be the best method for
keeping brain functionality active and healthy among older
generation. But there is limited research on the benefits of
physical activity on cognitive performance after stroke.
Figure 4. Types of memory

191

2012 IEEE EMBS International Conference on Biomedical Engineering and Sciences | Langkawi | 17th - 19th December 2012

Human brain memory system divided into three types:


Sensory memory, short term memory and long term memory
[11]. Sensory memory is an ultra-short-term memory and
decomposes shortly, (200 - 500 milliseconds) after the
perception of an item. Sensory memory passes information to
short term memory by selecting the presently intended info
through attention. Short term memory decays in 10 to 15
seconds normally, but a longer retain (up to 60 seconds) is
possible upon needs. Long term memory or stored brain
memory found to have involves a process of physical changes
in the structure of neurons (or nerve cells) in the brain. There
many different theories of memory relational activities. Poststroke cognitive dysfunction spectrum determined by size and
location of the infarction but there is no clear indication on
presence of memory dysfunction due to stroke mainly episodic
since its believed that almost never an infarction in the medial
temporal lobe [12]. Both working and episodic memory found
to be part of learning process.

The learning process and the process of formation can be


divided into four stages [11]:
a.
b.
c.
d.

Encoding. Attention focus and entering of new


information into the working memory. Finding
associations with already stored memories.
Consolidation. The process of stabilization of new
information, transformation into a long-term memory
by means of rehearsal.
Storage. Long-term storing of information in
memory.
Recall. Retrieval of information into the working
memory.

Table 2 summarizes the different types of memory


system, its associates to brain lobe storage and its relative
functionalities. The focus of this research will be on the
working and episodic [13] memory which found to be more
regularly diminished in stroke victims.

TABLE 2: TYPES OF MEMORY AND RELATED FUNCTIONALITY

Types of Memory System

Long Term
Memory

Short Term
Memory

Storage
Time

Input Speed

Storage
Capacity

Concern
Information

Episodic Memory

Medial temporal lobe,


Diencephalon

Life Time

Frequent
Repetition

Unlimited

Event, Experience

Semantic Memory

Inferior and lateral


temporal lobe

Life Time

Frequent
Repetition

Unlimited

Procedural
Memory

Basal ganglia,
Cerebellum

Life Time

Frequent
Repetition

Fact, Concepts,
Knowledge about the
world

Unlimited

Motor (skills, tasks)

Working Memory

Prefrontal cortex

<1 min

72
items

Different tasks (verbal and


visual)

Iconic

Sensory
Memory

functionality

Anatomy
(Brain lobes storage)

20 bits/sec

Sight

Echoic

Hearing

Haptic

Touch

Image
Sound
<1 sec

10 9 bits/sec

12 items

Tactile

Smell
Others

Odors
Taste

Zest

interface. There are three different measurements, verbal


followed by visuospatial aspects of short term memory and
working memory. Whereas, WMRS consist of twenty short
descriptions of problem behaviors and differentiate individuals
with low and average working memory abilities [16].

B. Brain Memory Clinical Assessment Technique


There are many types of memory assessment technique in
current clinical practice. In this paper, number of prominent
and effective assessment techniques have been selected for
post-stroke brain memory assessment.

ii. The Rivermead behavioural memory test (RBMT)


RBMT practiced among individuals with abnormal
memory ageing up to age 89 years. It is used for traumatic
brain injury, stroke, encephalitis and Alzheimers disease
related memory screening. The RBMT-3 includes fourteen
subtests assessing aspect of visual, verbal, recall, recognition

i. Working memory assessment scale


There are two different tools for effective identification
individual with poor working memory skills, Automated
Working Memory Assessment (AWMA) [14], and Working
Memory Rating Scale (WMRS) [15]. AWMA is a computer
based assessment of working memory skill, with attractive

192

2012 IEEE EMBS International Conference on Biomedical Engineering and Sciences | Langkawi | 17th - 19th December 2012

immediate and delayed every day memory. It takes about


thirty minute to complete the test with a trained medical
practioners [17].

and visual reproduction. An individual's performance is


reported as five Index Scores: Auditory Memory, Visual
Memory, Visual Working Memory, Immediate Memory, and
Delayed Memory [19]. Table 3 summarizes the different types
of memory assessment and types of memory testable.

iii. Memory assessment scale (MAS)


General memory impairment detection through twelve
subtests by MAS includes: verbal span, visual span, list
acquisition, list recall, delay list recall, delay prose recall,
immediate names faces, delayed names faces, visual
reproduction, immediate visual recognition, delayed visual
recognition and short term memory [18].
.
iv. The Wechsler Memory Scale (WMS)
WMS is a neuropsychological test designed to measure
different memory functions in an individual in response to
genetic defect. The fourth edition (WMS-IV) published in
2009 known as WAIS-IV is consisted of thirteen subtests
which measure verbal and performance (largely
visuospatial) intelligence, as well as working memory and
processing speed. WMS-IV is made up of seven subtests:
spatial addition, symbol span, design memory, general
cognitive screener, logical memory, verbal paired associates,

TABLE 3. BRAIN MEMORY IN RELATION TO MEMORY


ASSESSMENT TECHNIQUES
Brain Memory Clinical Assessment Techniques
Types of
Memory
Sensory
Memory
Long Term
Memory
Working
Memory
Procedural
Memory

AWMA

Figure5. Post-stroke Brain Memory Assessment Framework

193

WMRS

RBMT

MAS

WMS

2012 IEEE EMBS International Conference on Biomedical Engineering and Sciences | Langkawi | 17th - 19th December 2012

IV.

Discussion

The brain is the most complex part in the body and the
most complicate process is the information storage and
consolidation in memory. Each part of the brain is responsible
to perform special functionality as part of human
physiological, psychological and neurological response.
The aim of this paper is to illustrate the different parts of
brain memory functionalities that related to different types of
memory. A careful knowledge management of brain
structure, brain functionality and memory types resulted in a
comprehensive post-stroke brain memory assessment
framework as in figure 5. Reference to table 3, RBMT, WMS
and MAS are recommended for episodic memory assessment.
Whereas AWMA, WMRS, RBMT and MAS recommended
for are for working memory assessment. Automated Working
Memory Assessment (AWMA) scale can be used to assess
the working memory which is significantly related
establishing substantial construct validity for poor working
memory while the Working Memory Rating Scale (WMRS)
is used to assess other characteristics of working memory
such as high levels of attention and mind wandering [18,19].
The Rivermead behavioural memory test (RBMT) is used for
the sensory, short term, working, and long term memory. The
specific test used to evaluate and assess all types of memory
is the memory assessment scale (MAS). The last type
Wechsler Adult Intelligence Scale (WAIS) is used to measure
psychometric intelligence and Wechsler Memory Scale
(WMS) used for various aspects of verbal and visual
memory. It provides a fairly comprehensive assessment of
memory and is co-normed with the WAIS, leading to these
two tests often being administered together. The WMS is the
more purely neuropsychological of the Wechsler scales.
V.

CONCLUSION

Post-stroke brain memory classified as vascular dementia


is reversible. Timely diagnostic and systematic assessment
will be an added advantage in ensuring an effective recovery
through individualize rehabilitation program. The proposed
Post-stroke Brain Memory Assessment Framework expected
to assist the medical practioners in customize rehabilitation
program towards patient recovery needs. The proposed
framework generally will help in improving post-stroke
management and recovery practice. The framework also able

194

to provide indirect contribution in providing improved


lifestyle among post-stroke vascular dementia population.
REFERENCES
[1]
[2]
[3]

[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]

[14]
[15]
[16]
[17]
[18]
[19]

Huff FJ, Language in normal aging and age-related neurological


diseases. In Boller F, Grafman J(eds) handbook of neuropsychology,
vol. 4 Elsevier, Amsterdam, pp251-264, 1998
S Cooper, J D W Greene, The clinical assessment of the patient with
early dementia, J Neurol Neurosurg Psychiatry 2005; 76 (suppl
V):v15-v24
Schrijvers EM, Schrmann B, Koudstaal PJ, van den Bussche H, Van
Duijn CM, Hentschel F, Heun R, Hofman A, Jessen F, Klsch H,
Kornhuber J, Peters O, Rivadeneira F, Rther E, Uitterlinden AG,
Riedel-Heller S, Dichgans M, Wiltfang J, Maier W, Breteler MM,
Ikram MA, Genome- wide association study of vascular dementia,
Stroke.;43(2):315-9 , 2012 .
Maria A Patestas, Leslie P. Gartner, A textbook of neuroanatomy,
2006
Anthony Collins, the brain injury handbook, 2011
James S. White, Neuroscience, 2008
Reinhard Rohkamm, color atlas of neurology, 2004
Chisolm-Burns, Marie A., Pharmacotherapy principles and practice,
2008
Mayfield clinic and spine institute website:
http://www.mayfieldclinic.com/pdf/PE-stroke.pdf united states
Schacter DL and Tulving E, Memory system, 1994
Andrew E Budson and Bruce H Price, Memory : clinical Disorder,
Encyclopedia of life science, 2001 Macmillan Publishers Ltd, Nature
Publishing Group / www.els.net
Snaphaan L, de Leeuw FE. Poststroke memory function in
nondemented patients: a systematic review on frequency and
neuroimaging correlates. Stroke; 38: 198203, 2007.
Liselore Snaphaan, Mark Rijpkema, Inge van Uden, Guillen
Fernandez, Frank-Erik de Leeuw. Reduced medial temporal lobe
functionality in stroke patients: a functional magnetic resonance
imaging study. Brain A Journal of Neurology; 132;pp: 18821888.
2009.
Alloway T.P., Automatic working memory assessment, 2007
Allowy T.P. Banner, G. and smith P., working memory and cognitive
styles in adolescents attainment, 2008
Allowy T.P. , Gathercole, S.E., and Kirkwood, H., The working
memory rating scale, 2008
Smith, G. V., Della Sala, S., Logie, R. H, and Maylor, Prospective and
retrospective memory in normal aging and dementia: Aquestionnair
study, 2000
J. Michael Williams, Memorry assessment scale, 1991
The Psychological Corporation, a Harcourt Assessment Company.
Reproduced by permission, Wechsler Memory Scale and WMS are
trademarks of the Psychological Corporation, a Harcourt Assessment
Company, registered in the United States of America and/or other
jurisdictions,1974.

You might also like