Management of psychogenic non-epileptic seizures: a multidisciplinary approach.

The International League against Epilepsy (ILAE) proposed a diagnostic scheme for psychogenic non-epileptic seizure (PNES). The debate on ethical aspects of the diagnostic procedures is ongoing, the treatment is not standardized and management might differ according to age group. The objective was to reach an expert and stakeholder consensus on PNES management. A board comprising adult and child neurologists, neuropsychologists, psychiatrists, pharmacologists, experts in forensic medicine and bioethics as well as patients' representatives was formed. The board chose five main topics regarding PNES: diagnosis; ethical issues; psychiatric comorbidities; psychological treatment; and pharmacological treatment. After a systematic review of the literature, the board met in a consensus conference in Catanzaro (Italy). Further consultations using a model of Delphi panel were held. The global level of evidence for all topics was low. Even though most questions were formulated separately for children/adolescents and adults, no major age-related differences emerged. The board established that the approach to PNES diagnosis should comply with ILAE recommendations. Seizure induction was considered ethical, preferring the least invasive techniques. The board recommended looking carefully for mood disturbances, personality disorders and psychic trauma in persons with PNES and considering cognitive-behavioural therapy as a first-line psychological approach and pharmacological treatment to manage comorbid conditions, namely anxiety and depression. Psychogenic non-epileptic seizure management should be multidisciplinary. High-quality long-term studies are needed to standardize PNES management.

A morphometric analysis of the suitability of the transverse cervical artery as a recipient artery in head and neck free flap microvascular reconstruction.

PURPOSE: Gold standard recipient arteries in head and neck free flap microvascular reconstruction are currently branches of the external carotid. However, these arteries can be compromised by neck dissection or radiotherapy, resulting in 'vessel-depleted neck' and 'frozen neck' respectively. In such cases, the transverse cervical artery (TCA) may be a suitable recipient artery. METHODS: The origin, course and diameter of the TCA were determined in 46 sides of neck from 23 cadavers. The distances from the origin of the TCA to the angle of the mandible, floor of the mouth and mandibular symphysis were measured to determine the pedicle length required for free flap anastomosis. RESULTS: The TCA was present bilaterally in all subjects investigated and its course across the posterior triangle of the neck was constant between individuals. The mean distances from the origin of the TCA to the angle of mandible, floor of mouth and mandibular symphysis were 10.0, 9.2 and 12.6 cm, respectively. There were no significant differences in these distances between the left and right sides of the neck (p > 0.05 for all comparisons). The distances from the TCA origin to the angle of the mandible and floor of the mouth were significantly longer in males than in females (p = 0.004) and correlated directly with the greater height of males compared to females (p = 0.0004). The mean diameter of the TCA measured 2 cm from its origin was 2.2 mm. CONCLUSION: The TCA is a suitable and reliable recipient artery for free flap microvascular reconstruction, when branches of the external carotid artery are unavailable.

Let's cut it short: Italian standardization of the MMSPE (Mini-Mental State Pediatric Examination), a brief cognitive screening tool for school-age children.

A pediatric cognitive screening tool has been shaped in three versions according to school class to assess spatial and temporal orientation, language, reading, writing, drawing, number knowledge, memory, praxis and executive functions in children aged 6-13. It has been standardized on an Italian sample of 807 children. Raw scores were adjusted for critical variables (child's age and parents' education) and a cut-off for the resulting global cognitive score was made available for clinical practice. In line with previous research, adapting the Mini-Mental State Examination to pediatric neuropsychological assessment turned out to be useful in estimating global cognitive functioning in children.

Left caloric vestibular stimulation as a tool to reveal implicit and explicit parameters of body representation.

Homeostatic parameters, such as temperature, are related to body representation. In this study, we measured whether caloric vestibular stimulation (CVS) alters body temperature and tactile processing, and if in the direction predicted by a holistic body matrix representation. Skin temperature and tactile two-point discrimination (TPD) acuity were measured for both arms before, immediately after and with a delay from CVS. Participants were also administered a personality questionnaire and an anxiety inventory to rule out confounding factors. Two control experiments were planned to exclude casual variations. Our results show that temperature drops significantly in both arms after CVS. CVS also induces a bilateral improvement in tactile acuity (even though not immediately after but in the delayed condition). Finally, these effects are not due to learning, as demonstrated by the control experiment. In summary, our results suggest that vestibular stimulation updates body representation, supporting the evidence in favor of a body matrix.

Controlling the alien hand through the mirror box. A single case study of alien hand syndrome.

Disruption of motor control in the alien hand syndrome might result from a dissociation between intentions and sensory information. We hypothesized that voluntary motor control in this condition could improve by restoring the congruency between motor intentions and visual feedback. The present study shows that, in one patient with right alien hand syndrome, the use of a mirror box paradigm improved motor speed. We speculate that the visual feedback provided by the mirror increases the sense of congruence between intention and sensory feedback, leading to motor improvement.

Neglect's perspective on the Ponzo illusion.

Visual illusions have been used to explore implicit perception in neglect. Previous studies have highlighted differences between length and surface illusion perception in neglect, but much less is known about depth illusion perception. In the Ponzo illusion (a classic depth illusion), two converging oblique lines modulate the perceived length of two horizontal lines. In the current study, we presented modified versions of the Ponzo illusion in which only one of the converging oblique lines was presented (alternatively the right or the left one). This manipulation allowed us to explore (1) how acute patients with neglect process depth illusions, and (2) whether awareness of both converging lines is necessary for the full effect of the illusion. To examine these questions, we had participants (i.e. healthy controls, patients with neglect and right brain-damaged patients) to make a perceptual judgment regarding the perceived length of the upper versus lower horizontal line within the Ponzo frame in four conditions: (1) the classic Ponzo illusion, (2) a "modified left" Ponzo illusion with a single oblique line on the left, (3) a "modified right" Ponzo illusion with a single oblique line on the right and (4) a control condition with parallel lines. The results indicated that all participants perceived the canonical Ponzo illusion and the modified right illusion. Critically, patients with neglect did not perceive the modified left illusion. In addition, for neglect patients, there was no difference in the strength of the perceived illusion when comparing the canonical illusion with the modified right illusion. Importantly, single case analysis revealed a high degree of variability in the neglect group that seemed to be linked with the amount of damage to occipital areas. Overall our results indicate that: (1) the classic Ponzo illusion might be perceived in neglect patients based solely on perception of the right side of the stimulus configuration, and (2) differences between types of illusions (i.e. depth vs. length), and variability between patients suggest that caution is needed when utilizing these kinds of illusions to assess implicit processing in neglect.

Mental images across the adult lifespan: a behavioural and fMRI investigation of motor execution and motor imagery.

Motor imagery (M.I.) is a mental state in which real movements are evoked without overt actions. There is some behavioural evidence that M.I. declines with ageing. The neurofunctional correlates of these changes have been investigated only in two studies, but none of the these studies has measured explicit correlations between behavioural variables and the brain response, nor the correlation of M.I. and motor execution (M.E.) of the same acts in ageing. In this paper, we report a behavioural and functional magnetic resonance imaging (fMRI) experiment that aimed to address this issue. Twenty-four young subjects (27 ± 5.6 years) and twenty-four elderly subjects (60 ± 4.6 years) performed two block-design fMRI tasks requiring actual movement (M.E.) or the mental rehearsal (M.I.) of finger movements. Participants also underwent a behavioural mental chronometry test in which the temporal correlations between M.I. and M.E. were measured. We found significant neurofunctional and behavioural differences between the elderly subjects and the young subjects during the M.E. and the M.I. tasks: for the M.E. task, the elderly subjects showed increased activation in frontal and prefrontal (pre-SMA) cortices as if M.E. had become more cognitively demanding; during the M.I. task, the elderly over-recruited occipito-temporo-parietal areas, suggesting that they may also use a visual imagery strategy. We also found between-group behavioural differences in the mental chronometry task: M.I. and M.E. were highly correlated in the young participants but not in the elderly participants. The temporal discrepancy between M.I. and M.E. in the elderly subjects correlated with the brain regions that showed increased activation in the occipital lobe in the fMRI. The same index was correlated with the premotor regions in the younger subjects. These observations show that healthy elderly individuals have decreased or qualitatively different M.I. compared to younger subjects.

Exploring motor and visual imagery in Amyotrophic Lateral Sclerosis.

Amyotrophic Lateral Sclerosis (ALS) is a motor neuron disease characterized by the progressive atrophy of both the first and the second motor neurons. Although the cognitive profile of ALS patients has already been defined by the occurrence of language dysfunctions and frontal deficit symptoms, it is less clear whether the degeneration of upper and lower motor neurons affects motor imagery abilities. Here, we directly investigated motor imagery in ALS patients by means of an established task that allows to examine the presence of the effects of the biomechanical constraints. Twenty-three ALS patients and 23 neurologically unimpaired participants have been administered with the (1) hand laterality task (HLT) in which participants were asked to judge the laterality of a rotated hand and the (2) mirror letter discrimination task (MLD) in which participants were asked to judge whether a rotated alphanumeric character was in its canonical or mirror-reversed form (i.e. control task). Results show that patients present the same pattern of performance as unimpaired participants at the MLD, while at the HLT, they present only partially with the effects of biomechanical constraints. Taken together, our findings provide evidences that motor imagery abilities, related to the mental simulation of an action, are affected by this progressive disease.

Functional reconstruction of the masseter muscle by microvascular free gracilis muscle transfer: technique and outcome.

Microvascular reconstruction of the cheek is most often performed using fasciocutaneous flaps and without functional reconstruction of the masseter muscle. This article reports a technique of masseter muscle resection, dissection of the masseteric nerve, and masseter muscle reconstruction with a functional gracilis muscle flap. The technique was applied in a 38-year-old man with recurrent intramuscular lipoma of the right masseter muscle. The flap was highly stable in form and showed good function. Bite force, electromyography results, and the radiological appearance of the gracilis muscle were similar to those of the contralateral masseter muscle at 12 months after surgery. In conclusion, full rehabilitation of masseter muscle function and good facial aesthetics were achieved by functional gracilis muscle reconstruction of the masseter muscle in a case of total resection.

Prism adaptation in patients with unilateral lesion of the parietal or cerebellar cortex: A pilot study on two single cases using a concurrent exposure procedure.

Neuroimaging studies showed that prism adaptation (PA), a widely used tool for the rehabilitation of neglect, involves a wide network of brain regions including the parietal cortex and the cerebellum. In particular, the parietal cortex has been suggested to mediate the initial stage of PA through conscious compensatory mechanisms as a reaction to the deviation induced by PA. The cerebellum, on the other side, intervenes in sensory errors prediction to update internal models in later stages. It has been suggested that two mechanisms may underlie PA effects: recalibration, a strategic cognitive process occurring in the initial stages of PA, and realignment, a fully automatic reorganization of spatial maps emerging later and more slowly in time. The parietal lobe has been proposed to be involved mainly in the recalibration whereas the realignment would be carried over by the cerebellum. Previous studies have investigated the effects of a lesion involving either the cerebellum or the parietal lobe in PA taking into account both realignment and recalibration processes. Conversely, no studies have compared the performance of a patient with a cerebellar lesion to that of a patient with a parietal lesion. In the present study, we used a recently developed technique for digital PA to test for differences in visuomotor learning after a single session of PA in a patient with parietal and a patient with cerebellar lesions, respectively. The PA procedure, in this case, includes a digital pointing task based on a concurrent exposure technique, which allows patients to fully see their arm during the pointing task. This procedure has been shown to be as effective as the terminal exposure condition in neglect rehabilitation albeit different processes take place during concurrent exposure condition compared to the most used terminal exposure (allowing to see only the final part of the movement). Patients' performances were compared to that of a control group. A single session of PA was administered to 1) a patient (BC) with left parieto-occipital lesion involving superior parietal lobe (SPL) and inferior parietal lobe (IPL), 2) a patient (TGM) with a stroke in the territory sub-served by the superior cerebellar artery (SCA) , and 3) 14 healthy controls (HC). The task included three conditions: before wearing prismatic goggles (pre-exposure), while wearing prisms (exposure) and after removing the goggles (post-exposure). Mean deviations were calculated for the following phases: pre-exposure, early-exposure, late-exposure, post-exposure. The presence of after-effect was calculated as the difference between pre-exposure and post-exposure conditions. For each of these conditions, patients' performance was compared to that of the control group by using a modified Crawford t-test. We found that the patient with the parietal lesion had a significantly different performance in the late-exposure and in the post-exposure compared to both HC and the patient with the cerebellar lesion. Conversely, no differences were observed between TGM and HC across all the conditions. Our results show an increase in the magnitude of the adaptation during the late stage of PA in the patient with the parietal lesion whereas no differences in the performance between the cerebellar patient and the controls were found. These results confirm previous studies suggesting that the parietal cortex is an important node of a wider network involved in PA effect. Furthermore, results concerning the cerebellar patient suggest that visuomotor learning is not affected by lesions of the SCA territory when a concurrent exposure is used as, in such case, it less relies on sensory errors prediction to update internal models. Results are discussed considering the novelty of the applied PA technique.

Perseverations and non-verbal confabulations on the Rey-Osterrieth Complex Figure Test in a fronto-temporal dementia single case study.

We describe the case of a patient with late onset fronto-temporal dementia (FTD), who presented with typical personality changes, but also perseverative and confabulatory behaviors while performing the Rey-Osterrieth Complex Figure Test. We hypothesize that the progressive atrophy of orbitobasal, medial, and dorsolateral frontal cortices may give rise to both confabulations and perseverations in the non-verbal domain. In agreement with previous studies, reporting atypical profiles, this case report underlines the clinical heterogeneity of FTD. Authors declare that they have no conflicts of interest.

Brain abscess caused by dental peri-implantitis.

We report the case of a patient presenting with severe headache and progressive aphasia due to a large brain abscess. End-stage peri-implantitis on a dental implant in the upper jaw with contact to the maxillary sinus floor causing maxillary and frontal sinusitis could be identified as the source of infection. Multidisciplinary treatment included broad-spectrum antibiotics, craniotomy for abscess drainage, sinus surgery, and the removal of the implant. Despite all the care taken, the patient died, underlining the importance of oral hygiene and a frequent recall in patients with dental implants. To the best of our knowledge, this is the first report of a brain abscess caused by peri-implantitis in the literature.

Neural correlates of worry in generalized anxiety disorder and in normal controls: a functional MRI study.

BACKGROUND: Worry is considered a key feature of generalized anxiety disorder (GAD), whose neural correlates are poorly understood. It is not known whether the brain regions involved in pathological worry are similar to those involved in worry-like mental activity in normal subjects or whether brain areas associated with worry are the same for different triggers such as verbal stimuli or faces. This study was designed to clarify these issues. METHOD: Eight subjects with GAD and 12 normal controls underwent functional magnetic resonance imaging (fMRI) mood induction paradigms based on spoken sentences or faces. Sentences were either neutral or designed to induce worry. Faces conveyed a sad or a neutral mood and subjects were instructed to empathize with those moods. RESULTS: We found that the anterior cingulate and dorsal medial prefrontal cortex [Brodmann area (BA) 32/23 and BA 10/11] were associated with worry triggered by sentences in both subjects with GAD and normal controls. However, GAD subjects showed a persistent activation of these areas even during resting state scans that followed the worrying phase, activation that correlated with scores on the Penn State Worry Questionnaire (PSWQ). This region was activated during the empathy experiment for sad faces. CONCLUSIONS: The results show that worry in normal subjects and in subjects with GAD is based on activation of the medial prefrontal and anterior cingulate regions, known to be involved in mentalization and introspective thinking. A dysregulation of the activity of this region and its circuitry may underpin the inability of GAD patients to stop worrying.

With time on our side? Task-dependent compensatory processes in graceful aging.

Graceful aging has been associated with frontal hyperactivations in working- and episodic long-term memory tasks, a compensatory process, according to some, that allows the best normal elders to perform these tasks at a juvenile level, in spite of natural cortical impoverishment. In this study, 24 young and 24 healthy elderly participants were compared. Graceful aging was explored by investigating domains where most healthy elders perform like youngers (e.g. lexical-semantic knowledge) and tasks that are typically more challenging, like episodic long-term recognition memory tasks. With voxel-based morphometry, we also studied to what extent changes of fMRI activation were consistent with the pattern of brain atrophy. We found that hyperactivations and hypoactivations of the elders were not restricted to the frontal lobes, rather they presented with task-dependent patterns. Only hypoactivations and normal levels of activation systematically overlapped with regional atrophy. We conclude that compensatory processes associated with graceful aging may not necessarily be a sign of early saturation of executive resources, if this was to be represented by a systematic frontal hyperactivation, but rather they may represent the ability of recruiting new cognitive strategies. We discuss two possible approaches to further test this hypothesis.

Implicit mechanisms of body image alterations: The covert attention exposure effect.

Visual exposure to extreme-sized bodies elicits explicit self-body image variations. Several features of such modulation remain to be clarified. In this study we explored whether this effect: (i) acts on implicit mechanisms in modifying one's body-size perception, (ii) is body-exposure-specific also at the implicit level, and (iii) is modulated by interoceptive sensibility. We assigned a covert attention task to 100 women, exposing them to extreme-sized bodies (thin and fat) or extreme-sized objects (thin and fat bottles). Before and after the attentional exposure, we tested the association between the "self/others" and "thin/fat" concepts using an Implicit Association Test. We also collected a measure of interoceptive sensibility by means of a self-report questionnaire. Results showed that participants exposed to fat bodies implicitly presented a stronger association between the "self" and "thin" concepts. This association was significantly weaker in the group exposed to thin bodies. This effect was absent after exposure to thin and fat bottles. Notably, participants with a higher tolerance of negative bodily interoceptive signals were less susceptible to the malleability of body image exerted by the exposure attentional task. Our findings shed new light on the relationship between the perception of internal (e.g., visceral) and external (e.g., visual) signals in the representation of our body.

Donor site morbidity after microvascular medial femoral condylar flap procurement for facial reconstruction.

The medial femoral condyle (MFC) flap is considered an ideal graft for bone reconstructions. This study was performed to evaluate donor site knee joint function and scar appearance after MFC flap procurement. Adult patients who had undergone facial reconstruction with an MFC flap between March 2011 and March 2017 at the University Hospital Salzburg were enrolled. Knee function was assessed postoperatively using two validated orthopaedic scores: Tegner Lysholm Knee Scoring Scale (TL) and Knee Society Score (KSS); both range from 0 to 100 (100 being no impairment). Scars were evaluated using the Patient and Observer Scar Assessment Scale (POSAS) (range 6-60). Thirty-eight patients were enrolled. The average postoperative TL score was 95.68 (range 66-100). The mean KSS clinical examination and function scores were 96.8 (range 58-100) and 97.11 (range 60-100), respectively. Flap type (osteocutaneous vs. non-osteocutaneous) did not correlate with TL or KSS scores. KSS and TL scores showed no association with vascular pedicle length or transplant volume. The average POSAS patient and observer scores were 6.84 and 15.24, respectively. POSAS observer scores were significantly higher for osteocutaneous flaps than for non-osteocutaneous flaps. The MFC flap causes minimal donor site morbidity. No knee joint instability or range of motion limitation was found. Postoperative TL and KSS scores indicated excellent knee function.

Anatomy of the episodic buffer: a voxel-based morphometry study in patients with dementia.

In 2000 Baddeley proposed the existence of a new component of working memory, the episodic buffer, which should contribute to the on-line maintenance of integrated memory traces. The author assumed that this component should be critical for immediate recall of a short story that exceeds the capacity of the phonological store. Accordingly, patients with Alzheimer's dementia (AD) should suffer of a deficit of the episodic buffer when immediate recall of a short story is impossible. On the other hand, the episodic buffer should be somewhat preserved in such patients when some IR can occur (Baddeley and Wilson, 2002). We adopted this logic for a voxel-based morphometry study. We compared the distribution of grey-matter density of two such groups of AD patients with and of a group of age-matched controls. We found that both AD groups had a significant atrophy of the left mid-hippocampus; on the other hand, the anterior part of the hippocampus was significantly more atrophic in patients who were also impaired on the immediate prose recall task. Six out of ten patients with no immediate recall were spared at "central executive" tasks. Taken together our findings suggest that the left anterior hippocampus contributes to the episodic buffer of the revised working memory model. We also suggest that the episodic buffer is somewhat independent from the central executive component of working memory.

Rubber Hand Illusion survives Ventral Premotor area inhibition: A rTMS study.

The sense of body ownership is a fundamental feature that refers to the ability to recognize our body as our own, allowing us to interact properly with the outside world. Usually, it is explored by means of the Rubber Hand Illusion (RHI) during which a dummy hand is incorporated in the mental representation of one's own body throughout a multisensory (visuo-tactile) integration mechanism. Particular attention has been paid to the neurofunctional counterparts of this mechanism highlighting the pivotal role of an occipito-parieto-frontal network involving the Ventral Premotor area (PMv). To date, the specific role of the PMv in generating the sense of ownership is still unknown. In this study, we aimed at exploring the role of PMv in generating and experiencing the RHI. Off-line repetitive Transcranial Magnetic Stimulation (rTMS) was applied to a group of 24 healthy participants whilst changes in proprioceptive judgment and self-reported illusion sensations were collected and analysed separately. The PMv was not directly implicated in generating the sense of ownership. Indeed, its inhibition affected the explicit detection of the visuo-tactile congruence without interfering with the illusion experience itself. We hypothesized that the conscious visuo-tactile congruence detection may be independent from the conscious illusion experience. Also, our results support the view that the RHI grounds on a complex interaction between bottom-up and top-down processes, as the visuo-tactile integration per se may be not sufficient to trigger the subjective illusion.

Resting state brain connectivity patterns before eventual relapse into cocaine abuse.

According to recent theories, drug addicted patients suffer of an impaired response inhibition and salience attribution (I-RISA) together with a perturbed connectivity between the nuclei accumbens (NAcs) and the orbito-prefrontal (oPFC) and dorsal prefrontal (dPFC) cortices, brain regions associated with motivation and cognitive control. To empirically test these assumptions, we evaluated the (neuro)psychological trait and the functional organization of the resting state brain networks associated with the NAcs in 18 former cocaine abusers (FCAs), while being in drug abstinence since 5 months. The psychological data were grouped into three empirical variables related with emotion regulation, emotion awareness and strategic and controlled behaviour. Comparison of the resting state patterns between the entire sample of FCAs and 19 controls revealed a reduction of functional connectivity between the NAcs and the dPFC and enhanced connectivity between the NAcs and the dorsal-striatum. In the 8 FCAs who relapsed into cocaine use after 3 months, the level of functional connectivity between the NAcs and dPFC was lower than the functional connectivity estimated in the group of patients that did not relapsed. Finally, in the entire sample of FCAs, the higher the connectivity between the NAc and the oPFC the lower was the level of strategic and controlled behaviour. Taken together, these results are compatible with models of the interactions between the NAcs, the dorsal striatum and frontal cortices in the I-RISA syndrome, showing that such interactions are particularly perturbed in patients at greater risk of relapse into cocaine abuse.