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Delusion is a belief about yourself, people, or events that has no accordance with reality. Although it is known that stroke could cause various psychiatric and psychological effects, including depression, anxiety, and aggressiveness, psychotic symptoms, especially delusions, are rather uncommon. The most investigated poststroke delusions are paranoid type, nihilistic, and Fregoli syndrome. We will describe two patients showing delusion symptoms (Cotard-like and erotomanic ones) that occurred after a stroke involving the right temporal lobe, the basal ganglia and insular region, persisting for a long period after the stroke onset. We have, therefore, supposed that the simultaneous involvement of these brain areas could be involved in the neuroanatomical basis of delusions, as also demonstrated by the neurofunctional evaluation.

The assessment of behavioral responsiveness in patients suffering from chronic disorders of consciousness (DoC), including Unresponsive Wakefulness Syndrome (UWS) and Minimally Conscious State (MCS), is challenging. Even if a patient is unresponsive, he/she may be covertly aware in reason of a cognitive-motor dissociation, i.e., a preservation of cognitive functions despite a solely reflexive behavioral responsiveness. The approach of an external stimulus to the peripersonal space (PPS) modifies some biological measures (e.g., hand-blink reflex amplitude) to the purpose of defensive responses from threats. Such modulation depends on a top-down control of subcortical neural circuits, which can be explored through changes in cerebral blood flow velocity (CBFV), using functional transcranial Doppler (fTCD) and, thus, gaining useful, indirect information on brain connectivity. These data may be used for the DoC differential diagnosis. We evaluated the changes in CBFV by measuring the pulsatility index (PI) in 21 patients with DoC (10 patients with MCS and 11 with UWS) and 25 healthy controls (HC) during a passive movement and motor imagery (MI) task in which the hand of the subject approached and, then, moved away from the subject's face. In the passive movement task, the PI increased progressively in the HCs when the hand was moved toward the face and, then, it decreased when the hand was removed from the face. The PI increased when the hand was moved toward the face in patients with DoC, but then, it remained high when the hand was removed from the face and up to 30 s after the end of the movement in the patients with MCS (both MCS+ and MCS-) and 1 min in those with UWS, thus differentiating between patients with MCS and UWS. In the MI task, all the HCs, three out of four patients with MCS+, and one out of six patients with MCS- showed an increase-decrease PI change, whereas the remaining patients with MCS and all the patients with UWS showed no PI changes. Even though there is the possibility that our findings will not be replicated in all patients with DoC, we propose fTCD as a rapid and very easy tool to differentiate between patients with MCS and UWS, by identifying residual top-down modulation processes from higher-order cortical areas to sensory-motor integration networks related to the PPS, when using passive movement tasks.

Cognitive impairment occurs frequently in post-stroke patients. This study aimed to determine the effects of a virtual reality training (VRT) with BTs-Nirvana (BTsN) on the recovery of cognitive functions in stroke patients, using the Interactive-Semi-Immersive Program (I-SIP).We enrolled 12 subjects (randomly divided into two groups: experimental group (EG); and control group (CG)), who attended the Laboratory of Robotic and Cognitive Rehabilitation of IRCCS Neurolesi of Messina from January to June 2016. The EG underwent a VRT with BTsN, whereas CG received a standard cognitive treatment. Both the groups underwent the same conventional physiotherapy program. Each treatment session lasted 45 minutes and was repeated three times a week for 8 weeks. All the patients were evaluated by a specific clinical-psychometric battery before (T0), immediately (T1), and one month (T2) after the end of the training.At T1, the EG presented a greater improvement in the trunk control test (p = 0.03), the Montreal Cognitive Assessment (p = 0.01), the selective attention assessment scores (p = 0.01), the verbal memory (p = 0.03), and the visuospatial and constructive abilities (p = 0.01), as compared to CG. Moreover, such amelioration persisted at T2 only in the EG.According to these preliminary data, VRT with I-SIP can be considered a useful complementary treatment to potentiate functional recovery, with regard to attention, visual-spatial deficits, and motor function in patients affected by stroke.

Background Identifying the patients with mild cognitive impairment (MCI) who may develop dementia (MDC) is challenging. The study of peripersonal space (PPS) by using functional transcranial Doppler (fTCD) could be used for this purpose. Objective To identify changes in cerebral blood flow (CBF) during motor tasks targeting PPS, which can predict MDC. Methods We evaluated the changes in CBF in 22 patients with MCI and 23 with dementia [Alzheimer's disease (AD) and vascular dementia (VaD)] during a motor task (passive mobilization, motor imagery, and movement observation) in which the hand of the subject moved forward and backward the face. Results CBF increased when the hand approached the face and decreased when the hand moved from the face in the healthy controls (HCs). CBF changed were detectable only in patients with MCI but not in those with the AD and those who were MDC after 8-month follow-up. On the other hand, the patients with VaD presented a paradoxical response to the motor task (i.e., a decrease of CBF rather than an increase, as observed in HCs and MCI). Therefore, we found a modulation of PPS-related CBF only in HCs and patients with stable MCI (at the 8-month follow-up). Conclusions fTCD may allow preliminarily differentiating and following-up the patients with MCI and MDC, thus allowing the physician to plan beforehand more individualized cognitive rehabilitative training.

Background Acquired Brain injury (ABI) is a very critical event in a family, as it is a highly distressing and traumatic experience, imposing a very deep reorganization of the whole family. Objective This study aims to evaluate the possible correlation between the family aspects and the patients' functional outcomes after rehabilitation. Methods Fifteen patient-caregiver pairs were enrolled in the study. All the patients were assessed by using specific neuropsychological and functional scales, including the Family Adaptability and Cohesion Evaluation Scales, before and after treatment. Results The results reveal that when the caregiver is the son or the spouse (p = 0,71), the perception of the emotional and physical burden is stronger, while the scores related to the burden were lower in the presence of other kinds of relationship. The family functioning seems to be connected to the burden level for the caregivers. Furthermore, there is a significant correlation between the improvements observed in the patients during their rehabilitative training and the family dynamics. Conclusions in our opinion, the family plays a key role in allowing a suitable compliance of the patient to the treatments, and supports the processes of adaptive reorganization.

Cognitive impairment, as well as mood and anxiety disorders, occur frequently in patients following stroke. Aim of this study was to evaluate the effects of a combined rehabilitative treatment using conventional relaxation and respiratory techniques, in a specific rehabilitative virtual environment (by using Bts-Nirvana). A 58-year-old woman, affected by hemorrhagic stroke, underwent two different rehabilitation trainings, including either standard relaxation techniques alone in a common clinical setting or the same psychological approach in a semi-immersive virtual environment with an augmented sensorial (audio-video) and motor feedback (sensory motor-interaction). We evaluated the patient's cognitive and psychological profile before and after the two different trainings, by using a specific psychometric battery, aimed to assess cognitive status, attention processes and to estimate the presence of mood alterations, anxiety and coping strategies. Only at the end of the combined approach, we observed a significant improvement in attention and memory functions, with a nearly complete relief of anxiety symptoms and an improvement in coping strategies. Relaxation and respiratory techniques in a semi-immersive virtual reality environment, using Bts-Nirvana, may be a promising tool in improving attention process, coping strategies, and anxiety in individuals with neurological disorders, including stroke.

After experiencing a stroke in the right hemisphere, almost 50% of patients show unilateral spatial neglect (USN). Virtual Reality technologies offer impressive opportunities for both the rehabilitation and assessment of different cognitive deficits, including USN. A 57-year-old woman, affected by subarachnoid hemorrhage presented a severe left hemiparesis with severe cognitive and behavioral alterations, including temporal and spatial disorientation, reduction of attention and memory process, slowing ideation, USN, and depression of mood. She underwent two different rehabilitation trainings, including standard cognitive training (SCT) in addition to semi-immersive virtual training with her shadow (S-IVT_s) and SCT in addition to a Semi- immersive virtual training, without her shadow (S-IVT). The patient was assessed before and after each of the two different trainings, by using a specific psychometric battery and the event related potential, P300. Only at the end of the use of the S-IVT, we observed a significant improvement in the motor and cognitive function, with regard to USN. SCT in addition to S-IVT with Bts-Nirvana System may be a promising approach in improving attention process, spatial cognition, and mood in patients with post stroke USN, as also demonstrated by the electrophysiological parameters.

Background Cognitive impairment after stroke is common and can cause disability with a high impact on quality of life and independence. Cognitive rehabilitation is a therapeutic approach designed to improve cognitive functioning after central nervous system's injuries. Computerized cognitive rehabilitation (CCR) uses multimedia and informatics resources to optimize cognitive compromised performances. The aim of this study is to evaluate the effects of pc cognitive training with Erica software in patients with stroke. Methods We studied 35 subjects (randomly divided into 2 groups), affected by either ischemic or hemorrhagic stroke, having attended from January 2013 to May 2015 the Laboratory of Robotic and Cognitive Rehabilitation of Istituto di Ricerca e Cura a Carattere Scientifico Neurolesi in Messina. Cognitive dysfunctions were investigated through a complete neuropsychological battery, administered before (T0) and after (T1) each different training. Results At T0, all the patients showed language and cognitive deficits, especially in attention process and memory abilities, with mood alterations. After the rehabilitation program (T1), we noted a global cognitive improvement in both groups, but a more significant increase in the scores of the different clinical scales we administered was found after CCR. Conclusions Our data suggest that cognitive pc training by using the Erica software may be a useful methodology to increase the post-stroke cognitive recovery.

Managing individuals with chronic disorders of consciousness raises ethical questions about the appropriateness of maintaining life-sustaining treatments and end-of-life decisions for those who are unable to make decisions for themselves. For many years, the positions fostering the "sanctity" of human life (i.e., life is inviolable in any case) have led to maintaining life-sustaining treatments (including artificial nutrition and hydration) in patients with disorders of consciousness, allowing them to live for as long as possible. Seldom have positions that foster "dignity" of human life (i.e., everyone has the right to a worthy death) allowed for the interruption of life-sustaining treatments in some patients with disorders of consciousness. Indeed, most ethical analyses conclude that the decision to interrupt life-sustaining therapies, including artificial nutrition and hydration, should be guided by reliable information about how the patient wants or wanted to be treated and/or whether the patient wants or wanted to live in such a condition. This would be in keeping with the principles of patient-centered medicine, and would conciliate the duty of respecting both the dignity and sanctity of life and the right to a worthy death. This "right to die" has been recognized in some countries, which have legalized euthanasia and/or physician-assisted suicide, but some groups fear that legalizing end-of-life decisions for some patients may result in the inappropriate use of euthanasia, both voluntary and nonvoluntary forms (slippery slope argument) in other patients. This review describes the current opinions and ethical issues concerning end-of-life decisions in patients with disorders of consciousness, with a focus on the impact misdiagnoses of disorders of consciousness may have on end-of-life decisions, the concept of "dignity" and "sanctity" of human life in view of end-of-life decisions, and the risk of the slippery slope argument when dealing with euthanasia and end-of-life decisions. We argue that the patient's diagnosis, prognosis, and wishes should be central to determining the most appropriate therapeutic approach and end-of-life decisions for that individual. Each patient's diagnosis, prognosis, and wishes should also be central to legislation that guarantees the right to die and prevents the slippery slope argument through the establishment of evidence-based criteria and protocol for managing these patients with disorders of consciousness.

BACKGROUND Multiple sclerosis (MS) is a demyelinating disease, affecting both the sensorimotor and cognitive systems. The typical pattern of cognitive impairment includes reduced speed of information processing, decreased phonological and semantic speech fluency, deficits in verbal and visual episodic memory, as well as attention and executive dysfunctions. We aimed to investigate the influence of the neurologic music therapy (NMT) on mood, motivation, emotion status, and cognitive functions in patients with MS. METHODS Thirty patients with MS were randomly divided in 2 groups: the control group (CG) undergoing conventional cognitive rehabilitation (CCR), 6 times a week for 8 weeks, and the experimental group (EG) undergoing CCR 3 times a week for 8 weeks plus NMT techniques, performed 3 times a week for 8 weeks. All the participants were submitted to the same amount of treatment. Each patient was evaluated before (baseline: T0) and immediately after the end of each training (T1). MAIN OUTCOMES MEASURES We used as main outcome measure: the brief repeatable battery of neuropsychological test to assess various cognitive abilities; and the multiple sclerosis quality of life-54 (MSQoL-54). RESULTS Both the groups benefit from 8 weeks of CR. In particular, the EG got better results in cognitive function, with regard to selective reminding test long term storage (P

OBJECTIVE: Aim of this study was to evaluate the effects of an emerging rehabilitative tool (“Power-AFA” - software) in the recovery of a patient with chronic non-fluent aphasia. MATERIAL AND METHODS: A 56-year-old woman, affected by post-stroke severe expressive aphasia, underwent two different intensive rehabilitation trainings, including either standard language rehabilitation alone or a proper PC based speech training in addition to conventional treatment. We evaluated her cognitive and psychological profile in two separate sessions, before and after the two different trainings, by using a proper psychometric battery, to assess cognitive status, language abilities, and to estimate the presence of mood alterations and coping strategies. The overall PC-program was articulated in 6 sessions/weekly for 3 months. RESULTS: Only at the end of the PC-training, we observed an important improvement in peculiar cognitive domains (attention and memory functions), in denomination, in verbal understanding ability, in written, in communication skills as well as an optimization of the mood and coping styles. CONCLUSIONS: Computer-based cognitive and language rehabilitation, using proper and dedicated software, may be a valuable tool in improving either communication or cognitive skills in patient affected by aphasia, even in the chronic state.

Background Rehabilitation of impaired cognitive functions begins to be considered a standard component of medical care after acquired brain injury. Indeed, many evidences support the effectiveness of the two major categories of techniques, i.e. the traditional and computer-assisted ones, which are widely used in cognitive rehabilitative treatment. Objective Aim of this study is to evaluate the effects of pc – cognitive training in brain injury patients. Methods We studied 35 subjects (randomly divided into two groups), affected by traumatic or vascular brain injury, having attended from January 2010 to December 2012 the Laboratory of Robotic and Cognitive Rehabilitation of IRCCS Neurolesi of Messina. Cognitive impairment was investigated through psychometric battery, administered before (T0) and two months (T1) after the cognitive pc-training, which was performed only by the experimental group, in addition to conventional treatment. Statistical analysis was performed using Wilcoxon test with a p Results At time T0, all patients showed language deficits and cognitive alterations in visual attention and memory abilities. After the rehabilitation program we noted a global improvement in both the groups. However, at T1, the experimental group showed a greater cognitive improvement than the control group, with significant differences in nearly all the neuropsychological tests performed. Conclusions Our data suggest that cognitive pc-training may be a promising methodology to optimize the rehabilitation outcomes following brain injury.

Vascular dementia (VaD) is a general term describing problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to the brain. Cognitive rehabilitation and physical therapy are the mainstays of dementia treatment, although often ineffective because of the scarce collaboration of the patients. However, emerging data suggest that physical activity may reduce the risk of cognitive impairment, mainly VaD, in older people living independently. Herein, we describe a 72-year-old male affected by VaD, in which traditional cognitive training in addition to intensive gait robotic rehabilitation (by using Lokomat device) led to a significant improvement in the motor and cognitive function. This promising finding may be related either to the intensive and repetitive aerobic exercises or to the task-oriented training with computerized visual feedback, which can be considered as a relevant tool to increase patients' motor output, involvement, and motivation during robotic training.

ObjectiveQuality of life (QoL) is a growing issue in medicine, particularly in the evaluation of rehabilitative care. The concept of QoL is included in and expands the definition of health given by the WHO (World Health Organization) and comprises complete physical, mental, and social well-being. It expresses the degree of satisfaction in various areas as a result of the opportunities that arise during one's lifetime despite the restrictions and impediments that life itself puts forth. The last decade has exponentially increased the number of studies on QoL, although they are still limited.MethodsWe performed a literature review on the QoL scales used in patients with neurological disorders.ResultsRecent studies have shown the importance of QoL assessment because standard treatments do not assess the treatment impact felt by the patient. In fact, by understanding the impact of treatment on survival and QoL, one can make a clearer interpretation of the health of the patient.ConclusionThis review has adopted an innovative holistic methodological approach, which allowed a global evaluation of the comfort reported by the patients. The scales applied in this study allowed to choose the most suitable therapeutic strategies and programme individual therapeutic treatment.

Objective Although it is believed that patients with Unresponsive Wakefulness Syndrome (UWS) do not feel pain, recent neuroimaging and neurophysiologic studies have demonstrated some residual traces of nociceptive processing. Methods To confirm this growing evidence, we evaluated 21 patients suffering from chronic disorders of consciousness (DOC) (both UWS, n =11, and Minimally Conscious State – MCS –, n =10), using an Event-Related Potential (ERP) Low-Resolution Brain Electromagnetic Tomography (LORETA) approach, based on nociceptive repeated laser stimulation (RLS). We delivered laser stimuli to the dorsum of both hands and analysed the γ-band LORETA activations and the ERP γ-power magnitude induced by laser stimulation, as well as the heart rate variability (HRV). Results We found partially preserved cortical activations and ERP γ-power magnitude in all MCS and two UWS individuals. These effects were paralleled by a purposeful behaviour, and a reduced HRV concerning nociceptive stimulation, whereas the two UWS individuals showed no more than reflex behaviours, besides a strong limbic activation. Conclusions Some UWS patients may somehow perceive the affective components of nociceptive stimulation. Significance The diagnosis of functional locked-in syndrome should be taken into account when dealing with DOC differential diagnosis.

Gait, coordination, and balance may be severely compromised in patients with multiple sclerosis (MS), with considerable consequences on the patient's daily living activities, psychological status and quality of life. For this reason, MS patients may benefit from robotic-rehabilitation and virtual reality training sessions. Aim of the present study was to assess the efficacy of robot-assisted gait training (RAGT) equipped with virtual reality (VR) system in MS patients with walking disabilities (EDSS 4.0 to 5.5) as compared to RAGT without VR. We enrolled 40 patients (randomized into two groups) undergoing forty RAGT±VR sessions over eight weeks. All the patients were assessed at baseline and at the end of the treatment by using specific scales. Effect sizes were very small and non-significant between the groups for Berg Balance Scale (-0.019, CI95% -2.403 to 2.365) and TUG (-0.064, 95%CI -0.408 to 0.536) favoring RAGT+VR. Effects were moderate-to-large and significant for positive attitude (-0.505, 95%CI -3.615 to 2.604) and problem-solving (-0.905, 95%CI -2.113 to 0.302) sub-items of Coping Orientation to Problem Experienced, thus largely favoring RAGT+VR. Our findings show that RAGT combined with VR is an effective therapeutic option in MS patients with walking disability as compared to RAGT without VR. We may hypothesize that VR may strengthen RAGT thanks to the entrainment of different brain areas involved in motor panning and learning.

Introduction: Obstructive Sleep Apnea Syndrome (OSAS) is considered an emerging risk factor for cerebrovascular disease. Both the two conditions could share the same neurocognitive impairment, which, in the early phase of OSAS, are reversible and mediated by the excessive daytime sleepiness. Treatment with continuous positive air pressure (CPAP) device could improve the neurocognitive functions, and therefore, it could be considered as a valid treatment option in stroke patients affected by OSAS and neurocognitive impairment. Materials and Methods: Patients affected by unilateral ischemic stroke will be subdivided into two groups, according to the presence or absence of OSAS. All participants will be evaluated by using a specific neuropsychological battery exploring attention, memory, praxic abilities and executive functions. Patients presented with a moderate to severe OSAS will be treated with CPAP and followed for at least 1 year. Results: The data analysis requires a sample size of 550 to provide adequate power of the study. The outcome variable is the score of specific neuropsychological and quality of life tests at baseline, after 6 months and at 1 year follow-up. Discussion and Conclusion: This study design presents three specific analysis limitations. First, several other sleep disorders can produce drowsiness beyond OSAS. Second, the neurocognitive impairment in stroke patients is difficult to assess. Third, OSAS patients are often intolerant to diagnostic tests requiring an excessive length. However, the findings coming from the protocol may have important implications about the effect of sleep disorders on cognitive function in stroke patients. Moreover, the easy employed procedures could be translated into clinical practice to improve the quality of life of patients affected by both OSAS and stroke.

Introduction:Currently, none of the available multiple sclerosis (MS) disease-modifying medications has been shown to stop or reverse gait disability. Recently, the nabiximols has been tested for the treatment of spasticity and walking impairment in MS. Nabiximols (trade name Sativex) is an

Neurogenic erectile dysfunction can be broadly defined as an inability to sustain or maintain a penile erection due to neurologic impairment. Sexual problems can occur due to any lesion affecting the central and peripheral nervous system. The aim of this study was to evaluate the prevalence and causes of erectile dysfunction in a group of hospital inpatients suffering from neurologic disorders.Three-hundred and twenty six male patients admitted to the Neurorehabilitation Unit of IRCCS Centro Neurolesi "Bonino-Pulejo" in Messina Italy from March 2012 to June 2013 were screened for erectile dysfunction using the International Index of Erectile Function questionnaire. The patients who reported erectile dysfuntion underwent vascular, neurophysiological, and hormonal testing, and were divided into two groups according to their lesion sites: G1 (lesions above the S2-S4 center) and G2 (lesions below the S2-S4 center).Of the 326 admitted patients, 126 patients (38.6%), mean age of 54.56±11.74 years (age range 27-82 years), were affected by erectile dysfunction (i.e., scored ≤21). A statistically significant correlation between International Index of Erectile Function questionnaire scores and location of the neurologic lesions was observed in G2 (r=0.22) with an increased risk of erectile dysfuntion of around 2:1 (odds ratio=1.87) without influences related to aging.The occurence of erectile dysfunction is significantly more prevalent among neurologically disabled men, particularly those with lesions below S2-S4, than among men without neurologic disability. Considering the prevalence of erectile dysfunction among neurologically disabled men, sexual functioning should be regularly evaluated during acute and long-term rehabilitation, and any existing sexual dysfunction should be addressed in the treatment plan.

Rationale Aim of this study is to evaluate the cognitive and motor outcomes after a combined rehabilitative training using a standard cognitive approach and virtual reality (VR), in a patient with spinal cord injury (SCI). Patient's concerns A 60-year-old right-handed man, affected by incomplete cervical SCI, came to our observation for a moderate tetraparesis, mainly involving the left side, after about 6-months from the acute event. The neurological examination showed imbalance with upper limb incoordination, besides the paresis mainly involving the left side. At a neuropsychological evaluation, he presented important impairment in cognitive and behavioural status, with temporal and spatial disorientation, a reduction of attention and memory process, deficit of executive function and a severe depression of mood, which was not detected during the previous recovery. Diagnosis Motor and cognitive deficits in SCI. Interventions The patient was 1st submitted to standard cognitive training and traditional physiotherapy, and then to a combined therapeutic approach, in which virtual reality training was provided by means of the virtual reality rehabilitation system (VRRS, Khymeia, Italy). Outcomes After the combined therapeutic approach with the VRRS training, we observed a significant improvement in different cognitive domains, a notable reduction of anxiety and depressive symptoms, as well as motor performance, and balance improvement. Lessons Virtual reality can be considered a promising tool for the rehabilitation of different neurological disorders, including patients with both motor and cognitive deficits following SCI.

Dementia is an increasing challenge for health care and social system in developed countries. Interventions with a cognitive focus, also using assistive technology, are leading to promising results in improving cognitive and behavior symptoms in individuals with dementia. Aim of our study was to evaluate the combined effects of the standard cognitive training in addition to web-based rehabilitation in dementia people living in a nursing home. We have studied twenty dementia people (10 females and 10 males) with a mild to moderate cognitive decline (MMSE 25 ± 3.4) associated to moderate behavioral alterations, and mainly due to vascular causes. These patients were randomly assigned to one of two groups (experimental or standard treatment—namely the control group). All participants in the experimental group completed the specific training, consisting of 24 sessions of web-based cognitive training, for 8 weeks, in addition to standard rehabilitation. Each participant was evaluated by a skilled neuropsychologist before and after each treatment. The experimental group had a statistically significant change of the Geriatric Depression Scale (p = 0.03), Constructive Apraxia (p

The last few years have been characterized by a growing interest of the medical and scientific world for the field of consciousness and its related disorders. Medically speaking, consciousness can be defined as the state of awareness of self and environment and the alertness to external stimulation, besides responsiveness to inner need. Transient loss of consciousness can be due to alterations in cerebral blood flow leading to fainting or syncope, migraine, metabolic dysfunctions, unexpected intracranial pressure increases, epileptic seizures, and sleep disorders. Chronic disorders of consciousness are a tragic success of high-technology treatment, in an attempt to maintain or reestablish brain function, which is to be considered as the main goal of therapeutics. Management of vegetative or a minimally conscious state individuals involves charily getting the right diagnosis with an evidence-based prognosis, also taking into account the medical, ethical, and legal key factors of the ideal treatment. This paper is aimed at exploring the wide spectrum of consciousness disorders and their clinical differential diagnosis, with particular regards to those with a negative impact on patient and their caregiver quality of life, including epilepsy, sleep disorders, and vegetative/minimally conscious state.

Behavioural and psychological symptoms of dementia are very common. They represent a main cause of burden and distress in caregivers and can lead to early institutionalization of patients. We aimed to find the most specific behavioural and psychological symptoms of dementia that can strongly affect the caregivers' burden.Twenty-seven patients and their caregivers were enrolled in this study. All of the patients were affected by Alzheimer's, vascular, or frontotemporal dementia and were evaluated with the Neuropsychiatric Inventory and Mini-Mental State Examination. Caregivers were administered the Caregiver Burden Inventory.Apathy, depression, anxiety, and agitation were the most common symptoms and were found in up to 90% of the patients. We detected strong correlations between patient neuropsychiatric symptoms, (i.e. irritability, hallucinations, aberrant motor behavioural, depression, and agitation) and Caregiver Burden Inventory scores. Multiple regression analysis found hallucinations, irritability, and depression to be significant predictors of caregiver burden. Moreover, the Neuropsychiatric Inventory score was more closely related to caregiver burden than the Mini-Mental State Examination score.Our results revealed that demented patients' behavioural problems are related to the level of caregiver burden and distress. Further investigations are needed to differentiate the present findings among dementia subtypes and to better evaluate the effect of caregivers' personal characteristics on their own burden.

Mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes syndrome (MELAS) is a rare inherited mitochondrial disorder, commonly due to the m.3243A>G mutation, which typically presents with seizures, headaches, and acute neurological stroke-mimicking deficits. At onset, there is often no general intellectual deterioration in these patients, although specific cognitive deficits in peculiar language domains, visual construction, attention, abstraction, or flexibility may be present. To date, there is no evidence for an effective treatment in individuals with MELAS. Herein, we describe the case of young woman affected by MELAS who underwent an intensive cognitive training by means of the following methods: (a) traditional cognitive training, (b) computerized cognitive training (CCT), and (c) CCT plus a low-intensity aerobic motor exercise. We compared her cognitive and psychological profile at baseline (T0) and at the end of each training (i.e., (Time 1, Time 2, and Time 3 [T3]) using a proper psychometric battery, and we found a greater improvement at T3. Our findings support the idea that the combined CCT with motor training could represent a valuable therapeutic opportunity in MELAS.

Systemic lupus erythematosus (SLE) is a clinically heteroeneous autoimmune disease characterized by the presence of utoantibodies directed against nuclear antigens. SLE is, by defiition, a multisystem disease, which can present in a large variety f ways, including cutaneous rash, arthritis, oral ulcers and renal isorders. When SLE affects the nervous system, i.e., “neuropsychiatricLE” (NP-SLE), it can present a wide spectrum of neurologic or sychiatric symptoms (see Table 1). Although patients with NPLE commonly present mild symptoms such as paresthesias or a epressive mood, almost no major cerebrovascular events, psyhoses or even coma states have been described [1]. Moreover, cardiovascular autonomic dysfunction is frequent n patients with autoimmune diseases, such as SLE, rheumatoid rthritis and Sjogren’s syndrome [2]. Herein, we describe the case of a man presenting with dystheria as a possible symptom of SLE-related peripheral neuropathy ith autonomic dysfunction.

Dear Sir,The introduction of sildenafil in 1998 can be considered the watershed in the pharmacological treatment of erectile dysfunction (ED), because of its broad efficacy for different types of E...

Background: Aim of the present study was to evaluate whether the presence of body shadows during virtual reality (VR) training with BTS NIRVANA (BTs-N) may lead to a better functional recovery. Methods: We enrolled 20 poststroke rehabilitation inpatients, who underwent a neurocognitive-rehabilitative training consisting of 24 sessions (3 times a week for 8 weeks) of BTs-N. All the patients were randomized into 2 groups: semi-immersive virtual training with (S-IVTS group) or without (S-IVT group) body shadows. Each participant was evaluated before (T0) and immediately (T1) after the end of the training (Trial Registration Number: NCT03095560). Results: The S-IVTS group showed a greater improvement in visuo-constructive skills and sustained attention, as compared with the S-IVT group. The other measures showed nonsignificant within-group and between-group differences. Conclusion: Our results showed that body shadow may represent a high-priority class of stimuli that act by “pushing” attention toward the body itself. Further studies are needed to clarify the role of body shadow in promoting the internal representation construction and thus self-recognition.

Ovarian hyperstimulation syndrome (OHSS) is a severe iatrogenic complication of ovulation induction, which has a very serious impact on the patient's health, as it is often associated with a high morbidity and mortality risk. Indeed, patients classified as having severe OHSS presented with liquid imbalance signs (such as rapid weight gain, tense ascites, respiratory difficulty and progressive oliguria), which are related to the fluid shift from the intravascular space to third space compartments subsequent to an increased capillary permeability. In this way, cardiovascular system findings include decreased intravascular volume, decreased blood pressure, decreased central venous perfusion, and compensatory increased heart rate and cardiac output with arterial vasodilation might be found concomitantly. Notwithstanding that venous thromboembolic phenomena are a possible complication in advanced phases of OHSS, arterial ischemia involving the cerebral circulation is a rare but recently reported problem. The pathogenesis of thromboembolism in OHSS is not fully understood, even though hemoconcentration and blood hyperviscosity seem to play a role in developing thrombotic changes into both venous and arterial system. Interestingly, the presence of cardiac abnormalities in combination with inherited or acquired hypercoagulable state seems to increase the risk of cerebral infarct in these subjects, as recently shown by our group. This review is aimed at investigating the pathomechanism and the management of neurovascular complications related to OHSS, including new treatment options.

Sexuality and sexual health are significant factors in determining the quality of life (QoL). Multiple sclerosis (MS) is one of the most serious causes of neurological disability in young adults, therefore it can considerably reduce sexuality. Physical and cognitive symptoms of MS as well as mental and psycho-social issues can directly affect sexual life and body representation, causing reduced libido and self-esteem. Male patients with MS frequently develop sexual dysfunction (SD) as a result of their neurological impairment: in fact physical, psychological and neuropsychological changes indirectly interfere in the sexual response. Thus, MS physicians' greater concern on SD has led to the enhancement of diagnostic and therapeutic diagnoses on neurogenic SD. Given the increasing number of people coping with MS, a more effective focus on MS-related problems, including SD, is absolutely essential to provide the patients and their partner with the necessary information to achieve a better sexual health and consequently improve their QoL. This review aims to investigate the epidemiology and pathophysiology of SD in male patients, provide an insight into multidisciplinary diagnostic and therapeutic approaches, and focus on the need of proper counseling.

Anorgasmia is the inability to reach orgasm during sexual intercourse, and, although it is believed that around 90% of anorgasmia problems are related to psychological issues, the use of serotoninergic drugs, including antidepressants and atypical antipsychotics, is a common cause of situational anorgasmia. Pregabalin is a new antiepileptic drug, structurally related to gabapentin, and commonly used as adjunctive therapy for partial epilepsy and treatment of neuropathic pain in adults. Herein, we describe three men with epilepsy, who experienced severe anorgasmia after pregabalin add-on treatment.

Consciousness is a multifaceted concept that has two dimensions: arousal, or wakefulness (i.e., level of consciousness), and awareness (i.e., content of consciousness) (Laureys et al., 2004). An accurate and reliable assessment of the arousal and awareness of consciousness in patients with severe brain damage is of greatest importance for the differential diagnosis of low levels consciousness patients and for outcome evaluation. Following coma, some patients permanently lose all brainstem function (brain death), some progress to “wakeful unawareness” (vegetative state VS), whereas others recover typically and progress through different stages before fully or partly recovering consciousness (minimally conscious state MCS). Patients in VS can open their eyes and exhibit basic orienting responses, but show no conscious, purposeful activity. Reflex and other movements are seen, mediated by brainstem, spinal cord, and brainstem-diencephalic arousal systems (Laureys et al., 2004). VS can occur after patients emerge from an acute catastrophic brain insult causing coma, or can also be seen in degenerative or congenital nervous system disorders. The two common findings are necrosis of the cerebral cortex, thalamus and brainstem (usually after anoxic injury) and diffuse axonal injury (usually after trauma), although other pathological findings can be seen in degenerative and other disorders (Laureys, 2008). The MCS patients do not meet diagnostic criteria for coma or VS because they demonstrate some inconsistent but clear evidence of consciousness (Laureys et al., 2008; Giacino et al., 2002). In the MCS, there is variable impaired function of the cerebral cortex, diencephalons and upper brainstem. This allows occasional conscious behaviours to occur, unlike in VS or coma. Patients may enter the MCS as they emerge from coma or VS, or they can become minimally conscious as a result of acute injury or chronic degenerative diseases. Recent studies suggest a number of potential clinical and rehabilitative applications of magnetic resonance (MR) techniques. Although bedside clinical examination remains the criterion standard for establishing diagnosis, MR may provide an adjunctive diagnostic role when behavioural findings are very limited or ambiguous. The future of diagnostic and prognostic assessment of patients with disorders of consciousness (DOC) envisions a battery of neurobehavioral and neuroimaging techniques (such as structural and functional MR imaging (MRI and

The continued aging of the population is affecting the health of the industrialized countries, with an increasing burden for the healthcare system. Thus, during the last decade, we assisted to relevant progress in the medical treatment and rehabilitation techniques and devices, including the development of telemedicine for geriatric care. To demonstrate the effectiveness of a novel tele-health-care model allowing a better management of elderly living in nursing homes. Fifty-nine elderly patients (19 males and 40 females; mean age 79.1 (±9.2), were randomly divided into two groups: the experimental group that performed a proper telemonitoring with a multimodal approach (including monitoring of the vital signs and neurological/psychological counseling), and the control group, which underwent standard in-home nursing care. Neurobehavioral symptoms and quality of life were assessed in both the groups at baseline, and after the telecare protocol’s end. The experimental group had a statistically significant reduction in Geriatric Depression Scale (p