Brain MRI white matter lesions in migraine patients: is there a relationship with antiphospholipid antibodies and coagulation parameters?

Brain magnetic resonance imaging (MRI) studies in migraine patients have demonstrated lesions consisting of focal regions of increased signal intensity within the white matter. Antiphospholipid antibodies are known to have a role in many diseases including migraine. The aim of the present study was to ascertain the relationship between MRI-visualized cerebral focal hyperintense lesions and serum antiphospholipid antibody levels, as well as blood coagulation parameters in migraine patients. One hundred and two (77 females, 25 males, mean age 33.8 +/- 11.1) consecutive migraine patients and a control group of 94 (70 females, 24 males, mean age 33.2 +/- 10.8) healthy subjects were enrolled. All individuals underwent brain MRI. Complete blood examinations, autoantibodies, antiphospholipids antibodies including anticardiolipin and lupus anticoagulant (aCL, LAC), antithrombin III, Protein C and S serum levels were ascertained in the subjects who presented white matter lesions on MRI. Twenty-seven (26.4%) migraine patients and six (6.3%) healthy subjects in the control group showed focal regions of increased intensity signal within cerebral white matter (odds ratio 5.3, 95% CI: 1.98-16.36). In migraine patients with white matter lesions, antiphospholipid antibodies were not detected and serum levels of antithrombin III, and proteins C and S were normal. White matter lesions in migraine patients are fairly common. This finding is not associated with antiphospholipid antibodies or abnormal coagulation parameters. The significance of such lesions at present remains unclear.

Tumor necrosis factor alpha serum levels and inflammatory response in acute ischemic stroke patients.

Experimental evidence indicates that tumor necrosis factor alpha (TNF-alpha) is involved in brain damage following ischemic injury. The present study was designed to monitor serum TNF-alpha levels in acute stroke patients and to correlate TNF-alpha levels with lesion size, neurological impairment and vascular risk factors. In 41 patients with ischemic stroke, serum TNF-alpha levels were serially measured by a solid enzyme amplified sensitivity immunoassay (EASIA) in the first 10 days after stroke onset. Serum fibrinogen and C-reactive protein (CRP), white blood cell (WBC) and neutrophil counts were determined on the same days to monitor acute phase response changes. Lesion size was calculated on computed tomograms by a computer-assisted procedure. Neurological impairment was evaluated on the Canadian Neurological Scale. Forty age-matched subjects were used as controls. Compared to baseline, TNF-alpha levels significantly increased during the study ( p=0.0001), peaking on day 7. Peak TNF-alpha levels did not correlate with neurological impairment or lesion size. Multivariate analysis showed that sex, age, vascular risk factors and infectious complications did not influence TNF-alpha levels. Fibrinogen, CRP, WBC and neutrophil concentrations increased, indicating an acute phase response occurred after stroke. In conclusion, serum TNF-alpha levels showed an early and prolonged increase after stroke onset, unrelated to lesion size, neurological impairment, age, sex, vascular risk factors or infectious complications. Serum increase of TNF-alpha may be explained as part of the acute phase response occurring in stroke patients.

Incidence of first-ever ischemic and hemorrhagic stroke in a well-defined community of southern Italy, 1993-1995.

Most epidemiological surveys in the Italian population, have concentrated on areas of northern and central Italy. The incidence of the first-ever ischemic and hemorrhagic strokes in a well-defined population of the province of Foggia, a rural area of southern Italy, over a 3-year period has been investigated, to compare the occurrence of stroke by type in this and other areas. A retrospective study in a local health district (USL FG3) in the province of Foggia was conducted and all cases of first-ever cerebral infarction (CI) and intracerebral hemorrhage (ICH) in the local population (41 269) from January 1, 1993 to December 31, 1995 have been investigated. Case ascertainment was performed by a chart review in the two local hospitals and examination of death certificates. General practitioners were also asked to report on non-hospitalized cases suffering a stroke during the study period. Patients with recurrent stroke, unclassifiable stroke, transient ischemic attacks and subarachnoid hemorrhage were excluded. Risk factors for stroke and 30-day mortality were investigated. The rates were standardized to the Italian population (57 138 489, 1991 census). During the 3-year study period, 202 patients had a first-ever ischemic or hemorrhagic stroke (66 in 1993, 69 in 1994 and 67 in 1995). Of these, 174 (86.1%) had cerebral ischemia, accounting for 57, 60 and 57 cases in the three index years. The overall crude annual incidence of CI and ICH was 1.60, 1.67 and 1.62 of 1000 for 1993, 1994 and 1995, respectively. The corresponding standardized incidences rates were 2.0, 2.10 and 2.06 of 1000. The rate was 0.11 in patients <55 years of age, and 1.97, 7.01, 13.52, and 25.34 at ages 55-64, 65-74, 75-84, and 85+ years for the entire period; the 30-day mortality was 27.2, 21.7, and 15% for 1993, 1994, and 1995, respectively. Hypertension (45.9%), diabetes (26.4%) and atrial fibrillation (16.6%) were the most common risk factors. The incidence of CI and ICH was similar to that of most other Italian studies. It was constant during the 3-year period, and mostly involved older people.

Prevalence, characteristics, and patterns of health care use for chronic headache in two areas of Italy. Results of a questionnaire interview in general practice.

We set out to define the prevalence, clinical features and severity of chronic headache among the affiliates of two groups of general practitioners (GPs) and to illustrate the diagnostic and therapeutic modalities employed. A semistructured questionnaire was completed for 2291 children and adults, seen at office or home consultations over a 6-month period by 44 GPs in two areas of Northern Italy (Varese and Sondrio) and Southern Italy (San Giovanni Rotondo), to assess the presence and the clinical features of chronic headache, the severity of the disease (i.e. the degree of interference with work and daily living activities), the diagnostic work-up, and the main treatment modalities. GPs attempted the classification of headache according to the International Headache Society (IHS) criteria. The sample comprised 910 men and 1381 women aged 2-92 years; 39% of cases reported chronic headache (Varese/Sondrio 40%; San Giovanni Rotondo 38%; men 28%; women 47%). Headache was mostly present for> 10 years, with one to three attacks/month lasting 4-24 h. Headache was mild in 18% of cases, moderate in 29%, severe in 24%, and very severe in 29%. Diagnostic assessment and treatment varied in the study areas. Diagnostic work-up, hospital admissions, referral to headache centres, and treatment modalities tended to be correlated with headache severity. The GPs could not classify headache using the IHS categories in 27% of cases (Varese/Sondrio 11%; San Giovanni Rotondo 78%). An inverse correlation was found between case classification and use of subsidiary diagnostic and therapeutic aids. Chronic headache is common among individuals seen in general practice. The patterns of health care use tend to be correlated to its severity. A better knowledge of the IHS criteria may be directly related to lower management costs.

Arterial hypertension as a risk factor for chronic symmetric polyneuropathy.

OBJECTIVE: To assess whether arterial hypertension (AH) is an independent risk factor for chronic symmetric polyneuropathy (CSP) in the elderly. BACKGROUND: A strong relationship has been detected between AH and distal symmetric polyneuropathy in insulin-dependent and non-insulin-dependent diabetes. However, the correlation between AH and polyneuropathy caused by other clinical conditions has not yet been studied. METHODS: Four thousand one hundred and ninety-one subjects aged > or = 55 years seen in office consultations by 25 general practitioners (GPs) from two separate areas in Italy were interviewed, using a pretested semistructured questionnaire covering conditions commonly associated with neuropathy and symptoms of peripheral nerve disease. A neurologist later visited individuals with > or = 2 symptoms of polyneuropathy and a diagnosis of CSP was made in the presence of bilateral, fairly symmetric impairment of at least two among strength, sensation and tendon reflexes. AH was ascertained when known to the GP and/or if the patient was being treated with antihypertensive drugs. RESULTS: One hundred and fifty one subjects had CSP (3.6%). Diabetes was the commonest associated condition (18%). AH was present in 47 patients with CSP (31%). The odds ratio (OR) of AH in patients with CSP was 4.5 [95% confidence interval (CI) 3.1-6.6]. The OR of AH was 3.2 (95% CI 1.5-6.9) in patients with diabetes, and 5.7 (95% CI 3.6-9.3) in those without diabetes. The OR of AH was 4.8 (95% CI 4.4-5.2) after adjusting for the commonest risk factors for CSP. CONCLUSION: AH may be an independent risk factor for CSP in the elderly.

The international classification of the epilepsies and epileptic syndromes. An algorithm for its use in clinical practice.

An algorithm has been structured as a guided reading of the international league against epilepsy (ILAE) syndromic classification to be used in clinical practice by less experienced physicians in newly diagnosed patients. The algorithm followed the original structure of the classification, which identifies major syndromic groups, subgroups, and specific syndromes. Validation required two raters, a resident and a board-certified neurologist, to apply the algorithm with different techniques (direct or recorded interview, medical record consultation) to 19 children and 18 adults with epilepsy with information available at the time of diagnosis. The two raters' diagnoses were compared with those of the caring physicians, and cases where disagreement arose were discussed in conference to achieve consensus. The kappa statistic was used as a measure of inter-rater agreement. Caring physicians and both raters agreed in 51% of cases. Substantial agreement (kappa = 0.75) was obtained between the resident and the neurologist on major diagnostic groups and subgroups, mostly in adults. Agreement with the caring physician was slightly more satisfactory for the resident (kappa=0.67) than for the neurologist (kappa = 0.60). Agreement was better with direct or indirect interview than with record consultation, and improved further after discussion. Agreement was obtained after discussion in 32% of cases, in some of which the caring physician agreed on the resident's diagnosis. Agreement was less satisfactory for specific syndromes. On this basis, an algorithm of the ILAE classification is a fairly reliable instrument only for making a broad syndromic classification of epilepsy at the time of diagnosis. The limits of the algorithm tend mostly to reflect the intrinsic limitations of the classification itself.

Incidence of epileptic syndromes in Rochester, Minnesota: 1980-1984.

PURPOSE: To determine the incidence and the distribution of epileptic syndromes in a well-defined population. METHODS: By using the records-linkage system of the Rochester Epidemiology Project, we screened all the residents of Rochester, Minnesota, who received a diagnosis of seizures, convulsions, or epilepsy from 1980 through 1984. One hundred fifty-seven residents with incident epilepsy (recurrent unprovoked seizures) were classified by using the International League Against Epilepsy (ILAE) Classification of the Epilepsies and Epileptic Syndromes. Residents with special syndromes were excluded. With a pretested algorithm, patients were classified at three levels of specification: major syndromic groups (e.g., localization-related syndromes), syndromic subgroups (e.g., idiopathic epilepsy with age-related onset), and whenever possible, individual syndromes. RESULTS: All but one patient were classified into major syndromic groups and subgroups. The annual age-adjusted incidence per 100,000 population was 52.3 cases (34.9 for localization-related epilepsies; 7.7 for generalized epilepsies; 9.7 for undetermined epilepsies). Incidence was 0.2 for idiopathic, 17.2 for cryptogenic, 17.5 for symptomatic localization-related epilepsies, 3.7 for idiopathic, 1.7 for symptomatic or cryptogenic (age-related), and 2.3 for symptomatic (non age-related) generalized epilepsies. CONCLUSIONS: With the exception of idiopathic epilepsies, the incidence of the major syndromic categories in our study was higher than that provided by previous population-based studies.