G. Gallitto

Ischaemic Stroke in Young People: A Prospective and Long-Term Follow-Up Study

Background: A few studies have comprehensively assessed the epidemiology, aetiology, prognosis, and secondary prevention of ischaemic stroke in young adults. To gain further information on this field, we have prospectively studied a hospital-based series of young adults with a first-ever episode of cerebral ischaemia (CI). Methods: Sixty consecutive patients aged 17–45 with ischaemic stroke (55 patients) or transient ischaemic attack within 24 h before hospital admission were recruited and investigated by a standardized rigorous protocol. The patients were followed up for ≧1 year after hospital discharge. Arbitrary doses of aspirin 100 mg/d or ticlopidine 250 mg b.i.d. in case of intolerance to aspirin were given for the secondary prevention. Adjusted-dose oral anticoagulation (INR target 2.5) was used in the presence of cardioembolism or hypercoagulable states. Endpoints included the residual disability, rated by modified Rankin Scale (RS) and Barthel Index (BI), and poststroke recurrence. Results: CI was associated with two or more risk factors in 61.6% of patients. Cigarette smoking was more frequently associated with male gender (p < 0.05) and migraine history with female sex (p < 0.05). The atherothrombotic diagnostic subtype and the subtype from ‘other cause’ predominated significantly among patients ≧35 years old (p < 0.05) and <35 years (p < 0.025), respectively. The ‘other cause’ subset was more frequent in female gender (p < 0.05). Transoesophageal echocardiography (TEE) detected potential cardiac sources of emboli (PCSE) at an extent 3 times higher (p < 0.0001) than transthoracic echocardiography. Congenital heart defects were nearly threefold more frequent than acquired ones, with a prevalence of patent foramen ovale. At a mean of 6.1 ± 2.6 years (confidence interval 5.4 to 6.8), follow-up data were available for only 54 patients, since five patients were lost and one died in the acute phase. Poststroke recurrence rate was low (7.4%) and no event was fatal. General handicap was severe to moderately severe (RS>3) in 11% of the patients, slight to moderate (1≧RS≤3) in 59% and absent in 30% (RS = 0). Functional disability was relatively low with 50% of the patients independent (BI ≧95), 38.9% partially dependent (BI 60 to 86), and 11.1% fully dependent (BI <60). Thirty-seven (68.5%) patients returned to work, although adjustments (other job or part-time employment) were necessary for 10 out of them (27%). Conclusions: The present study, though limited by the relatively small number of subjects, suggests that the overall prognosis of ischaemic stroke in young adults is good. We strongly recommend TEE in all patients with ischaemic stroke as an essential tool to increase the detection of PCSE and make the therapeutic approach more efficient.

Amyotrophic Lateral Sclerosis: An Epidemiological Study in the Province of Messina, Italy, 1976–1985

An epidemiological investigation of 41 subjects with amyotrophic lateral sclerosis observed in the Province of Messina during 1976-1985 was performed. The incidence was 0.61/100,000 and the prevalence 2.48/100,000 inhabitants. The illness was found to be prevalent in males. The atrophic type occurred in 17 subjects, the bulbar type in 23 cases and the pseudo-polyneuritic form in only one patient. The mean age on the onset was 57.29 +/- 10.55 years. The duration of the illness was significantly higher in patients with atrophic type (p less than 0.01). No significant difference between occupation and development of the disease was found. Among all patients 12.19% presented evidence of trauma, but traumatic events were equally present in a control group.

First-Ever Stroke Incidence and 30-Day Case Fatality in the Sicilian Aeolian Archipelago, Italy

Background and Purpose— Not many data on stroke epidemiology come from studies on islands. This is the first report on a Mediterranean archipelago population. Methods— Using recommended criteria, from July 1, 1999, to June 30, 2002, information was collected on first-ever stroke and 30-day case fatality in Aeolian island residents (13 431). Results— The overall crude incidence rate was 154 of 100 000 (95% CI, 118 to 197; 128 in men and 180 in women) or 180, 154, and 87, if adjusted to the Italian, European, and world populations, respectively. The 30-day case fatality rate was 24.2% (95% CI, 14.22 to 36.75). Conclusions— Besides genetic or dietary factors, our results may reflect local, limited possibilities of diagnosis and management for stroke patients.

Synergistic Anticonvulsant Effect of Valproic Acid and Ethosuximide on Pentylenetetrazole-induced Epileptic Phenomena in Rats

The possible synergistic effect of valproic acid and ethosuximide in combination on pentylenetetrazole-induced epilepsy was investigated in rats. Valproic acid and ethosuximide administered intraperitoneally both showed dose-dependent anti-epileptic activity towards pentylenetetrazole-induced myoclonias and tonic – clonic seizures. The valproic acid – ethosuximide combination had a synergistic pharmacological effect. Against myoclonias combined valproic acid – ethosuximide produced a non-significant decrease in the effective dose of both drugs compared with treatment with either drug alone. In the case of tonic – clonic seizures the protective effect against the seizures was significantly increased by combined treatment compared with treatment with either drug alone. Neither plasma concentrations nor any other pharmacokinetic parameters were significantly changed when the same doses of valproic acid and ethosuximide were given, singly or in combination.

2. Cefazolin: a Valid Model of Experimental Epilepsy?

: In various animal species (chicks, rats and rabbits) the intravenous injection of high doses of cefazolin, a cephalosporin not hitherto reported to produce epileptic seizures, was found to produce epileptiform electrocortrical changes similar to those evoked by intravenous benzylpenicillin. Similar phenomena as those reported after systemic injection were also observed after microinjection of cefazolin into the III cerebral ventricle. In fact, both in chicks and rats cefazolin given by the latter route produced wild running crisis, myoclonic jerks of the limbs and in some instances generalized clonic convulsions. Concomitantly, bilateral electrocortical high voltage bursts of spikes were observed, followed during the intercritic period by periodic bilateral or unilateral single spikes.

Status cataplecticus misdiagnosed as recurrent syncope

A 76-year-old patient, since the age of 45, presented with frequent attacks often triggered by emotional stimuli and characterised by forward head drop and a fall to the ground without loss of consciousness. Clinically these episodes were misinterpreted as pseudoseizures and treated with clomipramine for more than 20 years. In spite of this chronic therapy, during the last year, the attacks presented with a daily recurrence and, moreover, after arbitrary clomipramine withdrawal, they increased in frequency until they became subcontinuous. Videopolygraphic analysis, multiple sleep latency test (MSLT) and human leukocyte antigen (HLA) association studies were suggestive of narcolepsy and the recurrent episodes, diagnosed as status cataplecticus, recovered after citalopram administration.

Spinal Grey Matter Infarction after Aortic Surgery: A Case of Persistent Pure Flaccid Paraplegia

Introduction In spite of great advances in the management of vascular diseases, spinal cord infarction still remains a rare but severe event after aortic surgery. The spectrum of clinical presentation includes segmental or distal spinal cord as well as lumbosacral nerve root or plexus syndrome, so that spastic (central) and/or fl accid (peripheral) paraparesis or paraplegia, associated with disturbances in sensory and vegetative functions, commonly occurs [1] . Electrophysiologic studies may help localize the injury [1–3] ; however, magnetic resonance imaging (MRI) is considered the fi rst-line investigation [4] .

Ulcerative colitis complicated by dural sina venous thrombosis

Dear Editor: Cerebral and dural sine venous thrombosis during ulcerative colitis is uncommon and is characterized by a severe prognosis in a high rate of cases [1]. We observed a case that showed thrombophlebitis of the upper sagittal sinus associated with cortical infarction and left frontal-parietal hemorrhage during a relapse of the ulcerative rectocolitis. A 17-year-old woman had been suffering since the age of 15 years from monthly attacks of migraine