The syndrome of Anosognosia for Hemiplegia (AHP) can provide unique insights into the neurocognitive processes of motor awareness. Yet, prior studies have only explored predominately discreet lesions. Using advanced structural neuroimaging methods in 174 patients with a right-hemisphere stroke, we were able to identify three neural systems that contribute to AHP, when disconnected or directly damaged: the (i) premotor loop (ii) limbic system, and (iii) ventral attentional network. Our results suggest that human motor awareness is contingent on the joint contribution of these three systems.

1The rare syndrome of Anosognosia for Hemiplegia (AHP) can provide unique insights into 2 the neurocognitive processes of motor awareness. Yet, prior studies have only explored 3 predominately discreet lesions. Using advanced structural neuroimaging methods in 174 patients with 4 a right-hemisphere stroke, we were able to identify three neural networks that contribute to AHP, 5 when disconnected: the (1) premotor loop (2) limbic system, and (3) ventral attention network. Our 6 results suggest that human motor awareness is contingent on the joint contribution of these three 7 systems. 83 Motor awareness allows individuals to have insight into their motor performance, a 9 fundamental aspect of self-awareness. However, following damage to the right hemisphere, patients 10 with left paralysis may show delusions of intact motor ability, or anosognosia for hemiplegia (AHP, 11 1). Hence, studying AHP offers unique opportunities to explore the neurocognitive mechanisms of 12 motor awareness. 13While early studies regarded AHP as secondary to concomitant spatial deficits such as hemineglect 14 2 caused by parietal lesions, more recent experimental and voxel-based, lesion-symptom mapping 15 (VLSM) results suggest that AHP is an independent syndrome. These earlier studies address AHP as 16 an impairment of action and body monitoring, with lesions to the lateral premotor cortex and the 17 anterior insula (3,4), affecting patients' ability to detect discrepancies between feed-forward motor 18 predictions and sensorimotor feedback. However, these hypotheses are insufficient to explain all the 19 AHP symptoms, such as patients' inability to update their beliefs based on social feedback or more 20 general difficulties experienced in their daily living (5,6). Indeed, others have suggested that AHP 21 can be caused by a functional disconnection between regions processing top-down beliefs about the 22

Specific, peripheral C-tactile afferents contribute to the perception of tactile pleasure, but the brain areas involved in their processing remain debated. We report the first human lesion study on the perception of C-tactile touch in right hemisphere stroke patients (N = 59), revealing that right posterior and anterior insula lesions reduce tactile, contralateral and ipsilateral pleasantness sensitivity, respectively. These findings corroborate previous imaging studies regarding the role of the posterior insula in the perception of affective touch. However, our findings about the crucial role of the anterior insula for ipsilateral affective touch perception open new avenues of enquiry regarding the cortical organization of this tactile system.

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Background: Few studies have investigated the experiences of patients around the conversion to secondary progressive multiple sclerosis (SPMS). ManTra is a mixed-method, co-production research project conducted in Italy and Germany to develop an intervention for newly-diagnosed SPMS patients. In previous project actions, we identified the needs and experiences of patients converting to SPMS via literature review and qualitative research which involved key stakeholders. Aims: The online patient survey aimed to assess, on a larger and independent sample of recently-diagnosed SPMS patients: (a) the characteristics associated to patient awareness of SPMS conversion; (b) the experience of conversion; (c) importance and prioritization of the needs previously identified. Methods: Participants were consenting adults with SPMS since ≤5 years. The survey consisted of three sections: on general and clinical characteristics; on experience of SPMS diagnosis disclosure (aware participants only); and on importance and prioritization of 33 pre-specified needs. Results: Of 215 participants, those aware of their SPMS diagnosis were 57% in Italy vs. 77% in Germany ( p = 0.004). In both countries, over 80% of aware participants received a SPMS diagnosis from the neurologist; satisfaction with SPMS disclosure was moderate to high. Nevertheless, 28–35% obtained second opinions, and 48–56% reported they did not receive any information on SPMS. Participants actively seeking further information were 63% in Germany vs. 31% in Italy ( p < 0.001). Variables independently associated to patient awareness were geographic area (odds ratio, OR 0.32, 95% CI 0.13–0.78 for Central Italy; OR 0.21, 95% CI 0.08–0.58 for Southern Italy [vs. Germany]) and activity limitations (OR 7.80, 95% CI 1.47–41.37 for dependent vs. autonomous patients). All pre-specified needs were scored a lot or extremely important, and two prioritized needs were shared by Italian and German patients: “physiotherapy” and “active patient care involvement.” The other two differed across countries: “an individualized health care plan” and “information on social rights and policies” in Italy, and “psychological support” and “cognitive rehabilitation” in Germany. Conclusions: Around 40% of SPMS patients were not aware of their disease form indicating a need to improve patient-physician communication. Physiotherapy and active patient care involvement were prioritized in both countries.