Normally, we are aware of the current functions of our arms and legs. However, this self-evident status may change dramatically after brain damage. Some patients with "anosognosia" typically are convinced that their limbs function normally, although they have obvious motor defects after stroke. Such patients may experience their own paretic limbs as strange or as not belonging to them and may even attribute ownership to another person and try to push their paralyzed limb out of bed. These odd beliefs have been attributed to disturbances somewhere in the right hemisphere. Here, we use lesion mapping in 27 stroke patients to show that the right posterior insula is commonly damaged in patients with anosognosia for hemiplegia/hemiparesis but is significantly less involved in hemiplegic/hemiparetic patients without anosognosia. The function of the posterior insular cortex has been controversially discussed. Recent neuroimaging results in healthy subjects revealed specific involvement of this area in the subject's feeling of being versus not being involved in a movement. Our finding corresponds with this observation and suggests that the insular cortex is integral to self-awareness and to one's beliefs about the functioning of body parts.

Background and Purpose-Hemiparetic stroke patients with disturbed awareness for their motor weakness (anosognosia for hemiparesis/-plegia [AHP]) may exhibit further abnormal attitudes toward or perceptions of the affected limb(s). The present study investigated the clinical relationship and the anatomy of such abnormal attitudes and AHP. Methods-In a new series of 79 consecutively admitted acute stroke patients with right brain damage and hemiparesis/ -plegia, different types of abnormal attitudes toward the hemiparetic/plegic limb (asomatognosia, somatoparaphrenia, anosodiaphoria, misoplegia, personification, kinaesthetic hallucinations, supernumerary phantom limb) were investigated. Results-Ninty-two percent of the patients with AHP showed additional "disturbed sensation of limb ownership" (DSO) for the paretic/plegic limb. The patients had the feeling that their contralesional limb(s) do not belong to their body or even belong to another person. Analysis of lesion location revealed that the right posterior insula is a crucial structure involved in these phenomena. Conclusions-DSO

Normally, we are aware that our arms and legs belong to us and not to someone else. However, some stroke patients with hemiparesis/-plegia after right-sided stroke show a disturbed sensation of limb ownership and a disturbed self-awareness of actions and such patients with anosognosia for hemiparesis/plegia typically deny their paresis/-plegia and are convinced that their limbs function normally. They may experience their limb(s) as not belonging to them and may even attribute them to other persons. Modern lesion analyses techniques in such patients and recent neuroimaging results in healthy subjects suggest a prominent role of the right insula for our sense of limb ownership as well as for our feeling of being involved in a movement-our sense of agency. We thus hypothesize that the right insular cortex constitutes a central node of a network involved in human body scheme representation.

Damage to these regions might lead to an imbalance within the vestibular network of one hemisphere due to a deficit in multimodal signal processing.

Successful remembering involves both hindering irrelevant information from entering working memory (WM) and actively maintaining relevant information online. Using a voxelwise lesion-behavior brain mapping approach in stroke patients, we observed that lesions of the left basal ganglia render WM susceptible to irrelevant information. Lesions of the right prefrontal cortex on the other hand make it difficult to keep more than a few items in WM. These findings support basal ganglia-prefrontal cortex models of WM whereby the basal ganglia play a gatekeeper role and allow only relevant information to enter prefrontal cortex where this information then is actively maintained in WM.

Previous studies have shown that processing information in one sensory modality can either be enhanced or attenuated by concurrent stimulation of another modality. Here, we reconcile these apparently contradictory results by showing that the sign of cross-modal interactions depends on whether the content of two modalities is associated or not. When concurrently presented auditory and visual stimuli are paired by chance, cue-induced preparatory neural activity is strongly enhanced in the task-relevant sensory system and suppressed in the irrelevant system. Conversely, when information in the two modalities is reliably associated, activity is enhanced in both systems regardless of which modality is task relevant. Our findings illustrate an ecologically optimal flexibility of the neural mechanisms that govern multisensory processing: facilitation occurs when integration is expected, and suppression occurs when distraction is expected. Because thalamic structures were more active when the senses needed to operate separately, we propose them to serve gatekeeper functions in early cross-modal interactions.

Sound-induced vestibular-evoked myogenic potentials (VEMPs) can be used to investigate saccular function, measured from the tonically contracted sternocleidomastoid muscles (SCM) in response to loud sound stimuli. The aim of the present study was to assess VEMPs in patients with vestibular migraine and to determine whether saccular function is affected by the disease. Furthermore, tests such as tilts of subjective visual vertical (SVV) and caloric testing were conducted to test whether deficits in the various tests are associated with each other. The amplitude and latency of VEMPs were measured from the SCM in 63 patients with vestibular migraine (median age 47 years; range 24-70 years) and compared with those of 63 sex- and age-matched healthy controls (median age 46 years; range 17-73 years). Of the 63 patients with vestibular migraine, 43 (68%) had reduced EMG-corrected VEMP amplitudes compared to the controls. Thus, the mean of the p13-n23 amplitudes of the vestibular migraine patients were 1.22 (SE +/-0.09) for the right and 1.21 (SE +/-0.09) for the left side, whereas the averaged amplitudes of the 63 healthy controls showed a mean of 1.79 (SE +/-0.09) on the right and of 1.76 (SE +/-0.09) on the left. No difference was seen in the latencies and there was no correlation between VEMP amplitudes, tilts of SVV and caloric testing. Our data on patients with vestibular migraine indicate that the VEMP amplitudes are significantly and bilaterally reduced compared to those of controls. This electrophysiological finding suggests that both peripheral vestibular structures, such as the saccule, but also central vestibular structures are affected. Thus, beside the brainstem, structures in the inner ear also seem to contribute to vertigo in vestibular migraine.

Unilateral stroke can lead to a disorder of postural balance that manifests as a pushing away toward the contralesional side. It is called "pusher syndrome" (PS). The aims of this study were first to assess the anatomical cortical regions that induce PS and second to clarify whether tilt of the subjective visual vertical (SVV)--a sign of vestibular otolith dysfunction--is associated with PS. Sixty-six patients with acute unilateral strokes (28 left-sided lesions, 38 right-sided lesions) were tested for PS, for tilts of the SVV, for hemineglect and for the anatomical lesion site by magnetic resonance imaging (MRI)-based voxelwise lesion-behavior mapping analysis. Our data indicated no significant voxels; however, there was a trend towards an association between lesions of the posterior part of the insula, the operculum and the superior temporal gyrus--key areas of the multisensory vestibular cortical network--and the extent of pushing in patients with right-sided lesions, whereas the rather anterior part of the insula, the operculum as well as the internal capsule reaching to the lateral thalamus seemed to be involved in PS in left-sided lesion patients. These data might point toward a link between the systems responsible for postural control and for processing vestibular otolith information. These findings indicate that vestibular information might be fundamental in right-sided lesion patients for maintaining body posture in space.