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However, an evaluation of the number of correct words alone does not enable one to determine precisely which processes are impaired. This study investigates post\u2010stroke fluency impairments, focusing on previously unexplored indices and their neuroanatomical correlates using voxel\u2010based lesion symptom mapping (VLSM). In total, 337 patients and 851 controls performed letter and semantic fluency tests. Analyses included overall performance (correct responses) and strategic indices (errors, time course, frequency, switches, and cluster size). Stroke patients produced fewer correct responses, more rule\u2010breaking errors, fewer words after 15\u2033, fewer infrequent words, fewer switches, and smaller clusters in letter fluency. Switching was strongly associated with letter fluency, while clustering was more related to semantic fluency. VLSM identified left\u2010hemisphere structures, particularly frontal tracts (e.g., anterior thalamic and frontostriatal tracts), associated with switching, and a smaller set of left\u2010hemisphere structures linked to clustering.<\/jats:p>\n                  <jats:p>Conceptually, the findings suggest stroke\u2010related fluency disorders primarily arise from impairments in executive strategic search, as indicated by switching impairments, with weaker impairment on lexicosemantic abilities. The rarity of rule\u2010breaking and perseverative errors indicates that inhibition and working memory deficits do not significantly contribute to poor fluency. The patients' production of infrequent words and fluency worsened over time, although the precise contributions of the three core processes to these additional changes require further investigation. Our results highlight the importance of detailed fluency evaluations in stroke patients for optimized rehabilitation.<\/jats:p>","DOI":"10.1111\/ejn.70022","type":"journal-article","created":{"date-parts":[[2025,3,11]],"date-time":"2025-03-11T22:09:18Z","timestamp":1741730958000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Mechanisms of Verbal Fluency Impairment in Stroke: Insights From \u201cStrategic Indices\u201d Derived From a Study of 337 Patients"],"prefix":"10.1111","volume":"61","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7094-1189","authenticated-orcid":false,"given":"Flore","family":"Dorchies","sequence":"first","affiliation":[{"name":"Laboratory of Functional Neurosciences (UR UPJV 4559) Jules Verne University of Picardie  Amiens France"},{"name":"Department of Speech Therapy Jules Verne University  Amiens France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5141-9248","authenticated-orcid":false,"given":"Ardalan","family":"Aarabi","sequence":"additional","affiliation":[{"name":"Laboratory of Functional Neurosciences (UR UPJV 4559) Jules Verne University of Picardie  Amiens France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rania","family":"Kassir","sequence":"additional","affiliation":[{"name":"Laboratory of Functional Neurosciences (UR UPJV 4559) Jules Verne University of Picardie  Amiens France"},{"name":"Laboratoire de Recherche en Neurosciences (LAREN) Universit\u00e9 Saint\u2010Joseph  Beyrouth Lebanon"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sandrine","family":"Wannepain","sequence":"additional","affiliation":[{"name":"Department of Neurology Amiens University Hospital  Amiens France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Claire","family":"Leclercq","sequence":"additional","affiliation":[{"name":"Department of Neurology Amiens University Hospital  Amiens France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Olivier","family":"Godefroy","sequence":"additional","affiliation":[{"name":"Laboratory of Functional Neurosciences (UR UPJV 4559) Jules Verne University of Picardie  Amiens France"},{"name":"Department of Neurology Amiens University Hospital  Amiens France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Martine","family":"Roussel","sequence":"additional","affiliation":[{"name":"Laboratory of Functional Neurosciences (UR UPJV 4559) Jules Verne University of Picardie  Amiens France"},{"name":"Department of Neurology Amiens University Hospital  Amiens France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"name":"the GRECogVASC study group","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2025,3,3]]},"reference":[{"key":"e_1_2_12_2_1","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.117.017937"},{"key":"e_1_2_12_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.neuropsychologia.2018.10.003"},{"key":"e_1_2_12_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.cortex.2022.12.012"},{"key":"e_1_2_12_5_1","doi-asserted-by":"publisher","DOI":"10.15761\/NDT.1000101"},{"key":"e_1_2_12_6_1","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.117.018889"},{"key":"e_1_2_12_7_1","doi-asserted-by":"publisher","DOI":"10.1038\/nn1050"},{"key":"e_1_2_12_8_1","doi-asserted-by":"publisher","DOI":"10.1111\/1460\u20106984.12710"},{"key":"e_1_2_12_9_1","doi-asserted-by":"publisher","DOI":"10.1111\/1460\u20106984.12276"},{"issue":"4","key":"e_1_2_12_10_1","first-page":"207","article-title":"Formal and Semantic Lexical Evocation in Normal Subjects. 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