Abstract:

Pusher syndrome, or contraversive pushing, is a common post-stroke condition, particularly in patients with right hemisphere lesions. It is characterized by an altered perception of verticality, leading patients to push toward their hemiplegic side, resulting in postural imbalance and increased fall risk. Unlike typical stroke patients who lean toward their weaker side, those with pusher syndrome actively push away from their non-paretic side, making rehabilitation more challenging. This study aimed to assess the prevalence of pusher syndrome in stroke patients, examine recovery duration, and evaluate its occurrence and rehabilitation outcomes in posterior cerebral artery (PCA) strokes. A 12-month cross-sectional observational study was conducted in a stroke rehabilitation facility using the Scale for Contraversive Pushing (SCP) and a questionnaire to assess pusher behavior in stroke survivors. PCA involvement was observed in 60% of participants, with pusher syndrome present in 36% of PCA cases. A significant association was found between PCA involvement and pusher syndrome (Chi-square = 23.70, P < 0.001), along with an impact on recovery duration (Chi-square = 37.0, P < 0.001). These findings emphasize PCA's role in pusher syndrome and its effect on rehabilitation. Pusher syndrome is more prevalent in PCA strokes, with moderate severity on the SCP scale. The results underscore the need for specialized rehabilitation strategies to manage pushing behavior in this stroke population.

References:

[1]. Valliappan, S., Indiran, M., Mallikarjuna, S. K., Arumugam, G. S., 2024, Atypical presentation of tuberculous vasculitis: dual large vessel occlusions leading to malignant ischaemic stroke. BMJ Case Reports CP, 17(12):e262681. Available at: https://doi.org/10.1136/bcr-2023-262681

[2]. Deepthi, V., Sriharsha, T., Nanda Gopal, Kannan, R., 2024, Role of serum ferritin and prediction of neurological outcome in acute ischemic stroke patients. South Eastern European Journal of Public Health, 25(S1):1223–1227. Available at: https://doi.org/10.70135/seejph.vi.2025

[3]. Sivalingam, A. M., Sureshkumar, D. D., Pandurangan, V., 2025. Cerebellar pathology in forensic and clinical neuroscience. Ageing Res. Rev. 84, 102697. https://doi.org/10.1016/j.arr.2025.102697

[4]. Pare, J. R., Kahn, J. H., 2012, Basic Neuroanatomy and Stroke Syndromes. Emergency Medicine Clinics of North America., 30(3):601-615. Available at: https://doi.org/10.1016/j.emc.2012.05.004.

[5]. Śliwka, A., Piliński, R., 2013, Pusher Syndrome in stroke patients. The current state of knowledge on assessment and physiotherapy. Medical Rehabilitation, 17(4):19-27. Available at: https://doi.org/10.5604/14266972.1118361.

[6]. Pedersen, P. M., Wandel, A., Jørgensen, H. S., Nakayama, H., Raaschou, H. O., Olsen, T. S., 1996, Ipsilateral pushing in stroke: incidence, relation to neuropsychological symptoms and impact on rehabilitation. Neurorehabilitation and Neural Repair, 10(3):187-194. Available at: https://doi.org/10.1177/154596839601000307

[7]. Babyar, S. R., Peterson, M. G. E., Reding, M., 2016, Case–Control Study of Impairments Associated with Recovery from “Pusher Syndrome” after Stroke: Logistic Regression Analyses. Journal of Stroke and Cerebrovascular Diseases. Available at: https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.08.024

[8]. Weiller, C., et al., 1996, The role of the right hemisphere in postural control: Evidence from a study of patients with stroke. Brain, 119(1):141-151. Available at: https://doi.org/10.1007/s00221-016-4603-y

[9]. Duncan, P. W., et al., 1990, Measurement of balance in stroke patients. Physical Therapy., 70(12):824-835. Available at: https://doi.org/10.1093/ptj/70.12.824

[10]. Bishop, A., et al., 2014, Assessment of contraversive pushing in stroke patients: The Scale for Contraversive Pushing. Journal of Neurology, 261(3):598-605. Available at: https://doi.org/10.1177/1545968306291849

[11]. Saver, J. L., et al., 2018, Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. New England Journal of Medicine, 378(1):11-21. Available at: https://doi.org/10.1056/NEJMoa1706442

[12]. Qureshi, A. I., et al., 2016, Intracerebral Hemorrhage: A Guide to Diagnosis and Treatment. Springer International Publishing. Available at: https://doi.org/10.1056/NEJMoa1603460

[13]. Jauch, E. C., et al., 2013, Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2013 Update. Stroke. Available at: https://doi.org/10.1161/STR.0b013e318284056a

[14]. Santos-Pontelli, T. E., Pontes-Neto, O. M., Leite, J. P., 2012, Letter by Santos-Pontelli et al regarding article, “Prevalence and length of recovery of pusher syndrome based on cerebral hemispheric lesion side in patients with acute stroke.” Stroke, 43(9): e89-e90. Available at: https://doi.org/10.1161/STROKEAHA.112.658310

[15]. von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C., Vandenbroucke, J. P., STROBE Initiative., 2007, Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ., 335(7624):806-808. Available at: https://doi.org/10.1136/bmj.39335.541782.AD

[16]. Baier, B., Karnath, H.O., 2005, Incidence and diagnosis of 'pusher syndrome'. Journal of Neurology., 252(8):927-934. Available at: https://doi.org/10.1007/s00415-005-0788-2

[17]. Babyar, S. R., Peterson, M. G. E., Reding, M., 2016, Case–Control Study of Impairments Associated with Recovery from “Pusher Syndrome” after Stroke. Journal of Stroke and Cerebrovascular Diseases., 25(8):2049-2056. Available at: https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.04.015

[18]. Patel, S. N., Huang, Y., 2022, Timing of Rehabilitation after Stroke: Improvement in Functional Independence. Stroke Rehabilitation Review., 14(4):223-224. Available at: https://doi.org/10.1007/s11739-022-02956-5

[19]. Gonzalez, R. A., Martin, P. F., 2021, Age-Related Factors in PCA Stroke Incidence and Recovery. Journal of Aging Health., 33(8):1845-1860. Available at: https://doi.org/10.1177/0898264321990290

[20]. Arboix, A., Arbe, G., García-Eroles, L., et al., 2011, Infarctions in the vascular territory of the posterior cerebral artery: clinical features in 232 patients. BMC Research Notes., 4:329. Available at: https://doi.org/10.1186/1756-0500-4-329