Original Contribution
Functional Role of the Corticoreticular Pathway in Chronic
Stroke Patients
Sung Ho Jang, MD; Chul Hoon Chang, MD; Jun Lee, MD; Chung Sun Kim, PhD;
Jeong Pyo Seo, MS; Sang Seok Yeo, PhD
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Background and Purpose—The corticoreticular pathway (CRP) is known to be an important extrapyramidal tract for walking
ability. However, little is known about the functional role of the CRP in recovery of walking ability. We investigated
relation between the CRP and walking ability in chronic hemiparetic stroke patients.
Methods—Among 209 consecutive patients, 54 patients, who showed complete injury of the corticospinal tract (CST) in
the affected hemisphere on diffusion tensor tractography, and 20 normal subjects were recruited. Functional ambulation
category was used in measurement of walking ability. The fractional anisotropy value, apparent diffusion coefficient
value, and fiber volume of the CRP and CST were used for the diffusion tensor imaging parameters.
Results—In the affected hemisphere, no significant difference in diffusion tensor imaging parameters of the CRP was
observed between patient subgroups. In the unaffected hemisphere, patients who were able to walk showed significantly
increased fiber volume of the CRP, compared with patients who could not walk and normal control subjects (P<0.05),
without significant difference in fractional anisotropy and apparent diffusion coefficient values. In addition, the fiber
volume of the CRP in the unaffected hemisphere showed positive correlation with functional ambulation category
(P<0.05). In contrast, diffusion tensor imaging parameters of the CST in the unaffected hemisphere showed no correlation
with functional ambulation category (P>0.05).
Conclusions—The increased fiber volume of the CRP in the unaffected hemisphere seems to be related to walking ability
in patients with chronic stroke. Therefore, the compensation of the CRP in the unaffected hemisphere seems to be one of
the mechanisms for recovery of walking ability after stroke. (Stroke. 2013;44:XXX-XXX.)
Key Words: corticoreticular pathway
■
corticoreticulospinal tract
S
troke is a leading cause of major disability in adults; ≈20%
to 30% of stroke patients have suffered walking dysfunction as a disabling sequela.1–5 The descending motor pathways
are classified according to the corticospinal tract (CST, pyramidal tract) and non-CST (extrapyramidal tract).6,7 A number
of studies have reported on stroke patients who were unable
to perform fine motor activities of the hands after complete
injury of the lateral CST;8–12 in contrast, recent studies have
demonstrated that stroke patients were able to walk even after
complete injury of the lateral CST, suggesting that walking
is not as strongly associated with the lateral CST as hand
function.3,9,13–15 Greater involvement of non-CSTs in walking
ability has been suggested.9,14,15 In particular, the corticoreticulospinal tract, consisting of the corticoreticular pathway
(CRP) and the reticulospinal tract, is known to be an important
neural tract for walking ability14–16 because it mainly mediates
proximal and axial muscles; consequently, it is known to have
a major role in relation to walking ability.16,17
■
diffusion tensor imaging
■
stroke
■
walking ability
Several previous studies using conventional brain
MRI, single photon emission computed tomography, and
functional near infrared spectroscopy have reported on the
relation between walking dysfunction and injury of the
premotor cortex (PMC).18–22 However, these studies could
not clearly elucidate definitive relation between specific
neural tracts and walking ability. The PMC is the main
origin site of the corticoreticulospinal tract; therefore, the
corticoreticulospinal tract has been suggested as one of the
plausible neural tracts.16 Recent development in diffusion
tensor imaging (DTI) has enabled investigators to estimate
the state of the neural tracts at the subcortical level in 3
dimensions.23 A study using DTI reported on a method
for identification of the CRP in the live human brain.24
Few studies have reported on injury of the CRP in patients
with stroke and traumatic brain injury.25,26 However,
little is known about the relation between the CRP and
walking ability.
Received November 28, 2012; final revision received December 27, 2012; accepted January 3, 2013.
From the Department of Physical Medicine and Rehabilitation (S.H.J., J.P.S., S.S.Y.), Department of Neurosurgery (C.H.C.), Department of Neurology
(J.L.), College of Medicine, Yeungnam University, Daemyungdong, Namku, Taegu, Republic of Korea; and Department of Physical Therapy, College of
Rehabilitation Science, Daegu University, Jillyang, Gyeongsan, Gyeongbuk, Republic of Korea (C.S.K.).
Correspondence to Sang Seok Yeo, PhD, Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1,
Daemyungdong, Namku, Taegu, 705-717, Republic of Korea. E-mail [email protected]
© 2013 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.111.000269
1
2 Stroke April 2013
In this study, using DTI, we attempted to investigate the
relation between the CRP and walking ability in chronic hemiparetic stroke patients.
Materials and Methods
Subjects
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Fifty-four stroke patients (39 men, 15 women; mean age, 54.4 years;
range, 32–75) and 20 age- and sex-matched control subjects (10 men,
10 women; mean age, 53.1 years; range, 33–72) with no history of
neurological or psychiatric disease were recruited for this study.
Stroke patients were recruited consecutively among 209 stroke
patients according to the following inclusion criteria: (1) first-ever
stroke, (2) age: 30 to 75 years, (3) >3 months after stroke onset, (4)
hemorrhage or infarction confined to the subcortical supratentorial
level (the corona radiata, basal ganglia, and internal capsule), (5) patients who could not walk within 24 hours after stroke onset, and
(5) patients who showed complete CST injury (discontinuation of the
CST around or below the lesion) in the affected hemisphere on diffusion tensor tractography (DTT). Patients with apraxia, somatosensory
problems, severe cognitive problems (mini-mental state examination
<25), or intracerebral hemorrhage because of vascular anomaly or
hemorrhagic transformation after cerebral infarct were excluded.
This study was conducted retrospectively, and the local ethics committee of a university hospital approved the study protocol.
tracking was performed using a fractional anisotropy (FA) threshold
of >0.2 and direction threshold <70°. We measured the FA value,
apparent diffusion coefficient (ADC) value, and fiber volume of the
CRP in both hemispheres and the CST in the unaffected hemisphere.
For measurement of interobserver and intraobserver reliability, random analyses of the data were performed by 2 evaluators who were
blinded to the other evaluator’s data.
Statistical Analysis
The χ2 test was used for determination of the difference in incidence of CRP injury in the affected hemisphere between patient
subgroups. The independent t test was performed for comparison of
motor functions between hemorrhagic and infarction patients. The
Mann–Whitney U test was performed for determination of difference
in motor function according to the CRP injury in the affected hemisphere. One-way ANOVA with Scheffe post hoc test was performed
for determination of the statistical difference of DTI parameters of
the CRP and CST between the patient and control groups. Spearman
correlation test was used for determination of correlation between
DTI parameters of constructed neural tracts and motor functions. For
evaluating interobserver and intraobserver reliability, we used intraclass correlation coefficient (ICC). Software (v.15.0; SPSS, Chicago,
IL) was used in performance of statistical analyses, and statistical
significance was set at P<0.05.
Clinical Evaluation
Motor function was evaluated at the time of DTI scanning. The functional ambulation category (FAC) scale was used for determination
of walking ability.27 The FAC was designed for examination of the
levels of assistance required during a 15-m walk. Six categories are
included in the FAC: 0 (nonambulatory), 1 (needs continuous support
from 1 person), 2 (needs intermittent support from 1 person), 3 (needs
only verbal supervision), 4 (help is required on stairs and uneven surfaces), and 5 (can walk independently anywhere). We classified patients into 2 subgroups according to the ability to walk independently;
subgroup A: patients who could not walk independently (FAC: 0 to 2)
and subgroup B: patients who could walk independently (FAC: 3 to
5). Motricity index (MI) was used for measurement of motor function
of the affected upper and lower extremities (maximum score: 100).28
The reliabilities and validities of FAC and MI have been well established.27,28 Evaluators of clinical data were blinded to DTT data, and
analyzers of DTT were also blinded to the clinical data.
Diffusion Tensor Imaging
DTI data were acquired at an average of 22 months (range, 3–125)
after stroke onset, using a 1.5-T Philips Gyroscan Intera system
equipped with a synergy-L Sensitivity Encoding head coil using a
single-shot, spin-echo planar imaging pulse sequence. For each
of the 32 noncollinear and noncoplanar diffusion sensitizing gradients, we acquired 60 contiguous slices parallel to the anterior
commissure-posterior commissure line. The imaging parameters
were matrix =128×128 matrix, field of view =221×221 mm2,
repetition time=76 ms, time to echo=10 726 ms, sensitivity encoding
facto =2; echo-planar imaging factor=67 and b=600 mm2⋅s-1; NEX
=1; and a slice thickness of 2.3 mm. We scanned T1-weighted, T2weighted, fluid attenuated inversion recovery, and T2-weighted gradient recall echo images to confirm the stroke lesion.
Affine multiscale 2-dimensional registration was used for reduction of eddy current-induced image distortions and motion artifacts.29
Preprocessing of DTI data sets was performed using the Oxford
Center for Functional MRI of Brain Software Library. DTI-Studio
software (CMRM, Johns Hopkins Medical Institute, MD) was used
for reconstruction of the CRP and CST. For analysis of the CRP, the
seed region of interest (ROI) was placed on the reticular formation of
the medulla and the target ROI on the midbrain tegmentum (Figure
1C).24 For analysis of the CST, the seed ROI was placed on the CST
portion of the pontomedullary junction and the target ROI on the CST
portion of the anterior midpons.30 The CRP and CST were determined
by selection of fibers passing through seed and target ROI. Fiber
Results
Thirty-nine (72.2%) of the 54 patients had experienced an
intracerebral hemorrhage and the remaining 15 had experienced a cerebral infarct. In terms of all motor functions, significant difference was not observed between hemorrhagic
and infarct patients (P>0.05). In classification according to
walking ability, 20 (37.0%) of 54 patients belonged to subgroup A (FAC: 0–2) and 34 to subgroup B (FA: 3–5).
All patients in subgroup A and 30 of 34 patients in subgroup
B showed a discontinuation of the CRP in the affected
hemisphere; however, no significant difference in incidence
of CRP injury was observed between subgroups A and B
(P>0.05). In addition, in subgroup B, patients with intact CRP
in the affected hemisphere showed significantly higher motor
function in terms of FAC and all MIs compared with patients
with injured CRP (P>0.05). In terms of FA, ADC and fiber
volume of the CRP in the affected hemisphere did not show
significant difference between patient subgroups (P>0.05). In
addition, no significant differences in FA and ADC values of
the CRP in the unaffected hemisphere were observed between
patient and control groups and between patient subgroups
A and B (p >0.05). By contrast, fiber volume of the CRP in
the unaffected hemisphere of subgroup B was significantly
higher than that of subgroup A and the control group (P<0.05)
(Table 1). Regarding the CST in the unaffected hemisphere,
the FA value of subgroup A was significantly lower than
that of the control group (P<0.05). In contrast, there were
no differences in ADC values and fiber volume of all patient
subgroups and the control group (P>0.05) (Table 1). In the
result of reliability, we observed strong intraobserver and
interobserver reliability of DTI parameters in the CST (intraICC =0.883–0.993, inter-ICC =0.872–0.996) and CRP (intraICC =0.874–0.957, inter-ICC =0.860–0.976).
A summary of the correlations between DTI parameters
of constructed neural tracts and motor functions is shown in
Table 2. Fiber volume of the CRP in the affected hemisphere
Jang et al Walking Ability in Chronic Stroke Patients 3
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Figure 1. Diffusion tensor
tractography (DTT) of the corticoreticular pathway (CRP)
and corticospinal tract (CST)
in patients and age-matched
control subjects. A, DTT results
of the CRP and CST in patient
subgroups. DTTs of the CST
and CRP in the affected hemisphere showed discontinuations attributable to stroke
(blue arrow). By contrast, in
subgroup B (functional ambulation category [FAC] ≥3), the
CRP in the unaffected hemisphere showed increased fiber
volume (green arrow), compared with subgroup A (FAC
<3) and normal control. B, DTT
results for the CRP and CST in
normal control. C, Seed region
of interest (ROI) was given on
the medullary reticular formation (yellow rectangle), and
the target ROI was placed on
the midbrain tegmentum (blue
rectangle).
did not show any correlation with FAC and all MIs (P>0.05).
By contrast, fiber volume of the CRP in the unaffected
hemisphere showed moderate positive correlation with FAC
(r=0.425, P=0.006), and mild positive correlation with upper
MI (r=0.307, P=0.038), lower MI (r=0.340, P=0.021), and
total MI (r=0.308, P=0.037). However, the FA and ADC values
did not show correlation with FAC and all MIs (P>0.05). On
the contrary, the ADC value of the CST in the unaffected
hemisphere showed negative correlation with upper MI
(r= −0.408, P=0.005), lower MI (r= −0.357, P=0.015), and
total MI (r= −0.401, P=0.006), without correlation with FAC.
In addition, the FA value and fiber volume of the CST in the
unaffected hemisphere did not show correlation with FAC and
all MIs (P>0.05) (Figure 2).
Table 1. Comparisons of Diffusion Tensor Image Parameters of the Corticoreticular Pathway and Corticospinal Tract Between
Patient Subgroups and Control Group
Unaffected Hemisphere
Corticoreticular Pathway
Corticospinal Tract
FA
ADC
FV
FA
ADC
FV
Subgroup A (FAC <3)
0.49 (0.03)
0.83 (0.05)
658.50 (298.50)
0.55 (0.02)
0.83 (0.05)
1074.15 (341.10)
Subgroup B (FAC ≥3)
0.50 (0.03)
0.84 (0.04)
1047.00 (323.38)
0.57 (0.02)
0.81 (0.08)
1205.32 (385.81)
Control
0.50 (0.02)
0.83 (0.05)
758.93 (282.52)
0.58 (0.03)
0.83 (0.06)
924.48 (305.59)
Subgroup A vs B
0.870
0.713
0.000*
0.207
0.497
0.404
Subgroup A vs Control
0.323
0.996
0.835
0.000*
0.900
0.280
Subgroup B vs Control
0.526
0.551
0.000*
0.063
0.671
0.380
Values represent mean (SD).
ADC indicates apparent diffusion coefficient; FAC, functional ambulation categories; FA, fractional anistrophy; and FV, fiber volume. One-way ANOVA with Scheffe post
hoc test was used for comparison of diffusion tensor parameters between patient groups and normal control.
*P<0.05.
4 Stroke April 2013
Table 2. Correlation Between Motor Function and Diffusion Tensor Imaging Parameters of the Corticoreticular Pathway and
Corticospinal Tract in the Unaffected Hemisphere
FAC
Unaffected
Hemisphere
CRP
CST
r
Upper MI
P Value
r
Lower MI
P Value
r
Total MI
P Value
r
P Value
FA
0.153
0.311
0.071
0.638
0.069
0.647
0.056
0.712
ADC
0.007
0.961
0.039
0.796
0.034
0.821
0.037
0.808
FV
0.455
0.001*
0.307
0.038*
0.340
0.021*
0.308
0.037*
FA
0.233
0.120
0.118
0.436
0.124
0.413
0.111
0.464
ADC
−0.282
0.057
−0.408
0.005*
−0.357
0.015*
−0.401
0.006*
FV
0.062
0.683
−0.182
0.226
−0.183
0.224
−0.178
0.237
ADC indicates apparent diffusion coefficient; CRP, corticoreticular pathway; CST, corticospinal tract; FA, fractional anistrophy; FAC, functional ambulation categories;
FV, fiber volume; and MI, motricity index.
*P<0.05.
Discussion
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In the current study, among 209 consecutive chronic stroke
patients, we recruited 54 stroke patients who showed
complete injury of the CST in the affected hemisphere on
DTT. We found that, in the unaffected hemisphere, the fiber
volume of the CRP was higher in patients who were able to
walk independently (subgroup B), compared with patients
who could not walk (subgroup A) and normal control subjects,
without change of FA and ADC values. In addition, in terms of
the CST in the unaffected hemisphere, the FA value was lower
in patients who could not walk (subgroup A), compared with
normal control subjects, without change of ADC values and
fiber volume. The fiber volume is determined by the number
of voxels contained within a neural tract.31,32 In contrast,
the FA value indicates the degree of directionality of water
diffusion.33,34 It represents the white matter organization; in
detail, the degree of directionality and integrity of white matter
microstructures, such as axon, myelin, and microtubule, and
the ADC value indicates the magnitude of water diffusion.33,34
Therefore, increased fiber volume and reduced FA value
without change of the ADC value seems to indicate increased
numbers of neural fibers and disintegration of neural fibers,
respectively.23,31–34 In the correlation analysis, the fiber volume
of the CRP in the unaffected hemisphere showed moderate
Figure 2. Scatter diagram for fiber volume of the corticoreticular pathway and each motor function. *P<0.05
Jang et al Walking Ability in Chronic Stroke Patients 5
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and mild positive correlation with walking ability and motor
functions, respectively; however, that of the CST showed no
correlation. Consequently, increased fiber volumes of the CRP
in the unaffected hemisphere seem to be related to recovery
of walking ability and some motor functions in hemiparetic
stroke patients. By contrast, decreased FA of the CST in
the unaffected hemisphere might be related to long-term
immobility after stroke.35,36
Several previous studies have reported on stroke patients
who were able to walk even after complete injury of the CST;
however, these studies could not elucidate the alternative
neural tract of the injured CST associated with walking ability.3,9,13 On the contrary, even without exact estimation of the
CRP, several studies have demonstrated the predominant role
of the PMC in control of walking ability. In 1999, Miyai et al19
reported on 12 stroke patients with a lesion in the PMC who
showed delayed recovery of walking ability. During the same
year, using single photon emission computed tomography,
Hanakawa et al18 reported on decreased activation in the PMC
in patients affected by Parkinson’s disease with gait disturbance. In 2002, using functional near infrared spectroscopy,
Miyai et al20 evaluated cortical activation patterns in stroke
patients with severe walking dysfunction during passive
treadmill walking. They demonstrated that passive treadmill
walking could activate the PMC in the affected hemisphere.
Subsequently, using functional near infrared spectroscopy,
Miyai et al21 reported that the enhanced PMC activation in
the affected hemisphere showed significant correlation with
improvement of walking ability in stroke patients. In 2006,
using functional near infrared spectroscopy, they also reported
on 6 patients with subcortical stroke, who showed improvement of walking ability with enhanced PMC activation in the
unaffected hemisphere.22 These results seem to be compatible
with the results of the current study, which showed increased
fiber volume of the CRP in the unaffected hemisphere.
Therefore, the compensation of the CRP in the unaffected
hemisphere seems to be one of the mechanisms for recovery
of walking ability after stroke.22
Conclusions
In conclusion, we investigated the role of the CRP in relation to walking ability for patients with chronic stroke. It
was found that the increased fiber volume of the CRP in the
unaffected hemisphere seems to be related to walking ability
in patients with chronic stroke. This result demonstrates the
importance of the CRP for walking ability in stroke patients.
Therefore, we suggest that evaluations of the CRP using DTT
would be useful for stroke patients with walking dysfunction.
However, limitations of this study should be considered. First,
because most recruited patients (92.6%) showed severe injury
of the CRP in the affected hemisphere, we were unable to
fully elucidate the functional role of the CRP in the affected
hemisphere. This seems to be ascribed to the fact that we
recruited stroke patients with severely affected motor function who showed complete injury of the CST in the affected
hemisphere. The CRP descends through the corona radiata
and posterior limb of the internal capsule just anterior to the
CST; patients with complete injury of the CST are vulnerable to severe injuries in the CRP pathway.24 Second, further
prospective studies involving follow-up clinical and DTT data
from acute to chronic stage of stroke are warranted because
this study was performed retrospectively. Third, DTI analysis
is operator-dependent, and because of fiber complexity and
crossing fiber effect, it may underestimate the fiber tracts.37,38
Another limitation is that we could not consider the other neural tracts that have been suggested as playing a role in walking, including the vestibulospinal tract and anterior CST.8
Therefore, conduct of further studies, including more neural
tracts that are related to walking ability, would be necessary.
In addition, the role of the CRP in the affected hemisphere
should be clarified by conduct of further studies involving
larger number of patients with mild CRP injury.
Sources of Funding
This research was supported by Basic Science Research Program
through the National Research Foundation of Korea (NRF)
funded by the Ministry of Education, Science, and Technology
(2012R1A1A4A01001873).
Disclosures
None.
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Functional Role of the Corticoreticular Pathway in Chronic Stroke Patients
Sung Ho Jang, Chul Hoon Chang, Jun Lee, Chung Sun Kim, Jeong Pyo Seo and Sang Seok Yeo
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30
Stroke 日本語版 Vol. 8, No. 2
Abstract
慢性期脳卒中患者における皮質網様体路の機能的役割
Functional Role of the Corticoreticular Pathway in Chronic Stroke Patients
Sung Ho Jang, MD1; Chul Hoon Chang, MD2 ; Jun Lee, MD3; Chung Sun Kim, PhD4; Jeong Pyo Seo, MS1;
Sang Seok Yeo, PhD1
1
Department of Physical Medicine and Rehabilitation, 2 Department of Neurosurgery, 3 Department of Neurology, College of Medicine, Yeungnam
University, Daemyungdong, Namku, Taegu, Republic of Korea; and 4 Department of Physical Therapy, College of Rehabilitation Science, Daegu
University, Jillyang, Gyeongsan, Gyeongbuk, Republic of Korea
背景および目的：皮質網様体路（ CRP ）は歩行能力に重要
た。非患側半球では，歩行可能群の方が歩行不可能群と
な椎体外路である。しかし，歩行能力回復時の CRP の機
正常対照群と比較して CRP の線維量が有意に増加した
能的役割についてはほとんど知られていない。我々は，慢 （p ＜ 0.05 ）が，異方性比率およびみかけの拡散係数には
性期脳卒中片麻痺患者の CRP と歩行能力の関係を調べた。 有意差はなかった。また，非患側半球の CRP の線維量と
方法：連続登録症例 209 例のうち拡散テンソルトラクト
functional ambulation category に正の相関が認められた
グラフィ上で患側半球の皮質脊髄路（ CST ）が完全に損 （p ＜ 0.05 ）
。対照的に，非患側半球の CST の拡散テンソ
傷している 54 例，および正常被験者 20 例を登録した。 ル画像パラメーターは functional ambulation category に相
functional ambulation category を使用して歩行能力を測定
関していなかった
（p ＞ 0.05 ）
。
した。CRP および CST の異方性比率，みかけの拡散係数， 結論：慢性期脳卒中患者では非患側半球の CRP における
および線維量を拡散テンソル画像パラメーターとした。
線維量増加が歩行能力と関連しているようである。した
結果：患側半球では，患者のサブグループ間において
がって，非患側半球の CRP の補償作用は，脳卒中後の歩
CRP の拡散テンソル画像パラメーターに有意差はなかっ
行能力回復のメカニズムの一つと考えられる。
Stroke 2013; 44: 1099-1104
A
サブグループA
皮質脊髄路
皮質網様体路
サブグループB
皮質脊髄路
皮質網様体路
R
A
（Stroke 誌の図を一部省略して掲載）
患者および同年齢の対照群被
験 者 の 皮 質 網 様 体 路（ CRP ）
および皮質脊髄路（ CST ）の拡
散テンソルトラクトグラフィ
（ DTT ）。
A　患者サブグループの CRP
および CST の DTT。患側半球
の CST および CRP に脳卒中
図 1 が原因の遮断が認められる（ 青
の矢印 ）。それとは対照的に，
サ ブ グ ル ー プ B［ functional
ambulation category
（ FAC ）≧ 3 ］では，サブグルー
プ A（ FAC ＜ 3 ）および正常対
照と比べて非患側半球の CRP
の線維量が増加している（ 緑の
矢印 ）。

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