Isolated Demyelination of Corpus Callosum Following Hypoxia

Corpus callosum includes a large amount of axons with various degrees of myelination, interconnecting cerebral hemispheres. Tumors, demyelinating diseases, infections, trauma and metabolic diseases as well as vascular lesions may affect corpus callosum, often extending to other white matter areas of the brain. We describe the case of a 76 years old male patient with history of arterial hypertension, diabetes mellitus and normal pressure hydrocephalus, developing dysphagia during hospitalization. Ab-ingestis pneumonia caused brain hypoxia and coma; brain magnetic resonance disclosed isolated demyelination of corpus callosum that was not present before hypoxia. Compared to neurons and astrocytes, oligodendrocytes are reported as particularly sensitive to hypoxia. Respiratory involvement without blood flow impairment could have lead to a prevalent oligodendrocytes damage, resulting in a selective demyelination of corpus callosum. Our patient indeed evolved into persistent vegetative state and died five months after hypoxic episode. This case report could give some insight about in vivo brain susceptibility to hypoxic damage

Effetto della terapia con onde d'urto radiali sul dolore e l'ipertonia muscolare: uno studio in doppio cieco in un gruppo di pazienti affetti da sclerosi multipla.

Effetto della terapia con onde d'urto radiali sul dolore e l'ipertonia muscolare: uno studio in doppio cieco in un gruppo di pazienti affetti da sclerosi multipla. Introduzione La sindrome del motoneurone superiore, caratterizzata da molteplici segni clinici, può essere dovuta a varie patologie: ictus, paralisi cerebrale infantile, sclerosi multipla, traumi cranici e tumori, per citare le più frequenti. La spasticità è uno dei segni clinici di questa sindrome e consiste in un aumento patologico del riflesso da stiramento. La caratteristica fondamentale della spasticità è la sua dipendenza dalla velocità dell'allungamento muscolare passivamente imposto dall'esaminatore: maggiore è tale velocità e maggiore è la risposta riflessa del muscolo. Tuttavia, nei pazienti affetti da sindrome del motoneurone superiore, l'aumento del tono muscolare è dovuto anche a modificazioni intrinseche del muscolo, dovute al fatto che esso tende a perdere la sua parte contrattile e ad aumentare le sue componenti fibrose (ipertono intrinseco). Clinicamente può essere molto difficile apprezzare in modo distinto queste due componenti dell'ipertono muscolare (spasticità ed ipertono intrinseco). Le onde d’urto, distinte in focali e radiali, sono delle onde acustiche ad alta energia, prodotte da specifici generatori, che sono state utilizzate nel trattamento dell'ipertono nei pazienti affetti da paralisi cerebrale infantile e nei pazienti affetti da ictus. Esse sono utili anche nella terapia del dolore, soprattutto nelle patologie che colpiscono il tendine e l'inserzione muscolo tendinea. E’ stato dimostrato che le onde d'urto producono bolle di cavitazione nei tessuti trattati. La cavitazione è una conseguenza della fase di pressione negativa durante la propagazione dell’onda. La rapida implosione delle bolle di cavitazione produce onde d’urto secondarie. Il meccanismo della cavitazione potrebbe giocare un ruolo di primo piano nell’azione delle onde d'urto focali e radiali. Nella speranza di combinare il duplice effetto della onde d'urto radiali sul dolore e l'ipertonia, nel presente studio esse sono state utilizzate per trattare l’ipertonia dolorosa dei muscoli estensori della caviglia (il muscolo tricipite surale) in un gruppo di soggetti affetti da sclerosi multipla (SM). Materiali e metodi I pazienti sono stati arruolati presso il Dipartimento di Neurologia dell’Università degli Studi di Genova, in accordo con i seguenti criteri: SM diagnosticata secondo i criteri di McDonald, con un punteggio maggiore di 4 alla Kurtzke Extended Disability Status Scale (EDSS); ipertonia dei muscoli estensori della caviglia; dolore durante la mobilizzazione della caviglia; nessuna ricaduta del quadro clinico e nessuna somministrazione di corticosteroidi e di tossina botulinica negli ultimi 6 mesi. Un totale di 120 soggetti (68 donne) sono stati valutati per l’idoneità all’inclusione nello studio. Alla fine della valutazione, 68 soggetti (40 donne; età media ± DS: 51,4 ± 12,2) hanno soddisfatto i criteri di inclusione e hanno partecipato allo studio. La misura principale di risultato (“primary outcome measure”) è stato il dolore riferito all’arto inferiore trattato, misurato utilizzando la scala visiva analogica per il dolore (VAS per il dolore). La misura secondaria di risultato (“secondary outcome measure”) è stato il tono muscolare degli estensori della caviglia, misurato in posizione supina mediante la scala di Ashworth modificata (MAS). Ulteriori misure di risultato sono state la forza dei muscoli della caviglia e la velocità nel cammino. La forza muscolare in estensione è stata misurata in accordo con il Medical Research Council (MRC) per la forza. La velocità nel cammino è stata rilevata tramite il 10-meter walking test (10-MWT). Le onde d'urto radiali sono state erogate utilizzando il dispositivo BTL-6000 SWT Topline Unit (BTL Italy). I pazienti sono stati trattati su un solo lato. La terapia con onde d’urto radiali è stata erogata in 4 sessioni, con una settimana di intervallo tra una sessione e l’altra. Durante ogni sessione, venivano somministrati 2000 colpi ai muscoli estensori della caviglia ed al tendine d’Achille. La frequenza utilizzata è stata di 4 Hz, con una pressione di 1,5 Bar. Il trattamento placebo è stato somministrato utilizzando la stessa apparecchiatura, regolata per erogare la stessa energia. Si è impedito però che le onde d’urto raggiungessero i muscoli bersaglio grazie a un sottile cuscino di gommapiuma posto sull’applicatore metallico. La valutazione clinica è stata condotta: prima del trattamento (T0); una settimana dopo la prima sessione (T1); una settimana dopo l'ultima sessione (T2) e 4 settimane dopo l’ultima sessione (T3). Risultati 34 soggetti hanno ricevuto il trattamento con onde d'urto e 34 soggetti hanno ricevuto il trattamento placebo. La tabella 1 e la tabella 2 mostrano le caratteristiche demografiche e cliniche pre-trattamento (T0) dei 68 soggetti arruolati nello studio. L’analisi statistica non ha evidenziato nessuna differenza significativa tra i soggetti trattati con onde d'urto e quelli trattati con il placebo per quanto riguarda la distribuzione dell’età, i punteggi EDSS e le misure di risultato (VAS, MAS, MRC per la forza e 10-MWT). La tabella 2 mostra l'andamento temporale degli indici di risultato. Dopo le onde d'urto, i punteggi VAS sono significativamente diminuiti in tutti i controlli, raggiungendo il loro massimo effetto a T2, quando l’85% dei soggetti ha avuto una diminuzione di almeno 1 punto. I valori della MAS sono diminuiti significativamente solo a T2, mentre non sono state osservate modificazioni significative della forza e della velocità del cammino. A seguito del trattamento placebo, nessun cambiamento significativo è stato evidenziato rispetto ai valori di partenza. Discussione Il principale risultato di questo studio è stato l'effetto delle onde d'urto sul dolore. Questo effetto, che ha raggiunto il suo massimo una settimana dopo l’ultima sessione di trattamento (T2), era già presente una settimana dopo la prima sessione (T1) ed è persistito per quattro settimane dall’ultima sessione (T3). Nel momento di massima riduzione del dolore (T2), si è osservata una riduzione del tono muscolare. Le onde d'urto non hanno avuto alcuna influenza sulla forza muscolare e sulla velocità del cammino. Nessun effetto è stato evidenziato a seguito del trattamento placebo. Il presente studio dimostra che la terapia con onde d'urto può ridurre il dolore e il tono muscolare in pazienti affetti da SM, senza alcun effetto sulla forza muscolare. Per ottimizzare l’effetto riportato ed ottenere risultati funzionali, è probabile che la terapia con onde d'urto debba essere integrata all’interno di un programma riabilitativo, dove la fisioterapia dovrebbe essere costituita dall’allungamento attivo e passivo dei muscoli ipertonici, allenamento della forza dei muscoli antagonisti, miglioramento della mobilità funzionale e rieducazione al corretto schema del passo. Tabelle Tabella 1. Caratteristiche demografiche e cliniche dei soggetti prima del trattamento (T0) Soggetti trattati con RSWT Soggetti trattati con placebo Età, anni, media ± DS 51.74 ± 11.29 51.00 ± 13.17 Sesso, M/F, n 14/20 16/18 Lato trattato, D/S, n 16/18 16/18 EDSS, media ± DS 6.60 ± 0.78 6.15 ± 1.23 RSWT: Radial Shock Wave Therapy; DS: Deviazione Standard; M: maschio; F: femmina; n: numero; D: destra; S: sinistra; EDSS: Expanded Disability Status Scale. Tabella 2. Misure di outcome (VAS, MAS, 10-MWT and MRC) distinte nelle differenti fasi temporali VAS (media ± DS) MAS (media ± DS) MRC (media ± DS) 10-MWT Soggetti trattati con RSWT T0 6.49 ± 1.60 2.68 ± 0.77 1.88 ± 1.14 34.17 ± 12.68 T1 5.22 ± 1.53 (p<0.0001) 2.62 ± 0.74 (p= 1) 1.94 ± 1.15 (p= 1) 33.14 ± 12.79 (p= 0.7) T2 3.44 ± 2.07 (p<0.0001) 1.90 ± 0.98 (p<0.0001) 1.99 ± 1.14 (p= 0.1) 32.25 ± 12.16 (p= 0.07) T3 5.21 ± 1.80 (p=0.0004) 2.56 ± 0.92 (p= 0.2) 1.87 ± 1.14 (p= 1) 33.05 ± 12.74 (p= 0.3) Soggetti trattati con placebo T0 6.15 ± 1.23 2.56 ± 0.99 2.12 ± 0.98 39.11 ± 14.91 T1 5.62 ± 1.26 (p= 0.08) 2.50 ± 1.05 (p= 0.4) 2.15 ± 0.74 (p= 1.0) 39.63 ± 13.67 (p= 0.8) T2 5.68 ± 1.49 (p= 0.2) 2.44 ± 1.05 (p= 0.2) 2.18 ± 0.67 (p= 0.8) 39.81 ± 14.30 (p= 0.8) T3 5.68 ± 1.30 (p= 0.2) 2.47 ± 1.08 (p= 0.3) 2.18 ± 0.80 (p= 0.8) 40.37 ± 14.39 (p= 0.7) RSWT: Radial Shock Wave Therapy; DS: Deviazione Standard; VAS: Visual Analogue Scale; MAS: Modified Ashworth Scale; MRC: Medical Research Council; 10-MWT: Ten-Meter Walking Test

The role of physical activity against chemotherapy-induced peripheral neuropathy: a narrative review

Several studies investigated the side effect of adjuvant cancer treatments, and different types of preventive techniques or treatments have been assessed. Chemotherapy-induced peripheral neuropathy (CIPN) is the most common neurological side effect. Exercise training has been widely studied as an adjuvant therapy to prevent CIPN and improve post-chemotherapy functional outcome and quality of life (QoL). This narrative review aims to summarize the data obtained from the latest studies about physical activity (PA) for the prevention and treatment of CIPN and associated QoL measures. Literature research was conducted to obtain studies including PA interventions for patients with CIPN. Ten studies met inclusion criteria and were therefore summarized and discussed, focusing on exercise type and functional outcome. It seems clear that, regardless of the type of exercise, PA plays a positive role in the treatment of CIPN, providing a significant symptom improvement. There has been no standardization of type, quantity, and intensity of PA administered to the subjects in the various studies probably due to a physiological difference between samples, grade of neuropathy, and difference among therapies

Time to reconcile research findings and clinical practice on upper limb neurorehabilitation

The problemIn the field of upper limb neurorehabilitation, the translation from research findings to clinical practice remains troublesome. Patients are not receiving treatments based on the best available evidence. There are certainly multiple reasons to account for this issue, including the power of habit over innovation, subjective beliefs over objective results. We need to take a step forward, by looking at most important results from randomized controlled trials, and then identify key active ingredients that determined the success of interventions. On the other hand, we need to recognize those specific categories of patients having the greatest benefit from each intervention, and why. The aim is to reach the ability to design a neurorehabilitation program based on motor learning principles with established clinical efficacy and tailored for specific patient's needs. Proposed solutionsThe objective of the present manuscript is to facilitate the translation of research findings to clinical practice. Starting from a literature review of selected neurorehabilitation approaches, for each intervention the following elements were highlighted: definition of active ingredients; identification of underlying motor learning principles and neural mechanisms of recovery; inferences from research findings; and recommendations for clinical practice. Furthermore, we included a dedicated chapter on the importance of a comprehensive assessment (objective impairments and patient's perspective) to design personalized and effective neurorehabilitation interventions. ConclusionsIt's time to reconcile research findings with clinical practice. Evidence from literature is consistently showing that neurological patients improve upper limb function, when core strategies based on motor learning principles are applied. To this end, practical take-home messages in the concluding section are provided, focusing on the importance of graded task practice, high number of repetitions, interventions tailored to patient's goals and expectations, solutions to increase and distribute therapy beyond the formal patient-therapist session, and how to integrate different interventions to maximize upper limb motor outcomes. We hope that this manuscript will serve as starting point to fill the gap between theory and practice in upper limb neurorehabilitation, and as a practical tool to leverage the positive impact of clinicians on patients' recovery

Cerebellum’s Contribution to Attention, Executive Functions and Timing: Psychophysiological Evidence from Event-Related Potentials

Since 1998, when Schmahmann first proposed the concept of the “cognitive affective syndrome” that linked cerebellar damage to cognitive and emotional impairments, a substantial body of literature has emerged. Anatomical, neurophysiological, and functional neuroimaging data suggest that the cerebellum contributes to cognitive functions through specific cerebral–cerebellar connections organized in a series of parallel loops. The aim of this paper is to review the current findings on the involvement of the cerebellum in selective cognitive functions, using a psychophysiological perspective with event-related potentials (ERPs), alone or in combination with non-invasive brain stimulation techniques. ERPs represent a very informative method of monitoring cognitive functioning online and have the potential to serve as valuable biomarkers of brain dysfunction that is undetected by other traditional clinical tools. This review will focus on the data on attention, executive functions, and time processing obtained in healthy subjects and patients with varying clinical conditions, thus confirming the role of ERPs in understanding the role of the cerebellum in cognition and exploring the potential diagnostic and therapeutic implications of ERP-based assessments in patients

Neuroradiological Evolution of Glycaemic Hemichorea-Hemiballism and the Possible Role of Brain Hypoperfusion

Background: Lateralized involuntary movements consistent with hemichorea-hemiballism (HCHB) may appear following the development of contralateral haemorrhagic or ischaemic lesions of the basal ganglia, particularly the striatum (caudate nucleus and putamen). This condition is called vascular HCHB, but the same symptoms can be caused by a completely different striatal lesion. Glycaemic HCHB may occur in patients with uncontrolled hyperglycaemia: basal ganglia hyperdensity is seen on brain CT, while increased T1 signal intensity and reduced susceptibility-weighted imaging (SWI) and gradient-echo sequences (T2*-GRE) are detected on MRI. Case description: An 83-year-old man with multiple vascular risk factors and uncontrolled chronic hyperglycaemia was admitted for ischaemic stroke presenting with dysarthria and mild left hemiparesis. No involuntary movements were reported at admission. The emergent brain CT scan was negative for vascular acute lesions, while a mild bilateral hyperdensity of the striata was detectable. Involuntary movements on the left side of the body, consistent with HCHB, appeared 27 days later. The alterations on brain CT completely disappeared after 3 months. On brain MRI, the T1 signal alterations resolved after 10 months, while SWI and T2*-GRE sequences showed persisting alterations after 2 years. Discussion: Detailed brain imaging demonstrated evolution of striatal alterations of glycaemic HCHB before the appearance of involuntary movements and during the following 2 years. The association between ischaemic stroke and glycaemic HCHB favours the hypothesis that chronic hyperglycaemia more likely determines striatal alterations and the clinical picture of HCHB when vascular hypoperfusion also occurs

Do flexible inter-injection intervals improve the effects of botulinum toxin A treatment in reducing impairment and disability in patients with spasticity?

In patients treated with botulinum toxin-A (BoNT-A), toxin-directed antibody formation was related to the dosage and frequency of injections, leading to the empirical adoption of minimum time intervals between injections of 3&nbsp;months or longer. However, recent data suggest that low immunogenicity of current BoNT-A preparations could allow more frequent injections. Our hypothesis is that a short time interval between injections may be safe and effective in reducing upper limb spasticity and related disability. IncobotulinumtoxinA was injected under ultrasound guidance in spastic muscles of 11 subjects, who were evaluated just before BoNT-A injection (T0), and 1&nbsp;month (T1), 2&nbsp;months (T2) and 4&nbsp;months (T3) after injecting. At T1, in the case of persistent disability related to spasticity interfering with normal activities, patients received an additional toxin dose. Seven subjects received the additional dose at T1 because of persistent disability; 4 of them had a decrease of disability 1&nbsp;month later (T2). Rethinking the injection scheme for BoNT-A treatment may have a major impact in the management of spasticity and related disability. Future studies with larger sample sizes are warranted to confirm that injection schedules with short time intervals should no longer be discouraged in clinical practice

Time to reconcile research findings and clinical practice on upper limb neurorehabilitation

In the field of upper limb neurorehabilitation, the translation from research findings to clinical practice remains troublesome. Patients are not receiving treatments based on the best available evidence. There are certainly multiple reasons to account for this issue, including the power of habit over innovation, subjective beliefs over objective results. We need to take a step forward, by looking at most important results from randomized controlled trials, and then identify key active ingredients that determined the success of interventions. On the other hand, we need to recognize those specific categories of patients having the greatest benefit from each intervention, and why. The aim is to reach the ability to design a neurorehabilitation program based on motor learning principles with established clinical efficacy and tailored for specific patient's needs. The objective of the present manuscript is to facilitate the translation of research findings to clinical practice. Starting from a literature review of selected neurorehabilitation approaches, for each intervention the following elements were highlighted: definition of active ingredients; identification of underlying motor learning principles and neural mechanisms of recovery; inferences from research findings; and recommendations for clinical practice. Furthermore, we included a dedicated chapter on the importance of a comprehensive assessment (objective impairments and patient's perspective) to design personalized and effective neurorehabilitation interventions. It's time to reconcile research findings with clinical practice. Evidence from literature is consistently showing that neurological patients improve upper limb function, when core strategies based on motor learning principles are applied. To this end, practical take-home messages in the concluding section are provided, focusing on the importance of graded task practice, high number of repetitions, interventions tailored to patient's goals and expectations, solutions to increase and distribute therapy beyond the formal patient-therapist session, and how to integrate different interventions to maximize upper limb motor outcomes. We hope that this manuscript will serve as starting point to fill the gap between theory and practice in upper limb neurorehabilitation, and as a practical tool to leverage the positive impact of clinicians on patients' recovery

A dataset of Visible – Short Wave InfraRed reflectance spectra collected in–vivo on the dorsal and ventral aspect of arms

Advancement of technology and device miniaturization have made near infrared spectroscopy (NIRS) techniques cost–effective, small–sized, simple, and ready to use. We applied NIRS to analyze healthy human muscles in vivo, and we found that this technique produces reliable and reproducible spectral “fingerprints” of individual muscles, that can be successfully discriminated by chemometric predictive models. The dataset presented in this descriptor contains the reflectance spectra acquired in vivo from the ventral and dorsal aspects of the arm using an ASD FieldSpec® 4 Standard–Res field portable spectroradiometer (350–2500 nm), the values of the anthropometric variables measured in each subject, and the codes to assist access to the spectral data. The dataset can be used as a reference set of spectral signatures of “biceps” and “triceps” and for the development of automated methods of muscle detection

A randomised controlled cross-over double-blind pilot study protocol on THC:CBD oromucosal spray efficacy as an add-on therapy for post-stroke spasticity

Stroke is the most disabling neurological disorder and often causes spasticity. Transmucosal cannabinoids (tetrahydrocannabinol and cannabidiol (THC:CBD), Sativex) is currently available to treat spasticity-associated symptoms in patients with multiple sclerosis. Cannabinoids are being considered useful also in the treatment of pain, nausea and epilepsy, but may bear and increased risk for cardiovascular events. Spasticity is often assessed with subjective and clinical rating scales, which are unable to measure the increased excitability of the monosynaptic reflex, considered the hallmark of spasticity. The neurophysiological assessment of the stretch reflex provides a precise and objective method to measure spasticity. We propose a novel study to understand if Sativex could be useful in reducing spasticity in stroke survivors and investigating tolerability and safety by accurate cardiovascular monitoring