Journal Club: Possible role of the basal ganglia in poor reward sensitivity and apathy after stroke One in 3 stroke survivors is affected by apathy, disturbance of goal-directed behavior (GDB) 1 that can result from the disruption of neural structures controlling GDB, of which the prefrontal cortex (PFC) and the basal ganglia (BG) are thought to be of particular relevance (figure).1,2 Recent proposals suggest that reward insensitivity associated with BG dysfunction may be a key component of apathy. 3,4 In a recent Neurology ® article, Rochat et al. 5 addressed this issue directly by assessing the contribution of reward insensitivity to self-reported apathy and how this may relate to damage within frontostriatal lesions in stroke patients.HYPOTHESIS AND DESIGN The authors asked 2 simple yet timely questions: is the insensitivity to reward a possible underlying cause of apathy, and, if so, what are the likely affected brain structures related in stroke causing insensitivity to reward and apathy?To this end, the authors performed an observational correlation study with a consecutive screening and enrollment of all eligible patients, the administration of simple cognitive tests, and the use of MRI and CT scans previously acquired for clinical purposes. Although classified as prospective, the work does not present a follow-up time or longitudinal historical data.METHODS Patients (55; age ,75 years) with a first ischemic or hemorrhagic stroke within 3 months prior to study entry and with a modified Rankin Scale score #3 were enrolled. Patients with a history of other neurologic or psychiatric disorders or signs of aphasia or dysarthria were excluded, providing for a relatively homogenous sample. A power analysis suggested that the sample was sufficient to detect a medium-sized effect in a correlation analysis. Fifteen healthy subjects were included as controls.The authors tested a range of cognitive functions, including self-reported apathy (Apathy Inventory), mood (Short Depression and Happiness Scale Of specific interest for the purpose of the study is the CRRT, requiring subjects to make responses corresponding to an "oddone-out" shape as fast and accurately as possible. The stimuli were preceded by 1 of 3 colored cues, associated with a 10%, 50%, or 90% probability of reinforcement. The association between cues and reward probability was unknown to the subjects. Correct responses yielded a green smiley face; incorrect responses, a red sad face. The magnitude of reinforcement (points) depended on both accuracy and reaction time (RT). No feedback or points were presented in unreinforced trials. Therefore, 2 dimensions were manipulated: reinforcement and cue incentive value, updated through the reinforcement learning. Response RTs were used as a measure of incentive motivation. 6 A behavioral task has the advantage of permitting an objective evaluation of the implicit reward sensitivity, including both the general trait level of reward responsiveness and the state of reward sensitivity.An implicit associative ...