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de Melo DLM, Comerlato EA, Pinheiro DS, Manzano GM. The feasibility and technical aspects of trigemino-cervical reflex elicitation in humans under general anesthesia. Clin Neurophysiol 2024; 161:173-179. [PMID: 38503202 DOI: 10.1016/j.clinph.2024.02.031] [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: 10/26/2023] [Revised: 02/10/2024] [Accepted: 02/28/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE To analyze the feasibility, neurophysiological aspects, stimulation patterns, and topographic distribution of trigemino-cervical reflex (TCR) components in humans under general anesthesia. METHODS This prospective observational study enrolled 20 participants who underwent posterior fossa surgery, surgical proceduresin thecraniovertebral junction,or spinal cord surgery. TCR responses were simultaneously recorded in the sternocleidomastoid (SCM) and trapezius muscles after electrical stimulation of the supraorbital and infraorbital nerves. TCR responses were recorded preoperatively and intraoperatively using single-pulse and multipulse (trains of 2-7 electrical stimuli) stimulation, respectively. Two stimulus duration patterns were evaluated: 0.2-0.5 ms and 0.5-1.0 ms. RESULTS Intraoperatively, short- and long-latency TCR components were obtained in the SCM ipsilateral to the stimulation with variable recordability. Short-latency responses were the most commonly recorded components. A longer stimulus duration (0.5-1.0 ms) seems to favor the elicitation of TCR responses under general anesthesia. CONCLUSIONS Short-latency components recorded in the SCM ipsilateral to the stimulation could be regularly elicited under general anesthesia when a larger stimulus duration (0.5-1.0 ms) was applied. SIGNIFICANCE This is the first study to demonstrate the elicitation of TCR components in humans under general anesthesia. This neurophysiological technique can potentially optimize intraoperative neurophysiological monitoring during brainstem surgery.
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Affiliation(s)
| | - Enio Alberto Comerlato
- Department of Clinical Neurophysiology. SARAH Network of Rehabilitation Hospitals, Brasília, DF, Brazil
| | - Denise Spinola Pinheiro
- Department of Clinical Neurophysiology. Federal University of São Paulo, São Paulo, SP, Brazil
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Kofler M, Hallett M, Iannetti GD, Versace V, Ellrich J, Téllez MJ, Valls-Solé J. The blink reflex and its modulation - Part 1: Physiological mechanisms. Clin Neurophysiol 2024; 160:130-152. [PMID: 38102022 PMCID: PMC10978309 DOI: 10.1016/j.clinph.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 11/11/2023] [Accepted: 11/22/2023] [Indexed: 12/17/2023]
Abstract
The blink reflex (BR) is a protective eye-closure reflex mediated by brainstem circuits. The BR is usually evoked by electrical supraorbital nerve stimulation but can be elicited by a variety of sensory modalities. It has a long history in clinical neurophysiology practice. Less is known, however, about the many ways to modulate the BR. Various neurophysiological techniques can be applied to examine different aspects of afferent and efferent BR modulation. In this line, classical conditioning, prepulse and paired-pulse stimulation, and BR elicitation by self-stimulation may serve to investigate various aspects of brainstem connectivity. The BR may be used as a tool to quantify top-down modulation based on implicit assessment of the value of blinking in a given situation, e.g., depending on changes in stimulus location and probability of occurrence. Understanding the role of non-nociceptive and nociceptive fibers in eliciting a BR is important to get insight into the underlying neural circuitry. Finally, the use of BRs and other brainstem reflexes under general anesthesia may help to advance our knowledge of the brainstem in areas not amenable in awake intact humans. This review summarizes talks held by the Brainstem Special Interest Group of the International Federation of Clinical Neurophysiology at the International Congress of Clinical Neurophysiology 2022 in Geneva, Switzerland, and provides a state-of-the-art overview of the physiology of BR modulation. Understanding the principles of BR modulation is fundamental for a valid and thoughtful clinical application (reviewed in part 2) (Gunduz et al., submitted).
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Affiliation(s)
- Markus Kofler
- Department of Neurology, Hochzirl Hospital, Zirl, Austria.
| | - Mark Hallett
- National Institute of Neurological Disorders and Stroke, NIH, USA.
| | - Gian Domenico Iannetti
- University College London, United Kingdom; Italian Institute of Technology (IIT), Rome, Italy.
| | - Viviana Versace
- Department of Neurorehabilitation, Hospital of Vipiteno (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Vipiteno-Sterzing, Italy.
| | - Jens Ellrich
- Friedrich-Alexander-University Erlangen-Nuremberg, Germany.
| | | | - Josep Valls-Solé
- IDIBAPS (Institut d'Investigació August Pi i Sunyer), University of Barcelona, Spain.
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Choi J, Díaz-Baamonde A, Sánchez Roldán MDLÁ, Mirallave Pescador A, Kim JS, Téllez MJ, Park KS, Deletis V. Advancing Intraoperative Neurophysiological Monitoring With Human Reflexes. J Clin Neurol 2024; 20:119-130. [PMID: 38433484 PMCID: PMC10921042 DOI: 10.3988/jcn.2023.0416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 03/05/2024] Open
Abstract
Human reflexes are simple motor responses that are automatically elicited by various sensory inputs. These reflexes can provide valuable insights into the functioning of the nervous system, particularly the brainstem and spinal cord. Reflexes involving the brainstem, such as the blink reflex, laryngeal adductor reflex, trigeminal hypoglossal reflex, and masseter H reflex, offer immediate information about the cranial-nerve functionality and the overall state of the brainstem. Similarly, spinal reflexes such as the H reflex of the soleus muscle, posterior root muscle reflexes, and sacral reflexes provide crucial information about the functionality of the spinal cord and peripheral nerves. One of the critical benefits of reflex monitoring is that it can provide continuous feedback without disrupting the surgical process due to no movement being induced in the surgical field. These reflexes can be monitored in real time during surgical procedures to assess the integrity of the nervous system and detect potential neurological damage. It is particularly noteworthy that the reflexes provide motor and sensory information on the functional integrity of nerve fibers and nuclei. This article describes the current techniques used for monitoring various human reflexes and their clinical significance in surgery. We also address important methodological considerations and their impact on surgical safety and patient outcomes. Utilizing these methodologies has the potential to advance or even revolutionize the field of intraoperative continuous monitoring, ultimately leading to improved surgical outcomes and enhanced patient care.
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Affiliation(s)
- Jongsuk Choi
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Alba Díaz-Baamonde
- Department of Clinical Neurophysiology, King's College Hospital NHS Trust, London, UK
| | | | | | - Jun-Soon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Maria J Téllez
- Department of Intraoperative Neuromonitoring, Mount Sinai West Hospital, New York, NY, USA.
| | - Kyung Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Vedran Deletis
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia and Albert Einstein College of Medicine, New York, NY, USA
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Deletis V, Seidel K, Fernández-Conejero I. Intraoperative Neurophysiologic Monitoring and Mapping in Children Undergoing Brainstem Surgery. J Clin Neurophysiol 2024; 41:108-115. [PMID: 38306218 DOI: 10.1097/wnp.0000000000001037] [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: 02/04/2024] Open
Abstract
SUMMARY Intraoperative neurophysiologic monitoring during surgery for brainstem lesions is a challenge for intraoperative neurophysiologists and surgeons. The brainstem is a small structure packed with vital neuroanatomic networks of long and short pathways passing through the brainstem or originating from it. Many central pattern generators exist within the brainstem for breathing, swallowing, chewing, cardiovascular regulation, and eye movement. During surgery around the brainstem, these generators need to be preserved to maintain their function postoperatively. This short review presents neurophysiologic and neurosurgical experiences of brainstem surgery in children.
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Affiliation(s)
- Vedran Deletis
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
- Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
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Moncho D, Poca MA, Rahnama K, Sánchez Roldán MÁ, Santa-Cruz D, Sahuquillo J. The Role of Neurophysiology in Managing Patients with Chiari Malformations. J Clin Med 2023; 12:6472. [PMID: 37892608 PMCID: PMC10607909 DOI: 10.3390/jcm12206472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/25/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Chiari malformation type 1 (CM1) includes various congenital anomalies that share ectopia of the cerebellar tonsils lower than the foramen magnum, in some cases associated with syringomyelia or hydrocephalus. CM1 can cause dysfunction of the brainstem, spinal cord, and cranial nerves. This functional alteration of the nervous system can be detected by various modalities of neurophysiological tests, such as brainstem auditory evoked potentials, somatosensory evoked potentials, motor evoked potentials, electromyography and nerve conduction studies of the cranial nerves and spinal roots, as well as brainstem reflexes. The main goal of this study is to review the findings of multimodal neurophysiological examinations in published studies of patients with CM1 and their indication in the diagnosis, treatment, and follow-up of these patients, as well as their utility in intraoperative monitoring.
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Affiliation(s)
- Dulce Moncho
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (K.R.); (M.Á.S.R.); (D.S.-C.)
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
| | - Maria A. Poca
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain
| | - Kimia Rahnama
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (K.R.); (M.Á.S.R.); (D.S.-C.)
| | - M. Ángeles Sánchez Roldán
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (K.R.); (M.Á.S.R.); (D.S.-C.)
| | - Daniela Santa-Cruz
- Department of Clinical Neurophysiology, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (K.R.); (M.Á.S.R.); (D.S.-C.)
| | - Juan Sahuquillo
- Neurotraumatology and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain;
- Department of Neurosurgery, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain
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López JR, Legatt AD. Monitoring surgery around the cranial nerves. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:319-351. [PMID: 35772894 DOI: 10.1016/b978-0-12-819826-1.00020-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Intraoperative neurophysiologic monitoring (IONM) of cranial nerve (CN) function is an essential component in multimodality monitoring of surgical procedures where CNs are at risk for injury. In most cases, IONM consists of localizing and mapping CNs and their pathways, and monitoring of CN motor function during surgery. However, CN VIII, which has no motor function, and is at risk for injury in many surgical procedures, can be easily and accurately monitored using brainstem auditory evoked potentials. For motor CNs, the literature is clear that function can be safely and adequately performed using basic electromyographic (EMG) techniques, such as recording of continuous EMG activity and electrically evoked compound muscle actions potentials. Newer techniques, such as corticobulbar motor evoked potentials and reflex studies, show good potential for a greater degree of functional assessment but require further study to determine their clinical utility. EMG remains the basic clinical neurophysiologic technique with the greatest clinical research supporting its utility in IONM of motor CN function and should be used as part of a comprehensive multimodality IONM protocol. Understanding the physiologic basis of EMG and the changes associated with altered motor function will allow the practitioner to alter surgical course to prevent injury and improve patient safety.
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Affiliation(s)
- Jaime R López
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States.
| | - Alan D Legatt
- Department of Neurology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, United States
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Mirallave Pescador A, Téllez MJ, Sánchez Roldán MDLÁ, Samusyte G, Lawson EC, Coelho P, Lejarde A, Rathore A, Le D, Ulkatan S. Methodology for eliciting the brainstem trigeminal-hypoglossal reflex in humans under general anesthesia. Clin Neurophysiol 2022; 137:1-10. [DOI: 10.1016/j.clinph.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/05/2022] [Accepted: 02/11/2022] [Indexed: 11/03/2022]
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Fernández-Conejero I, Ulkatan S, Deletis V. Monitoring cerebellopontine angle and skull base surgeries. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:163-176. [PMID: 35772885 DOI: 10.1016/b978-0-12-819826-1.00016-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Cerebellopontine angle (CPA) surgery represents a challenge for neurosurgeons due to the high risk of iatrogenic injury of vital neurological structures. Therefore, important efforts in improving the surgical techniques and intraoperative neurophysiology have been made in the last decades. We present a description and review of the available methodologies for intraoperative neuromonitoring and mapping during CPA surgeries. There are three main groups of techniques to assess the functional integrity of the nervous structures in danger during these surgical procedures: (1) Electrical identification or mapping of motor cranial nerves (CNs), which is essential in order to locate the nerve in their different parts during the tumor resection; (2) Monitoring, which provides real-time information about functional integrity of the nervous tissue; and (3) Brainstem reflexes including blink reflex, masseteric reflex, and laryngeal adductor reflex. All these methods facilitate the removal of lesions and contribute to notable improvement in functional outcome and permit on the investigation of their physiopathology in certain neurosurgically treated diseases. Such is the case of hemifacial spasm (HFS). We describe the methodology to evaluate the efficacy of microvascular decompression for HFS treatment at the end of this chapter.
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Affiliation(s)
- Isabel Fernández-Conejero
- Unit of Intraoperative Neurophysiology, Department of Neurology, University hospital of Bellvitge, Barcelona, Spain.
| | - Sedat Ulkatan
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States
| | - Vedran Deletis
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia; Albert Einstein College of Medicine, New York, NY, United States
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Téllez MJ, Mirallave-Pescador A, Seidel K, Urriza J, Shoakazemi A, Raabe A, Ghatan S, Deletis V, Ulkatan S. Neurophysiological monitoring of the laryngeal adductor reflex during cerebellar-pontine angle and brainstem surgery. Clin Neurophysiol 2020; 132:622-631. [PMID: 33272821 DOI: 10.1016/j.clinph.2020.10.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/09/2020] [Accepted: 10/06/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To correlate intraoperative changes of the laryngeal adductor reflex (LAR), alone or in combination with corticobulbar motor evoked potential of vocal muscles (vocal-CoMEPs), with postoperative laryngeal function after posterior fossa and brainstem surgery. METHODS We monitored 53 patients during cerebellar-pontine angle and brainstem surgeries. Vocal-CoMEPs and LAR were recorded from an endotracheal tube with imbedded electrodes or hook-wires electrodes. A LAR significant change (LAR-SC) defined as ≥ 50% amplitude decrement or loss, was classified as either transient or permanent injury to the vagus or medullary pathways by the end of the surgery. RESULTS All patients with permanent LAR loss (n = 5) or LAR-SC (n = 3), developed postoperative laryngeal dysfunction such as aspiration/pneumonia and permanent swallowing deficits (5.6%). Vocal-CoMEP findings refined postoperative vocal motor dysfunction. All seven patients with transient LAR-SC or loss, reverted by changing the surgical approach, did not present permanent deficits. CONCLUSIONS Permanent LAR-SCs or loss correlated with postoperative laryngeal dysfunction and predicted motor and sensory dysfunction of the vagus nerve and reflexive medullary pathways. In contrast, a LAR-SC or loss, averted by a timely surgical adjustment, prevented irreversible damage. SIGNIFICANCE Monitoring of the LAR, with vocal-CoMEPs, may enhance safety to resect complex posterior fossa and brainstem lesions.
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Affiliation(s)
- Maria J Téllez
- Department of Intraoperative Neurophysiology. Mount Sinai West Hospital. New York, NY, USA.
| | - Ana Mirallave-Pescador
- Department of Intraoperative Neurophysiology. Queen's Hospital. Barking, Havering, and Redbridge University Hospitals NHS Trust. London, UK
| | - Kathleen Seidel
- Department of Neurosurgery. Inselspital Bern University Hospital, Bern, Switzerland
| | - Javier Urriza
- Department of Clinical Neurophysiology. Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Alireza Shoakazemi
- Department of Neurosurgery. Queen's Hospital. Barking, Havering, and Redbridge University Hospitals NHS Trust. London, UK
| | - Andreas Raabe
- Department of Neurosurgery. Inselspital Bern University Hospital, Bern, Switzerland
| | - Saadi Ghatan
- Department of Neurosurgery. Mount Sinai West Hospital. New York, NY, USA
| | - Vedran Deletis
- Albert Einstein College of Medicine, New York, NY, USA; Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Sedat Ulkatan
- Department of Intraoperative Neurophysiology. Mount Sinai West Hospital. New York, NY, USA
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Libonati L, Barone TF, Ceccanti M, Cambieri C, Tartaglia G, Onesti E, Petrucci A, Frasca V, Inghilleri M. Heteronymous H reflex in temporal muscle as sign of hyperexcitability in ALS patients. Clin Neurophysiol 2019; 130:1455-1459. [PMID: 31164256 DOI: 10.1016/j.clinph.2019.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 04/23/2019] [Accepted: 05/13/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The stimulation of the masseteric nerve elicits a homonymous and a heteronymous H reflex in the masseter muscle and in the temporalis one. The presence of the H reflex may be considered a sign of upper motor neuron (UMN) involvement in amyotrophic lateral sclerosis (ALS) patients. The aim of this study was to evaluate the presence of the heteronymous H reflex in patients with ALS and compare it with normal subjects. METHODS We enrolled 36 ALS patients and 52 healthy subjects. We stimulated the masseteric nerve in the infratemporal fossa and recorded the muscle responses ipsilaterally to the stimulation. RESULTS The heteronymous temporalis H reflex was elicitable in 88.9% of ALS patients and in none of the controls. CONCLUSION The heteronymous H reflex does not disappear when the stimulation intensity is increased. It can be used as sign of UMN involvement and may prove useful in patients with suspected MND/ALS with purely lower motor neurons (LMN) signs and no signs of UMN involvement. SIGNIFICANCE The heteronymous H reflex is present far more often in ALS patients than in healthy people. It is a simple test that may be used to detect UMN involvement in patients in whom the only evident signs are LMN impairment, improving diagnosis of ALS.
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Affiliation(s)
- Laura Libonati
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | | | - Marco Ceccanti
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Chiara Cambieri
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Giorgio Tartaglia
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Emanuela Onesti
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Antonio Petrucci
- Neuromuscular and Neurological Rare Diseases Center ASO San Camillo-Forlanini, Rome, Italy
| | - Vittorio Frasca
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Maurizio Inghilleri
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy.
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