Prevalence and features of delirium in older patients admitted to rehabilitation facilities: a multicenter study

BACKGROUND

Delirium is thought to be common across various settings of care; however, still little research has been conducted in rehabilitation.

AIM

We investigated the prevalence of delirium, its features and motor subtypes in older patients admitted to rehabilitation facilities during the three editions of the "Delirium Day project".

METHODS

We conducted a cross-sectional study in which 1237 older patients (age ≥ 65 years old) admitted to 50 Italian rehabilitation wards during the three editions of the "Delirium Day project" (2015 to 2017) were included. Delirium was evaluated through the 4AT and its motor subtype with the Delirium Motor Subtype Scale.

RESULTS

Delirium was detected in 226 patients (18%), and the most recurrent motor subtype was mixed (37%), followed by hypoactive (26%), hyperactive (21%) and non-motor one (16%). In a multivariate Poisson regression model with robust variance, factors associated with delirium were: disability in basic (PR 1.48, 95%CI: 1.17-1.9, p value 0.001) and instrumental activities of daily living (PR 1.58, 95%CI: 1.08-2.32, p value 0.018), dementia (PR 2.10, 95%CI: 1.62-2.73, p value < 0.0001), typical antipsychotics (PR 1.47, 95%CI: 1.10-1.95, p value 0.008), antidepressants other than selective serotonin reuptake inhibitors (PR 1.3, 95%CI: 1.02-1.66, p value 0.035), and physical restraints (PR 2.37, 95%CI: 1.68-3.36, p value < 0.0001).

CONCLUSION

This multicenter study reports that 2 out 10 patients admitted to rehabilitations had delirium on the index day. Mixed delirium was the most prevalent subtype. Delirium was associated with unmodifiable (dementia, disability) and modifiable (physical restraints, medications) factors. Identification of these factors should prompt specific interventions aimed to prevent or mitigate delirium.

Modeling Intestinal Epithelial Response to Interferon-γ in Induced Pluripotent Stem Cell-Derived Human Intestinal Organoids

Human intestinal organoids (HIOs) are increasingly being used to model intestinal responses to various stimuli, yet few studies have confirmed the fidelity of this modeling system. Given that the interferon-gamma (IFN-γ) response has been well characterized in various other cell types, our goal was to characterize the response to IFN-γ in HIOs derived from induced pluripotent stem cells (iPSCs). To achieve this, iPSCs were directed to form HIOs and subsequently treated with IFN-γ. Our results demonstrate that IFN-γ phosphorylates STAT1 but has little effect on the expression or localization of tight and adherens junction proteins in HIOs. However, transcriptomic profiling by microarray revealed numerous upregulated genes such as IDO1, GBP1, CXCL9, CXCL10 and CXCL11, which have previously been shown to be upregulated in other cell types in response to IFN-γ. Notably, "Response to Interferon Gamma" was determined to be one of the most significantly upregulated gene sets in IFN-γ-treated HIOs using gene set enrichment analysis. Interestingly, similar genes and pathways were upregulated in publicly available datasets contrasting the gene expression of in vivo biopsy tissue from patients with IBD against healthy controls. These data confirm that the iPSC-derived HIO modeling system represents an appropriate platform to evaluate the effects of various stimuli and specific environmental factors responsible for the alterations in the intestinal epithelium seen in various gastrointestinal conditions such as inflammatory bowel disease.

Functional transcranial Doppler assessment of cerebral blood flow velocities changes during attention tasks

BACKGROUND AND PURPOSE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Prognostic factors in multiple sclerosis rehabilitation

AIM

The aim of our study was to evaluate the effectiveness of inpatient multidisciplinary rehabilitation treatment in multiple sclerosis (MS) and identify reliable prognostic factors.

METHODS

Two hundred patients were enrolled for this study (65% females), with a mean age of 49.77+11.32 years and a mean disease duration of 17.33+10.15 years.

RESULTS

The results of rehabilitation were assessed in the whole sample, as well as by comparing three subgroups, divided according to their basal Expanded Disability Status Scale of Kurtzke (EDSS) score: a ''mild'' group (EDSS score 2-5.5), a ''moderate'' group (EDSS 6-6.5), and a ''severe'' group (EDSS 7-8.5). All three subgroups of patients showed a significant improvement in functional status in both the Barthel Index and Rivermead Mobility Index (Wilcoxon Test) at discharge. However the effectiveness observed in patients with mild and moderate MS in both ADL and mobility was significantly higher than that observed in patients with the severe form.

CONCLUSIONS

A multidisciplinary rehabilitative approach should be recommended for patients with a short disease duration and a relatively moderate disability.

Pain in multiple sclerosis: a clinical and instrumental approach

BACKGROUND

Pain is a frequent and disabling symptom in multiple sclerosis (MS) patients. In this study we assess the frequency and intensity of pain, as well as its impact on the quality of life and activities of daily living, in a sample of MS patients.

METHODS

One hundred and twenty eight MS patients underwent a neurological examination, a structured interview designed to assess pain, and a Medical Outcome 36-item Short Form Health Survey. Functional status was assessed by means of the Barthel Index (BI) and Rivermead Mobility Index. We also assessed the presence of depression, by means of the Montgomery and Asberg Depression Rating Scale, and fatigue, by means of the Fatigue Severity Scale. An algometer was used to measure thermal and discomfort thresholds in all of the patients and a group of 61 age- and sex-matched healthy subjects.

RESULTS

Pain was present in 61 patients. No differences were found between patients with and those without pain in disease duration, disease form or Expanded Disability Status Scale and its functional systems. Patients with pain had a lower vitality score (p = 0.008), mental health score (p = 0.03) and physical (p < 0.001) and mental composite scores (p = 0.01) than patients without pain. Furthermore, there was a significant difference between patients with and those without pain in the BI (p = 0.04). Both thermal and discomfort thresholds, as assessed by means of the algometer, were statistically lower in MS patients than in controls, whereas no difference was observed between patients with and those without pain. There was a statistically significant improvement in the thermal threshold in patients with pain who were treated pharmacologically when compared with those who were not treated (p = 0.049).

CONCLUSION

The results of this study provide further evidence of the negative impact that the presence of pain has on both the quality of life and activities of daily living in MS patients. The lower thermal and discomfort thresholds observed in our MS patients, compared with controls, may represent a predisposition to develop pain during the course of the disease.

Prognostic factors in multidisciplinary rehabilitation treatment in multiple sclerosis: an outcome study

The aim of this outcome study was to evaluate the effectiveness and prognostic factors of inpatient multidisciplinary rehabilitation treatment in patients with multiple sclerosis (MS). We analysed 230 consecutive inpatients with MS admitted to an MS rehabilitation ward who followed an individualized, goal-oriented, multidisciplinary rehabilitation program. Every patient was submitted to a neurological examination and evaluated by means of Kurtzke's Expanded Disability Status Scale (EDSS), with its functional systems (FS), Barthel Index (BI) and the Rivermead Mobility Index (RMI). We observed an effectiveness (percentage of potential improvement achieved during rehabilitation) of nearly 16% on BI and 8% on RMI, corresponding to an improvement in 124 patients (54%) on BI and 113 patients (49%) on RMI. Basal EDSS (beta = -0.32, P <0.001), cognitive status (beta = -0.15, P <0.05) and disease duration (beta = -0.13, P <0.05) were negatively associated with effectiveness of treatment on BI (adjusted R2 = 0.176), whereas effectiveness on RMI was correlated only with the EDSS score (beta = -0.34, P <0.001, adjusted R2 = 0.113). In the logistic regression analysis, the absence of severe sphincteric disturbances was correlated with the probability of improvement on BI that was nearly twice as high (OR =2.25, 95% CI 1.24-4.08) as that of other patients. Moreover, patients without severe cognitive deficits showed a similar probability (OR =2.37, 95% CI 1.05-5.33) of improvement on RMI. The results of this study provide further evidence that intensive multidisciplinary rehabilitation in MS is effective in the majority of MS patients and that early treatment may favour functional recovery.

Cerebral blood flow velocity changes during meaningful and meaningless gestures - a functional transcranial Doppler study

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.

Emotional processing in Parkinson's disease. A study using functional transcranial doppler sonography

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.

Prognostic factors in stroke rehabilitation: the possible role of pharmacological treatment

OBJECTIVES

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.

MATERIAL AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

Post-stroke depression, antidepressant treatment and rehabilitation results. A case-control study

The aim of this study was to assess the specific influence of poststroke depression (PSD) on both basal functional status and rehabilitation results. We performed a case-control study in 290 stroke inpatients, matched for age (+/-1 year) and onset admission interval (+/-3 days) and divided in two groups according to the presence (PSD+) or absence (PSD-) of PSD. All PSD+ patients were treated with antidepressants (AD), mainly with fluoxetine. PSD+ patients, despite similar severity of stroke, showed greater disability in coping with activities of daily living (ADL) on admission and greater disability both in ADL and mobility at discharge than PSD- patients. Although both groups exhibited similar average functional improvement during rehabilitation, PSD- patients were nearly twice as likely to show excellent recovery both on ADL and mobility as PSD+ patients (OR = 1.95, 95% CI = 1.01-3.75 and OR = 2.23, 95% CI = 1.14-4.35, respectively). All AD drugs improved depressive symptoms. Few relevant side effects were observed: fluoxetine was discontinued in 2 patients because of insomnia and in 2 patients because of nausea; paroxetine was stopped in 1 patient because of nausea and dry mouth. Our results confirm the unfavorable influence of PSD on functional outcome, despite pharmacological treatment.

Effect of collateral blood flow and cerebral vasomotor reactivity on the outcome of carotid artery occlusion

BACKGROUND AND PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Changes in cerebral blood flow induced by passive and active elbow and hand movements

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.

Mobility status after inpatient stroke rehabilitation: 1-year follow-up and prognostic factors

OBJECTIVES

To evaluate the stability of mobility status achieved by stroke patients during hospital rehabilitation treatment over time and to identify reliable prognostic factors associated with mobility changes.

DESIGN

Follow-up evaluation in consecutive first-ever stroke patients 1 year after hospital discharge. Multiple logistic regressions were used to analyze increases and decreases in Rivermead Mobility Index (RMI) scores (dependent variables) between discharge and follow-up. Independent variables were medical, demographic, and social factors.

SETTING

Rehabilitation hospital.

PATIENTS

A cohort of 155 patients with sequelae of first stroke, with a final sample of 141.

MAIN OUTCOME MEASURES

Mobility status at 1-year follow-up, as measured by the RMI, and odds ratios (OR) for improvement and decline in mobility.

RESULTS

Functionally, 19.9% improved the mobility levels achieved during the inpatient rehabilitation treatment; levels of 42.6% worsened. Patients with global aphasia (OR = 5.66; 95% confidence interval [CI], 1.50-21.33), unilateral neglect (OR = 3.01; 95% CI, 1.21-7.50), and age 75 years or older (OR = 5.77; 95% CI, 1.42-23.34) had a higher probability of mobility decline than the remaining patients. Postdischarge rehabilitation treatment (PDT), received by 52.5% of the final sample, was significantly and positively associated with mobility improvement (OR = 5.86; 95% CI, 2.02-17.00). Absence of PDT was associated with a decline in mobility (OR = 3.73; 95% CI, 1.73-8.04).

CONCLUSIONS

In most cases, mobility status had not yet stabilized at hospital discharge. PDT was useful in preventing a deterioration in mobility improvement achieved during inpatient treatment and in helping increase the likelihood of further mobility improvement.

Correlation of cerebral hemodynamic changes during mental activity and recovery after stroke

OBJECTIVE

To investigate the correlation between changes in cerebral functional activity during mental engagement and the potential for neurologic recovery after stroke.

BACKGROUND

Transcranial Doppler ultrasonography (TCD) makes it possible to detect the dynamic adjustment of cerebral perfusion related to functional neuronal changes.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Early versus delayed inpatient stroke rehabilitation: a matched comparison conducted in Italy

OBJECTIVE

To assess the specific influence of onset-admission interval (OAI) on rehabilitation results.

DESIGN

A case-control study in consecutive stroke inpatients, enrolled in homogeneous subgroups, matched for age (within 1 year) and Barthel Index (BI) score at admission, and different for OAI to the rehabilitation ward. The short OAI group began rehabilitation treatment within the first 20 days from stroke, medium OAI group between days 21 and 40, and long OAI between days 41 and 60.

SETTING

Rehabilitation hospital.

PATIENTS

One hundred forty-five patients with sequelae of first stroke.

MAIN OUTCOME MEASURES

Efficiency (average increase in BI per day), effectiveness (proportion of potential improvement achieved during rehabilitation) of treatment, and percentage of low- and high-response patients, calculated on BI, were evaluated. Odds ratios (ORs) of dropouts and of poor and excellent therapeutic response were also quantified.

RESULTS

The short OAI subgroup had significantly higher effectiveness of treatment than did the medium (p < .05) and the long OAI groups (p < .005). Beginning treatment within the first 20 days was associated with a significantly high probability of excellent therapeutic response (OR = 6.11; 95% confidence interval [CI], 2.03-18.36), and beginning later was associated with a similar risk of poor response (OR = 5.18; 95% CI, 1.07-25.00). On the other hand, early intervention was associated with a five times greater risk of dropout than that of patients with delayed start of treatment (OR = 4.99; 95% CI, 1.38-18.03). The three subgroups were significantly (p < .05) different regarding the percentage of low and high responders.

CONCLUSION

Our results showed a strong association between OAI and functional outcome.

Impaired cerebral vasoreactivity and risk of stroke in patients with asymptomatic carotid artery stenosis

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.

One-year follow-Up in stroke patients discharged from rehabilitation hospital

This study was designed to evaluate functional status at a 1-year follow-up in consecutive first-stroke patients after discharge from rehabilitation hospital and to identify reliable prognostic factors associated with changes in their abilities. Functional evaluation was made of consecutive patients 1 year after discharge to their own homes. Two multiple logistic regressions (forward stepwise) were performed using both improvement and worsening of the Barthel Index score between discharge and follow-up as dependent variables. Independent variables were medical, demographic and social factors. The final sample included 157 out of 172 patients. During the follow-up, 10 patients (5.81%) died because of a new cerebrovascular event, 1 patient died of myocardial infarction, 2 patients had new strokes and 2 fractured their paretic legs. Functionally, 43.3% of the patients maintained the level they achieved during inpatient rehabilitation treatment, 23.6% improved and the remaining 33.1% worsened. Patients with hemineglect and aged >/=65 years had a higher probability of functional worsening (odds ratio, OR = 3.77, 95% confidence interval, CI = 1.42- 10.0 and OR = 3.93, 95% CI = 1. 72-8.95, respectively). Postdischarge rehabilitation (performed for 46.5% of the final sample) was significantly and positively associated with functional improvement (OR = 7.23, 95% CI = 2.89-18. 05), and its absence with functional worsening (OR = 12.32, 95% CI = 4.47-37.01). In conclusion, in nearly half of the cases, functional status was still not stabilized at the time of discharge from the rehabilitation hospital. Postdischarge outpatient treatment was useful for preventing worsening of the functional ability achived during inpatient treatment and increased the possibility of further functional improvement. Age >/=65 years and hemineglect were predictors of functional worsening at follow-up.

Emotion-related cerebral asymmetry: hemodynamics measured by functional ultrasound

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.

Patterns of cerebrovascular reactivity in patients with carotid artery occlusion and severe contralateral stenosis

There is evidence suggesting that among other factors, an alteration in cerebral hemodynamics plays a relevant role in the occurrence of strokes in patients with carotid disease. The purpose of this study was to investigate patterns of cerebrovascular reactivity in patients with internal carotid occlusion and severe contralateral carotid stenosis and their relationship with symptomatology. Using transcranial Doppler ultrasound, cerebrovascular reactivity to hypercapnia in middle cerebral arteries was evaluated with the breath-holding index (BHI) in 42 patients with internal carotid occlusion and severe contralateral carotid stenosis and in 40 control subjects. A significant decrease of BHI on the occluded side was observed in symptomatic patients with respect to asymptomatic ones (0.12+/-0.1 vs. 0.75+/-0.4, P<0.0001) and with respect to the control group (1.11+/-0.1, P<0.0001). The difference was also significant between asymptomatic patients and controls (P<0.0001). Breath-holding values on the stenotic side were significantly higher (P<0.0001) in asymptomatic patients (1.01+/-0.2) with respect to symptomatic ones (0.39+/-0.1). A significant difference (P<0.0001) was also present between controls and symptomatic patients. The pattern of cerebrovascular reactivity in patients with severe bilateral carotid steno-occlusive disease seems to be strictly dependent on the presence of previous symptoms. Further studies are needed to investigate whether the study of cerebral hemodynamics in patients with bilateral carotid artery disease is important for planning therapeutic strategies.

Cerebrovascular reactivity in carotid artery occlusion: possible implications for surgical management of selected groups of patients

OBJECTIVES

The aim of this study was to use transcranial Doppler ultrasonography to investigate cerebrovascular reactivity to hypercapnia in the middle cerebral arteries of patients with carotid occlusion with different outcomes.

PATIENTS AND METHODS

Cerebrovascular reactivity to hypercapnia was calculated with the breath-holding index (BHI). Patients with unilateral carotid occlusion were divided as follows: asymptomatic (20 patients), transient ischemic attack (TIA) (20 patients), minor (20 patients) and major stroke (14 patients). Values of BHI homolateral to the carotid occlusion were compared with those of 25 healthy subjects and 34 stroke patients without significant carotid stenosis.

RESULTS

BHI values were comparable in healthy controls, non stenotic stroke patients and asymptomatic occluded patients. BHI values of patients with symptomatic occlusion were significantly lower than those of the above-mentioned groups (P<0.0001). Moreover, the reduction of BHI was significantly associated with the extent of the neurological impairment. In fact, BHI values were significantly higher in TIA than in minor and major stroke (P<0.0001) and in minor than in major stroke patients (P<0.02). Finally, we found that a BHI value homolateral to carotid occlusion of 0.69 can be considered the cut-point for distinguishing between symptomatic and asymptomatic patients.

CONCLUSION

Prospective studies are needed to demonstrate if the presence of this threshold value may help in selecting a subset of patients with asymptomatic carotid occlusion or with transient or mild neurological deficit with the highest probability of benefiting from surgical therapy.

Does the antimigraine action of flunarizine involve the dopaminergic system? A clinical-neuroendocrinological study

We have investigated the prolactin response to bromocriptine (BRC), a D2 dopamine receptor agonist in migrainous women before and after treatment with flunarizine. We evaluated whether this test was predictive of therapeutic efficacy of flunarizine treatment and whether the therapeutic response to flunarizine treatment was related to its effect on dopaminergic system at tuberoinfundibular level. Ten migrainous women underwent a BRC test in the late follicular phase before and after 1 and 3 months of treatment with flunarizine 10 mg at bedtime. Blood samples of prolactin (PRL), growth hormone, follicle-stimulating hormone, luteinizing hormone, estradiol and progesterone were taken at basal condition. PRL was also evaluated 1 and 2 h after BRC (2.5 mg) administration. Each patient kept a daily headache diary for 1 month prior to the test and throughout the study. The level of PRL inhibition after BRC administration, observed before flunarizine treatment, was not predictive of the therapeutic response observed after 1 and 3 months of treatment. The effect of flunarizine on PRL level was not related to the therapeutic efficacy of the drug. These data suggest that flunarizine does not attenuate the activity of dopaminergic neurons in migrainous patients, and that the antimigraine effect of flunarizine does not seem related to its action on dopaminergic system at least at tuberoinfundibular level.

Leukocyte count and aggregation during the evolution of cerebral ischemic injury

We evaluated leukocyte aggregation by means of the leukergy test and count in 26 patients with atherothrombotic stroke and in 10 patients with transient ischemic attacks. The evaluation was performed within 24 h from the onset of symptoms and then repeated on day 2, 4, 6 and 8. Data were compared with those of 10 healthy controls. Stroke patients were followed until day 30 when a clinical examination and brain computed tomography were performed to evaluate the extent and outcome of cerebral damage. Both leukocyte aggregation and count were significantly increased in stroke patients with respect to controls. While leukocyte count was not able to differentiate the severity of neurological impairment in stroke patients, leukocyte aggregation was significantly higher in major than in minor stroke patients on days 2 and 4 (p < 0.05). Moreover, while values of leukocyte count recorded at entry remained substantially stable in the following determinations in all groups, leukocyte aggregation showed a significant increase (p < 0.05) on day 4 with respect to all the other determinations in major stroke patients. These findings show that the extent and temporal profile of changes in leukocyte count and aggregation are different in patients with cerebrovascular disease and suggest an involvement of altered leukocyte rheology in the development of cerebral ischemic injury.

Cerebral hemodynamics in young hypertensive subjects and effects of atenolol treatment

The aim of this study was to evaluate changes in cerebral hemodynamics in young patients with uncomplicated hypertension before and after effective antihypertensive treatment with a beta-blocker drug. Changes in mean flow velocity in the middle cerebral artery from normal condition to hypercapnia were evaluated by means of a transcranial Doppler in 42 hypertensive patients and 21 healthy subjects comparable for age and sex distribution. We obtained hypercapnia with breath-holding and evaluated cerebrovascular reactivity with the breath-holding index (BHI). After a baseline evaluation (time 0), patients were randomly assigned to a placebo (group 1) or atenolol (group 2) therapy. The evaluation was repeated after 30 (time 1) and 60 (time 2) days of treatment. Before treatment, hypertensive patients had significantly lower BHI values (0.96 +/- 0.1 group 1 and 0.85 +/- 0.3 group 2) than controls (1.69 +/- 0.4) (P < 0.0001). During treatment, mean blood pressure significantly decreased in group 2 patients. In the same group, BHI values significantly increased with respect to the pre-treatment evaluation: 1.39 +/- 0.2 at time 1 and 1.44 +/- 0.2 at time 2 (P < 0.0001). On the contrary, mean blood pressure and BHI values remained unchanged in the placebo group. Furthermore, BHI values were significantly higher in group 2 than in group 1 patients at times 1 (P < 0.001) and 2 (P < 0.0001). These findings suggest that hypertension causes reduced capability of cerebral vessels to adapt to functional changes. This condition, which is reversible after treatment, could be implicated in the increased susceptibility to ischemic stroke in hypertension.

Cerebral hemodynamic patterns during stimuli tasks in multi-infarct and Alzheimer types of dementia

OBJECTIVES

To examine differences in cerebrovascular reactivity between multi-infarct and Alzheimer types of dementia.

PATIENTS AND METHODS

Using transcranial Doppler, measurements of flow velocity in the middle cerebral arteries during apnea, thumb-to-finger opposition and verbal and design discrimination tasks were recorded in patients with multi-infarct (n=10; mean age 68+/-7.5 years) and Alzheimer types of dementia (n=10; mean age 62+/-9.1 years). Controls were 20 healthy subjects matched for age and sex.

RESULTS

Cerebral reactivity to apnea was significantly lower (P<0.0001) in the multi-infarct group compared to the other 2 groups. During the motor task, a nearly selective increase of mean flow velocity in the middle cerebral artery contralateral to the hand performing the task occurred in both controls and Alzheimer patients. A bilateral increase, without side-to-side differences, of flow velocity during movement of each hand was observed in multi-infarct patients. With respect to baseline values, the cognitive tasks produced significant and distinct effects on the left and right side in the controls but not in the patients. Controls showed a significant increase of left middle cerebral artery mean flow velocity during a verbal task (P<0.0001), and of the right middle cerebral artery mean flow velocity during a design discrimination task (P<0.001) when side-to-side comparisons were done. Differently, a bilateral and comparable increase of flow velocity was observed in all patients during performance of the same cognitive tasks.

CONCLUSION

These data suggest that cerebrovascular reactivity to apnea could be an additional criterion for discriminating between MID and DAT patients. Transcranial Doppler assessment during cognitive and motor tasks could provide useful complementary information for comprehension changes in cerebral activity in patients with dementia.

Age and sex differences in cerebral hemodynamics: a transcranial Doppler study

BACKGROUND AND PURPOSE

Hemodynamic factors seem to play an important role in the pathogenesis of cerebral ischemic events. The aim of this study was to evaluate whether changes in cerebrovascular reactivity occur in women after menopause.

METHODS

Using transcranial Doppler ultrasonography, we studied the changes of flow velocity after hypercapnia in the middle cerebral arteries of 45 healthy premenopausal women (mean age, 32.3 years; range, 20 to 47 years) and 40 postmenopausal women (mean age, 54.4 years; range, 48 to 64 years). The same measurements were recorded in two groups of healthy male subjects age matched with premenopausal (45 subjects) and postmenopausal women (40 subjects). Moreover, a subgroup of postmenopausal women aged 48 to 53 years (15 subjects) were compared with a group of 15 premenopausal women of the same age. We obtained hypercapnia with breath holding and evaluated cerebrovascular reactivity with the breath-holding index (BHI).

RESULTS

BHI was significantly lower in postmenopausal women (0.89+/-0.3) than in premenopausal women (1.59+/-0.3; P<0.0001) and in young (1.34+/-0.5; P<0.001) and old men (1.20+/-0.4; P<0.04). In the latter group, BHI was significantly lower than in premenopausal women (P<.0001). BHI values were also significantly lower in postmenopausal than in premenopausal women of the same age (0.81+/-0.1 versus 1.34+/-0.1; P<0.0001).

CONCLUSIONS

These findings suggest that the large reduction of cerebrovascular reactivity in postmenopausal women cannot be considered a simple factor related to aging but is probably influenced by hormonal changes. The alteration in cerebrovascular regulation could be involved in the increase of cerebrovascular disease in postmenopausal women.

Post-stroke rehabilitation: an economic or medical priority? Current issues and prospects in light of new legislative regulations

The aim of this study was to evaluate: 1) whether the reduction in duration of in-patient rehabilitation imposed by the Italian Ministry of Health's circular of 29/6/95 has been accompanied by a decline in the results achieved; and 2) whether the system of basing payments on diagnosis related group (DRG) criteria is capable of correctly evaluating differences in post-stroke clinical pictures. The study involved 461 of 497 patients consecutively admitted between 1991 and 1996 for rehabilitation after a first stroke. The average duration of hospitalisation for the period 1995-1996 was significantly shorter (p<0.001) than that of the previous years; at the same time, there was a significant increase (p<0.05) in the number of poor responders in both neurological and functional (mobility) terms. Furthermore, the early discharge after 60 days of the 1995-1996 patients compromised the stabilisation of recovery and led to a subsequent functional decline. It is therefore hoped that the current regulations will be revised and that payments based on a functional related group (FRG) criterion will be introduced.

Correlations of flow velocity changes during mental activity and recovery from aphasia in ischemic stroke

Mean flow velocity in the middle cerebral arteries (MCAs) during a rest period and during execution of a word-fluency task were measured by means of bilateral transcranial Doppler ultrasonography in 26 stroke patients with Broca's aphasia and in 25 healthy controls. Changes in flow velocity were calculated as percentage of increase from rest to mental activity. In patients, the evaluation was made within 21 days from onset of symptoms and after 2 months of speech therapy, when they were classified into two groups on the basis of extent of recovery from aphasia: absent or slight recovery (group 1, 10 patients) and good recovery (group 2, 16 patients). During the word-fluency task in the first evaluation, the increase in flow velocity in the left MCA was similar in controls and in group 2 patients. In both groups the increase was higher than in group 1 patients (p < 0.0001). Changes in mean flow velocity on the right side were slight and comparable in the three groups of study subjects. After speech therapy, group 1 patients showed a hemodynamic pattern on both sides similar to that observed in the first examination. In group 2 patients, comparison between values of the first and second evaluations showed that the increase of flow velocity in the left MCA was similar. On the right side, the increase was higher in the second than in the first examination (p < 0.01). These data further support the involvement of cerebral areas contralateral to the lesion in functional recovery after stroke. Moreover, the presence of an activation of areas in the lesioned hemisphere, soon after stroke onset, seems to be a predictor of recovery from aphasia.

Transcranial doppler assessment of cerebral flow velocity during perception and recognition of melodies

The role of each cerebral hemisphere in the perception and recognition of musical information is not yet well understood. We studied cerebral blood flow changes during a melody perception task and a melody recognition task. Blood flow velocity in the two middle cerebral arteries of twenty right-handed musically naif volunteers were simultaneously measured by means of bilateral transcranial Doppler ultrasonography during two minutes of passive melody listening and two minutes of a melody recognition task. With respect to baseline values, a bilateral increase of flow velocity occurred in the middle cerebral arteries with a non-significant trend for the right artery during the melody perception task. During the melody recognition task, a significant increase in flow velocity was recorded on the right side with respect to the left side, where a slight simultaneous decrease was found. Our data suggest that melody perception requires bilateral activation of hemispheres and melody recognition mainly an activation of the right hemisphere. This study confirms the ability of transcranial Doppler ultrasonography to correlate artery flow dynamics with selective cerebral activation.

Prolactin response to bromocriptine in flunarizine-treated migrainous women

Flunarizine, a calcium channel blocker, is widely used in migraine prophylaxis. Although an antidopaminergic effect has been suggested for this drug, it is unclear whether the antimigraine action of flunarizine involves the dopaminergic system. We studied the inhibitory response of prolactin to acute administration of bromocriptine, a D2 dopamine receptor agonist, before and after 1 month of treatment with flunarizine in migrainous women. Flunarizine treatment increased basal prolactin levels, but it did not reduce the inhibitory response of prolactin to acute bromocriptine administration. These findings do not support the hypothesis that flunarizine acts as a direct antagonist at the D2 dopamine receptor.

Transcranial Doppler assessment of cerebrovascular reactivity in symptomatic and asymptomatic severe carotid stenosis

BACKGROUND AND PURPOSE

Some studies have suggested a link between impaired cerebral hemodynamics and stroke in patients with carotid stenosis. The aim of this study was to assess the effects of severe carotid stenosis on cerebrovascular reactivity and the possible changes after endarterectomy.

METHODS

Using bilateral transcranial Doppler ultrasound, we studied the changes of flow velocity after hypercapnia in the middle cerebral arteries of 10 control subjects and 24 patients (13 symptomatic and 11 asymptomatic) with unilateral severe carotid stenosis before and after endarterectomy. Cerebrovascular reactivity was evaluated with the breath-holding index (BHI).

RESULTS

Before endarterectomy, BHI (mean value +/- SD) was significantly lower (P < .001) in the stenotic side of symptomatic patients (0.40 +/- 0.2) than in control subjects (1.12 +/- 0.3), the stenotic side of asymptomatic patients (0.80 +/- 0.4), and the normal side of both symptomatic (0.93 +/- 0.3) and asymptomatic ultrasonics (1.03 +/- 0.2) patients. On the other hand, no significant difference in BHI was detected in control subjects, on the normal side of symptomatic and asymptomatic patients, and the stenotic side of asymptomatic patients. After endarterectomy, BHI significantly increased (P < .0001) on the stenotic side of symptomatic patients (1.06 +/- 0.2) while remaining substantially stable on the normal side of both symptomatic and asymptomatic patients and on the stenotic side of asymptomatic patients.

CONCLUSIONS

These findings suggest that the study of cerebrovascular reactivity to hypercapnia may be relevant in evaluating the functional effects of carotid stenosis. Further investigations are needed to confirm the reliability of the breath-holding method in the selection of patients who might benefit most from carotid endarterectomy.

Bilateral simultaneous transcranial Doppler monitoring of flow velocity changes during visuospatial and verbal working memory tasks

Twenty-two normal volunteers were studied by simultaneous bilateral transcranial Doppler (TCD) monitoring of flow velocity changes in the middle cerebral arteries during visuospatial and verbal working memory tasks. All tasks were visually presented material; they required full engagement of subjects during the study, similar attention demands and a manual response when the appropriate target was recognized. Stimuli were presented tachistoscopically. Each task produced significant and distinct effects on flow velocity with respect to baseline values. When side-to-side comparisons were performed, a significantly higher increase in flow velocity was observed in the right middle cerebral artery (MCA) compared with the left one during the visuospatial task (P < 0.005). Our findings agree with results of recent studies using PET which show lateralized activation during working memory tasks. The high temporal resolution of this technique suggests that further application in cerebral flow change monitoring during neuropsychological studies could be promising.

Effect of smoking on cerebrovascular reactivity

Current smoking is a risk factor for stroke. The aim of this study was to evaluate the effect of smoking one cigarette on cerebral hemodynamics. Using transcranial Doppler ultrasound, we studied the changes of flow velocity after hypercapnia in the middle cerebral arteries (MCAs) of 24 healthy young smokers and 24 healthy controls matched for age and sex. We obtained hypercapnia with breath-holding and evaluated cerebrovascular reactivity with the breath-holding index. In smokers, the evaluation was performed during basal condition, immediately after smoking one cigarette, and at 10-, 20-, and 30-min intervals thereafter. In controls, the evaluation was performed at corresponding time intervals. Breath-holding index (BHI) values at rest were similar for both controls and smokers. In the former, breathholding index values remained constant for each of the different evaluations. On the contrary, in smokers, breath-holding index values were significantly lower immediately (p < 0.0001), at 10 min (p < 0.001), and at 20 min (p < 0.0001) after smoking with respect to baseline values. Smoking also caused more short-lasting changes, in this case increases in mean flow velocity (MFV), heart rate (HR), and mean blood pressure (MBP). These results suggest that a failure of cerebrovascular regulation occurs after smoking. This phenomenon might contribute to the increased risk of cerebrovascular disease in current smokers.

Implicit memory in parkinsonian patients: evidence for deficient skill learning

The aim of this study was to investigate procedural learning in idiopathic Parkinson's disease (PD) patients. For this purpose, 18 nondemented PD patients and 20 age-matched healthy subjects were trained to learn a visuoperceptual skill (mirror reading) and a cognitive skill with a motor demand (puzzle assembly task). In 3-day sessions, the patients were requested to perform with repeated and unrepeated stimuli, in order to distinguish between pure procedural learning and skill learning at least partially supported by explicit memory retrieval. In the mirror reading task, the PD patients showed normal improvement in reading times for repeated words but no improvement at all for unrepeated stimuli. In the puzzle assembly task, PD patients did not show any significant learning either for repeated or unrepeated stimuli. These results, which document deficient learning of procedures in parkinsonians, are discussed in the light of conflicting data reported regarding implicit memory in PD.

Cerebrovascular reactivity in migraine with and without aura

Abnormal cerebrovascular regulation has been implicated in the pathogenesis of migraine. Our aim in this study was to evaluate cerebrovascular reactivity to different stimulations in migraine with and without aura. Using bilateral transcranial Doppler, the changes of flow velocity during hypercapnia and mental and motor activity were measured in the middle cerebral arteries of 15 controls and 30 patients with migraine with aura (n = 15) or without aura (n = 15) in an attack-free period. Vascular response to all tests was similar in controls and patients. In patients with unilateral headache, no side-to-side difference was found. These findings suggest that no alteration of cerebrovascular reactivity exists outside attacks in migraine with and without aura. Further studies with transcranial Doppler considering all intracranial vessels and the comparison with other techniques of flow investigation with better regional resolution are needed to confirm these data.

Involvement of the healthy hemisphere in recovery from aphasia and motor deficit in patients with cortical ischemic infarction: a transcranial Doppler study

Activation of areas of the health hemisphere seems to play a role in functional recovery from stroke. We studied cerebral blood flow changes during motor and mental activity in patients with cortical ischemic lesions. We simultaneously measured blood flow velocity in the two middle cerebral arteries of 45 patients with single cortical ischemic lesions and good functional recovery and of 16 healthy controls by means of bilateral transcranial Doppler ultrasonography during a 2-minute sequential thumb-to-finger opposition task, alternately performed with the right and left hands, and during a 1-minute word-fluency task. Twenty-five patients had left cortical lesions, 12 with previous motor deficit alone and 13 with associated motor deficit and Broca's aphasia. Twenty patients had right cortical lesions with previous motor deficit. With respect to baseline values, the increase of flow velocity in the middle cerebral artery contralateral to the hand performing the motor task was comparable in controls and patients, regardless of the side of the lesion and the hand (normal or recovered) involved in the task. During movement of the recovered hand, the increase of flow velocity in the ipsilateral middle cerebral artery was significantly greater (p < 0.001, two-way ANOVA) than the increase during movement of the normal hand in both controls and patients. During performance of the word-fluency task, the increase of flow velocity in the left middle cerebral artery was comparable in controls and patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Sex-hormone-related events in migrainous females. A clinical comparative study between migraine with aura and migraine without aura

In this study, the relationship between hormonal-related events and migraine with aura (MA) and without aura (MO) was investigated. Subjects included 268 women suffering from MA (88) and MO (180). Data were collected on the relationship between sex-hormone-related events and migraine. Migraine during menses was observed in a significantly higher percentage of MO than MA patients (p < 0.03). Menstrual migraine was significantly more common in MO than in MA patients (p < 0.01). Migraine began during pregnancy in a significantly higher percentage of MA than of MO patients (p < 0.01). No significant difference was observed between the two groups of patients regarding the onset of migraine at menarche, after menopause, in the postpartum period or during the early cycles of oral contraceptives. Also, both groups of patients showed a similar migraine course during pregnancy, oral contraceptive use and menopause. Eight patients with coexisting migraine with aura and migraine without aura attacks reported the appearance of the aura symptom for the first time in the early cycles of oral contraceptive intake. These findings suggest that gonadal hormone fluctuation may influence both types of migraine.

Estimation of cerebrovascular reactivity in migraine without aura

BACKGROUND AND PURPOSE

The nature and role of vascular abnormalities in migraine are controversial. In this study we evaluated cerebrovascular reactivity to hypercapnia in patients suffering from migraine without aura with unilateral headache.

METHODS

Using bilateral transcranial Doppler ultrasound, we studied the changes of flow velocity after hypercapnia in the anterior, middle, and posterior cerebral arteries of 16 migraine patients and 16 healthy control subjects. All patients were studied during an attack-free interval and during a migraine attack. Cerebrovascular reactivity was evaluated with the breath-holding index, obtained by dividing the percent increase in mean flow velocity occurring during breath-holding by the time (seconds) in which the subjects held their breath after a normal inspiration.

RESULTS

The response to breath-holding was similar for all arteries considered in both control subjects and patients during the attack-free interval. During the migraine attack, the breath-holding index in patients was significantly lower than the migraine-free interval in all arteries (P < .001). No side-to-side difference in cerebrovascular reactivity was detected in migraine patients either outside or during attacks.

CONCLUSIONS

These results suggest that a failure of cerebrovascular regulation occurs during attacks of migraine without aura.

Transcranial Doppler assessment of the functional effects of symptomatic carotid stenosis

Mean flow velocity changes in the middle cerebral arteries (MCAs) during a 2-minute thumb-to-finger opposition task were measured by means of transcranial Doppler ultrasonography in patients with severe unilateral carotid stenosis and ipsilateral transient ischemic attacks and in control subjects. The increase of flow velocity in the MCA contralateral to the hand performing the task was significantly different (p < 0.001, one-way ANOVA) in controls (+5.52 +/- 2.4 cm/sec) and in patients (+1.76 +/- 1.6 cm/sec, side of stenosis; +3.83 +/- 2.1 cm/sec, normal side). A post hoc least significant difference test revealed a significant difference between controls and patients on the side of stenosis (p < 0.001) and between the normal side and the stenotic side in patients (p < 0.03). One month after carotid endarterectomy, the effect of the motor task produced a significantly different effect on flow velocity in patients (p < 0.01, two-way ANOVA) because the increase of flow velocity during the motor task on the side of stenosis (4.84 +/- 1.9 cm/sec) was similar to that observed on the normal side (4.63 +/- 1.4 cm/sec). These findings suggest that the effect of a simple motor task on flow velocity of MCAs may allow for the evaluation of the functional effects of carotid lesions. Prospective studies are needed to evaluate whether this test constitutes a useful approach for the identification of patients who would benefit from a surgical procedure.

Ophthalmoplegic migraine-like syndrome due to pituitary apoplexy

A patient with a history of migraine without aura developed a complete left III nerve palsy a day after the onset of bilateral throbbing headache associated with vegetative symptoms. Magnetic resonance imaging showed a hemorrhagic pituitary adenoma as the probable cause of the symptoms, presumably by a compressive mechanism. This case suggests a further possible cause of ophthalmoplegia associated with migraine and confirms the clinical utility of magnetic resonance imaging in the differential diagnosis of ophthalmoplegic migraine and other conditions in which the symptomatology is secondary to intracranial lesions.

Bilateral simultaneous assessment of cerebral flow velocity during mental activity

The purpose of this study was to assess the potential of transcranial Doppler (TCD) ultrasonography for detecting selective changes in cerebral blood flow velocity during mental activity. Mean flow velocity was continuously and simultaneously measured in the right and left middle cerebral arteries in 26 healthy right-handed young subjects at rest and during performance of verbal and visual-imaging mental tasks. These two mental tasks produced significantly different effects on the right and left sides: the verbal task produced a higher increase of flow velocity (mean absolute difference above baseline +/- SD) with respect to the basal values in the left than in the right middle cerebral artery (5.56 +/- 3.8 cm/s vs 1.25 +/- 3.1 cm/s); the visual-imaging task was accompanied by a higher increase in the right than in the left middle cerebral artery (3.92 +/- 3.3 cm/s vs 1.52 +/- 3.1 cm/s)--analysis of variance (ANOVA) three-fold interaction side of recording x task x condition, F = 25.67, p < .0001). Heart rate, blood pressure, and skin conductance showed comparable increases during performance of both mental tasks. Respiratory activity showed no modification during the mental activity with respect to the rest phase. These results demonstrate the possibility of delivering specific functional information via bilateral TCD and suggest wider utilization of this noninvasive technique in neuropsychological studies.

Migrainous stroke and the antiphospholipid antibodies

The pathogenesis of migrainous stroke is controversial. The possibility that a number of migraine-related strokes is associated with the presence of antiphospholipid antibodies, a condition predisposing to coagulopathy, has been suggested. We investigated the prevalence of lupus anticoagulant and anticardiolipin antibodies in patients with migrainous stroke. In 6 out of 16 patients with migrainous cerebral infarction, the presence of antiphospholipids antibodies was detected. In such patients, the presence of other risk factors for stroke was significantly lower (chi 2 = 5.6; p = 0.01) with respect to patients with negative results for antiphospholipid antibodies. These results suggest that antiphospholipid antibodies associated with migraine may be an important marker for ischemic stroke.

Three primitive reflexes in HIV-1-infected individuals: a possible clinical marker of early central nervous system involvement

We studied one hundred and six neurologically asymptomatic HIV-1-seropositive patients, mostly drug abusers, in various stages of HIV-1 infection to evaluate the frequency of three primitive reflexes: snout, palmomental, and glabellar. We also examined one hundred HIV-1-seronegative drug abusers and one hundred healthy heterosexual individuals. We observed the presence of one or more primitive reflexes in 41% of HIV-1-seropositive subjects, in 8% of HIV-1-seronegative drug abusers and in 3% of healthy individuals. We elicited more than one primitive reflex in 22% of patients, but never among the subjects of the two control groups. The associations of multiple reflexes were significantly more frequent in the most severe CDC stages. Our observations suggest that including evaluation of primitive reflexes in a standard neurologic examination may be useful in screening for early non specific cerebral dysfunction in neurologically asymptomatic HIV-1-seropositive subjects.

Activation of healthy hemisphere in poststroke recovery. A transcranial Doppler study

BACKGROUND AND PURPOSE

The possible involvement of the healthy hemisphere in functional recovery in stroke hemiplegia is still controversial. This study of patients who had suffered ischemic stroke assessed circulatory changes in the healthy hemisphere by transcranial Doppler ultrasonography during opposition exercise of fingers that had recovered movement.

METHODS

Measurements of flow velocity in the middle cerebral arteries were recorded in 12 recovered hemiplegic stroke patients and 12 healthy sex- and age-matched control subjects during a 2-minute sequential thumb-to-finger opposition task, alternatively performed with normal and recovered fingers. The effects of the motor task on heart rate, blood pressure, and end-tidal PCO2 were also evaluated.

RESULTS

With respect to the basal values, a comparable increase of flow velocity (%mean +/- SD) in the contralateral middle cerebral artery occurred in patients during movement of normal (9.7 +/- 2.7%) and recovered fingers (10.4 +/- 5.1%) and in controls (11.3 +/- 4.9%). However, in the middle cerebral artery ipsilateral to the hand performing the motor task, the increase of flow velocity was significantly higher (P < .001, two-way analysis of variance) during movement of the recovered hand in patients (10.5 +/- 4.6%) than during the movement of the normal hand in both patients (1.7 +/- 3.7%) and controls (1.8 +/- 4.5%). No significant difference of changes in heart rate, blood pressure, and end-tidal PCO2 was observed for patients or normal control subjects during the various phases of the study.

CONCLUSIONS

Our data suggest that activation of the healthy hemisphere contributes toward functional recovery of motor deficit after stroke and confirms the ability of transcranial Doppler ultrasonography to correlate cerebral artery flow dynamics with selective cerebral activation.

[Cerebral toxoplasmosis in subjects with acquired immunodeficiency syndrome]

Cerebral toxoplasmosis is the most common cause of focal CNS disease complicating AIDS and may afflict 10% to 33% of such patients. We present the clinical, neuroradiological and immunological findings in 5 cases with cerebral toxoplasmosis complicating the acquired immune deficiency syndrome. All patients had focal neurological signs and symptoms; CT scan findings included single or multiple lesions with ring contrast enhancement, mass effect and oedema. CSF analysis showed increased protein levels, decreased glucose levels and pleocytosis; CSF IgG antitoxoplasma antibodies were positive in 4 patients; serum IgG antitoxoplasma antibodies were positive in all patients, while IgM resulted always negative in serum and in CSF. After therapy, in 2 cases CT scans showed small areas of encephalomalacia replacing the abscesses. We think that non-invasive techniques (CT scans, CSF and serum immunochemical tests) together with the finding of a favourable response to therapy may be useful for the diagnosis of cerebral toxoplasmosis, allowing to avoid invasive technique such as cerebral biopsy.

[AIDS and opportunistic infections of the central nervous system]

Central nervous system diseases occur frequently in patients with AIDS. From 20 to 40% of all these patients develop neurological symptoms and in about 10% of AIDS patients the onset of the disease is characterized by neurological symptoms. These may be related to primary HIV infection or to any of a large number of opportunistic viral and non-viral infections. Moreover, the observation of multiple central nervous system infections is frequent, making the diagnosis difficult. AIDS-related opportunistic infections of the central nervous system are discussed, presenting both a review of the literature and several case reports.