Outcome After Acute Ischemic Stroke Treatment During Covid-19 Outbreak in South-East Tuscany.

BACKGROUND: During Covid-19 pandemic, the Italian National Healthcare Service has faced increasing pressure, especially in Northern Italy. Even in less-affected regions, such as Tuscany, the changes in the healthcare system to prevent Covid-19 spread resulted in difficulty in treating time-dependent disorders like ischemic stroke rapidly. OBJECTIVE: The aim of our study was to assess the outcome after acute ischemic stroke treatments during the Covid-19 spread in comparison with a similar period of the previous year in Siena-Hospital (Hub center in the South-East Tuscany). METHODS: We enrolled all patients admitted to Siena-Hospital for ischemic stroke and submitted them to acute treatments (intravenous and/or mechanical thrombolysis) between February 21st and May 18th, 2020 (study group, n:38) and compared the results with ischemic strokes acutely treated in a similar period in 2019 (control group, n:39). The modified Rankin scale score was assessed at 90 days to evaluate a 3-month clinical outcome. RESULTS: In the study group, the time from symptoms onset to hospital arrival and the door-to-groin puncture time were significantly more prolonged than in the control group. In moderate-severe strokes, the 3-month mortality was significantly higher in the study group (31% vs. 6%; p=0.01), and the number of patients with poor functional outcomes was significantly higher in the study group (73% vs. 44%; p=0.03). CONCLUSION: During the lockdown period due to Covid-19 pandemic, patients with acute ischemic stroke had a worse prognosis. These findings suggest the need to improve the health system organization to guarantee an appropriate treatment during the pandemic, including the patients that are not affected by Covid-19.

Appropriateness, safety, and effectiveness of "drip and ship" teleconsultation model in Southeastern Tuscany: a feasibility study.

PURPOSE: Teleconsultation is a consultation between two or more physicians about the diagnostic work-up and therapeutic strategy in the treatment of an individual case by means of modern telematics. 'Drip-and-ship' teleconsultation model consists of the transfer of patients, through telematics stroke networks, with large arteries occlusions from primary to comprehensive stroke centers equipped for endovascular therapy. We retrospectively investigated appropriateness, safety, and effectiveness of 'drip-and-ship' teleconsultation model in a rural area of Tuscany. METHODS: Outcome measures were: door-to-ship time (including door-to-needle time), ratio of number treated/total sent patients, adverse events/mortality during transfer, and mortality and modified Rankin scale at 90 days. Analysis of non-treated patients was also done. RESULTS: Seventy-eight patients were included; 16/78 patients were sent for endovascular therapy alone, and 62/78 for "drip-and-ship"; 12 patients were not treated. Door-to-ship, and door-to-needle times (mean ± SD) were 105 ± 29.8 and 62.5 ± 37.5 min, respectively. The ratio number of treated/total sent patients was 0.85. At 90 days, the global mortality rate was 21%, and 40% of patients showed favorable outcome. The main cause of non-treatment was spontaneous recanalization. CONCLUSIONS: The high value for treated/total sent patients' ratio underlines that "drip-and-ship" teleconsultation model is appropriate and effective, with a few untreated patients. The model is safe, without adverse events during transfer. Taken together, our outcomes are in line with the previous reports. "Drip-and-ship" teleconsultation model is safe and effective in rural areas, allowing good selections and rapid treatments for stroke patients, based on the transfer from the primary to the comprehensive stroke center.

Paraneoplastic movement disorders: phenomenology, diagnosis, and treatment.

Paraneoplastic syndromes include, by definition, any symptomatic and non-metastatic condition associated with a neoplasm. Paraneoplastic movement disorders are a heterogeneous group of syndromes encompassing both hyperkinetic and hypokinetic conditions, characterized by acute/sub-acute onset, rapidly progressive evolution, and multifocal localizations with several overlapping features. These movement disorders are immune-mediated, as shown by the rapid onset and by the presence of antineuronal antibodies in biological samples of patients, fundamental for the diagnosis. Antineuronal antibodies could be targeted against intracellular or neuronal surface antigens. Paraneoplastic movement disorders associated with anti-neuronal surface antigens antibodies respond more frequently to immunotherapy. The underlying tumors may be different, according to the clinical presentation, age, and gender of patients. Our search considered articles involving human subjects indexed in PubMed. Abstracts were independently reviewed for eligibility criteria by one author and validated by at least one additional author. In this review, we sought to critically reappraise the clinical features and the pathophysiological mechanisms of paraneoplastic movement disorders, focusing on diagnostic and therapeutic strategies. Our main aim is to make clinicians aware of paraneoplastic movement disorders, and to provide assistance in the early diagnosis and management of these rare but life-threatening conditions.

Headache secondary to cervical artery dissections: practice pointers.

Cervical artery dissections may present with mild and misleading symptoms such as a headache or cervical pain. In the absence of early diagnosis and therapy, such patients may have a high risk of cerebrovascular events. In order to refine evaluation of cervical artery dissections, we report the experience of a single center, focusing on clinical findings (e.g., headache and pain-related features at onset). From 2012 to 2017, 49 patients with cervical arteries dissections were admitted to our institution; 28 out of 49 patients (57%) presented with a headache or cervical pain, which were evaluated according to the International Classification of Headache Disorders (ICHD-III beta). Item C3a of ICHD-III beta ("pain is severe and continuous for days or longer") was present in all patients symptomatic for a headache. Another common characteristic was the recent onset, with an average (± SD) timing from the onset of a headache to the first neurologic evaluation of 3 (± 2) days (range 1-5). A refined clinical evaluation of patients presenting with a headache at the Emergency Department could improve the early detection and management of patients with cervical artery dissections, in particular when presenting without other associated neurological symptoms.

The FRAGAMP study: environmental and genetic factors in Parkinson's disease, methods and clinical features.

The Fattori di Rischio Ambientali e Genetici Associati alla Malattia di Parkinson (FRAGAMP) study is a multicenter case-control study carried out to evaluate the possible role of environmental and genetic factors in Parkinson's disease (PD). Cases and controls were enrolled from five Movement Disorder centers in Central-Southern Italy. PD was diagnosed according to Gelb's criteria while the control groups consisted of the spouses of the enrolled patients or of healthy controls matched by age and area of residence. Cases and controls underwent a standardised questionnaire and a blood sample was taken for molecular analyses. At the end of the study 585 cases and 481 control subjects (287 spouse-controls and 194 generic-controls) were enrolled. Patients had a Hoehn-Yahr score of 2.3 +/- 0.8; 85% of them took levodopa and 47% had motor complications. The FRAGAMP study represents one of the largest case-control studies carried out in Europe to investigate the possible role of environmental and genetic factors in PD.

Stroke and age-brain barrier: how many bricks in the wall?

Although older people contribute more and more to the increasing social burden of stroke, they are often excluded from potentially effective treatments in clinical practice. With the aim to separate myth from reality, we have examined the barriers preventing such therapies (with reference to atrial fibrillation, thrombolysis, carotid stenosis and patent foramen ovale) in the elderly. We conclude that elevated age alone should not be considered an exclusion criterion and both stroke physicians and researchers should make efforts to greatly improve management of these patients.

Multiple cranial nerve palsies in testicular lymphoma: report of a case.

BACKGROUND: Testicular lymphoma is an aggressive, extranodal, non-Hodgkin lymphoma, accounting for less than 10% of all testicular neoplasms and less than 1% of lymphoproliferative malignancies. A paraneoplastic syndrome has been reported and may precede diagnosis of testicular cancer. A delay in diagnosis results in more advanced stage at clinical presentation and resultant poor outcome. CASE SUMMARY: We report here a case of testicular lymphoma associated with multiple cranial nerve palsies contributing to the diagnosis of an occult lymphoproliferative malignancy. CONCLUSIONS: In elderly men, accurate urologic examination is mandatory, particularly when other malignancies have been ruled out, since timely diagnosis of testicular malignancy may allow successful treatment. Paraneoplastic syndromes secondary to extranodal malignancies should be always taken into account in the evaluation of patients with multiple nerve palsies with no apparent primary neurologic disease.

Intracranial hypotension syndrome following chiropractic manipulation of the cervical spine.

Cervical spine manipulation has been associated with several disorders such as cervical arteries dissection, but rarely has a relationship with intracranial hypotension been reported. We describe a patient showing intracranial hypotension syndrome following chiropractic cervical spine treatment. Magnetic resonance showed the presence of dural leakage at cervical level, suggesting the pathogenesis of the syndrome. We state that cervical spine manipulation should be considered a treatment with risk of neurological complications, including the occurrence of intracranial hypotension.

Prevalence of right-to-left shunt in patients with cluster headache.

Recent investigations documented that the prevalence of right-to-left shunt (RLS) in patients with migraine with aura (MA) is significantly higher than in healthy controls and similar to prevalence of RLS in young patients with cryptogenic stroke (CS). Nevertheless, little data are available in the literature about RLS prevalence in the other forms of primary headache. The aim of this study was to investigate the occurrence of RLS in patients with cluster headache (CH). We enrolled 30 consecutive patients with CH diagnosis according to the IHS criteria and 40 controls. RLS was assessed with bilateral transcranial Doppler contrast (TCDc) monitoring of middle cerebral arteries. Eleven patients (37%) resulted positive to TCDc monitoring for evaluation of RLS. These data show that the presence of RLS in this group is more prevalent than in the general population and similar to that found in MA and in CS.