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Cerebral aneurysms are occasionally associated with anomalies of the cerebral arteries. Most reports on anomalies of the anterior cerebral artery have been concerned with hypoplasia, fenestration and the infra-optic course of the A1, variant A1 perforators or Heubner's artery, multichanneled anterior communicating artery, and azygos anterior cerebral artery. Distal anterior cerebral artery (ACA) aneurysms are known to have a poor clinical course and prognosis compared to other supratentorial aneurysms. The presence of the unpaired, distal, postcommunicating (A2) segment of the ACA is very rare in adults. We describe a patient with a ruptured aneurysm arising from the proximal end of the azygos ACA, first surgically treated with clipping and then with endovascular coiling. A 37-year-old woman at 34 weeks'gestation was transferred to our emergency room with sudden onset of severe headache and vomiting. Computed tomography (CT) revealed subarachnoid hemorrhage in the basal cisterna and the sylvian and interhemispheric fissures. Cerebral angiography showed an azygos ACA, a saccular aneurysm at the junction of the azygos ACA and the right A1 segment. A right fronto-temporal craniotomy was performed in the day of admission, and the neck of the aneurysm was clipped. One year later, an angiographic control examination revealed a regrowth of the aneurysm. The patient underwent endovascular treatment with coiling. Aneurysms of the azygos ACA are rare and their pathogenesis and course are still a matter of discussion. Developmental abnormalities or dynamic vessel wall stresses can explain the high incidence of aneurysms in these cases. The association of a rare anatomical variant with an aneurysm in the same location may suggest an embryogenesis alteration in the Willis circulation. [ABSTRACT FROM AUTHOR]

Background: Driving is a complex ability requiring a broad range of motor, cognitive-behavioral and visual skills that may be impaired after severe acquired brain injury (sABI). Resumption of driving is perceived as a major need by patients, being closely linked to personal autonomy, work and social activities., Aim: The objective of this study was to identify a short battery of neuropsychological tests with predictive value with regard to safe return to driving after sABI., Design: Observational study., Setting: Outpatient of a rehabilitation center for sABI., Population: A continuous series of 127 patients with stable sABI, well-reintegrated at a family and social level, dismissed since at least one year from the end of their intensive rehabilitation, enrolled between 2006 and 2014., Methods: Patients underwent an extensive battery of neuropsychological tests (pencil and paper and specific PC programs), aimed at assessing cognitive functions, in performance and verbal tasks. The results were analyzed in relation to their on-road performance during the driving test conducted by the office of the Italian Government Authority (success or failure of the test)., Results: No correlations were found between demographic data, etiology, driving experience, verbal competence and the decision of the competent authority. Significant correlation was found between attention, executive functions, overall visual-spatial exploration and driving performance., Conclusions: Both "pencil and paper" and computerized tests in the cognitive domains of attentive functions, and those involving performance with visual-spatial material, are significantly correlated with the driving test outcome, even if there is not enough evidence of the relative value of off-road compared to direct on-road tests., Clinical Rehabilitation Impact: We propose a small neuropsychological battery of tests with normative data for Italian population, predictive with respect to the ability to drive safely. We recommend to use it as first screening before submitting patients to more demanding and risky on-road driving tests.

A 51-year-old woman was admitted to the emergency unit with diffuse headache, visus reduction, and paraesthesias of the trigeminal area and the left hand. Three days after admission she showed shaking chills, vomiting, and sudden onset of fever (39·4°C). Blood cultures were performed soon after fever onset. Fever persisted for the whole day, decreasing slowly after 12 hours. No empirical antibiotic treatment was started in order to better define the diagnosis. Fever completely disappeared the day after. Two blood cultures for aerobes were positive for Chryseobacterium indologenes. The patient was discharged with the diagnosis of transient bacteraemia and transferred to the neurology unit for further investigations. C. indologenes infections are described in 31 studies with a total of 171 cases (pneumonia and bacteraemia being the most frequent). Our case is the first report of transient bacteraemia caused by C. indologenes in an immunocompetent, non-elderly patient without needing medical devices.

Patients with neglect show disorders in horizontal space perception. It has been argued that these disorders may depend on a distortion of space that takes the form of a left-right relaxation of the representational medium that becomes progressively "relaxed" toward the contralesional space and progressively "compressed" toward the ipsilesional space (the space anisometry hypothesis). In the present paper we tested this hypothesis by using the Oppel-Kundt illusion that consists of the perception of a filled space as larger than an empty space of the same size. Two experiments were carried out with 14 brain-damaged patients with neglect, 9 brain-damaged patients without neglect and 12 healthy subjects. In the first experiment participants were requested to bisect and read words with different letter spacing simulating the way space is thought to be distorted in neglect. In the second experiment we asked the participants to physically and numerically bisect numerical intervals. The results of the two experiments are in line with the predictions of the space anisometry hypothesis. Specifically, with a background resembling the space distortion proposed by the space anisometry hypothesis, neglect signs are ameliorated in reading words and in numerically bisect numerical intervals, while they are worsened in bisecting words and physically bisect numerical intervals. These results support the idea that the abnormalities observed in typical neglect tests are due to a distorted internal representation of the outside world that takes the form of a mental continuum logarithmically distorted along the horizontal dimension., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

The observation of touch can be grounded in the activation of brain areas underpinning direct tactile experience, namely the somatosensory cortices. What is the behavioral impact of such a mirror sensory activity on visual perception? To address this issue, we investigated the causal interplay between observed and felt touch in right brain-damaged patients, as a function of their underlying damaged visual and/or tactile modalities. Patients and healthy controls underwent a detection task, comprising visual stimuli depicting touches or without a tactile component. Touch and No-touch stimuli were presented in egocentric or allocentric perspectives. Seeing touches, regardless of the viewing perspective, differently affects visual perception depending on which sensory modality is damaged: In patients with a selective visual deficit, but without any tactile defect, the sight of touch improves the visual impairment; this effect is associated with a lesion to the supramarginal gyrus. In patients with a tactile deficit, but intact visual perception, the sight of touch disrupts visual processing, inducing a visual extinction-like phenomenon. This disruptive effect is associated with the damage of the postcentral gyrus. Hence, a damage to the somatosensory system can lead to a dysfunctional visual processing, and an intact somatosensory processing can aid visual perception.

Crossing the hands over the midline reduces left tactile extinction to double simultaneous stimulation in right-brain-damaged patients, suggesting that spatial attentional biases toward the ipsilesional (right) side of space contribute to the patients' contralesional (left) deficit. We investigated (1) whether the position of the left hand, and its vision, affected processing speed of tactile stimuli, and (2) the electrophysiological underpinnings of the effect of hand position. (1) Four right-brain-damaged patients with spatial neglect and contralesional left tactile extinction or somatosensory deficits, and eight neurologically unimpaired participants, performed a speeded detection task on single taps delivered on their left index finger. In patients, placing the left hand in the right (heteronymous) hemi-space resulted in faster reaction times (RTs) to tactile stimuli, compared to placing that hand in the left (homonymous) hemi-space, particularly when the hand was visible. By contrast, in controls placing the left hand in the heteronymous hemi-space increased RTs. (2) Somatosensory event-related potentials (ERPs) were recorded from one patient and two controls in response to the stimulation of the left hand, placed in the two spatial positions. In the patient, the somatosensory P70, N140, and N250 components were enhanced when the left hand was placed in the heteronymous hemi-space, whereas in controls these components were not modulated by hand position. The novel findings are that in patients placing the left hand in the right, ipsilesional hemi-space yields a temporal advantage in processing tactile stimuli, and this effect may rely on a modulation of stimulus processing taking place as early as in the primary somatosensory cortex, as indexed by evoked potentials. Furthermore, vision enhances tactile processing specifically when the left hand is placed in the hemi-space toward which the patients' attentional biases are pathologically directed, namely rightwards.

Following brain damage, typically of the right hemisphere, patients can show reduced awareness of sensory events occurring in the space contralateral to the brain damage. The present work shows that a hypnotic suggestion can temporarily reduce tactile extinction to double bilateral stimulation, i.e., a loss of contralesional stimuli when these are presented together with ipsilesional ones. Patient EB showed an improved detection of contralesional targets after a single 20-min hypnosis session, during which specific suggestions were delivered with the aim of increasing her insight into somatosensory perception on both sides of the body. Simple overt attention orienting toward the contralesional side, or a hypnotic induction procedure not accompanied by specifically aimed suggestions, were not effective in modulating extinction. The present result is the first systematic evidence that hypnosis can temporarily improve a neuropsychological condition, namely Extinction, and may open the way for the use of this technique as a fruitful rehabilitative tool for brain-damaged patients affected by neuropsychological deficits.

The Five-Point Test is one of the various measures of figural fluency functions that have been developed as nonverbal analogues to word fluency tasks, and used in neuropsychological assessment to evaluate the ability to initiate and sustain mental productivity, and to self-monitor and regulate responding in the visual-spatial domain. The aim of the current study was to collect normative data for a version of the Five-Point Test (M-FPT) administered to a sample of Italian healthy adults aged 16-60 (n = 332). Performance on the M-FPT was scored by computing the cumulative number of unique designs (UDs) performed on a 3-min administration time. Two supplemental scores were also computed: (a) the cumulative strategies (CSs) consisting with the number of UDs incorporated into enumerative or rotational strategies; (b) the error index (ErrI), consisting with the percentage between the number of perseverative or rule-breaking errors and the number of designs overall. Multiple regression analyses revealed a significant effect of age and education, but not gender, for both UDs and CSs. Equivalent scores and cut-off scores were then determined for UDs and CSs. Descriptive statistical analyses and cut-off scores were reported for ErrI. The availability of normative data for the M-FPT will be valuable in clinical settings for assessing of executive dysfunctions on the visual-spatial subdomain of subjects with brain injury. However, in order to increase the usefulness of the test, the upper limits of the age range of the normative sample should be widened. Moreover, further analyses should be required for determining the inter-rater and test-retest reliability for M-FPT performances, and providing evidence of the sensitivity of this measure to brain disturbances generally and to frontal lobe dysfunction specifically.

Objective: Adaptation to prisms displacing the visual scene rightward is a therapeutic tool for left unilateral spatial neglect (USN). We aimed at comparing the effects of the classic adaptation procedure (repeated pointing toward visual targets, control treatment, C), with those of a novel adaptation method, involving ecological visuomotor activities (experimental treatment, E)., Method: In 10 right-brain-damaged USN patients, each treatment was given for 1 week, with a crossover design, for a total of 20 sessions, twice per day. USN was assessed by cancellation, reading, and drawing tasks, and by a standardized scale. Neurological severity was assessed by the National Institutes of Health (NIH) stroke scale (Brott et al., 1989), disability by the Functional Independence Measure (FIM) scale., Results: The 2-week treatments (EC, CE) were equally effective, improving both USN, confirming previous reports (Frassinetti, Angeli, Meneghello, Avanzi, & Làdavas, 2002) and, importantly, disability. The improvement was independent of baseline performance, duration of disease, and neurological severity. Recovery took place after the first week, continued in the second week, and was stable at the follow-up of 3 months. The improvement of USN, measured by cancellation performance, and, in part, that of disability, measured through the FIM scale, were mediated by the size of the leftward aftereffects, suggesting a causal relationship between prism exposure and recovery. The E protocol was better tolerated., Conclusions: Daily life visuomotor activities, associated with prism exposure, are a useful tool for rehabilitating USN patients. This new treatment may widen the compliance with prism exposure treatments and their feasibility within home-based programs.

Body parts are represented in the brain in a very specific fashion, as compared to other three-dimensional objects, with reference to their prototypic shape and multisensory coding. However, evidence is lacking about the spatial representation of body parts. To address this issue, in Experiment 1 we first compared the metric representation of body parts and of non-bodily objects in 14 right-brain-damaged patients with left unilateral spatial neglect (USN), and in 14 neurologically unimpaired control participants. Participants bisected, by manual pointing, a three-dimensional object, or their own left forearm. Patients showed the well-known ipsilesional rightward displacement of the subjective midpoint, in both forearm and solid bisection. Both USN patients and control participants were overall more accurate in the bisection of their own forearm, relative to the extracorporeal object. In four patients this advantage of the forearm was significant in a single-case analysis, while two patients showed the opposite dissociation, being more accurate with the solid object. In Experiment 2 neurologically unimpaired participants were more accurate in the bisection of a fake forearm, as well as of their own forearm, as compared to the extrapersonal object. Overall, the results indicate that the representation of the metric of the body is more reliable than that of extrapersonal objects, and also more resistant to the disruption of spatial representations brought about by USN, possibly due to the prototypical shape of body parts. Furthermore, the double dissociation found in USN patients suggests that the metrics of body parts and of extrapersonal objects are supported by independent spatial processes.

Aim: The assessment of major obstacles to community integration which may result from an acquired brain injury (ABI) is needed for rational planning and effective management of ABI patients' social adjustment. Currently, such a generally acceptable measure is not available for the Italian population. This paper reports the translation process, the internal consistency, and the inter-rater reliability data for the Italian version of the Mayo-Portland Adaptability Inventory-4 (MPAI-4), a useful measure with highly developed and well documented psychometric properties. The MPAI-4 is specifically designed to assess socially relevant aspects of physical status and cognitive-behavioural competence following ABI. It is a 29-item inventory which is divided into three subdomains (Abilities, Adjustment, and Participation indices) covering a reasonably representative range, Methods: Twenty ABI patients with at least one-year discharge from the rehabilitation facilities were submitted to the Italian MPAI-4. They were independently rated by two different rehabilitation professionals and a family member/significant other serving as informant (SO). Internal consistency was assessed by calculating the Cronbach's alpha values. Inter-rater agreement for individual items was statistically examined by determining the interclass correlation coefficient (ICC)., Results: In addition to the 8% of perfectly correspondent sentences, a clear prevalence (75.5%) of minor semantic variations and formal variations with no semantic value at the sentence-to-sentence matching was found. Full-scale Cronbach's alpha was 0.951 and 0.947 for the two professionals (rater #1 and rater #2, respectively), and was 0.957 for the family member serving as informant (rater #3). Full-Scale ICC (2.1) between professionals and SOs was 0.804 (CI=95%; lower-upper bound=0.688-0.901)., Conclusions: The Italian MPAI-4 shares many psychometric features with the original English version, demonstrates both good internal consistency and good inter-rater reliability. The MPAI-4 confirms to be suitable for research applications in postacute settings as an efficient, broad and inclusive outcome measure for adult subjects with ABI.

Neglect can be ego-centered or object-centered depending on the reference frames for "left" and "right", of either the body or an object. It has been suggested that object-centered neglect is not a general phenomenon but is limited to words because only they have a true canonical representation. Here, we examined whether object-centered neglect could be observed for non-verbal material by creating, after repeated exposure, a canonical representation of a nonsense figure. Fourteen neglect patients repeatedly bisected a series of asymmetrical nonsense drawings containing two different shapes at their right and left end-points (canonical trials). In the critical trials, which were the last three in the series, the position of the two shapes was mirror-reversed. Afterwards, neglect patients were asked to draw the stimulus, which provided a further measure of whether a canonical representation of the object has been built by the patients. All the patients made rightward errors with the canonical stimuli. With mirror-reversed stimuli, the bisection errors were reversed to the contralesional side in one patient, returned to zero in one patient and significantly decreased in three patients. In addition, 10 patients reliably drew the canonical stimulus at the end of the series of trials, providing an indication that they built up a canonical representation of the stimulus. The present data provide evidence that object-centered neglect is a phenomenon that is not limited to words. The nature of a stimulus, verbal or non-verbal, is not critical for observing object-centered neglect. What is critical is the way in which material is represented by the patients.

Perseveration in target cancellation tasks and in drawing by copy and from memory was investigated in 21 right-brain-damaged patients, seven with no evidence of left visuo-spatial neglect, and 14 with neglect. Eight such neglect patients showed perseveration in both cancellation and drawing tasks, although no correlation was found with the severity of neglect. Patients with perseveration were not disproportionately impaired in tasks assessing executive (fluency, Stroop colour-word interference, and Weigl's sorting test), and visuo-spatial short-term memory function. In the context of a two-component hypothesis, graphic perseveration (the first component) is a specific disorder that manifests in a variety of tasks, particularly those requiring serial graphic production. Unilateral spatial neglect (the second component) may trigger and facilitate the production of perseveration errors, with a contra-ipsilateral gradient of increasing severity.

Human eyes are a powerful social cue that may automatically attract the attention of an observer. Here we tested whether looking toward open human eyes, as often arises in standard clinical "confrontation" tests, may affect contralesional errors in a group of right brain-damaged patients showing visual extinction. Patients were requested to discriminate peripheral shape-targets presented on the left, right, or bilaterally. On each trial they also saw a central task-irrelevant stimulus, comprising an image of the eye sector of a human face, with those seen eyes open or closed. The conditions with central eye stimuli open (vs closed) induced more errors for contralesional peripheral targets, particularly for bilateral trials. These results suggest that seeing open eyes in central vision may attract attentional resources there, reducing attention to the periphery, particularly for the affected contralesional side. The seen gaze of the examiner may thus need to be considered during confrontation testing and may contribute to the effectiveness of that clinical procedure.

Neglect patients, when asked to bisect a horizontal line, typically show large rightward errors with long lines and a decreased error with medium length lines. With very short lines the bisection bias reverses from the right to left side of the line physical centre (the so-called crossover effect). It is commonly pointed out that such a leftward bias is difficult to explain by traditional theories of neglect. Several accounts propose two distinct mechanisms, one that works for short lines and one that works for long. In the present study we demonstrated that the crossover effect can be explained by means of a unitary mechanism that derives from the space anisometry hypothesis. This hypothesis postulates that in neglect patients representational space is progressively 'relaxed' contralesionally and progressively 'compressed' ipsilesionally. In a series of five experiments, we investigated the crossover effect in 26 right-brain damaged patients: 17 with neglect without hemianopia, 4 with neglect and hemianopia and 6 without neglect or hemianopia. Patients were to bisect or extend lines of objectively and subjectively different lengths. The modulation of subjective length was created by an Oppel-Kundt illusion that is thought to resemble the distortion of representational space that occurs with neglect. All groups, except for the patients with neglect and hemianopia, were prone to the illusion. The rightward bias was reduced when the illusion induced a perceptual distortion opposite to that thought to underlie neglect. Importantly, the strength of the illusion decreased with reducing the physical line length and reversed with very short lines. These results argue for a simple and unitary explanation of the crossover effect in spatial neglect within the framework of the space anisometry hypothesis.

Aim: It is important to assess aphasics' quality of life in order to plan a rehabilitation treatment. To date such a tool is still missing for Italian patients. This paper reports normative data of the Italian version of SAQOL-39, a British questionnaire aimed to assess aphasics' quality of life. It consists of 39 items, divided into 4 subdomains (Physical, Communication, Psychosocial and Energy)., Methods: Forty-two patients coming from 3 different Speech Therapy Services were enrolled. All patients completed speech therapy before examination. They were submitted to the Italian SAQOL-39 and 2 screening tests for aphasia: 1) Communication Assessment Scale according Goodglass and Kaplan; 2) Franchay Aphasia Screening Test (FAST). A receptive FAST score of 7 out of 15 was used as a cut-off score for SAQOL-39 administration., Results: The Italian SAQOL-39 showed good internal consistency (full scale Cronbach's alpha 0.939). Cronbach's alpha for every subdomains ranged from 0.950 (Communication) to 0.720 (Energy). Fluent aphasics gave significantly higher scores than nonfluent ones on full scale, and all out of Energy subdomains. Furthermore gravity of aphasia correlated with both full scale and Communication subdomain scores., Conclusions: In authors' opinion, the Italian SAQOL-39 shares many psychometric features with the English one. This questionnaire seems to be suitable for clinical practice.

Aim: In recent times there has been an increasing interest in assessing the quality of life (QOL) in stroke clinical trials. To our knowledge, an Italian tool suitable for this purpose is still missing. So we adapted to Italian language the Stroke and Aphasia Quality of Life Scale-39 (SAQOL-39), that is a British questionnaire recently validated with aphasic subjects. The aim of this paper is to validate our version of SAQOL-39., Methods: To determine the matching of our version, we requested a native English speaker to translate the Italian version into English. Twelve patients (7 male, 5 female; mean age 66.4 years) were submitted to our test. All subjects were interviewed twice by 2 raters, at 24 h of distance. Neither examinator knew results of the other interview. Statistical analysis was performed by determining Cronbach's a and the intraclass correlation coefficient (ICC)., Results: Comparing the original SAQOL-39 to the English translation of our Italian version, we found only a low percentage (10%) of minimal semantic variations. As for test-retest reliability, ICC for global score was 0.898 (ICC(2,39)). ICC range for SAQOL-39 subdomains was 0.816 to 0.969. Cronbach's a for full scale scores was 0.916 (subdomains ranged 0.767 to 0.976). Results seem good as for usefulness, reliability and acceptability of the Italian version of SAQOL-39, like the original version of this test., Conclusions: Our Italian version of SAQOL-39 seems suitable for clinical use. A multicentric study aiming to compare our data to original English ones is in progress.

In a first experiment, 11 neglect patients repeatedly bisected the elongated caricature of a basset hound with head on the right and tail on the left side with respect to the viewer. On the last (critical) trial, in which the figure was left-right reversed, the bisection error towards the ipsilesional side reversed its direction in three patients and significantly decreased in one patient. In a second experiment, 13 different neglect patients had to bisect the elongated caricature of the basset hound with head on the left and tail on the right side. On the last trial, the bisection error reversed its direction in three patients and significantly decreased in three patients. These results suggest that object-centred neglect (OCN) may affect newly established knowledge about the canonical orientation of a non-verbal visual stimulus.

This paper describes a case of Ollier's disease, an uncommon, nonhereditary skeletal disorder affecting enchondral ossification. The patient was referred to our Rehabilitation Unit after resection of scapular chondroma. He had previously been submitted to several surgical treatments for multiple enchondromatosis. Rehabilitation goals were increasing range of motion, relieving pain and training activities of daily living (ADL). After one month treatment, the patient reported pain relief and showed good improvement of articular function and better performances on ADL. According to our experience, it seems that rehabilitation could play a complementary role as regards surgical treatment of this complex pathology.

A patient who developed a unilateral opercular syndrome following a cerebrovascular accident is described. Computed tomography showed that the lesion did not affect the opercular cortex, but involved deep white matter and the head of the caudate nucleus of the left hemisphere. Persistent hypophonia and transient aphasia were associated. Comparison with previous cases is discussed.

The case of an Italian dysgraphic patient (S.E.), who showed a deficit of both written and oral spelling capacities, without significant differences between words and nonwords, is reported. The pattern of the patient's performance was identical on writing to dictation, delayed copying, and written naming. The most common category of errors was single-letter deletions, and errors were predominantly made in medial positions. Stimulus length appeared to be the single factor that most affected performance. This pattern is consistent with the hypothesis that S.E.'s spelling disorder results from selective damage of the Graphemic Buffer. The case is discussed in relation to current functional models of writing and is compared with similar cases reported previously.

Temporary memory disorders following closed head injuries are presented, with special remark on the cases of transient global amnesia (TGA) triggered by head trauma. The relationship with idiopathic forms of TGA is discussed.

A Multivariate Analysis of Covariance and Discriminant Analysis were carried out on complete WAIS profiles obtained from three groups of demented patients: Multi-Infarct Dementia patients, Senile Dementia of Alzheimer Type patients, and Alcoholic Dementia patients. A group of middle-aged Depressed patients was also included. WAIS did not differentiate among dementias, but Picture Completion and Block Design subtests proved to be effective in differentiating dementia from depression.