Search

Nitric oxide (NO) is an essential component of the human body, involved in blood vessel dilation, stimulation of hormone release, signaling and regulation of neurotransmission. Nitric oxide is synthesized by nitric-oxide-synthase-dependent and -independent pathways. Nitric oxide supplementation improves cardiac health, enhances performance during exercise, reduces high blood pressure during pregnancy, reduces erectile dysfunction and improves healing processes and respiratory response. Nitric-oxide-associated benefits are mostly apparent in untrained or moderately trained individuals. L-arginine and L-citrulline supplementation contributes to nitric oxide levels because L-arginine is directly involved in NO synthesis, whereas L-citrulline acts as an L-arginine precursor that is further converted to NO by a reaction catalyzed by NO synthase. L-arginine supplements increase respiratory response and enhance performance during exercise, while L-citrulline with malate and other molecules increase working capacity. Various studies involving beetroot juice have reported a significant increase in plasma nitrite levels, regarded as markers of NO, after intake of beetroot juice. Although NO supplementation may have mild to moderate side-effects, using smaller or divided doses could avoid some of these side-effects. Since nitric oxide supplementation may worsen certain health conditions and may interfere with certain medicines, it should only be taken under medical supervision., Journal of Preventive Medicine and Hygiene, Vol. 63 No. 2S3 (2022): The secret of Mediterranean food: How “omic” sciences, biochemistry and human physiology can be applied to exploit the secrets of Mediterranean foods

Physical activity plays a substantial role in maintaining people’s good health and mental wellbeing, but that is not all: not only it positively affects the individuals’ mental and physical health, but a lack of physical exercise exerts a negative impact also on the overall economy of a nation. In addition, physical inactivity not only increases the risk of non-communicable diseases (NCD), but also contributes significantly to the increased morbidity and mortality in patients suffering from these diseases. On the contrary, physical activity reduces the risk of NCDs – such as cardiovascular diseases, type 2 diabetes, and cancer – in a dose-dependent manner; regular exercise is also associated with many health benefits and delayed mortality. However, understanding the role of physical activity in modern society and creating an awareness in the general population is one of the most important tasks of health and recreation promoters. Correspondingly, there is a dire need to enhance our knowledge, perception, and awareness of physical activity and its impacts on an individual’s health, ultimately contributing to developing a healthy society. The current review will focus on the health benefits of the two most widely studied modifiable lifestyle risk factors, physical activity and diet, focusing particularly on the Mediterranean diet., Journal of Preventive Medicine and Hygiene, Vol. 63 No. 2S3 (2022): The secret of Mediterranean food: How “omic” sciences, biochemistry and human physiology can be applied to exploit the secrets of Mediterranean foods

A healthy diet shapes a healthy mind. Diet quality has a strong association with brain health. Diet influences the onset and consequences of neurological diseases, and dietary factors may influence mental health at individual and population level. The link between unhealthy diet, impaired cognitive function and neurodegenerative diseases indicates that adopting a healthy diet would ultimately afford prevention and management of neurological diseases and brain aging. Neurodegenerative diseases are of multifactorial origin and result in progressive loss of neuronal function in the brain, leading to cognitive impairment and motoneuron disorders. The so-called Mediterranean diet (MedDiet) with its healthy ingredients rich in antioxidant, anti-inflammatory, immune, neuroprotective, antidepressant, antistress and senolytic activity plays an essential role in the prevention and management of neurological diseases and inhibits cognitive decline in neurodegenerative diseases such as Alzheimer’s, Parkinson’s and Huntington’s diseases. The MedDiet also modulates the gut-brain axis by promoting a diversity of gut microbiota. In view of the importance of diet in neurological diseases management, this review focuses on the dietary components, natural compounds and medicinal plants that have proven beneficial in neurological diseases and for brain health. Among them, polyphenols, omega-3 fatty acids, B vitamins and several ayurvedic herbs have promising beneficial effects., Journal of Preventive Medicine and Hygiene, Vol. 63 No. 2S3 (2022): The secret of Mediterranean food: How “omic” sciences, biochemistry and human physiology can be applied to exploit the secrets of Mediterranean foods

Parkinson’s disease (PD) is generally associated with abnormally increased beta band oscillations in the cortico-basal ganglia loop during walking. PD patients with freezing of gait (FOG) exhibit a more distinct, prolonged narrow band of beta oscillations that are locked to the initiation of movement at ∼18 Hz. Upon initiation of cycling movements, this oscillation has been reported to be weaker and rather brief in duration. Due to the suppression of the overall beta band power during cycling and its continuous nature of the movement, cycling is considered to be less demanding for cortical networks compared to walking, including reduced need for sensorimotor processing, and thus unimpaired continuous cycling motion. Furthermore, cycling has been considered one of the most efficient non-pharmacological therapies with an influence on the subthalamic nucleus (STN) beta rhythms implicative of the deep brain stimulation effects. In the current review, we provide an overview of the currently available studies and discuss the underlying mechanism of preserved cycling ability in relation to the FOG in PD patients. The mechanisms are presented in detail using a graphical scheme comparing cortical oscillations during walking and cycling in PD.

Additional file 1: Fig. S1 Olfactory mucosa (OM) sample without substrate (recombinant α-syn and reaction buffer) (red trace) and substrate without OM (black trace) were tested by RT-QuIC.

Data from literature on clinical manifestation of thalamic strokes have been published for ages. First in 1906 Dejerine e Roussy have spoken about sensorymotor disturbances and have opened the door to new pathologic disorders that may occur after thalamic lesions. From 1925 behavior and speech disorders related with thalamic injury were described. Since then a classification of thalamic syndromes into four groups based on the four main arterial territories was accepted. As we know thalamic stroke account for 11% of vertebra basilar infarct. Inferolateral territory infarctions are the most common injury (45%), followed by the paramedian territory infarctions (35%) and the anterior territory lesions (12%), the posterior territory infarctions are less frequent (8%). Anyway lots of symptoms cannot still be classified easily and strictly into only one of this four groups and several variant topographic patterns of thalamic strokes with distinct manifestation and etiology have been proposed. Here we described the case of one young Caucasian man that was admitted to the emergency department for a sudden onset of dizziness with left lateropulsion, vertigo, visual impairment and speech disorder involving unpredictable topic shifts but grammatically correct. During recovery patient performed a typical behavior disorder consisting mainly in lack of emotion and memory long or short term loss. Magnetic resonance was performed and showed left thalamic infarction involving paramedian territory. The complex cognitive and behavioral disorders described can be explaned only supporting the already described different topographic patterns of thalamic infarction

Stroke leaves many patients disabled even after rehabilitative training, representing a major cause of disability. Several approaches to improve outcomes have been attempted in recent years, with only relative benefit. Emerging evidences show a potential role of pharmacological intervention to enhance motor recovery after stroke. Contrasting evidence are coming from experimental and clinical studies, so far, and pharmacological intervention during rehabilitation represents a major controversial in neurorehabilitation. Dopaminergic stimulation appears as one of the most promising way to improve motor recovery. Subject of this paper will be the ratio underlying the clinical use of levodopa in chronic stroke patients, trying to outline the most convincing evidences about a potential role of this drug in rehabilitative strategies.

We postulate that “system epilepsies” (SystE) are due to an enduring propensity to generate seizures of functionally characterized brain systems. Data supporting this hypothesis—that some types of epilepsy depend on the dysfunction of specific neural systems—are reviewed. The SystE hypothesis may drive pathophysiologic and clinical studies that can advance our understanding of epilepsies and can open up new therapeutic perspectives.

Background and purpose: Among the most common post-COVID symptoms, many patients experienced subjective cognitive deficit, commonly named "brain fog," that might be present also in those individuals without severe acute COVID-19 respiratory involvement. Some studies have investigated some of the mechanisms that might be associated with the brain fog with objective techniques including transcranial magnetic stimulation and neuroimaging. Methods: The aim of this study was to investigate the presence of electroencephalographic (EEG) alterations in people with post-COVID self-reported cognitive deficit. Results: Out of the 90 patients attending the post-COVID neurology ambulatory service, twenty patients presenting brain fog at least 4 weeks after acute non-severe COVID-19 infection, and without previous history of epilepsy, were investigated with 19-channel EEG, Montreal Cognitive Assessment (MoCA), and magnetic resonance imaging (MRI). EEG was found altered in 65% of the sample, among which 69% presented a slowing activity and 31% were characterized by epileptic discharges principally in the frontal areas. None of the patients showed DWI MRI lesions. Conclusions: These findings highlight the usefulness of EEG analysis to objectively describe possible neurophysiological abnormalities in post-COVID patients presenting subjective cognitive deficit.

The autonomic nervous system (ANS) can be affected by COVID-19, and dysautonomia may be a possible complication in post-COVID individuals. Orthostatic hypotension (OH) and postural tachycardia syndrome (POTS) have been suggested to be common after SARS-CoV-2 infection, but other components of ANS function may be also impaired. The Composite Autonomic Symptom Scale 31 (COMPASS-31) questionnaire is a simple and validated tool to assess dysautonomic symptoms. The aim of the present study was to administer the COMPASS-31 questionnaire to a sample of post-COVID patients with and without neurological complaints. Participants were recruited among the post-COVID ambulatory services for follow-up evaluation between 4 weeks and 9 months from COVID-19 symptoms onset. Participants were asked to complete the COMPASS-31 questionnaire referring to the period after COVID-19 disease. Heart rate and blood pressure were manually taken during an active stand test for OH and POTS diagnosis. One-hundred and eighty participants were included in the analysis (70.6% females, 51 ± 13 years), and OH was found in 13.8% of the subjects. Median COMPASS-31 score was 17.6 (6.9–31.4), with the most affected domains being orthostatic intolerance, sudomotor, gastrointestinal and pupillomotor dysfunction. A higher COMPASS-31 score was found in those with neurological symptoms (p p p p p

Owing to the large inter-subject variability, early post-stroke prognosis is challenging, and objective biomarkers that can provide further prognostic information are still needed. The relation between quantitative EEG parameters in pre-thrombolysis hyper-acute phase and outcomes has still to be investigated. Hence, possible correlations between early EEG biomarkers, measured on bedside wireless EEG, and short-term/long-term functional and morphological outcomes were investigated in thrombolysis-treated strokes. EEG with a wireless device was performed in 20 patients with hyper-acute (

We provide here the first systematic review on the studies dealing with repetitive transcranial magnetic stimulation (rTMS) for traumatic brain injury (TBI) in animals and humans. Several experimental studies in animal models have explored with promising results the use of rTMS to enhance neuroprotection and recovery after TBI. However, there are surprisingly few studies that have obtained substantial evidence regarding effects of rTMS in humans with TBI, many of them are case reports investigating the heterogeneous conditions linked to TBI. The most studies have investigated the effects of rTMS in subjects with post-traumatic depression and variable effects have been observed. rTMS has been proposed as an experimental approach for the treatment of disorders of consciousness (DOC), but in subjects with TBI therapeutic effects on DOC have also been variously documented. Beneficial effects have been reported in subjects with cognitive/emotional disturbances and auditory dysfunction (tinnitus and hallucinations), although the results are somewhat conflicting. rTMS applied over the left prefrontal cortex may relieve, at least transiently, post-traumatic headache. Isolated rTMS studies have been performed in TBI patients with motor impairment, chronic dizziness or pain. Especially whether provided in combination, rTMS and neurorehabilitation may be synergistic in the potential to translate experimental findings in the clinical practice. In order to reach definitive conclusions, well-designed randomized controlled studies with larger patient samples, improved design and optimized rTMS setup, are warranted to verify and corroborate the initial promising findings.

Background: It is unclear how multiple sclerosis (MS) affects the severity of Covid-19. Methods: Hospitalization, Intensive Care Unit (ICU) admission and death after Covid-19 diagnosis of 1362 MS patients were compared to the age and sex-matched Italian population in a retrospective observational case-cohort study with population-based control. The observed vs the expected events were compared in the whole MS cohort and in different subgroups (higher-risk: EDSS>3 or at least one comorbidity, lower-risk: EDSS

We herein report an unusual case of a 40-year-old woman presenting to the emergency department with acute-onset tetraparesis due to inhalation of chemical solvents containing n-hexane. The clinical picture, a mild albumin-cytologic dissociation and the demyelinating features on nerve conduction study initially mimicked the presentation of Guillain-Barré syndrome (GBS), but the patient failed to respond to intravenous immunoglobulin treatment and plasma exchange. Diagnosis of hexane-induced neuropathy was then confirmed by means of sural nerve biopsy, showing axonal enlargement with secondary retraction and thinning of the myelin sheath.

Background The first years of relapsing-remitting multiple sclerosis (RRMS) constitute the most vulnerable phase for the progression of cognitive impairment (CImp), due to a gradual decrease of compensatory mechanisms. In the first 10 years of RRMS, the temporal volumetric changes of deep gray matter structures must be clarified, since they could constitute reliable cognitive biomarkers for diagnostic, prognostic, and therapeutic purposes. Methods Forty-five cognitively asymptomatic patients with RRMS lasting ≤ 10 years, and with a brain MRI performed in a year from the neuropsychological evaluation (Te-MRI), were included. They performed the Brief International Cognitive Assessment battery for MS. Thirty-one brain MRIs performed in the year of diagnosis (Td-MRI) and 13 brain MRIs of age- and sex-matched healthy controls (HCs) were also included in the study. The relationships between clinical features, cognitive performances, and Te- and Td-MRI volumes were statistically analyzed. Results Cognitively preserved (CP) patients had significantly increased Td-L-putamen (P = 0.035) and Td-R-putamen volume (P = 0.027) with respect to cognitively impaired (CI) ones. CI patients had significantly reduced Te-L-hippocampus (P = 0.019) and Te-R-hippocampus volume (P = 0.042) compared, respectively, with Td-L-hippocampus and Td-R-hippocampus volume. Td-L-putamen volume (P = 0.011) and Te-L-hippocampus volume (P = 0.023) were independent predictors of the Symbol Digit Modalities Test score in all patients (r2 = 0.31, F = 6.175, P = 0.001). Conclusion In the first years of RRMS, putamen hypertrophy and hippocampus atrophy could represent promising indices of cognitive performance and reserve, and become potentially useful tools for diagnostic, prognostic, and therapeutic purposes.

Objective A very high-resolution (70 MHz) ultrasound device (VHRUS) has recently been approved for use in humans. The aim of this study was to use VHRUS to collect data on healthy subjects to propose some reference values for the digital branches of the median nerves of the hand. Methods A VHRUS with 70 MHz linear array transducer was used to measure the cross sectional area of the median nerve at the wrist (CSAw) and digital branches (CSAf), largest and smallest fascicles, the fascicles number (Nfasc), the fascicle density (FD), the flattening ratio (FR) and CSAw/CSAf. Results Data from 20 healthy subjects were obtained for both hands. The median nerve at the wrist and digital branches were properly identified without anatomical alterations. No differences were found between the right and the left hand. In the dominant hand, CSAw was 9.35 mm2 (4.57–12.35) and Nfasc was 24 (18–38). FD and FR were respectively 2.94 (2.47–4.91) and 2.74 (1.70–4.90). Conclusion VHRUS technology can visualize the median nerves at the wrist, their internal structure and their small branches at the fingers, providing both a qualitative and quantitative assessment. Results from this study provide preliminary reference values in a young healthy sample. Significance Most conventional ultrasound devices are not able to properly visualize the distal branches of the median nerve. In contrast, VHRUS allows to detect and measure smaller structures of the nerve, assisting in clinical practice.

Mild cognitive impairment (MCI) converts to Alzheimer's disease within a few years of diagnosis in up to 80% of patients. The identification among such a population of a rare form of epilepsy (transient epileptic amnesia [TEA]), characterized by mixed anterograde and retrograde amnesia with apparent preservation of other cognitive functions, excessively rapid decay of newly acquired memories, and loss of memories for salient personal events of the remote past, strongly affects prognosis and medical treatment. Our aim was to define the clinical utility of routine high-density electroencephalography (EEG) in patients with MCI for the detection of epilepsy, especially TEA. Using high-density EEG (256 channels), we were able to single out 3 cases of TEA previously misdiagnosed as MCI in this cohort of 76 consecutive patients with MCI diagnosed at our center. Antiepileptic treatment effectively stopped the acute episodes of memory loss. To our knowledge, this is the first report of an incidence of 4% of TEA recorded in such a cohort.

BACKGROUND: The current understanding of the mechanisms underlying photosensitivity is still limited, although most studies point to a hyperexcitability of the visual cortex. METHODS: Using transcranial magnetic stimulation, we determined the resting motor threshold (rMT) and the phosphene threshold (PT) in 33 patients with IGEs (8 with photosensitivity) compared with 12 healthy controls. RESULTS: Eleven controls (92%) reported phosphenes compared with fifteen (46%) patients with idiopathic generalized epilepsy (p=0.015). Phosphenes were reported more frequently among patients with epilepsy with photosensitivity (87.5%) than in patients with active epilepsy without photosensitivity (30.8%) (p=0.038) and patients with epilepsy in remission without photosensitivity (33.3%) (p=0.054); no differences were found between patients with epilepsy with photosensitivity and controls (p=0.648). Resting motor threshold and phosphene threshold were significantly higher among patients with epilepsy (active epilepsy or epilepsy in remission without photosensitivity) compared to healthy controls (p

OBJECTIVES/HYPOTHESIS: The possibility that long-term mobile phone use increases the incidence of astrocytoma, glioma and acoustic neuroma has been investigated in several studies. Recently, our group showed that direct exposure (in a surgical setting) to cell phone electromagnetic fields (EMFs) induces deterioration of auditory evoked cochlear nerve compound action potential (CNAP) in humans. To verify whether the use of Bluetooth devices reduces these effects, we conducted the present study with the same experimental protocol. STUDY DESIGN: Randomized trial. METHODS: Twelve patients underwent retrosigmoid vestibular neurectomy to treat definite unilateral Ménière's disease while being monitored with acoustically evoked CNAPs to assess direct mobile phone exposure or alternatively the EMF effects of Bluetooth headsets. RESULTS: We found no short-term effects of Bluetooth EMFs on the auditory nervous structures, whereas direct mobile phone EMF exposure confirmed a significant decrease in CNAPs amplitude and an increase in latency in all subjects. CONCLUSIONS: The outcomes of the present study show that, contrary to the finding that the latency and amplitude of CNAPs are very sensitive to EMFs produced by the tested mobile phone, the EMFs produced by a common Bluetooth device do not induce any significant change in cochlear nerve activity. The conditions of exposure, therefore, differ from those of everyday life, in which various biological tissues may reduce the EMF affecting the cochlear nerve. Nevertheless, these novel findings may have important safety implications. LEVEL OF EVIDENCE: 4

The artery of Percheron is a rare anatomical variant where a single thalamic perforating artery arises from the proximal posterior cerebral artery (P1 segment) between the basilar artery and the posterior communicating artery and supplies the rostral mesencephalon and both paramedian territories of the thalami. Almost one-third of human brains present this variant. Occlusion of the artery of Percheron mostly results in a bilateral medial thalamic infarction, which usually manifests with altered consciousness (including coma), vertical gaze paresis, and cognitive disturbance. The presentation is similar to the "top of the basilar syndrome", and early recognition should be prompted. We describe the case of a young female with this vessel variant who experienced a bilateral thalamic stroke. Magnetic resonance angiography demonstrated bilateral thalamic infarcts and a truncated artery of Percheron. Occlusion of the vessel was presumably due to embolism from a patent foramen ovale. Thrombolysis was performed, with incomplete symptom remission, cognitive impairment, and persistence of speech disorders. Early recognition and treatment of posterior circulation strokes is mandatory, and further investigation for underlying stroke etiologies is needed.

Objective To investigate blood oxygenation level-dependent (BOLD) activation during somatosensory electrical stimulation of the median nerve in acute stroke patients and to determine its correlation with ischemic damage and clinical recovery over time. Methods Fourteen acute stroke patients underwent functional magnetic resonance imaging (fMRI) during contralesional median-nerve electrical stimulation 12–48 h after stroke. Findings were then validated by diffusion tensor imaging (DTI) and motor evoked potential by transcranial magnetic stimulation (TMS). Results Poor clinical recovery at three months was noted in four patients with no activation in the early days after stroke, whereas good clinical recovery was observed in eight patients with a normal activation pattern in the primary sensory motor area in the acute phase. In two patients BOLD activation correlated weakly with clinical recovery. Findings from TMS and DTI partially correlated with clinical recovery and functional scores. Conclusions Clinically relevant insights into the “functional reserve” of stroke patients gained with peripheral nerve stimulation during fMRI may carry prognostic value already in the acute period of a cerebrovascular accident. Significance BOLD activation maps could provide insights into the functional organization of the residual systems and could contribute to medical decision making in neurological and rehabilitative treatment.

In the last few years much has been published to validate new technology in brain mapping for clinical purposes, but there have been few clinical results. In this report we describe our five-year experience in the surgical management of malignant gliomas around motor areas with an evaluation of the impact of functional magnetic resonance imaging (fMRI) plus navigator and intraoperative neurophysiology (IN). End-points were extent of removal, morbidity, and survival. Variables describing patient and tumor characteristics and treatment modalities were statistically weighted in relation to treatment outcome. Tumor depth (P = 0.01), midline shift >/=1 cm. (P = 0.05), and insular location (P = 0.001) negatively affected extent of removal, whereas IN (P < 0.001) and fMRI plus navigator (P = 0.02) contributed to increasing the rate of total removal (73\%, 71\% vs. 40\%). Postoperative motor impairment was mild and transient in a minority of cases (20\%). General complications, as defined by the Glioma Outcome Project, occurred in 23\% of cases. IN was the only factor associated with acute postoperative motor deterioration (P < 0.001). IN and age >65 years (P = 0.01) were associated with the occurrence of complications. Overall survival was significantly higher in patients operated with IN or fMRI plus navigator (P < 0.01). Comparing different surgical strategies used in the same period, we observed that supportive technologies in glioma surgery have their primary impact on the quality of resection and survival. IN led to transient motor impairment and some additional complications which did not affect functional outcome.

Background The effect of various drugs was investigated by using transcranial magnetic stimulation (TMS) both in healthy subjects and patients, and the results indicated an influence of antidepressant drugs (ADs) on motor excitability. Objective The aim of our study was to analyze the effects of two ADs, the tricyclic (TCA) clomipramine and the serotoninergic antidepressant (SSRI) citalopram on the motor cortex excitability in major depressed patients with TMS. Methods Thirty affected subjects were placed into three groups: two received an intravenous dose of 25 mg clomipramine or 40 mg citalopram, and one received an injection of a placebo. Motor cortex excitability was studied by single and paired TMS before and after 3.5, 8, and 24 hours from administration of the drugs and placebo. Motor cortical excitability was measured using different TMS parameters: resting motor threshold (RMT), motor-evoked potential (MEP) amplitude, intracortical inhibition (ICI), and intracortical facilitation (ICF). Results The results indicated a temporary but significant increase of RMT and ICI and a decrease of ICF after the administration of both drugs, with a longer inhibition for the clomipramine rather than the citalopram. MEP amplitude was not significantly affected by the antidepressant injections. Conclusions Our findings highlight that a single intravenous dose of clomipramine or citalopram exerts a significant but transitory suppression of motor cortex excitability in depressed patients. TMS represents a useful research tool in assessing the effects of motor cortical excitability of drugs used in the treatment of mental disorders.

Background The treatment of amyotrophic lateral sclerosis (ALS) is still disappointing. Repetitive transcranial magnetic stimulation (rTMS) has been suggested to modify the rate of disease progression in ALS. Objective In a pilot controlled study, we tested the effect of 5-Hz rTMS on motor performance, fatigue and quality of life (QoL) in ALS. Methods Ten ALS patients underwent a two-week period of daily active or sham 5-Hz rTMS. Outcome measures were assessed with functional, fatigue and QoL scales. Muscle strength was evaluated with the MRC scale and measured with isometric and isokinetic dynamometer. Results Significant difference at the end of rTMS treatment was found for QoL, maximum voluntary isometric contraction and isokinetic average power when comparing active vs sham treatment. These changes were transitory and outcome measures were not significant two weeks after discontinuation of rTMS. Conclusions Though preliminary, our results suggest that 5-Hz rTMS may improve motor function and QoL in ALS. The present data indicate the need of a double-blind therapeutic trial of rTMS in ALS.

Summary Intraoperative neurophysiological monitoring (IOM) has established itself as one of the paths by which modern neurosurgery can improve surgical results while minimizing morbidity. IOM consists of both monitoring (continuous “on-line” assessment of the functional integrity of neural pathways) and mapping (functional identification and preservation of anatomically ambiguous nervous tissue) techniques. In posterior-fossa and brainstem surgery, mapping techniques can be used to identify — and therefore preserve — cranial nerves, their motor nuclei and corticospinal or corticobulbar pathways. Similarly, free-running electromyography (EMG) and muscle motor-evoked potential (mMEP) monitoring can continuously assess the functional integrity of these pathways during surgery. Mapping of the corticospinal tract, at the level of the cerebral peduncle as well as mapping of the VII, IX–X and XII cranial nerve motor nuclei on the floor of the fourth ventricle, is of great value to identify “safe entry-zones” into the brainstem. Mapping techniques allow recognizing anatomical landmarks such as the facial colliculus, the hypoglosseal and glossopharyngeal triangles on the floor of the fourth ventricle, even when normal anatomy is distorted by a tumor. On the basis of neurophysiological mapping, specific patterns of motor cranial nuclei displacement can be recognized. However, brainstem mapping cannot detect injury to the supranuclear tracts originating in the motor cortex and ending on the cranial nerve motor nuclei. Therefore, monitoring techniques should be used. Standard techniques for continuously assessing the functional integrity of motor cranial nerves traditionally rely on the evaluation of spontaneous free-running EMG in muscles innervated by motor cranial nerves. Although several criteria have been proposed to identify those EMG activity patterns that are suspicious for nerve injury, the terminology remains somewhat confusing and convincing data regarding a clinical correlation between EMG activity and clinical outcome are still lacking. Transcranial mMEPs are also currently used during posterior-fossa surgery and principles of MEP monitoring to assess the functional integrity of motor pathways are similar to those used in brain and spinal-cord surgery. Recently, current concepts in muscle MEP monitoring have been extended to the monitoring of motor cranial nerves. So-called “corticobulbar mMEPs” can be used to monitor the functional integrity of corticobulbar tracts from the cortex through the cranial motor nuclei and to the muscle innervated by cranial nerves. Methodology for this purpose has appeared in the literature only recently and mostly with regards to the VII cranial nerve monitoring. Nevertheless, this technique has not yet been standardized and some limitations still exist. In particular, with regards to the preservation of the swallowing and coughing reflexes, available intraoperative techniques are insufficient to provide reliable prognostic data since only the efferent arc of the reflex can be tested.

The purpose of this pilot study was to evaluate the effect of treatment with botulinum toxin A (BTX-A) injections on function in children with cerebral palsy (CP) using pedobarometric data collected in a standing position. Ten children with CP (seven males, three females) participated, five with diplegia and five with hemiplegia. All children exhibited signs of unilateral dynamic equinus foot disorder and were community ambulators. Age range at the time of treatment was 6 to 13 years (mean age 9 y, SD 2.5). A comprehensive clinical examination and a pedobarometric evaluation were performed before and after BTX-A injection. All children received at least one injection in each spastic muscle. BTX-A was given to eight children unilaterally and to two children bilaterally. A maximum dose of 4 to 8 units of BTX-A per kilogram body weight was administered. In comparison with pretreatment values, the pedobarometric evaluation revealed a significant increase in the whole plantar surface area on the affected side (p < 0.05), an increase in the peak pressure value at the hindfoot on the affected side (p < 0.05), and a significant shift in the body centre of mass to the affected limb (p < 0.05) 1 month after treatment with BTX-A. A significant decrease in the peak pressure value at the hindfoot on the unaffected side was also observed. Similarly, a decrease in the modified Ashworth scale and an increase in the range of motion were observed. Thus, BTX-A produces a significant plantar surface modification and a significant shift of the body centre of mass which represents an indirect measure of postural attitude. Pedobarometric evaluation can also be useful in quantifying clinical changes after treatment with BTX-A.

OBJECTIVE: To develop a clinical and instrumental protocol to assess the postural and dynamic effects following treatment with botulinum neurotoxin A in children with cerebral palsy affected by spastic equinus. DESIGN: Open study, in which every patient served as his or her own control.Patients: Ten sequential children with cerebral palsy and spastic dynamic equinus foot. METHODS: Botulinum neurotoxin A was injected in the gastrocnemius, soleus and tibialis posterior muscles. The main measures were: pedobarometry, dynamic surface electromyography, video gait analysis scale, and the modified Ashworth Scale. RESULTS: After treatment with botulinum neurotoxin A, pedobarometric evaluation revealed a significant change in all parameters, including a decrease in the modified Ashworth Scale and an increase in the range of motion. All children showed significant improvement in initial foot contact, as documented by the video gait analysis scale. The calf muscle electromyography pattern showed a decrease in co-contraction during gait in all children. These modifications were statistically significant for all parameters considered (p < 0.05). CONCLUSION: This pilot study suggests that dynamic electromyography and pedobarometry are simple to use and provide useful data; this protocol could be preferable in young and uncooperative children in order to monitor rehabilitation treatments.

Rehabilitation programs, to be efficiently tailored, need clear prognostic markers. In acute stroke, neurophysiological measures, such as motor evoked potentials (MEPs), have been proposed, although with discordant results. The aim of this study was to identify a reliable neurophysiological measure of recovery in acute post-stroke individuals by combining MEPs and the N100 component of transcranial magnetic stimulation-evoked potentials (TEPs). Nine acute post-stroke subjects were included. Clinical evaluation performed in the first week after the event included administration of the European Stroke Scale and Barthel Index and recording of MEPs and TEPs; administration of the clinical scales was repeated after one and three months. The presence/absence of MEPs and TEPs showed correlations with motor outcome. Individuals with a poorer outcome showed absence of both MEPs and TEPs; absence of MEPs alone was related to a partial recovery. Given the results of this exploratory study, further investigation is needed to define the accuracy of combined use of MEPs and TEPs as an approach for predicting motor recovery after acute stroke.

Combined transcranial magnetic stimulation/electroencephalography (TMS/EEG) was used to study the activation and interaction of cortical regions to a variety of focused sub- and suprathreshold magnetic pulses over the left primary motor cortex (M1) in ten healthy subjects. Five single-pulse TMS conditions were performed based on the individual resting motor threshold (RMT): (1) 80%; (2) 100%; (3) 120%; (4) 130%; and (5) sham. Simple self-paced movements of the right first finger were also executed. We evaluated the reactions to magnetic stimulation and movement conditions using event-related power and event-related coherence transformations of alpha and beta rhythms. Event-related power reflected regional oscillatory activity of neural assemblies, while event-related coherence reflected the inter-regional functional coupling of oscillatory neural activity. The event-related power transformation revealed that the magnetic pulse modulated cortical oscillations within the first half second for both frequency ranges. For the alpha rhythm, threshold TMS induced a small decrease in the amplitude of EEG oscillations over the stimulation site, while for both rhythms, a progressive synchronization was observed as the intensity of TMS was increased in both hemispheres. Movement onset produced a greater bilateral decrease of power compared with the effects of a magnetic pulse. The event-related coherence revealed that TMS enhanced the electrode connectivity of both hemispheres. Additionally, it was more enhanced within the first 500 ms following stimulation and was seen only for the alpha frequency rhythm. The increase of functional connectivity between cortical areas was minor for magnetic stimulation conditions compared with that for finger movements. The single-pulse TMS over M1 partially modulated the motor cortex generators of oscillatory activity, while a simple active self-paced movement of the right first finger induced greater cortex activation and coupling between cortical regions. We propose that finger movements impose higher functional demands on the motor system compared to artificial magnetic stimulation. These findings are consistent with the possibility that the human motor system may be based on network-like oscillatory cortical activity and might be modulated by brief electromagnetic sub- and suprathreshold pulses applied to M1, suggesting a phenomenon of resetting.

In patients without a behavioral response, non-invasive techniques and new methods of data analysis can complement existing diagnostic tools by providing a method for detecting covert signs of residual cognitive function and awareness. The aim of this study was to investigate the brain oscillatory activities synchronized by single-pulse transcranial magnetic stimulation (TMS) delivered over the primary motor area in the time–frequency domain in patients with the unresponsive wakefulness syndrome or in a minimally conscious state as compared to healthy controls. A time–frequency analysis based on the wavelet transform was used to characterize rapid modifications of oscillatory EEG rhythms induced by TMS in patients as compared to healthy controls. The pattern of EEG changes in the patients differed from that of healthy controls. In the controls there was an early synchronization of slow waves immediately followed by a desynchronization of alpha and beta frequency bands over the frontal and centro-parietal electrodes, whereas an opposite early synchronization, particularly over motor areas for alpha and beta and over the frontal and parietal electrodes for beta power, was seen in the patients. In addition, no relevant modification in slow rhythms (delta and theta) after TMS was noted in patients. The clinical impact of these findings could be relevant in neurorehabilitation settings for increasing the awareness of these patients and defining new treatment procedures.

Summary The aim of the study was to detect abnormalities of sensorimotor interactions and their topographic distribution in the hand muscles of dystonic patients. We investigated the effect of electrical stimulation of the second (D2) and fifth (D5) fingers on the amplitude of motor evoked potentials (MEPs) in response to transcranial magnetic stimulation (TMS) and transcranial electrical stimulation (TES) in the relaxed first dorsal interosseous (FDI) and abductor digiti minimi (ADM) muscles on both sides of eight patients with unilateral hand dystonia (HD) and in four patients with cervical dystonia (CD). Six Parkinson’s disease patients were used as the disease control group and 10 healthy subjects served as normal controls. For each muscle, the digital stimulation was applied to a contiguous finger (CF) and to a non-contiguous finger (NCF). The digital stimulation was set at three times the sensory threshold and preceded TMS or TES at intervals ranging from 10 to 100 ms. In normal subjects, a somatotopic inhibitory effect was detected, since the CF stimulation was significantly more powerful in determining the reduction of MEPs in response to TMS at intervals ranging from 20 to 50 ms. In dystonic patients, on the contrary, the somatopic effect was not present, because both CF and NCF stimulation evoked a consistent MEP inhibition and no significant difference was detected between the conditioning effect of CF and NCF stimulation. These abnormalities were present in the muscles of both the affected and unaffected hands of HD patients, as well as in CD patients. TES conditioning provoked MEP inhibition only at interstimulus intervals (ISIs)

Gamma knife radiosurgery (GK-RS) is a technique applied in selected cases of mesial-temporal epilepsy, although still limited to centres with adequate instrumentation and expertise. Here, we report a case of radio surgery targeted with the aid of electrical source imaging that localizes the cortical area generating the scalp epileptic discharges. The patient, a 39-year-old male, presented with a right mesio-temporal lesion; electrical source imaging localization partially overlapped with the lesional area but showed an important activation of the omolateral frontal area, concordant with the epileptic network. The patient underwent GK-RS, with good neurosurgical and clinical results. A radiosurgical ellipsoidal treatment volume area of 2 × 2 × 2 cm³, located over the right temporo-mesial region within a centre showing abnormal signal intensity, was considered. Seven months after treatment, the patient developed brain oedema that gradually resolved after one year. After three years of follow-up, the patient was seizure-free (Engel class I). Our very preliminary experience suggests that electrical source imaging appears to be a useful supporting tool for the definition of the radiosurgical treatment volume in selected patients with temporo-mesial lesional epilepsy.

Functional neuroimaging has revealed persistence of ongoing activity in the idling brain, which is the default mode network (DMN) [1]. Other networks, which are devoted to physiological functions, have also been described; they have been recognised during wake time but also during sleep, although modulated by vigilance in extension and connections [2]. The present report described the modulation of these networks in two subjects, which spontaneously fell asleep in the scanner during an electrical stimulation.

Objectives : Among the different kinds of rolandic epilepsy there is a form of benign epilepsy with centrotemporal spikes (BECT) presenting the peculiar characteristic of evoking rolandic paroxysmal activity, characterized by a spike followed by a slow wave, using electrical stimulation of the fingers. Methods : We evaluated 7 patients suffering from BECT presenting evoked scalp activity by electrical stimulation of the fingers of the hand. Electrical stimulation was performed using a pair of ring electrodes applied to the thumb. The motor evoked potentials (MEPs) were elicited in hand muscles by transcranial magnetic stimulation (TMS) and were conditioned by the same electrical digital stimulation producing the evoked spikes at interstimulus intervals ranging from 10 to 200 ms. Results : Digital stimulation in epileptic patients produced an increase in MEP amplitude substantially above the normal ranges. MEP facilitation showed a time course overlapping the ascending phase and peak of the evoked spike, whereas no significant MEP changes were found during the early positive peak and the descending phase of the spike, or during the following slow wave. Conclusions : Several considerations support the hypothesis that the short-lasting M1 facilitation is related to the spread of an abnormal hypersynchronous discharge of the S1 neurones to functionally related motor areas via cortico-cortical connections.

We evaluated vertex-parietal P37, N50, and contralateral N37 somatosensory evoked potentials (SEPs) to posterior tibial nerve stimulation during weak (20 to 30%) and strong (80 to 90%) ipsilateral gastrocnemius-soleus contraction. The results were compared with data obtained during full relaxation. P37 and N50 were attenuated significantly during weak contraction and then abolished during strong contraction, whereas the contralateral N37 was not. The N37 potential spreads over the vertex and over the ipsilateral parietal region during strong contraction. The Cz'-F3 montage was not appropriate for detecting these SEP patterns. These findings suggest that thalamic or cortical gating mechanisms affect specific cortical responses. P37 and N50 could reflect the arrival of the afferent volley into the motor areas from thalamic and cortical (subareas 1 and 2 of S1) projections. N37 could be generated in subarea 3b. Differential analysis of N37 and P37 is required in clinical practice, mainly in those conditions that involve the motor system and in those conditions in which tonic muscular activity is increased.

To investigate the activity of cortical regions in the control of movement, we studied event-related desynchronization/synchronization (ERD/ERS), event-related coherence (ERC), and phase coherence in 29-channel EEGs from 9 subjects performing self-paced movements of the right index finger. Movement preparation and execution produced ERD over the sensorimotor areas at 10 Hz and 20 Hz, followed by ERS. ERD corresponded spatiotemporally to an increase in coherence over the frontocentral areas. For both frequency bands, ERD began over the left sensorimotor areas and became bilateral at the time of movement onset. The coherence increase with frontal areas began in the left central areas and became symmetrical after EMG onset. The ERD and coherence increase was longer at 10 Hz than at 20 Hz. Phase coherence at 10 Hz showed a lead of anterior regions to posterior regions throughout the time period, and at 20 Hz showed a tendency toward zero phase delay corresponding with the movement. EEG desynchronization parallels functional coupling over sensorimotor and frontal areas. Event-related coherence and phase coherence findings implicate the frontal lobes in control of movement planning and execution. The involvement of different frequency bands with different timings may represent parallel changes in the cortical network.

We performed topographical mapping of somatosensory evoked potentials (SEPs) to the posterior tibial nerve using earlobe references both ipsilateral and contralateral to the stimulation side. The voltage of the frontal contralateral N37 and P50 components was enhanced, while the voltage of the parietal ipsilateral P37 and N50 components was reduced when the contralateral earlobe was substituted by the ipsilateral earlobe reference. Maps of the same data documented concomitant changes in negative and positive potential fields, showing an expansion of the pre-Rolandic N37 toward the centrotemporal contralateral regions, and a tendency of the parietal ipsilateral P37, N50 components to be more focally distributed at the vertex. SEPs recorded at each earlobe (Cv6 reference) provided an explanation of these results: The contralateral earlobe detected a negative potential corresponding to the N37 potential recorded over the scalp, followed by a P50 potential that attenuated the contralateral responses and enhanced the ipsilateral ones. The ipsilateral earlobe had no significant effects on scalp SEPs, since it detected only a large N33 negativity. Current source density (CSD) maps were, of course, not influenced by the ear used as reference. Our results suggest that the ipsilateral ear reference is better than the contralateral one for recording "genuine" cortical SEPs. Therefore, it can be recommended in the clinical domain for mapping studies of lower-limb cortical SEPs.

The development of an innovative functional assessment procedure based on the combination of electroencephalography (EEG) and robot-assisted upper limb devices may provide new insights into the dynamics of cortical reorganization promoted by rehabilitation. The aim of this study was to evaluate changes in event-related synchronization/desynchronization (ERS/ERD) in alpha and beta bands in a patient with pure sensory stroke who underwent a specific rehabilitation program for somatic sensation recovery. A 49-year-old, right-handed woman (time since stroke, 12 months) with severe upper limb somatic sensation deficits was tested using validated clinical scales and a standardized video-EEG system combined with the Bi-Manu-Track robot-assisted arm trainer protocol. The patient underwent a 3-month home-based rehabilitation program for promoting upper limb recovery (1 hour a day for 5 days a week). She was tested before treatment, at 1-month, and at 3-month during treatment. Results showed progressive recovery of upper limb function over time. These effects were associated with specific changes in the modulation of alpha and beta event-related synchronization/desynchronization. This unique study provides new perspectives for the assessment of functional deficits and changes in cortical activity promoted by rehabilitation in poststroke patients.

When localization of the epileptic focus is uncertain, the epileptic activity generator may be more accurately identified with non-invasive imaging techniques which could also serve to guide stereo-electroencephalography (sEEG) electrode implantation. The aim of this study was to assess the diagnostic value of perfusion magnetic resonance imaging with arterial spin labeling (ASL) in the identification of the epileptogenic zone, as compared to the more invasive positron-emission tomography (PET) and other established investigation methods for source imaging of electroencephalography (EEG) data. In 6 patients with drug-resistant focal epilepsy, standard video-EEG was performed to identify clinical seizure semeiology, and high-density EEG, ASL and FDG-PET to non-invasively localize the epileptic focus. A standardized source imaging procedure, low-resolution brain electromagnetic tomography constrained to the individual matter, was applied to the averaged spikes of high-density EEG. Quantification of current density, cerebral blood flow, and standardized uptake value were compared over the same anatomical areas. In most of the patients, source in the interictal phase was associated with an area of hypoperfusion and hypometabolism. Conversely, in the patients presenting with early post-ictal discharges, the brain area identified by electrical source imaging (ESI) as the generating zone appeared to be hyperperfused. In 2 patients in whom the focus remained uncertain, the postoperative follow-up showed the disappearance of epileptic activity. As an innovative and more comprehensive approach to the study of epilepsy, the combined use of ESI, perfusion MRI, and PET may play an increasingly important role in the non-invasive evaluation of patients with refractory focal epilepsy.

Drug addiction can be a devastating and chronic relapsing disorder with social, psychological and physical consequences, and more effective treatment options are needed. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation technique that has been assessed in a growing number of studies for its therapeutic potential in treating addiction. This review paper offers an overview on the current state of clinical research in treating drug addiction with rTMS. Because of the limited research in this area, all studies (including case reports) that evaluated the therapeutic use of rTMS in nicotine, alcohol or illicit drug addiction were included in this review. Papers published prior to December 2012 were found through an NCBI PubMed search (http://www.ncbi.nlm.nih.gov). A total of eleven studies were identified that met review criteria. There is nascent evidence that rTMS could be effective in reducing cocaine craving, and nicotine and alcohol craving and consumption, and might represent a potential therapeutic tool for treating addiction. Further studies are needed to identify the optimal parameters of stimulation for the most effective treatment of drug addiction, to improve our comprehension of the treatment neurophysiological effects, and to conduct rigorous, controlled efficacy studies with adequate power.

Stimulation of the tibial nerve evokes a P30 far-field potential over the scalp which, like the median nerve P14, probably originates in the vicinity of the cervico-medullary junction. Unlike the P14 potential, P30 recording has not been systematically performed in clinical practice, probably because of doubts about the generator of the potential and the possibility of consistently recording it on the scalp after the unilateral stimulation of the tibial nerve. In this study, we tested the reliability of the tibial nerve scalp far-field P30 potential in 34 normal subjects using different montages, of which the Fpz-Cv6 derivation gave the highest signal to noise ratio, making it possible to obtain a P30 potential peaking at 29.2 +/- 1.6 msec in all normal subjects. This suggests that this component should to be included in the routine recording of tibial nerve SEPs in order to evaluate the spinal and intracranial conduction of the somatosensory pathway separately.

Non-invasive pulsed arterial spin labeling (PASL) MRI is a method to study brain perfusion that does not require the administration of a contrast agent, which makes it a valuable diagnostic tool as it reduces cost and side effects. The purpose of the present study was to establish the viability of PASL as an alternative to dynamic susceptibility contrast (DSC-MRI) and other perfusion imaging methods in characterizing changes in perfusion patterns caused by seizures in epileptic patients. We evaluated 19 patients with PASL. Of these, the 9 affected by high-frequency seizures were observed during the peri-ictal period (within 5 hours since the last seizure), while the 10 patients affected by low-frequency seizures were observed in the post-ictal period. For comparison, 17/19 patients were also evaluated with DSC-MRI and CBF/CBV. PASL imaging showed focal vascular changes, which allowed the classification of patients in three categories: 8 patients characterized by increased perfusion, 4 patients with normal perfusion and 7 patients with decreased perfusion. PASL perfusion imaging findings were comparable to those obtained by DSC-MRI. Since PASL is a) sensitive to vascular alterations induced by epileptic seizures, b) comparable to DSC-MRI for detecting perfusion asymmetries, c) potentially capable of detecting time-related perfusion changes, it can be recommended for repeated evaluations, to identify the epileptic focus, and in follow-up and/or therapy-response assessment.

Background The rapid spread of devices generating electromagnetic fields (EMF) has raised concerns as to the possible effects of this technology on humans. The auditory system is the neural organ most frequently and directly exposed to electromagnetic activity owing to the daily use of mobile phones. In recent publications, a possible correlation between mobile phone usage and central nervous system tumours has been detected. Very recently a deterioration in otoacoustic emissions and in the auditory middle latency responses after intensive and long-term magnetic field exposure in humans has been demonstrated. Methods To determine with objective observations if exposure to mobile phone EMF affects acoustically evoked cochlear nerve compound action potentials, seven patients suffering from Ménière's disease and undergoing retrosigmoid vestibular neurectomy were exposed to the effects of mobile phone placed over the craniotomy for 5&emsp14;min. Results All patients showed a substantial decrease in amplitude and a significant increase in latency of cochlear nerve compound action potentials during the 5&emsp14;min of exposure to EMF. These changes lasted for a period of around 5&emsp14;min after exposure. Discussion The possibility that EMF can produce relatively long-lasting effects on cochlear nerve conduction is discussed and analysed in light of contrasting previous literature obtained under non-surgical conditions. Limitations of this novel approach, including the effects of the anaesthetics, craniotomy and surgical procedure, are presented in detail.

The purpose of the present work was to investigate the correlation between topographical changes in brain oscillatory activity and the blood oxygenation level-dependent (BOLD) signal during a motor imagery (MI) task using electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) coregistration. EEG was recorded in 7 healthy subjects inside a 1.5 T MR scanner during the imagination of the kinesthetic experience of movement. A Fast Fourier Transform was applied to EEG signal in the rest and active conditions. We used the event-related-synchronization (ERS)/desynchronization (ERD) approach to characterize where the imagination of movement produces a decrease in alpha and beta power. The mean alpha map showed ERD decrease localized over the contralateral sensory motor area (SM1c) and a light desynchronization in the ipsilateral sensory motor area (SM1i); whereas the mean beta map showed ERD decrease over the supplementary motor area (SMA). fMRI showed significant activation in SMA, SM1c, SM1i. The correlation is negative in the contralateral side and positive in the ipsilateral side. Using combined EEG-fMRI signals we obtained useful new information on the description of the changes in oscillatory activity in alpha and beta bands during MI and on the investigation of the sites of BOLD activity as possible sources in generating these rhythms. By correlating BOLD and ERD/ERS we may identify more accurately which regions contribute to changes of the electrical response.

WOS: 000264016900002, PubMed ID: 19197564, A group of clinicians from across Europe experienced in the use of botulinum toxin type a for the treatment of spasticity following acquired brain injury gathered to develop a consensus statement on best practice in managing adults with spasticity. this consensus table summarizes the current published data, which was collated following extensive literature searches, their assessment for level of evidence and discussion among the whole group. published information is supplemented by expert opinion based on clinical experience from 16 European countries, involving 28 clinicians, who treat an average of approximately 200 patients annually, representing many thousand spasticity treatments with botulinum toxin per year., AllerganAllergan; Ipsen; Merz; Elan; MedtronicMedtronic; NovartisNovartis; BoehringerBoehringer Ingelheim, J. Wissel has received unrestricted educational grants and sponsorship from Allergan, Ipsen, Merz and Elan. He has also received honoraria from Allergan, Ipsen, Merz, Elan and Medtronic. A. Ward has received unrestricted educational grants and sponsorship from Allergan and Medtronic for carrying out research studies. He has also received honoraria from Allergan, Ipsen and Medtronic. P. Erztgaard receives educational grants from Allergan for educating doctors in the use of botulinum toxin. M. J. Hecht has received honoraria from Allergan, Ipsen, Merz and Elan. P. Schnider has received honoraria from Allergan, Ipsen and Merz. M. C. Altavista has received honoraria for lectures from Novartis and Boehringer. T. Deltombe has received an honorarium for chairing a meeting and sponsorship for running teaching workshops from Allergan. E. Duarte has received honoraria for lectures from Allergan. A. C. H. Geurts has received a research grant from Allergan and Ipsen. J.-M. Gracies has consultancies with Allergan, Ipsen, Merz, and Solstice. N. Haboubi has received honoraria for lectures from Allergan. F. J. Juan has received honoraria for organizing training and teaching courses for doctors from Allergan and Ipsen. C. K tterer is a consultant to Allergan. Y. Parman has received honoraria from Allergan and Ipsen. T. Paternostro-Sluga has received honoraria for lecturing and training from Allergan. R. Prempeh has received grants and honoraria for lecturing and training from Allergan and Ipsen. M. Rousseaux has received honoraria for organizing training and teaching courses for doctors from Allergan. J. Slawek has been a medical consultant to Allergan, Ipsen, Merz, Roche, Glaxo-SmithKline, Worwag-Pharma and Schwartz-Pharma. N. Tieranta has received honoraria for lectures from Allergan. All other authors (D. Bensmail, S. Cavazza, H. Kasch, Y. Kirazli, T. M. Lejeune, P. Manganotti, K. Petropoulou) have no conflicts of interest and are not in receipt of pharmaceutical industry funding.

We report the first case, to our knowledge, of non-ketotic hyperglycemic (NKH) related occipital seizures studied by continuous EEG-fMRI in an undiagnosed diabetic patient. Ictal EEG showed left posterior spikes and sharp-waves. Seizures subsided after insulin therapy was started. Continuous EEG-fMRI was performed and BOLD activation was identified in the left Brodmann's area 18 (visual association area). Activation of an epileptic focus related with the patient's metabolic disturbance can be postulated.

Optimal treatment of spasticity requires a combination of pharmacotherapy and muscle lengthening. We evaluated 13 stroke patients with equinovarus foot randomized to treatment with either botulinum toxin A (BTA) injection plus ankle-foot casting (n=6) or BTA alone (n=7). The tibialis posterior and calf muscles (range of BTA injection: 190 to 320 U) were treated in each patient. Castings were worn at night for four months. Each patient was examined before, and at two and four months after BTA injection using the static and dynamic baropodometric tests, the Modified Ashworth Scale and the 10-meter walking test. At two months, therapeutic effects were observed in both groups. At four months, the study group showed further clinical improvement, while the control group returned to baseline performance. Thus, prolonged stretching of spastic muscles after BTA injection affords long-lasting therapeutic benefit, enhancing the effects of the toxin alone.

Purpose To verify whether in patients with partial epilepsy and routine electroenecephalogram (EEG) showing focal interictal slow-wave discharges without spikes combined EEG–functional magnetic resonance imaging (fMRI) would localize the corresponding epileptogenic focus, thus providing reliable information on the epileptic source. Methods Eight patients with partial epileptic seizures whose routine scalp EEG recordings on presentation showed focal interictal slow-wave activity underwent EEG–fMRI. EEG data were continuously recorded for 24 min (four concatenated sessions) from 18 scalp electrodes, while fMRI scans were simultaneously acquired with a 1.5-Tesla magnetic resonance imaging (MRI) scanner. After recording sessions and MRI artefact removal, EEG data were analyzed offline. We compared blood oxygen level-dependent (BOLD) signal changes on fMRI with EEG recordings obtained at rest and during activation (with and without focal interictal slow-wave discharges). Results In all patients, when the EEG tracing showed the onset of focal slow-wave discharges on a few lateralized electrodes, BOLD-fMRI activation in the corresponding brain area significantly increased. We detected significant concordance between focal EEG interictal slow-wave discharges and focal BOLD activation on fMRI. In patients with lesional epilepsy, the epileptogenic area corresponded to the sites of increased focal BOLD signal. Conclusions Even in patients with partial epilepsy whose standard EEGs show focal interictal slow-wave discharges without spikes, EEG–fMRI can visualize related focal BOLD activation thus providing useful information for pre-surgical planning.