The role of the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke (GLOBE-3S) in the prevention of stroke-associated pneumonia (SAP).

BACKGROUND AND PURPOSE: Stroke-associated pneumonia (SAP) affects 10 to 38% of patients in the acute phase of stroke. Stroke patients diagnosed with dysphagia have an 11-fold higher risk of developing SAP. Thus, identifying dysphagic patients through a highly accurate screening tool might be crucial in reducing the incidence of SAP. We present a case-control study designed to evaluate efficacy in reducing the risk of SAP between two swallowing screening tools, the classic water swallow test (WST) and a recently validated tool such as the GLOBE-3S (the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke), which is a highly sensitive swallowing screening tool particularly accurate in detecting silent aspiration as well. METHODS: We analyzed the occurrence of dysphagia in 100 acute stroke patients distributed in two groups: half were screened with WST and the other half with GLOBE-3S. RESULTS: Dysphagia was diagnosed in 28 patients. The main result is that, among patients who passed the dysphagia screenings, none of those screened with the GLOBE-3S method developed pneumonia compared to 31.82% in the WST group. Discriminant function analysis (DFA) showed that NIH Stroke Scale (NIHSS) score and the dysphagia screening method (i.e., GLOBE-3S vs. WST) were the two main factors in the SAP's predicting model and the only significant ones per se. CONCLUSIONS: The new GLOBE-3S screening test can reduce the risk of SAP compared to WST.

Sapienza Global Bedside Evaluation of Swallowing after Stroke: the GLOBE-3S study.

BACKGROUND AND PURPOSE: Dysphagia occurs in up to 50% of all patients with acute stroke. There is debate regarding which is the most effective screening tool in identifying aspiration in patients with acute stroke. We assessed the accuracy of the Sapienza Global Bedside Evaluation of Swallowing after Stroke (GLOBE-3S), which combines the Toronto Bedside Swallowing Screening Test (TOR-BSST©) with oxygen desaturation and laryngeal elevation measurement during swallowing. METHODS: We prospectively enrolled consecutive patients with stroke within 72 h of symptom onset. All patients with stroke firstly underwent a standard neurological examination, then the GLOBE-3S evaluation and finally the fiberoptic endoscopic evaluation of swallowing (FEES). Two different assessors, a neurologist and a speech pathologist, blind to both the clinical data and each other's evaluation, administered the GLOBE-3S and FEES examination. We assessed the accuracy of the GLOBE-3S in detecting post-stroke swallow impairment with aspiration using the FEES as the standard. RESULTS: We enrolled 50 patients with acute stroke, 28 of whom (56%) had swallowing impairment with aspiration at FEES evaluation. A total of 33 patients (66%) failed the GLOBE-3S evaluation. The GLOBE-3S reached a sensitivity of 100% and a specificity of 77.3% (negative predictive value, 100%; positive likelihood ratio, 4.34). The median time required for the GLOBE-3S to be performed was 297 s. CONCLUSIONS: GLOBE-3S is quick to perform at the bedside and can accurately identify aspiration in patients with acute stroke. By including the measurement of laryngeal elevation and monitoring of oxygen desaturation, it could represent a highly sensitive instrument to avoid the misdiagnosis of silent aspirators.

A novel ATP1A2 mutation in a family with FHM type II.

Familial hemiplegic migraine (FHM) is a rare subtype of migraine with aura with an autosomal dominant pattern of inheritance. Six FHM families underwent extensive clinical and genetic investigation. The authors identified a novel ATP1A2 mutation (E700K) in three patients from one family. In the patients, attacks were triggered by several factors including minor head trauma. In one subject a 3-day coma developed after a cerebral angiography. Overall, the phenotype of the patients closely resembles that of previously reported cases of FHM type II. The E700K variant might be regarded as the cause of the disease in this family, but this was not tested functionally.

Acute posttraumatic paraplegia caused by epidural hematoma at the vertex.

Vertex epidural hematomas (VEDHs) are well known but uncommon. Their clinical presentation may be misleading and missed by routine CT axial scanning; thus, diagnosis may be delayed, with possibly fatal consequences. We report a case of acute posttraumatic paraplegia caused by a VEDH, which was evident at CT and for which the patient underwent successful surgery.

Neuromagnetic integrated methods tracking human brain mechanisms of sensorimotor areas 'plastic' reorganisation.

The potential for reorganization in the adult brain has been largely underestimated in the past and we are just beginning to understand the organisational principles involved in functional recovery. A bulk of experimental evidences have been accumulated in support of the hypothesis that neuronal aggregates adjacent to a lesion in the cortical brain areas can be progressively vicarious to the function of the damaged neurones. Such a reorganisation, if occurring in the affected hemisphere of a patient with a monohemispheric lesion, should significantly modify the interhemispheric symmetry of somatotopic organisation of the sensorimotor cortices, both in terms of absolute surfaces and number of "recruited" neurons, as well as of spatial coordinates. In fact, a roughly symmetrical organisation of sensorimotor - particularly for the hand contorl - in the right and left hemisphere has been observed in healthy humans by different methods of functional brain imaging, including fMRI, TMS, MEG, HD-EEG. Not uniform results about the functional brain activity related to sensory, motor and cognitive functions in normal and diseased subjects are often due to differences in the experimental paradigm designed as well as in the spatial and temporal resolution of the neuroimaging techniques used. The multi-modal integration of data obtained with several neuroimaging techniques allowed a coherent modelling of human brain higher functions. Functional magnetic resonance imaging (fMRI) provided fine spatial details (millimetres) of the brain responses, which were compared with the cortical maps of the motor output to different body districts obtained with transcranial magnetic stimulation (TMS). Magnetoencephalography (MEG) ability to study sensorimotor areas by analysing cortical magnetic fields, is also complementary to the motor cortex topographical mapping provided by TMS. MEG high temporal resolution allows to detect relatively restricted functional neuronal pools activated during cerebral processing of external stimuli. Moreover, these brain responses can be investigated with magnetoencephalography (MEG) and high density electroencephalography (EEG) techniques, with elevated time resolution (ms). With respect to the high resolution EEG technique, the MEG technique allowed a more precise localisation of the sites of neural activity buried into the cortical sulci, but was unable to detect the response of the crown of the cortical giri and of the frontal-mesial cortex (including the supplementary motor area), because of its poor sensitivity to radially oriented dipoles. The integration of functional and anatomical information provide cues on the relationship between brain activity and anatomic sites where this takes place, allowing the characterisation of the physiological activity of the cortical brain layers as well as to study the plastic reorganisation of the brain in different pathological conditions following stroke, limb amputation, spinal cord injury, hemisperectomy.

Peroneal mononeuropathy: predisposing factors, and clinical and neurophysiological relationships.

The most common mononeuropathy in the lower extremity involves the nerve. We retrospectively evaluated the etiological predisposing factors and clinical-neurophysiological features of 36 patients affected by peroneal mononeuropathy (PM). In 30 patients, a clear predisposing factor was identified. PM was more frequently perioperative (11 cases), associated with axonal involvement. Unexpectedly, PM was not only due to surgery close to the peroneal region, but was mostly associated with hip surgery and, rarely, with thoracic-abdominal surgery. A postural predisposing factor of PM was also frequently observed, usually associated with a pure conduction block. Conversely, most patients with bedridden predisposing factor presented axonal involvement, which was rarely associated with conduction block. In 25 of 36 PM cases, a long-term follow-up lead to an improvement (12 cases) or to good recovery (13 cases) of PM. In conclusion, our study shows that: (1) in most PM cases it is possible to identify a predisposing factor; (2) there is a good correlation between predisposing factor and neurophysiological involvement, and (3) PM usually has usually a good prognosis.

Cardiac myxoma with glandular elements metastatic to the brain 12 years after the removal of the original tumor.

This report describes a case of cardiac myxoma with glandular elements metastatic to the brain. The histological appearance of the brain tumor was characterized by irregularly shaped glands lined by a single layer of mucous-secreting cells. The glands rested on a stroma made of connective tissue with myxoid changes in which short cords of cells with eosinophilic cytoplasm were occasionally detected. The cardiac tumor was a myxoma in which only 2 small glandular structures were identified. Immunohistochemically, the gland-lining cells were positively stained by cytokeratin AE1-AE3, CAM 5.2, and B 72.3. CEA was detected as a thin layer on the luminal surface of the cells and in the cytoplasm of goblet cells. The myxoma cells in the stroma were not stained by cytokeratins. This is the first report of brain metastases from a cardiac myxoma made of glandular elements.

Gigantic epidermoid cyst of the skull.

One case of an unusually giant epidermoid cyst of the skull is described. The neoformation had been present for 40 years, becoming extremely large in the last 20 years, in a 65-year-old woman. Difficulty in wearing glasses was the sole complaint of the patient, who otherwise concealed the mass by wearing a wig. Preoperative examinations (x-rays, CT scan, MRI) were important to better evaluate the nature of the cyst and to make a differential diagnosis. Dissection of the mass from the surrounding tissues was extremely easy because of its capsule. Sixteen months of follow-up have been pleasant, with no evidence of recurrence.

Electrocorticography in patients with medically intractable temporal lobe seizures. I. Quantification of epileptiform discharges prior to resective surgery.

We studied retrospectively the intraoperative preresection electrocorticograms (ECoGs) of 72 patients undergoing surgery for medically intractable, mostly complex partial, temporal lobe seizures (TLS). Quantification of interictal epileptiform discharges (EDs) detected visually at each electrode location in 2 min recording epochs included computations of ED rates (EDs/min) and cumulative voltages (CuVs) (microV/min). Of 6388 EDs, 81% involved the infratemporal surface, 18% the lateral temporal surface and 1% the orbital frontal area. Forty-eight patients (67%) demonstrated multiple (up to 5 or more), temporally independent foci. Dominant foci in medial and lateral infratemporal locations were about equally common and were significantly more frequent than in lateral temporal locations. Rankings of ED CuVs and rates at individual cortical locations defined 4 areas of "relative interictal cortical epileptogenicity." These were arranged in an orderly pattern with the anterior parahippocampal gyrus and the inferomedial surface of the temporal tip displaying the highest and the lateral temporal and posterior infratemporal cortices showing the lowest propensity to the interictal epileptiform discharge. Individual areas were not characterized by distinct clinical seizure manifestations. Preresection ECoGs provide information on the epileptogenic dysfunction that involves most of the temporal lobe of patients with medically intractable TLS.