Structural and functional MRI study in mentally ill persons considered socially dangerous with diminished penal responsibility

La complessa relazione tra malattia mentale e criminalità rappresenta un tema di concreta rilevanza sociale, dibattuto da anni ma sempre di grande attualità. Secondo il codice penale, è considerato “socialmente pericoloso” il soggetto autore di reato, anche se non imputabile per vizio totale o parziale di mente, che abbia una elevata probabilità di recidiva del reato. Per questo motivo la prevenzione delle azioni socialmente pericolose riveste un ruolo di fondamentale importanza giuridica e sociale. In questo contesto la psichiatria forense si occupa delle questioni che sorgono all’interfaccia tra psichiatria e giurisprudenza, con l’obiettivo principale di evidenziare lo stato di salute mentale dei soggetti che commettono un reato attraverso una perizia psichiatrica. La disciplina neuroradiologica, grazie anche all’utilizzo di tecniche avanzate di analisi delle immagini, si pone oggi come strumento di valido ausilio nella valutazione clinica dei pazienti psichiatrici e può supportare gli sforzi congiunti di psichiatri e giuristi per studiare la relazione tra malattia mentale e criminalità. L’obiettivo di questo progetto di dottorato è stato quello di effettuare uno studio volumetrico della sostanza grigia cerebrale attraverso un esame di Risonanza Magnetica (RM) su un gruppo di soggetti autori di reato, considerati non imputabili al momento del fatto per vizio totale o parziale di mente, detenuti nella REMS dell’ASL Rm5 e considerati socialmente pericolosi. I risultati dell’analisi volumetrica sono stati confrontati con un gruppo di controllo, comparabile per età e sesso. E’stata inoltre effettuata un’analisi della connettività funzionale cerebrale a riposo (resting-state functional MRI) con l’intento di indagare i network cerebrali alla base del comportamento morale, dell’attribuzione della salienza e dei processi di ricompensa, confrontando sempre i risultati con un gruppo di controllo. Nel gruppo sperimentale sono stati inclusi 13 individui destrorsi (età media: 44 ± 7 anni) detenuti nella REMS dell’ASL Rm5 con disturbo dello spettro psicotico (schizofrenia, disturbo bipolare con caratteristiche psicotiche, disturbo schizo-affettivo, disturbi deliranti), che hanno commesso crimini violenti (omicidi, tentati omicidi, aggressioni e violenze domestiche) e che sono stati dichiarati socialmente pericolosi dall’autorità giudiziaria a causa dell’ alto rischio di recidiva criminale. I dati di RM sono stati acquisiti su un magnete 3 Tesla (Verio, Siemens) dotato di una bobina a 12 canali, utilizzando sequenze volumetriche T13D e sequenze BOLD eco-planari (EPI). Nello studio I abbiamo eseguito un’analisi della volumetria cerebrale con tecnica VBM (Voxel-based morphometry) utilizzando il Computational Anatomy Toolbox (CAT12) del software Statistical Parametric Mapping (SPM12). Abbiamo riscontrato come il volume della sostanza grigia cerebrale del gruppo sperimentale fosse significativamente ridotto, rispetto ai controlli, a livello della corteccia insulare bilaterale, nel giro temporale superiore (STG) dell’emisfero sinistro e nel giro fusiforme dell’emisfero destro. Abbiamo infine eseguito un’analisi di correlazione tra la gravità dei sintomi psichiatrici e le regioni con volume corticale ridotto. I cluster di volume a livello di STG e insula sinistra sono risultati essere significativamente correlati alla gravità dei sintomi espressa dalla scala di valutazione BPRS (Brief Psychiatric Rating Scale). Nello studio II abbiamo esaminato la connettività cerebrale a riposo nelle 19 regioni selezionate “a priori” sulla base della letteratura che risultassero coinvolte nella morale, nell’ attribuzione della salienza e nei processi di ricompensa. L’analisi è stata effettuata utilizzando il software CONN v. 18a, sulla piattaforma Matlab. Abbiamo documentato una ridotta connettività tra le regioni del sistema limbico, come il nucleo accumbens e l’amigdala, ed aumentata connettività nello striato dorsale, tra il nucleo accumbens e la corteccia cingolata posteriore, tra corteccia fronto-orbitale e gangli della base e tra corteccia cingolata anteriore e amigdala. Sulla base di questi risultati ipotizziamo che l’alterata connettività in queste specifiche aree possa rappresentare la modificazione del comportamento in senso maladattativo degli individui del gruppo sperimentale, in termini di alterata risposta emotiva circa le proprie violazioni morali o di mancanza di empatia verso gli altri al fine di ottenere vantaggi personali o riguardo al controllo dell’impulsività. Nonostante la bassa numerosità campionaria non consenta di approdare a conclusioni definitive, questo studio cerca di approfondire i correlati neurali degli individui autori di reato con ridotta responsabilità penale e socialmente pericolosi al fine di fornire un eventuale strumento di ausilio nella valutazione di questa particolare categoria di persone, con importanti risvolti giuridici ed etici oltre che nella pianificazione e nello sviluppo del trattamento di questi pazienti durante la loro permanenza nelle REMS.The relation between mental illness and criminality is a relevant social issue that has been debated over the years. Socially dangerous actions committed by mentally ill patients often have severe consequences, which is why much public attention is directed toward the prevention of these actions by these individuals. Modern neuroimaging investigations support the joint efforts of psychiatrists and lawyers to study the relationship between psychiatric illness and criminality. The overall aim of this PhD project was to investigate differences in cortical GM volumes of this population, compared to a control group of healthy non-offender participants, using a VBM analysis of structural MRI. We also decided to investigate brain networks underpinning moral behaviour, salience attribution and reward processes performing a functional MRI at resting-state. Experimental Group (EG) included 13 right-handed individuals (mean age: 44 ± 7 yrs) who committed violent crimes (homicides, attempted homicides, aggressions, and domestic violence), had a diagnosis included in the psychotic spectrum (schizophrenia, bipolar disorder with psychotic features, schizoaffective disorder, delusional disorders) and were declared socially dangerous by the judicial authority due to a high risk of criminal recidivism. All subjects of the EG were institutionalized in the REMS psychiatric unit of ASL RM5 (Rome, Italy) for no longer than two years. Thirteen healthy right-handed men, who had never received a psychiatric diagnosis, undergone any psychiatric treatment, or been convicted of any crime were included in the control group (CG) (mean age: 38 ± 11yrs). MRI data were acquired using a 3 Tesla Siemens imaging system (Siemens, Verio, Erlangen, Germany) equipped with a 12-channel head coil. Structural scans of the brain were acquired for each participant using a T1-weighted three dimensionals sagittal magnetization-prepared rapid gradient echo sequence. Resting state functional (rs-fMRI) data were collected while participants lay still and awake, with eyes closed using T2*-weighted gradient-echo echo-planar functional images (EPIs). In study I we performed a voxel-based morphometry (VBM) analyses on participants’ T1-weighted structural images using Computational Anatomy Toolbox (CAT12), which runs within SPM12. We found that total cerebral GM volume was significantly reduced in EG in specific regions within the bilateral insular cortex compared to controls. We also found a reduced GM volume in the superior temporal gyrus (STG) of left hemisphere and in the fusiform gyrus of the right hemisphere. We finally performed a correlation analyses between psychiatric symptoms and regions with reduced GM volume. The clusters in STG and insula of left hemisphere significantly correlated with the gravity of symptoms expressed by the BPRS (Brief Psychiatric Rating Scale). In study II, temporal correlations of the resting-state BOLD signal time series were examined between nineteen seed regions that we selected “a priori” among those known to be involved in moral judgment salience attribution and reward processes. Analysis was performed using the software CONN v. 18a, running in Matlab. Our results documented reduced connectivity in limbic regions like the nucleus accumbens and the amiygdala and augmented connectivity within the dorsal striatum, between nucleus accumbens and the posterior cingulate cortex, between fronto- orbitalis cortex and basal ganglia and anterior cingulate cortex and amygdala. We suggest that dysregulation in these areas reflects the maladaptive behavior of socially dangerous subjects in terms of an altered emotional response to their own moral violations and a lack of empathy for others when making personal desire-oriented decisions. While the small sample size does not allow definitive conclusions to be reached, the present study sheds some light on the neural correlates of this specific population, which deserves further attention due to their theoretical and clinical implications. A further understanding of the neural basis of risk evaluation in mentally ill persons with a history of violence who are judged not criminally responsible could aid in forensic assessment and treatment development

The choice of gadolinium-based contrast agents: a radiologist’s responsibility between pharmaceutical equivalence and bioethical issues

Contrast Agents (CA) are among the most commonly prescribed drugs worldwide, and are used, with a variety of techniques, to increase and intensify the differences between body tissues and to help radiologist make diagnoses in a fast and precise way. In recent decades, advancements in research have resulted in significant improvements in their composition, and have made them safer and better-tolerated by patients; this notwithstanding, although the currently available CA are generally considered to be safe, their use is not completely without risk. The use of CA faces the radiologist with economic considerations, bioethical dilemmas, and possible profiles of professional responsibility. In fact, to achieve the best results in diagnostic imaging, radiologists have to focus on making an appropriate choice of CA, in consideration of efficacy, safety and appropriateness. Moreover, besides by cost/benefit models widely introduced in health management, radiologists are also influenced by their responsibility of appropriate use for the various diagnostic tests and, finally, the choice of best CA to utilise for each individual patient. Thus, the dilemma of choosing between the best and the most cost-effective tests and procedures is occurring more frequently every day. Different variables, such as the patient, examinations, and technology available, can affect the choice of CA in terms of obtaining the highest diagnostic quality, minimum impact on higher-risk patients, and optimisation of used volumes and injection flow

The relationships between vitamin K and cognition: a review of current evidence

Vitamin K is a fat-soluble nutrient discovered in 1935 and its role in blood coagulation has been thoroughly explored. In recent years, studies conducted in vitro and on animals highlighted vitamin K involvement in brain cells development and survival. In particular, vitamin K seems to have an antiapoptotic and anti-inflammatory effect mediated by the activation of Growth Arrest Specific Gene 6 and Protein S. Moreover, this vitamin is involved in sphingolipids metabolism, a class of lipids that participate in the proliferation, differentiation, and survival of brain cells. An altered expression in sphingolipids profile has been related to neuroinflammation and neurodegeneration. This review stems from a growing interest in the role of vitamin K in brain functions, especially in cognition, also in view of an expected increase of prevalence of Alzheimer's disease and other forms of dementia. It collects recent researches that show interesting, even though not definitive, evidence of a direct correlation between vitamin K levels and cognitive performance. Moreover, vitamin K antagonists, used worldwide as oral anticoagulants, according to recent studies may have a negative influence on cognitive domains such as visual memory, verbal fluency and brain volume. The aim of this review is to analyze the evidence of clinical studies carried out up to date on the relationship between vitamin K intake and cognitive performances. The involvement of vitamin K antagonists (VKAs) in declining cognitive performances is also addressed separately

Shaken Baby Syndrome: Magnetic Resonance Imaging Features in Abusive Head Trauma

In the context of child abuse spectrum, abusive head trauma (AHT) represents the leading cause of fatal head injuries in children less than 2 years of age. Immature brain is characterized by high water content, partially myelinated neurons, and prominent subarachnoid space, thus being susceptible of devastating damage as consequence of acceleration–deceleration and rotational forces developed by violent shaking mechanism. Diagnosis of AHT is not straightforward and represents a medical, forensic, and social challenge, based on a multidisciplinary approach. Beside a detailed anamnesis, neuroimaging is essential to identify signs suggestive of AHT, often in absence of external detectable lesions. Magnetic resonance imaging (MRI) represents the radiation-free modality of choice to investigate the most typical findings in AHT, such as subdural hematoma, retinal hemorrhage, and hypoxic-ischemic damage and it also allows to detect more subtle signs as parenchymal lacerations, cranio-cervical junction, and spinal injuries. This paper is intended to review the main MRI findings of AHT in the central nervous system of infants, with a specific focus on both hemorrhagic and non-hemorrhagic injuries caused by the pathological mechanisms of shaking. Furthermore, this review provides a brief overview about the most appropriate and feasible MRI protocol to help neuroradiologists identifying AHT in clinical practice

Cerebral gray matter volume in patients with chronic migraine: correlations with clinical features

Abstract Background To date, few MRI studies have been performed in patients affected by chronic migraine (CM), especially in those without medication overuse. Here, we performed magnetic resonance imaging (MRI) voxel-based morphometry (VBM) analyses to investigate the gray matter (GM) volume of the whole brain in patients affected by CM. Our aim was to investigate whether fluctuations in the GM volumes were related to the clinical features of CM. Methods Twenty untreated patients with CM without a past medical history of medication overuse underwent 3-Tesla MRI scans and were compared to a group of 20 healthy controls (HCs). We used SPM12 and the CAT12 toolbox to process the MRI data and to perform VBM analyses of the structural T1-weighted MRI scans. The GM volume of patients was compared to that of HCs with various corrected and uncorrected thresholds. To check for possible correlations, patients’ clinical features and GM maps were regressed. Results Initially, we did not find significant differences in the GM volume between patients with CM and HCs (p < 0.05 corrected for multiple comparisons). However, using more-liberal uncorrected statistical thresholds, we noted that compared to HCs, patients with CM exhibited clusters of regions with lower GM volumes including the cerebellum, left middle temporal gyrus, left temporal pole/amygdala/hippocampus/pallidum/orbitofrontal cortex, and left occipital areas (Brodmann areas 17/18). The GM volume of the cerebellar hemispheres was negatively correlated with the disease duration and positively correlated with the number of tablets taken per month. Conclusion No gross morphometric changes were observed in patients with CM when compared with HCs. However, using more-liberal uncorrected statistical thresholds, we observed that CM is associated with subtle GM volume changes in several brain areas known to be involved in nociception/antinociception, multisensory integration, and analgesic dependence. We speculate that these slight morphometric impairments could lead, at least in a subgroup of patients, to the development and continuation of maladaptive acute medication usage

Post-mortem computed tomography (PMCT) radiological findings and assessment in advanced decomposed bodies.

PURPOSE: The aim of the study is to report radiological findings and features in advanced decomposed bodies obtained by post-mortem computed tomography (PMCT) with autopsy correlation. MATERIALS AND METHODS: This retrospective descriptive multicentric study included 41 forensic cases examined between May 2013 and November 2016. All the bodies were PMCT-scanned prior to autopsy, and internal putrefactive state was determined using the radiological alteration index (RAI) by a radiologist with expertise in forensic radiology and a forensic pathologist trained in forensic imaging. After PMCT scans, grade of external putrefaction (GEP) was assigned during the external examination and the complete autopsy was performed by forensic pathologists. RESULTS: The PMCT images evaluation revealed that the RAI index was > 61 in all bodies, corresponding to a moderate-massive presence of putrefactive gas. The gas grade was > II in correspondence of the major vessels, heart cavities, liver parenchyma, vertebra L3 and subcutaneous pectoral tissues, and varied from I to III in correspondence of the kidney. Cadaveric external examination revealed the presence of advanced transformative phenomena, with a GEP3 and GEP4 in most of the cases, with body swelling, eyes and tongue protrusion, body fluids expulsion and fat liquefaction. CONCLUSION: Radiological imaging by PMCT as an adjunct to autopsy in advanced decomposed bodies represents a useful tool in detecting post-mortem gas, even in very small amounts. A correct interpretation process of the PMCT data is essential to avoid images pitfalls, due to natural decomposition that can be mistaken for pathologic processes

Increased neural connectivity between the hypothalamus and cortical resting-state functional networks in chronic migraine

Objective The findings of resting-state functional MRI studies have suggested that abnormal functional integration between interconnected cortical networks characterises the brain of patients with migraine. The aim of this study was to investigate the functional connectivity between the hypothalamus, brainstem, considered as the migraine generator, and the following areas/networks that are reportedly involved in the pathophysiology of migraine: default mode network (DMN), executive control network, dorsal attention system, and primary and dorsoventral visual networks. Methods Twenty patients with chronic migraine (CM) without medication overuse and 20 healthy controls (HCs) were prospectively recruited. All study participants underwent 3-T MRI scans using a 7.5-min resting-state protocol. Using a seed-based approach, we performed a ROI-to-ROI analysis selecting the hypothalamus as the seed. Results Compared to HCs, patients with CM showed significantly increased neural connectivity between the hypothalamus and brain areas belonging to the DMN and dorsal visual network. We did not detect any connectivity abnormalities between the hypothalamus and the brainstem. The correlation analysis showed that the severity of the migraine headache was positively correlated with the connectivity strength of the hypothalamus and negatively with the connectivity strength of the medial prefrontal cortex, which belongs to the DMN. Conclusion These data provide evidence for hypothalamic involvement in large-scale reorganisation at the functional-network level in CM and in proportion with the perceived severity of the migraine pain

Tiny events: tales of urban domesticity from Lingotto, a former working-class neighborhood in Turin

Article published by 12 authors, coordinated by Filippo De Pieri and Gaia Caramellino, as "The Housing History Collective

Cerebral venous thrombosis: A case series and a neuroimaging review of the literature

Cerebral venous thrombosis (CVT) is a rare condition, difficult to diagnose because of its non specific clinical symptoms. In some cases CVT can mimic other conditions as subarachnoid hemorrhage, ischemia or tumor and for these reasons diagnosis is delayed or missed. CT, DSA and MRI findings help to obtain an early diagnosis and to distinguish it from other diseases. Our cases involved four patients with no signs or symptoms suspected for CVT and without risk factors associated to this disease; furthermore some early imaging findings observed in these patients could mimic other diseases. The aim of presenting these cases is to underline the importance of some findings at imaging techniques in obtaining an early diagnosis of CVT; in particular we describe the usefulness of MRI with gradient echo sequences (GRE) in detecting the venous thrombus, suggesting that GRE sequences should be included in the MRI protocol when a CVT is suspected. We also underline the role of radiologists in helping neurologists to make an early diagnosis of CVT or when in doubt to encourage further investigations in order to begin the anticoagulation therapy as soon as possible avoiding the onset of complications as permanent parenchymal damage, cerebral hemorrhage and venous infarction