Serotonergic correlation with anger and aggressive behavior in acute stroke patients: an intensity dependence of auditory evoked potentials (IDAP) study.

Anger and aggressive behavior (AB) are two of the main post-stroke behavioral manifestations, which could imply both an anger trait (TA) or a state condition of anger (SA). Serotonergic system is thought to play an inhibitory control on aggressive impulse. Nevertheless, whether 5HT has the same role in TA and in SA, is still debated. Intensity dependence of auditory evoked potentials (IDAP) is thought to be inversely related to the central 5HT tone. The aim of this study was to evaluate, in acute stroke patients, the 5HT system involvement in AB by IDAP. Consecutive stroke patients were evaluated and compared with healthy controls. The Spielberger Trait Anger Scale (STAS) was used to assess AB, SA and TA. Patients with AB and TA showed a significantly increased IDAP value, whereas patients with SA had a significantly lower IDAP; this indicates an increased 5HT tone. In acute stroke patients with AB, there is a decreased central 5HT tone. Surprisingly, we found an opposite 5HT feature between patients with TA and those showing SA, suggesting that the hypothesis of aggression based on 5HT deficiency requires further investigations. This might open new strategies in the treatment of post-stroke AB.

Attachment models affect brain responses in areas related to emotions and empathy in nulliparous women.

BACKGROUND: The attachment model, as assessed by means of the Adult Attachment Interview (AAI), is crucial for understanding emotion regulation and feelings of security in human interactions as well as for the construction of the caregiving system. The caregiving system is a set of representations about affiliative behaviors, guided by sensitivity and empathy, and is fully mature in young-adulthood. Here, we examine how different attachment models influence brain responses in areas related to empathy and emotions in young-adult subjects with secure and dismissing attachment models. METHODS: By means of AAI, we selected 11 nulliparous young-adult females with a secure model and 12 with a dismissing model. Subjects underwent functional magnetic resonance, whereas imitating or observing and empathizing with infant facial expressions. Subjects were tested for alexithymia and reflective functioning. RESULTS: Dismissing subjects activated motor, mirror, and limbic brain areas to a significantly greater extent, but deactivated the medial orbitofrontal cortex (mOFC) and the perigenual anterior cingulated cortex (pACC). During emotional faces, increased activity in dismissing women was seen in the right temporal pole. Furthermore, greater alexithymia was correlated with greater activity in the entorhinal cortex and greater deactivation in the pACC/mOFC. CONCLUSIONS: These findings provide evidence of how the attachment model influences brain responses during a task eliciting attachment. In particular, hyperactivation of limbic and mirror areas may reflect emotional dysregulation of infantile experiences of rejection and lack of protection, whereas increased deactivation of fronto-medial areas may be the expression of the inhibition of attachment behaviors, which is a typical aspect of dismissing attachment.

Rivastigmine in the treatment of hypersexuality in Alzheimer disease.

Inappropriate sexual behaviors (ISB) represent uncommon and often misdiagnosed clinical disorders among patients with Alzheimer disease. So far, no randomized clinical trials regarding the treatment of ISB in demented people have been conducted, but available data from case series and isolated case reports suggest the efficacy of selective serotonin reuptake inhibitors (SSRIs), antipsychotics, antiandrogens, and H2-receptor antagonists. Controversial data exist on the therapeutic influence of cholinesterase inhibitors on sexual disorders. In the present article, we describe the case of an Alzheimer disease patient presenting hypersexuality, successfully treated with rivastigmine. Thus, we perform a revision of the existing literature regarding the therapeutical effect of cholinesterase inhibitors in the treatment of ISB.

Bilateral spontaneous internal carotid artery dissection with both early and very late recanalization: A case report.

Spontaneous bilateral internal carotid artery dissection has frequently been described in the literature as a cause of stroke. In more than half of the patients with internal carotid artery dissection, recanalization occurs early after the event and is unusual later than 6 months after onset of the dissection. We describe a patient with ischemic stroke due to left internal carotid artery occlusion in the extracranial segment. The patient was treated with anticoagulants and early vessel recanalization did not occur. Ten months later, he developed contralateral internal carotid occlusion in the intracranial tract, which was followed by early complete recanalization. Anticoagulation therapy was continued and, 16 months after the initial event, the left internal carotid artery unexpectedly also reopened.

Extracranial and intracranial sonographic findings in vertebral artery diseases.

OBJECTIVE: The aim of this review is to illustrate the sonographic features that can be detected in vertebral artery (VA) diseases. METHODS: We conducted a review of sonographic findings in VA diseases. RESULTS: Various VA diseases are described, and sonographic techniques and features are discussed. CONCLUSIONS: Posterior circulation vascular imaging can be performed by means of various neuroimaging techniques. Intra-arterial angiography remains the reference standard. The use of this technique has become even more widespread since it has become possible to perform endovascular procedures; it is, however, an invasive procedure that is associated with a not irrelevant level of risk. Computed tomographic angiography and magnetic resonance angiography with and without contrast agents have been proposed as less invasive alternatives, although these techniques can only be performed in the radiology unit and may not be readily available in daily clinical management. Sonography, which combines an extracranial and intracranial evaluation, is highly suited to the assessment of the vertebrobasilar system on account of its widespread availability and its unique capacity to study real-time hemodynamics. Furthermore, new sonographic applications and sonographic contrast agents have improved the sensitivity and specificity of this technique with regard to diagnostic accuracy for the posterior circulation.

Noninvasive imaging of carotid arteries in stroke: emerging value of real-time high-resolution sonography in carotid occlusion due to cardiac embolism.

OBJECTIVE: Comprehension of the pathophysiologic characteristics of atherosclerosis has focused its attention on the study of dynamic and metabolic processes involving the vessel wall as possible causes of stroke. When compared with conventional radiologic techniques, sonography has the main advantage of being a real-time imaging modality. We report 2 acute stroke cases in which carotid sonography showed some dynamic features that could not be identified with computed tomography (CT) and magnetic resonance angiography (MRA). METHODS: Carotid sonography with high-resolution probes (9-14 MHz) was compared with CT and MRA findings showing carotid axis occlusion in 2 patients with acute stroke. RESULTS: In case 1, the internal carotid artery occlusion observed on CT and MRA was interpreted as a dissection on a clinical basis, but sonography showed a mobile embolus originating from the heart in the internal carotid artery. In case 2, the occlusion of the whole carotid axis observed on CT and MRA was instead related to a heart-originating embolus floating in the common carotid artery. CONCLUSIONS: The evaluation of dynamic aspects of atherosclerosis is fundamental to understanding the pathophysiologic characteristics of stroke. Sonography is fundamental in carotid artery imaging for its possibility of showing dynamic processes that could be misdiagnosed with "static" imaging. The correct identification of the pathophysiologic characteristics of stroke in these cases could have led to different diagnostic and therapeutic algorithms.

Imaging of carotid plaque angiogenesis.

Currently, characterization of the vulnerable plaque is a hot research topic as a more adequate strategy for preventing cerebrovascular events is being sought. Histological studies have recognized that plaque inflammation and the presence of adventitial vasa vasorum, intimal angiogenesis and plaque neovascularization are strong predictors of instability in atheromatous lesions of cerebrovascular and cardiovascular patients. The in vivo study of these features has been the focus of development of several new radiological imaging methods. Carotid ultrasound, with ultrasound contrast agents, is not only able to provide an enhanced assessment of the arterial lumen and plaque morphology with an improved resolution of the carotid intima-media thickness, but also to directly visualize adventitial vasa vasorum and plaque neovascularization. This technique and its future clinical implications are discussed in the present review.

Contribution of right hemisphere to visual imagery: a visual working memory impairment?

Visual Imagery is the ability to generate mental images in the absence of perception, that is, We describe a patient, IM, who suffered from an acute ischemic stroke in the right anterior choroidal artery who appeared to demonstrate relatively isolated impairment in visual imagery. Her cognitive function, including her performance on tests of semantic function, was at ceiling, apart from a deficit in visual memory. IM failed in tasks involving degraded stimuli, object decision involving reality judgments on normal animals, and drawings from memory. By contrast, she was able to match objects seen from an unfamiliar viewpoint and to perform tasks of semantic and visual association. We hypothesize that IM has a visual working memory deficit that impairs her ability to generate full visual representations of objects given their names, individual feature, or partial representations. The deficit appears to be the result of damage to connections between the right thalamus and the right temporal lobe. Our findings may help to clarify the role of the thalamus in the cortical selective engagement processes that underlie working memory.

Complete versus partial lateral sinus thrombosis: a pathophysiological hypothesis.

BACKGROUND/AIM: The lateral sinus (LS) is composed of the transverse sinus (TS) and sigmoid sinus (SiS). METHODS: We studied the clinical pattern of complete or isolated LS thrombosis in 22 consecutive patients. RESULTS: Isolated LS thrombosis patients had a more severe clinical presentation, and more frequent intracranial hemorrhages and seizures. CONCLUSION: These data suggest that partial involvement of the LS in the thrombotic process may cause more severe clinical symptoms.

Cerebral vasomotor reactivity is reduced in patients with erectile dysfunction.

BACKGROUND: Erectile dysfunction (ED) is not only evidence of diffuse atherosclerosis but also an index of early endothelial damage. We investigated cerebrovascular reactivity, expression of early arterial damage, in patients with isolated ED (ED+) and controls (ED-). MATERIALS AND METHODS: Fifteen ED+ and 15 ED- subjects, matched for age (ED+: 58+/-6, ED-: 59 +/- 4 years) and vascular risk factors, were submitted to carotid duplex ultrasound and transcranial Doppler. Cerebrovascular reactivity was assessed on both middle cerebral arteries simultaneously calculating (a) the total vasomotor range (VMR) measured after breath holding and hyperventilation and (b) the rate of change (VMR/CO(2)) after breath holding. RESULTS: Carotid Duplex scanning showed a light carotid stenosis only in 3 (2 in the ED+ and 1 in the ED- group). No differences were observed in intima-media thickness between ED+ and ED-. Slightly slower mean middle cerebral artery flow velocities were observed in ED+ with respect to ED-. ED+ patients showed a reduced VMR (p < 0.001) and a slower VMR/CO(2) rate of change (p < 0.001) compared to ED-. CONCLUSIONS: The reduced reactivity in patients with isolated ED may represent a marker of early cerebral vasomotor dysfunction due to subclinical endothelial damage.

Sonographic carotid plaque morphologic characteristics and vascular risk factors: results from a population study.

OBJECTIVE: The role of vascular risk factors in atherosclerosis development is well established, whereas risk factors involved in determining plaque vulnerability are still a matter of debate. We investigated the vascular risk factor distribution in patients with carotid plaques. METHODS: We consecutively assessed sonographic plaque morphologic characteristics, the degree of stenosis, and the common carotid artery intima-media thickness (IMT) in 1655 patients. Demographic data, a documented history of symptomatic cerebrovascular disease (CVD), and the presence of vascular risk factors were collected. According to literature, heterogeneous hypoechoic plaques with an irregular surface or ulcerations and those with a severe degree of stenosis (>or=70%) have been considered "complex" plaques at "major" risk of stroke; homogeneous hyperechoic plaques with smooth surface lesions have been considered "simple" plaques at minor risk. RESULTS: Univariate analysis showed that all vascular risk factors were associated with the presence of carotid atherosclerotic lesions. Multiple logistic regression showed an independent association of hypertension and diabetes with complex plaques, which also had a thicker IMT. A history of CVD was observed more frequently in complex plaques, which had a higher stenosis percentage even after patients with a severe degree of stenosis (>or=70%) and indications for carotid surgery were excluded. CONCLUSIONS: Hypertension and diabetes are related to a thicker IMT and more severe complex plaques, which may reflect the instability of atherosclerotic process. Because two-thirds of the patients with complex plaques were asymptomatic for CVD, this raises the importance of surveillance sonography to monitor plaque evolution for prevention of symptomatic CVD.

Detection of carotid adventitial vasa vasorum and plaque vascularization with ultrasound cadence contrast pulse sequencing technique and echo-contrast agent.

BACKGROUND AND PURPOSE: Adventitial vasa vasorum and plaque vascularization have been established as predictors of unstable atheromasic lesions in cerebro- and cardiovascular patients. Ultrasound contrast agents provide reliable information on tissue perfusion and microcirculation. We used contrast ultrasound duplex scanning to identify carotid plaque vascularization. METHODS: Contrast carotid duplex scanning was performed in 23 patients with plaques of different degree of stenosis and echogenicity. RESULTS: Plaque vascularization was detected in the fibrous and fibro-fatty tissue and not observed in the calcific nor in the necrotic and hemorrhagic tissue. Constantly, a small vessel was observed under ulcerations. CONCLUSIONS: Carotid contrast ultrasound imaging appears to be an emerging technique for identifying plaque angiogenesis. Further studies are needed to clarify the role of plaque angiogenesis for assessing cerebrovascular risk and to monitor effects of therapies aimed to plaque remodelling.

Intravenous ancrod for acute ischaemic stroke in the European Stroke Treatment with Ancrod Trial: a randomised controlled trial.

BACKGROUND: Intravenous tissue plasminogen activator is the only approved specific treatment for acute ischaemic stroke. Ancrod, a natural defibrinogenating agent from snake venom, has proved to have a favourable effect when given within 3 h after an acute ischaemic stroke. The European Stroke Treatment with Ancrod Trial was undertaken to assess the effects of ancrod when given within 6 h. METHODS: 1222 patients with an acute ischaemic stroke were included in this randomised double-blind placebo-controlled trial. Brain CT scans were done to exclude intracranial haemorrhages and large evolving ischaemic infarctions. Patients were randomly assigned ancrod (n=604) or placebo (n=618). The primary outcome was functional success at 3 months (survival, Barthel Index of 95 or 100, or return to prestroke level). The analysis was by intention-to-treat. This trial is registered with ClinicalTrials.gov, trial number NCT00343174. FINDINGS: Functional success at 3 months did not differ between patients given ancrod (42%) and those given placebo (42%) (p=0.94, OR=0.99, 95% CI, 0.76-1.29). INTERPRETATION: On the basis of our findings, ancrod should not be recommended for use in acute ischaemic stroke beyond 3 h.

Cerebrovascular reactivity in degenerative and vascular dementia: a transcranial Doppler study.

BACKGROUND: An impairment of cerebral microvessels is reported both in normal ageing and in senescence-associated processes, as well as in Alzheimer's disease (AD) and vascular dementia (VaD). The aim of this study was to explore cerebral hemodynamics by transcranial Doppler in VaD and AD, compared with age-matched control subjects. METHODS: Transcranial Doppler was investigated in all patients in the basal condition. Cerebral vasoreactivity to hyper- and hypocapnia was evaluated with CO2 mixture inhalation followed by hyperventilation. RESULTS: We studied 60 AD and 58 VaD patients and 62 nondemented controls. Both AD and VaD subjects showed lower flow velocities (FV) and higher pulsatility indices (PI) as compared with controls. Lower total vasomotor reactivity and lower response to hypercapnia were observed in the AD and VaD groups as compared with controls. AD and VaD patients did not show significant differences in FV, PI values or cerebral vasoreactivity. CONCLUSIONS: Reduced FV and increased PI with a significant vasoreactivity reduction in VaD and AD patients are indicators of impairment of cerebral microvasculature circulation in both diseases. The identification of vascular function impairment in all kinds of dementia could be of help in identifying patients who would thus benefit more from specific therapeutic approaches.

Update on stroke.

PURPOSE OF REVIEW: This review highlights the progress achieved in stroke during the last year, and emphasizes recent controversies concerning its pathophysiology, therapy and secondary complications. RECENT FINDINGS: Studies published in 2004 provided new insights into the therapeutic window and ischemic penumbra, thrombolysis therapy, uncommon risk factors for stroke, and neuropsychological post-stroke complications. Despite the diffusion-perfusion mismatch remaining the most widely used technique to identify thresholds for ischemic penumbra and irreversible brain tissue damage, new imaging such as arterial spin-labeling perfusion and computed tomographic perfusion may define this impaired tissue more accurately. New studies assessed the relation of the interval from stroke onset to start intravenous thrombolysis treatment (tissue plasminogen activator) on favorable 3-month outcome, and on the occurrence of clinically relevant parenchymal hemorrhage: the benefit of tissue plasminogen activator could extend beyond 3 h, but with a few risks. Systemic inflammations and infections have been found to be associated with a substantial increase in the risk of developing vascular events, supporting the concept that systemic inflammation itself alters the probability of stroke occurrence. Recent literature concerning neuropsychological post-stroke complications focused mainly on the concept of mixed dementia and confirmed that mood disorders are common after stroke, and interfere with its long-term outcome. SUMMARY: Significant advances have been made during the last year in determining more accurately the therapeutic window, using new strategies and clinical markers. Moreover, new light has been thrown on less common stroke risk factors, and neuropsychological post-stroke complications.

High cholesterol affects platelet APP processing in controls and in AD patients.

Alzheimer disease (AD) is characterised by a decrease of platelet Amyloid Precursor Protein forms ratio (APPr), which parallels symptoms' severity. Recent studies have suggested that cholesterol might play a role in the pathophysiology of AD by modulating Abeta production. Aim of this study was to evaluate the relationship between serum cholesterol levels and platelet APP processing in controls and AD. Sixty AD patients and 45 age-matched controls (CTRL) were investigated. Neuropsychological assessment, cholesterol dosage and APP forms' evaluation were performed on each subject. CTRL showed lower serum cholesterol levels compared to AD (P<0.01) and higher mean APPr scores (P<0.0001). Hypercholesterolaemic AD patients showed lower APPr scores compared to normocholesterolaemic AD patients matched for disease severity (0.31+/-0.16 versus 0.45+/-0.28; P<0.05), since the early stage of the disease. In AD, cholesterol levels influence APPr independently of disease severity. These findings confirm the association between cholesterol and AD, and suggest that in vivo cholesterol affects APP processing by interfering with its maturation.