Deep brain stimulation in patients with long history of drug resistant epilepsy and poor functional status: Outcomes based on the different targets.

BACKGROUND: Deep brain stimulation (DBS) is a widely used surgical procedure for the treatment of patients with drug resistant epilepsy (DRE) and several anatomical target have been described. Indications for DBS includes patients with focal, partial seizure and those for which resective or disconnective surgery are contraindicated, such as involvement of eloquent cortex or significant comorbidities. Despite the SANTE trial has clearly indicated the efficacy of DBS of anterior nucleus of the thalamus (ANT), specific indications regarding the best anatomical target and outcome in patients with severe disability are lacking. Here we described our case series of patients underwent DBS of three different target including ANT, centromedian thalamic nucleus (CMN) and subthalamic nucleus (STN). METHOD: Six patients with DRE have been treated with DBS of ANT (n = 3), STN (n = 2) and CMN (n = 1). Outcome has been expressed as seizures frequency reduction and patients functional status after surgery with a follow-up of 5-11 years. RESULTS: Four out of six patients show no reduction of seizures frequency after DBS implant with one case of increasing atypical absence. Two cases, one ANT and one CMN, show a significant reduction of seizures frequency of 50-60%. No patients improve relative to functional outcome and one showed psychiatric symptoms worsening. CONCLUSIONS: For patients with DRE and severe functional disability, DBS may reduce seizure frequency in some cases, but it does not improve functional outcome.

Cognitive and linguistic outcomes after awake craniotomy in patients with high-grade gliomas.

BACKGROUND: Preservation of language and cognition is crucial in glioma surgery, as they are crucial aspects of daily life functioning. Several studies claimed that awake surgery in eloquent areas is demanded in low and high-grade gliomas. Cognitive and language outcome has been less investigated in high-grade gliomas compared to low-grade. METHOD: We analyzed the neuropsychological and neuro-oncological outcome of nineteen patients (from a cohort of forty patients) who underwent fully awake surgery for resection of malignant tumors located in eloquent areas. RESULTS: Post-surgery, linguistic functions were unchanged in 80 % of patients. Slight impairments in memory and executive functions were observed in about 50 % of patients. Survival rate at one year follow-up was 89 %. Results showed that awake procedure is safe, well tolerated and related with good linguistic outcome similar to low-grade gliomas. The majority of patients reported a good outcome in term of quality of life. CONCLUSIONS: Our results confirm that awake surgery is associated to good cognitive and linguistic clinical outcome also in malignant tumors.

Action observation as a useful approach for enhancing recovery of verb production: new evidence from aphasia.

BACKGROUNDS: Evidence exists that the observation of actions performed by others enhance word retrieval and can be used in aphasia rehabilitation to treat naming impairments. AIM: The aim of the present study was to assess to what extent action observation treatment may improve verb retrieval in chronic aphasics. DESIGN: This was an observational study. SETTING: Patients were recruited from the Neurorehabilitation Centre of Ancona Hospital. POPULATION: Six aphasic patients underwent an intensive language training to improve verb naming. METHODS: Language evaluation was carried out before and after the treatment. A rehabilitation therapy based on observation of actions was administered daily to each patient for two consecutive weeks. Four different rehabilitation procedures were adopted: 1) "observation of action performed by the examiner"; 2) "observation and then execution of action"; 3) "observation of videoclips of actions"; and, as a control condition; 4) "observation of action and execution of meaningless movement". RESULTS: In four participants, a significant improvement in verb retrieval was found for the three experimental procedures (χ² (3)=75.212, P<0.0001), with respect to the control condition. No significant improvement was observed in the two patients with severe deficits in verb semantics (χ² (3)=0.592, P=0.892). CONCLUSIONS: Action observation therapy may become a useful intervention strategy to promote verb retrieval in aphasic patients. CLINICAL REHABILITATION IMPACT: The observation of videoclips of actions may be an efficacious alternative approach to traditional rehabilitation programs for lexical deficits. This finding endorses the planning of innovative low-cost interventions in language rehabilitation.

Electrical stimulation over the left inferior frontal gyrus (IFG) determines long-term effects in the recovery of speech apraxia in three chronic aphasics.

A number of studies have shown that modulating cortical activity by means of transcranial direct current stimulation (tDCS) affects the performance of both healthy and brain-damaged subjects. In this study, we investigated the potential of tDCS for the recovery of apraxia of speech in 3 patients with stroke-induced aphasia. Over 2 weeks, three aphasic subjects participated in a randomized double-blinded experiment involving intensive language training for their articulatory difficulties in two tDCS conditions. Each subject participated in five consecutive daily sessions of anodic tDCS (20 min, 1 mA) and sham stimulation over the left inferior frontal gyrus (referred to as Broca's area) while they performed a repetition task. By the end of each week, a significant improvement was found in both conditions. However, all three subjects showed greater response accuracy in the anodic than in the sham condition. Moreover, results for transfer of treatment effects, although different across subjects, indicate a generalization of the recovery at the language test. Subjects 2 and 3 showed a significant improvement in oral production tasks, such as word repetition and reading, while Subjects 1 and 2 had an unexpected significant recovery in written naming and word writing under dictation tasks. At three follow-ups (1 week, 1 and 2 months after the end of treatment), response accuracy was still significantly better in the anodic than in sham condition, suggesting a long-term effect on the recovery of their articulatory gestures.

Dynamic size-change of peri-hand space through tool-use: spatial extension or shift of the multi-sensory area.

Several studies in humans and non-human primates have shown that tool-use can expand near peripersonal space (Farnè & Làdavas, 2000; Iriki, Tanaka, & Iwamura, 1996). In humans, the extension of the near peripersonal space is revealed by an increase in the severity of cross-modal extinction caused by visual stimulation at the distal edge of a rake after its use as a reaching tool. The crucial question addressed here concerns whether the dynamic re-sizing of the peri-hand space in humans constitutes a real spatial expansion of visual-tactile peri-hand area along the tool axis. Alternatively, it could constitute a shift of the integrative area from the hand towards the distal edge of the tool, or the formation of a novel visual-tactile integrative area at the same distal location (Holmes, Calvert, & Spence, 2004). We contrasted the alternative predictions made by these hypotheses in a group of RBD patients by probing, at different locations along the tool axis, the changes induced by tool-use on cross-modal extinction. By assessing the visual-tactile extinction near the hand, midway along the tool, and at the distal edge of the tool we found an increase in visual-tactile extinction after tool-use both at the middle and the distal location along the tool axis. In contrast, no change intervened at the hand proximity. These findings support the view that the tool-use dependent re-mapping of peri-hand space in humans consists of a continuous elongation of visual-tactile peri-hand area from the hand towards the tip of the tool.

Magnesium metabolism in open-heart surgery.

The levels of magnesium in serum, urine and erythrocytes were studied in 22 patients undergoing cardiac surgery for valvular prosthesis. Magnesium values were correlated with serum albumin and non-esterified fatty acids (NEFA). Data were collected before anesthesia, 10 min after sternotomy, heparinization and declamping of the aorta and in the 1st postoperative day. A slight decrease in magnesemia was observed before extracorporeal circulation (ECC) and was mainly due to haemodilution. The correlation of magnesium with NEFA was significant only after heparinization. The use of the St Thomas solution as cardioplegia fully corrected the hypomagnesemia previously reported during ECC as well as in the 1st postoperative day. A moderate hypermagnesemia was observed at the end of ECC, but no patient reached dangerous levels of serum magnesium. Urinary losses increased during and after ECC. Red blood cell magnesium showed a slight increase before ECC, followed by a significant reduction at the end of ECC.