case_images: PMC11787550_01
case_images: Preoperative and postoperative axial CT Images. (A) Preoperative CT scans: Axial CT slices labeled (1) through (8), obtained upon admission, demonstrate a right putaminal hemorrhage (yellow arrows) measuring approximately 50 mL. The hematoma extends into the putamen, external and internal capsules, and the insular cortex. Each numbered slice corresponds to a successively higher axial level, highlighting the cranio-caudal extent of the hemorrhage.. (B) Postoperative CT scans: Axial CT slices labeled (1) through (8), obtained 24 hours after emergency hematoma evacuation, show that the previously observed hyperdense hemorrhage is no longer visible (compare each slice with its corresponding slice in (A)), confirming successful evacuation of the hematoma. Mild postoperative changes, including subtle ventricular shifts, may be noted; however, there is no evidence of rebleeding or significant residual hematoma.. Note: The slice numbers (1) through (8) in both (A) and (B) are matched by approximate axial levels to facilitate direct comparison of preoperative and postoperative scans. These CT images have been left-right reversed by MRIcron to maintain a consistent orientation with subsequent figures.
case_images: cureus-0017-00000077951-i01.jpg
case_images: PMC11787550_01_cureus-0017-00000077951-i01.jpg
case_images: FIG1
case_images: An initial computed tomography (CT) scan revealed a right putaminal hemorrhage (hematoma volume: 50 mL) involving the putamen, as well as the external/internal capsules and the insular cortex (Figure 1A). Emergency hematoma evacuation was performed approximately five hours after onset, and a post-operative CT scan at 15 hours confirmed successful removal of the hematoma (Figure 1B).
case_images: White matter disconnection analysis. (A) Images illustrating the lesion distribution (in red). Panel (1) shows a coronal slice, while panels (2)-(5) depict axial slices. Crosshairs indicate the analysis coordinates. Estimation of damaged fibers in these slices indicates severe disruption (in some tracts >90%) in the AR, CBT, CPT, IFOF, MdLF, and others.. (B) Graphical representations of the structural network disruptions from the connectome analysis. The left panel (direct disconnections) shows direct disruptions to neuronal pathways (blue lines indicate disrupted connections), whereas the right panel (indirect disconnections) highlights the top 25% of indirect disruptions stemming from these direct lesions.. (C) A bar graph displaying the percentage of disconnection for each white matter tract. The horizontal axis lists the tract names, and the vertical axis indicates the percentage of disruption. Higher bars denote a greater proportion of disruption within that tract.. AR, acoustic radiation; CBT, corticobulbar tract; CPT, corticopontine tract; CST, corticospinal tract; CS, corticostriatal tract; DRTT, dentatorubrothalamic tract; EMC, extreme capsule; IFOF, inferior fronto-occipital fasciculus; RST, reticulospinal tract; UF, uncinate fasciculus; OR, optic radiation; ML, medial lemniscus; AC, anterior commissure; TR, thalamic radiation; MdLF, middle longitudinal fasciculus; F, fornix; ILF, inferior longitudinal fasciculus; AF, thalamic radiation; FAT, frontal aslant; CNII, cranial nerve II; CC, corpus callosum; SLF, superior longitudinal fasciculus; Subscript R, right; Subscript F, frontal; Subscript O, occipital; Subscript P, parietal; Subscript A, anterior; Subscript P, posterior; Subscript S, superior
case_images: cureus-0017-00000077951-i02.jpg
case_images: PMC11787550_01_cureus-0017-00000077951-i02.jpg
case_images: FIG2
case_images: This method estimated the affected white matter fibers and mapped pathways with disconnections. The analysis revealed extensive white matter disconnection, with particularly severe (>90%) disruptions in tracts such as the acoustic radiation, corticobulbar tract, corticopontine tract, IFOF, and MdLF (Figure 2).
case_images: Comprehensive rehabilitation timeline and interventions. Timeline showing the progression of rehabilitation interventions from acute to recovery phase. PT progressed from basic motor function training to independent ambulation. OT focused on upper limb function and activities of ADL, with emphasis on spatial awareness and self-monitoring strategies in preparation for work reintegration. ST addressed attention, spatial awareness, and work-specific cognitive skills.. Green boxes indicate PT interventions progressing from basic mobility to advanced functional training. Pink boxes show OT interventions advancing from basic ADL to community mobility. Blue boxes represent ST interventions focusing on cognitive and work-related skills. Therapy duration increased from 20-40 minutes per day in the acute phase to 60 minutes per day in the subacute to recovery phase.. Italicized notes highlight specific therapeutic strategies focusing on spatial awareness, self-monitoring, and work reintegration goals.. PT, physical therapy; OT, occupational therapy; ADL, daily living; ST, speech-language-hearing therapy
case_images: cureus-0017-00000077951-i03.jpg
case_images: PMC11787550_01_cureus-0017-00000077951-i03.jpg
case_images: FIG3
case_images: The timeline of key clinical events and interventions is shown in Figure 3. Initial behavioral inattention test (BIT) score was 139 (conventional subtests: line crossing 36/36, letter cancellation 37/40, star cancellation 54/54, figure copying 3/4, line bisection 7/9, representational drawing 2/3), indicating mild USN symptoms.
case_images: Visual attention assessment paradigm. (A) Test procedure: A schematic diagram depicting the @ATTENTION tool. Each target in a 35-object grid blinks for up to five seconds, and the RT is measured from the onset of blinking until the participant responds. If no response is made within five seconds, a timeout is recorded.. (B) Scoring metrics: Two primary metrics are assessed. RT mean (green box), the average RT across all 35 targets. L/R ratio (blue/orange boxes), this ratio is calculated by dividing the mean RT for 15 left-sided targets by the mean RT for 15 right-sided targets. A value greater than 1.0 indicates slower responses to left-sided targets, potentially reflecting inattention or neglect toward the left side.. Note: In clinical contexts, a higher L/R ratio often suggests a relative difficulty in detecting or responding to stimuli presented on the left side of the visual field.. RT, reaction time
case_images: cureus-0017-00000077951-i04.jpg
case_images: PMC11787550_01_cureus-0017-00000077951-i04.jpg
case_images: FIG4
case_images: The @ATTENTION tool (Figure 4) initially indicated delayed responses on the left side, with a left-to-right response time ratio of 1.63 and a mean RT of 2.03 seconds. This asymmetry in response times showed marked improvement during rehabilitation, with the left-to-right ratio normalizing to 1.0 by day 122 and mean RTs improving from 2.03 to 1.26 seconds, indicating recovery of spatial attention (Table 1).
case_images: Sequential changes in copying and drawing tasks demonstrating hyperschematia. Serial assessment of copying and drawing tasks from one to six months post-onset, illustrating the evolution of hyperschematia with the "over-generation" phenomenon. The tasks included copying (star and daisy) and free drawing (clock and butterfly). In the star copying task, left-sided enlargement became prominent after four months (122 days). The daisy copying task showed consistent over-generation of petals (10 instead of the model's nine) from month one to four, with an additional flower appearing on the left side at four months. The clock drawing task demonstrated significant left-sided over-generation at one month (32 days), with numbers extending to 16. The butterfly drawing task exhibited progressive addition of unrelated elements on the left side: a tree at two months (64 days), leaves at three months, a flower at four months, a tree at five months, and a flower at six months. These patterns illustrate the persistence and evolution of hyperschematia characterized by both spatial enlargement and element over-generation, particularly affecting the left side of drawings.
case_images: cureus-0017-00000077951-i05.jpg
case_images: PMC11787550_01_cureus-0017-00000077951-i05.jpg
case_images: FIG5
case_images: The patient demonstrated notable left-sided object enlargement in the star copying task, an increased number of flower petals in copying tasks, and excessive number writing in clock drawing tasks, sometimes extending to as many as 16 numbers (Figure 5).
case_images: Temporal changes in FIM scores. Changes in total FIM scores from admission to six months post-onset, showing three distinct recovery phases (highlighted in white and gray bands). The initial phase shows gradual improvement from admission (30 points) to month two (45 points), during which assistance was required for all ADL tasks. The second phase demonstrates the achievement of independence in basic ADLs, with scores increasing to 72 points by month three. The final phase shows rapid improvement in mobility, with the achievement of independent walking, reaching 116 points by month six. The graph illustrates a stepwise recovery pattern, with marked improvements particularly after month four.. ADL, activities of daily living; FIM, functional independence measure
case_images: cureus-0017-00000077951-i06.jpg
case_images: PMC11787550_01_cureus-0017-00000077951-i06.jpg
case_images: FIG6
case_images: The functional independence measure (FIM) showed a stepwise improvement pattern across three distinct phases (Figure 6).