Evaluation of Executive Functions in stroke patients with a novel Virtual Reality Tool

Abstract

Background and aims: Executive dysfunction is a frequent and disabling cognitive sequelae after stroke, particularly following damage to frontal and basal ganglia circuits. Conventional neuropsychological tests often lack ecological validity and may underestimate deficits affecting everyday functioning. Immersive virtual reality (VR) offers a novel approach to assess executive functions under naturalistic conditions. This study aimed to assess executive functions in chronic stroke patients using an immersive VR task and to examine its associations with lesion burden, functional outcome, and resting-state functional connectivity (rsFC) measured with functional near-infrared spectroscopy (fNIRS).

Methods: Twenty-four chronic stroke patients and a matched group of healthy controls completed the Nesplora Ice Cream task, which evaluates planning, working memory, cognitive flexibility, and interference control within a realistic everyday scenario. Group differences in behavioral performance were analyzed using Welch’s ANOVA and Bayesian approaches. Correlational analyses examined relationships between executive performance, lesion volume, functional disability (modified Rankin Scale, mRS), and rsFC within frontoparietal networks.

Results: Stroke patients demonstrated significantly reduced planning accuracy, poorer working memory performance, and a higher frequency of incorrect assignments and perseverative behaviors. Greater functional disability (higher mRS scores) were associated with reduced flexibility. Resting-state analyses revealed increased functional connectivity between the right posterior parietal cortex and right primary motor cortex in stroke patients. Across the whole sample, stronger rPPC–rM1 connectivity was associated with worse executive performance.

Conclusions: Chronic stroke patients show persistent executive impairments linked to frontoparietal and motor network disconnection. Immersive VR assessment provides an ecologically valid approach for detecting these deficits and may inform personalized rehabilitation strategies.