Comparison between different referral strategies for acute ischemic stroke patients in a hub-spoke emergency stroke network: a real-world experience in south-east Lazio

AIM

To describe different referral strategies for acute ischemic stroke (AIS) patients in a Hub-Spoke emergency stroke network with their incidence, time metrics and related outcomes.

METHODS

Referral paradigms were defined as follows: primary transfer to the comprehensive stroke center (CSC) from a remote region, called mothership (MS); secondary transfer to the CSC from a primary stroke center where intravenous thrombolysis was available, called drip and ship (DS); secondary transfer to the CSC from a community hospital where no reperfusion therapy was available, called ship and drip (SD); primary transfer to the CSC from its catchment area, called direct CSC (dCSC).

RESULTS

Among 517 anterior circulation AIS patients treated with mechanical thrombectomy between 2015 and 2020, 16.6% of them were SD, in addition to the well-known referral paradigms of MS (21.8%) and DS (18.1%). This rate grew to 30% when only patients whose place of onset was outside the CSC catchment area were considered. In the SD group, onset to CSC and onset to groin were significantly longer (178±80 min vs. 102±60 min, p<0.001, and 277±77 min vs. 211±61 min, p<0.001, respectively), and the risk of any intracranial hemorrhage (ICH) was significantly higher (OR: 2.514; 95%CI: 1.18-5.35, p=0.017) compared to MS.

CONCLUSION

In this hub-spoke stroke network, a high proportion of SD paradigm was found, which was associated with longer times to treatment and higher rates of any ICH. A closer cooperation between hospital stroke physicians, national health system staff, and paramedics is warranted to identify the most appropriate referral strategy for each patient.

Histologic and Immunohistochemical Evaluation of Human Breast Capsules Formed around Five Different Expander Surfaces

BACKGROUND

Polyurethane (PU) coating and implant texturization were designed to reduce the incidence of capsular contracture (CC), even if the link between surface type and CC remains unclear. To date, the etiopathogenetic aspects have not been fully clarified. The aim of this study was to evaluate capsules formed around five different breast expanders.

METHODS

Thirty patients were divided into randomized groups implanted with five different expanders: smooth, coated with PU foam (poly), with a low-microtextured, high-microtextured, and macrotextured surface (L-micro, H-micro, macro). Specimens of the capsules were removed at implant reconstruction and evaluated for morphology and immunohistochemistry expression of α-smooth muscle actin (α-SMA), collagen type I and III, CD68, CD34, and CD3. Remodeling Combined Index was also evaluated.

RESULTS

Expression of α-SMA was significantly increased in smooth capsules versus poly, low-microtextured, and high-microtextured groups ( P = 0.007; P = 0.010; P = 0.028), whereas the prevalence of collagen type I in smooth capsules and collagen type III in poly capsules identified a stable versus an unstable tissue. Remodeling Combined Index and α-SMA showed an inverted correlation. CD68 and CD34 cellular expression increased significantly in poly capsules with respect to smooth ( P < 0.001; P < 0.001) and macrotextured groups ( P < 0.001; P < 0.001). CD3 showed no significant difference among the groups.

CONCLUSION

In this human study, the authors observed that increased tissue remodeling and reduced myofibroblast activation, along with the inflammatory infiltration and neoangiogenesis, especially in the poly and low-microtextured groups, might promote the formation of an unstable and less fibrotic capsule, lowering the risk of CC.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Efficacy of Flap-based Posterior Trunk Reconstruction after Vertebrectomy and Radiation Therapy: A Retrospective Cohort Study

Background

Adjuvant radiation therapy following vertebrectomy is a major risk factor for local wound complications such as dehiscence, infection, and skin necrosis. In selected cases, well-vascularized coverage and modification of tension forces on the wound might reduce the risk of postoperative complications and reoperations. We aimed to demonstrate a reduction in general and specific complications in patients undergoing vertebral resection and flap coverage compared with vertebral resection alone.

Methods

We retrospectively analyzed and collected data from patients diagnosed with a tumor involving the spine and requiring a total or partial posterior vertebrectomy between January 2012 and October 2022, referred to a single tertiary-level orthopedic and trauma center. We included only patients in whom primary closure of the wound was possible but judged to be under excessive tension.

Results

A total of 145 patients underwent partial or total vertebrectomy for oncological reasons at our tertiary-level trauma hospital. Among these, 73 patients were eventually included according to the inclusion and exclusion criteria: 53 in the orthopedic group and 20 in the orthoplastic group. Considering only patients undergoing radiation therapy, the orthoplastic group showed significantly lower rates of overall complications (33% versus 69%) than the orthopedic group.

Conclusions

Primary flap coverage, especially in patients receiving RT, reduces the risk of postoperative complications and avoids a second reconstructive operation, consequently reducing patient discomfort, length of hospital stay, and healthcare costs.

AB0731 Thyroid disorders assessment: an unmet need in patients with idiopathic inflammatory myopathies?

Background

Thyroid diseases (TD) might compromise health status of patients, in particular owing to their possible impact on cardiovascular risk, bone mineral density (BMD) and muscle function. The prevalences of Hashimoto thyroiditis (HT), multinodular goiter (MNG) and Graves’ disease (GD) in general population correspond respectively to about 12%, 10% and 1.3%; it is well known HT represents a risk factor for the development of thyroid papillary cancer (TPC). Idiopathic inflammatory myopathies (IIMs) are rare systemic autoimmune disorders, with a pleiotropic clinical picture. TD are a known comorbidity of patients with connective tissue diseases; in particular, they might increase the risk of osteoporosis (OP) and fragility fractures (FF) in patients with SLE1. A recent study described the association between IIMs and both hyper- and hypo-thyroidism2.

Objectives

To evaluate the prevalence of TD in a monocentric cohort of patients with IIMs, exploring possible correlations with serology, organ involvement and comorbidities.

Methods

We retrospectively analyzed medical records of consecutive patients diagnosed with IIM according the EULAR/ACR 2017 criteria and regularly followed at our specialistic outpatient Myositis Clinic from January 2018 to December 2021. We collected data about demography, subset and duration of disease, organ involvement, serology, thyroid dysfunction and other comorbidities. As TD, we took into account the occurrence of HT, MNG and GD. Intergroups comparisons were assessed by using Chi-square, t-test and ANOVA. P values <0.05 were considered significant.

Results

The clinical charts of 151 patients were examined: 101 (66,9%) were female, the mean age was 65,1±14,0 years and the mean disease duration was 8,5±6,5 years. Clinical diagnosis were the following: 69 (45.7%) polymyositis, 59 (39.1%) dermatomyositis, 11 (7.3%) clinically amyopathic dermatomyositis, 10 (6.6%) inclusion body myositis, 2 (1.3%) juvenile dermatomyositis. Seventy-five patients (49.7%) had a TD; in particular, 39/151 (25.8%) had MNG, 34/151 (22.6%) had HT and 2/151 (1.3%) GD. The presence of a TD was significantly related with esophagus’ involvement (p=0.037), Raynaud’s phenomenon (RP) (p=0.045), sicca syndrome (SiS) (p<0,001), OP (p<0,001) and cataract (p=0,017). In particular, HT and MNG occurrence was respectively associated with a higher risk of OP (p<0,001) and of sicca syndrome (p<0,001). Interestingly, TD were significantly less frequent in patients with anti-Mi2beta autoantibodies (p=0,003) and anti-Jo1 autoantibodies (p=0,026). No further significant correlations emerged.

Conclusion

Our study showed nearly half of our IIMs patients had a TD, with a prevalence of both MNG and HT significantly higher than in general population; besides, owing to the retrospective nature of our study, these data could be underestimated. In addition to correlating with RP and SiS, TD showed a significant association with esophagus involvement; this result should be confirmed and clarified with future analyses. Moreover, in our cohort, TD were confirmed as a risk factor for a compromised BMD; in particular, HT was significantly associated with the occurrence of OP. Further studies are needed to corroborated our data in other cohorts of IIM patients and to explore if TD represent a risk factor for FF also in IIM; finally, since HT is a risk factor for TPC, an evaluation of its occurrence in our cohort should be designed. However, our data seem sufficient to underline the need to regularly screen IIM patients for thyroid function, aiming at optimizing their quality of care, both for activity and damage domains of their autoimmune disease.

References

[1]Carli L, et al. Risk factors for osteoporosis and fragility fractures in patients with systemic lupus erythematosus. Lupus Sci Med. 2016 Jan 19;3(1):e000098.

[2]Watad A, et al. Dysthyroidism in dermato/polymyositis patients: A case-control study. Eur J Clin Invest. 2021;51:e13460.

Disclosure of Interests

None declared

AB1152 COVID-19 mRNA VACCINE BOOSTER IN PATIENTS WITH SYSTEMIC AUTOIMMUNE DISEASES

Background

Patients with systemic autoimmune diseases (SADs) are often treated with drugs that interfere with the immune system and previous data showed a reduced seroconversion rate after anti-SARS-CoV2 vaccine in these subjects compared to healthy controls1. Administration of a booster dose of the vaccine could be particularly important in these patients, but data available to date are still scarce.

Objectives

To evaluate the antibody response to the booster dose of mRNA SARS-CoV2 vaccine in patients with SADs and to compare it to the response after completion of the first vaccination course. Secondly, to find possible correlations between a low antibody titre and patients’ clinical features, with special regard to ongoing immunosuppressive therapies.

Methods

Consecutive patients with an established diagnosis of SADs undergoing SARS-CoV2 vaccine were prospectively enrolled from January 2021; among them, we selected the patients who received the third vaccination dose between September and December 2021. Demographic and clinical data were collected at enrolment (sex, age, diagnosis, disease duration, ongoing therapies, previous SARS-CoV2 infection, presence of hypogammaglobulinemia); the last three elements were reassessed at each follow-up visit. Blood samples were collected 4 weeks both after the second (W4a) and the third (W4b) dose of the vaccine; a minority of patients was also tested 12 weeks after the second dose (W12). IgG antibodies to SARS-CoV2 receptor-binding domain (RBD) and neutralizing antibodies inhibiting the interaction between RBD and angiotensin converting enzyme 2 were evaluated. IgG anti-RBD were detected by solid phase assay on plates coated with recombinant RBD, while neutralising antibodies by using the kit SPIA (Spike Protein Inhibition Assay). Cut-off values were defined as the 97.5th percentile of a pre-vaccine healthy population. Statistical analysis was performed using IBM SPSS Statistics 20 and GraphPad Prism statistical packages. P values <0.05 were considered significant.

Results

Forty-five patients (95.6% female; mean age ±SD 55.6±14.1 years; mean disease duration 12.9±10.6 years) were enrolled. Diagnosis was in most cases connective tissue disease (31/45, 68.9%), followed by inflammatory arthritis (11/45, 24.4%) and systemic vasculitis (3/45, 6.7%). Two patients (4.4%) had a previous SARS-CoV2 infection and three had hypogammaglobulinemia (6.7%). At the time of the second dose, 18/45 patients were treated with glucocorticoids (GCs) [mean daily 6-methylprednisolone (6MP) dose 3.9 mg (min. 2, max. 14)], 17/45 with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and 12/45 with biologic DMARDs (bDMARDs). At the third dose administration, 19/45 patients were treated with GCs [mean daily 6MP dose 4.1 mg (min. 1.5, max. 10)], 18/45 with csDMARDs and 13/45 with bDMARDs. Anti-RBD IgG were positive in 42/45 patients (93.3%) at W4a, in 16/18 (88.9%) at W12 and in 42/45 (93.3%) at W4b. Neutralizing antibodies were present in 38/45 patients (84.4%) at W4a, in 14/18 (77.8%) at W12 and in 42/45 (93.3%) at W4b. Both anti-RBD IgG titers and neutralizing antibody titers significantly increased after the third dose if compared to W4a (p<0.0001 both) (Figure 1). Interestingly, of the 7 patients who had not developed an adequate neutralizing antibody response after the first vaccination course, 5 mounted an adequate titer after the booster. Two non-responder patients were both on combination therapy (one with low dose of GCs plus mycophenolate mofetil, the other with methotrexate and infliximab).

Conclusion

Our data suggest that in patients with SADs there is a decline in the antibody titers developed after COVID-19 vaccination, however the booster dose is effective in restoring an adequate antibody titre. These data consolidate the importance of a booster dose of COVID-19 vaccination in patients with SADs to aid in the generation of an immune response.

References

[1]Jena A et al. Response to SARS-CoV-2 vaccination in immune mediated inflammatory diseases: systematic review and meta-analysis. Autoimmun Rev. 2022

Acknowledgements

The authors would like to thank all the patients who participated in the study and the nurses Sabrina Gori, Rosanna Lo Coco, Lucia Pedrocco, Carla Puccini, Pasqualina Semeraro, Manuela Terachi, Maria Tristano, Valentina Venturini and Catiuscia Zoina who took care of the patients.

Disclosure of Interests

None declared

POS0910 PSYCHIATRIC COMORBIDITIES ASSESSMENT: AN UNMET NEED IN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOPATHIES?

Background

Idiopathic Inflammatory Myopathies (IIMs) are rare and complex chronic diseases, with a strong impact on patients’ Quality of Life (QoL) in terms of both physical and emotional functioning. Despite its key role in daily life, patients’ emotional status could be difficult to be investigated by physicians. As known, patients with chronic conditions are at higher risk of anxiety and depression, but data about their prevalence in IIMs are still limited. The Hospital Anxiety and Depression Scale (HADS) is a validated questionnaire to evaluate the presence and severity of both anxiety (HADS-A) and depression (HADS-D) in patients.

Objectives

To determine the prevalence of anxiety and depression in a monocentric cohort of IIMs patients and to evaluate possible correlations with clinical features, disease activity and parameters of QoL.

Methods

Consecutive adult patients with a diagnosis of IIM (2017 EULAR/ACR criteria) were recruited during a scheduled follow-up visit. Demographic and clinical features were recorded (sex, age, disease subset and duration, organ involvement, comorbidities). IIM disease activity was evaluated following International Myositis Assessment & Clinical Studies Group Disease Activity Core Set Measures. To detect anxiety and depression status, HADS was administered to patients, who were also asked to fill in Short-Form 36 Items Health Survey (SF-36). For both HADS-A and -D subscales, patients were classified as at risk for scores ≥8 (borderline for scores 8-10, high risk if ≥11). Results were reported as mean±SD for continuous variables and as percentage for categorical variables. Intergroup comparisons were assessed by using Chi-square, t-test and ANOVA. Pearson coefficient was used to analyse the correlations between variables. P values <0.05 were considered significant.

Results

Fifty-three patients (72% female; mean age 64.8±12.0 years; mean disease duration 7.4±6.2 years) were enrolled. Twenty (37.7%) showed increased anxiety scores (mean 11.35, min. 8 – max. 17): 10 (50%) borderline and 10 (50%) high risk. Twenty (37.7%) had an increased depression score (mean 11.75, min. 8 – max. 19): 6 (30%) borderline and 14 (70%) high risk. If abnormal scores of both HADS-A and -D were found in 15 patients (28.3%), 17 patients (32.1%) were at high risk of at least one of the conditions. Sex, age, disease subset and duration did not seem to influence patients’ emotional status. Apart from an association between Raynaud’s Phenomenon occurrence and higher HADS-A scores (p=0.045), no significant correlations with organ involvements emerged. A strong association was found between fibromyalgia and higher HADS-A and -D scores (p=0.006 both). Patients with elevated anxiety levels presented significantly higher scores of Patient Global Assessment (PGA, p=0.002) and Health Assessment Questionnaire (HAQ, p=0.007) and significantly lower scores of Manual Muscle Testing (MMT8, p=0.004). HADS-D scores were similarly associated with PGA (p=0.001), HAQ (p<0.0001) and MMT8 (p=0.001). The presence of anxiety and depression was associated with lower scores in all SF-36 domains (all p≤0.016 for HADS-A and all p≤0.006 for HADS-D). Moreover, a correlation was found among SF-36 scores and PGA (all r <-0.516, p<0.01), HAQ (all r <-0.541, p<0.01) and MMT8 values (all r >0.299, p<0.05).

Conclusion

These results show nearly 40% of our cohort was at risk of anxiety or depression; almost 30% were at risk of developing both conditions together and quite one third was at high risk to develop at least one of them. As expected, these conditions were favoured from a concomitant fibromyalgia. Moreover, a compromised QoL and a functional limitation, as evaluated by PGA, HAQ and MMT8, in agreement with SF-36 domains, were significant risk factors for their occurrence. Therefore, our data, although preliminary, underline the need of a more comprehensive evaluation of IIMs patients, who should be screened for psychiatric comorbidities and, in case of high risk, referred to a specialist evaluation, in the perspective of improving their quality of care.

Disclosure of Interests

None declared

POS0909 THE ROLE OF IMACS CORE SET MEASURES TO ROUTINELY EVALUATE THE QUALITY OF LIFE OF IDIOPATHIC INFLAMMATORY MYOPATHIES PATIENTS IN CLINICAL PRACTICE

Background

Idiopathic Inflammatory Myopathies (IIMs) are rare, multisystemic and complex diseases, often impacting on patients’ quality of life (QoL). Patient Reported Outcomes (PROs) assess the overall health status of patients, particularly for emotional and functional domains. In clinical practice the administration of PROs might have some limitations, because they tend to be time-consuming and sometimes difficult to be filled in by patients. The International Myositis Assessment & Clinical Studies Group Disease Activity Core Set Measures (IMACS-CSM) are a tool created to specifically assess disease activity and QoL in IIMs.

Objectives

To evaluate the ability of IMACS-CSM in assessing IIMs patients’ QoL in comparison with both generic and IIMs specific PROs.

Methods

Consecutive adult patients with an established diagnosis of IIM (2017 EULAR/ACR criteria) followed at our Myositis Clinic were enrolled and evaluated during scheduled follow-up visits. Demographic and clinical data (age, sex, disease subset and duration, organ involvement) were collected. IMACS-CSM [Physician Global Activity (PhGA), Patient Global Activity (PGA), 8-items Manual Muscle Testing (MMT8), Health Assessment Questionnaire (HAQ), CPK values, Myositis Disease Activity Assessment Tool (MDAAT)] were used to evaluate both disease activity and QoL. Patients’ perspective was evaluated also by administration of PROs not included in the IMACS-CSM: Short-Form 36 Items Health Survey (SF-36), Functional Assessment of Chronic Illness Therapy Fatigue Subscale (FACIT-F), Myositis Activity Profile (MAP), MD Anderson Dysphagia Inventory (MDADI). Results were expressed as mean±SD for continuous variables and as percentage for categorical variables. Intergroup comparisons were assessed by using Chi-square, t-test and ANOVA. Pearson coefficient was used to analyse the correlations between IMACS-CSM variables and the other PROs. P values <0.05 were considered significant.

Results

Sixty patients (65% female, mean age 59.9±13.5 years, mean disease duration 7.7±6.1 years), 37 (61.7%) with polymyositis, 20 (33.3%) with dermatomyositis and 3 (5%) with inclusion body myositis, were enrolled. Among IMACS-CSM, the mean HAQ and PGA scores were significantly worse in case of muscle (p=0.017) and oesophageal involvement (p=0.017), respectively; as expected, MMT8 score was associated with muscle involvement (p=0.017); MDAAT score was instead associated with oesophageal dysfunction (p<0.001). No associations were found between IMACS-CSM and others clinical and demographic parameters. FACIT-F correlated positively with MMT8 (r 0.432, p=0.001) and negatively with PhGA, PGA, HAQ and MDAAT (all r <-0.404 and p≤0.002 except for PhGA with r=-0.338 and p=0.016). SF-36 domains correlated positively with MMT8 (all r >0.259, p≤0.05) and negatively with PGA (all r <-0.393, p≤0.001), HAQ (all r <-0.422, p≤0.001) and MDAAT (all r <-0.276, p≤0.05). Opposite correlations were found for MAP domains: MMT8 all r <-0.297, p≤0.05; PGA all r >0.326, p≤0.05; HAQ all r >0.483, p≤0.001; MDAAT all r >0.268, p≤0.05. Similarly, MDADI scores correlated negatively with MMT8 (r <-0.363, p=0.005) and positively with PGA, HAQ and MDAAT (all r >0.318, p≤0.015). Notably, no correlations emerged between these PROs and CPK values.

Conclusion

Even if IMACS-CSM offer a partial evaluation of patients’ perspective, our data show how not only HAQ and PGA, but also PhGA, MMT8 and MDAAT (expressing rheumatologist’s point of view) seem to adequately reflect overall health status of IIMs patients, thus giving to clinicians a reliable assessment of their QoL. Therefore, the core set should be routinely used in clinical practice during every outpatient visit, while more accurate and complex PROs might be administered at larger time intervals or during disease flares, to optimize IMACS-CSM’s analysis.

Disclosure of Interests

None declared

Impact of old and very old age on outcomes in patients with acute ischemic stroke undergoing endovascular therapy

Background and purpose

Only a restricted number of elderly patients has been included in the majority of recent endovascular stroke trials. We provided an analysis about differences in outcomes after mechanical thrombectomy (MT) according to age.

Methods

A retrospective analysis of an observational registry of patients with anterior large vessel acute ischemic stroke was performed. Main analysis was performed comparing patients &lt;80 vs. ≥80 years old. A sensitivity analysis was performed comparing 3 age groups: i) &lt;80 years; ii) 80–84 years; iii) ≥85 years. Outcomes were: i) any hemorrhagic infarction; ii) alive with disability; iii) death; iv) a composite outcome of alive with disability/death.

Results

615 patients were identified. 227 (36.9%) patients were ≥80 years old, with 115 (18.5%) ≥85 years old. Elderly (≥80 years) patients showed a higher modified Rankin Scale (mRS) at discharge and 3-months follow-up (F=9.819, p=0.001) [Figure 1]. Comparing the three groups (&lt;80 years, 80–84 years, ≥85 years) a progressively higher mRS was found at discharge and 3 months follow-up (F=4.899, p=0.008). A progressively higher rate of death and composite outcome between the age groups was found, both in the main and sensitivity analyses. In the logistic regression analysis age ≥80 years was found associated with an increased risk of death (odds ratio [OR]: 2.25, 95% confidence interval [CI]: 1.27–4.00) and showed a trend in higher risk for composite outcome (OR: 1.61, 95% CI: 0.92–2.281). No difference was found between 80–84 years and &lt;80 years patients, while very elderly (≥85 years) had an increased risk of death (OR: 2.85, 95% CI: 1.60–5.10) and composite outcome (OR: 2.37, 95% CI: 1.30–4.33).

Conclusions

In our analysis elderly patients have an increased risk of death and composite outcome of disability and death. In particular, this risk appears to be significantly higher in very elderly patients (≥85 years old).

Figure 1. mRS according to main analysis

Funding Acknowledgement

Type of funding source: None

Carotid Stenting and Mechanical Thrombectomy in Patients with Acute Ischemic Stroke and Tandem Occlusions: Antithrombotic Treatment and Functional Outcome

BACKGROUND AND PURPOSE

There is no consensus on the optimal antithrombotic medication for patients with acute ischemic stroke with anterior circulation tandem occlusions treated with emergent carotid stent placement and mechanical thrombectomy. The identification of factors influencing hemorrhagic risks can assist in creating appropriate therapeutic algorithms for such patients. This study aimed to investigate the impact of medical therapy on functional and safety outcomes in patients treated with carotid stent placement and mechanical thrombectomy for tandem occlusions.

MATERIALS AND METHODS

A multicenter retrospective study on prospectively collected data was conducted. Only patients treated with carotid stent placement and mechanical thrombectomy for tandem occlusions of the anterior circulation were included. Univariate and multivariate analyses were performed on preprocedural, procedural, and postprocedural variables to assess factors influencing clinical outcome, symptomatic intracranial hemorrhage, stent patency, and successful intracranial vessel recanalization.

RESULTS

Ninety-five patients with acute ischemic stroke and tandem occlusions were included. Good clinical outcome (mRS ≤ 2) at 3 months was reached by 33 (39.3%) patients and was associated with baseline ASPECTS ≥ 8 (OR = 1.53; 95% CI, 1.16-2.00), ≤2 mechanical thrombectomy attempts (OR = 0.71; 95% CI, 0.55-0.99), and the absence of symptomatic intracranial hemorrhage (OR = 0.13; 95% CI , 0.03-0.51). Symptomatic intracranial hemorrhage was associated with a higher amount of intraprocedural heparin, ASPECTS ≤ 7, and ≥3 mechanical thrombectomy attempts. No relationships among types of acute antiplatelet regimen, intravenous thrombolysis, and symptomatic intracranial hemorrhage were observed. Patients receiving dual-antiplatelet therapy after hemorrhagic transformation had been ruled out on 24-hour CT were more likely to achieve functional independence and had a lower risk of symptomatic intracranial hemorrhage.

CONCLUSIONS

During carotid stent placement and mechanical thrombectomy for tandem occlusion treatment, higher intraprocedural heparin dosage (≥3000 IU) increased symptomatic intracranial hemorrhage risk when the initial ASPECTS was ≤7, and mechanical thrombectomy needs more than one passage for complete recanalization. Antiplatelets antiplatelets use were safe, and dual-antiaggregation therapy was related to better functional outcomes.

Practice recommendations for neurovascular ultrasound investigations of acute stroke patients in the setting of the COVID-19 pandemic: an expert consensus from the European Society of Neurosonology and Cerebral Hemodynamics

Background and purpose

Patients with acute ischemic stroke are at high‐risk for contracting COVID‐19 infection. Additionally, healthcare professionals including neurovascular ultrasound providers are also at risk of being infected by SARS‐CoV‐2 virus. Yet, preparedness to continue to guarantee hyperacute treatment is vital for patients outcome. In light of this situation, the European Society of Neurosonology and Cerebral Hemodynamic (ESNCH) appointed a task force to provide consensus recommendations for the performance of neurovascular ultrasound investigations in acute ischemic stroke during the COVID‐19 pandemic with the aim of protecting both patients and ultrasound providers.

Methods

The “ultrasound in acute stroke working group” of the ESNCH examined literature articles and reviews using the following key words: “corona virus” or “COVID‐19” or “SARS‐CoV‐2 virus”, and “acute stroke” or “cerebrovascular disease”, and “ultrasound”. Thereafter, a thorough discussion was conducted with the “education and guidelines working group” of the ESNCH.

Results

We propose rapid up‐to‐date recommendations for healthcare personnel involved in the pre‐hospital and intra‐hospital assessment of stroke patients, with a particular attention to neurovascular ultrasound performance.

Conclusion

The ESNCH provides a guidance summary for the performance of neurovascular ultrasound investigations in acute ischemic stroke in the time of COVID‐19.

CT Angiography ASPECTS Predicts Outcome Much Better Than Noncontrast CT in Patients with Stroke Treated Endovascularly

BACKGROUND AND PURPOSE

Noncontrast CT ASPECTS has been investigated as a predictor of outcome in patients with acute ischemic stroke. Our purpose was to investigate whether CTA source images are a better predictor of clinical and radiologic outcomes than NCCT ASPECTS in candidates for endovascular stroke therapy.

MATERIALS AND METHODS

CT scans of patients (n = 124) were independently evaluated by 2 readers for baseline NCCT and CTA source image ASPECTS and for follow-up ASPECTS. An mRS of ≤2 at 3 months was considered a favorable outcome. Receiver operating characteristic curve analysis was used to assess the ability of NCCT and CTA source image ASPECTS to identify patients with favorable outcomes. A stepwise multiple regression analysis was performed to find independent predictors of outcome.

RESULTS

Baseline CTA source image ASPECTS correlated better than NCCT ASPECTS with follow-up ASPECTS (r = 0.76 versus r = 0.51; P for comparison of the 2 coefficients < .001). Receiver operating characteristic curve analysis showed that baseline CTA source image ASPECTS compared with NCCT ASPECTS can better identify patients with favorable outcome (CTA source image area under the curve = 0.83; 95% CI, 0.76-0.91; NCCT area under the curve = 0.67; 95% CI, 0.58-0.77; P < .001). Finally, the stepwise regression analysis showed that lower age, good recanalization, lower time to recanalization, and good baseline CTA source image ASPECTS, not NCCT ASPECTS, were independent predictors of favorable outcome.

CONCLUSIONS

CTA source image ASPECTS predicts outcome better than NCCT ASPECTS; this finding suggests CTA rather than NCCT as a main step in the decision-making process for patients with acute ischemic stroke.

Acanthocytosis as a predisposing factor for non-ketotic hyperglycaemia induced chorea-ballism

BACKGROUND

Episodic non-ketotic hyperglycaemia in patients with diabetes may be responsible for a syndrome characterised by hemichorea-hemiballism associated with unique radiological features.

OBJECTIVE

To investigate whether factors other than hyperglycaemia may be responsible for the neurological involvement.

METHODS

Three patients who developed a persistent chorea-ballism syndrome triggered by a hyperglycaemic crisis were investigated. In these patients, the persistence of the involuntary movements required neuroleptic medication.

RESULTS

T1 weighted magnetic resonance imaging revealed bilateral hyperintense lesions involving the striatum. Surprisingly, in these patients, the laboratory investigations revealed peripheral red blood cell acanthocytosis in a significant proportion of cells.

CONCLUSION

Compared with the large population of patients with diabetes who do not show abnormal involuntary movements, unrecognised acanthocytosis in diabetes might render patients prone to develop hemichorea-hemiballism.

Sildenafil increases cerebrovascular reactivity: A transcranial Doppler study

The authors performed a double-blind, placebo-controlled study in 28 patients to evaluate the effects of sildenafil on cerebral hemodynamics. A significant improvement of cerebrovascular reactivity, without any modification of other variables, was recorded 1 hour after the administration of 50 mg sildenafil. Further investigations are needed to evaluate whether cerebrovascular reactivity improvement could contribute to triggering sildenafil-induced migraine.

CagA-positive Helicobacter pylori strains may influence the natural history of atherosclerotic stroke

OBJECTIVE

To test the hypothesis that infection with virulent cytotoxin-associated gene-A (CagA)-bearing Helicobacter pylori strains influences the atherosclerotic process and the clinical course in atherosclerotic stroke patients.

METHODS

ELISA was used to assess the seroprevalence of infection by H. pylori and CagA-positive strains in 185 patients. Intima-media thickness (IMT) was determined by Doppler ultrasound. Baseline, 1-week, and 1-month NIH Stroke Scale (NIHSS) scores were used to evaluate the short-term clinical course.

RESULTS

H. pylori infection was found in 79% of patients; 58% of these tested positive for CagA. IMT was higher among CagA-positive patients than among CagA-negative ones (1.13 +/- 0.26 mm vs 0.97 +/- 0.15 mm; univariate analysis, p = 0.0001; multivariate analysis, odds ratio [OR], 2.36; 95% CI, 1.57 to 3.54; p = 0.0001) or H. pylori-negative ones (1.01 +/- 0.17 mm; univariate analysis, p = 0.007; multivariate analysis, OR, 1.90; 95% CI, 1.22 to 2.97; p = 0.005). CagA-positive patients had poorer initial outcomes based on serial measurements of the NIHSS score (repeated measures analysis of variance, p < 0.0001). No significant difference in IMT and NIHSS score was found between H. pylori-positive and H. pylori-negative patients.

CONCLUSIONS

Infection with cytotoxin-associated gene-A-positive Helicobacter pylori strains in atherosclerotic stroke patients is associated with greater intima-media thickness and poorer short-term outcome compared with cytotoxin-associated gene-A-negative patients.

Carotid artery intima-media thickness and lacunar versus nonlacunar infarcts

BACKGROUND AND PURPOSE

Increases in the thickness of the intima and media of the carotid artery have been associated with an increased risk of myocardial infarction and stroke in subjects without a history of cardiovascular disease. Lacunar infarcts, one of the most common subtype of ischemic stroke, show unique pathological and clinicoradiological characteristics. The present study examines the relationship between vascular risk factors, including carotid artery intima-media thickness (IMT), and lacunar versus nonlacunar infarcts.

METHODS

We collected data from patients with acute ischemic stroke admitted to hospital. Patients and 129 control subjects underwent B-mode ultrasonographic measurements of IMT of the common carotid artery. We examined the association of lacunar and nonlacunar infarcts with age, sex, and potential vascular risk factors.

RESULTS

Of 292 adult patients with an acute first-ever ischemic stroke, 96 were considered lacunar and 196 were considered nonlacunar strokes. We did not find a significantly different percentage of diabetes, smoking, hypertension, dyslipidemia, myocardial infarction, and previous transient ischemic attack between the 2 groups of patients. The multinomial logistic regression procedure selected carotid artery IMT and atrial fibrillation as the only independent factors able to discriminate between lacunar and nonlacunar patients. IMT values were significantly higher in patients with nonlacunar stroke versus both those with lacunar stroke and control subjects.

CONCLUSIONS

The present results indicate the usefulness of noninvasive measurement of IMT with ultrasonic techniques as a diagnostic tool that may help to identify different subtypes of ischemic stroke patients. The noninvasive measurements may have predictive power with respect to lacunar versus nonlacunar infarcts.

Cerebrovascular reactivity and subcortical infarctions

OBJECTIVES

To investigate the association between different kinds of ischemic lesions and cerebrovascular reactivity (CR) and to evaluate their relationships with the major risk factors for stroke.

SUBJECTS AND METHODS

We evaluated CR using the breath-holding index technique during bilateral transcranial Doppler monitoring of flow velocity in the middle cerebral arteries of 41 consecutive patients attending our clinic for a recent, first-ever, ischemic stroke and in 15 control subjects. Based on the location of the lesion determined by computed tomography, the following 3 types of infarctions were identified: cortical (or territorial), single subcortical, and subcortical with multiple silent subcortical infarctions. Patients with a condition of severe carotid artery stenosis or occlusion, which in itself could account for altered CR, were excluded from this study. All physiological and pathologic conditions that could possibly cause an impairment in CR were recorded.

RESULTS

The breath-holding index was significantly lower in the multiple subcortical infarctions group than in the control subjects (P < .001), single subcortical infarctions group (P < .01), and cortical infarctions group (P < .01). In all of the groups male sex (P < .05) and a history of hypertension (P < .05), regardless of whether hypertension was treated, correlated with low CR. The multiple regression analysis indicated that the only significant factor able to influence the breath-holding index was the type of lesion.

CONCLUSIONS

Nonstenotic patients with first-ever stroke who had a recent symptomatic subcortical infarction associated with multiple silent infarctions seem to have an impaired cerebrovascular reserve capacity. The strong association of subcortical infarctions with multiple silent infarctions with low CR indicates the role of small vessel vasculopathy and hypoperfusion as possible pathogenetic mechanisms of subcortical infarctions with multiple silent infarctions.

Cerebral hemodynamics in patients with carotid artery occlusion and contralateral moderate or severe internal carotid artery stenosis

OBJECT

The purpose of this study was to evaluate cerebral hemodynamics in patients suffering from occlusion of the carotid artery (CA) and contralateral CA stenosis.

METHODS

Using transcranial Doppler ultrasonography, the cerebrovascular reactivity to hypercapnia in the middle cerebral arteries was evaluated by calculating the breath-holding index (BHI) of 69 symptomatic patients suffering from internal CA (ICA) occlusion and moderate or severe contralateral ICA stenosis. To evaluate which variables influenced BHIs ipsilateral to the site of ICA occlusion, a multiple stepwise linear regression analysis was performed that included the following factors: patient age, percentage of contralateral ICA stenosis, contralateral BHI, number of collateral pathways, and presence of hypertension, diabetes, smoking, and hyperlipidemia. An analysis of variance was conducted to evaluate the impact of the type of collateral vessels on the BHI. A regression analysis showed that the BHI ipsilateral to the site of ICA occlusion could be accounted for by the contralateral BHI (which was entered at the first step of the analysis, p < 0.001) and by the number of collateral pathways (which was entered at the second step, p = 0.033). Neither the degree of contralateral ICA stenosis nor the other variables could be added to improve the model. The analysis demonstrated that the absence of collateral pathways and the presence of the anterior communicating artery (ACoA) alone were associated with lower BHI values than those found in the presence of two or three collateral vessels, regardless of the presence of an anterior collateral pathway.

CONCLUSIONS

On the basis of these data one can infer that the cerebral hemodynamic status of patients with occlusive disease of the CA is influenced by individual anatomical and functional characteristics. Because improvement in contralateral hemodynamics after surgical correction of an ICA stenosis can only be expected in the presence of an ACoA, the planning of strategies for influencing cerebral blood flow distal to an ICA occlusion and, in particular, the consideration of a contralateral carotid endarterectomy, should be preceded by a careful evaluation of the intracranial hemodynamic adaptive status of the patient. Particular attention should be paid to cerebrovascular reactivity and the number and type of collateral vessels that are present.

Influence of physiologic oscillation of estrogens on cerebral hemodynamics

The interactions between estrogens and the cerebrovascular system are complex and not fully understood. There are evidences suggesting that the hormones confer protection against cerebral ischemia. Our aim in this study was to investigate the effects of physiological variations of estradiol plasmatic concentration on cerebral hemodynamics. We investigated cerebrovascular reactivity to hypercapnia with transcranial Doppler ultrasonography and the breath-holding index method in the right middle cerebral artery of 20 young women during the menstrual and the ovulatory phase. Data were compared with those of 20 men matched for age. The mean value of the breath-holding index was significantly higher (p<0.001) in females during the ovulatory phase than in the menstrual phase. In men, values were similar to those of women during the menstrual phase. These results suggest that estrogens influence the adaptation capacity of the cerebrovascular system. The possible pathophysiological implications of the relationships between sex hormones and cerebral hemodynamics deserve further investigation.

Effect of antiepileptic drugs on sleep

The interactions between sleep and epilepsy are well known. A nodal point of the relationship between sleep and epilepsy is represented by pharmacological treatment. Sleep disturbances such as drowsiness are among the most frequent side effects of treatment with antiepileptic drugs, since they can deeply modify both sleep architecture and the sleep-wake cycle. Severe daytime somnolence affects patients' activities and it may facilitate the occurrence of seizures. These considerations underline the importance of antiepileptic drugs having anticonvulsant properties that do not negatively influence sleep and daytime somnolence. In this paper we review some relevant aspects of the effects of antiepileptic drugs on sleep.

Effects of lamotrigine on nocturnal sleep, daytime somnolence and cognitive functions in focal epilepsy

OBJECTIVES

The aim of our study was to evaluate possible changes in nocturnal sleep, daytime somnolence and cognitive functions induced by add-on therapy with lamotrigine (LTG).

MATERIAL AND METHODS

Thirteen patients affected by seizures resistant to common antiepileptic drugs (AEDs) underwent nocturnal polysomnographic monitorings, daytime somnolence evaluations and a neuropsychological battery before and after 3 months of treatment with LTG.

RESULTS

With LTG therapy we observed a significant increase in REM sleep and a significant reduction in the number of entries into REM and stage shifts. No significant correlation was observed between the decrease in nocturnal epileptiform activity and the increase in REM sleep. Other sleep parameters were unmodified. No significant changes were observed in daytime somnolence and in cognitive performances.

CONCLUSION

LTG may produce positive effects on epileptic seizures and interictal abnormalities without interfering negatively on REM sleep, with improvement of sleep stability and without changes in daytime somnolence and neuropsychological performances. For these reasons it could be an important drug for improving epileptic patients' quality of life.

Effect of anticonvulsants on nocturnal sleep in epilepsy

Our objective was to determine, in three separate studies, the effects of controlled-release carbamazepine (CBZ-CR), lamotrigine (LTG), and gabapentin (GBP) on nocturnal sleep in epilepsy. Antiepileptic drugs (AEDs) control seizures and also modify hypnic structure. Despite widespread clinical use, their effects on sleep are not well known. PSG was performed in all three studies as follows: CBZ-CR: at baseline, after initial administration of CBZ-CR 400 mg, and after 1 month of CBZ-CR treatment (400 mg BID) in a sample of seven temporal lobe epileptic (TLE) patients. Results were compared with those of nine healthy volunteers; LTG: at baseline, after 3 months of stable treatment with LTG (300 mg/day); GBP: at baseline, after 3 months of stable treatment with GBP (1800 mg/day). Significant findings are as follows for each study. The acute administration of CBZ-CR increased number of stage shifts, reduced REM sleep, and increased REM sleep fragmentation. In the TLE group, these effects were almost completely reversed after chronic treatment. LTG increased REM sleep, reduced number of entries into REM sleep, decreased number of phase shifts, and decreased percentage of slow-wave sleep. GBP increased REM sleep percentage, increased mean duration of REM periods, reduced number of awakenings, and reduced stage 1 sleep percentage. We conclude that CBZ-CR disrupts REM sleep, but only during acute administration. LTG and GBP improve sleep stability while reducing seizures.

Sleep abnormalities in mentally retarded autistic subjects: Down's syndrome with mental retardation and normal subjects

We compared sleep parameters in mentally retarded infantile autism (MRIA) and mentally retarded Down's syndrome (MRDS) by means of polysomnography, evaluating traditional analysis with particular attention to the phasic components in each disorder. Data were compared with those obtained in normal subjects matched for age and sex. Mental age, Intellectual Quotient and the Childhood Autism Rating Scale were performed to obtain an estimation of the neuropsychological deficit. Abnormalities of phasic components of sleep and the presence of REM sleep components into non-REM sleep were observed in both MRIA and MRDS even if in different ways. In fact, MRDS subjects presented a reduction of REM sleep percentage and R index (number of high frequency REMs against number of low frequency REMs) and this was positively correlated to a low IQ. Unlike MRDS subjects, MRIA subjects did not show any parallelism between intellectual abilities and REM sleep deficit. In addition, the presence of undifferentiated sleep in autistic subjects implies a maturational deficit that is still present in adulthood. Finally, a high R index in MRIA was observed. This finding, which is not present in MRDS, could represent an estimation of the disorganized arrival of information caused by a dyscontrol or a reduction of inhibitor pathway. With reference to sleep mechanisms, our results suggest that the cognitive deficit in MRIA may differ from that of MRDS subjects. A maturational deficit of CNS with a dysfunction of brainstem monoaminergic neurons could represent the underlying mechanism.

Association of trisomy 9p and band heterotopia

Patients with the trisomy 9p syndrome and CNS abnormalities have been poorly assessed. We report a patient with trisomy 9p who showed band heterotopia on MRI. Abnormal neuronal migration is sufficiently frequent in patients with the trisomy 9p syndrome that brain MRI should be routinely considered in all patients with this syndrome.

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.

Impairment of daytime cerebrovascular reactivity in patients with obstructive sleep apnoea syndrome

Several studies have demonstrated a clear association between snoring, sleep apnoea and increased risk of stroke. However, the possible role of sleep apnoea in the pathophysiogenetic mechanisms of cerebrovascular disease is still unknown. Our aim in this study was to investigate cerebral haemodynamic changes during the waking state in eight patients with sleep apnoea syndrome (OSAS) by means of transcranial Doppler (TCD). In particular, we studied cerebral vascular reactivity (CVR) to hypercapnia calculated by means of the breath holding index (BHI). The investigation was performed in the early morning, soon after awakening, and in the late afternoon. Data were compared with those of eight healthy subjects matched for age and vascular risk factors. OSAS patients showed significantly lower BHI values with respect to controls both in the morning (0.56 vs. 1.36; P < 0.0001) and in the afternoon (1.12 vs. 1.53; P < 0.0001). In patients, BHI values in the afternoon were significantly higher than in the morning (P < 0.0001). These data demonstrate a diminished vasodilator reserve in OSAS patients, particularly evident in the morning. This reduction of the possibility of cerebral vessels to adapt functionally in response to stimulation could be linked to hyposensitivity of cerebrovascular chemoreceptors after the continuous stress caused by nocturnal hypercapnia.

Cerebral hemodynamic changes in sleep apnea syndrome and effect of continuous positive airway pressure treatment

BACKGROUND AND OBJECTIVE

A clear association among snoring, sleep apnea, and increased risk of stroke has been shown by previous studies. However, the possible role played by sleep apnea in the pathogenesis of cerebrovascular disease is subject to debate. To evaluate the influence of hemodynamic changes caused by obstructive sleep apnea syndrome (OSAS), we investigated cerebrovascular reactivity to hypercapnia in patients with OSAS.

METHODS

The study was performed at baseline and after 1 night and 1 month of nasal continuous positive airway pressure (n-CPAP) therapy, with patients in the waking state (8:00 to 8:30 AM and 5:30 to 6:00 PM) with transcranial Doppler ultrasonography. Cerebrovascular reactivity was calculated with the breath-holding index (BHI).

RESULTS

In the baseline condition, compared with normal subjects, patients with OSAS showed significantly lower BHI values in both the morning (0.57 versus 1.40, p < 0.0001) and the afternoon (1.0 versus 1.51, p < 0.0001). Cerebrovascular reactivity was significantly higher in the afternoon than it was in the morning in both patients (p < 0.0001) and controls (p < 0.05). In patients, the BHI returned to normal values, comparable with those of control subjects, after both 1 night and 1 month of n-CPAP therapy.

CONCLUSIONS

These findings suggest an association between OSAS and diminished cerebral vasodilator reserve. This condition may be related to the increased susceptibility to cerebral ischemia in patients with OSAS, particularly evident in the early morning.

Bilateral hemispheric activation in the early recovery of motor function after stroke

BACKGROUND AND PURPOSE

Functional recovery after cerebral infarction is a complex phenomenon that depends on various factors. The aim of this study was to investigate changes in cerebral perfusion during motor activity in stroke patients with very early recovery of motor function.

METHODS

We included 9 consecutive patients hospitalized for acute-onset hemiparesis who showed complete functional recovery within 24 hours. CT of the brain showed an ischemic or hemorrhagic cerebral lesion in areas compatible with the symptomatology. Within 36 hours (range, 28 to 36) all patients were examined for the effects of a thumb-to-finger opposition task on cerebral blood flow in the middle cerebral arteries, evaluated by means of bilateral transcranial Doppler ultrasonography. Data were compared with those of 9 healthy subjects matched for age and sex. In patients, the evaluation was repeated 2 to 4 months later.

RESULTS

A comparable increase in flow velocity (% mean+/-SD) was observed with respect to baseline in the contralateral middle cerebral artery during motor activity with patients' normal (8.8+/-2.0%) and recovered hand (9.7+/-4.1%) and with both hands of control subjects (10.6+/-1.4%). In the middle cerebral artery ipsilateral to the hand performing the motor task, the increase in flow velocity was significantly higher (P<0.0001) during movement of the recovered hand in patients (8.6+/-2.7%) than during movement of the normal hand in both patients (2.6+/-1.6%) and control subjects (1.4+/-0.7%). In patients, pattern of changes in flow velocity during motor performance remained the same in the second evaluation.

CONCLUSIONS

These observations suggest that areas of the healthy hemisphere can be activated soon after a focal injury and contribute to the positive evolution of a functional deficit in some patients. This phenomenon of ipsilateral activation cannot be considered transient because it is evident months after stroke onset.

Case report: subependymal diffuse heterotopia. Clinical, EEG, and neuroimaging findings

We report the case of a 41 year-old woman with a slight mental retardation and epilepsy. MRI showed a diffuse subependymal heterotopia. The cognitive level supports the view that the ectopic cells are probably not important for the normal cortical functions but that they are likely able to maintain some of the electric properties of normal neurons, even if with altered discharge modalities. The genetic etiology of subependymal neuronal migration disorders is discussed. This is the second reported case of diffuse subependymal heterotopia in a female patient.

Nocturnal sleep and daytime somnolence in untreated patients with temporal lobe epilepsy: changes after treatment with controlled-release carbamazepine

PURPOSE

To define sleep disturbances in patients with temporal lobe epilepsy (TLE) and explore the association between carbamazepine (CBZ) therapy, sleep, and daytime somnolence.

METHODS

We recorded nocturnal polysomnography and measured subjective and objective daytime somnolence in a group of newly diagnosed TLE patients, who had no evidence of anatomic brain lesion on neuroimaging and had never been treated before. Recordings were performed at baseline, after the initial administration of 400 mg CBZ-controlled release (CR) and after 1 month of treatment (400 mg twice daily b.i.d.). The findings were compared with those of a group of young healthy volunteers, both at baseline and after the first administration of CBZ. The chronic effect of CBZ-CR treatment was evaluated only in TLE patients.

RESULTS

At baseline, nocturnal sleep patterns of TLE patients did not show marked alterations when the influence of seizures, cerebral lesions, and drugs had been ruled out. In both the TLE and the control groups, initiation of CBZ therapy provoked a reduction and a fragmentation of rapid eye movement (REM) sleep and an increase in the number of sleep stage shifts. In the TLE group, these effects were almost completely reversed after 1 month of treatment, and no significant difference was noted between baseline condition and long-term follow-up. With regard to daytime sleepiness, initial administration of the drug caused an increase in objective sleepiness only in the control group. Subjective sleepiness was higher in the control group than in the TLE group but was not modified by the drug.

CONCLUSIONS

We conclude that CBZ-CR has negative effects on REM sleep during initial administration but chronic treatment does not significantly modify nocturnal sleep or daytime somnolence.

Clinical case report: multiple idiosyncratic adverse effects of antiepileptic drugs in trisomy 9p

We report the case of a mentally retarded 30 y.o. patient with partial trisomy of chromosome 9, affected by epilepsy. Following treatment with antiepileptic drugs (AEDs), the patient developed several rare complications: after beginning therapy with phenytoin, the patient developed pseudolymphoma; after monotherapy with carbamazepine (CBZ), the patient thereafter developed myoclonic jerks of upper and lower limbs upon awakening; after one year of treatment with valproate (VPA) the patient developed clinical and immuno-haematological signs of SLE. Gradual withdrawal of AED, obtained clinical remission. The possibility that the chromosomal abnormality of the patient was responsible for the three rare complications observed during AED therapy is considered.

Cognitive performances in newly referred patients with temporal lobe epilepsy: comparison with normal subjects in basal condition and after treatment with controlled-release carbamazepine

In order to verify whether the performance of patients with temporal lobe epilepsy (TLE) were different from those of the normal controls in various cognitive tasks, we conducted a neuropsychological study in the two groups, excluding the presence of other confounding factors in the group of TLE patients (newly referred, previously untreated, without cerebral lesions at neuroimaging, with low recurrence of seizures). In basal condition, no significant difference was found between the nine healthy controls and the eight TLE patients. The second aim of the study was to investigate the effect of the first administration of 400 mg controlled-release carbamazepine (CBZ-CR). The drug caused a significant decrease in verbal memory (short and long-term) in TLE patients, whereas, in the control group, the first administration of CBZ-CR caused only a less significant impairment of long-term verbal-memory. Finally, the cognitive effects of CBZ-CR were assessed after one month of therapy, only in the group of patients. Our data suggest that: 1) differences between patients and controls in basal conditions are not relevant, once the influence of seizures, of treatment and of anatomical lesions has been ruled out. In other words, our patients did not perform differently from controls simply because they had become epileptic 2) also in the controlled-release preparation, adverse effects of CBZ on cognitive function are minimal and limited to the beginning of treatment.

Valproate-induced systemic lupus erythematosus in a patient with partial trisomy of chromosome 9 and epilepsy

We report a mentally retarded 30-year-old woman with partial trisomy of chromosome 9 (46, XX-6, +der(6)t(6,9)pat) who has had epilepsy since age 11 months. She had been treated with various combinations of drugs. After 1 year of treatment with valproate (VPA) and ethosuximide (ESM), the patient developed arthralgias, muscle weakness, fatigue, and fever. Laboratory examination showed increased sedimentation rate, hypergammaglobulinemia, and high titers of antinuclear antibodies (ANA). The possibility of VPA-induced systemic lupus erythematosus (SLE) was considered. This diagnosis was supported by detection of antihistone antibodies and the HLA-DR4 antigen. VPA dosage was tapered and discontinued, with accompanying resolution of clinical, immunological and hematological signs of SLE 6 weeks after VPA discontinuation. This is the fourth reported case of VPA-induced SLE.

Sleep in healthy elderly subjects: a 24-hour ambulatory polysomnographic study

It is still debated whether the deterioration of the sleep pattern, frequently reported by elderly subjects, is due only to aging per se. Other factors associated with aging or modifications of biological rhythms could also be involved. Elderly subjects frequently complain of daytime sleepiness, but it is not clear whether this actually represents a return to a polyphasic structure of sleep, or only a consequence of a disturbed night sleep. Ten healthy, independent and active elderly subjects (age > 72 years) were elevated by means of 24-hour ambulatory polysomnography. Findings of nocturnal sleep were compared with sleep of the same group in the 24-hour period and with sleep of young healthy controls. We observed a fragmentation of nocturnal sleep, but a fairly good representation of stages and a preservation of cyclicity. Except for three cases, with early or late times of sleep onset and wake-up, sleep disruption did not seem to be related to modification of circadian rhythms. Only three subjects presented undesired daytime naps, whereas the others either did not show daytime sleep at all, or were used to having their siesta after lunch since their young adulthood. In normal aging, daytime sleep does not constitute a social problem. Ambulatory polysomnography is a valid alternative to laboratory recordings in the identification of daytime sleep.

Distinguishing forms of generalized epilepsy using magnetic brain stimulation

In this study, we have used paired transcranial stimulation of the motor cortex to test the hypothesis that cortical inhibition is decreased in juvenile myoclonic epilepsy (JME). The double shock technique was adopted here because it offers a means for highlighting abnormal inhibitory mechanisms. From previous experiments performed on healthy subjects, it is known that a magnetic conditioning stimulus, of subthreshold intensity, suppresses the MEP in response to a subsequent suprathreshold stimulus delivered after 1-4 msec. JME patients were selected as a potential contrast with other forms of idiopathic generalized epilepsy, because they complain of myoclonic jerks without loss of consciousness, indicating with certainty a dysfunction of the motor cortex. Two patients with sporadic grand mal and one non-epileptic patient were also investigated. Paired stimulation was produced by a Bi-stim (Magstim) stimulator, with a figure-of-8 coil placed over the hand area of the motor cortex, and a set of interstimulus intervals (ISIs) ranging from 1 to 6 msec was analyzed. In JME patients there were two indications of abnormality with respect to normal subjects and to the other epileptic patients: (1) the absence of MEP suppression to paired stimulation; (2) a progressive amplitude increase of MEPs to the test stimulus alone. In the two patients with the other form of epilepsy the pattern of inhibition was broadly preserved, even though there was some difference from the normal profile. The results suggest that the loss of MEP inhibition can be regarded as a marker of JME.

Lack of potentiation of anticonvulsant effect by fluoxetine in drug-resistant epilepsy

To test the hypothesis that fluoxetine may be a useful adjunct to antiepileptic therapy, we treated with fluoxetine (20-40 mg/day) nine patients suffering from medically intractable epilepsy with daily seizures. Five patients remained unchanged and four worsened. Worsening was more evident at 40 mg/day. One patient improved when receiving the lower dose (20 mg/day) and worsened with the higher dose (40 mg/day). These data suggest: (1) that fluoxetine is not effective as add-on antiepileptic treatment; (2) that caution should be exerted when using fluoxetine as an antidepressive treatment in epileptic patients.

Spastic paraplegia, epilepsy, and mental retardation in several members of a family: a novel genetic disorder

We report on a family in which an association between spastic paraplegia and epilepsy has been observed. This disorder is an autosomal dominant trait with incomplete penetrance and variable expressivity. The onset was limited to the first four decades of life; the symptoms were typically those of progressive weakness and spasticity of lower limbs. Epilepsy was present in members of three of the four generations on whom we have information. The concomitance of spastic paraplegia and epilepsy in several members of the same family is unlikely to be fortuitous and probably represents the pleiotropic effect of a single mutant gene.

Sleep microstructure and EEG epileptiform activity in patients with juvenile myoclonic epilepsy

Clinical and EEG manifestations of juvenile myoclonic epilepsy (JME) occur in a strict relationship to the sleep-wake cycle, particularly to transition phases (awakening, falling asleep, afternoon relaxation after work). JME manifestations are deactivated during sleep. Because arousal fluctuations during NREM sleep may be controlled by the same neurophysiologic mechanisms regulating awakening, we studied the relationship between the cyclic alternating pattern (CAP) and JME manifestations. All-night polysomnographic recordings of 10 JME patients were analyzed for variations of epileptiform EEG abnormalities in relation to sleep stages and to different microstructural variables (NCAP, CAP, phases A and B). CAP rates (ratio between total CAP duration and total NREM sleep duration) were also calculated. Average CAP rate was 46.70%, significantly higher than that (23%) of an age-matched control group. Macrostructural analysis showed only a trend toward a slight predominance of EEG epileptiform activity during slow wave sleep but no significant correlation between spiking rates and sleep stages. Microstructural analysis confirmed the CAP modulation of EEG epileptiform activity, with maximum appearance of epileptiform abnormalities during phase A CAP (normalized spiking rate = 4.00 +/- 0.98) and strong inhibition during phase B (0.06 +/- 00.6). Intermediate values were noted during NCAP (0.54 +/- 0.27). No correlation was noted between spiking rates during NREM sleep and CAP rates, possibly indicating that in JME patients the increased CAP rate may be partially independent of epileptiform EEG activity. Our data suggest that in JME patients CAP may be a neurophysiologic oscillator organizing expression of the epileptiform discharges independent of the tendency of the individual patient to produce epileptiform EEG discharges.

Eye closure sensitivity without photosensitivity in juvenile myoclonic epilepsy: polysomnographic study of electroencephalographic epileptiform discharge rates

Two cases of juvenile myoclonic epilepsy (JME) presented with myoclonic jerks and EEG activation after eye closure, without sensitivity to intermittent photic stimulation. The effect of eye closure was computed by comparing discharge rates of polyspike-and-wave (PSW) complexes after eye closure and after eye opening. For one patient, never treated pharmacologically, a nocturnal polysomnograph was performed to study the variation of discharge rates of PSW complexes during wakefulness and sleep. The rate of PSW complexes was high during wakefulness before sleep onset, increased during spontaneous nocturnal awakenings, and became maximal during final morning awakening. Among nonrapid eye movement (NREM) sleep stages, EEG epileptiform activity was maximal during stages III and IV. Discharges were completely suppressed by rapid eye movement (REM) sleep. Awakenings following deep NREM sleep were very activating if no REM sleep was interposed. Awakenings from light NREM sleep were much less activating. There were no EEG abnormalities in awakenings immediately following REM sleep. Results suggest that REM sleep, similarly to eye opening, plays a role in inhibiting EEG manifestations of JME with eye closure sensitivity.