Trends of recanalization therapies and state of art for ischemic stroke treatment in Campania region, Italy.

BACKGROUND: According to the last Italian report by the Ministry of Health in 2018, the estimated number of acute ischemic strokes (AIS) in Campania is 10,000/year, with an expected number of 1390 intravenous thrombolysis (IVT) and 694 mechanical thrombectomies (MT). In 2017, only 1.5% of expected patients received IVT and 0.2% MT. This study analyzed the trend of IVT and MT in 2019-2020 and depicted the state of art of Stroke Care in Campania. METHODS: From the regional health task force, we obtained the hospital discharge forms from all private and public hospitals in Campania; we selected patients with a principal diagnosis of AIS and measured the rate of patients admitted to neurology units and the rate of IVT, MT, and IVT + MT for both 2019 and 2020. RESULTS: In 2019, we observed 4817 admissions for AIS; 2858/4817 (59.3%) patients were admitted to neurology units. Out of 4817 patients, 192 received IVT, 165 MT, and 131 IVT + MT (488 treated patients; 10.1%). In 2020, we observed 4129 admissions for AIS; 2502/4129 (62.7%) patients were admitted to neurology units. Out of 4129 patients, 198 received IVT, 250 MT, and 180 IVT + MT (628 treated patients; 15.2%). These results showed that despite a reduction of AIS admissions in 2020, the relative and absolute rate of recanalization treatments increased. However, the number of patients who were not admitted to neurology units nor received acute treatments remained dramatically high. CONCLUSION: Despite the development of acute treatments, the Campania Stroke Network still needs significative efforts to improve.

Action Observation in People with Parkinson's Disease. A Motor⁻Cognitive Combined Approach for Motor Rehabilitation. A Preliminary Report.

The aim of this study was to assess the role of Action Observation (AO) to improve balance, gait, reduce falls, and to investigate the changes in P300 pattern. Five cognitively intact People with Parkinson’s disease (PwP) were enrolled in this prospective, quasi-experimental study to undergo a rehabilitation program of AO for gait and balance recovery of 60 min, three times a week for four weeks. The statistical analysis showed significant improvements for Unified Parkinson’s Disease Rating Scale (UPDRS) motor section III p = 0.0082, Short form 12-items Healthy Survey (SF-12) Mental Composite Score (MCS) p = 0.0007, Freezing of gait Questionnaire (FOG-Q) p = 0.0030, The 39-items Parkinson’s Disease Questionnaire (PDQ-39) p = 0.100, and for P300ld p = 0.0077. In conclusion, AO reveals to be a safe and feasible paradigm of rehabilitative exercise in cognitively preserved PwP.

Primary Headaches in an Elderly Population Seeking Medical Care for Cognitive Decline.

OBJECTIVES: To assess the prevalence of specific headache disorders in a population older than 65 years seeking consultation due to memory problems or cognitive impairment. METHODS: We verified the occurrence of headache symptoms and the impact of headaches on daily life. Headaches were classified as per the International Classification of Headache Disorders, 2nd edition (ICHD-2). All patients were screened with the Mini-Mental State Examination (MMSE), followed by the Selective Reminding Test and neuroimaging. Participants with severe cognitive impairment or dementia were excluded. RESULTS: A total of 1,237 patients (51.6% women), with mean age of 75.6 years (SD = 6.9) were screened from January 2006 to December 2014. Of them, 302 (24.4%) patients suffered from headaches. Most common individual diagnoses were probable migraine (13.8%), episodic tension-type headache (3.4%), and episodic migraine (3.0%). Chronic migraine or probable chronic migraine happened in 3.5%, while chronic tension-type headache affected 0.6%. Most patients with headaches routinely used symptomatic medications (55.6%). Mean MMSE scores were similar in patients with or without headaches, or with different headache diagnoses. CONCLUSIONS: Headache disorders overall, frequent headaches, and headaches requiring treatment are commonly seen in the elderly seeking care for cognitive decline and should be properly assessed and managed.

Cerebral Venous Thrombosis and Headache--A Case-Series.

BACKGROUND: Headache happens in the majority of patients with Cerebral Venous Thrombosis (CVT) being sometimes the sole manifestation of the disease. Herein we report a case-series of CVT, focusing on headache characteristics. METHODS: Etiological, clinical, and radiological features of 25 consecutive adult patients with CVT were compiled from August 2005 to December 2013. Diagnosis of CVT was confirmed by brain magnetic resonance imaging and magnetic resonance venography. All patients underwent extensive systematic etiological and genetic work-up at admission. A structured questionnaire about the characteristics of headache was responded by all participants. RESULTS: Headache was reported by 23 out of 25 (92%) of participants, being by far the most frequent symptom. It was the sole manifestation in nearly one third of the patients (8/25, 32.0%). Headache was typically severe (19/23, 82.6%) and throbbing (16/23, 69.5%), with sudden onset (13/23, 56.5%) and non-remitting (20/23, 86.9%) characteristics. The sinus most frequently involved was the transverse sinus (24/25, 96.0%), either alone or in association with other sinuses. CONCLUSION: Headache is the most frequent symptom and sometimes the sole presentation of CVT.

Endoscopic sinus surgery in individuals with facial pain due to chronic maxillary sinusitis ? a functional controlled study / Cirurgia endoscópica de seio da face em indivíduos com dor facial devida a sinusite maxilar crônica ? um estudo funcional controlado

Objective: To measure the intra-sinus pressure and the maxillary sinus functional efficiency (MSFE) in individuals with chronic facial pain after conservative or conventional endoscopic maxillary surgery, as well as in controls. Method: Sinus manometry was performed 5 times during inhalation. Results: The resemblance of pressure values comparing those treated with minimally invasive surgery and controls was remarkable, while traditional surgery significantly decreased intrasinusal pressures. The MSFE was 100% in the three tested times for controls, close to that in those submitted to minimally invasive surgery (98.3%, 98.8%, and 98.0%) and significantly impaired after conventional surgery (48.8%, 52.1%, 48.5 %, p<0.01). All patients submitted to minimally invasive surgery remained pain-free after three months of surgery, relative to 46.7% of the submitted to conventional surgery (p<0.05). Conclusion: Minimally invasive sinus surgery is associated with functionality of the chambers that resemble what is found in normal individuals. .

Objetivo: Medir a pressão intrasinusal e a eficiência funcional do seio maxilar (EFSM) em indivíduos com dor facial crônica após cirurgia endoscópica maxilar conservadora ou convencional em comparação a pessoas normais. Método: A manometria do seio foi feita 5 vezes durante a inalação. Resultados: A semelhança entre os valores das pressões comparando aqueles tratados com cirurgia minimamente invasiva e os controles foi notável, enquanto que na cirurgia tradicional houve diminuição significativa das pressões intrasinusais. A EFSM foi 100% nas três vezes testadas nos controles, de modo muito semelhante ao que foi observado naqueles submetidos a cirurgia minimamente invasiva (98,3%, 98,8%, e 98,0%) e significativamente diminuída naqueles submetidos a cirurgia convencional (48,8%, 52,1%, 48,5 %, p<0,01). Todos os pacientes submetidos a cirurgia minimamente invasiva mantiveram-se sem dor três meses depois da cirurgia, comparados a 46,7% naqueles submetidos a cirurgia convencional (p<0,05). Conclusão: Cirurgia minimamente invasiva está associada a funcionalidade das câmaras sinusais que se assemelha ao que é observado em indivíduos normais. .

Endoscopic sinus surgery in individuals with facial pain due to chronic maxillary sinusitis - a functional controlled study.

OBJECTIVE: To measure the intra-sinus pressure and the maxillary sinus functional efficiency (MSFE) in individuals with chronic facial pain after conservative or conventional endoscopic maxillary surgery, as well as in controls. METHOD: Sinus manometry was performed 5 times during inhalation. RESULTS: The resemblance of pressure values comparing those treated with minimally invasive surgery and controls was remarkable, while traditional surgery significantly decreased intrasinusal pressures. The MSFE was 100% in the three tested times for controls, close to that in those submitted to minimally invasive surgery (98.3%, 98.8%, and 98.0%) and significantly impaired after conventional surgery (48.8%, 52.1%, 48.5 %, p<0.01). All patients submitted to minimally invasive surgery remained pain-free after three months of surgery, relative to 46.7% of the submitted to conventional surgery (p<0.05). CONCLUSION: Minimally invasive sinus surgery is associated with functionality of the chambers that resemble what is found in normal individuals.

Fronto-turbinalis sinus expansion and headache.

Headaches of rhinogenic origin illustrate an interesting paradox. Little is known about their pathophysiology, mechanisms, and prevalence; yet, the concept that these headaches are of importance is widely accepted. This article discusses the relationship between fronto-turbinalis sinus expansion and headaches, as well as headache outcomes after surgical approach.

Friedreich's ataxia: oxidative stress and cytoskeletal abnormalities.

Friedreich's ataxia (FRDA) is an autosomal recessive disorder caused by mutations in the gene encoding frataxin, a mitochondrial protein implicated in iron metabolism. Current evidence suggests that loss of frataxin causes iron overload in tissues, and increase in free-radical production leading to oxidation and inactivation of mitochondrial respiratory chain enzymes, particularly Complexes I, II, III and aconitase. Glutathione plays an important role in the detoxification of ROS in the Central Nervous System (CNS), where it also provides regulation of protein function by glutathionylation. The cytoskeletal proteins are particularly susceptible to oxidation and appear constitutively glutathionylated in the human CNS. Previously, we showed loss of cytoskeletal organization in fibroblasts of patients with FRDA found to be associated with increased levels of glutathione bound to cytoskeletal proteins. In this study, we analysed the glutathionylation of proteins in the spinal cord of patients with FRDA and the distribution of tubulin and neurofilaments in the same area. We found, for the first time, a significant rise of the dynamic pool of tubulin as well as abnormal distribution of the phosphorylated forms of human neurofilaments in FRDA motor neurons. In the same cells, the cytoskeletal abnormalities co-localized with an increase in protein glutathionylation and the mitochondrial proteins were normally expressed by immunocytochemistry. Our results suggest that in FRDA oxidative stress causes abnormally increased protein glutathionylation leading to prominent abnormalities of the neuronal cytoskeleton.

Early poststroke seizures.

We define as early seizure (ES) those occurring within 7 days after stroke and late seizures those developing beyond 1 week after stroke. Seizures are well known to occur at the onset of intracerebral hemorrhage and serve as a clinical marker. Onset seizures may be focal or generalized, are usually brief and are associated with loss of consciousness in the setting of hemorrhage. A similar concept of immediate seizure occurs in traumatic brain injury. Predictive factors of ES can be classified of general and neurologic origin. An important question is whether ES per se worsen prognosis and outcome. The viability of the penumbral region in animal models of focal ischemia is influenced by the peri-infarct depolarization waves. If this also is true in humans, seizures in the immediate poststroke period might worsen outcome. Recently, hypercholesterolemia has been associated with better functional outcome at 1 month after a first-ever stroke, and multivariate analysis studies have shown that mean cholesterol values were lower in patients with ES compared with controls.

Assessment of adverse events associated with triptans--methods of assessment influence the results.

BACKGROUND: A recent study conducted in triptan-naive migraine patients showed that tolerability was the second most important attribute of an acute treatment. However, the proportion of patients reporting side effects after any acute treatment may vary with regard to the method of assessment. OBJECTIVES: To contrast two methods of assessing adverse events (prompted and unprompted) in those with headache using triptans. METHODS: This study was conducted in two sites, a headache center in the United States, and a neurology office focusing on headache in Italy. We prospectively surveyed 415 adults with headache, who had been using the same triptan for at least 3 months. Participants were asked about their headache and treatment history. Subjects then completed a standardized questionnaire, assessing adverse events in two different ways. First, subjects were asked if they had any adverse events when using the triptan. After returning the first part of the questionnaire, subjects received a second form, where 49 possible adverse events were listed. We contrasted and correlated both sets of answers. RESULTS: Most patients (U.S.=74.9%, Italy=65.5%) reported no side effects in the unprompted questionnaire. However, most of them (U.S.=62.9%, Italy=54.1%) reported at least one side effect in the prompted questionnaire. Most patients that reported side effects in the unprompted questionnaire said they had just one adverse event, while most reported two or more side effects in the prompted questionnaire. Both in the unprompted and in the prompted questionnaires, most side effects were rated as mild or moderate. Interestingly, 31 (7.5%) subjects (pooling data from both sites together) graded their adverse events as severe in the prompted questionnaire, but had not self-reported them. CONCLUSIONS: (1) When assessing adverse events, the method of data collection may dramatically influence the results. (2) From those subjects who did not self-report adverse events after using a triptan, most of them will report positively if presented with a list of side effects.

Patterns of use of triptans and reasons for switching them in a tertiary care migraine population.

OBJECTIVE: To assess the reasons for switching triptans within migraine patients presenting to a specialty clinic. DESIGN AND METHODS: We reviewed data of migraineurs who (1) were currently using a triptan as acute treatment medication for migraine, and (2) had previously used at least one other triptan, or a different triptan formulation. All subjects were followed for at least 1 year. For every triptan/formulation used, the reasons for discontinuation were obtained. RESULTS: Our sample consisted of 386 patients, 339 of whom (87.8%) were females. Sumatriptan was first used by 349 (90.4%); zolmitriptan, by 238 (61.5%); rizatriptan, by 195 (50.5%); naratriptan, by 137 (35.4%); and almotriptan, by 31 (8.0%). Almotriptan was excluded from this analysis because of our small sample. We found significant differences among those who wanted to try another triptan to see if it would be better in those who first used sumatriptan 25 mg, compared to those first using sumatriptan 50 mg (P = .01), sumatriptan 100 mg (P < .001), sumatriptan nasal spray (NS) (P < .001), sumatriptan subcutaneous (SC) (P < .001), zolmitriptan 5 mg (P < .001), rizatriptan 10 mg (P < .001), and naratriptan (P = .001). Patients using rizatriptan, sumatriptan NS, and sumatriptan SC had significantly lower rates of reporting this answer. Subjects first using naratriptan were less likely to report recurrence than those using sumatriptan 25 mg (P = .004), sumatriptan 50 mg (P = .0005), sumatriptan 100 mg (P = .003), zolmitriptan (P = .02), and rizatriptan (P = .006). Incomplete relief was more frequently reported by those first using sumatriptan 25 mg and naratriptan. Inconsistency was a reason for switching in those initially using sumatriptan NS, sumatriptan 25 mg, and naratriptan and less frequently reported in those using zolmitriptan and sumatriptan SC. Side effects were major factors for those first using sumatriptan 100 mg, NS, and SC, and less for those using naratriptan and sumatriptan 25 mg. From those subjects that initially used sumatriptan SC and were switched to a different triptan or formulation, 19.5% returned to sumatriptan SC; for the other triptans/formulations, the percentages were: sumatriptan 25 mg, 7.8%; sumatriptan 50 mg or 100 mg, 42.3%; sumatriptan NS, 17.7%; zolmitriptan, 17.6%; rizatriptan, 16.5%; naratriptan, 9.4%. For those who used more than three triptans/formulations, the last triptan used was: sumatriptan, 29.5%; zolmitriptan, 31.8%; rizatriptan, 25.0%; naratriptan, 12.5%. CONCLUSIONS: A variety of treatment attributes are important in determining the reasons involved in switching a triptan. To assess this attributes can provide additional information to supplement the traditional tests of efficacy provided by randomized clinical trials.

Naratriptan in the preventive treatment of refractory chronic migraine: a review of 27 cases.

OBJECTIVE: To review the efficacy of naratriptan as preventive treatment in 27 patients with chronic migraine refractory to other commonly used preventive therapies. BACKGROUND: The treatment of chronic migraine often poses a major challenge to the clinician. Even when given expert care, patients with chronic migraine may continue to have daily or near-daily headaches. METHODS: Clinical records and headache calendars were reviewed of 27 patients fulfilling the following inclusion criteria: (1) aged 18 to 65 years; (2) diagnosis of chronic migraine (formerly transformed migraine), according to the criteria proposed by Silberstein et al; (3) previous failure of at least 4 preventive medications prescribed as part of a management program that included nonpharmacological measures, preventive medication, acute care medication, and detoxification from overused medication; and (4) have used daily naratriptan for no less than 2 consecutive months. The dose of naratriptan prescribed was 2.5 mg twice daily. We considered the following outcomes: (1) frequency of headache, (2) intensity of pain, (3) number of days per month with severe headache, (4) headache index (frequency times intensity), and (5) proportion of patients who reverted to an episodic pattern of pain after 6 months of treatment. RESULTS: There was a statistically significant reduction in the frequency of headache days 2 months (15.3 days versus 24.1 days at baseline, P<.001), 6 months (9.1 days, P<.001), and 1 year (7.3 days, P<.001) after daily treatment with naratriptan was initiated. There was also a statistically significant reduction in the number of days per month of severe pain at 1 month (5.6 days versus 12.5 days at baseline, P<.01), 2 months (5.7 days, P<.01), 6 months (2.8 days, P<.01), and 1 year (2.6 days, P<.01). Similarly, there was a statistically significant reduction in the headache index at 2 months (33 versus 56.4 at baseline, P<.001), 6 months (19.5, P<.001), and 1 year (17.2, P<.001). Of the 20 patients who continued to use naratriptan daily for at least 6 months, 13 (65%) reverted to an episodic pattern of pain (migraine). At 1 year, 11 (55%) still continued to experience episodic headache, 1 (5%) relapsed to chronic migraine, and 2 (10%) were lost to follow-up. No patients had intolerability to naratriptan during the treatment period, and no one stopped treatment due to adverse events. CONCLUSIONS: Naratriptan may have a role in the preventive treatment of intractable chronic migraine. Prospective, controlled studies should be considered.