A Life Worth Living: Seven Years after Craniectomy

Appendix

Physical Therapy Progress

One month after my stroke, I had neither volitional control nor palpable contractions in the muscles of my right upper or right lower extremities. I also had moderate to high levels of flexor tone. I was not able to sit outside of my base of support and I needed to both wear a right knee ankle foot orthotic (KAFO) and have the assistance of two people in order to stand between the parallel bars and attempt to walk. Today, I have made significant gains in strength and control of my right trunk, right hip, and right knee although increased muscle tone on my right side is still a problem intermittently. I wear a right ankle foot orthotic (AFO) to help control muscle tone and need no help to sit, transfer, walk on level surfaces or climb stairs with banisters. I use a cane if I am fatigued, walking on uneven surfaces, or in unfamiliar surroundings. For long distances, I still use a wheelchair.¹

Occupational Therapy Progress

Before my stroke, I had mixed dominance using my right hand for all tasks except for handwriting. One month after my stroke, I had no use of my right upper extremity and I had some difficulty using my left hand to accomplish tasks. I was not independent in any activities of daily living and I had no ability to do any mathematical calculations. I had great difficulty finding my way around a small rehabilitation center. Today, I can easily navigate to various locations throughout the country. I manage the finances for our home using Quicken, a computer program, and excel in doing mathematical calculations in my head. I am nearly independent in all activities of daily living; my left arm and hand have become proficient in executing all necessary tasks. I still do not have functional use of my right arm and hand but I continue to work on regaining motor control of my right upper extremity and have shown some active movement at the right shoulder girdle. Due to continued therapy and persistent attention to doing all of my assigned exercises, I have no contractures or loss of muscle mass on my right side.²

Speech and Language Therapy Progress

One month after my stroke, I had no gestures beyond shaking my head “no” and “yes”. I was unable to vocalize any sounds. I could not read or write any words. The speech language pathologist’s official diagnosis was global aphasia. She stated that the prognosis for recovery was fair.

March 2008 testing using the Boston Naming Test and the full Boston Diagnostic Aphasia Examination demonstrates that I have a “…moderate non-fluent mixed aphasia with coexisting apraxia of speech …receptive language skills outpace …expressive ability”. I am able to name objects and produce connected speech that is “…non-fluent and characterized by occasional paraphasic errors and agrammatisms.” September 2008 speech therapy sessions are now demonstrating “…significant improvement in verbal expression over the past year … with an increase in utterance length for sentence production as well as improved structure (morphological usage) and content (word-finding)”.³

A functional MRI study was performed in February 2008 (nearly 7 years after the stroke) to try to localize the neural substrate for language prior to possible intervention for a persistent left internal carotid artery pseudoaneurysm due to the initial dissection. The fMRI study included three language tasks: passive listening, sentence completion, and word generation. The fMRI study demonstrated language task activation primarily in the right hemisphere including the superior temporal lobe on the right, though there was no convincing activation of the right frontal operculum. Little activation of the left hemisphere was seen in the presence of a chronic infarct of the entire left middle cerebral artery territory. However, lack of activation does not exclude the presence of task function in surviving perilesional tissue and the presence of activation in the right hemisphere does not prove that these regions are sufficient for maintaining task function. Furthermore, language lateralization prior to the infarct was unknown. Note was made of right greater than left frontoparietal activation around the sensorimotor cortex and left greater than right cerebellar hemisphere activation, which may reflect the recruitment of compensatory regions and strategies for language function.⁴ (See Figs. 1, 2, 3.)

Fig. 1

fMRI examination from 2/19/2008 showing brain activity with passive listening. There was activation along the right superior lobe posteriorly, with no convincing activation on the left

Fig. 2

fMRI examination from 2/19/2008 showing brain activity with sentence completion that should activate expressive and receptive language areas. There was weak motor and a little premotor activation including supplemental motor areas right greater than left posterior frontal lobes, as well as left greater than right cerebellum. There was no convincing right frontal opercular activation and only a small focus of right superior temporal lobe activation

Fig. 3

fMRI examination from 2/19/2008 showing brain activity with word generation. There was right greater than left frontoparietal activation along and behind the sensorimotor cortex, and also left greater than right supplemental motor area and cerebellar activation. There was focal activation in the posterior right superior temporal lobe. There was little or no activation in or around the region of encephalomalacia in the left middle cerebral artery distribution

Repeated visual field studies show that following my stroke, I developed a partial, homonymous, slightly incongruous, right hemianopsia. Since then, there has been gradual improvement with the deficit mostly reduced to a right homonymous inferior quadranopsia. The right homonoymous superior field cut has significantly resolved.⁵ (See Figs. 4, 5).

Fig. 4

Visual field examination performed 14 months after stroke demonstrating a partial, homonymous, slightly incongruous, right hemianopsia. Increasing darkness correlates with a denser scotoma or blind spot. The right eye is on the right side of the figure and the left eye is on the left side of the figure. (Fig. 4 visual field examination was generated with the same equipment as Fig. 5)

Fig. 5

Visual field examination performed 81 months after stroke. The examination demonstrates a right homonymous inferior quadranopsia with a significantly resolved right homonoymous superior field cut. Increasing darkness correlates with a denser scotoma or blind spot. The right eye is on the right side of the figure and the left eye is on the left side of the figure. (Fig. 5 visual field examination was generated with the same equipment as Fig. 4)

Functionally, I communicate by instant messenger with my son (DBL) and am learning how to write emails to friends on my own. I worked with my wife and son to express my thoughts for this paper that they then wrote down and read back to me for my approval. I’m able to spot typographical errors on my wife’s slides. I read voraciously with little assistance and I no longer require large-print texts. Recently, I was able to enjoy the movie The Kite Runner, even though the characters spoke Dari with English captions. When I’m tired I can communicate my needs with a combination of words and gestures. When I’m feeling well, I can speak full sentences. Usually I speak several words in a row to convey my thoughts.