ASL MRI and 18F-FDG-PET in autoimmune limbic encephalitis: clues from two paradigmatic cases.

BACKGROUND: Autoimmune limbic encephalitis (LE) is a neurological condition characterized by seizures and cognitive dysfunction. Fluorine-18 fluorodeoxyglucose (18F-FDG-PET) has recently proved to be an important diagnostic tool in this condition since it may highlight brain metabolism abnormalities in a very early stage of the disease. Two main 18F-FDG-PET patterns have been described: the mixed hypermetabolic/hypometabolic and the neurodegenerative one. Arterial spin labeling (ASL) is an MRI technique showing brain perfusion, rarely used in autoimmune neurological conditions. The aim of the present study was to study patients with LE with both techniques, in order to compare their results. METHODS: Two patients with LE underwent to 18F-FDG-PET and ASL MRI scans using the pseudo-continuous arterial spin labeling (PCASL) technique. Areas of altered perfusion and metabolism were analyzed by visual inspection, and findings were compared between the two techniques. RESULTS: In the first patient, a relapsing LGI-1 LE, right hippocampal hypermetabolism was detected by 18F-FDG-PET (mixed hypermetabolic/hypometabolic pattern), while ASL MRI showed right hippocampal increased perfusion. In the second patient, a seronegative LE, 18F-FDG-PET scan detected a left hemispheric hypoperfusion (neurodegenerative pattern) and ASL MRI yielded similar results. The two 18F-FDG-PET patterns of altered metabolism were similarly detected by ASL imaging. CONCLUSION: ASL and 18F-FDG-PET findings are strongly concordant in LE. ASL imaging was able to detect the two main 18F-FDG-PET patterns previously described in patients with LE.

Multimodal CT pc-ASPECTS in infratentorial stroke: diagnostic and prognostic value.

BACKGROUND AND PURPOSE: Diagnosis of posterior circulation stroke may be challenged. National Institutes of Health Stroke Scale (NIHSS) and brain imaging (non-contrast brain computed tomography-CT) are used for diagnosis; evaluation on posterior circulation stroke remains a limit of NIHSS, and the value of non-contrast CT (NCCT) is limited due to artifacts caused by the bones of the base of the skull. We tested the validity and prognostic value of posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) in patients with posterior circulation stroke. METHODS: Pc-ASPECTS allots the posterior circulation 10 points. We studied 50 patients with posterior circulation stroke. We applied pc-ASPECTS to NCCT, CT angiography, and CT Perfusion. We evaluated the correlation of pc-ASPECT with outcome parameters for stroke. RESULTS: Out of 50 patients, CTP showed abnormalities in 34 cases. The pc-ASPECT score calculated on brain CT and on the brain CT + angio CT had a sensibility of 24%, calculated on brain CT, angio CT and CTPerfusion gain a sensibility of 72%. Pc-ASPECT MTT resulted to be the more reliable parameter: outcome given by NIHSS score at discharge, mRS at discharge, and at 3 months was more severe in patients with Pc-ASPECT MTT alteration. Outcome given by NIHSS score at discharge and mRS at discharge and 1 at 3 months was more severe in patients with higher NIHSS score at admission. CONCLUSION: We evaluated the usefulness of pc-ASPECTS on CTP in predicting functional outcome in acute posterior circulation stroke that appears to be a powerful marker for predicting functional outcome.

A novel computed tomography perfusion-based quantitative tool for evaluation of perfusional abnormalities in migrainous aura stroke mimic.

BACKGROUND: Migrainous aura (MA) represents the third most common stroke mimic (SM). Advanced neuroimaging is pivotal in the assessment of patients with focal neurological acute symptoms. We investigated brain perfusion alterations in MA-SM patients using a novel CT perfusion (CTP)-based quantitative approach in order to improve differential diagnosis between MA and acute stroke. METHODS: We processed and analysed the clinical and neuroimaging CTP data, acquired within 4.5 h from symptom onset, of patients with acute focal neurological symptoms receiving a final diagnosis of MA. The differences between ROI, compatible with MA symptoms, and contralateral side were automatically estimated in terms of asymmetry index (AI%) by the newly developed tool for mean transit time (MTT), CBF, and cerebral blood volume (CBV) CTP parameters. The AI% ≥ 10% was considered significant. RESULTS: Out of 923 admitted patients, 14 patients with MA were included. In 13 out of 14 cases, a significant pattern of hypoperfusion was observed by quantitative analysis in at least one of the CTP maps. In 7 patients, all three CTP maps were significantly altered. In particular, MTT-AI% increased in 11 (79%) cases, while CBF-AI% and CBV-AI% decreased in 12 (86%) and in 9 (64%) patients, respectively. All CBV values were above ischemic stroke core threshold and all MTT-AI were below ischemic penumbra threshold. CONCLUSIONS: Our data suggest that a novel CTP-quantitative approach may detect during MA a moderate hypoperfusion pattern in the cerebral regions compatible with aura symptoms. The use of this novel tool could support differential diagnosis between MA and acute stroke.

Wake-up stroke and CT perfusion: effectiveness and safety of reperfusion therapy.

OBJECTIVE: Ischemic stroke is a neuroemergency condition highly treatable with thrombolysis and thrombectomy. Recently, observational studies have brought insights into clinical and imaging characteristics of wake-up stroke, which interested up to 25% of ischemic stroke patients. In clinical practice, wake-up strokes are usually not considered for reperfusion therapy. The aim of this study was to investigate the use CT perfusion imaging in patients with wake-up stroke and to assess the effect of neuroimaging information provided by CT perfusion maps on the efficacy and safety of thrombolysis and thrombectomy. PATIENTS AND METHOD: We studied 22 wake-up stroke (WUS) patients (13F/9M mean age) who underwent reperfusion therapy after the eligibility assessed by the CT perfusion imaging (< 50% core-to-penumbra ratio and negative CT perfusion). RESULTS: Mean National Institutes of Health Stroke Scale (NIHSS) was 8.1 ± 4.9 at admission while 3.3 ± 5.1 at discharge, significantly different from admission (p < 0.001). As many as ten patients had mRS lower than 3 at discharge. Intracranial hemorrhage occurred in five patients and caused symptoms worsening only in two patients (decrease of NIHSS score of 4 points) of which one patient died. CONCLUSION: The main finding of this study is that wake-up stroke with adequate selection by CT perfusion may benefit reperfusion treatment.

Ischemic Volume and Neurological Deficit: Correlation of Computed Tomography Perfusion with the National Institutes of Health Stroke Scale Score in Acute Ischemic Stroke.

BACKGROUND: The National Institutes of Health Stroke Scale (NIHSS) is the most adopted stroke patients' evaluation tool in emergency settings to assess the severity of stroke and to determine the patients' eligibility for specific treatments. Computed tomography perfusion (CTP) is crucial to identify salvageable tissue that can benefit from the reperfusion treatment. The aim of this study is to identify the relation between the NIHSS scores and the hypoperfused volumes evaluated by CTP in patients with hyperacute ischemic stroke. METHODS: This retrospective study was conducted on 105 patients with ischemic stroke who underwent NIHSS assessment and CTP in the hyperacute phase. Hypoperfused volume was evaluated by CTP maps processed with semi-automatic algorithm. An analysis was conducted to determine the degree of correlation between the NIHSS scores and the ischemic lesion volumes and to investigate the relation between the anterior and the posterior circulation strokes, as well as between the right and the left hemispheric strokes. RESULTS: A significant correlation was found between ischemic volume and NIHSS score at baseline (r = .82; P < .0001) in the entire cohort. A high NIHSS-volume correlation was identified in the anterior circulation stroke (r = .76; P < .0001); whereas, it was nonsignificant in the posterior circulation stroke. NIHSS score and volume correlated for the left and the right hemispheric strokes (r = .83 and .81; P < .0001), showing a slightly higher slope in the left. CONCLUSION: This study showed a strong correlation between the baseline NIHSS score and the ischemic volume estimated by CTP. We confirmed that NIHSS is a reliable predictor of perfusion deficits in acute ischemic stroke. CTP allows fast imaging assessment in the hyperacute phase. The results highlight the importance of these diagnostic tools in the assessment of stroke severity and in acute decision-making.

Selective imitation impairments differentially interact with language processing.

Whether motor and linguistic representations of actions share common neural structures has recently been the focus of an animated debate in cognitive neuroscience. Group studies with brain-damaged patients reported association patterns of praxic and linguistic deficits whereas single case studies documented double dissociations between the correct execution of gestures and their comprehension in verbal contexts. When the relationship between language and imitation was investigated, each ability was analysed as a unique process without distinguishing between possible subprocesses. However, recent cognitive models can be successfully used to account for these inconsistencies in the extant literature. In the present study, in 57 patients with left brain damage, we tested whether a deficit at imitating either meaningful or meaningless gestures differentially impinges on three distinct linguistic abilities (comprehension, naming and repetition). Based on the dual-pathway models, we predicted that praxic and linguistic performance would be associated when meaningful gestures are processed, and would dissociate for meaningless gestures. We used partial correlations to assess the association between patients' scores while accounting for potential confounding effects of aspecific factors such age, education and lesion size. We found that imitation of meaningful gestures significantly correlated with patients' performance on naming and repetition (but not on comprehension). This was not the case for the imitation of meaningless gestures. Moreover, voxel-based lesion-symptom mapping analysis revealed that damage to the angular gyrus specifically affected imitation of meaningless gestures, independent of patients' performance on linguistic tests. Instead, damage to the supramarginal gyrus affected not only imitation of meaningful gestures, but also patients' performance on naming and repetition. Our findings clarify the apparent conflict between associations and dissociations patterns previously observed in neuropsychological studies, and suggest that motor experience and language can interact when the two domains conceptually overlap.

Arterial enhancing-only nodules less than 2 cm in diameter in patients with liver cirrhosis: predictors of hepatocellular carcinoma diagnosis on gadobenate dimeglumine-enhanced MR imaging.

PURPOSE: To assess whether gadobenate dimeglumine (Gd-BOPTA)-enhanced MR imaging could predict hepatocellular carcinoma (HCC) diagnosis in small arterial enhancing-only nodules detected by contrast-enhanced computed tomography (CT) in patients with liver cirrhosis. MATERIALS AND METHODS: We prospectively recruited 125 cirrhotic patients (67 males, and 58 females; age: 68 ± 12.36 years) with 151 small (<2 cm in diameter) arterial enhancing-only nodules identified by contrast-enhanced CT. All patients were scanned by MR imaging before and after Gd-BOPTA injection during the hepatic arterial phase (HAP), portal venous phase (PVP), equilibrium phase (EP), and hepatobiliary phase (HP). Nodule characterization was based on reference imaging criteria (n = 29 nodules), follow-up (n = 105), or histology (n = 17). Two radiologists (5 and 10 years experience) analyzed the MR images, and logistic regression was conducted to assess how well MR imaging findings could predict HCC diagnosis. RESULTS: Final diagnoses included 115 benign nodules and 36 HCCs. Nodule T2 hyperintensity, T1 hypointensity, PVP-EP hypointensity, and HP hypointensity were the best predictors of HCC on univariate analysis. Nodule T2 hyperintensity, T1 hypointensity, and HP hypointensity, were independent predictors of HCC on multivariate analysis. CONCLUSION: Gd-BOPTA-enhanced MR imaging provides imaging findings which may predict a diagnosis of HCC in small arterial enhancing-only nodules in cirrhotic patients.

Predictors of dysplastic nodule diagnosis in patients with liver cirrhosis on unenhanced and gadobenate dimeglumine-enhanced MRI with dynamic and hepatobiliary phase.

OBJECTIVE: The purpose of this article is to assess whether unenhanced and gadobenate dimeglumine-enhanced MRI with dynamic and hepatobiliary phase may predict the diagnosis of dysplastic nodules in patients with liver cirrhosis. MATERIALS AND METHODS: We retrospectively analyzed 75 cirrhotic patients (47 men and 28 women; mean [± SD] age, 55 ± 12 years) with 82 hepatocellular nodules, including histology-proven dysplastic nodules (n = 25; diameter, 1-3 cm) and hepatocellular carcinomas (n = 57; diameter, 2-3 cm) scanned by MRI before and after gadobenate dimeglumine injection during hepatic arterial phase (HAP), portal venous phase (PVP), equilibrium phase, and hepatobiliary phase. Nodule T1 and T2 intensities before contrast agent injection and nodule HAP, PVP, equilibrium phase, and hepatobiliary phase intensities were compared with the adjacent liver. Univariate and multivariate logistic regression analysis was conducted to assess how the nodule could predict dysplastic nodule diagnosis. RESULTS: Some imaging findings were independent predictors of dysplastic nodule diagnosis-namely, nodule T2 isohypointensity (odds ratio [OR], 12.28; 95% CI, 3.88-38.82), T1 isohyperintensity (OR, 26.74; 95% CI, 7.53-94.90), HAP isohypointensity (OR, 97.16; 95% CI, 20.06-470.49), PVP-equilibrium phase isohyperintensity (OR, 20.53; 95% CI, 5.36-78.62), and hepatobiliary phase isohyperintensity (OR, 119.6; 95% CI, 21.59-662.40). Nodule T2 and HAP isohypointensity (OR 31.47; 95% CI, 7.88-125.58), nodule T2 isohypointensity and hepatobiliary phase isohyperintensity (OR, 28.77; 95% CI, 7.79-106.19), nodule T1 isohyperintensity and HAP isohypointensity (OR, 17.22; 95% CI, 4.85-61.14), and nodule T1 and hepatobiliary phase isohyperintensity (OR, 19.39; 95% CI, 5.38-69.90) were also predictors of dysplastic nodule diagnosis. CONCLUSION: The combination of nodule appearance on T2-weighted MRI and nodule enhancement after gadobenate dimeglumine injection may predict dysplastic nodule diagnosis in patients with liver cirrhosis.

Magnetic resonance urography vs computed tomography urography in the evaluation of patients with haematuria.

PURPOSE: This study was done to evaluate by direct comparison the image quality of magnetic resonance urography (MRU) and computed tomography urography (CTU) and to assess the diagnostic confidence of the two techniques in detecting urothelial malignancy in patients with haematuria MATERIALS AND METHODS: Thirty-five patients with haematuria underwent both CTU and MRU. Two different investigators evaluated calyceal, renal pelvis, ureteral and bladder visibility. Their diagnostic confidence in detecting urothelial malignancy with the two procedures was assessed. A Wilcoxon matched-pairs test was performed to compare results. Inter-reader agreement was calculated by weighted kappa (WK) statistic. Patient history (further examinations, cystoscopy and histological specimens) was considered as reference standard to calculate receiver operating characteristic (ROC) curves of diagnostic confidence. RESULTS: CTU provided better visibility of urothelial structures (p<0.01) and allowed for greater diagnostic confidence (ROC area 0.994 vs. 0.938) than MRU, with a good inter-reader agreement (WK=0.62). Nevertheless, in obstructive patients with impaired excretory function, MRU, thanks to the static-fluid technique, offered better visualisation than CTU. CONCLUSIONS: There is a potential role for MRU in urinary tract imaging, but as diagnostic confidence in detecting urothelial malignancy is poorer than in CTU, it might be stareserved for patients at low risk for malignancy and for evaluating obstructed patients.

Cerebral hypoperfusion in post-COVID-19 cognitively impaired subjects revealed by arterial spin labeling MRI.

Cognitive impairment is one of the most prevalent symptoms of post Severe Acute Respiratory Syndrome COronaVirus 2 (SARS-CoV-2) state, which is known as Long COVID. Advanced neuroimaging techniques may contribute to a better understanding of the pathophysiological brain changes and the underlying mechanisms in post-COVID-19 subjects. We aimed at investigating regional cerebral perfusion alterations in post-COVID-19 subjects who reported a subjective cognitive impairment after a mild SARS-CoV-2 infection, using a non-invasive Arterial Spin Labeling (ASL) MRI technique and analysis. Using MRI-ASL image processing, we investigated the brain perfusion alterations in 24 patients (53.0 ± 14.5 years, 15F/9M) with persistent cognitive complaints in the post COVID-19 period. Voxelwise and region-of-interest analyses were performed to identify statistically significant differences in cerebral blood flow (CBF) maps between post-COVID-19 patients, and age and sex matched healthy controls (54.8 ± 9.1 years, 13F/9M). The results showed a significant hypoperfusion in a widespread cerebral network in the post-COVID-19 group, predominantly affecting the frontal cortex, as well as the parietal and temporal cortex, as identified by a non-parametric permutation testing (p < 0.05, FWE-corrected with TFCE). The hypoperfusion areas identified in the right hemisphere regions were more extensive. These findings support the hypothesis of a large network dysfunction in post-COVID subjects with cognitive complaints. The non-invasive nature of the ASL-MRI method may play an important role in the monitoring and prognosis of post-COVID-19 subjects.

Early EEG Alterations Correlate with CTP Hypoperfused Volumes and Neurological Deficit: A Wireless EEG Study in Hyper-Acute Ischemic Stroke.

Brain electrical activity in acute ischemic stroke is related to the hypoperfusion of cerebral tissue as manifestation of neurovascular coupling. EEG could be applicable for bedside functional monitoring in emergency settings. We aimed to investigate the relation between hyper-acute ischemic stroke EEG changes, measured with bedside wireless-EEG, and hypoperfused core-penumbra CT-perfusion (CTP) volumes. In addition, we investigated the association of EEG and CTP parameters with neurological deficit measured by NIHSS. We analyzed and processed EEG, CTP and clinical data of 31 anterior acute ischemic stroke patients registered within 4.5 h from symptom onset. Delta/alpha ratio (DAR), (delta + theta)/(alpha + beta) ratio (DTABR) and relative delta power correlated directly (ρ = 0.72; 0.63; 0.65, respectively), while alpha correlated inversely (ρ = - 0.66) with total hypoperfused volume. DAR, DTBAR and relative delta and alpha parameters also correlated with ischemic core volume (ρ = 0.55; 0.50; 0.59; - 0.51, respectively). The same EEG parameters and CTP volumes showed significant relation with NIHSS at admission. The multivariate stepwise regression showed that DAR was the strongest predictor of NIHSS at admission (p < 0.001). The results of this study showed that hyper-acute alterations of EEG parameters are highly related to the extent of hypoperfused tissue highlighting the value of quantitative EEG as a possible complementary tool in the evaluation of stroke severity and its potential role in acute ischemic stroke monitoring.

A Novel Fast CT Perfusion Core-Penumbra Mismatch Score: Correlation With Stroke Outcome.

BACKGROUND: Advanced neuroimaging can identify patients who can most benefit from reperfusion treatment, discriminating between ischemic core and penumbra area in a quick and accurate manner. Despite core-penumbra mismatch being an independent prognostic factor, computed tomography perfusion (CTP) assessment is still debated in hyperacute decision-making. The authors aimed to study a novel CTP mismatch score in emergency settings and to investigate its relation with clinical outcome in acute ischemic stroke patients treated with intravenous thrombolysis (IVT). METHODS: Neuroimaging and clinical data of 226 consecutive acute ischemic stroke patients were analyzed. The study population was divided into 5 different CTP scores: (0) without perfusion deficit, (1) only penumbra, (2) penumbra > core, (3) core ≥ penumbra, (4) only core. For differences in outcome between treated and nontreated patients, and among CTP core-penumbra groups to be assessed, the authors have evaluated the outcome in terms of National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) at discharge and symptomatic intracerebral hemorrhage. RESULTS: A decrease in NIHSS was statistically greater in IVT-treated patients compared to nontreated patients showing only penumbra (ΔNIHSS%: 80.0% vs. 50.0%; P=0.0023) or no perfusion deficit (ΔNIHSS%: 89.4% vs. 61.5%; P=0.027) on CTP maps. The same trend was found in other groups without significant difference. A significant correlation was found in IVT patients between core/penumbra score and outcome in terms of ΔNIHSS (Kendall τ=-0.19; P=0.004). CONCLUSIONS: The authors proposed a novel immediate CTP assessment to score perfusion mismatch in emergency settings to guide clinicians' decision-making for aggressive treatment and to prevent stroke-related disability.

Novel quantitative approach for crossed cerebellar diaschisis detection in acute ischemic stroke using CT perfusion.

PURPOSE: Crossed cerebellar diaschisis (CCD) is a common finding in hyper-acute ischemic stroke, related to supratentorial dysfunction of the contralateral hemisphere. Several studies investigated a possible relationship between CCD and clinical outcomes but still no evidence emerged. We proposed a novel quantitative whole cerebellum analysis using CT perfusion (CTP) imaging to investigate the relationship between CCD and stroke severity, hypoperfused volume and outcome measures. METHODS: 55 patients with supratentorial ischemic stroke who underwent CTP evaluation within 4.5 h since symptom onset were enrolled. CCD was evaluated by CTP image-processing and by calculating the mean transit time (MTT)-map asymmetry index in the whole cerebellum. MTT asymmetry correlation with ischemic volume and clinical outcomes was investigated. RESULTS: MTT asymmetry was found in most of the included patients and significantly correlated with NIH Stroke Scale (NIHSS) score at baseline and CTP ischemic volume. MTT asymmetry was significantly correlated with hemorrhagic transformation, NIHSS and modified Rankin Scale (mRS) score on discharge in treated patients. CONCLUSIONS: CCD was detectable by CTP in acute supratentorial ischemic stroke by processing the whole cerebellum volume. CCD perfusion asymmetry was significantly correlated with neurological and perfusion deficit on admission as well as with clinical outcomes in treated patients.

The Role of Amygdala in Self-Conscious Emotions in a Patient With Acquired Bilateral Damage.

Shame plays a fundamental role in the regulation of our social behavior. One intriguing question is whether amygdala might play a role in processing this emotion. In the present single-case study, we tested a patient with acquired damage of bilateral amygdalae and surrounding areas as well as healthy controls on shame processing and other social cognitive tasks. Results revealed that the patient's subjective experience of shame, but not of guilt, was more reduced than in controls, only when social standards were violated, while it was not different than controls in case of moral violations. The impairment in discriminating between normal social situations and violations also emerged. Taken together, these findings suggest that the role of the amygdala in processing shame might reflect its relevance in resolving ambiguity and uncertainty, in order to correctly detect social violations and to generate shame feelings.

A CT perfusion based model predicts outcome in wake-up stroke patients treated with recombinant tissue plasminogen activator.

OBJECTIVE: Advanced neuroimaging has proved to be pivotal in the management of acute ischemic stroke. The use of CT perfusion (CTP) core and penumbra parameters to predict the outcome in wake-up stroke (WUS) patients in everyday clinical scenarios has not yet been investigated. The aim of our study was to investigate the predictive power of CTP parameters on functional and morphological outcomes in WUS patients treated with recombinant tissue plasminogen activator (rTPA). APPROACH: We analyzed clinical data and processed CTP images of 83 consecutive WUS patients treated with rTPA. The predictive power of whole-brain CTP features and of the clinical stroke-related parameters to predict the National Institutes of Health Stroke Scale (NIHSS) score at the seventh day and ischemic lesion volume outcome was investigated by means of multivariate regression analysis as well as least absolute shrinkage and selection operator (LASSO) modeling. MAIN RESULTS: Multivariate analysis showed that CTP core volume (ß = 0.403, p = 0.000), NIHSS at admission (ß = 0.323, p = 0.005) and Alberta Stroke Program Early CT (ASPECT) score (ß = -0.224, p = 0.012) predict NIHSS at 7 days, while total hypoperfused volume (ß = 0.542, p = 0.000) and core volume on CTP (ß =0.441, p = 0.000) predict infarct lesion volume at follow-up CT. The LASSO modeling approach confirmed the significant predictive power of CTP core volume, total hypoperfused CTP volume, NIHSS at baseline and ASPECT score, producing a sparse model with adequate reliability (the root mean square error on a previously unseen testing dataset was 3.68). SIGNIFICANCE: Our findings highlight the importance of CT multimodal imaging features for decision-making and prediction in the hyperacute phase of WUS. The predictive model supports the hypothesis that an irreversible necrotic core rather than the extent of the penumbra is the main prognostic factor in WUS patients treated with rTPA.

Brain oscillatory activity and CT perfusion in hyper-acute ischemic stroke.

OBJECTIVES: The combined use of perfusion neuroimaging and brain oscillatory activity may provide a better clinical picture of neurovascular coupling of the injured area in ischemic stroke. The aim is to assess stroke-related topographic electroencephalography (EEG) changes during the earliest phase of ischemic stroke and to compare them with hypoperfusion identified by computer tomography perfusion (CTP). PATIENTS AND METHODS: The study included 15 patients with ischemic stroke, who underwent both CTP and EEG recording within 4.5 h. Topographic representation of power for each band was calculated and compared with hypoperfusion areas estimated by CTP maps. RESULTS: Predominance of slow delta frequencies was found in all patients. The main finding is the agreement between slow rhythms hemispheric prevalence on EEG maps and cerebral hypoperfusion area identified using CTP. CONCLUSION: The results of this preliminary study show that the combined use of EEG and CTP, as highly available techniques, in acute ischemic stroke may be helpful in clinical practice and provide information about functional and metabolic aspects of brain involvement. The joint use of these methodologies may give a better clinical insight of the functionality of injured area in the hyperacute phase.

Neuropsychological evidence for a strategic control of multiple routes in imitation.

Previous studies have suggested that imitators can reproduce known gestures shown by a model using a semantic, indirect route, and novel gestures using a sublexical, direct route. In the present study we aimed at testing the validity of such a dual-route model of action imitation. Patients with either left-brain damage (LBD) or right-brain damage (RBD) were tested on an action imitation task. Actions were either meaningful (n = 20) or meaningless (n = 20), and were presented in an intermingled list and, on a different day, in separate lists. We predicted that, in the mixed condition, patients would use a direct route to imitate meaningful and meaningless actions, as it allows the imitation of both action types. In the blocked condition, patients were expected to select the semantic route for meaningful actions and the direct route for meaningless actions. As hypothesized, none of the 32 patients showed dissociations between imitation of meaningful and meaningless actions in the mixed presentation. In contrast, eight patients showed a dissociation between imitation of meaningful actions and imitation of meaningless actions in the blocked presentation. Moreover, two of these patients showed a classical double dissociation between the imitation of the two action types. Results were interpreted in support of the validity of a dual-route model for explaining action imitation. We argue that the decrease in imitation of meaningful actions, relative to meaningless actions, is caused by a damage of the semantic route, and that the decline in imitation of meaningless actions, relative to meaningful actions, is produced by a breakdown of the direct route. The brain areas that were lesioned in all six LBD patients who showed a dissociation were in the superior temporal gyrus and the angular gyrus, whereas the two RBD subjects had common lesions of the pallidum and of the putamen. The brain structures affected in our patients with selective apraxia are consistent with those reported before in other neuropsychological reports. They are also in agreement with areas found activated in imaging studies in which the neural mechanisms underlying imitation were examined.

[Hyperammoniemia and central pontine myelinolysis in a patient with Sjögren syndrome and chronic valproate use]. / Iperammoniemia e mielinolisi pontina centrale in paziente con sindrome di Sjögren ed assunzione cronica di valproato.

The authors describe a case of a drug-associated hyperammonemia, central pontine myelinolysis and coma occurring in a patient with Sjögren's syndrome chronically treated with valproic acid for an underlying psychotic disorder. The possible differential diagnoses are reviewed and discussed.

Migrainous aura as stroke-mimic: The role of perfusion-computed tomography.

OBJECTIVES: The acute-onset of migrainuos aura (MA) can be erroneously diagnosed in Emergency Department (ED) as acute stroke (AS) and it can be classified as "stroke mimic" (SM). Perfusion computer tomography (PCT) may be useful to improve detection of infarcts. The aim of the study was to investigate the role in ED of PCT in improving diagnosis of migrainous aura. Data were compared with the well-defined perfusion patterns in patients with acute ischemic stroke. PATIENTS AND METHODS: A standardized Stroke Protocol was planned. The protocol consisted in centralizing in ED all the patients with acute-onset of neurological symptoms compatible with cerebrovascular disease and in performing a general and neurological examination, hematological tests, brain non-contrast computed tomography (NCCT), CT angiography (CTA) of the supra-aortic and intracranial arteries and cerebral PCT. Patients with diagnosis of definite or probable acute stroke were hospitalized in Stroke Unit (SU). A six-months retrospective analysis of all the patients included in the Stroke Protocol and discharged from ED or from SU with a diagnosis of migraine with aura was performed. RESULTS: 172 patients were included in the Stroke Protocol and 6 patients were enrolled. NCCT, CTA and PCT were performed after 60-90 min from symptoms onset and revealed normal perfusion. Intravenous thrombolysis was performed only in one patient. CONCLUSION: Patients with acute-onset of neurological symptoms, who have rapid progressive improvement of symptoms, normal neuroimaging, in particular PCT, and preceding episodes of migraine with aura, may be considered as suffering from MA. In these cases, even if thrombolysis is safe, clinicians may defer a prompt aggressive treatment.