Medical and endovascular treatments of symptomatic intracranial stenosis. A Bayesian network meta-analysis

Intracranial stenosis is a well-established stroke risk factor with an increase of stroke recurrence or TIA up to 12.6% at 1 year. Treatments are different: medical and endovascular. We performed a multiple treatment comparison analysis to detect the best treatment in reducing the risk of stroke recurrence. We searched in Medline, Embase, Cochrane Central Register of Controlled Trials databases between 1979 and October 2017. Inclusion criteria were prospective randomized trials that evaluated patients with TIA or stroke due to intracranial stenosis and treated with different medical therapies and/or endovascular procedures. Primary endpoint was the recurrence of TIA or stroke in the territory of intracranial stenosis, while secondary endpoint was represented by any stroke or vascular death. Multiple treatment comparison meta-analysis based on a Bayesian fixed and random effects Poisson model was performed. Seven trials were included with a total of 1337 patients. At multiple treatment comparison, no significant differences between treatments were observed for both primary (median fixed effect standard OR: 0.40; 95%CI: 0.02-1.07) and secondary endpoints (median random effect standard OR: 1.17; 95%CI: 0.32-1.92). Treatment with aspirin alone ranked with high values both for primary and secondary endpoints (surface under the cumulative ranking curve of 70% and 82%, respectively). In patients with symptomatic intracranial stenosis, no differences between treatments were observed. However, aspirin alone was more effective than stenting in the reduction of TIA or stroke recurrences, with a better safety profile than oral anticoagulants.

Previous infection and the risk of ischaemic stroke in Italy: the IN2 study

BACKGROUND AND PURPOSE

There is an increasing interest in new risk factors for ischaemic stroke. Acute and chronic infections could contribute to different aetiological mechanisms of atherosclerosis that lead to cerebrovascular disease. The aim of this study was to investigate the hypothesis that previous infections and Chlamydia pneumoniae in particular increase the risk of ischaemic stroke in the population.

METHODS

This was a prospective case-control study involving 11 Italian stroke units. Controls were age- and sex-matched with cases, represented by patients admitted to hospital for acute ischaemic stroke. For each participant classical vascular risk factors and previous inflammatory and infectious events up to 1 month before were registered. Blood samples were collected to analyse inflammatory markers and titres of antibodies against C. pneumoniae.

RESULTS

A total of 1002 participants were included (mean age 69 years) with 749 ischaemic stroke patients. Infections occurred within 1 month previously in 12% of the entire sample with a higher prevalence in the case group (14.4% vs. 3.9%). At multivariate analysis of the seropositivity of IgA antibodies against C. pneumoniae increased the risk of stroke significantly (relative risk 2.121; 95% confidence interval 1.255-3.584) and an early previous infection (up to 7 days before the event) contributed to a rise in probability of acute cerebral ischaemia (relative risk 3.692; 95% confidence interval 1.134-6.875).

CONCLUSIONS

Early previous infections and persistent chronic infection of C. pneumoniae could contribute to increase the risk of ischaemic stroke significantly, in the elderly especially.

Chronic migraine in women is associated with insulin resistance: a cross-sectional study

BACKGROUND AND PURPOSE

Migraine is a common neurological disorder. It can be divided into episodic migraine (EM) and chronic migraine (CM), based on headache frequency. Some studies have shown that insulin sensitivity is impaired in migraine; moreover, hypertension, diabetes and obesity are common in patients with CM. The aim of this study was to assess serum glucose, insulin levels and insulin resistance (IR) in a sample of episodic migraineurs, chronic migraineurs and non-pain healthy controls.

METHODS

Eighty-three women with EM, 83 with CM and 83 healthy controls were recruited. Headache was diagnosed according to the latest International Classification of Headache Disorders 2 criteria. Waist circumference, body mass index (BMI) and blood pressure were measured. Checked metabolic parameters included fasting glucose, the 2 h 75 g oral glucose tolerance test (2 h OGTT), serum HbA1c, blood lipid profile, C-reactive protein and prolactin. The homeostasis model assessment formula was used to calculate IR.

RESULTS

A significant prevalence of IR in CM was observed (P = 0.002). No significant associations were found with fasting glycaemia, the 2 h OGTT, HbA1c, blood lipid profile, C-reactive protein, prolactin and waist circumference. Obesity (BMI >30 kg/m(2)) was associated with an increased risk of CM [odds ratio (OR) 2.4]. When the outcome of interest was the association between IR and obesity, the OR was significantly increased compared with IR alone (OR = 13.2).

CONCLUSION

This may suggest that CM is associated with IR status, particularly when it is in partnership with obesity.

Levetiracetam versus carbamazepine in patients with late poststroke seizures: a multicenter prospective randomized open-label study (EpIC Project)

BACKGROUND

Strokes are the leading cause of epileptic seizures in adults and account for 50% of seizures in those over the age of 65 years. The use of antiepileptic drugs to prevent recurrent poststroke seizures is recommended.

METHODS

One hundred and twenty-eight patients with poststroke seizures were randomly allocated to treatment with either levetiracetam (LEV) or sustained-release carbamazepine (CBZ) in a multicenter randomized open-label study. After a titration study phase (2 weeks), the optimal individual dose of trial medication was determined and treatment was continued for another 52 weeks. The primary endpoint was defined as the proportion of seizure-free patients; the secondary endpoints were: evaluation of time recurrence to the first seizure, EEG tracings, cognitive functions and side effects.

RESULTS

Of 128 patients, 22 discontinued the trial prematurely; thus a total of 106 patients (52 treated with LEV and 54 treated with CBZ) were included in the analysis. The results of the study were as follows: no significant difference in number of seizure-free patients between LEV and CBZ (p = 0.08); time to the first recurrence tended to be longer among patients on LEV; there was no correlation between the therapeutic effect and the EEG findings in either treatment group; LEV caused significantly fewer (p = 0.02) side effects than CBZ; attention deficit, frontal executive functions and functional scales (Activities of Daily Living and Instrumental Activities of Daily Living indices) were significantly worse in the CBZ group.

CONCLUSIONS

This trial suggests that LEV may be a valid alternative to CBZ in poststroke seizures, particularly in terms of efficacy and safety. In addition, our results show that LEV has significant advantages over CBZ on cognitive functions. This trial also indicates that LEV in monotherapy is a safe and effective therapeutic option in elderly patients who have suffered epileptic seizures following a stroke.

Incidence and predictors of acute symptomatic seizures after stroke

OBJECTIVE

To assess incidence and predictors of acute symptomatic seizures in a prospective cohort of patients with first stroke.

METHODS

Patients with first stroke hospitalized in 31 Italian centers were recruited. Relevant demographic data, disease characteristics, and risk factors were collected. Acute symptomatic seizures (≤7 days) were recorded and correlated to age, gender, family history of epilepsy, and vascular risk factors.

RESULTS

A total of 714 patients (315 women, 399 men; age 27-97 years) were enrolled. A total of 609 (85.3%) had cerebral infarction (32 cerebral infarction with hemorrhagic transformation [CIHT]) and 105 (14.7%) primary intracerebral hemorrhage (PIH). A total of 141 (19.7%) had a large lesion (>3 cm) and 296 (41.5%) cortical involvement. Twelve patients reported family history of seizures. Forty-five patients (6.3%) presented acute symptomatic seizures, 24 with cerebral infarction (4.2%), 4 with CIHT (12.5%), and 17 (16.2%) with PIH. In multivariate analysis, compared to cerebral infarction, PIH carried the highest risk (odds ratio [OR] 7.2; 95% confidence interval [CI] 3.5-14.9) followed by CIHT (OR 2.7; 95% CI 0.8-9.6). Cortical involvement was a risk factor for PIH (OR 6.0; 95% CI 1.8-20.8) and for CI (OR 3.1; 95% CI 1.3-7.8). Hyperlipidemia (OR 0.2; 95% CI 0.03-0.8) was a protective factor for IPH.

CONCLUSION

The incidence of acute symptomatic seizures is the highest reported in patients with first stroke with prospective follow-up. Hemorrhagic stroke and cortical lesion were independent predictors of acute symptomatic seizures. Hyperlipidemia was a protective factor for hemorrhagic stroke.

Bell's palsy: a manifestation of prediabetes?

BACKGROUND

Idiopathic peripheral facial nerve palsy or Bell's palsy (BP) is the most common cause of facial nerve palsy.

OBJECTIVE

To evaluate the role of glucose metabolism abnormalities in BP.

METHODS

We identified 148 patients with unilateral BP and 128 control subjects. In all we evaluated glucose level at fasting and after a 2-h oral glucose tolerance test (2h-OGTT). In addition we determined insulin resistance (IR), by HOMA-index. Patients and controls were divided in to two groups, according to their Body Mass Index (BMI).

RESULTS

Following a 2h-OGTT, the prevalence of glucose metabolism abnormalities was significantly higher in patients with BP than in controls (P < 0.001). Impaired glucose tolerance (IGT) was found in 57 (38%) patients and in 23 (18%) controls, while a new-diagnosed DM (NDDM) was found in 29 (19%) patients and in 8 (6%) controls. The IR was significantly increased only in BP patients with BMI ≥ 24.9 (P = 0.005). BMI, waist circumference, blood pressure, tryglicerides, serum lipid, drugs use were not significantly different between patients and controls.

CONCLUSIONS

In this study we found that prediabetes is frequently associated with facial palsy. We propose to perform a 2h-OGTT in patients with peripheral facial palsy and normal fasting glycaemia. HOMA-index should be evaluated in obese facial palsy patients.

Uterine rupture after prostaglandin analogues to induce midtrimester abortion

Although prostaglandins are largely used and considered safe drugs to induce midtrimester abortion, the literature reports several cases of uterine rupture consequent to their administration. We report the second ever-described case of uterine rupture after administration of gemeprost and sulprostone for midtrimester abortion in a 45 years-old women with scarred uterus.She was admitted to our Unit for termination at 20 weeks' gestation because of trisomy 21 diagnosed by chromosomal analysis of amniotic liquid at 16 weeks' gestation. Five pessaries of gemeprost (one pessary, every 3 hours) were administered into the posterior vaginal fornix. Since the cervix remained closed and uneffaced, another cycle of 5 gemeprost administration was conducted. When the cervix changed in consistency and dilatation, we decided to administrate sulprostone. At the obstetric examination any visible fetus was evidenced. The abdominal ultrasonography showed an empty uterine cavity and the gestational sac with the dead fetus in abdomen. Emergency laparotomy was therefore undertaken. Primary suture of the ruptured uterus was initially attempted but in vain. Therefore, total abdominal hysterectomy was performed to control bleeding and eventual hypovolemic shock.Given the lack of strong evidence in literature and the fact that case reports are not an optimal method for assessing frequency of an event nor the overall risks of a procedure since they frequently report rare single events, other larger studies are needed to assess whether women with multiple risk factors (e.g. advanced age and previous uterine surgery), and administered with prostaglandins' association have a higher risk of uterine rupture.

Binge-like eating in mice

OBJECTIVE

Given the lack of reliable murine model of binge-like eating, we tried to induce this pathological behavior in mice.

METHOD

We used an experimental protocol mimicking the etiological factors involved in the development of binge eating in humans, that is, food restriction, refeeding (R-R) in presence of high palatable food, and stress (S).

RESULTS

Mice subjected to at least three cycles of R-R plus S (forced swimming stress), showed a binge-like behavior evident as early as 4 h, persisting 24 h after stress application and not associated to depressive-like behavior. However, after the third R-R/S cycle, food intakes of mice returned to normal levels.

DISCUSSION

(i) at least three cycles of R-R plus S are required to promote abnormal eating in mice, (ii) this is not associated to depressive-like behaviors, and (iii) the enhanced pathological behavior showed a transient nature not persisting after the third R-R/S cycle.

Role of the corticotropin-releasing factor receptor type 2 in the control of food intake in mice: a meal pattern analysis

The actions of corticotropin-releasing factor (CRF) and related peptides are mediated by two receptors (CRF(1) and CRF(2)). The respective role of each subtype in the control of food intake remains poorly known. In the present study, we examined the quantity and microstructure of ingestive behavior of knockout (KO) mice lacking CRF(2) receptors and their wild-type (WT) littermates. Under basal conditions, CRF(2) KO mice showed increased nocturnal food intake, evident as an increased zenith in circadian cosinor analysis of food intake. Microstructure analysis revealed that this greater food intake reflected increased meal size, rather than meal frequency, suggesting a decreased satiating value of food. Following acute restraint stress, CRF(2) KO mice showed an intact immediate anorectic response with increased latency to eat and decreased meal size. However, CRF(2) deletion abolished the prolonged phase of restraint-induced anorexia. CRF(2) KO mice did not differ from WT controls in feeding responses to food deprivation or injection of ghrelin receptor agonists. Independent of genotype, food deprivation increased food intake, with dramatic changes in meal size, meal frequency, water : food ratio and eating rate. Acyl-ghrelin or BIM-28131, a potent ghrelin analog, dose-dependently stimulated food intake by increasing meal size (ghrelin, BIM-28131) and meal number (BIM-28131), while slowing the average eating rate (BIM-28131) similarly in WT and KO mice. These results suggest that the CRF(2) receptor is involved in the control of meal size during the active phase of eating and following acute exposure to stress.

Behavioral effects of the β3 adrenoceptor agonist SR58611A: Is it the putative prototype of a new class of antidepressant/anxiolytic drugs?

A large body of evidence corroborates the notion that deficiencies of serotonergic system are likely involved in the pathogenesis of both depression and anxiety. Activation of beta(3) adrenoceptors has been shown to increase brain tryptophan content suggesting an elevation of brain serotonin (5HT) synthesis. SR58611A is a selective beta(3) adrenergic agent possessing a profile of antidepressant activity in routine rodents' experimental models of depression. The present study was undertaken to evaluate in rodents the antidepressant properties of SR58611A and to assess its putative anxiolytic value in experimental models of depression and anxiety. Compared to the control group, SR58611A (0.1, 1, 5 or 10 mg/kg) caused a dose-dependent reduction in immobility of Wistar male rats in the forced swim test. The maximum dose appeared to be equivalent to an effective dose of clomipramine (50 mg/kg). In addition, acute injection of SR58611A induced in rats a dose-dependent decrease in grooming response to a novel environment (novelty-induced grooming test). For any dose, the effect was lower than that of diazepam (1 mg/kg). Chronic treatment with SR58611A resulted also in an increased social interaction time in the social interaction test without affecting motor activity of rats. Furthermore, similarly to diazepam a chronic treatment with the highest doses of SR58611A was followed by increased exploratory behavior in Swiss male mice exposed to the elevated plus maze test. These effects are mediated by beta(3) adrenoceptors since i.p. pretreatment with the selective beta(3) adrenoceptor antagonist SR59230A (5 mg/kg) blocked the effects of SR58611A. Finally, also the 5HT antagonist methysergide (2 mg/kg) prevented the antidepressant and anxiolytic-like activity of SR58611A indicating that 5HT transmission is strictly involved in its action.

Subcortical ischaemic changes in young hypertensive patients: frequency, effect on cognitive performance and relationship with markers of endothelial and haemostatic activation

Information on subcortical ischaemic changes (SIC) in young hypertensive patients is scarce. We evaluated the frequency of SIC at magnetic resonance imaging (MRI), the possible effect on cognition of these patients, and the role of plasma markers known as indicators of endothelial and haemostatic activation. Inclusion criteria were age <or=54 years, hypertension for at least 2 years and absence of cerebrovascular disease or other conditions possibly related to SIC. Patients with SIC at MRI and two control groups (matched for age, sex and education) of hypertensive patients without SIC and non-hypertensive healthy subjects underwent an extensive neuropsychological examination and evaluation of plasma markers. Amongst the 200 patients evaluated, 50 (25%) showed SIC at MRI. Mean age was 48.4 +/- 4.8 years. Compared with both control groups, hypertensive patients with SIC performed significantly worse in general cognition, attention, memory and executive functions. Moreover, they showed significantly more often increased levels of all plasma markers compared with healthy controls, and of von Willebrand factor (vWF) compared with both control groups (P < 0.001). In young hypertensive patients SIC are frequent, related to a worse cognitive performance and endothelial dysfunction. Our findings suggest vWF as marker of end-organ damage, underscoring the relevance of treating hypertension at younger age.

Stressors affect the response of male and female rats to clomipramine in a model of behavioral despair (forced swim test)

Aim of the present study was to evaluate the effects of physical stressors (electric foot-shocks) on effect of the antidepressant drug, clomipramine and plasma corticosterone levels in male and female rats tested in a model of behavioral despair (forced swim test,). Male and female rats of the Wistar strain were injected with clomipramine (50 mg/kg, i.p.) or saline. A group of animals also received electric shocks of different intensity and duration of 24, 5 and 1 h before being subjected to forced swim test. At the end of behavioral procedures, vaginal smears were assessed in all female animals and data on immobility time were plotted according to the ovarian cycle phase. After decapitation, corticosterone plasma levels were measured by radioimmunoassay in both male and female rats. Application of mild shocks (5 ms, 0.1 mA) significantly reduced immobility time in forced swim test of untreated male rats and augmented clomipramine effect on this parameter. Moderate shocks of higher intensity or duration (5 ms, 1.0 mA) also resulted in decreased immobility time of untreated male rats, but in reduced effect of clomipramine treatment. Furthermore, application of severe shocks (10 ms, 1.0 mA) increased the immobility time in untreated animals and totally abolished clomipramine effect in forced swim test. Untreated non-shocked female rats in proestrous and estrous phases exhibited a longer immobility time as compared to diestrous animals. Immobility time appeared to be generally higher when mild, moderate or severe shocks were applied prior to behavioral testing in proestrous and estrous animals, while the behavioral response of diestrous and metestrous animals did not differ from that of controls. Clomipramine effect on immobility time was generally reduced by application of shocks of every strengths. Stress-induced plasma corticosterone levels surge correlated with intensity and duration of shocks in both male and female rats, but clomipramine treatment generally blunted the hormonal response. However, severe shocks were followed by a surge of plasma corticosterone levels in both male and female clomipramine-treated rats. These results demonstrate that duration and intensity of stressful stimuli may deeply affect the behavioral response of rats in forced swim test and influence clomipramine effect in this behavioral model depending on gender-based variables, probably of the hormonal type. Plasma corticosterone levels correlate with the behavioral response to clomipramine treatment suggesting that reactivity of hypothalamus-pituitary-adrenal axis to stress may be involved in the antidepressant effect of this drug.

The spectrum of Notch3 mutations in 28 Italian CADASIL families

BACKGROUND

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) is a cause of hereditary cerebrovascular disease. It results from mutations in the Notch3 gene, a large gene with 33 exons. A cluster of mutations around exons 3 and 4 was originally reported and limited scanning of these exons was suggested for the diagnosis in most cases.

OBJECTIVE

To report Notch3 mutation analysis in 28 unrelated Italian CADASIL families from central and south Italy.

RESULTS

The highest rate of mutations was found in exon 11 (21%) and only 18% of mutations were in exon 4. This may be related to the peculiar distribution of Notch3 mutations in the regions of origin of the families.

CONCLUSIONS

The results suggest that limited scanning of exons 3 and 4 is inadvisable in CADASIL cases of Italian origin.

Unusual clincal presentation of cerebral-isolated sarcoidosis. Case report and review of the literature

The authors report the case of a 31-year-old man, who presented an hemorrhagic onset of a cerebral-isolated sarcoidosis, to date never described in the literature. Unusual clinical manifestation, neuroradiological study and direct histological confirmation are presented. Moreover, Gallium-67 Single Photon Emission Computed Tomography (Ga-67 SPECT) contribution is indicated to complete the evaluation of patients with cerebral inflammatory lesions, such as neurosarcoidosis, and in cases of equivocal neuroradiological imaging, to evaluate uptake activity of the inflammatory tissue. The patient did well and reported no further progression of his disease during 7 months of follow-up.

Production of somatic hybrids between frost-tolerant Solanum commersonii and S. tuberosum: characterization of hybrid plants

Somatic fusion of mesophyll protoplasts was used to produce hybrids between the frost-tolerant species Solanum commersonii (2n=2x=24) and dihaploid S. tuberosum (2n=2x=24). This is a sexually incompatible combination due to the difference in EBN (Endosperm Balance Number, Johnston et al. 1980). Species with different EBNs as a rule are sexually incompatible. Fifty-seven hybrids were analysed for variation in chromosome number, morphological traits, fertility and frost tolerance. About 70% of the hybrids were tetraploid, and 30% hexaploid. Chloroplast counts in stomatal guard cells revealed a low frequency of cytochimeras. The frequency of aneuploids was relatively higher at the hexaploid level (hypohexaploids) than at the tetraploid level (hypotetraploids). The somatic hybrids were much more vigorous than the parents, and showed an intermediate phenotype for several morphological traits and moderate to profuse flowering. Hexaploid hybrid clones were less vigorous and had a lower degree of flowering than the tetraploid hybrid clones. All of the hybrids were female fertile but male sterile except for one, which was fully fertile and self-compatible. Many seeds were produced on the latter clone by selfing and on the male-sterile clones by crossing. The somatic hybrid plants showed an introgression of genes for frost tolerance and an adaptability to cold from S. commersonii. Therefore, the use of these somatic hybrids in breeding for and in genetic esearch on frost tolerance and cold-hardening is suggested.

Correlates of adaptation to the sleep laboratory. Behavior, sleep organization, quantitative EEG

The present study aims at establishing to what extent adaptation phenomena should be taken into consideration for the definition of an independent baseline in sleep research. To this purpose we have studied: (1) a standard battery of neuropsychological test evaluating performance, subjective assessments of moods and sleep quality; (2) classical sleep parameters; (3) data derived from quantitative analysis of sleep EEG. 19 young male volunteers have been recorded for consecutive nights; 7 of them underwent the recordings for 3, 8 for 6 and 4 for 10 nights. Results can be summarized as follows: (A) both interindividual and intraindividual variability show a progressively decreasing trend toward homogeneity for most of the explored parameters; (B) steady state is reached in different times for different groups of parameters; (C) an adequate group homogeneity was achieved from the 5th night onwards. Implications of these data in sleep studies, namely in sleep active drug research are discussed.

[Statistical study on the medical management of patients with epilepsy in a district of Reggio Calabria]

The epilepsy service provided by 143 doctors in the district of Vibo Valentia (Calabria) which has a population of 180,000 was studied by a team of specially trained medical students. The answers to a questionnaire given in personal interviews were statistically processed and revealed: a) a 3-4% incidence of epilepsy corresponding closely to the national average (Almost all doctors questioned had epileptic patients). b) that only 3% of the doctors tested drug concentration in the blood, while 33% relied on regular EEG checks. c) that Depakin (valproic acid) was the drug most often used, followed by Metinal-Idontoine (phenytoin + barbiturate), Dintoine (phenytoin) and Gardenal (phenobarbital). Almost all doctors were in favour of refresher courses to improve the service to epileptic patients.