Right now, neuroplasticity is not repeatable on demand.
When your incompetent? doctor uses this word ask then to EXPLAIN EXACTLY what needs to happen for a neuron to drop a current task and take on a neighbors!
NO explanation; PURE FUCKING INCOMPETENCE! Not knowing that makes neuroplasticity non repeatable on demand!
Katerina Poprelka1
· Maria Stefanatou1 · Stylianos Gatzonis1
Received: 9 May 2026 / Accepted: 26 September 2026
© Fondazione Società Italiana di Neurologia 2026
To the Editor,
Cases demonstrating discordance between marked structural brain abnormalities and preserved clinical function are
rare but informative. We report such a case in a 52-year
old woman, highlighting the limits and resilience of neuro
plastic adaptation. The patient presented to the outpatient
neurology clinic following two witnessed generalized
tonic-clonic seizures, both associated with a postictal phase
of impaired awareness, drowsiness, and confusion, with
gradual recovery over several minutes. On examination, she
was alert and oriented, with no focal neurological deficits.
However, deep tendon reflexes were brisk throughout, and
plantar responses were indifferent bilaterally.
Her past medical history was notable for childhood men
ingitis, the exact etiology of which was not documented,
and longstanding macrocephaly. No prior neurosurgical
intervention has been reported. Despite these early neuro
logical factors, she achieved normal developmental mile
stones, completed secondary education, and maintained
consistent employment, indicating a high level of functional
adaptation. She had no history of epilepsy until the age of
43, when she began experiencing focal seizures characterized by impaired awareness, automatisms, and behavioral
arrest, consistent with focal impaired awareness seizures.
These were managed with lacosamide at a dose of 150 mg
twice daily. In 2023, she experienced an episode of status
epilepticus, precipitated by poor medication adherence. Fol
lowing this, brivaracetam was added to her treatment regi
men, resulting in improved seizure control.
Neuroimaging revealed striking abnormalities. A CT
scan demonstrated marked enlargement of the lateral and
third ventricles, consistent with severe ventriculomegaly,
along with significant thinning of the cortical mantle. Brain
1
Katerina Poprelka
katerinapop@med.uoa.gr
First Department of Neurosurgery, Evangelismos Hospital,
National & Kapodistrian University of Athens, 45-47
Ipsilantou Str., Athens 10676, Greece
MRI (Fig. 1) provided further detail, showing diffuse cere
bral atrophy, most prominently involving the corpus cal
losum, which appeared significantly thinned. Additionally,
an empty sella turcica was noted. Electroencephalogra
phy showed generalized slowing with predominant theta
activity, intermittent epileptiform discharges, and bilateral
temporo-occipital slowing, more prominent over the left
hemisphere.
We believe that the observed ventricular enlargement
most likely reflects a long-standing developmental or post
inflammatory process, rather than active hydrocephalus.
The available clinical and imaging data do not allow a clear
distinction between chronic post-infectious hydrocephalus,
arrested hydrocephalus, and long-standing overt ventriculo
megaly in adults (LOVA). The degree of ventricular enlarge
ment is disproportionate to the observed cortical atrophy,
making hydrocephalus ex vacuo less likely. We therefore
favor a multifactorial explanation involving chronic ventric
ulomegaly with secondary cerebral atrophy, while acknowl
edging the inherent diagnostic uncertainty.
A comprehensive neuropsychological assessment was
conducted to evaluate cognitive functions in greater depth.
Mild executive dysfunction was observed, particularly
affecting cognitive flexibility, planning, and processing
speed, as evidenced by reduced performance on Stroop
Neuropsychological Screening Test, Trail Making Test Part
B, and Digit Symbol Coding. Memory performance was dis
proportionately affected, with severe impairments in verbal
and visual learning and delayed recall on the Rey Auditory
Verbal Learning Test and the Rey-Osterrieth Complex Fig
ure Test, suggesting deficits across encoding, consolidation,
and retrieval processes. Increased susceptibility to interfer
ence was also observed. The non-modality-specific pattern,
affecting both verbal and visual memory, points to dysfunc
tion within distributed memory networks rather than a focal
deficit. Despite these objective deficits, the patient did not
report significant subjective cognitive complaints in daily
life. However, cognitive fatigue was observed during test
ing, which may have contributed to reduced performance
and suggests limited cognitive reserve under sustained demand. Importantly, there was no evidence of coexisting
mood or anxiety disorders that could otherwise explain or
exacerbate cognitive findings.
The prevalence of hydrocephalus in the adult population
is estimated at roughly 1 per 10,000, with aqueductal steno
sis accounting for approximately 10% of cases [1]. Additional
common etiologies include congenital abnormalities, infec
tious processes, head trauma, and space-occupying obstructive
lesions. Among these etiologies, long-standing hydrocepha
lus, including cases secondary to early-life insults such as
infection, is of particular interest, as it may be associated with
severe anatomical distortion yet relatively preserved clini
cal function. This case demonstrates a marked dissociation
between extensive structural brain abnormalities and func
tional outcome. Although the degree of ventriculomegaly, cor
tical thinning, and diffuse atrophy would typically be expected
to result in significant neurological and cognitive impairment,
the most striking feature in this patient is the preservation of
functional independence despite objectively significant neu
ropsychological deficits, including severe memory impair
ment and mild executive dysfunction. Notwithstanding these
findings, she maintained autonomy in everyday activities for
decades, underscoring a complex and non-linear relationship
between cognitive impairment and real-world functioning.
Similar cases have been described in the literature, particularly
in individuals with long-standing or congenital hydrocepha
lus, in whom profound anatomical distortion is accompanied
by relatively mild clinical manifestations [2, 3].
A 44-year-old man with a history of childhood hydro
cephalus and shunt placement demonstrated severe ventricu
lomegaly and a markedly thin cortical mantle, accompanied
by low-average intellectual functioning; nevertheless, he
maintained functional independence and relatively stable
neurological status over time, with cognitive deficits that
appeared chronic rather than progressive [2]. Similarly, in a
(C) Sagittal and coronal views illustrating the marked expansion of the
ventricular system and compression of the brain parenchyma
72-year-old woman with overt ventriculomegaly, preserved
independence and normal cognitive screening were reported
despite severe structural abnormalities, with seizures emerg
ing late in life in the context of otherwise minimal neurolog
ical impairment [3]. Compared with these cases, the present
patient shares the characteristic dissociation between severe
structural brain changes and preserved daily functioning;
however, she is distinguished by more pronounced memory
impairment on formal neuropsychological testing despite
long-term independence.
These observations may be considered within the frame
work of developmental plasticity, whereby cognitive func
tions developing in the context of early neurodevelopmental
abnormalities may adapt to an atypical neural substrate. In
this context, adaptation is more appropriately conceptual
ized as the development of cognitive functions within exist
ing structural constraints rather than as “reorganization”
of previously established networks. Such developmental
adaptation may partly account for the preservation of func
tional independence despite severe structural abnormalities,
although the mechanisms underlying this dissociation can
not be established from the present case. The presence of
significant memory impairment and milder executive dys
function, together with the later emergence of epilepsy, nev
ertheless suggests that this adaptation may be incomplete
and may not fully protect against cognitive and neurological
vulnerability. Cognitive reserve may also have contributed
to the relatively preserved everyday functioning; however,
available proxies are limited to educational attainment and
sustained employment, precluding stronger conclusions
regarding its role. Age-related changes, increasing network
inefficiency, and reduced cognitive reserve have been pro
posed as factors that may reveal previously compensated
vulnerabilities over time; however, their contribution in the
present case remains speculative
In summary, this case highlights that functional outcome
in chronic structural brain disease is not determined solely
by anatomical integrity. Instead, the marked dissociation
between structural abnormalities and everyday functioning
may reflect the influence of developmental adaptation and
individual differences in cognitive reserve, although their
respective contributions cannot be established in this case.
While the brain demonstrates remarkable adaptability in the
context of longstanding structural abnormalities, cognitive
deficits and neurological complications may still emerge,
underscoring the importance of comprehensive evaluation
and long-term follow-up.
Author Contribution Credit authorship contribution statement Kateri
na Poprelka: Conceptualization, Investigation, Formal Analysis, Writ
ing Original Draft. Maria Stefanatou: Validation, Writing- Review &
Editing. Stylianos Gatzonis: Supervision, Writing- Review & Editing.
Funding No funding was received to assist with the preparation of
this manuscript.
Declarations
Ethics approval The authors have obtained patient consent.
Competing interest The authors have no competing interests to de
clare that are relevant to the content of this article.
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