Elisa Giorli

Association between migraine and cervical artery dissection the Italian project on stroke in young adults

Importance Although sparse observational studies have suggested a link between migraine and cervical artery dissection (CEAD), any association between the 2 disorders is still unconfirmed. This lack of a definitive conclusion might have implications in understanding the pathogenesis of both conditions and the complex relationship between migraine and ischemic stroke (IS). Objective To investigate whether a history of migraine and its subtypes is associated with the occurrence of CEAD. Design, Setting, and Participants A prospective cohort study of consecutive patients aged 18 to 45 years with first-ever acute ischemic stroke enrolled in the multicenter Italian Project on Stroke in Young Adults was conducted between January 1, 2000, and June 30, 2015. In a case-control design, the study assessed whether the frequency of migraine and its subtypes (presence or absence of an aura) differs between patients whose IS was due to CEAD (CEAD IS) and those whose IS was due to a cause other than CEAD (non-CEAD IS) and compared the characteristics of patients with CEAD IS with and without migraine. Main Outcomes and Measures Frequency of migraine and its subtypes in patients with CEAD IS vs non-CEAD IS. Results Of the 2485 patients (mean [SD] age, 36.8 [7.1] years; women, 1163 [46.8%]) included in the registry, 334 (13.4%) had CEAD IS and 2151 (86.6%) had non-CEAD IS. Migraine was more common in the CEAD IS group (103 [30.8%] vs 525 [24.4%], P = .01), and the difference was mainly due to migraine without aura (80 [24.0%] vs 335 [15.6%], P < .001). Compared with migraine with aura, migraine without aura was independently associated with CEAD IS (OR, 1.74; 95% CI, 1.30-2.33). The strength of this association was higher in men (OR, 1.99; 95% CI, 1.31-3.04) and in patients 39.0 years or younger (OR, 1.82; 95% CI, 1.22-2.71). The risk factor profile was similar in migrainous and non-migrainous patients with CEAD IS (eg, hypertension, 20 [19.4%] vs 57 [24.7%], P = .29; diabetes, 1 [1.0%] vs 3 [1.3%], P > .99). Conclusions and Relevance In patients with IS aged 18 to 45 years, migraine, especially migraine without aura, is consistently associated with CEAD. This finding suggests common features and warrants further analyses to elucidate the underlying biologic mechanisms.

Differential Motor Neuron Impairment and Axonal Regeneration in Sporadic and Familiar Amyotrophic Lateral Sclerosis with SOD-1 Mutations: Lessons from Neurophysiology

Amyotrophic Lateral Sclerosis (ALS) is a degenerative disorder of the motor system. About 10% of cases are familial and 20% of these families have point mutations in the Cu/Zn superoxide dismutase 1 (SOD-1) gene. SOD-1 catalyses the superoxide radical (O−2) into hydrogen peroxide and molecular oxygen. The clinical neurophysiology in ALS plays a fundamental role in differential diagnosis between the familial and sporadic forms and in the assessment of its severity and progression. Sixty ALS patients (34 males; 26 females) were enrolled in the study and examined basally (T0) and every 4 months (T1, T2, and T3). Fifteen of these patients are SOD-1 symptomatic mutation carriers (nine males, six females). We used Macro-EMG and Motor Unit Number Estimation (MUNE) in order to evaluate the neuronal loss and the re-innervation process at the onset of disease and during follow-up period. Results and Discussion: SOD-1 mutation carriers have a higher number of motor units at the moment of diagnosis when compared with the sporadic form, despite a more dramatic drop in later stages. Moreover, in familiar SOD-1 ALS there is not a specific time interval in which the axonal regeneration can balance the neuronal damage. Taken together, these results strengthen the idea of a different pathogenetic mechanism at the base of sALS and fALS.

Propensity Score–Based Analysis of Percutaneous Closure Versus Medical Therapy in Patients With Cryptogenic Stroke and Patent Foramen Ovale The IPSYS Registry (Italian Project on Stroke in Young Adults)

Background—We sought to compare the benefit of percutaneous closure to that of medical therapy alone for the secondary prevention of embolism in patients with patent foramen ovale (PFO) and otherwise unexplained ischemic stroke, in a propensity scored study. Methods and Results—Between 2000 and 2012, we selected consecutive first-ever ischemic stroke patients aged 18 to 45 years with PFO and no other cause of brain ischemia, as part of the IPSYS registry (Italian Project on Stroke in Young Adults), who underwent either percutaneous PFO closure or medical therapy for comparative analysis. Primary end point was a composite of ischemic stroke, transient ischemic attack, or peripheral embolism. Secondary end point was brain ischemia. Five hundred and twenty-one patients qualified for the analysis. The primary end point occurred in 15 patients treated with percutaneous PFO closure (7.3%) versus 33 patients medically treated (10.5%; hazard ratio, 0.72; 95% confidence interval, 0.39–1.32; P=0.285). The rates of the secondary end point brain ischemia were also similar in the 2 treatment groups (6.3% in the PFO closure group versus 10.2% in the medically treated group; hazard ratio, 0.64; 95% confidence interval, 0.33–1.21; P=0.168). Closure provided a benefit in patients aged 18 to 36 years (hazard ratio, 0.19; 95% confidence interval, 0.04–0.81; P=0.026) and in those with a substantial right-to-left shunt size (hazard ratio, 0.19; 95% confidence interval, 0.05–0.68; P=0.011). Conclusions—PFO closure seems as effective as medical therapy for secondary prevention of cryptogenic ischemic stroke. Whether device treatment might be more effective in selected cases, such as in patients younger than 37 years and in those with a substantial right-to-left shunt size, deserves further investigation.

Transcranial Direct Current Stimulation and Cerebral Vasomotor Reserve: A Study in Healthy Subjects

Cerebral vasomotor reserve (VMR) is the capability of cerebral arterioles to change their diameter in response to various stimuli, such hypercapnia. Changes of VMR due to transcranial direct current stimulation (tDCS) have been poorly studied.

Ramsay Hunt syndrome with trochlear nerve involvement and EEG abnormalities: Multicranial neuritis or encephalitis?

A 69-year-old woman was admitted to the emergency room ith vomit and vertigo since two days before. She was under treatent for hypertension, hypercholesterolemia and hyperuricemia. brain computed tomography was normal. At the admission to our department she had fever (38.8 ◦C). Neurological examination showed rotatory right-beat nystagmus and vertical diplopia on right and down gaze direction. She had no consciousness impairment. The following day she developed complete left facial palsy. At otorhinolaringoiatric examination herpetic vesicles around the left concha auricolae and the homolateral hard

To FAST or Not to FAST: SHOUT-FAST!

To the Editor: We read with great interest the article by Kleindorfer et al1 evaluating the effectiveness of FAST and “SUDDENS” message to identify stroke. We agree that FAST may be easier for the lay public to remember, but we have …

Anticoagulants Resumption after Warfarin-Related Intracerebral Haemorrhage: The Multicenter Study on Cerebral Hemorrhage in Italy (MUCH-Italy)

Whether to resume antithrombotic treatment after oral anticoagulant-related intracerebral haemorrhage (OAC-ICH) is debatable. In this study, we aimed at investigating long-term outcome associated with OAC resumption after warfarin-related ICH, in comparison with secondary prevention strategies with platelet inhibitors or antithrombotic discontinuation. Participants were patients who sustained an incident ICH during warfarin treatment (2002-2014) included in the Multicenter Study on Cerebral Hemorrhage in Italy. Primary end-point was a composite of ischemic stroke/systemic embolism (SE) and all-cause mortality. Secondary end-points were ischemic stroke/SE, all-cause mortality and major recurrent bleeding. We computed individual propensity score (PS) as the probability that a patient resumes OACs or other agents given his pre-treatment variables, and performed Cox multivariable analysis using Inverse Probability of Treatment Weighting (IPTW) procedure. A total of 244 patients qualified for the analysis. Unlike antiplatelet agents, OAC resumption was associated with a lower rate of the primary end-point (weighted hazard ratio [HR], 0.21; 95% confidence interval [CI], 0.09-0.45), as well as of overall mortality (weighted HR, 0.17; 95% CI, 0.06-0.45) and ischemic stroke/SE (weighted HR, 0.19; 95% CI, 0.06-0.60) with no significant increase of major bleeding in comparison with patients receiving no antithrombotics. In the subgroup of patients with atrial fibrillation, OACs resumption was also associated with a reduction of the primary end-point (weighted HR, 0.22; 95% CI, 0.09-0.54), and the secondary end-point ischemic stroke/SE (weighted HR, 0.09; 95% CI, 0.02-0.40). In conclusion, in patients who have an ICH while receiving warfarin, resuming anticoagulation results in a favorable trade-off between bleeding susceptibility and thromboembolic risk.

Central nervous system involvement in mycosis fungoides: relevance of tcr gene testing in cerebrospinal fluid

IntroductionMycosis Fungoides (MF) is a rare malignant T-cell lymphoma, involving mainly the skin. In 50%–75% of cases, it can involve organs other than skin, with a 11%–14% Central Nervous System involvement (CNS).Case reportA 82-year-old woman presented to our Department with a 15-years history of MF with skin lesions. Neurological examination showed dysarthria and a left facio-brachial-crural hemiparesis. A CT scan showed a right fronto-rolandic lesion. A MRI, including DWI, confirmed the presence of the “neoplastic” lesion with slight hemorrhagic component and leptomeningeal contrast enhancement. Molecular TCR rearrangement test by PCR analysis was performed on skin biopsy, showed the presence of a single peak which fits with a monoclonal TCRG gene rearrangement (size 67). Molecular TCR test was also performed on the cerebrospinal fluid (CSF), which confirmed the presence of lymphocyte clone T g/ more expressed with the same size of that observed in the skin biopsy A total body CT scan did not show any lymphnodal or extranodal disease. The patient died after ten days.ConclusionMF usually occurs in the context of advanced and often histologically transformed cutaneous disease. Isolated CNS involvement is remarkably rare. This case highlights the need for regular neurologic follow-up after the diagnosis of MF, in particular when features that suggest risk of disease progression are present. Furthermore, the analysis of the skin biopsy and above all of CSF by PCR technique, based on our experience, should always be executed in MF patients with signs or symptoms suggesting CNS involvement.

Tongue's motor evoked potentials in the diagnosis of Primary Lateral Sclerosis (PLS): Preliminary report

BACKGROUND Primary Lateral Sclerosis (PLS) is an adult-onset neurodegenerative disorder due to a selective loss of precentral pyramidal neurons. Our purpose was to evaluate preferential impairment of pyramidal tract to bulbar muscles in patients with PLS and identify a valuable electrophysiological method to help clinicians in the differential diagnosis from Amyotrophic Lateral Sclerosis (ALS). MATERIALS AND METHODS We recorded Motor Evoked Potentials (MEPs) from tongues and anterior tibialis muscles in six patients with PLS and compared the results, in terms of Central Motor Conduction Time (CMCT), amplitude of MEPs and duration of controlateral silent period (cSP), with those obtained both from ten age-matched healthy volunteers and ten patients affected by ALS. RESULTS For lower limbs, CMCT resulted significantly increased in PLS and ALS samples compared with healthy subjects (p<0.01); we did not disclose any difference between ALS and PLS groups (p=0.417). Instead for tongues recordings, CMCT, absolute amplitude of MEPs and cSP were significantly altered in PLS patients towards both ALS patients and healthy volunteers. CONCLUSIONS We showed that tongues MEPs are selectively impaired in PLS. This technique could be helpful to differentiate patients with PLS from those affected by upper motor neuron-predominant variants of ALS. Tongues MEPs could represent an interesting electrodiagnostic test, potentially useful for the diagnosis of PLS.

Thrombolysis for Acute Stroke: What about the Actual Impact on Patients Older Than 80 Years?

abled at discharge (median mRS at discharge 3.9, range 3–5 vs. median mRS at admission 2.4, range 2–3). Both hospital stay length [4] and disability rate [5] could probably have been reduced by thrombolysis. In our analysis, 2 patients aged 80 with ischemic stroke were admitted within 3 h of symptom onset and were excluded from thrombolysis because of severe stroke. Treatment of 80-year-old patients – according to Zeevi’s age dichotomization data [1] – would have further increased the number of elderly patients who could have benefited from treatment. Based on our data, we estimate that about one third of patients aged 1 80 years with ischemic stroke arriving at hospital within 3 h of stroke onset could be treated, that is 7/62 (11.3%) of elderly stroke patients. This percentage could be higher if we consider that late admission to a hospital providing thrombolysis represents the most relevant modifiable barrier to delivering treatment, involving up to 84% of stroke patients [6, 7] . Our data confirm that rtPA treatment should also be implemented in carefully selected elderly patients. We read with great interest the study by Zeevi et al. [1] evaluating acute stroke management in the elderly. The authors found that early treatment with rtPA in patients 1 80 years appears to be both safe and efficacious. The issue of thrombolysis in the elderly has previously been addressed by other groups and is summarized in a recent review [2] , which concluded that, in spite of a poorer outcome compared to younger patients, there is a spectrum of benefit from thrombolysis in this group. Even if the results of a specific trial are not available at the moment, these data support the hypothesis that older age stroke patients should not be excluded from thrombolysis because of age alone [3] . Thus, the elderly could benefit from thrombolysis, but what would its actual impact in clinical practice be? To elucidate this issue, we retrospectively reviewed data from patients admitted to our hospital for acute stroke in 2005. Twohundred and fifty-eight patients [median age 71 years, range 19– 97, 62/258 (24.0%) at age 1 80 years] were admitted, but only 102/258 (39.5%) arrived within 3 h of stroke onset and, in 72/102 (70.6%), cranial computed tomography showed no hemorrhage or neoplasm. Fifty-one of 72 (70.8%) patients were aged ̂ 80 and 12/51 (23.5%) had undergone thrombolysis, with no subsequent symptomatic intracranial hemorrhage. Twenty-one of 72 (29.2%) were 1 80 years old (median age 84 years, range 81–90) and none of them was treated according to the SITS-MOST selection criteria, which prevent thrombolysis in the elderly. However, only 7/21 (33.3%) presented no other defined exclusion criteria [minor neurological deficit or symptoms rapidly improving before start of infusion in 2/21 (9.5%); severe stroke in 7/21 (33.3%); prior stroke within the previous 3 months in 2/21 (9.5%); major surgery in the previous 3 months in 1/21 (4.8%); oral anticoagulant treatment with INR 1 1.7 in 1/21 (4.8%); arrival at the limit of the 3-hour time window in 1/21 (4.8%)]. These patients (median age 85.6 years, range 82–90; median NIHSS at admission 15.7, range 8–24) had a median hospital stay of 22.7 days (range 12–35) and were all disPublished online: November 27, 2007