OBJECTIVE Awake surgery and mapping are performed in patients with low-grade tumors infiltrating functional brain areas for which the greater the resection, the longer the patient survival. However, the extent of resection is subject to preservation of cognitive functions, and in the absence of proper feedback during mapping, the surgeon may be less prone to perform an extensive resection. The object of this study was to perform real-time continuous assessment of cognitive function during the resection of tumor tissue that could infiltrate eloquent tissue. METHODS The authors evaluated the use of new, complex real-time neuropsychological testing (RTNT) in a series of 92 patients. They reported normal scoring and decrements in patient performance as well as reversible intraoperative neuropsychological dysfunctions in tasks (for example, naming) associated with different cognitive abilities. RESULTS RTNT allowed one to obtain a more defined neuropsychological picture of the impact of surgery. The influence of this monitoring on surgical strategy was expressed as the mean extent of resection: 95% (range 73%-100%). At 1 week postsurgery, the neuropsychological scores were very similar to those detected with RTNT, revealing the validity of the RTNT technique as a predictive tool. At the follow-up, the majority of neuropsychological scores were still > 70%, indicating a decrease of < 30%. CONCLUSIONS RTNT enables continuous enriched intraoperative feedback, allowing the surgeon to increase the extent of resection. In sharp contrast to classic mapping techniques, RTNT allows testing of several cognitive functions for one brain area under surgery.

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Deficit in planning and problem-solving, affecting a wide range of neuropsychological patients, has been widely investigated using the Tower of London (ToL) test, as developed by Shallice (Philos Trans R Soc Lond Ser B Biol Sci 298:199-209, 1). The ToL taps on several executive functions (EF), such as planning, time for planning or rule breaks, which may be usefully indexed by different ToL measurements. However, in its original version, the different aspects involved in ToL are not evaluated in a specific way.Here, we report the standardization of the ToL, on 896 individuals aged 15-86 years, taking in account individual factors (i.e. gender, age, years of education) which may affect performances on ToL. We computed several indexes on the ToL including score, planning and execution times, perseverations, rule breaks and self-monitoring. We found that these indexes were affected by individual factors such as gender, age and education. Present results not only provide extensive normative data according to gender, as well as different age and education ranges, but also represent a very useful instrument for a more fine-grained diagnosis of EF deficits in a wide range of neuropsychological patients, including traumatic brain injury and brain-damaged patients, as well as Alzheimer's disease and Parkinson's disease patients.

We investigated the relationship between verbal and visuo-spatial measures of working memory, inhibition, fluid intelligence and the performance on the Tower of London (ToL) task in a large sample of 830 healthy participants aged between 18 and 71 years. We found that fluid intelligence and visuo-spatial working memory accounted for a significant variance in the ToL task, while performances on verbal working memory and on the Stroop Test were not predictive for performance on the ToL. The present results confirm that fluid intelligence has a fundamental role on planning tests, but also show that visuo-spatial working memory plays a crucial role in ToL performance.

We report the case of an elderly patient with cobalamin deficiency who progressively developed cognitive and behavioral symptoms associated with neuropsychiatric disturbances. His neuropsychological profile showed many features suggestive for a frontal-dysexecutive syndrome and was related to a predominant asymmetric (right > left) frontal lobe hypoperfusion. He completely recovered after a treatment with vitamin B12 and follow-up of 7 years showed that his improvement remained stable. Along with the other cases reported in the literature, our case also proves that there are some cases of vitamin B12 deficiency that can manifest with the symptoms of frontotemporal dementia and that they are completely reversible after substitution therapy.

The relation between the sensorimotor cortex and the language network has been widely discussed but still remains controversial. Two independent theories compete to explain how this area is involved during action-related verbs processing. The embodied view assumes that action word representations activate sensorimotor representations which are accessed when an action word is processed or when an action is observed. The abstract hypothesis states that the mental representations of words are abstract and independent of the objects' sensorimotor properties they refer to. We combined neuropsychological and fMRI-PPI connectivity data, to address action-related verbs processing in neurosurgical patients with lesions involving (N = 5) or sparing (N = 5) the primary motor cortex and healthy controls (N = 12). A lack of significant changes in the functional coupling between the left M1 cortex and functional nodes of the linguistic network during the verb generation task was found for all the groups. In addition, we found that the ability to perform an action verb naming task was not related to a damaged M1. These data showed that there was not a task-specific functional interaction active between M1 and the inferior frontal gyrus. We will discuss how these findings indicate that action words do not automatically activate the M1 cortex; we suggest rather that its enrolment could be related to other not strictly linguistic processing.

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