Comparative Study of the Efficacy of Anti-CGRP mAbs on Migraineurs: Analysis of the First Year of Therapy, 1-Month Suspension Period, and Reprisal.

Background: Few studies compare the clinical effectiveness of the three anti-CGRP mAbs. Moreover, no studies compare their efficacy during suspension and reprisal. Our study aimed to compare the efficacy of migraine frequency, intensity, and symptomatic medication intake during the first year of therapy, a 1-month suspension period, and a 3-month drug reprisal. Methods: A total of 160 migraineurs (chronic and high-frequency episodic) were treated with anti-CGRP mAbs (49 with fremanezumab, 55 with erenumab, and 55 with galcanezumab) for 12 months. They discontinued the therapy for 1 month and then reprised the therapy. In the three groups, we analyzed and compared the migraine days per month, migraine intensity, and symptomatic medication intake per month at baseline, 3-month, 6-month, and 12-month follow-up. We also compared these variables during the 1-month suspension and 3 months after the reprisal of the therapy. We compared the data and evaluated the response rate (>50% reduction in migraine days per month) at different follow-ups. This comparison was also performed separately for chronic and high-frequency episodic migraineurs. Results: There was no statistical difference in monthly migraine days, intensity, or symptomatic medication intake per month at the different follow-ups. Moreover, there was no difference in the response rate overall. However, in chronic migraineurs treated with galcanezumab, the response rate was higher during the 1-month suspension when compared to fremanezumab and erenumab. In high-frequency episodic migraineurs, fremanezumab had a higher response rate at 12-month follow-up when compared to galcanezumab and erenumab. Conclusions: In our study, the three anti-CGRP mAbs presented a similar response, with no significant differences, during the first year of therapy, the suspension period, and 3 months after the drug reprisal. The response rate during the 1-month suspension period in chronic migraineurs may be higher with galcanezumab.

Ischemic strokes in COVID-19: risk factors, obesity paradox, and distinction between trigger and causal association.

Background and purpose: Stroke has been described as a COVID-19 complication. However, its occurrence rate, risk factors, and causal relationships are still not well established. Methods: We describe the characteristics of confirmed COVID-19-related strokes among all cases of COVID-19 hospitalized in our health network, from November 1, 2020 to April 30, 2021. Risk factor analysis has been conducted for ischemic stroke (IS), which represents 92% of all confirmed cases of Covid-19-related strokes, and a "causal attribution to infection" classification is provided. Results: In all, 62/4105 hospitalized COVID-19 patients had an acute stroke (1.51%). Severe COVID-19 (OR 2.27-CI 1.06-4.77; p = 0.032), atrial fibrillation (OR 3.65-CI 1.63-7.98; p = 0.001), and ischemic heart disease (OR 4.590-CI 1.714-12.137; p = 0.002) proved to be independent risk factors for IS, while obesity was a protective factor (OR 0.90-CI 0.82-0.97; p = 0.012). COVID-19 had a causal role in 32.1% of IS cases, was a relevant cofactor in 28.6% of cases of IS, and was a possible trigger in 39.3% of events. Conclusion: Our stroke occurrence rate is consistent with other population-based reports (range 0.34-2.7%). Prespecified peculiar clinical and radiological features allow the distinction between "IS caused by COVID-19" and "IS triggered by COVID-19." Clinical history of vascular diseases and risk factors is crucial in determining the risk of IS in patients with COVID-19. However, the protective effect of a BMI > 30 kg/m2 seems to suggest an obesity paradox.

The use of alteplase, although safe, does not offer clear clinical advantages when mild stroke is non-disabling.

Introduction: It is unknown whether alteplase is effective and safe in patients with mild acute ischemic stroke (AIS). Determining whether symptoms are "disabling" or not is a crucial factor in the management of these patients. This study aimed to investigate the efficacy and safety of alteplase in patients with mild, non-disabling AIS. Methods: We included all consecutive patients admitted for AIS at our institution from January 2015 to May 2022 who presented a baseline NIHSS score of 0-5 and fit the criteria to receive intravenous thrombolysis. In order to select only subjects with non-disabling AIS, we excluded patients who scored more than 1 point in the following NIHSS single items: vision, language, neglect, and single limb. Patients who scored at least 1 point in the NIHSS consciousness item were excluded as well. This study is a retrospective analysis of a prospectively collected database. Results: After the application of the exclusion criteria, we included 319 patients, stratified into patients receiving and not receiving alteplase based on non-disabling symptoms. The two groups were comparable regarding demographic and clinical data. Rates of a 3-month favorable outcome, defined as a 3-month mRS score of 0-1, were similar, being 82.3% and 86.1% in the treated and untreated patients, respectively. Hemorrhagic complications and mortality occurred infrequently and were not affected by alteplase treatment. Discussion: This observational study suggests that the use of alteplase, although safe, is not associated with a better outcome in highly selected patients with non-disabling AIS.

Meningioma-Related Epilepsy: A Happy Ending?

(1) Background: More than one-third of patients with meningiomas experience at least one seizure during the course of their disease, and in the 20-50% of cases, seizure represents the onset symptom. After surgery, up to 30% of patients continue to have seizures, while others may experience them later; (2) Methods: The study analyzed retrospectively the risk factors for pre-operative seizures in a large cohort of 358 patients who underwent surgery for newly diagnosed brain meningioma; (3) Results: We identified age, peritumor edema, and location as risk factors for seizure at the onset. Patients with seizures differed from patients without seizures for the following characteristics: younger average age, lower pre-operative Karnofsky Performance Status (KPS), location on the convexity, lower Simpson Grade, lower incidence of pre-operative neurological deficits, and higher incidence of pre-operative peritumor edema. After 24 months, 88.2% of patients were classified as Engel class Ia, and no correlation with disease progression was observed; (4) Conclusions: Meningioma-related epilepsy has generally a positive outcome following surgery and it seems not to be linked to disease progression, even if further studies are needed.

2:1 ketogenic diet and low-glycemic-index diet for the treatment of chronic and episodic migraine: a single-center real-life retrospective study.

AIMS: The evidence supporting the efficacy of dietary preventive therapy in migraine is rising, particularly regarding the ketogenic diet. However, less evidence exists for the Low-Glycemic Index Diet and the 2:1 KD. This retrospective single-center real-life study aims to evaluate the efficacy of a 2:1 ketogenic diet and a Low-Glycemic-index Diet in chronic and high-frequency episodic migraine. METHODS: Sixty patients with high-frequency episodic and chronic migraine were treated with either a Low-Glycemic-index diet (39 patients) or a 2:1 (21 patients) ketogenic diet for three months. We collected data on the migraine frequency and intensity and the MIDAS and HIT-6 scores through the headache diary. Anthropometric measurements (BMI, fat mass, free fat mass, and weight) were also collected and analyzed similarly. Data obtained at the baseline and after three months of each diet were compared. RESULTS: Migraine intensity, frequency, MIDAS and HIT-6 scores, fat mass, weight, and BMI improved in both diet groups. CONCLUSIONS: Both diets are effective in reducing migraine symptoms and migraine-related disability.

Stress hyperglycemia as a modifiable predictor of futile recanalization in patients undergoing mechanical thrombectomy for acute ischemic stroke.

Introduction: Mechanical thrombectomy (MT) is the first line treatment in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Approximately half of patients treated with MT does not have a favorable outcome 3 months after stroke. The aim of this study was to identify predictors of futile recanalization (FR) in patients with LVO treated with MT. Methods: A retrospective analysis of consecutive patients with acute ischemic stroke due to anterior circulation LVO who underwent MT. Patients with a TICI score of 2b or 3 were included. We distinguished two groups, FR and meaningful recanalization (MR), according to patients' disability three months after stroke (FR: mRS score > 2; MR: mRS score < 2). Results: We enrolled 238 patients (FR, n = 129, 54.2%; MR, n = 109, 45.8%). Age (OR 1.05, 95% CI 1.01-1.09, p = 0.012), female sex (OR 2.43, 95% CI 1.12-5.30, p = 0.025), stress hyperglycemia, as measured by the GAR index, (OR 1.17, 95% CI 1.06-1.29, p = 0.002), NIHSS at admission (OR 1.15, 95% CI 1.07-1.25, p = 0.001) and time from symptoms onset to MT (OR 1.01, 95% CI 1.00-1.01, p = 0.020) were independent predictors of FR. The AUC for the model combining age, female sex, GAR index, NIHSS at admission and time from symptoms onset to MT was 0.81 (95% CI 0.76-0.87; p < 0.001). The optimal GAR index cut-off score to predict FR was 17.9. Discussion: FR is common after MT. We recognized older age, female sex and baseline NIHSS as non-modifiable predictors of FR. On the other hand, time from symptoms onset to MT and stress hyperglycemia were modifiable pre- and post-MT factors, respectively. Any effort should be encouraged to reduce the impact of these modifiable predictors.

Sleep of migraine patients is ameliorated by ketogenic diet, independently of pain control.

OBJECTIVE/BACKGROUND: Migraine patients are frequently affected by sleep complaints. The ketogenic diet (KD) is an option for the treatment of migraine. Our aim was: 1) to assess the effects of KD on sleep complaints in patients affected by migraine and 2) to verify if sleep changes were related to the effects of the diet on headache symptoms. PATIENTS/METHODS: From January 2020 to July 2022 we consecutively enrolled 70 migraine patients who were treated with KD as a preventive therapy. We collected information regarding: 1) anthropometric measures; 2) migraine intensity, frequency and disability; 3) subjective sleep complaints, i.e. insomnia, sleep quality, by the Pittsburgh Sleep Quality Index (PSQI), and excessive Daytime Sleepiness (EDS), by the Epworth Sleepiness Scale (ESS). RESULTS: After 3 months of KD therapy, anthropometric measures considerably changed, i.e. body mass index and free fat mass, and migraine significantly improved, i.e. lower intensity, frequency and disability. Regarding sleep, we observed that insomnia affected a decreased rate of patients (T0: 60% versus T1: 40%, p < 0.001). Similarly, patients with poor sleep were significantly less after KD therapy (T0: 74.3% versus T1: 34.3%, p < 0.001). Finally, EDS prevalence declined at the follow-up (T0: 40% versus T1: 12.9%, p < 0.001). Sleep features modifications were not correlated with migraine improvements and with anthropometric changes. CONCLUSIONS: For the first time we demonstrated that KD may improve sleep complaints in migraine patients. Interestingly, the positive effect of KD on sleep is independent of migraine improvements and anthropometric modifications.

Efficacy and safety of two different botulinum toxin type A dilutions in chronic migraineurs.

Botulinum toxin type A is an effective preventive therapy for chronic migraine. Although the guidelines suggest a 50U/ml dilution of OnabotulinumtoxinA (BoNT/A), many clinicians use more concentrated solutions. However, there are no studies regarding the effect and safety of 100U/ml BoNT/A dilution with the saline solution following the PREEMPT paradigm. Our primary goal was to evaluate the efficacy, in reducing migraine frequency, and safety of two different BoNT/A dilutions (100U/ml vs 50U/ml) in the treatment of Chronic migraine. Our secondary goal was to determine the predictors of BoNT/A response. We retrospectively collected data from 113 chronic migraine patients treated with 3 rounds of BoNT/A according to the PREEMPT protocol as a preventive therapy. Patients were divided into two groups, based on BoNT/A dilution: 50U/ml (49 patients) vs. 100U/ml (64 patients) of sodium chloride 0.9%. We compared the migraine days/month, intensity, and intake of symptomatic medications at the baseline with the data obtained after the treatment; moreover, we evaluated the occurrence of adverse effects observed in the two groups. There was no difference regarding efficacy and safety between the two groups except for eyelid ptosis, which was more common in the 50U/ml BoNT/A group (p 0.018). Unilateral localization of migraine was associated with a more favorable outcome (OR 5.593, C.I. 2.358-13.268; p < 0.001) while Major Depressive Disorder predicted a less favorable response (OR 0.213, C.I. 0.087-0.523; p < 0.001). In our study, BoNT/A dilution did not influence the response to the therapy, but 100U/ml dilution could reduce the risk of eyelid ptosis. Unilateral localization of migraine pain might predict a more favorable response to the therapy, while the presence of a Major Depressive Disorder might predict a less favorable response.

Effect of Dexmedetomidine versus Propofol on Intraoperative Seizure Onset During Awake Craniotomy: A Retrospective Study.

OBJECTIVE: The effect of dexmedetomidine (DEX) compared with propofol on intraoperative seizures (IOSs) detected using electrocorticography during awake craniotomy for resection of brain tumors is unknown. This investigation aimed to compare IOS rate in patients receiving DEX versus propofol as sedative agent. METHODS: In this retrospective single-center study, awake craniotomies performed from January 2014 to December 2019 were analyzed. All IOSs detected by electrocorticography along with vital signs were recorded. RESULTS: Of 168 adults enrolled in the study, 58 were administered DEX and 110 were administered propofol. IOSs occurred more frequently in the DEX group (22%) versus the propofol group (11%) (P = 0.046). A higher incidence of bradycardia was also observed in the DEX group (P < 0.001). Higher incidence of hypertension and a higher mean heart rate were recorded in the propofol group (P = 0.006 and P < 0.001, respectively). No serious adverse events requiring active drug administration were noted in either group. At univariate regression analysis, DEX demonstrated a tendency to favor IOS onset but without statistical significance (odds ratio = 2.36, P = 0.051). Patients in both groups had a similar epilepsy outcome at the 1-year postoperative follow-up. CONCLUSIONS: IOSs detected with electrocorticography during awake craniotomy occurred more frequently in patients receiving DEX than propofol. However, patients receiving DEX were not shown to be at a statistically significant greater risk for IOS onset. DEX is a valid alternative to propofol during awake craniotomy in patients affected by tumor-related epilepsy.

Hyperdense middle cerebral artery sign predicts favorable outcome in patients undergoing mechanical thrombectomy.

Non-contrast computer tomography detects the presence of hyperdense middle cerebral artery sign (HMCAS). Studies on the prognostic value of HMCAS among patients undergoing mechanical thrombectomy (MT) are conflicting. A retrospective analysis of consecutive patients with acute ischemic stroke due to middle cerebral artery occlusion, presenting with or without HMCAS, who underwent MT, was performed. We enrolled 191 patients (HMCAS +, n = 140; HMCAS -, n = 51). Prevalence of successful recanalization was significantly higher in patients with HMCAS than in those without HMCAS (92.1% versus 74.5%, p = 0.001). Patients with HMCAS had a better clinical outcome than those HMCAS - (54.3% versus 37.3%, p = 0.037, for three-month favorable outcome; 62.9% versus 39.3%, p = 0.004, for major neurological improvement at discharge; 8.6% versus 19.6%, p = 0.035, for in-hospital mortality; 14.3% versus 27.5%, p = 0.035, for intracranial hemorrhage; 2.9% versus 17.6%, p = 0.001, for symptomatic intracranial hemorrhage). Multivariate analyses confirmed that HMCAS represents an independent predictor of three-month favorable outcome (OR 2.48, 95% CI 1.10-5.58, p = 0.028), major neurological improvement at discharge (OR 2.40, 95% CI 1.09-5.20, p = 0.030), in-hospital mortality (OR 0.29, 95% CI 0.010-0.81, p = 0.018), presence of ICH (OR 0.49, 95% CI 0.25-0.97, p = 0.042) and presence of SICH (OR 0.16, 95% CI 0.04-0.63, p = 0.009). HMCAS presence predicts favorable outcome in patients undergoing MT. This result may indicate that hyperdense clots are more likely to respond to MT than isodense ones. This effect is mediated by reduction in hemorrhagic transformation.

New-onset Myasthenia Gravis after SARS-CoV-2 infection: case report and literature review.

We report the case of a 19-year-old female patient who developed Myasthenia Gravis 13 days after SARS-CoV-2 infection with positive RT-PCR testing. Her symptoms initially involved the oculo-bulbar district, but they gradually worsened in 3 months converting into a generalized form of Myasthenia Gravis complicated with a myasthenic crisis. A high level of anti-acetylcholine receptor antibodies was found in the serum, while anti-MuSK antibodies were negative; Repetitive Nerve Stimulation and Single-fiber Electromyography were suggestive of Myasthenia Gravis. Intravenous immunoglobulin courses and specific therapy were able to improve her symptoms, but thymic resection was needed to control the disease. This is a report of new-onset Myasthenia Gravis correlated to COVID-19 in which thymic resection was described and the histologic analysis of the thymus was performed showing thymic hyperplasia despite negative thoracic Magnetic Resonance Imaging. SARS-CoV-2 infection releases inflammatory cytokines that could dysregulate the immune system and lead to Myasthenia Gravis in susceptible subjects.

Impact of Disease-Modifying Therapies on Gut-Brain Axis in Multiple Sclerosis.

Multiple sclerosis is a chronic, autoimmune-mediated, demyelinating disease whose pathogenesis remains to be defined. In past years, in consideration of a constantly growing number of patients diagnosed with multiple sclerosis, the impacts of different environmental factors in the pathogenesis of the disease have been largely studied. Alterations in gut microbiome composition and intestinal barrier permeability have been suggested to play an essential role in the regulation of autoimmunity. Thus, increased efforts are being conducted to demonstrate the complex interplay between gut homeostasis and disease pathogenesis. Numerous results confirm that disease-modifying therapies (DMTs) used for the treatment of MS, in addition to their immunomodulatory effect, could exert an impact on the intestinal microbiota, contributing to the modulation of the immune response itself. However, to date, the direct influence of these treatments on the microbiota is still unclear. This review intends to underline the impact of DMTs on the complex system of the microbiota-gut-brain axis in patients with multiple sclerosis.

Disease Activity and Progression in Multiple Sclerosis: New Evidences and Future Perspectives.

Multiple sclerosis (MS) is a chronic, debilitating, autoimmune-mediated, inflammatory disease of the central nervous system (CNS), in which a combination of inflammation, demyelination and axonal degeneration takes place with extreme highly interpersonal variability [...].

Performing real time neuropsychological testing during awake craniotomy: are dexmedetomidine or propofol the same? A preliminary report.

PURPOSE: In awake surgery, the patient is sedated, but is also required to be sufficiently alert and collaborative during extensive neurocognitive testing. In the present preliminary report of a retrospective single-center study, a continuous series of 168 patients who underwent awake surgery for brain tumor located near eloquent areas, was investigated to observe the effect of dexmedetomidine (n = 58) compared with propofol (n = 110) on vigilance and collaboration required to perform extensive intra-operatory Real Time Neuropsychological Testing (RTNT). METHODS: We assigned a score to each patient, by using a scale that combines vigilance and collaboration in a 5 levels score (the higher score denoting higher level). RESULTS: The median interquartile range was significantly lower (range 3-5) for the dexmedetomidine group compared to the propofol one (range 4-5, p = .044). Patients with intra-operative seizures (p = .014) and/or electrocorticographic slow/epileptiform activity (p = .042), and patients in the propofol group who showed increased heart rate (p = .032) were those who obtained the lower scores (lower vigilance and collaboration level). CONCLUSION: The study shows that the effect of dexmedetomidine or propofol -based conscious sedation on ability to perform Real Time Neuropsychological Testing during awake surgery for supratentorial tumor resection is different. Although both permit high mean levels of vigilance and collaboration, the patient who received dexmedetomidine was more likely to show lower vigilance and collaboration during RTNT.

Stress Hyperglycemia Does Not Affect Clinical Outcome of Diabetic Patients Receiving Intravenous Thrombolysis for Acute Ischemic Stroke.

Although stress hyperglycemia represents a main risk factor for poor outcome among patients with acute ischemic stroke (AIS) undergoing recanalization therapy, we have limited information regarding a possible influence of the premorbid diabetic status on this association. We recruited consecutive patients admitted to the Udine University Hospital with AIS who were treated with intravenous thrombolysis (IVT) from January 2015 to September 2020. On the basis of the premorbid diabetic status, our sample was composed of 130 patients with and 371 patients without diabetes. The glucose-to-glycated hemoglobin ratio (GAR) was used to measure stress hyperglycemia. Patients were stratified into 3 groups by tertiles of GAR (Q1-Q3). The higher GAR index was, the more severe stress hyperglycemia was considered. Among diabetic patients we did not observe any significant association between severe stress hyperglycemia and outcome measures (three-month poor outcome: Q1, 53.7%; Q2, 53.5%; Q3, 58.7%; p = 0.854; three-month mortality: Q1, 14.6%; Q2, 9.3%; Q3, 23.9%; p = 0.165; symptomatic intracranial hemorrhage: Q1, 7.3%; Q2, 14%; Q3, 19.6%; p = 0.256). Differently, non-diabetic subjects with more severe stress hyperglycemia showed a higher prevalence of three-month poor outcome (Q1, 32.2%; Q2, 27.7%; Q3, 60.3%; p = 0.001), three-month mortality (Q1, 9.1%; Q2, 8.4%; Q3, 18.3%; p = 0.026), and symptomatic intracranial hemorrhage (Q1, 0.8%; Q2, 0.8%; Q3, 9.9; p = 0.001). After controlling for several confounders, severe stress hyperglycemia remained a significant predictor of three-month poor outcome (OR 2.1, 95% CI 1.03-4.28, p = 0.041), three-month mortality (OR 2.39, 95% CI 1.09-5.26, p = 0.029) and symptomatic intracranial hemorrhage (OR 12.62, 95% CI 1.5-106, p = 0.02) among non-diabetics. In conclusion, premorbid diabetic status seems to influence outcome in AIS patients receiving IVT. Indeed, odds of functional dependency, mortality and hemorrhagic complications were significantly increased in patients with more severe stress hyperglycemia only when they were not affected by diabetes.

Neurological disorders in COVID-19: a case of Acute Disseminated Encephalomyelitis in an adult patient.

Different neurological complications associated with the severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection have been widely documented. Acute disseminated encephalomyelitis (ADEM) is a rare immune-mediated demyelinating disorder, described within the spectrum of neurological manifestations of COVID-19. Herein, we describe a case of adult-ADEM presenting with diplopia and slowly progressive ataxia developed one month after SARS-CoV-2 infection. Brain magnetic resonance imaging (MRI) revealed acute multifocal demyelinating lesions throughout the brain. Other possible etiologies have been ruled out. After treatment with high-dose steroids, we observed a progressive clinical and radiological improvement. A 4-months follow-up showed complete clinical recovery. Although extremely rare, ADEM could be associated to SARS-CoV-2 infection and should be considered in the differential diagnosis. Early recognition of this COVID-19 neurological complication, even in the absence of pulmonary involvement, is important to start a prompt immune-modulatory treatment and, consequently, ensure a good outcome.

Erenumab Impact on Sleep Assessed With Questionnaires and Home-Polysomnography in Patients With Migraine: The ERESON Study.

Introduction: Migraine and sleep share a complex and unclear relationship. Poor sleep may trigger migraine attacks; migraine, in turn, is frequently associated with sleep disorders. Few previous studies used questionnaires to assess sleep changes in patients who were treated with migraine-preventive medications (MPMs). More extensive polysomnography (PSG)-based studies for this purpose were not available. Objective: To investigate possible sleep changes in patients with migraine treated with erenumab, using validated sleep questionnaires and home-PSG. Methods: This observational, prospective, open-label pilot study was conducted at the Clinical Neurology Unit Headache Center of Udine University Hospital from 2020 to 2021. Patients were treated with erenumab as monotherapy or add-on treatment for migraine prevention. Sleep changes were evaluated with questionnaires and polysomnographic recordings at baseline, after 3 and 12 months of treatment. Erenumab efficacy and safety in migraine prophylaxis were also investigated. Results: Twenty-nine patients completed 3 months of follow-up, whereas 15 patients completed 12 months. We found a weak trend of improvement in daytime somnolence after 3 months of treatment, with stronger results after 12 months (median Epworth Sleepiness Scale (ESS) score from 6.0 to 4.0, p = 0.015); a significant improvement in subjective sleep quality (median Pittsburgh Sleep Quality Index (PSQI) total score from 7 to 5; p = 0.001) was also observed. Home-PSG showed a significant increase in objective sleep efficiency (SE), both after 3 (from 88.1 to 91.0, p = 0.006) and 12 months (from 87.1 to 91.0, p = 0.006) of treatment. In addition, our data confirmed erenumab effectiveness and safety in migraine prevention. Conclusion: Our study demonstrated an improvement in both subjective and objective sleep quality in patients treated with a migraine-preventive therapy. Erenumab, in particular, does not cross the blood-brain barrier (BBB), thus a direct effect on sleep is unlikely. Future studies are needed to better understand the mutual influence between migraine and sleep disorders.

Stress Hyperglycemia in Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion Undergoing Mechanical Thrombectomy.

Stress hyperglycemia may impair outcomes in patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT). The glucose-to-glycated hemoglobin ratio (GAR) was used to measure stress hyperglycemia. Data from our database of consecutive patients admitted to the Udine University Hospital with AIS who were treated with MT between January 2015 and December 2020 were retrospectively analyzed. We included 204 patients in the study and stratified them into four groups according to the quartiles of GAR (Q1-Q4). The higher the GAR index, the more severe the stress hyperglycemia was considered. Patients with more severe stress hyperglycemia showed a higher prevalence of 3-month poor outcome (Q1, 53.1%; Q2, 40.4%; Q3, 63.5%; Q4, 82.4%; p = 0.001), 3-month mortality (Q1, 14.3%; Q2, 11.5%; Q3, 15.4%; Q4, 31.4%; p = 0.001), and symptomatic intracranial hemorrhage (Q1, 2%; Q2, 7.7%; Q3, 7.7%; Q4, 25.4%; p = 0.001). After controlling for several confounders, severe stress hyperglycemia remained a significant predictor of 3-month poor outcome (OR 4.52, 95% CI 1.4-14.62, p = 0.012), 3-month mortality (OR 3.55, 95% CI 1.02-12.29, p = 0.046), and symptomatic intracranial hemorrhage (OR 6.89, 95% CI 1.87-25.36, p = 0.004). In summary, stress hyperglycemia, as measured by the GAR index, is associated with a detrimental effect in patients with AIS undergoing MT.

Recanalisation theraphy for acute ischemic stroke in cancer patients.

To date, very few studies focused their attention on efficacy and safety of recanalisation therapy in acute ischemic stroke (AIS) patients with cancer, reporting conflicting results. We retrospectively analysed data from our database of consecutive patients admitted to the Udine University Hospital with AIS that were treated with recanalisation therapy, i.e. intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and bridging therapy, from January 2015 to December 2019. We compared 3-month dependency, 3-month mortality, and symptomatic intracranial haemorrhage (SICH) occurrence of patients with active cancer (AC) and remote cancer (RC) with that of patients without cancer (WC) undergoing recanalisation therapy for AIS. Patients were followed up for 3 months. Among the 613 AIS patients included in the study, 79 patients (12.9%) had either AC (n = 46; 7.5%) or RC (n = 33; 5.4%). Although AC patients, when treated with IVT, had a significantly increased risk of 3-month mortality [odds ratio (OR) 6.97, 95% confidence interval (CI) 2.42-20.07, p = 0.001] than WC patients, stroke-related deaths did not differ between AC and WC patients (30% vs. 28.8%, p = 0.939). There were no significant differences between AC and WC patients, when treated with MT ± IVT, regarding 3-month dependency, 3-month mortality and SICH. Functional independence, mortality, and SICH were similar between RC and WC patients. In conclusion, recanalisation therapy might be used in AIS patients with nonmetastatic AC and with RC. Further studies are needed to explore the outcome of AIS patients with metastatic cancer undergoing recanalisation therapy.

Stress hyperglycemia is predictive of worse outcome in patients with acute ischemic stroke undergoing intravenous thrombolysis.

No study investigated the possible detrimental effect of stress hyperglycemia on patients affected acute ischemic stroke (AIS) undergoing intravenous thrombolysis (IVT). A new index, the glucose-to-glycated hemoglobin ratio (GAR), has been developed for assessing stress hyperglycemia. We retrospectively analyzed data from a prospectively collected database of consecutive patients admitted to the Udine University Hospital with AIS that were treated with IVT from January 2015 to December 2019. Four hundred and fourteen consecutive patients with AIS undergoing IVT entered the study. The patients were then stratified into four groups by quartiles of GAR (Q1-Q4). The higher GAR index was, the more severe stress hyperglycemia was considered. Prevalence of 3 months poor outcome (37.7% for Q1, 34% for Q2, 46.9% for Q3, and 66.7% for Q4, p for trend = 0.001), 3 months mortality (10.5% for Q1, 7.5% for Q2, 11.2% for Q3, and 27.1% for Q4, p for trend = 0.001), and symptomatic intracranial hemorrhage (0.9% for Q1, 0.9% for Q2, 5.1% for Q3, and 17.7% for Q4, p for trend = 0.001) was significant different among the four groups. AIS patients with severe stress hyperglycemia had a significantly increased risk of 3 months poor outcome (OR 2.43, 95% CI 1.14-5.22, p = 0.02), 3 months mortality (OR 2.38, 95% CI 1.01-5.60, p = 0.04), and symptomatic intracranial hemorrhage (OR 16.76, 95% CI 2.09-134.58, p = 0.008) after IVT. In conclusion, we demonstrated that stress hyperglycemia, as measured by the GAR index, is associated to worse outcome in AIS patients undergoing IVT.