M Matteis

Sapienza University of Rome, Roma, Latium, Italy

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Publications (47)228.64 Total impact

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    ABSTRACT: To evaluate the efficacy and the safety of repeated botulinum toxin type A (BT-A) injections in patients with severe acquired brain injury (ABI) and to gain a better knowledge of possible clinical or demographic characteristics associated with a better rehabilitation outcome. Prospective study with a 1-year follow-up period. Twenty-one patients with spasticity due to severe ABI and no further improving with rehabilitation treatment and oral anti-spastic drugs. Repeated BT-A injections associated to a rehabilitation programme. Barthel Index (BI), Modified Ashworth Score (MAS) and VAS score for pain subjective perception were recorded. At the end of the follow-up study, MAS, BI and VAS significantly improved. Despite the number of BT-A injections, a shorter interval between severe ABI onset and first BT-A treatment correlated to a better BI improvement. None of the patients experienced adverse events attributable to BT-A. BT-A was effective and safe in the treatment of spasticity in severe ABI patients, with a better functional outcome in those subjects treated earlier after spasticity onset. The lack of correlation between clinical outcome and number of injections suggests, in addition to a direct inhibition at the neuromuscular junction, a more distant BT-A long-term effect.
    Brain Injury 05/2012; 26(7-8):979-83. · 1.51 Impact Factor
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    ABSTRACT: The aim of this study was to investigate the correlation between cerebral hemodynamic changes and the evolution of neurological deficit after stroke. We included 65 patients with non-lacunar stroke admitted to a rehabilitation hospital within 4 weeks from the event. An evaluation of cerebrovascular reactivity to hypercapnia was performed with transcranial Doppler ultrasonography using the breath-holding index (BHI). Activities of daily living status was measured by the Barthel Index (BI) and impairment of mobility was assessed by means of the Rivermead Mobility Index (RMI). Multivariate analyses were performed using effectiveness of treatment, evaluated on BI and RMI as dependent variables. Independent variables were BHI values, age, sex, length of stay, hypertension, smoking habit, presence of aphasia and neglect, poststroke depression, and the degree of severity of stroke. The effectiveness on BI was associated positively with normal BHI values and with neurological severity at admission, measured by the Canadian Neurological Scale. The regression coefficients for effectiveness on RMI showed that the most relevant predictor was ipsilateral BHI (the slope resulted equal to 5.8), followed by age (a 10-year age difference is expected to diminish the effectiveness by about 4.3%) and by depression (depressed patients have almost 11% less effectiveness than non-depressed patients). These findings suggest that a satisfactory recovery from neurologic deficits requires a preserved cerebrovascular reactivity in the lesioned hemisphere despite the presence of an anatomic lesion.
    European Neurology 02/2012; 67(4):200-5. · 1.50 Impact Factor
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    ABSTRACT: Aim of our study was to evaluate cerebral hemodynamic changes during performance of attention tasks and to correlate them with reaction time (RT) and percentage of right answers. Mean flow velocity (MFV) in middle cerebral arteries was monitored in 30 subjects by transcranial Doppler during tonic alertness, phasic alertness, focused and divided attention tasks. Mean flow velocity increase was significantly higher during divided attention with respect to other tasks (P < .001). MFV increase was higher in the right than in the left side (P < .001). Asymmetry during attention tasks resulted significantly higher than that observed in tonic alertness condition. RT was increased during focused attention tasks (P < .001 vs. both alert tasks), with further increase during divided attention tasks (P < .001 vs. focused attention task). RT was inversely related to MFV increase only during tonic alertness (P = 0.012 for left side; P = 0.008 for right side). During the divided attention tasks, an association was found between MFV increase and correct answers (r = 0.39, P = 0.033). These data show a relationship between RT, correct answers and changes in blood flow velocity and suggest that this method of cerebral blood flow investigation could be a useful approach during assessment of patients with attention deficit.
    European Journal of Neurology 01/2009; 16(1):81-7. · 4.16 Impact Factor
  • Frontiers in Human Neuroscience - FRONT HUM NEUROSCI. 01/2008;
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    ABSTRACT: Cerebral hemodynamics play a pivotal role in stroke pathogenesis. Transcranial Doppler (TCD) studies demonstrated the importance of cerebral vasomotor reactivity (VMR) on the outcome of carotid artery occlusion (CAO). So far, positron emission tomography represents the best technique for detecting both hemodynamic and metabolic aspects of cerebral perfusion adaptive processes in cerebrovascular patients. Near-infrared spectroscopy (NIRS) is a new method allowing for a non-invasive assessment of cerebral blood flow and hemoglobin (Hb) oxygenation parameters.A recent TCD and NIRS study demonstrated that patients with symptomatic CAO had lower VMR values measured by TCD and lower oxygen saturation (oxygen%) increases detected by NIRS than asymptomatic ones. The parameters were obtained simultaneously after CO(2) inhalation. The present study aims to investigate if Hb oxygen % could represent also at rest a marker of hemodynamic status in carotid disease.Thirty-five symptomatic and 17 asymptomatic patients with CAO underwent a simultaneous examination by means of TCD and NIRS at rest condition and during CO(2) reactivity test. Symptomatic patients presented with oxygen% values at rest higher (p = 0.001) and VMR values lower (p < 0.001) than asymptomatic subjects. According to a logistic model, for each unitary VMR increase, the odds of being symptomatic decreases of about 10% (OR = 0.9, p = 0.001); for each unitary increase of oxygen% at baseline, this odd increases of about 23% (OR = 1.23, p = 0.031). In addition to TCD VMR values, oxygen hemoglobin saturation at rest detected by NIRS can discriminate symptomatic from asymptomatic patients with CAO. NIRS can add an important contribution to explain pathophysiological mechanisms of stroke occurrence.
    Journal of Neurology 11/2006; 253(11):1459-65. · 3.58 Impact Factor
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    ABSTRACT: We report on a patient with left hemiparesis and peripersonal neglect after post-traumatic left frontal hemorrhage, who underwent fMRI, TMS and TCD to identify the functional abnormalities that account for his neurological symptoms, in the absence of any detectable lesion affecting right motor areas.
    Neurocase 09/2006; 12(4):232-5. · 1.05 Impact Factor
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    ABSTRACT: The aim of this study was to explore the possible contribution of alterations in cerebral hemodynamics to the evolution of cognitive impairment in patients with Alzheimer disease (AD). Fifty-three patients with AD were investigated. The evolution of cognitive decline over 12 months was evaluated by means of changes in Mini Mental State Examination (MMSE) and AD Assessment Scale for Cognition (ADAS-Cog) scores. Demographic characteristics, vascular risk profile, pharmacological treatment, and presence of white matter lesions were assessed at entry. Further, a basal evaluation of cerebrovascular reactivity to hypercapnia was measured with transcranial Doppler ultrasonography using the breath-holding index (BHI). Of all the variables considered, both MMSE and ADAS-Cog changes had the highest correlation with BHI, followed by age and diabetes. After subdividing both cognitive measures reductions into bigger and smaller-than-average decline (2 points for MMSE; 5 points for ADAS-Cog), multiple logistic regression indicated BHI as the sole significant predictor of cognitive decline. These results show an association between impaired cerebral microvessels functionality and unfavorable evolution of cognitive function in patients with AD. Further research is needed to fully establish whether altered cerebral hemodynamics may be considered an independent factor in sustaining cognitive decline progression or an effect of pathological processes involved in AD.
    Stroke 05/2006; 37(4):1010-5. · 6.16 Impact Factor
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    ABSTRACT: The aim of the study was to use functional transcranial Doppler to investigate the possibility of revealing different activation patterns during healthy subjects' performance of meaningful and meaningless actions. Mean flow velocity (MFV) changes were recorded in middle cerebral arteries (MCAs) of 26 normal subjects during a rest phase and during performance of meaningful and meaningless actions. The meaningful task consisted of pouring sugar into a cup with a teaspoon. The meaningless action was an arm movement similar to that necessary for pouring sugar in a cup but without any tool and thus without a goal. Performing actions with or without meaning was associated with different patterns of MFV changes, as documented by the triple interaction condition x performing arm x side of recording [F(1, 25)=10.977; P=0.003]. During the meaningful action, MFV in MCAs increased significantly more than during the meaningless action. During the meaningless action, the MFV increase was significantly higher in the contralateral than in the ipsilateral MCA to the arm performing the task and the meaningful action determined a bilateral MFV increase only when the task was performed with the left arm. When the same task was performed with the right arm, the MFV increase was significantly higher in the contralateral than in the ipsilateral MCA. These findings suggest that the content of an action can influence MFV changes and further confirm the usefulness of transcranial Doppler in neuropsychological investigation.
    European Journal of Neurology 02/2006; 13(1):24-9. · 4.16 Impact Factor
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    ABSTRACT: In severe brain injury patients few studies have examined the role of early clinical factors emerging before recovery of consciousness. Patients suffering from vegetative state and minimally conscious state in fact may need variable periods of time for recovery of the ability to follow commands. In a previous study we retrospectively examined a population of very severe traumatic brain injury patients with coma duration of at least 15 days (prolonged coma), and we found, as significant predictive factors for the final outcome, the time interval from brain injury to the recovery of the following clinical variables: optical fixation, spontaneous motor activity and first safe oral feeding. Psychomotor agitation and bulimia during coma recovery were also favourable prognostic factors for the final outcome. In a further study, also as for the neuropsychological recovery, the clinical variable with the best significant predictive value was the interval from head trauma to the recovery of safe oral feeding. In the present study the presence of psychomotor agitation diagnosed by means of LCF (score 4 = confused-agitated) at the admission time in rehabilitation predicted a statistically significant better outcome at the discharge time in comparison with patients without agitation.
    Acta neurochirurgica. Supplement 02/2005; 93:201-5.
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    ABSTRACT: Migraine has been reported as a possible risk factor for ischemic stroke. The mechanisms underlying this association are unknown. To evaluate cerebrovascular reactivity to hypercapnia in the anterior and posterior circulation of patients with migraine, as reduced cerebrovascular reactivity is associated with a predisposition to stroke in various clinical conditions. Using transcranial Doppler ultrasonography, changes in flow velocity during apnea were measured in both middle cerebral arteries and in the basilar artery of 15 control subjects and 30 patients with migraine (15 with aura and 15 without aura) during an attack-free period. Cerebrovascular reactivity was evaluated using the breath-holding index, which is calculated by dividing the percent increase in mean flow velocity recorded during a breath-holding episode by its duration (in seconds) after a normal inspiration. Vascular reactivity in the middle cerebral arteries was similar in patients and controls and significantly lower in the basilar artery of patients with migraine with aura compared with the other 2 groups (P <.0001). These findings show that in patients with migraine with aura, there is an impairment in the adaptive cerebral hemodynamic mechanisms in the posterior circulation. This fact could have pathogenetic implications since the association between migraine and stroke frequently regards patients with migraine with aura, and cerebral infarcts occur more commonly in the vertebrobasilar district.
    Headache The Journal of Head and Face Pain 01/2004; 44(1):29-34. · 2.94 Impact Factor
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    ABSTRACT: Recovery from hemiplegia is a complex phenomenon that depends on various adaptive processes involving both the affected and the unaffected hemisphere. Our aim in this study was to investigate changes in cerebral perfusion in hemiplegic stroke patients during passive movements and their correlation with the subsequent motor recovery. The study included 30 patients with single, subcortical ischemic cerebral lesions. Within 14 days (range 8 to 14 days) from stroke onset, all patients were examined for the effects of passive elbow movements on cerebral blood flow in the middle cerebral arteries (MCAs) by means of bilateral transcranial Doppler (TCD) ultrasonography. On the same day as TCD assessment, they were also evaluated clinically with the Canadian Neurological Scale (CNS) and with Medical Research Council (MRC) scale for motor deficit of the affected arm. A clinical evaluation using the same scales was repeated after two months of motor rehabilitation therapy. We investigated the relationship between changes of Mean Flow Velocity (MFV) during passive movements and degree of recovery after stroke. The logistic regression procedure indicated that out of all factors considered as possibly related to a good clinical motor deficit recovery of the affected arm, evaluated by means of MRC, only the MFV percentage increase played a predictive role. In particular, for each additional point of contralateral MFV percentage increase during passive movement of the affected arm, the relative probability of good clinical recovery increased 5.68 times (95% CI=1.76-18.40; p=0.004). Similar results were found when the clinical recovery was measured by means of the CNS (slope=0.40, p<0.001). Passive movements in hemiplegic stroke patients before clinical recovery elicit activation patterns that may be critical for the restoration of motor function.I n particular, early and consistent activation of the affected hemisphere, as detected with TCD, seems to predict the positive evolution of a motor deficit.
    Journal of Neurology 08/2003; 250(7):810-7. · 3.58 Impact Factor
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    ABSTRACT: This study evaluated the use of transcranial Doppler ultrasonography for detecting selective changes in cerebral blood flow velocity during emotional processes. The aim was to investigate the possibility of obtaining functional information on the neuropsychology of emotions in patients with Parkinson's disease (PD). For this reason, blood flow velocity changes were investigated in both middle cerebral arteries (MCA) during a rest condition and when viewing non emotional (tasks 1 and 3) and emotional (task 2) slide sequences. The study included 12 PD patients and 12 healthy subjects. All patients were in treatment with levodopa or dopamine agonist. Investigation of PD patients was performed during an on-phase. The three tasks produced significantly different effects on the right and left side in the PD patients compared with the control group. During the two non emotion-related tasks the increase of mean flow velocity (MFV) compared with the basal values was similar in the two middle cerebral arteries in both groups [(PD Patients: Task 1: left MCA = 3.95 % 2.2, Right MCA = 4.33 % +/- 2.3, Task 3: left MCA = 3.04 % +/- 1.9, Right MCA = 2.71 % +/- 2.2) (control group: Task 1: left MCA = 4.57 % +/- 1.4, Right MCA = 4.46 % +/- 1.7, Task 3: left MCA = 2.32 % +/- 0.9, Right MCA = 2.52 % +/- 1.2)] The negative emotional task was accompanied by a significantly higher increase in the right (10.53 % +/- 3.2) than in the left middle cerebral artery (4.52 % +/- 1.51) only in the control group. The PD patients showed a bilateral and symmetrical increase of MFV (left MCA = 4.28 % +/- 2.3 and right MCA 5.77 % +/-3.8). To determine whether there was a dysfunction in cerebrovascular reactivity and a deficit in the ability to activate both hemispheres in response to non emotion-related stimuli in the PD patients, the protocol study included a cerebrovascular reactivity test to apnea, a motor task (thumb-to-finger opposition), a cognitive task (word fluency and visual discrimination of objects), performed by both patients and controls. The pattern of MFV changes during these tasks was not statistically significantly different in the two experimental groups. In order to evaluate the possible influence of drug treatment on cerebrovascular reactivity, seven patients were also evaluated during an off-phase, after a 48-hour wash-out period. Changes in MFV during every task were similar to that observed during the on-phase. These findings show the possibility of obtaining specific functional information from bilateral transcranial Doppler and suggest the selective and specific deficit of PD patients in emotional processing.
    Journal of Neurology 09/2002; 249(8):993-1000. · 3.58 Impact Factor
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    ABSTRACT: The aim of the present study was to determine the impact of commonly used and potentially detrimental drugs on rehabilitation results and to clarify their role as prognostic factors. The study included 154 patients admitted to a rehabilitation hospital for sequelae of a first stroke. Multivariate analyses were performed using effectiveness of treatment, evaluated by both the Barthel Index (BI) and the Rivermead Mobility Index (RMI) and low response on both of these indexes as dependent variables. Independent variables were medical, demographic and pharmacological factors. The use of detrimental drugs was negatively associated with effectiveness on both BI and RMI. Severity of stroke (Canadian Neurological Scale score at admission) and hemineglect were the other negative prognostic factors that significantly entered the analyses. On the other hand, the presence of Broca's aphasia positively influenced the recovery, essentially due to prolonged length of stay. The presence of detrimental drugs and hemineglect were associated with a higher risk of low response on both BI and RMI. These findings confirm that the use of some drugs can influence rehabilitation results. Therefore, the choice of pharmacological treatment of stroke patients should be carefully evaluated by considering the potential detrimental effects of some drugs commonly used for the treatment of coincidental medical conditions.
    Acta Neurologica Scandinavica 03/2002; 105(2):100-6. · 2.47 Impact Factor
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    ABSTRACT: Evidence suggests that an alteration in cerebral hemodynamics plays a relevant role in the occurrence of stroke in patients with carotid occlusion. The purpose of the present study was to evaluate the relationships among baseline characteristics, type and number of collateral pathways, cerebral vasomotor reactivity (VMR), and outcome of patients with carotid occlusion. One hundred four patients with symptomatic or asymptomatic internal carotid artery occlusion were followed up prospectively for a median period of 24 months. Cerebral VMR to apnea was calculated with transcranial Doppler ultrasonography by means of the breath-holding index (BHI) in the middle cerebral arteries. The patency of the 3 major intracranial collateral vessels was also evaluated. During the follow-up period, 18 patients experienced an ischemic stroke ipsilateral to internal carotid artery occlusion. Among factors considered, only older age, number of collateral pathways, and BHI values in the middle cerebral artery ipsilateral to the occluded side were significantly associated with the risk of ipsilateral stroke (P<0.001, P=0.008, and P<0.001, respectively; multiple Cox regression analysis). A normal VMR and favorable prognosis characterized patients with full collateral development; in this group, no patient experienced an ischemic event. On the other hand, an impaired VMR and increased probability of experiencing a stroke were found in patients without collateral pathways; the annual risk of ipsilateral stroke in this group was 32.7%. Patients with 1 or 2 collateral pathways showed a different VMR ranging from normal to strongly reduced BHI values. The ipsilateral stroke event risk was 17.5% in patients with 1 collateral vessel and 2.7% in patients with 2 collateral pathways. In this case, the risk of cerebrovascular events occurring during the follow-up period was significantly related to VMR. These data suggest that cerebral hemodynamic status in patients with carotid occlusive disease is influenced by both individual anatomic and functional characteristics. The planning of strategies to define the risk profile and any attempt to influence patients' outcome should be based on the evaluation of the intracranial hemodynamic adaptive status, with particular attention to the number of collateral vessels and the related VMR.
    Stroke 08/2001; 32(7):1552-8. · 6.16 Impact Factor
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    ABSTRACT: Transcranial Doppler ultrasonography (TCD) has been widely used to obtain information about changes in cerebral perfusion during motor activity after stroke. This type of application is greatly limited when severe motor deficits are present that impede the performance of an active motor task. In this study, we explored the effect of performing passive arm movements on cerebral perfusion. Twenty healthy subjects were investigated. A bilateral TCD monitoring of the middle cerebral artery (MCA) flow velocity was performed during the following experimental conditions: 1-min of active and passive flexion-extension elbow movement and 1-min of active and passive dorsal extension hand movement. Each task was performed with both left and right arms. The percentage increase in flow velocity from rest to task performance was calculated. Each task produced a significantly greater increase in mean flow velocity in the contralateral MCA with respect to the ipsilateral. When comparing the effect of passive and active tasks, no significant difference in mean flow velocity changes recorded in the ipsilateral and the contralateral MCA was detected regarding either elbow or hand movements. These findings demonstrate the possibility of obtaining information about changes in hemispheric cerebral perfusion during passive movements involving elbow and hand. This type of application deserves further attention in the study of cerebral functional changes following cerebral lesions.
    Journal of Neurology 03/2001; 248(2):104-8. · 3.58 Impact Factor
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    ABSTRACT: Active improvised music therapy may offer an adjuvant from of treatment in the early rehabilitation of severe brain-injured patients. Active music therapy consists of musical improvisation between patient and therapist by singing or by playing different musical instruments, according to the vital functions, the neurological conditions and the motor abilities of the patients. We studied 34 severe brain-injured patients with a mean coma duration of 52 days +/- 37.21 and a mean interval from coma onset to the beginning of rehabilitation of 154 days on average. Our preliminary results show a significant improvement of the collaboration of the severe brain-injured patients and a reduction of undesired behaviours such as inertia (reduced psychomotor initiative) or psychomotor agitation.
    Annali dell'Istituto superiore di sanita 02/2001; 37(4):627-30. · 0.76 Impact Factor
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    ABSTRACT: To investigate the correlation between changes in cerebral functional activity during mental engagement and the potential for neurologic recovery after stroke. Transcranial Doppler ultrasonography (TCD) makes it possible to detect the dynamic adjustment of cerebral perfusion related to functional neuronal changes. TCD monitoring of flow velocity changes in the middle cerebral artery of 29 ischemic stroke patients was performed during an object recognition task. The study took place within 4 weeks from stroke onset. Based on recovery occurring after 2 months, the patients were divided into four groups depending on the side of hemispheric lesion and the presence or absence of neurologic recovery. Ten healthy subjects served as control subjects. During the recognition task, control subjects showed a bilateral increase in flow velocity with respect to the rest phase (right side, 7.02 +/- 1.3%; left side, 6.65 +/- 1. 1%), with no side-to-side difference. In patients who experienced recovery, a similar pattern of bilateral activation was observed, irrespective of the side of the lesion. Conversely, in patients with no recovery, the increase of flow velocity was significantly higher on the side contralateral to the brain lesion (p < 0.0001) with respect to the lesion side. Performance during the recognition task was comparable in the four groups of patients. These findings suggest that satisfactory recovery from a neurologic deficit requires the persistence of functional activity in the damaged hemisphere despite the presence of an anatomic lesion. The possibility of obtaining early prognostic indications with TCD may be relevant for an early selection of patients with the best probability of benefiting from rehabilitation therapy.
    Neurology 08/2000; 55(1):35-40. · 8.25 Impact Factor
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    ABSTRACT: Standards for treating patients with asymptomatic carotid artery stenosis have been difficult to establish because of the lack of evidence for factors influencing these patients' prognoses. However, preliminary evidence suggests that an alteration in cerebral hemodynamic function may play a relevant role in the occurrence of stroke in patients with carotid artery disease. To investigate the relationship between cerebrovascular reactivity to hypercapnia and cerebrovascular events in patients with severe unilateral asymptomatic carotid artery stenosis. Prospective, blinded longitudinal study conducted in an outpatient neurovascular department in Italy between June 1996 and April 1998, with a median follow-up of 28.5 months. Ninety-four patients with asymptomatic carotid artery stenosis of at least 70% (74 men; mean age, 71 years). Subsequent occurrence of cerebral ischemic events (transient ischemic attack or stroke) or death, analyzed by cerebrovascular reactivity to hypercapnia (measured by transcranial Doppler ultrasonography and calculated by the breath-holding index values in the middle cerebral arteries). The overall annual rate for all ischemic events was 7.9%. Seventeen patients (18%) had ischemic events, all but 1 of which were ipsilateral to the carotid artery stenosis. Among factors considered, only lower breath-holding index values in the middle cerebral artery ipsilateral to carotid artery stenosis were significantly associated with the risk of an event (hazard ratio, 0.09; 95% confidence interval, 0.02-0.38; P=.001, by multivariate analysis). Based on data from previously studied healthy subjects, the cutoff of the breath-holding index for distinguishing between impaired and normal cerebrovascular reactivity was determined to be 0.69. Using this cutoff, the annual ipsilateral ischemic event risk was 4.1% in patients with normal and 13.9% in those with impaired breath-holding index values. These results suggest a link between impaired cerebrovascular reactivity and the risk of ischemic events ipsilateral to severe asymptomatic carotid stenosis.
    JAMA The Journal of the American Medical Association 05/2000; 283(16):2122-7. · 29.98 Impact Factor
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    ABSTRACT: This study assessed the use of transcranial Doppler ultrasound in detecting selective changes in cerebral blood flow velocity during emotional processes. The role of the respective hemispheres in emotional processing is controversial. Cerebral control of emotional processing has previously been investigated by analysis of patients with unilateral brain damage, experiments with selective stimulation of only one hemisphere, and more recently by imaging techniques measuring local cerebral blood flow. We investigated mean flow velocity continuously and simultaneously in both the right and left middle cerebral arteries (MCAs) in 16 healthy right-handed young subjects at rest and during the performance of three tasks: task 1: 15 slides with nonemotional content; task 2: 15 slides with negative emotional content; task 3: 15 slides with nonemotional content with different content from that in task 1. The three tasks produced significantly different effects on the right and left hemispheres. During the two nonemotional tasks the increase in mean flow velocity over basal values was similar in the two MCAs (task 1: left MCA = 3.27 +/- 1.9%; right MCA = 3.63 +/- 2.1%; task 3: left MCA = 2.42 +/- 0.7%; right MCA = 2.56 +/- 1.3%); the negative emotional task was accompanied by a significantly higher increase in the right (11.31 +/- 1.6%) than in the left MCA (4.72 +/- 3.7%; analysis of variance two-way interaction: side of recording x task, F = 43.6, P < 0.001). These results show the possibility of obtaining specific functional information from bilateral transcranial Doppler ultrasound and suggest the involvement of the right hemisphere in emotional processing.
    Journal of Neurology 01/2000; 246(12):1172-6. · 3.58 Impact Factor
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    ABSTRACT: Context Standards for treating patients with asymptomatic carotid artery stenosis have been difficult to establish because of the lack of evidence for factors influencing these patients' prognoses. However, preliminary evidence suggests that an alteration in cerebral hemodynamic function may play a relevant role in the occurrence of stroke in patients with carotid artery disease.Objective To investigate the relationship between cerebrovascular reactivity to hypercapnia and cerebrovascular events in patients with severe unilateral asymptomatic carotid artery stenosis.Design and Setting Prospective, blinded longitudinal study conducted in an outpatient neurovascular department in Italy between June 1996 and April 1998, with a median follow-up of 28.5 months.Patients Ninety-four patients with asymptomatic carotid artery stenosis of at least 70% (74 men; mean age, 71 years).Main Outcome Measures Subsequent occurrence of cerebral ischemic events (transient ischemic attack or stroke) or death, analyzed by cerebrovascular reactivity to hypercapnia (measured by transcranial Doppler ultrasonography and calculated by the breath-holding index values in the middle cerebral arteries).Results The overall annual rate for all ischemic events was 7.9%. Seventeen patients (18%) had ischemic events, all but 1 of which were ipsilateral to the carotid artery stenosis. Among factors considered, only lower breath-holding index values in the middle cerebral artery ipsilateral to carotid artery stenosis were significantly associated with the risk of an event (hazard ratio, 0.09; 95% confidence interval, 0.02-0.38; P=.001, by multivariate analysis). Based on data from previously studied healthy subjects, the cutoff of the breath-holding index for distinguishing between impaired and normal cerebrovascular reactivity was determined to be 0.69. Using this cutoff, the annual ipsilateral ischemic event risk was 4.1% in patients with normal and 13.9% in those with impaired breath-holding index values.Conclusions These results suggest a link between impaired cerebrovascular reactivity and the risk of ischemic events ipsilateral to severe asymptomatic carotid stenosis. Figures in this Article The management of patients with asymptomatic carotid artery stenosis is one of the most controversial topics in the cerebrovascular disease literature. The results of the Asymptomatic Carotid Atherosclerosis Study (ACAS)1 showed a reduction of the risk of stroke in patients undergoing endarterectomy compared with those treated medically. However, the actual benefit of carotid endarterectomy in asymptomatic patients, in terms of prevention of annual disabling stroke vs the risk of angiography and surgery, may not justify its introduction into routine clinical practice.2 The benefit of surgery could be significantly increased in a subgroup of patients with a high predisposition to develop cerebrovascular events. However, defining a high-risk patient with severe asymptomatic carotid stenosis remains difficult. Selecting patients for surgery based on their age, progression of lesion, morphologic characteristics, and degree of carotid stenosis and concomitant risk factors is apparently acceptable,3(pp1506-1507) but to date, there is no evidence of any factor that may influence the prognosis of patients with asymptomatic carotid stenosis.4 Based on pathophysiological considerations, the hemodynamic intracerebral effects of a cervical artery stenosis could help to identify high-risk patients. There is evidence that the prognosis of stroke patients with carotid occlusion depends on collateral flow.5 Some studies demonstrated that symptomatic patients differ from asymptomatic patients because of the presence of a more impaired cerebrovascular reserve.6- 7 Preliminary studies also suggested that reduced cerebrovascular reactivity may be a marker of increased risk of stroke in carotid stenosis.8- 9 However, the relationship found in these studies between impaired cerebral hemodynamics and stroke is not linear enough to suggest a univocal therapeutic decision in patients with carotid stenosis, especially asymptomatic carotid stenosis. The aim of the present study was to test the possibility of predicting cerebrovascular events in patients with severe unilateral asymptomatic carotid stenosis by means of a transcranial Doppler ultrasonographic evaluation of cerebrovascular reactivity to hypercapnia.
    JAMA The Journal of the American Medical Association 01/2000; 283(16):2122-2127. · 29.98 Impact Factor

Publication Stats

947 Citations
228.64 Total Impact Points

Institutions

  • 2006
    • Sapienza University of Rome
      • Department of Psychology
      Roma, Latium, Italy
  • 2002–2006
    • Foundation Santa Lucia
      Roma, Latium, Italy
  • 2004
    • Azienda Ospedaliera Fatebenefratelli e Oftalmico Milano
      Roma, Latium, Italy
  • 1993–2001
    • University of Rome Tor Vergata
      • Dipartimento di Dirito Pubblico
      Roma, Latium, Italy