Visual vertical neglect in acquired brain injury: a systematic review.

Vertical neglect represents a visuospatial deficit occurring as a possible consequence of acquired brain injury (ABI). Differently from unilateral spatial neglect on horizontal space, vertical neglect is poorly studied in the literature and rarely assessed in clinical practice. In the available studies, the terms "radial," "vertical," and "altitudinal" neglect are often used interchangeably, although they do not describe the same spatial dimension. "Altitudinal" and "vertical" refer to the sagittal plane, whereas "radial" refers to the transverse plane. The term "vertical" is sometimes used interchangeably with respect to both axes. The aim of this systematic review was to identify the main characteristics of vertical neglect after ABI, the diagnostic tools used, and the treatment options. We also proposed a clarification of the manifestations and characteristics of vertical and radial neglect. The 23 articles reviewed, showed that the vertical neglect occurred more frequently on the lower space than on the upper space, that its presence was associated with horizontal neglect, and that it could also occur with compromise of the radial space, with the near radial being more common. The most frequent etiology associated with vertical neglect is vascular, particularly ischaemic. The lesions side are very heterogeneous and include both cortical and subcortical areas and all lobes, although the temporal lobe is most affected. With regard to the assessment tools, paper and pencil tasks are the most commonly used diagnostic tools to identify vertical neglect, although in recent years the use of computer-based tasks increased. Taken together, our results suggest that vertical neglect may be underestimated in patients with right hemisphere lesions and should always be assessed, especially in cases where the patient shows signs of horizontal neglect. The clinical assessment of vertical neglect is very important since it can lead to important functional limitations in everyday life, such as poor wheelchair handling, stumbling over unnoticed obstacles located below (or above), walking down stairs, taking off shoes.

Family caregivers improve the diagnostic accuracy of disorders of consciousness: from remote to near-bed auditory stimulation.

BACKGROUND: Family caregivers (FC) contribute to reducing the misdiagnosis rate in patients with disorders of consciousness (DOC). Unfortunately, the recent pandemic of COVID-19 imposed drastic restrictions that limited the access of FC to the sensory/cognitive stimulation protocols. Telemedicine approaches have been implemented to avoid discontinuity in care pathways and to ensure caregivers involvement in rehabilitation programs. AIM: The aim was to investigate whether the presence of FC remotely connected might help clinicians in eliciting higher cortically mediated behavioral responses in patients with DOC. DESIGN: Cross-sectional study. SETTING: Post-acute Unit of Neurorehabilitation. POPULATION: DOC due to severe brain injury. METHODS: Consecutive patients with DOC were assessed by means of the Coma Recovery Scale-Revised (CRS-R) by two expert examiners. Each patient underwent to five assessments in two weeks in three different conditions: 1) by the examiner only (standard); 2) with the verbal stimulation given by the FC remotely connected by PC tablet (caregiver in remote); and 3) with the verbal stimulation given by the FC physically present (caregiver in presence). RESULTS: Thirty patients with DOC (VS/UWS=10; MCS=20; mean age: 51, range: 21-79; vascular: 16; anoxic: 6; TBI=8) and their FC were enrolled. Higher total scores of CRS-R were recorded both in "caregiver in remote" and in "caregiver in presence" than in standard condition (standard vs. remote, Z=2.942, P=0.003; standard vs. presence, Z=3.736, P<0.001). Furthermore, the administration of the CRS-R with a FC, elicited higher levels of behavioral responses in MCS patients, than CRS-R performed in standard condition. In particular, 2 patients out of 30 (6.66%) showed higher scores and better diagnosis when the CRS-R was administered with FC in remote. Similarly, 5 out of 30 patients (16.66%) showed better diagnoses when the CRS-R was administered with FC in presence. Five patients changed diagnosis between standard and presence conditions (3 MCS- were diagnosed as MCS+; 2 MCS+ were diagnosed as conscious). CONCLUSIONS: Our findings add new evidence regarding the beneficial role of family members in the diagnosis of DOC, even mediated by telemedicine approach. CLINICAL REHABILITATION IMPACT: In future guidelines, FC should have an active and supporting role in the diagnostic and rehabilitative process of DOC.

Body Representation Alterations in Patients with Unilateral Brain Damage.

OBJECTIVE: Systematic studies about the impact of unilateral brain damage on the different body representations (body schema, body structural representation, and body semantics) are still rare. Aim of this study was to evaluate body representation deficits in a relatively large sample of patients with unilateral brain damage and to investigate the impact of right or left brain damage on body representations (BRs), independently from deficits in other cognitive processes. METHOD: Sixty-four patients with unilateral stroke (22 with left brain damage, LBD; 31 with right brain damage without neglect, RBD-N; 11 with right brain damage with neglect, RBD+N) and 41 healthy individuals underwent a specific battery including BR as well as control tasks. RESULTS: In more than a third of the sample, selective (37.5%) and pure (31%) deficits of BR were presented and equally distributed among the different BRs (˜10% for each representation), with selective (27.2%) and pure (22.7%) body schema deficit mainly presented after left brain damage. As a group, patients with unilateral brain damage, independently of the side of lesion (LBD, RBD-N, RBD+N), had significantly worse performance on body structural representation with respect to healthy individuals, whereas LBD had numerically worse performance on body schema with respect to healthy individuals and RBD-N. No significant differences among groups were found on body semantics. CONCLUSION: BR deficits are not a rare consequence of unilateral brain damage and are independent of a more general cognitive dysfunction. Accordingly, the need for an accurate assessment and specific neuropsychological training in clinical settings is discussed.

MRX87 family with Aristaless X dup24bp mutation and implication for polyAlanine expansions.

BACKGROUND: Cognitive impairments are heterogeneous conditions, and it is estimated that 10% may be caused by a defect of mental function genes on the X chromosome. One of those genes is Aristaless related homeobox (ARX) encoding a polyA-rich homeobox transcription factor essential for cerebral patterning and its mutations cause different neurologic disorders. We reported on the clinical and genetic analysis of an Italian family with X-linked mental retardation (XLMR) and intra-familial heterogeneity, and provided insight into its molecular defect. METHODS: We carried out on linkage-candidate gene studies in a new MRX family (MRX87). All coding regions and exon-intron boundaries of ARX gene were analysed by direct sequencing. RESULTS: MRX87 patients had moderate to profound cognition impairment and a combination of minor congenital anomalies. The disease locus, MRX87, was mapped between DXS7104 and DXS1214, placing it in Xp22-p21 interval, a hot spot region for mental handicap. An in frame duplication of 24 bp (ARXdup24) in the second polyAlanine tract (polyA_II) in ARX was identified. CONCLUSION: Our study underlines the role of ARXdup24 as a critical mutational site causing mental retardation linked to Xp22. Phenotypic heterogeneity of MRX87 patients represents a new observation relevant to the functional consequences of polyAlanine expansions enriching the puzzling complexity of ARXdup24-linked diseases.