Stefano Gipponi

Primitive reflex evaluation in the clinical assessment of extrapyramidal syndromes

The aim of the present study was to evaluate the role of primitive reflexes (PRs) as additional alert sign in routine clinical practice in patients with extrapyramidal syndrome. We considered glabellar, snout, palmomental and grasp reflexes in patients with mild stage of Lewy body dementia (LBD), corticobasal degeneration, progressive supranuclear palsy or Parkinson disease (PD). We also enrolled mild Alzheimer disease (AD) patients, and healthy subjects, as controls. LBD patients showed the highest prevalence of PRs compared with the other groups. The odds ratio of the risk of LBD in PRs ≥ 2 was 27.9 (95% CI 2.9–269.0) compared with control group, 14.6 (95% CI 2.7–79.6) compared with mild AD, and 19.7 (95% CI 3.7–104.3) compared with PD. These data suggest that the occurrence of combination of PRs might be an useful additional warning sign of possible diffuse Lewy body pathology more than other causes of extrapyramidal syndrome.

Investigating the association between Notch3 polymorphism and migraine.

Objective.—The aim of the present study was to evaluate whether the functional Notch3 polymorphism T6746C, which is not causative for cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), might be a risk factor for migraine.

Where SUNCT contacts TN: a case report.

Background.—Short‐lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) and trigeminal neuralgia (TN) are unilateral painful conditions that can share the same triggering factors, autonomic features and the main location, as well as the cyclically recurrent crises. Both these syndromes are associated with a high percentage of findings of vascular malformation touching the trigeminal nerve, suggesting a pathophysiological relationship.

Cerebrovascular risk factors and MRI abnormalities in migraine

Case series have demonstrated an increased incidence of white matter lesions (WMLs) in patients with migraine. It is controversial whether the evidence of subclinical brain lesions relates to a higher risk of cerebrovascular disease. The objective of this study was to evaluate the association between magnetic resonance imaging (MRI) subclinical brain lesions and cerebrovascular risk factors (hyperhomocysteinaemia, MTHFR genotype, patent foramen ovale, hypertension, smoking and hypercholesterolaemia). From our database of 1201 patients followed at our Headache Clinic since September 2003 we analysed the MRI findings of 253 individuals. All MRI were blindly analysed by a second neuroradiologist (C.A.) and patients with WMLs (study group) were evaluated. In order to assess the association of WMLs with specific vascular risk factors, patients with WMLs were matched, according to age, sex and ICHD II diagnosis, with an equal number of individuals with normal MRI (control group). Headache was classified by the International Classification of Headache Disorders (ICHD 2004) criteria. We did not find any statistically significant difference between the two groups with regard to the presence of the cerebrovascular disease risk factors considered. Our results confirm that the WMLs are not related to the cerebrovascular disease risk factors.

Potentially Serious Drug-Drug Interactions in Older Patients Hospitalized for Acute Ischemic and Hemorrhagic Stroke.

Background: Polypharmacy is very common in older persons and it is associated with inappropriate prescribing and potential drug-drug interactions (DDIs). Aims of this study were to identify prevalence of DDIs in older persons with acute stroke and to evaluate the association between stroke and DDIs. Methods: One hundred forty-six patients admitted with diagnosis of acute stroke were enrolled. The therapeutic regimen of patients was analyzed at admission to identify the number of DDIs, prevalence and sorts of serious DDIs according to subtype of acute stroke (ischemic or hemorrhagic) and to its recurrence. Results: Five hundred eighty-two DDIs were identified: 18 mild, 415 moderate and 149 serious. Sixty-one percent of patients were exposed to at least one serious DDI. A higher percentage of patients were exposed to at least one serious DDI among those with a recurring ischemic event compared to those with a first event (74 vs. 50%; p < 0.01, respectively). Serious DDIs potentially associated with an increased risk of a cerebral event were identified in 19 (17%) patients with ischemic stroke, and in 7 (19%) patients with hemorrhagic stroke. Conclusions: The prevalence of serious DDIs was high in aging patients with acute stroke but different according to subtype and recurrence of the cerebrovascular event.

Dementia with Lewy bodies with and without hallucinations: a clue to different entities?

Patients who have Dementia with Lewy Bodies (DLB) commonly experience psychotic symptoms, most notably visual hallucinations, but different estimates of their frequency exist and their pathophysiology is still debated (Hirono and Cummings, 1999). A cholinergic mechanism has been proposed, implicating the loss of either cortical choline acetyltransferase activity or cortical nicotinic receptors. Some authors report a striking association between visual hallucinations and the distributions of Lewy bodies in the temporal lobe (Harding et al., 2002). Retinal involvement in DLB hallucination-related symptoms has been proposed, with claims for a more widespread synucleopathy (Maurage et al., 2003). When the associated clinical features of hallucinations in DLB have been investigated, a lack of correlation with the severity of motor impairment has been reported (Aarsland et al., 2001). These data describe a complex scenario, and no study evaluating the cooccurrence of other behavioral symptoms in DLB with hallucinations is yet available. We aimed to examine whether DLB-associated hallucinations may underscore a distinct clinical entity. To this end, a large representative sample of DLB patients was considered, and the demographic, neuropsychological and behavioral features in DLB with and without hallucinations were analyzed. Eighty-seven DLB patients were recruited from the Center of Movement Disorder and the Center for Aging Brain and Neurodegenerative Disorders, University of Brescia, Italy. Patients fulfilled international consensus criteria for probable DLB (McKeith et al., 2005). Further, DLB patients were grouped according to the presence (n = 47, 54%, H+) or the absence (n = 40, 46%, H−) of hallucinations. Visual hallucinations were required to be present, at least intermittently, for one month or longer, and severe enough to cause some disruption in patients’ and/or others’ functioning. Each patient underwent a neurological and neuropsychological evaluation and routine laboratory examinations as well as a structural neuroimaging study (Brain Computed Tomography or/and Magnetic Resonance Imaging). Caregivers were interviewed and comorbidities were carefully recorded. All patients were followed for at least one year after enrollment, and the diagnosis of probable DLB confirmed. Motor impairment was evaluated by motor subscale of Unified Parkinson Disease Rating Scale (UPDRS III) and Hoehn-Yahr Scale. Global cognitive

A neuro-oncologic challenge: the case of a large, aggressive, malignant meningioma of the skull base with paranasal sinus involvement.

Background Malignant meningiomas, rare tumors that account for approximately 1%-3% of all meningioma, have high recurrence, morbidity, and mortality rate and a particularly poor outcome. Surgical excision followed by adjuvant radiotherapy is the current approach for the treatment of these tumors. Methods In the case reported, the disease, characterized by a high proliferative index (Ki67 60%-70%), was treated with endoscopic surgery limited to the extracranial portion; then the patient underwent radiotherapy, on the residual tumor volume, to a total dose of 66 Gy delivered in 33 fractions (2 Gy/fraction) by helical intensity-modulated radiation therapy with image-guided radiotherapy daily checks (tomotherapy). Results Two and a half years after the treatment, the patient is alive and a partial response is maintained. The patient is healthy overall with grade I fatigue and grade II hearing loss as late toxicity (Common Terminology Criteria for Adverse Events 4.1). Conclusions Within a multidisciplinary approach, new radiotherapy techniques confirm their effectiveness and reliability for the treatment of malignant meningioma.

Headaches in the elderly, in an out-patient population over 60 years of age

Headache in community-living adults age 65 and older is the 10th most common reported symptom in women and the 14th most common in men. Although the prevalence of headache declines with age, approximately 10% of women and 5% of men at age 70 experience severe recurrent or constant headaches. Much less is known about the evolving clinical profile of migraine over the life span. The present study aimed to investigate every type of headaches in elderly people and was carried out on a group of patient over 60 years of age, selected from 771 consecutive patients to the Headache Centre in the period January 2011-December 2011. Methods This study was conducted in a university-based outpatient headache clinic. The study population consisted of 771 consecutive headache patients treated by the authors in one year. Variables studied included gender, headache duration in years, aura, headache characteristics, associated symptoms, presence of allodynia, headache frequency, headache days, and disability. Amedical history of these patients was also recorded. The headache diagnosis were made according to ICHD-2 criteria. Patients were stratified by age into 3 groups: group 1, 16 to 39, group II, 40 to 59, and group III, 60 years and older. Results A total of 605 patients were female and 166 were male, mean age was 36.9 + 13.6 years (range 16 to 84), average headache duration 18.4 years, and headache days/month 7.9. The average age of older headache suffers was 66.5 years. There were 48 female patients (7.9%) and 6 male patients (3.6%) in the older age group. There were no differences between the groups in gender and other variables assessed. The 60+ age group tended to have more chronic migraine and to use more acute medication. Discussion In our population chronic migraine and medication overuse don’t decline over time. We found that, compared with younger patients, older headache patients had not a “lesser migraine” as reported in previous studies. Studies of community-based headache population are warranted to define the influence of age on the full spectrum of migraine.