Good recovery is not full recovery: emotion recognition deficits and different regulation strategies in mild right-hemisphere ischemic stroke survivors

Introduction: Mild right-hemisphere ischemic stroke can affect socioemotional functioning even in patients with excellent functional recovery, yet facial emotion identification and habitual emotion regulation remain undercharacterized in this population. This study examined both domains in stroke survivors with little-to-no residual disability compared to healthy controls. Methods: Fifty-three mild right-hemisphere ischemic stroke survivors (modified Rankin Scale < 2; chronic phase, 12-24 months post-stroke) and 60 neurologically healthy controls completed a 24-item forced-choice identification task covering six basic emotions and the Emotion Regulation Questionnaire (ERQ). Group differences and the associations between regulation and recognition were examined with repeated-measures ANOVA and ANCOVA, including general cognitive status (MoCA) and ERQ indices as covariates. Results: In the unadjusted model, stroke participants showed lower overall accuracy and a significant Emotion × Group interaction, with the clearest group differences for anger, disgust, and fear. The stroke group also reported markedly higher expressive suppression and lower cognitive reappraisal. When MoCA was included as the sole covariate, the between-subjects group effect on overall accuracy was no longer significant, indicating that the global accuracy decrement is substantially tied to the mild cognitive sequelae of right-hemisphere stroke; however, the Emotion × Group interaction retained significance with an identical effect size, becoming non-significant only in the extended model that simultaneously controlled for both MoCA and ERQ indices. Expressive suppression showed a significant emotion-dependent association with recognition accuracy after adjustment for both ERQ and MoCA, whereas reappraisal did not. Formal ANCOVAs confirmed that regulation differences were not accounted for by cognitive status. Discussion: These findings reveal a functional dissociation: the overall level of facial emotion identification is sensitive to general cognitive integrity, whereas habitual emotion regulation represents a higher-order, cognitively independent dimension of socioemotional functioning that is robustly and independently affected by mild stroke. The results argue for dedicated socioemotional assessment - and particularly regulation-focused characterization - in well-recovered stroke survivors, and motivate future work linking these profiles to lesion mechanisms and targeted interventions.