Improvement rate of patients with severe brain injury during post-acute intensive rehabilitation.

Patients with severe acquired brain injury (SABI) may evolve towards different outcomes. The primary aim was to evaluate the clinical evolution of a large population of patients with SABI admitted to post-acute rehabilitation from 2001 to 2016, diagnosed with severe brain injury (GCS ≤ 8) in the acute phase and a coma duration of at least 24 h. The possible changes between the admission time to a post-acute rehabilitation hospital and the discharge time were measured by means of Glasgow Outcome Scale (GOS), Level of Cognitive Functioning (LCF), and Disability Rating Scale (DRS). We also correlated the improvement rate with some sociodemographic and clinical features of the individuals with SABI enrolled. Data of 890 patients were analyzed (54% TBI, length of stay = 162 ± 186 days, GCS = 7.46 ± 1.28); time interval from the SABI (OR = 0.246, CI 95% = 0.181 - 0.333), scores at admission of LCF (OR = 2.243, CI 95% = 1.492 - 3.73), GOS (OR = 0.138, CI 95% = 0.071 - 0.266), DRS (OR = 0.457, CI 95% = 0.330 - 0.632), and etiology (OR = 2.273, CI 95% = 1.676 - 3.084) played a significant role (p < 0.001, explained variance 69.9%) for improving GOS score. Time interval from the SABI to admission in our post-acute rehabilitation ward (OR = 0.300, CI 95% = 0.179 - 0.501, p < 0.001), length of rehabilitation stay (OR = 2.808, CI 95% = 1.694 - 4.653, p < 0.001), and etiology (OR = 1.769, CI 95% = 1.095 - 2.857, p = 0.020) led to a statistically significant improvement in DRS (explained variance 91%). The most significant predictive factors for the outcome of patients with SABI were etiology, time interval from SABI to admission in rehabilitation, and length of rehabilitation stay.

Care management of spasticity with botulinum toxin-A in patients with severe acquired brain injury: a 1-year follow-up prospective study.

OBJECTIVE: To evaluate the efficacy and the safety of repeated botulinum toxin type A (BT-A) injections in patients with severe acquired brain injury (ABI) and to gain a better knowledge of possible clinical or demographic characteristics associated with a better rehabilitation outcome. DESIGN: Prospective study with a 1-year follow-up period. SUBJECTS: Twenty-one patients with spasticity due to severe ABI and no further improving with rehabilitation treatment and oral anti-spastic drugs. INTERVENTION: Repeated BT-A injections associated to a rehabilitation programme. MAIN MEASURES: Barthel Index (BI), Modified Ashworth Score (MAS) and VAS score for pain subjective perception were recorded. RESULTS: At the end of the follow-up study, MAS, BI and VAS significantly improved. Despite the number of BT-A injections, a shorter interval between severe ABI onset and first BT-A treatment correlated to a better BI improvement. None of the patients experienced adverse events attributable to BT-A. CONCLUSION: BT-A was effective and safe in the treatment of spasticity in severe ABI patients, with a better functional outcome in those subjects treated earlier after spasticity onset. The lack of correlation between clinical outcome and number of injections suggests, in addition to a direct inhibition at the neuromuscular junction, a more distant BT-A long-term effect.

Blink reflex changes in parkinsonism following severe traumatic brain injury correlates with diffuse axonal injury.

BACKGROUND: Survivors of severe traumatic brain injury (TBI) may show transient or persistent extrapyramidal symptoms such as rigidity, akinesia and parkinsonian posture, associated with hypomimia, not estinguishable glabellar tap reflex, seborrhea and hypersalivation. The Blink Reflex (BR), an electrically-induced reflex, is abnormal in Parkinson's disease (PD) and in some parkinsonisms. The aim of the study was to investigate BR habituation and its recovery cycle in survivors of severe TBI suffering from parkinsonian syndrome and the possible correlation with neuroimaging findings. MATERIAL/METHODS: Twenty-three patients (18 males, 5 females; mean age 23.7 years, range 13-35), who sustained a severe TBI, (Glasgow Coma Scale or GCS, lower than 8 in the first 48 hours), and followed by coma for a duration equal or longer than 15 days, were studied during the post-acute or chronic phase. Enrollement criteria include the presence of at least 3 extrapyramidal symptoms. BR was elicited by electrical stimulation of the supraorbital nerve and responses were recorded with surface electrodes from the orbicularis oculi muscle ipsilateral to the stimulation. A repeated series of 10 electrical stimuli was applied at the frequencies of stimulation of 0.3, 0.5, 0.7, 1.0, 1.5, 2.0 and 3.0 Hz, respectively. Values between 0.5 and 1 Hz were considered as normal, according to the international literature, Cerebral Magnetic Resonance (C-MRI), with fast sequences was performed within 3 months after brain injury. Ten healthy subjects, age and sex matched, served as controls and underwent the same procedure. RESULTS: Nineteen of the twenty-three patients (82.6%) showed a significantly reduced BR habituation in comparison with controls. This findings highly correlated with C-MRI diagnosis of Diffuse Axonal Injury (DAI). A normal BR habituation was found in only 4 out of 23 patients (17%). In these subjects, C-MRI revealed focal lesions rather than DAI. CONCLUSIONS: BR changes correlate with parkinsonian signs and neuroimaging findings. BR may have a role as a diagnostic tool in post-traumatic parkinsonism and as a prognostic tool to evaluate the effect of therapeutic options.

Symptomatic cluster-like headache triggered by forehead lipoma: a case report and review of the literature.

We describe the case of a patient with symptomatic strictly unilateral paroxysmal headache mimicking cluster headache related to an ipsilateral forehead lipoma. Interestingly, immediately after the surgical excision of the lipoma pain attacks disappeared with no recurrence during a follow-up period of 18 months. Like other descriptions of cluster-like headaches secondary to extracranial lesions, this case report focuses on the hypothetical role of a peripheral trigger factor for trigeminal autonomic cephalgias (TACs). To our knowledge, this is the first well-described cluster-like headache case secondary to an extracerebral lipoma. This case offered the opportunity to discuss the possible pathophysiological mechanisms underlying probable TACs and the relationship with peripheral extracerebral activation of the trigeminal-autonomic reflex.

Dysfunction of a structurally normal motor pathway in a brain injury patient as revealed by multimodal integrated techniques.

We report on a patient with left hemiparesis and peripersonal neglect after post-traumatic left frontal hemorrhage, who underwent fMRI, TMS and TCD to identify the functional abnormalities that account for his neurological symptoms, in the absence of any detectable lesion affecting right motor areas.

Imagery-induced cortical excitability changes in stroke: a transcranial magnetic stimulation study.

Focal transcranial magnetic stimulation (TMS) was employed in a population of hemiparetic stroke patients in a post-acute stage to map out the abductor digiti minimi (ADM) muscle cortical representation of the affected (AH) and unaffected (UH) hemisphere at rest, during motor imagery and during voluntary contraction. Imagery induced an enhancement of the ADM map area and volume in both hemispheres in a way which partly corrected the abnormal asymmetry between AH and UH motor output seen in rest condition. The voluntary contraction was the task provoking maximal facilitation in the UH, whereas a similar degree of facilitation was obtained during voluntary contraction and motor imagery in the AH. We argued that motor imagery could induce a pronounced motor output enhancement in the hemisphere affected by stroke. Further, we demonstrated that imagery-induced excitability changes were specific for the muscle 'prime mover' for the imagined movement, while no differences were observed with respect to the stroke lesion locations. Present findings demonstrated that motor imagery significantly enhanced the cortical excitability of the hemisphere affected by stroke in a post-acute stage. Further studies are needed to correlate these cortical excitability changes with short-term plasticity therefore prompting motor imagery as a 'cortical reservoir' in post-stroke motor rehabilitation.

Psychiatric disorders and pain location in unilateral migraineurs.

To explore the relationship between the side of pain during attacks and psychopathological features in strictly unilateral migraine, we recruited 35 patients affected by migraine with and/or without aura diagnosed according to the revised ICHD-II criteria. Seventeen patients had right side-locked pain (R-SUM), 11 had left side-locked (L-SUM) and 7 had side-shifting pain (SSM). Patients were administered the Hamilton Anxiety Scale, the State and Trait Anxiety Inventory-State Anxiety, the Beck Depression Inventory and the 20-item Toronto Alexithymia Scale. Statistical analyses showed that the L-SUM group was significantly more anxious and depressed than the other two groups of patients. Our preliminary data suggest that strictly left unilateral migraine is associated with more severe anxiety and depression. This finding appears to be consistent with studies that reported a higher degree of these disorders in patients with left cerebral hemispheric damage.

Interhemispheric asymmetries of motor cortex excitability in the postacute stroke stage: a paired-pulse transcranial magnetic stimulation study.

BACKGROUND AND PURPOSE: Changes in the intracortical inhibition (ICI) and facilitation (ICF) of motor cortex paired-pulse transcranial magnetic stimulation were reported in the affected (AH) and unaffected (UH) hemispheres of stroke patients and reflect some of the mechanisms related to motor cortex plasticity and different degrees of functional recovery. The interhemispheric differences of the ICI/ICF slopes have been found to have a nearly identical time course in the 2 hemispheres of healthy subjects, and whether such symmetry is modified after monohemispheric stroke has not yet been examined. Our goal was to investigate the interhemispheric asymmetries of the time course of ICI/ICF between the AH and UH of stroke patients in the postacute phase of recovery. METHODS: ICI/ICF recovery curves to subthreshold-conditioning suprathreshold-test magnetic stimuli were recorded from the paretic and nonparetic hand muscles of 10 well-recovered stroke patients and compared with those of a population of 10 control subjects. RESULTS: In the healthy subjects, ICI/ICF showed a symmetrical time evolution between the 2 hemispheres. In stroke patients, the ICI/ICF slopes were significantly different between the UH and AH; the intracortical inhibition was reduced in the AH and normal in the UH. CONCLUSIONS: The defective AH ICI associated with the effective UH ICI could represent a marker of poststroke cortical plasticity implicated as a mechanism relevant to functional recovery. Analysis of the interhemispheric asymmetries of the ICI/ICF recovery curves might provide a valuable neurophysiological parameter in the prognosis and follow-up of patients with monohemispheric stroke.

Specific forms of neural activity associated with tactile space awareness.

Left tactile extinction, in which a left tactile stimulus fails to access consciousness only when a right stimulus is presented simultaneously, offers a model for studying tactile awareness from its transitory absence. Pairs of transcranial magnetic stimuli (TMS) on the parietal cortex inhibit contralateral tactile perception when separated by an interval of 1 ms. We have applied this technique on the left parietal cortex of right brain damaged (RBD) patients and normal subjects and have shown a selective lack of paired TMS inhibitory effects on right tactile perception of patients during bimanual stimulation. TMS effects were normal during unimanual right stimulation. These results suggest the presence of a specific pattern of inhibitory/excitatory interactions in parietal brain areas as critical for tactile awareness.