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Broomfield NM, Blake J, Gracey F, Steverson T. Post-stroke emotionalism: Diagnosis, pathophysiology, and treatment. Int J Stroke 2024:17474930241242952. [PMID: 38503711 DOI: 10.1177/17474930241242952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Post-stroke emotionalism affects one in five stroke sufferers 6 months after their stroke, but despite its frequency remains a poorly understood stroke symptom. The literature is limited, especially compared to other frequently observed neurological conditions such as aphasia and visual neglect. AIM AND METHODS This narrative review presents a summary of the post-stroke emotionalism literature, to inform clinical practice and future research. We cover discussion of definitions, prevalence, neurobiology, predisposing and precipitating factors, and treatment. RESULTS Increasing evidence suggests that damage to specific areas functionally linked to emotion expression or regulation processes, disruption to structural pathways and those related to serotonin production and modulation individually or in concert give rise to emotionalism-type presentations. A range of emotionalism measurement tools have been used in research contexts making between study comparisons difficult. Testing for Emotionalism after Recent Stroke-Questionnaire (TEARS-Q) has recently been developed to allow standardized assessment. Treatment options are limited, and there have been few adequately powered treatment trials. Antidepressants may reduce severity, but more trial data are required. There have been no randomized-controlled trials of non-pharmacological interventions. CONCLUSIONS More research is needed to improve recognition and treatment of this common and disabling symptom. We conclude with research priorities and recommendations for the field.
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Affiliation(s)
- Niall M Broomfield
- Department of Clinical Psychology and Psychological Therapies (CPPT), Norwich Medical School, University of East Anglia, Norwich, UK
| | - Joshua Blake
- Department of Clinical Psychology and Psychological Therapies (CPPT), Norwich Medical School, University of East Anglia, Norwich, UK
| | - Fergus Gracey
- Department of Clinical Psychology and Psychological Therapies (CPPT), Norwich Medical School, University of East Anglia, Norwich, UK
| | - Tom Steverson
- Department of Clinical Psychology and Psychological Therapies (CPPT), Norwich Medical School, University of East Anglia, Norwich, UK
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2
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Long RM, DuVal M, Mulvany-Robbins B, Wagner AN, Jickling GC. Emotional dysmetria after cerebellar-pontine stroke: a case report. J Med Case Rep 2023; 17:544. [PMID: 38098127 PMCID: PMC10722665 DOI: 10.1186/s13256-023-04294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/29/2023] [Indexed: 12/17/2023] Open
Abstract
INTRODUCTION Pseudobulbar affect, or emotional dysregulation, commonly occurs following stroke. However, it is frequently missed in cases involving the cerebellum, resulting in a lack of treatment, which can directly impact stroke rehabilitation. CASE PRESENTATION A 63-year-old Caucasian female with no history of mood disorders presented with gait instability, dysarthria, and right sided hemiplegia, secondary to cerebellar and pontine ischemic stroke from a basilar occlusion. She underwent endovascular therapy and her deficits gradually improved. However during recovery she began to develop uncontrollable tearfulness while retaining insight that her emotional expression was contextually inappropriate. She was treated with a selective serotonin reuptake inhibitor with reported improvements in her emotional regulation at one year follow up. CONCLUSION This case highlights cerebellar injury as a potential cause of poorly regulated emotions, or an emotional dysmetria. The recognition of this disorder in patients with cerebellar or pontine strokes is critical, as untreated pseudobulbar affect can impact future stroke rehabilitation.
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Affiliation(s)
- Rebecca M Long
- Cumming School of Medicine, University of Calgary, Calgary, Canada.
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
| | - Michèle DuVal
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Canada
| | | | - Amanda N Wagner
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Canada
| | - Glen C Jickling
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Canada
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3
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Schnetzer L, McCoy M, Bergmann J, Kunz A, Leis S, Trinka E. Locked-in syndrome revisited. Ther Adv Neurol Disord 2023; 16:17562864231160873. [PMID: 37006459 PMCID: PMC10064471 DOI: 10.1177/17562864231160873] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/14/2023] [Indexed: 03/31/2023] Open
Abstract
The locked-in syndrome (LiS) is characterized by quadriplegia with preserved vertical eye and eyelid movements and retained cognitive abilities. Subcategorization, aetiologies and the anatomical foundation of LiS are discussed. The damage of different structures in the pons, mesencephalon and thalamus are attributed to symptoms of classical, complete and incomplete LiS and the locked-in plus syndrome, which is characterized by additional impairments of consciousness, making the clinical distinction to other chronic disorders of consciousness at times difficult. Other differential diagnoses are cognitive motor dissociation (CMD) and akinetic mutism. Treatment options are reviewed and an early, interdisciplinary and aggressive approach, including the provision of psychological support and coping strategies is favoured. The establishment of communication is a main goal of rehabilitation. Finally, the quality of life of LiS patients and ethical implications are considered. While patients with LiS report a high quality of life and well-being, medical professionals and caregivers have largely pessimistic perceptions. The negative view on life with LiS must be overthought and the autonomy and dignity of LiS patients prioritized. Knowledge has to be disseminated, diagnostics accelerated and technical support system development promoted. More well-designed research but also more awareness of the needs of LiS patients and their perception as individual persons is needed to enable a life with LiS that is worth living.
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Affiliation(s)
| | - Mark McCoy
- Department of Neurology, Neurological Intensive Care and Neurorehabilitation, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
| | - Jürgen Bergmann
- Department of Neurology, Neurological Intensive Care and Neurorehabilitation, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
| | - Alexander Kunz
- Department of Neurology, Neurological Intensive Care and Neurorehabilitation, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute of Neurorehabilitation and Space Neurology, Salzburg, Austria
| | - Stefan Leis
- Department of Neurology, Neurological Intensive Care and Neurorehabilitation, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Neurological Intensive Care and Neurorehabilitation, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
- MRI Research Unit, Neuroscience Institute, Christian Doppler Medical Centre, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute of Neurorehabilitation and Space Neurology, Salzburg, Austria
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Abstract
BACKGROUND Antidepressants may be useful in the treatment of abnormal crying associated with stroke. This is an update of a Cochrane Review first published in 2004 and last updated in 2019. OBJECTIVES To evaluate the benefits and harms of pharmaceutical treatment in people with emotionalism after stroke. SEARCH METHODS We searched the Cochrane Stroke Group Register, CENTRAL, MEDLINE, Embase, four other databases, and three trials registers (May 2022). SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing psychotropic medication to placebo in people with stroke and emotionalism (also known as emotional lability, pathological crying or laughing, emotional incontinence, involuntary emotional expression disorder, and pseudobulbar affect). DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed risk of bias, extracted data from all included trials, and used GRADE to assess the certainty of the body of evidence. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I2 statistic. The primary emotionalism measures were the proportion of participants achieving at least a 50% reduction in abnormal emotional behaviour at the end of treatment, improved score on the Center for Neurologic Study - Lability Scale (CNS-LS) or Clinician Interview-Based Impression of Change (CIBIC), or diminished tearfulness. MAIN RESULTS We did not identify any new trials for this update. We included seven trials with a total of 239 participants. Two trials had a cross-over design, but outcome data were not available from the first phase (precross-over) in an appropriate format for inclusion as a parallel randomised controlled trial (RCT). Thus, the results of the review are based on five trials with a total of 213 participants. It is uncertain whether fluoxetine increases the number of people who have a 50% reduction in emotionalism when compared to placebo (risk ratio (RR) 0.26, 95% CI 0.09 to 0.77; P = 0.02; 1 trial, 19 participants) because the certainty of evidence is very low. Sertraline may lead to little to no difference in Center for Neurologic Study - Lability Scale (CNS-LS) scores and Clinician Interview-Based Impression of Change (CIBIC) scores when compared to placebo (RR 0.20, 95% CI 0.03 to 1.50; P = 0.12; 1 trial, 28 participants; low-certainty evidence). Antidepressants probably increase the number of people who experience a reduction in tearfulness (RR 0.32, 95% CI 0.12 to 0.86; P = 0.02; 3 trials, 164 participants; moderate-certainty evidence). No trials were found that evaluated the impact of other pharmaceutical interventions. Only two trial authors systematically recorded and reported adverse events, resulting in limited data on the potential harms of treatment. Six trials reported death as an adverse event and found no difference between the groups (antidepressants versus placebo) in the number of deaths reported (RR 0.59, 95% CI 0.08 to 4.50; P = 0.61; 172 participants; moderate-certainty evidence). This review provides very low- to moderate-certainty evidence that antidepressants may reduce the frequency and severity of emotionalism. The included trials were small and had some degree of bias. AUTHORS' CONCLUSIONS Antidepressants may reduce the frequency and severity of crying or laughing episodes when compared to placebo, based on very low-certainty evidence. Our conclusions must be qualified by several methodological deficiencies in the trials and interpreted with caution despite the effect being very large. The effect does not seem specific to one drug or class of drugs. More reliable data are required before appropriate conclusions can be made about the treatment of post-stroke emotionalism. Future trialists investigating the effect of antidepressants in people with emotionalism after stroke should consider developing and using a standardised method to diagnose emotionalism, determine severity, and assess change over time; provide treatment for a sufficient duration and follow-up to better assess rates of relapse or maintenance; and include careful assessment and complete reporting of adverse events.
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Affiliation(s)
- Sabine Allida
- Mental Health Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Allan House
- Division of Psychological and Social Medicine, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Maree L Hackett
- Mental Health Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
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Tan X, Sun Y, Gao J. Investigating Structure-Function Connectivity in a Patient With Locked-In Syndrome by 7 T Magnetic Resonance Imaging: A Case Report. Neurologist 2022; 27:367-372. [PMID: 35238835 DOI: 10.1097/nrl.0000000000000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Functional neuroimaging studies have been conducted to investigate cognitive and behavioral dysfunctions in locked-in syndrome (LIS). This study, we used a multimodal neuroimaging approach to investigate functional and structural connectivity in a LIS patient. CASE REPORT A 39-year-old patient who was in a total locked-in state was admitted in our department. The Coma Recovery Scale-Revised score, event-related potential, and ultra-high-field 7 T magnetic resonance imaging (MRI) were used to investigate this patient. White matter connectometry and seed-based resting-state functional connectivity analysis were used to compare the patient with an age-matched, sex-matched healthy control. Diffusion MRI findings indicated that fibers in the brainstem significantly decreased, especially in the cross region of pons, whereas the fibers above the brainstem in the deep brain increased particularly in the posterior cingulate cortex (PCC), the left parietal lobe, and parts of the corpus callosum. Meanwhile, using the PCC as the seed region, the functional connectivity between PCC and left parietal and occipital lobes, right occipital and temporal lobes increased, respectively, especially in the area of left inferior parietal gyrus and the postcentral gyrus, which were in accordance with the most increased fiber density areas observed in diffusion MRI. CONCLUSIONS These results provide tentative evidences to reveal the important role of PCC and corpus callosum in the LIS patient. These findings may be informative to the study of patients with LIS.
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Affiliation(s)
- Xufei Tan
- Department of Clinical Medicine, School of Medicine, Zhejiang University City College
| | - Yuan Sun
- Department of Clinical Medicine, School of Medicine, Zhejiang University City College
| | - Jian Gao
- Hangzhou Mingzhou Naokang Rehabilitation Hospital, Hangzhou, Zhejiang Province, China
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Fitzgerald S, Gracey F, Trigg E, Broomfield N. Predictors and correlates of emotionalism across acquired and progressive neurological conditions: A systematic review. Neuropsychol Rehabil 2022; 33:945-987. [PMID: 35323084 DOI: 10.1080/09602011.2022.2052326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Emotionalism can develop following a range of neurological disorders; however the aetiology of emotionalism is still unclear. To identify anatomical, neuropsychological and psychological predictors and correlates of emotionalism across neurological disorders: stroke, Parkinson's disease, multiple sclerosis, traumatic brain injury, Alzheimer's disease, vascular dementia and amyotrophic lateral sclerosis. To explore if these predictors and correlates of emotionalism differ across neurological disorders. A comprehensive systematic search was completed of four databases: MEDLINE, CINAHL Complete, PsycINFO and EMBASE. Methodological quality was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and each study was graded according to the level of evidence using the Scottish Intercollegiate Guidelines Network. Fifty papers (participants N = 1922) were included. 25 studies were rated as "Fair," 21 "Good" and 4 "Poor." The review identified predictors and correlates found in several neurological disorder such as bulbar networks, serotonergic pathways, genetics and female gender. Multiple studies across diseases (stroke, MS, ALS) indicate emotionalism is associated with cognitive impairment, especially frontal deficits. Due to the disproportionate number of studies identified across neurological disorders, it is difficult to draw definitive answers. Further research is required across neurological disorders to explore similarities and differences in anatomical, neuropsychological and psychological predictors and correlates.
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Affiliation(s)
- Sophie Fitzgerald
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Fergus Gracey
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Emma Trigg
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Niall Broomfield
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
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7
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Halan T, Ortiz JF, Reddy D, Altamimi A, Ajibowo AO, Fabara SP. Locked-In Syndrome: A Systematic Review of Long-Term Management and Prognosis. Cureus 2021; 13:e16727. [PMID: 34471579 PMCID: PMC8402869 DOI: 10.7759/cureus.16727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2021] [Indexed: 11/05/2022] Open
Abstract
Locked-in syndrome (LIS) is a neurological disorder in which there is damage to the ventral pons and caudal midbrain. An ischemic cause, such as basilar artery occlusion, can often lead to LIS. LIS has three subtypes: classical, partial, and total. There is loss of motion in the four extremities in classical LIS, loss of horizontal gaze, and aphasia. In partial LIS, the patient still has some motor function. Complete LIS has the worst outcome because patients cannot blink or have vertical gaze, thus rendering them incapable of communicating. Most cases of LIS occur due to ischemic infarcts. These patients require a great deal of physical rehabilitation to regain partial motor ability and a means to communicate. While the clinical features and pathophysiology are known, the prognosis and long-term treatment remain unknown. We conducted a systematic review using the Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) protocol. We use an advanced PubMed strategy using the inclusion criteria of observational studies or clinical trials conducted in the last 20 years, written in English, and conducted on humans. We excluded systematic reviews, literature reviews, metanalysis, and studies that did not meet the outcomes of our objectives. The prognosis of LIS is not good, and most patients remain locked in, with poor quality of life, especially motor functions. Respiratory failure and depression are big comorbidities. In the acute setting, patients benefit from rapid intervention. The subacute treatment needs to manage aggressively to improve functional scores best. The long-term treatment focus is on the quality of life and managing comorbidities.
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Affiliation(s)
- Taras Halan
- General Medicine, Ternopil National Medical University, Ternopil, UKR
| | - Juan Fernando Ortiz
- Neurology, Universidad San Francisco de Quito, Quito, ECU.,Neurology, Larkin Community Hospital, Miami, USA
| | | | | | - Abimbola O Ajibowo
- Internal Medicine, University Hospitals Cleveland Medical Center, Dallas, USA
| | - Stephanie P Fabara
- General Medicine, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
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8
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Secco A, Tonin A, Rana A, Jaramillo-Gonzalez A, Khalili-Ardali M, Birbaumer N, Chaudhary U. EEG power spectral density in locked-in and completely locked-in state patients: a longitudinal study. Cogn Neurodyn 2021; 15:473-480. [PMID: 34035865 PMCID: PMC8131474 DOI: 10.1007/s11571-020-09639-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 08/14/2020] [Accepted: 09/30/2020] [Indexed: 12/14/2022] Open
Abstract
Persons with their eye closed and without any means of communication is said to be in a completely locked-in state (CLIS) while when they could still open their eyes actively or passively and have some means of communication are said to be in locked-in state (LIS). Two patients in CLIS without any means of communication, and one patient in the transition from LIS to CLIS with means of communication, who have Amyotrophic Lateral Sclerosis were followed at a regular interval for more than 1 year. During each visit, resting-state EEG was recorded before the brain-computer interface (BCI) based communication sessions. The resting-state EEG of the patients was analyzed to elucidate the evolution of their EEG spectrum over time with the disease's progression to provide future BCI-research with the relevant information to classify changes in EEG evolution. Comparison of power spectral density (PSD) of these patients revealed a significant difference in the PSD's of patients in CLIS without any means of communication and the patient in the transition from LIS to CLIS with means of communication. The EEG of patients without any means of communication is devoid of alpha, beta, and higher frequencies than the patient in transition who still had means of communication. The results show that the change in the EEG frequency spectrum may serve as an indicator of the communication ability of such patients.
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Affiliation(s)
- Arianna Secco
- Department of Information Engineering, Bioengineering, Università Degli Studi di Padova, Padua, Italy
| | - Alessandro Tonin
- Wyss-Center for Bio- and Neuro-Engineering, Chemin de Mines 9, 1202 Geneva, Switzerland
| | - Aygul Rana
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
| | - Andres Jaramillo-Gonzalez
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
| | - Majid Khalili-Ardali
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
| | - Niels Birbaumer
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
| | - Ujwal Chaudhary
- Wyss-Center for Bio- and Neuro-Engineering, Chemin de Mines 9, 1202 Geneva, Switzerland
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
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9
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Farr E, Altonji K, Harvey RL. Locked-In Syndrome: Practical Rehabilitation Management. PM R 2021; 13:1418-1428. [PMID: 33465298 DOI: 10.1002/pmrj.12555] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 11/07/2022]
Abstract
Locked-in syndrome is a rare and devastating condition that results in tetraplegia, lower cranial nerve paralysis, and anarthria with preserved cognition, vertical gaze, and upper eyelid movements. Although acute management is much like that of any severe stroke, rehabilitation and recovery of these patients have not been previously described. Challenges relevant to this population include blood pressure management and orthostasis, timing and appropriateness of reinstating oral feeding, ventilatory support, decannulation after tracheostomy, bowel and bladder management, vestibular dysfunction, and eye care. Targeted rehabilitation of head, neck, and trunk stability to improve function, and proper fit in an appropriate wheelchair are essential to assist with mobility. Rehabilitation interventions should include a focus on distal motor control and upright tolerance training followed by balance and mobility exercises. In addition, special considerations must be given to developing early methods of communication through use of augmentative systems to call for help and express needs. These systems along with additional technology provide the basis to promote connectivity to family and friends through the use of social media and the internet. Establishment of communication, mobility, and connectivity is essential in promoting independence, autonomy, and improving quality of life. Overall, with specialized rehabilitative care and access to the proper equipment, long-term outcomes and quality of life in these patients can be favorable.
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Affiliation(s)
- Ellen Farr
- Shirley Ryan AbilityLab, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kathryn Altonji
- Shirley Ryan AbilityLab, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard L Harvey
- Shirley Ryan AbilityLab, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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10
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Gillespie DC, Cadden AP, West RM, Broomfield NM. Non-pharmacological interventions for post-stroke emotionalism (PSE) within inpatient stroke settings: a theory of planned behavior survey. Top Stroke Rehabil 2019; 27:15-24. [DOI: 10.1080/10749357.2019.1654241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- David C Gillespie
- Clinical Neuropsychology Service, Department of Clinical Neurosciences (DCN), Western General Hospital, Edinburgh, UK
| | - Amy P Cadden
- Neuropsychology Service, Great Ormond Street Hospital for Children, London, UK
| | - Robert M West
- Institute of Health Sciences, University of Leeds, Leeds, UK
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11
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Leonard M, Renard F, Harsan L, Pottecher J, Braun M, Schneider F, Froehlig P, Blanc F, Roquet D, Achard S, Meyer N, Kremer S. Diffusion tensor imaging reveals diffuse white matter injuries in locked-in syndrome patients. PLoS One 2019; 14:e0213528. [PMID: 30969973 PMCID: PMC6457498 DOI: 10.1371/journal.pone.0213528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 02/22/2019] [Indexed: 12/03/2022] Open
Abstract
Locked-in syndrome (LIS) is a state of quadriplegia and anarthria with preserved consciousness, which is generally triggered by a disruption of specific white matter fiber tracts, following a lesion in the ventral part of the pons. However, the impact of focal lesions on the whole brain white matter microstructure and structural connectivity pathways remains unknown. We used diffusion tensor magnetic resonance imaging (DT-MRI) and tract-based statistics to characterise the whole white matter tracts in seven consecutive LIS patients, with ventral pontine injuries but no significant supratentorial lesions detected with morphological MRI. The imaging was performed in the acute phase of the disease (26 ± 13 days after the accident). DT-MRI-derived metrics were used to quantitatively assess global white matter alterations. All diffusion coefficient Z-scores were decreased for almost all fiber tracts in all LIS patients, with diffuse white matter alterations in both infratentorial and supratentorial areas. A mixture model of two multidimensional Gaussian distributions was fitted to cluster the white matter fiber tracts studied in two groups: the least (group 1) and most injured white matter fiber tracts (group 2). The greatest injuries were revealed along pathways crossing the lesion responsible for the LIS: left and right medial lemniscus (98.4% and 97.9% probability of belonging to group 2, respectively), left and right superior cerebellar peduncles (69.3% and 45.7% probability) and left and right corticospinal tract (20.6% and 46.5% probability). This approach demonstrated globally compromised white matter tracts in the acute phase of LIS, potentially underlying cognitive deficits.
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Affiliation(s)
- Mylene Leonard
- Service d’imagerie 2, Hopitaux Universitaires de Strasbourg, Strabourg, France
- Faculté de medecine, Université de Strasbourg, Strasbourg, France
- * E-mail:
| | - Felix Renard
- Unité IRM 3T-Recherche-IRMaGE-Inserm US 17/CNRS UMS 3552, Université de Grenoble-Alpes, Grenoble, France
- Laboratoire MATICE-Pôle Recherche, CHU de Grenoble, Grenoble, France
- EA AGEIS, Univ. Grenoble-Alpes, Grenoble, France
| | - Laura Harsan
- Faculté de medecine, Université de Strasbourg, Strasbourg, France
- Engineering science, computer science and imaging laboratory (ICube), Integrative Multimodal Imaging in Healthcare, UMR 7357, University of Strasbourg-CNRS, Strasbourg, France
- Department of Biophysics and Nuclear Medicine, University Hospital Strasbourg, Strasbourg, France
| | - Julien Pottecher
- Service d’Anesthésie-Réanimation Chirurgicale, Hopitaux Universitaires de Strasbourg, Strasbourg, France
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de medecine, Université de Strasbourg, Strasbourg, France
- EA3072, Université de Strasbourg, Strasbourg, France
| | - Marc Braun
- Service de Neuroradiologie, CHRU de Nancy, Nancy, France
- Département d’anatomie, Faculté de medecine, Université de Lorraine, Nancy, France
- Inserm U947, Université de Lorraine, Nancy, France
| | - Francis Schneider
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de medecine, Université de Strasbourg, Strasbourg, France
- Service de Réanimation Médicale, Hopitaux Universitaires de Strasbourg, Strasbourg, France
- Inserm U1121, Université de Strasbourg, Strasbourg, France
| | - Pierre Froehlig
- Service de neurochirurgie, Hopitaux universitaires de Strasbourg, Strasbourg, France
| | - Frederic Blanc
- Laboratoire ICube, Strasbourg, France
- Service de gériatrie, Hopitaux universitaires de Strasbourg, Strasbourg, France
| | | | - Sophie Achard
- CNRS, Université de Grenoble Alpes, Grenoble, France
| | - Nicolas Meyer
- Laboratoire ICube, Strasbourg, France
- GMRC, Service de Santé Publique, Hopitaux universitaires de Strasbourg, Strasbourg, France
| | - Stephane Kremer
- Service d’imagerie 2, Hopitaux Universitaires de Strasbourg, Strabourg, France
- Faculté de medecine, Université de Strasbourg, Strasbourg, France
- Laboratoire ICube, Strasbourg, France
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12
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Abstract
BACKGROUND Antidepressants may be useful in the treatment of abnormal crying associated with stroke. This is an update of a Cochrane Review first published in 2004 and last updated in 2010. OBJECTIVES To determine whether pharmaceutical treatment reduces the frequency of emotional displays in people with emotionalism after stroke. SEARCH METHODS We searched the trial register of Cochrane Stroke (last searched May 2018). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; to May 2018), MEDLINE (1966 to 14 May 2018), Embase (1980 to 14 May 2018), CINAHL (1982 to 14 May 2018), PsycINFO (1967 to 14 May 2018), BIOSIS Previews (2002 to 14 May 2018), Web of Science (2002 to 14 May 2018), WHO ICTRP (to 14 May 2018), ClinicalTrials.gov (to 14 May 2018), and ProQuest Dissertations and Theses Database (to 14 May 2018). SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing psychotropic medication to placebo in people with stroke and emotionalism (also known as emotional lability, pathological crying or laughing, emotional incontinence, involuntary emotional expression disorder, and pseudobulbar affect). DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed risk of bias, extracted data from all included studies, and used GRADE to assess the quality of the body of evidence. We calculated mean difference (MD) or standardised mean difference (SMD) for continuous data and risk ratio (RR) for dichotomous data with 95% confidence intervals (CIs). We assessed heterogeneity using the I2 statistic. The primary emotionalism measures were the proportion of participants achieving at least a 50% reduction in abnormal emotional behaviour at the end of treatment, improved score on Center for Neurologic Study - Lability Scale (CNS-LS), Clinician Interview-Based Impression of Change (CIBIC) or diminished tearfulness. MAIN RESULTS We included seven trials with a total of 239 participants. Two trials were of cross-over design, and outcome data were not available from the first phase (precross-over) in an appropriate format for inclusion as a parallel randomised controlled trial (RCT). Thus, the results of the review are based on five trials with 213 participants. Treatment effects were observed on the following primary endpoints of emotionalism: There is very low quality of evidence from one small RCT that antidepressants increased the number of people who had 50% reduction in emotionalism (RR 16.50, 95% CI 1.07 to 253.40; 19 participants) and low quality evidence from one RCT of improved scores on Center for Neurologic Study - Lability Scale (CNS-LS) and Clinician Interview-Based Impression of Change (CIBIC) with antidepressants (RR 1.44, 95% CI 0.95 to 2.19; 28 participants). There was moderate quality evidence from three RCTS that they increased the number of people who had a reduction in tearfulness (RR 2.18, 95% CI 1.29 to 3.71; 164 participants); and low quality evidence from one RCT of improved scores on the Pathological Laughter and Crying Scale (PLCS) (MD 8.40, 95% CI 11.56 to 5.24; 28 participants).Six trials reported adverse events (death) and found no difference between the groups in death (RR 0.59, 95% CI 0.08 to 4.50; 6 RCTs, 172 participants, moderate-quality evidence). AUTHORS' CONCLUSIONS Antidepressants may reduce the frequency and severity of crying or laughing episodes based on very low quality evidence. Our conclusions must be qualified by several methodological deficiencies in the studies and interpreted with caution despite the effect being very large. The effect does not seem specific to one drug or class of drugs. More reliable data are required before appropriate conclusions can be made about the treatment of post-stroke emotionalism. Future trialists investigating the effect of antidepressants in people with emotionalism after stroke should consider developing and using a standardised method to diagnose emotionalism, determine severity and assess change over time; provide treatment for a sufficient duration and follow-up to better assess rates of relapse or maintenance and include careful assessment and complete reporting of adverse events.
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Affiliation(s)
- Sabine Allida
- University of Technology SydneyFaculty of Health235 Jones StreetSydneySydneyAustralia2007
| | - Kulsum Patel
- University of Central LancashireClinical Practice Research Unit, School of HealthPrestonLancashireUKPR1 2HE
| | - Allan House
- Leeds Institute of Health Sciences, University of LeedsDivision of Psychological and Social MedicineRoom 1090c, Worsley BuildingClarendon WayLeedsUKLS2 9LJ
| | - Maree L Hackett
- The University of SydneySchool of Public HealthSydneyNSWAustralia2050
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Sarà M, Cornia R, Conson M, Carolei A, Sacco S, Pistoia F. Cortical Brain Changes in Patients With Locked-In Syndrome Experiencing Hallucinations and Delusions. Front Neurol 2018; 9:354. [PMID: 29867752 PMCID: PMC5966526 DOI: 10.3389/fneur.2018.00354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 05/01/2018] [Indexed: 11/14/2022] Open
Abstract
Previous evidence suggests that hallucinations and delusions may be detected in patients with the most severe forms of motor disability including locked-in syndrome (LIS). However, such phenomena are rarely described in LIS and their presence may be underestimated as a result of the severe communication impairment experienced by the patients. In this study, we retrospectively reviewed the clinical history and the neuroimaging data of a cohort of patients with LIS in order to recognize the presence of hallucinations and delusions and to correlate it with the pontine damage and the presence of any cortical volumetric changes. Ten patients with LIS were included (5 men and 5 women, mean age 50.1 ± 14.6). According to the presence of indicators of symptoms, these patients were categorized as hallucinators (n = 5) or non-hallucinators (n = 5). MRI images of patients were analyzed using Freesurfer 6.0 software to evaluate volume differences between the two groups. Hallucinators showed a selective cortical volume loss involving the fusiform (p = 0.001) and the parahippocampal (p = 0.0008) gyrus and the orbital part of the inferior frontal gyrus (p = 0.001) in the right hemisphere together with the lingual (p = 0.01) and the fusiform gyrus (p = 0.01) in the left hemisphere. Moreover, a volumetric decrease of bilateral anterior portions of the precuneus was recognized in the hallucinators (right p = 0.01; left p = 0.001) as compared to non-hallucinators. We suggested that the presence of hallucinations and delusions in some LIS patients could be accounted for by the combination of a damage of the corticopontocerebellar pathways with cortical changes following the primary brainstem injury. The above areas are embedded within cortico-cortical and cortico-subcortical loops involved in self-monitoring and have been related to the presence of hallucinations in other diseases. The two main limitations of our study are the small sample of included patients and the lack of a control group of healthy individuals. Further studies would be of help to expand this field of research in order to integrate existing theories about the mechanisms underlying the generation of hallucinations and delusions in neurological patients.
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Affiliation(s)
- Marco Sarà
- Post-Coma Intensive Rehabilitation Care Unit, San Raffaele Hospital, Cassino, Italy
| | - Riccardo Cornia
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Massimiliano Conson
- Neuropsychology Laboratory, Department of Psychology, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Antonio Carolei
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
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Pistoia F, Mattiacci G, Sarà M, Padua L, Macchi C, Sacco S. Development of the Italian Version of the Near-Death Experience Scale. Front Hum Neurosci 2018; 12:45. [PMID: 29479314 PMCID: PMC5811479 DOI: 10.3389/fnhum.2018.00045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/25/2018] [Indexed: 11/18/2022] Open
Abstract
Near-death experiences (NDEs) have been defined as any conscious perceptual experience occurring in individuals pronounced clinically dead or who came very close to physical death. They are frequently reported by patients surviving a critical injury and, intriguingly, they show common features across different populations. The tool traditionally used to assess NDEs is the NDE Scale, which is available in the original English version. The aim of this study was to develop the Italian version of the NDE Scale and to assess its reliability in a specific clinical setting. A process of translation of the original scale was performed in different stages in order to obtain a fully comprehensible and accurate Italian translation. Later, the scale was administered to a convenience sample of patients who had experienced a condition of coma and were, at the time of assessment, fully conscious and able to provide information as requested by the scale. Inter-rater and test–retest reliability, assessed by the weighted Cohen’s kappa (Kw), were estimated. A convenience sample of 20 subjects [mean age ± standard deviation (SD) 51.6 ± 17.1, median time from injury 3.5 months, interquartile range (IQR) 2–10] was included in the study. Inter-rater [Kw 0.77 (95% CI 0.67–0.87)] and test–retest reliability [Kw 0.96 (95% CI 0.91–1.00)] showed good to excellent values for the total scores of the Italian NDE Scale and for subanalyses of each single cluster of the scale. An Italian Version of the NDE Scale is now available to investigate the frequency of NDE, the causes for NDE heterogeneity across different life-threatening conditions, and the possible neural mechanisms underlying NDE phenomenology.
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Affiliation(s)
- Francesca Pistoia
- Neurological Institute, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Giulia Mattiacci
- Neurological Institute, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Marco Sarà
- Post-Coma Intensive and Rehabilitation Care Unit, San Raffaele Hospital, Cassino, Italy
| | - Luca Padua
- Don Carlo Gnocchi Onlus Foundation, Milan, Italy.,Department of Geriatrics, Neurosciences and Orthopaedics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Claudio Macchi
- Don Carlo Gnocchi Foundation, Istituto di Ricovero e Cura a Carattere Scientifico, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Simona Sacco
- Neurological Institute, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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15
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Pistoia F, Sarà M, Carolei A, Sacco S. Commentary: Why Your Body Can Jog Your Mind. Front Psychol 2018; 9:33. [PMID: 29472877 PMCID: PMC5809815 DOI: 10.3389/fpsyg.2018.00033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 01/10/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Marco Sarà
- Post-Coma Rehabilitative Care Unit, San Raffaele Hospital, Cassino, Italy
| | - Antonio Carolei
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
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16
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Pistoia F, Carolei A, Sacco S, Sarà M. Commentary: Embodied Medicine: Mens Sana in Corpore Virtuale Sano. Front Hum Neurosci 2017; 11:381. [PMID: 28785213 PMCID: PMC5519604 DOI: 10.3389/fnhum.2017.00381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/07/2017] [Indexed: 12/03/2022] Open
Affiliation(s)
- Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'AquilaL'Aquila, Italy
| | - Antonio Carolei
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'AquilaL'Aquila, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'AquilaL'Aquila, Italy
| | - Marco Sarà
- Post-Coma Intensive Rehabilitation Care Unit, San Raffaele HospitalCassino, Italy
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Disorders of Consciousness: Painless or Painful Conditions?-Evidence from Neuroimaging Studies. Brain Sci 2016; 6:brainsci6040047. [PMID: 27740600 PMCID: PMC5187561 DOI: 10.3390/brainsci6040047] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/26/2016] [Accepted: 09/28/2016] [Indexed: 01/18/2023] Open
Abstract
The experience of pain in disorders of consciousness is still debated. Neuroimaging studies, using functional Magnetic Resonance Imaging (fMRI), Positron Emission Tomography (PET), multichannel electroencephalography (EEG) and laser-evoked potentials, suggest that the perception of pain increases with the level of consciousness. Brain activation in response to noxious stimuli has been observed in patients with unresponsive wakefulness syndrome (UWS), which is also referred to as a vegetative state (VS), as well as those in a minimally conscious state (MCS). However, all of these techniques suggest that pain-related brain activation patterns of patients in MCS more closely resemble those of healthy subjects. This is further supported by fMRI findings showing a much greater functional connectivity within the structures of the so-called pain matrix in MCS as compared to UWS/VS patients. Nonetheless, when interpreting the results, a distinction is necessary between autonomic responses to potentially harmful stimuli and conscious experience of the unpleasantness of pain. Even more so if we consider that the degree of residual functioning and cortical connectivity necessary for the somatosensory, affective and cognitive-evaluative components of pain processing are not yet clear. Although procedurally challenging, the particular value of the aforementioned techniques in the assessment of pain in disorders of consciousness has been clearly demonstrated. The study of pain-related brain activation and functioning can contribute to a better understanding of the networks underlying pain perception while addressing clinical and ethical questions concerning patient care. Further development of technology and methods should aim to increase the availability of neuroimaging, objective assessment of functional connectivity and analysis at the level of individual cases as well as group comparisons. This will enable neuroimaging to truly become a clinical tool to reliably investigate pain in severely brain-injured patients as well as an asset for research.
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Pistoia F, Carolei A. The Role of Neuroimaging in the Diagnosis, Prognosis and Management of Disorders of Consciousness and Locked-in Syndrome. Open Neuroimag J 2016; 10:20-2. [PMID: 27347261 PMCID: PMC4894861 DOI: 10.2174/1874440001610010020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Disorders of consciousness and locked-in syndrome are two completely different neurological conditions which share unresponsiveness or minimal responsiveness at an observable behavioral level. The key element of disorders of consciousness is the loss of self- and environmental awareness, while the main feature of locked-in syndrome is extreme motor entrapment despite preserved awareness. In both cases accurate diagnosis may come late and patients are at risk of being wrongly diagnosed and missing out on appropriate rehabilitative opportunities. Clinical assessment alone often does not suffice in establishing the correct diagnosis and prognosis. The contribution of advanced neuroimaging techniques is essential in order to properly recognize patients’ conditions and formulate a tailored rehabilitative approach. Neuroimaging findings are also crucial in identifying the neuropathological substrate of the disorders: they contribute to elucidating the dynamics of cortical-subcortical networks in disorders of consciousness and the neural correlates of recently reported non-motor symptoms in locked-in syndrome.
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Affiliation(s)
- Francesca Pistoia
- Neurological Institute, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Antonio Carolei
- Neurological Institute, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Pistoia F, Cornia R, Conson M, Gosseries O, Carolei A, Sacco S, Quattrocchi CC, Mallio CA, Iani C, Mambro DD, Sarà M. Disembodied Mind: Cortical Changes Following Brainstem Injury in Patients with Locked-in Syndrome. Open Neuroimag J 2016; 10:32-40. [PMID: 27347263 PMCID: PMC4894864 DOI: 10.2174/1874440001610010032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/06/2016] [Accepted: 04/11/2016] [Indexed: 11/22/2022] Open
Abstract
Locked-in syndrome (LIS) following ventral brainstem damage is the most severe form of motor disability. Patients are completely entrapped in an unresponsive body despite consciousness is preserved. Although the main feature of LIS is this extreme motor impairment, minor non-motor dysfunctions such as motor imagery defects and impaired emotional recognition have been reported suggesting an alteration of embodied cognition, defined as the effects that the body and its performances may have on cognitive domains. We investigated the presence of structural cortical changes in LIS, which may account for the reported cognitive dysfunctions. For this aim, magnetic resonance imaging scans were acquired in 11 patients with LIS (6 males and 5 females; mean age: 52.3±5.2SD years; mean time interval from injury to evaluation: 9±1.2SD months) and 44 healthy control subjects matching patients for age, sex and education. Freesurfer software was used to process data and to estimate cortical volumes in LIS patients as compared to healthy subjects. Results showed a selective cortical volume loss in patients involving the superior frontal gyrus, the pars opercularis and the insular cortex in the left hemisphere, and the superior and medium frontal gyrus, the pars opercularis, the insular cortex, and the superior parietal lobule in the right hemisphere. As these structures are typically associated with the mirror neuron system, which represents the neural substrate for embodied simulation processes, our results provide neuroanatomical support for potential disembodiment in LIS.
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Affiliation(s)
- Francesca Pistoia
- Neurological Institute, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Riccardo Cornia
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Massimiliano Conson
- Neuropsychology Laboratory, Department of Psychology, Second University of Naples, Naples, Italy
| | | | - Antonio Carolei
- Neurological Institute, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Simona Sacco
- Neurological Institute, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Carlo C Quattrocchi
- Departmental Faculty of Medicine and Surgery, Unit of Diagnostic Imaging, University Campus Bio-Medico of Rome, Rome, Italy
| | - Carlo A Mallio
- Departmental Faculty of Medicine and Surgery, Unit of Diagnostic Imaging, University Campus Bio-Medico of Rome, Rome, Italy
| | - Cristina Iani
- Department of Communication and Economy, University of Modena and Reggio Emilia, Modena, Italy
| | - Debora Di Mambro
- Post-Coma Rehabilitation Care Unit, San Raffaele Hospital, Cassino, Italy
| | - Marco Sarà
- Post-Coma Rehabilitation Care Unit, San Raffaele Hospital, Cassino, Italy
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Gosseries O, Pistoia F, Charland-Verville V, Carolei A, Sacco S, Laureys S. The Role of Neuroimaging Techniques in Establishing Diagnosis, Prognosis and Therapy in Disorders of Consciousness. Open Neuroimag J 2016; 10:52-68. [PMID: 27347265 PMCID: PMC4894918 DOI: 10.2174/1874440001610010052] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/06/2016] [Accepted: 04/11/2016] [Indexed: 12/30/2022] Open
Abstract
Non-communicative brain damaged patients raise important clinical and scientific issues. Here, we review three major pathological disorders of consciousness: coma, the unresponsive wakefulness syndrome and the minimally conscious state. A number of clinical studies highlight the difficulty in making a correct diagnosis in patients with disorders of consciousness based only on behavioral examinations. The increasing use of neuroimaging techniques allows improving clinical characterization of these patients. Recent neuroimaging studies using positron emission tomography, functional magnetic resonance imaging, electroencephalography and transcranial magnetic stimulation can help assess diagnosis, prognosis, and therapeutic treatment. These techniques, using resting state, passive and active paradigms, also highlight possible dissociations between consciousness and responsiveness, and are facilitating a more accurate understanding of brain function in this challenging population.
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Affiliation(s)
- Olivia Gosseries
- Coma Science Group, GIGA, University of Liege, Liege, Belgium; Department of Psychology and Psychiatry, University of Wisconsin, Madison, WI, United-States
| | - Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | | | - Antonio Carolei
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Steven Laureys
- Coma Science Group, GIGA, University of Liege, Liege, Belgium
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Pistoia F, Sacco S, Sarà M, Franceschini M, Carolei A. Intrathecal baclofen: effects on spasticity, pain, and consciousness in disorders of consciousness and locked-in syndrome. Curr Pain Headache Rep 2015; 19:466. [PMID: 25416459 DOI: 10.1007/s11916-014-0466-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Disorders of consciousness (DOCs) include coma, vegetative state (VS), and minimally conscious state (MCS). Coma is characterized by impaired wakefulness and consciousness, while VS and MCS are defined by lacking or discontinuous consciousness despite recovered wakefulness. Conversely, locked-in syndrome (LIS) is characterized by quadriplegia and lower cranial nerve paralysis with preserved consciousness. Intrathecal baclofen (ITB) is a useful treatment to improve spasticity both in patients with DOCs and LIS. Moreover, it supports the recovery of consciousness in some patients with VS or MCS. The precise mechanism underlying this recovery has not yet been elucidated. It has been hypothesized that ITB may act by reducing the overload of dysfunctional sensory stimuli reaching the injured brain or by stabilizing the imbalanced circadian rhythms. Although the current indication of ITB is the management of severe spasticity, its potential use in speeding the recovery of consciousness merits further investigation.
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Affiliation(s)
- Francesca Pistoia
- Neurological Institute, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio, 67100, L'Aquila, Italy,
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Lugo ZR, Bruno MA, Gosseries O, Demertzi A, Heine L, Thonnard M, Blandin V, Pellas F, Laureys S. Beyond the gaze: Communicating in chronic locked-in syndrome. Brain Inj 2015; 29:1056-61. [DOI: 10.3109/02699052.2015.1004750] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Patatanian E, Casselman J. Dextromethorphan/quinidine for the treatment of pseudobulbar affect. THE CONSULTANT PHARMACIST : THE JOURNAL OF THE AMERICAN SOCIETY OF CONSULTANT PHARMACISTS 2014; 29:264-9. [PMID: 24704895 DOI: 10.4140/tcp.n.2014.264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the role of dextromethorphan/quinidine (DM/Q; Nuedexta™) in the treatment of pseudobulbar affect (PBA). DATA SOURCES A literature search of MEDLINE/PubMed (January 1966-June 2013) was conducted using search terms pseudobulbar affect, pathological laughing and/or crying, emotional lability, dextromethorphan, and quinidine. STUDY SELECTION AND DATA EXTRACTION English language clinical trials and case reports evaluating the safety and efficacy of DM/Q in PBA were included for review. Bibliographies of all relevant articles were reviewed for additional citations. DATA SYNTHESIS PBA, a poorly understood disorder, is characterized by involuntary crying and/or laughing. In the past, antidepressants and antiepileptics have been used off-label with mixed results. Four clinical trials have evaluated the use of DM/Q for the treatment of PBA. Although the therapeutic outcomes with DM/Q have been positive, interpretation of the published evidence is limited by small sample size and short treatment duration. CONCLUSIONS Based on the data available, DM/Q may be a viable, short-term treatment alternative for PBA. Long-term safety and efficacy data are lacking.
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Affiliation(s)
- Edna Patatanian
- College of Pharmacy, Southwestern Oklahoma State University, Weatherford, Oklahoma
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Miller A, Pratt H, Schiffer RB. Pseudobulbar affect: the spectrum of clinical presentations, etiologies and treatments. Expert Rev Neurother 2014; 11:1077-88. [PMID: 21539437 DOI: 10.1586/ern.11.68] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Ariel Miller
- Technion-Israel Institute of Technology, Carmel Medical Center, Department of Neurology, 7 Michal St., Haifa 34362, Israel.
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Abstract
Pseudobulbar affect (PBA) may occur in association with a variety of neurological diseases, and so may be encountered in the setting of amyotrophic lateral sclerosis, extrapyramidal and cerebellar disorders, multiple sclerosis, traumatic brain injury, Alzheimer’s disease, stroke, and brain tumors. The psychological consequences and the impact on social interactions may be substantial. Although it is most commonly misidentified as a mood disorder, particularly depression or a bipolar disorder, there are characteristic features that can be recognized clinically or assessed by validated scales, resulting in accurate identification of PBA, and thus permitting proper management and treatment. Mechanistically, PBA is a disinhibition syndrome in which pathways involving serotonin and glutamate are disrupted. This knowledge has permitted effective treatment for many years with antidepressants, particularly tricyclic antidepressants and selective serotonin reuptake inhibitors. A recent therapeutic breakthrough occurred with the approval by the Food and Drug Administration of a dextromethorphan/quinidine combination as being safe and effective for treatment of PBA. Side effect profiles and contraindications differ for the various treatment options, and the clinician must be familiar with these when choosing the best therapy for an individual, particularly elderly patients and those with multiple comorbidities and concomitant medications.
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Affiliation(s)
- Aiesha Ahmed
- Department of Neurology, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Zachary Simmons
- Department of Neurology, Penn State Hershey Medical Center, Hershey, PA, USA
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Lauterbach EC, Cummings JL, Kuppuswamy PS. Toward a more precise, clinically—informed pathophysiology of pathological laughing and crying. Neurosci Biobehav Rev 2013; 37:1893-916. [PMID: 23518269 DOI: 10.1016/j.neubiorev.2013.03.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 03/01/2013] [Accepted: 03/11/2013] [Indexed: 12/11/2022]
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King RR, Reiss JP. The epidemiology and pathophysiology of pseudobulbar affect and its association with neurodegeneration. Degener Neurol Neuromuscul Dis 2013; 3:23-31. [PMID: 30890891 PMCID: PMC6065587 DOI: 10.2147/dnnd.s34160] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Pseudobulbar affect is a disorder resulting from neurologic damage manifesting as sudden, stereotyped affective outbursts that are not reflective of internal emotion. A literature review was completed to examine the current understanding of the epidemiology, characterization, diagnosis, pathophysiology, and treatment of pseudobulbar affect. This review revealed that it is common in neurodegenerative disorders but is poorly recognized, placing significant impacts on patients and their families. The disorder appears to result from a disruption of the cortico-limbic-subcortical-thalamic-pontocerebellar network involved in emotional expression and regulation with resulting disruptions of neurotransmitter systems. Effective treatment is available with agents such as selective serotonin reuptake inhibitors and dextromethorphan combined with quinidine, but further well-designed comparative studies are needed. Advances in technology such as neuroimaging may enhance knowledge about the pathophysiology of this disorder, and help guide future interventions.
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Affiliation(s)
- Rebecca R King
- Department of Psychiatry, University of Western Ontario, London Health Sciences Centre, Victoria Hospital, London, Ontario, Canada,
| | - Jeffrey P Reiss
- Department of Psychiatry, University of Western Ontario, London Health Sciences Centre, Victoria Hospital, London, Ontario, Canada,
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Karaca S, Göksel BK, Tan M, Alkan Ö. Foix-Chavany-Marie syndrome due to cerebral infarctions with relatively good recovery. Neurol Sci 2012; 34:765-7. [PMID: 23079851 DOI: 10.1007/s10072-012-1217-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Accepted: 10/05/2012] [Indexed: 11/26/2022]
Affiliation(s)
- Sibel Karaca
- Department of Neurology, Adana Teaching and Medical Research Center, Baskent University Medical School, Dadaloglu Mah. 39. sokak. No: 6, 01250 Adana, Turkey
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Schjolberg A, Sunnerhagen KS. Unlocking the locked in; a need for team approach in rehabilitation of survivors with locked-in syndrome. Acta Neurol Scand 2012; 125:192-8. [PMID: 21707549 DOI: 10.1111/j.1600-0404.2011.01552.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES A stroke that affects the medulla oblongata and/or pons can result in tetra pareses and paralysis of the lower cranial nerves while other parts of the brain remain intact, thus locking the person in. The incidence and prevalence is not known. The aim of this article is to communicate the need for and benefits of a comprehensive rehabilitation and a standardized way of approaching the locked-in person. MATERIAL AND METHODS To illustrate the rehabilitation process, we present four cases to highlight the needs of the person and what is required of the team. RESULTS Communication at arrival: three persons communicated through eye movement, one by weak voice. At follow-up (1-6 years later): computer assisted communication was used by two persons, a letter board by one and 'ordinary communication' by one. CONCLUSIONS There is a need for follow-up not only to re-assess skills and needs partly owing to new technologies but also to see whether the person needs more assistance to adapt to the alternative means of communication or whether the carers of the person need extra information about communication. We conclude that the low incidence of the syndrome necessitates a skilled team in which different professionals can together assess the person. This probably requires some centralization.
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Affiliation(s)
- A Schjolberg
- Sunnaas Rehabilitation Hospital and Faculty of Medicine, University of Oslo, Norway
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I. Kneebone I, B. Lincoln N. Psychological Problems after Stroke and Their Management: State of Knowledge. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/nm.2012.31013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Impaired conscious recognition of negative facial expressions in patients with locked-in syndrome. J Neurosci 2010; 30:7838-44. [PMID: 20534832 DOI: 10.1523/jneurosci.6300-09.2010] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The involvement of facial mimicry in different aspects of human emotional processing is widely debated. However, little is known about relationships between voluntary activation of facial musculature and conscious recognition of facial expressions. To address this issue, we assessed severely motor-disabled patients with complete paralysis of voluntary facial movements due to lesions of the ventral pons [locked-in syndrome (LIS)]. Patients were required to recognize others' facial expressions and to rate their own emotional responses to presentation of affective scenes. LIS patients were selectively impaired in recognition of negative facial expressions, thus demonstrating that the voluntary activation of mimicry represents a high-level simulation mechanism crucially involved in explicit attribution of emotions.
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Hackett ML, Yang M, Anderson CS, Horrocks JA, House A. Pharmaceutical interventions for emotionalism after stroke. Cochrane Database Syst Rev 2010:CD003690. [PMID: 20166068 DOI: 10.1002/14651858.cd003690.pub3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Antidepressants may be useful in the treatment of abnormal crying associated with stroke. This is an update of a Cochrane Review first published in 2004. OBJECTIVES To determine whether pharmaceutical treatment reduces the frequency of emotional displays in people with emotionalism after stroke. SEARCH STRATEGY We searched the trials registers of the Cochrane Stroke Group and the Cochrane Depression Anxiety and Neurosis Group (last searched August 2009). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2009), MEDLINE (1966 to May 2008), EMBASE (1980 to May 2008), CINAHL (1982 to May 2008), PsycINFO (1967 to May 2008), Arts and Humanities Index (1991 to May 2008), BIOSIS Previews (2002 to May 2008), Science Citation Index (1992 to May 2008), Social Sciences Citation Index (1991 to May 2008), Sociological Abstract/Sociofile (1974 to May 2008), ISI Web of Science (2002 to May 2008), reference lists, clinical trials registers, conference proceedings and dissertation abstracts. We also contacted authors, researchers and pharmaceutical companies. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing psychotropic medication to placebo in people with stroke and emotionalism (also known as emotional lability or pathological crying and laughing). DATA COLLECTION AND ANALYSIS We obtained data for people who no longer met the criteria for emotionalism, and on reduction in frequency of crying. Primary analyses were the proportion of patients who met the criteria for emotionalism at the end of treatment. Secondary outcomes included emotionalism and depression scores, cognitive function, death, activities of daily living and adverse effects. MAIN RESULTS We included seven trials involving 239 participants. Data were available for five trials with 213 participants. Five trials showed large effects of treatment: 50% reduction in emotionalism, diminished tearfulness, improvements (reduction) in lability, tearfulness and scores on the Pathological Laughter and Crying Scale. However, confidence intervals were wide indicating that treatment may have had only a small positive effect, or even a small negative effect (in one trial). Only two studies systematically reported adverse events; no discernible differences were seen between groups. AUTHORS' CONCLUSIONS Antidepressants can reduce the frequency and severity of crying or laughing episodes. The effect does not seem specific to one drug or class of drugs. Our conclusions must be qualified by several methodological deficiencies in the studies. More reliable data are required before recommendations can be made about the treatment of post-stroke emotionalism.
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Affiliation(s)
- Maree L Hackett
- Department of Neurological and Mental Health, The George Institute for International Health, PO Box M201, Missenden Road, Sydney, NSW, Australia, 2050
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Conson M, Sacco S, Sarà M, Pistoia F, Grossi D, Trojano L. Selective motor imagery defect in patients with locked-in syndrome. Neuropsychologia 2008; 46:2622-8. [PMID: 18533201 DOI: 10.1016/j.neuropsychologia.2008.04.015] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Revised: 04/21/2008] [Accepted: 04/24/2008] [Indexed: 11/25/2022]
Abstract
Recent studies indicate that motor imagery is subserved by activation of motor information. However, at present it is not clear whether the sparing of motor efferent pathways is necessary to perform a motor imagery task. To clarify this issue, we required patients with a selective, severe de-efferentation (locked-in syndrome, LIS) to mentally manipulate hands and three-dimensional objects. Compared with normal controls, LIS patients showed a profound impairment on a modified version of the hand-laterality task and a normal performance on mental rotation of abstract items. Moreover, LIS patients did not present visuomotor compatibility effects between anatomical side of hands and spatial location of stimuli on the computer screen. Such findings confirmed that the motor system is involved in mental simulation of action but not in mental manipulation of visual images. To explain LIS patients' inability in manipulating hand representations, we suggested that the pontine lesion, both determined a complete de-efferentation, and affected a component of the motor system, which is crucial for mental representation of body parts, probably the neural connections between parietal lobes and cerebellum.
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Affiliation(s)
- Massimiliano Conson
- Neuropsychology Laboratory, Department of Psychology, Second University of Naples, via Vivaldi 43, 81100 Caserta, Italy.
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