EFFECT OF INDIVIDUALLY-TAILORED TDCS AND SYMBOLIC ART THERAPY FOR CHRONIC ASSOCIATIVE PROSOPAGNOSIA AFTER INFECTION BY SARS-COV-2, NEUROCOVID-19 AND ISCHEMIC STROKE

Abstract

Background The rehabilitation of patients with chronic prosopagnosia that occurs following a stroke is a challenge for modern medicine. Dysfunction to the facial processing areas is permanent and standard rehabilitation brings only limited improvement. Therefore, therapists suggest reinforcing the compensatory strategies used by such patients such as voice, figure, and gait recognition to help with the identification of a particular person, which promotes their social functioning. New neurotechnologies, especially QEEG/ERPs, displays of functional brain impairment in prosopagnosia, may be helpful in developing an appropriate neurotherapy protocol and create the conditions for other forms of rehabilitation in such patients. The purpose of our study was twofold: 1) to evaluate QEEG/ ERPs shows of post-stroke functional impairment associated with prosopagnosia, 2) to construct a neurofeedback protocol based on these indices to sup- port the neuropsychological rehabilitation of the case study described herein. We present the case of a 23-year-old right-handed student of the Graphics Faculty of the Academy of Fine Arts, with chronic associative prosopagnosia after infection with SARS-CoV-2 followed by Covid-19 and a right hemisphere stroke. He was re- ferred in April 2021 for diagnosis and therapy at the Reintegration and Training Cen- ter of the Polish Neuropsychological Society (PTNeur). Six months earlier, in October 2020, the patient had been admitted to the Infectious Disease Hospital. COVID-19 was diagnosed based on coronavirus 2 (SARS-CoV-2) reverse transcrip- tion PCR (RT-PCR) on a nasopharyngeal swab. The neurological examination re- vealed muscle weakness on the left side of the body, slow and aprosodic speech, preserved comprehension, and acute left homonymous hemianopsia, as well as prosopagnosia and mirror symptom. The patient was sedated and mechanically ventilated for six days. The CT-scan showed foci in the posterior part of the superior temporal lobe and hyperintense changes in the blood supply area of the right middle cerebral artery. After 30 days of hospitalization, the patient was discharged from this hospital and referred to an outpatient rehabilitation center for five months. Ther- apy improved his general condition but did not remove the chronic prosopagnosia: a personal tragedy for the patient which prevented him from continuing his studies. He was diagnosed at the PTNeur Reintegration and Training Center within the next few weeks: (1). ophthalmologic examinations revealed no pathology; (2) neuropsy- chological testing confirmed the presence of chronic apperceptive prosopagnosia; (3) examination of event-related potentials (ERPs) revealed a large delay of the N170 wave, particularly on the right side, indicating a slowing of the rate of nerve impulses in early face processing and a cause of prosopagnosia. The patient was referred for rehabilitation: he participated in 20 sessions of individually tailored anodal transcranial direct current stimulation (tDCS) twice a week for ten weeks, and in parallel, for indi- vidualized Prosopagnosia Symbolic Art Therapy provided once a week for ten weeks. By the end of therapy, the patient was not only recognizing but also painting portraits of faces. He returned to college, finished and defended a master’s thesis in Artistic Drawing, in which facial presentation played an important role. Quantitative EEG (QEEG) and event-related potentials (ERPs) neuromarkers helped to understand the mechanism of prosopagnosia and to choose an individualized protocol, thus the appropriate application of tDCS in our patient, which accelerated the recovery of the ability to perform complex tasks and created the conditions for Symbolic Art Therapy. Modern medicine can successfully use such a management protocol in individuals with chronic prosopagnosia.