Marco Sarà
Education
The University of Genova, School of medicine, M.D. (84-91)
Degree of Medicine & Surgery 91, University of Genova
Specialization in neurophysiology 92-96, University of Genova
Master in Critical Respiratory Care 2000-02, University of Bari
Hospital Appointments
from 2003 Head, Department of Intensive Care & Rehabilitation, "Coma Center" San Raffaele Cassino & IRCCS San Raffaele Rome
Via G. Di Biasio 1 03043 Cassino (FR)
Major Clinical Interest
Managment of patients with Severe Brain Injury (Acquired) from the Sub-Intensive Care Unit to the Rehabilitation/Intensive Care Ward.
Major Research interest (only with a published result):
1) Exploring Non-Motor Symptoms in Locked-In Syndrome (LIS) due to the cortico-cerebellar deafferentation in patients with a ventral pontine injury.
Patients with LIS due to a ventral pontine damage immediately after the awakening (pharmacological coma interruption) shows some cognitive impairment lasting both cortico-spine and cortico-cerebellar interrupted
In this way the pathophysiology of the LIS as a hidden "Disembodied Mind Syndrome."
2) Corticomotor Facilitation in patients with Disorders Of Consciousness (DOC) (single pulse TMS together with
3) Nonlinear analysis of EEG and EKG time series in DOC and developing (for the first time in this kind of patients) of a prognostic tool (at six months from the injury)
4) GABA effect in patients with DOC, we started from the intrathecal baclofen administration (ITB) and his effect on coma recovery scale. In a second period, we develop some interpretative models of GABA neurons stimulation rule on higher cognitive functions improvement in DOC patients.
5) Some contributions, from an epistemic perspective, about DOC and Self-Monitoring in LIS and partial conceptual overlapping
6) Some contributions to classification of DOC
Supervisors: Associated editor of Frontiers In Neurology and Reviewer for many indexed journals
The University of Genova, School of medicine, M.D. (84-91)
Degree of Medicine & Surgery 91, University of Genova
Specialization in neurophysiology 92-96, University of Genova
Master in Critical Respiratory Care 2000-02, University of Bari
Hospital Appointments
from 2003 Head, Department of Intensive Care & Rehabilitation, "Coma Center" San Raffaele Cassino & IRCCS San Raffaele Rome
Via G. Di Biasio 1 03043 Cassino (FR)
Major Clinical Interest
Managment of patients with Severe Brain Injury (Acquired) from the Sub-Intensive Care Unit to the Rehabilitation/Intensive Care Ward.
Major Research interest (only with a published result):
1) Exploring Non-Motor Symptoms in Locked-In Syndrome (LIS) due to the cortico-cerebellar deafferentation in patients with a ventral pontine injury.
Patients with LIS due to a ventral pontine damage immediately after the awakening (pharmacological coma interruption) shows some cognitive impairment lasting both cortico-spine and cortico-cerebellar interrupted
In this way the pathophysiology of the LIS as a hidden "Disembodied Mind Syndrome."
2) Corticomotor Facilitation in patients with Disorders Of Consciousness (DOC) (single pulse TMS together with
3) Nonlinear analysis of EEG and EKG time series in DOC and developing (for the first time in this kind of patients) of a prognostic tool (at six months from the injury)
4) GABA effect in patients with DOC, we started from the intrathecal baclofen administration (ITB) and his effect on coma recovery scale. In a second period, we develop some interpretative models of GABA neurons stimulation rule on higher cognitive functions improvement in DOC patients.
5) Some contributions, from an epistemic perspective, about DOC and Self-Monitoring in LIS and partial conceptual overlapping
6) Some contributions to classification of DOC
Supervisors: Associated editor of Frontiers In Neurology and Reviewer for many indexed journals
less
Related Authors
InterestsView All (8)
Uploads
Papers by Marco Sarà
Design: Cross-sectional survey.
Setting: Post-coma and rehabilitation care unit.
Participants: Patients (NZ6) with a diagnosis of vegetative state.
Interventions: A cascade of consecutive motor-evoked potentials (MEPs) was elicited under 3 different conditions: in the first condition, patients were at rest (Rest); in the second, they were asked to open and close the right hand (Execution); in the third, the examiner modeled a movement of abduction of the thumb in front of the patient who was encouraged in advance to imitate the action (Observation to Imitate).
Main Outcome Measures: Changes in MEP values from the abductor pollicis brevis muscle and improvement in scores on the Coma Recovery Scale-Revised.
Results: TMS-CF alone or combined with verbal instructions did not yield any change; only the combination with imitation caused changes in MEPs (shorter latency and increased amplitude) associated with behavioral improvement in 4 patients.
Conclusions: Encouraging observation to imitate may favor the transformation of some perceived actions into motor images and performances, probably depending on the activation of mirror motor neurons. In our opinion, combining visual input with TMS-CF might have reinforced the coupling between movement planning and execution, promoting the recovery of elementary motor activities in some patients. The proposed protocol may contribute to unmasking signs of preserved consciousness in patients with latent capacities for recovery.
Archives of Physical Medicine and Rehabilitation 2013
View
I read with interest the article by Machado and colleagues in the January 2012 issue of MEDICC Review (A Cuban Perspective on Management of Persistent Vegetative State). There are two main ways of considering vegetative state: as a pathology of consciousness per se or as a multifaceted ensemble of different neurological syndromes. As reported in their review, the identification of both anatomical and functional impairment may be—and in our opinion must be—the first step in the assessment of these challenging patients. In our work at San Raffaele Cassino Hospital, we see the vegetative state as a matryoshka [a Russian nesting doll—Eds.] syndrome with a pattern of lesions that is rarely the same from one patient to another. All aspects of impairment, or spared functioning, should, therefore, be examined, from motor potential to higher cognitive functions.
In the literature, we are seeing a growing emphasis on connectivity as the keystone in the structural and functional foundations of consciousness. However, this conceptual framework seems to collapse in the case of vegetative or minimally conscious states. In a clinical setting, various means of assessment are generally available to us, including functional MRI with various stimuli; standard MRI to assess extent of brain damage; and neurophysiological assessments using very refined techniques of quantitative analysis.
Nonetheless it is rare to read a paper describing both structural lesions and functional aspects in the same cohort of subjects. Failure to do this leads to serious limitations, since neurophysiological data are thus rarely compared with structural data. Functional MRI findings are generally reported in isolation, without corresponding information concerning whether or not the supporting brain structures are anatomically (as opposed to functionally) compromised. In conclusion, we believe there is a need to reinforce anatomical study as the first step in both clinical practice and science. The work of Machado et al. exemplifies this new and necessary approach—starting from the anatomical picture.
Marco Sarà MD
Post-Coma Intensive Care and Rehabilitation Unit San Raffaele Cassino Hospital Cassino, Italy
Calixto Machado Responds for the Authors
We appreciate Dr Sarà’s comments and agree that the literature has a plethora of articles about disorders of consciousness (DOC) emphasizing isolated results from highly refined techniques of quantitative brain function analysis, and that inability to compare functional data with structural-anatomic information is very limiting.[1]
As Dr Sarà affirms, anatomical lesions in DOC are always a mixture of different patterns and vary from patient to patient.[2] Thus, his matryoshka metaphor for lesions found in persistent vegetative state cases is quite apt.
Most authors overemphasize connectivity as the structural and functional mechanism of consciousness generation, [3] but it is only part of the picture. Although it is very important to assess connectivity between thalamus and neocortex in studying DOC, the presence of anatomical—sometimes sizable—lesions in the brainstem, thalamus, or cerebral hemispheres, plays a key role in explaining consciousness impairment. That is, it is important to assess more than connectivity, because grey matter lesions—which usually also involve neighboring white matter disruption—are also fundamental in DOC pathophysiology.[2]
We agree entirely with Dr Sarà that identifying and correlating both anatomical and functional impairments are necessary to recognize, assess and explain DOC in these challenging patients. And yes, the first step is the anatomical picture.
Sarà M, Pistoia F. Defining consciousness: lessons from patients and modern techniques.J Neurotrauma. 2010 Apr;27(4):771–3.
Machado C. Persistent vegetative and minimally conscious states. Rev Neurosci. 2009;20(3–4):203–20.
Vanhaudenhuyse A, Noirhomme Q, Tshibanda LJ, Bruno MA, Boveroux P, Schnakers C, et al. Default network connectivity reflects the level of consciousness in non-communicative brain-damaged patients. Brain. 2010 Jan;133(Pt 1):161–71.
April–July 2017, Vol 19, No 2–3 » Letters to the Editor
Research design: Case study.
Methods and procedures: A patient in MCS was asked to ‘imagine an unpleasant odour’ or to ‘relax’ in response to the appearance on a screen of a downward pointing arrow or a cross, respectively. Electrophysiological responses to stimuli were investigated by means of an 8-channel EEG equipment and analyzed using a specific threshold algorithm. The protocol was repeated for 10 sessions separated from each other by 2 weeks. Accuracy, defined as the number of successes with respect to the total number of trials, was used to evaluate the number of times in which the classification strategy was successful.
Main outcomes and results: Analyses of accuracy showed that the patient was able to activate and to relax himself purposefully and that he optimized his performances with the number of sessions, probably as a result of training-related improvements.
Conclusions: Subtle signs of consciousness may be under-estimated and need to be revealed through specific activation tasks. This paradigm may be useful to detect covert signs of consciousness, especially when patients are precluded from carrying out more complex cognitive tasks.
Design: Cross-sectional survey.
Setting: Post-coma and rehabilitation care unit.
Participants: Patients (NZ6) with a diagnosis of vegetative state.
Interventions: A cascade of consecutive motor-evoked potentials (MEPs) was elicited under 3 different conditions: in the first condition, patients were at rest (Rest); in the second, they were asked to open and close the right hand (Execution); in the third, the examiner modeled a movement of abduction of the thumb in front of the patient who was encouraged in advance to imitate the action (Observation to Imitate).
Main Outcome Measures: Changes in MEP values from the abductor pollicis brevis muscle and improvement in scores on the Coma Recovery Scale-Revised.
Results: TMS-CF alone or combined with verbal instructions did not yield any change; only the combination with imitation caused changes in MEPs (shorter latency and increased amplitude) associated with behavioral improvement in 4 patients.
Conclusions: Encouraging observation to imitate may favor the transformation of some perceived actions into motor images and performances, probably depending on the activation of mirror motor neurons. In our opinion, combining visual input with TMS-CF might have reinforced the coupling between movement planning and execution, promoting the recovery of elementary motor activities in some patients. The proposed protocol may contribute to unmasking signs of preserved consciousness in patients with latent capacities for recovery.
Archives of Physical Medicine and Rehabilitation 2013
View
I read with interest the article by Machado and colleagues in the January 2012 issue of MEDICC Review (A Cuban Perspective on Management of Persistent Vegetative State). There are two main ways of considering vegetative state: as a pathology of consciousness per se or as a multifaceted ensemble of different neurological syndromes. As reported in their review, the identification of both anatomical and functional impairment may be—and in our opinion must be—the first step in the assessment of these challenging patients. In our work at San Raffaele Cassino Hospital, we see the vegetative state as a matryoshka [a Russian nesting doll—Eds.] syndrome with a pattern of lesions that is rarely the same from one patient to another. All aspects of impairment, or spared functioning, should, therefore, be examined, from motor potential to higher cognitive functions.
In the literature, we are seeing a growing emphasis on connectivity as the keystone in the structural and functional foundations of consciousness. However, this conceptual framework seems to collapse in the case of vegetative or minimally conscious states. In a clinical setting, various means of assessment are generally available to us, including functional MRI with various stimuli; standard MRI to assess extent of brain damage; and neurophysiological assessments using very refined techniques of quantitative analysis.
Nonetheless it is rare to read a paper describing both structural lesions and functional aspects in the same cohort of subjects. Failure to do this leads to serious limitations, since neurophysiological data are thus rarely compared with structural data. Functional MRI findings are generally reported in isolation, without corresponding information concerning whether or not the supporting brain structures are anatomically (as opposed to functionally) compromised. In conclusion, we believe there is a need to reinforce anatomical study as the first step in both clinical practice and science. The work of Machado et al. exemplifies this new and necessary approach—starting from the anatomical picture.
Marco Sarà MD
Post-Coma Intensive Care and Rehabilitation Unit San Raffaele Cassino Hospital Cassino, Italy
Calixto Machado Responds for the Authors
We appreciate Dr Sarà’s comments and agree that the literature has a plethora of articles about disorders of consciousness (DOC) emphasizing isolated results from highly refined techniques of quantitative brain function analysis, and that inability to compare functional data with structural-anatomic information is very limiting.[1]
As Dr Sarà affirms, anatomical lesions in DOC are always a mixture of different patterns and vary from patient to patient.[2] Thus, his matryoshka metaphor for lesions found in persistent vegetative state cases is quite apt.
Most authors overemphasize connectivity as the structural and functional mechanism of consciousness generation, [3] but it is only part of the picture. Although it is very important to assess connectivity between thalamus and neocortex in studying DOC, the presence of anatomical—sometimes sizable—lesions in the brainstem, thalamus, or cerebral hemispheres, plays a key role in explaining consciousness impairment. That is, it is important to assess more than connectivity, because grey matter lesions—which usually also involve neighboring white matter disruption—are also fundamental in DOC pathophysiology.[2]
We agree entirely with Dr Sarà that identifying and correlating both anatomical and functional impairments are necessary to recognize, assess and explain DOC in these challenging patients. And yes, the first step is the anatomical picture.
Sarà M, Pistoia F. Defining consciousness: lessons from patients and modern techniques.J Neurotrauma. 2010 Apr;27(4):771–3.
Machado C. Persistent vegetative and minimally conscious states. Rev Neurosci. 2009;20(3–4):203–20.
Vanhaudenhuyse A, Noirhomme Q, Tshibanda LJ, Bruno MA, Boveroux P, Schnakers C, et al. Default network connectivity reflects the level of consciousness in non-communicative brain-damaged patients. Brain. 2010 Jan;133(Pt 1):161–71.
April–July 2017, Vol 19, No 2–3 » Letters to the Editor
Research design: Case study.
Methods and procedures: A patient in MCS was asked to ‘imagine an unpleasant odour’ or to ‘relax’ in response to the appearance on a screen of a downward pointing arrow or a cross, respectively. Electrophysiological responses to stimuli were investigated by means of an 8-channel EEG equipment and analyzed using a specific threshold algorithm. The protocol was repeated for 10 sessions separated from each other by 2 weeks. Accuracy, defined as the number of successes with respect to the total number of trials, was used to evaluate the number of times in which the classification strategy was successful.
Main outcomes and results: Analyses of accuracy showed that the patient was able to activate and to relax himself purposefully and that he optimized his performances with the number of sessions, probably as a result of training-related improvements.
Conclusions: Subtle signs of consciousness may be under-estimated and need to be revealed through specific activation tasks. This paradigm may be useful to detect covert signs of consciousness, especially when patients are precluded from carrying out more complex cognitive tasks.