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Pierini P, Novelli A, Bossi F, Corinaldesi R, Paciaroni M, Mosconi MG, Alberti A, Venti M, de Magistris IL, Caso V. Medical versus neurosurgical treatment in ICH patients: a single center experience. Neurol Sci 2024; 45:223-229. [PMID: 37578629 PMCID: PMC10761447 DOI: 10.1007/s10072-023-07015-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/07/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND AND AIMS The effect of surgical treatment for spontaneous intracerebral hemorrhage (ICH) remains uncertain. We conducted an observational retrospective cohort study on supra-centimeter spontaneous ICH treated with either neurosurgical or conservative management. The baseline demographics and risk factors were correlated with in-hospital mortality and 3 and 6-month survival rates stratified by management. METHODS We included all patients with evidence of spontaneous ICH > 1 cm detected by CT and admitted between august 2020 and march 2021 to the "SMM" Hospital in Perugia. RESULTS Onehundredandtwentytwo patients were included in the study, and 45% (n.55) were surgically treated. The mean age was 71.9 ± 15.3, and 61% (n.75) were males. Intra-hospital mortality ended up being 31% (n.38), 3 months-survival was 63% (n.77) and 6 months-survival was 60% (n.73). From the multivariate analysis of the surgical patients versus medical patient, we observed that the surgical patients were younger (67.5 ± 14.9 vs 75.5 ± 14.7 y; OR 0.87; Cl 95% 0.85-0.94; p 0.001), with greater ICH volume at the onset (61 ± 39.4 cc vs 51 ± 64 cc; OR 1.03; Cl 95% 1.005-1.07; p 0.05), more midline shift (7.61 ± 5.54 mm vs 4.09 ± 5.88 mm; OR 1.37; Cl 95% 1.045-1.79; p 0.023), and a higher ICH score (3 vs 2 mean ICH score; OR 21.12; Cl 95% 2.6-170.6; p 0.004). Intra-hospital mortality in the surgical group and in the conservative treatment group was respectively 33% vs 30%, 3 month-survival was 64% vs 63% and 6 month- survival were 60% in both groups. CONCLUSIONS Our patient cohort shows no overall benefit from surgery over conservative treatment, but surgical patients were younger and had larger ICH volume.
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Affiliation(s)
- P Pierini
- Department of Emergency Medicine, Città Di Castello Hospital, Città Di Castello, Italy
| | - Agnese Novelli
- Internal, Vascular and Emergency Medicine-Stroke Unit, Santa Maria della Misericordia University of Perugia, 06139, Perugia, Italy.
| | - F Bossi
- Internal, Vascular and Emergency Medicine-Stroke Unit, Santa Maria della Misericordia University of Perugia, 06139, Perugia, Italy
| | - R Corinaldesi
- Neurosurgery Department, Santa Maria Della Misericordia Hospital, Perugia, Italy
| | - M Paciaroni
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - M G Mosconi
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - A Alberti
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - M Venti
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - I Leone de Magistris
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - V Caso
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
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2
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Tsivgoulis G, Katsanos AH, Seiffge DJ, Paciaroni M, Wilson D, Koga M, Macha K, Cappellari M, Kallmünzer B, Polymeris AA, Toyoda K, Caso V, Werring DJ, Engelter ST, De Marchis GM. Fatal intracranial haemorrhage occurring after oral anticoagulant treatment initiation for secondary stroke prevention in patients with atrial fibrillation. Eur J Neurol 2020; 27:1612-1617. [PMID: 32333493 DOI: 10.1111/ene.14280] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE In this pooled analysis of seven multicentre cohorts potential differences were investigated in the incidence, characteristics and outcomes between intracranial haemorrhages (ICHs) associated with the use of non-vitamin K antagonist oral anticoagulants (NOAC-ICH) or with vitamin K antagonists (VKA-ICH) in ischaemic stroke patients after oral anticoagulant treatment initiation for atrial fibrillation (AF). METHODS Data from 4912 eligible AF patients who were admitted in a stroke unit with ischaemic stroke or transient ischaemic attack and who were treated with either VKAs or NOACs within 3 months post-stroke were included. Fatal ICH was defined as death occurring during the first 30 days after ICH onset. A meta-analysis of available observational studies reporting 30-day mortality rates from NOAC-ICH or VKA-ICH onset was additionally performed. RESULTS During 5970 patient-years of follow-up 71 participants had an ICH, of whom 20 were NOAC-ICH and 51 VKA-ICH. Patients in the two groups had comparable baseline characteristics, except for the higher prevalence of kidney disease in VKA-ICH patients. There was a non-significant higher number of fatal ICH in patients with VKAs (11 events per 3385 patient-years) than in those with NOACs (three events per 2623 patient-years; hazard ratio 0.32, 95% confidence interval 0.09-1.14). Three-month functional outcomes were similar (P > 0.2) in the two groups. The meta-analysis showed a lower 30-day mortality risk for patients with NOAC-ICH compared to VKA-ICH (relative risk 0.70, 95% confidence interval 0.51-0.95). CONCLUSIONS Non-vitamin K oral anticoagulants for intracranial haemorrhages and VKA-ICH occurring during secondary stroke prevention of AF patients have comparable baseline characteristics and outcomes except for the risk of fatal ICH within 30 days, which might be greater in VKA-ICH.
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Affiliation(s)
- G Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens School of Medicine, Attikon' University Hospital, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - A H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - D J Seiffge
- Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland.,Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK.,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - M Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - D Wilson
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - M Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - K Macha
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - M Cappellari
- Stroke Unit, Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - B Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - A A Polymeris
- Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland
| | - K Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - V Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - D J Werring
- Stroke Research Center, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - S T Engelter
- Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland
| | - G M De Marchis
- Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland
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3
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Tsivgoulis G, Goyal N, Katsanos AH, Malhotra K, Ishfaq MF, Pandhi A, Frohler MT, Spiotta AM, Anadani M, Psychogios M, Maus V, Siddiqui A, Waqas M, Schellinger PD, Groen M, Krogias C, Richter D, Saqqur M, Garcia-Bermejo P, Mokin M, Leker R, Cohen JE, Magoufis G, Psychogios K, Lioutas VA, Van Nostrand M, Sharma VK, Paciaroni M, Rentzos A, Shoirah H, Mocco J, Nickele C, Mitsias PD, Inoa V, Hoit D, Elijovich L, Arthur AS, Alexandrov AV. Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity. Eur J Neurol 2020; 27:1039-1047. [PMID: 32149450 DOI: 10.1111/ene.14199] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 02/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points. METHODS The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0-1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding. RESULTS We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 ± 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09-4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10-3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67-5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy. CONCLUSIONS Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding.
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Affiliation(s)
- G Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Second Department of Neurology, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - N Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A H Katsanos
- Second Department of Neurology, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - K Malhotra
- Charleston Division, Department of Neurology, West Virginia University, Charleston, WV, USA
| | - M F Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - A Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - M T Frohler
- Cerebrovascular Program, Vanderbilt University, Nashville, TN, USA
| | - A M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - M Anadani
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - M Psychogios
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - V Maus
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - A Siddiqui
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | - M Waqas
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | - P D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - M Groen
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - C Krogias
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - D Richter
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - M Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Neurology, Hamad General Hospital, Doha, Qatar
| | - P Garcia-Bermejo
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - M Mokin
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - G Magoufis
- Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - K Psychogios
- Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - V A Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - M Van Nostrand
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - V K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, National University Hospital, Singapore, Singapore
| | - M Paciaroni
- Stroke Unit, Divisione di Medicina Cardiovascolare, Università di Perugia, Perugia, Italy
| | - A Rentzos
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - H Shoirah
- Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, USA
| | - C Nickele
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - P D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.,Department of Neurology, School of Medicine, University of Crete, Herakleion, Greece
| | - V Inoa
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - D Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - L Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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4
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Romoli M, Tuna MA, Li L, Paciaroni M, Giannandrea D, Tordo Caprioli F, Lotti A, Eusebi P, Mosconi MG, Pellizzaro Venti M, Salvadori N, Gili A, Ricci S, Stracci F, Sarchielli P, Parnetti L, Rothwell PM, Calabresi P. Time trends, frequency, characteristics and prognosis of short-duration transient global amnesia. Eur J Neurol 2020; 27:887-893. [PMID: 32012408 PMCID: PMC7115816 DOI: 10.1111/ene.14163] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 01/20/2020] [Indexed: 12/20/2022]
Abstract
Background and purpose Transient global amnesia (TGA) is characterized by a sudden onset of anterograde amnesia lasting up to 24 h. One major differential for TGA is transient epileptic amnesia, which typically lasts < 1 h. However, TGA can also be short in duration and little is known about the time trends, characteristics and prognosis of TGA cases lasting < 1 h. Methods We compared the clinical features of TGA ascertained in two independent cohort studies in Oxfordshire, UK [Oxford cohort 1977–1987 versus Oxford Vascular Study (OXVASC) 2002–2018] to determine the time trends of clinical features of TGA. Results were validated in another independent contemporary TGA cohort in Italy [Northern Umbria TGA registry (NU) 2002–2018]. We compared the risk factors, clinical features and long‐term prognosis (major cardiovascular events, recurrent TGA and seizure/epilepsy) of patients presenting with episodes lasting < 1 h versus those lasting ≥ 1 h. Results Overall, 639 patients with TGA were included (114 Oxford cohort, 100 OXVASC, 425 NU). Compared with the original Oxford cohort, there were more cases with TGA lasting < 1 h in OXVASC [32 (32.0%) vs. 9 (8.8%)] and NU (11.8% vs. 8.8% in Oxford cohort). In both OXVASC and NU, patient age, vascular risk factors and clinical features were largely similar between those with TGA lasting < 1 h versus those lasting ≥ 1 h. Moreover, there was no difference in the long‐term risk of seizure/epilepsy or major cardiovascular events between TGA lasting < 1 h versus TGA lasting ≥ 1 h. Conclusions Short‐duration TGA episodes (<1 h) were not uncommon and were more frequent than in earlier studies. The clinical features and long‐term prognosis of short‐duration TGA did not differ from more typical episodes lasting ≥ 1 h.
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Affiliation(s)
- M Romoli
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Neurology Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia.,Neurology Unit, Rimini 'Infermi' Hospital - AUSL Romagna, Rimini
| | - M A Tuna
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - L Li
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - M Paciaroni
- Stroke Unit, University of Perugia - S. Maria della Misericordia Hospital of Perugia, Perugia
| | - D Giannandrea
- Neurology and Stroke Unit, USL Umbria 1, Gubbio and Città di Castello Hospital, Perugia, Italy
| | - F Tordo Caprioli
- Neurology Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia
| | - A Lotti
- Neurology Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia
| | - P Eusebi
- Neurology Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia
| | - M G Mosconi
- Stroke Unit, University of Perugia - S. Maria della Misericordia Hospital of Perugia, Perugia
| | - M Pellizzaro Venti
- Stroke Unit, University of Perugia - S. Maria della Misericordia Hospital of Perugia, Perugia.,Stroke Unit, Addenbrooke's Hospital - Cambridge University Hospital, Cambridge, UK
| | - N Salvadori
- Neurology Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia
| | - A Gili
- Public Health Department, University of Perugia, Perugia
| | - S Ricci
- Neurology and Stroke Unit, USL Umbria 1, Gubbio and Città di Castello Hospital, Perugia, Italy
| | - F Stracci
- Public Health Department, University of Perugia, Perugia
| | - P Sarchielli
- Neurology Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia
| | - L Parnetti
- Neurology Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia
| | - P M Rothwell
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - P Calabresi
- Neurology Clinic, University of Perugia - S. Maria della Misericordia Hospital, Perugia.,IRCCS 'Santa Lucia', Rome, Italy
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5
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Katsanos AH, Schellinger PD, Köhrmann M, Filippatou A, Gurol ME, Caso V, Paciaroni M, Perren F, Alexandrov AV, Tsivgoulis G. Fatal oral anticoagulant‐related intracranial hemorrhage: a systematic review and meta‐analysis. Eur J Neurol 2018; 25:1299-1302. [DOI: 10.1111/ene.13742] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/21/2018] [Indexed: 01/17/2023]
Affiliation(s)
- A. H. Katsanos
- Second Department of Neurology Attikon University Hospital National & Kapodistrian University of Athens Athens
- Department of Neurology University of Ioannina Ioannina Greece
| | - P. D. Schellinger
- Departments of Neurology and Neurogeriatry Johannes Wesling Medical Center Ruhr University Bochum Minden
| | - M. Köhrmann
- Department of Neurology Universitätsklinikum Essen Essen Germany
| | - A. Filippatou
- Second Department of Neurology Attikon University Hospital National & Kapodistrian University of Athens Athens
| | - M. E. Gurol
- J. P. Kistler Stroke Research Center Massachusetts General Hospital Boston MA USA
| | - V. Caso
- Stroke Unit and Division of Cardiovascular Medicine University of Perugia Perugia Italy
| | - M. Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine University of Perugia Perugia Italy
| | - F. Perren
- Department of Neurology University Hospital of Geneva Geneva Switzerland
| | - A. V. Alexandrov
- Department of Neurology University of Tennessee Health Science Center Memphis TN USA
| | - G. Tsivgoulis
- Second Department of Neurology Attikon University Hospital National & Kapodistrian University of Athens Athens
- Department of Neurology University of Tennessee Health Science Center Memphis TN USA
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6
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Poli L, Zedde M, Zini A, Del Sette M, Lodigiani C, Spalloni A, Di Lisi F, Toriello A, Piras V, Stilo C, Tomelleri G, Tancredi L, Paciaroni M, Silvestrelli G, Adami A, Costa P, Morotti A, De Giuli V, Caria F, Gamba M, Malferrari G, Simone AM, Musolino R, Giorli E, Banfi E, Marcheselli S, Rasura M, Pugliese N, Melis M, Bovi P, Padovani A, Burlina A, Pezzini A. Screening for Fabry disease in patients with ischaemic stroke at young age: the Italian Project on Stroke in Young Adults. Eur J Neurol 2017; 24:e12-e14. [DOI: 10.1111/ene.13254] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 01/04/2017] [Indexed: 11/30/2022]
Affiliation(s)
- L. Poli
- Dipartimento di Scienze Cliniche e Sperimentali; Clinica Neurologica; Università degli Studi di Brescia; Brescia
| | - M. Zedde
- S.C. Neurologia; Arcispedale ‘Santa Maria Nuova - IRCCS’; Reggio Emilia
| | - A. Zini
- Stroke Unit; Clinica Neurologica; Nuovo Ospedale Civile ‘S. Agostino Estense’, AUSL; Modena
| | | | - C. Lodigiani
- Centro Trombosi; IRCCS Humanitas Research Hospital; Rozzano-Milano
| | - A. Spalloni
- Stroke Unit; Azienda Ospedaliera Sant'Andrea; Università ‘La Sapienza’; Roma
| | - F. Di Lisi
- Stroke Unit; Azienda Ospedaliera Sant'Andrea; Università ‘La Sapienza’; Roma
| | - A. Toriello
- U.O.C. Neurologia; A.O. Universitaria ‘San Giovanni di Dio e Ruggi d'Aragona’; Salerno
| | - V. Piras
- Stroke Unit; Azienda Ospedaliera ‘G. Brotzu’; Cagliari
| | - C. Stilo
- Dipartimento di Neuroscienze; Scienze Psichiatriche e Anestesiologiche; Clinica Neurologica; Università di Messina; Messina
| | - G. Tomelleri
- UO Neurologia; Azienda Ospedaliera-Universitaria Borgo Trento; Verona
| | - L. Tancredi
- U.O. Neurologia; ASST Lariana - Ospedale Sant'Anna; Como
| | - M. Paciaroni
- Stroke Unit; Divisione di Medicina Cardiovascolare; Università di Perugia; Perugia
| | - G. Silvestrelli
- Stroke Unit; Dipartimento di Neuroscienze; Azienda Ospedaliera Carlo Poma; Mantova
| | - A. Adami
- Stroke Center; Dipartimento di Neurologia; Ospedale Sacro Cuore Negrar; Verona
| | - P. Costa
- Dipartimento di Scienze Cliniche e Sperimentali; Clinica Neurologica; Università degli Studi di Brescia; Brescia
| | - A. Morotti
- Dipartimento di Scienze Cliniche e Sperimentali; Clinica Neurologica; Università degli Studi di Brescia; Brescia
| | - V. De Giuli
- Dipartimento di Scienze Cliniche e Sperimentali; Clinica Neurologica; Università degli Studi di Brescia; Brescia
| | - F. Caria
- Dipartimento di Scienze Cliniche e Sperimentali; Clinica Neurologica; Università degli Studi di Brescia; Brescia
| | - M. Gamba
- Stroke Unit; Neurologia Vascolare; Spedali Civili di Brescia; Brescia
| | - G. Malferrari
- S.C. Neurologia; Arcispedale ‘Santa Maria Nuova - IRCCS’; Reggio Emilia
| | - A. M. Simone
- Stroke Unit; Clinica Neurologica; Nuovo Ospedale Civile ‘S. Agostino Estense’, AUSL; Modena
| | - R. Musolino
- Dipartimento di Neuroscienze; Scienze Psichiatriche e Anestesiologiche; Clinica Neurologica; Università di Messina; Messina
| | - E. Giorli
- Unità di Neurologia; Ospedale S. Andrea; La Spezia
| | - E. Banfi
- Centro Trombosi; IRCCS Humanitas Research Hospital; Rozzano-Milano
| | - S. Marcheselli
- Neurologia d'Urgenza and Stroke Unit; IRCCS Humanitas Research Hospital; Rozzano-Milano
| | - M. Rasura
- Stroke Unit; Azienda Ospedaliera Sant'Andrea; Università ‘La Sapienza’; Roma
| | - N. Pugliese
- U.O.C. Neurologia; A.O. Universitaria ‘San Giovanni di Dio e Ruggi d'Aragona’; Salerno
| | - M. Melis
- Stroke Unit; Azienda Ospedaliera ‘G. Brotzu’; Cagliari
| | - P. Bovi
- UO Neurologia; Azienda Ospedaliera-Universitaria Borgo Trento; Verona
| | - A. Padovani
- Dipartimento di Scienze Cliniche e Sperimentali; Clinica Neurologica; Università degli Studi di Brescia; Brescia
| | - A. Burlina
- Neurologia; Dipartimento di Medicina Interna; Ospedale San Bassiano; Bassano del Grappa Italy
| | - A. Pezzini
- Dipartimento di Scienze Cliniche e Sperimentali; Clinica Neurologica; Università degli Studi di Brescia; Brescia
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7
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Abdul-Rahim AH, Fulton RL, Frank B, Tatlisumak T, Paciaroni M, Caso V, Diener HC, Lees KR. Association of improved outcome in acute ischaemic stroke patients with atrial fibrillation who receive early antithrombotic therapy: analysis from VISTA. Eur J Neurol 2014; 22:1048-55. [DOI: 10.1111/ene.12577] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 08/01/2014] [Indexed: 12/17/2022]
Affiliation(s)
- A. H. Abdul-Rahim
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
| | - R. L. Fulton
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
| | - B. Frank
- Department of Neurology; University Hospital Essen; Essen Germany
| | - T. Tatlisumak
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - M. Paciaroni
- Stroke Unit and Division of Internal and Cardiovascular Medicine; University of Perugia; Perugia Italy
| | - V. Caso
- Stroke Unit and Division of Internal and Cardiovascular Medicine; University of Perugia; Perugia Italy
| | - H.-C. Diener
- Department of Neurology; University Hospital Essen; Essen Germany
| | - K. R. Lees
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
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8
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Pezzini A, Grassi M, Paciaroni M, Zini A, Silvestrelli G, Del Zotto E, Caso V, Dell'Acqua ML, Giossi A, Volonghi I, Simone AM, Lanari A, Costa P, Poli L, Morotti A, De Giuli V, Pepe D, Gamba M, Ciccone A, Ritelli M, Colombi M, Agnelli G, Padovani A. Antithrombotic medications and the etiology of intracerebral hemorrhage: MUCH-Italy. Neurology 2014; 82:529-35. [DOI: 10.1212/wnl.0000000000000108] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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9
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Santalucia P, Pezzella FR, Sessa M, Monaco S, Torgano G, Anticoli S, Zanoli E, Maimone Baronello M, Paciaroni M, Caso V. Sex differences in clinical presentation, severity and outcome of stroke: results from a hospital-based registry. Eur J Intern Med 2013; 24:167-71. [PMID: 23167980 DOI: 10.1016/j.ejim.2012.10.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 10/16/2012] [Accepted: 10/17/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Sex related differences in cardiovascular disease and stroke are issues of increasing interest. The aim of this study was to evaluate for sex differences in clinical presentation, severity of stroke and outcome in a population of patients admitted to 4 public and 1 private hospitals in three different regions of Italy. METHODS All hospital admissions for ischemic and haemorrhagic stroke (ICD-IX code 434 and 431 respectively) between January 1st and December 31st, 2011 at five different hospitals located in three different regions of Italy: Milan (North), Rome and Perugia (Center), and Palermo (South) have been recorded and sex-differences have been evaluated. RESULTS A total of 1272 stroke patients were included in the analysis: 1152 ischemic and 120 haemorrhagic strokes, 567 women and 705 men. Compared to men, women were significantly older (mean age 75.2 SD 13.7 vs 71.5 SD 12.5 years, P<0.001) and their stroke severities at onset, measured by NIHSS, were also compared to men (10 SD 8 vs 8 SD 7, P<0.001). Female sex was associated with a worse functional prognosis measured by modified Rankin Scale score (mRS≥3), as well as in-hospital mortality, without reaching statistical significance. There were no observed significant differences between sexes regarding the number of patients treated with thrombolytic therapy. Analysis of the distribution of risk factors between sexes showed a prevalence of atrial fibrillation in women (29% vs 21%, P=0.003). CONCLUSIONS Both stroke severity and functional outcome were worse in women.
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Affiliation(s)
- P Santalucia
- Scientific Direction and Emergency Medicine Dpt., Fondazione IRCCS Ospedale Maggiore Cà Granda Policlinico, Milan, Italy.
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10
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Abstract
Hormone-replacement therapy (HRT) has been used for more than 40 years to reduce perimenopausal symptoms. Estrogens may protect brain structures and functional systems affected by Alzheimer's disease, which suggests that maintaining high levels of hormones with HRT can protect against Alzheimer's disease. Moreover, high premenopausal estrogen concentrations are thought to be protective against stroke and, consequently, in the past, HRT was considered to be a potential protective agent against stroke. However, large clinical trials have failed to demonstrate a benefit from HRT on either cognitive performance or risk of dementia. In addition, although HRT has been associated with a reduction in the risk of heart disease in observational studies, results regarding stroke have been less clear. Recently, evidence has shown that HRT does not reduce but actually increases vascular risk. Here, the data from the most important studies are examined, concluding that HRT has no beneficial effect on dementia or stroke risk reduction in postmenopausal women.
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Affiliation(s)
- Amr Billeci
- University of Perugia, Stroke Unit and Division of Cardiovascular Medicine, Ospedale SM della Misericordia, Sant'Andrea delle Fratte, 06129 Perugia, Italy.
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11
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Paciaroni M, Agnelli G, Venti M, Alberti A, Acciarresi M, Caso V. Efficacy and safety of anticoagulants in the prevention of venous thromboembolism in patients with acute cerebral hemorrhage: a meta-analysis of controlled studies. J Thromb Haemost 2011; 9:893-8. [PMID: 21324058 DOI: 10.1111/j.1538-7836.2011.04241.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The role of anticoagulants for the prevention of venous thromboembolism in acute hemorrhagic stroke is uncertain. We performed an updated meta-analysis of studies to obtain the best estimates of the efficacy and safety of anticoagulants for the prevention of venous thromboembolism in patients with acute hemorrhagic stroke. METHODS Using electronic and manual searches of the literature, we identified randomized and non-randomized studies comparing anticoagulants (unfractionated heparin or low-molecular-weight heparin or heparinoids) with treatments other than anticoagulants (elastic stockings, intermittent pneumatic compression or placebo) in patients with acute hemorrhagic stroke. Study outcomes included symptomatic and asymptomatic deep venous thrombosis (DVT), symptomatic and asymptomatic pulmonary embolism (PE), any hematoma enlargement or death. Risk ratios (RRs) for individual outcomes were calculated for each study and data from all studies were pooled using the Mantel-Haenszel method. RESULTS Four studies (two randomized) involving 1000 patients with acute hemorrhagic stroke met the criteria for inclusion in this meta-analysis. Compared with other treatments, anticoagulants were associated with a significant reduction in PE (1.7% vs. 2.9%; RR, 0.37; 95% CI, 0.17-0.80; P = 0.01), a DVT rate of 4.2% compared with 3.3% (RR, 0.77; 95% CI, 0.44-1.34; P = 0.36), an increase in any hematoma enlargement (8.0% vs. 4.0%; RR, 1.42; 95% CI, 0.57-3.53; P = 0.45), and a non-significant reduction in mortality (16.1% vs. 20.9%; RR, 0.76; 95% CI, 0.57-1.03; P = 0.07). CONCLUSIONS Our findings indicate that in patients with hemorrhagic stroke, early anticoagulation is associated with a significant reduction in PE and a non-significant reduction in mortality, with the trade-off of a non-significant increase in hematoma enlargement. These results must be taken with caution and should encourage the assessment of the clinical benefit of antithrombotic prophylaxis in patients with cerebral bleeding by properly designed clinical trials.
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Affiliation(s)
- M Paciaroni
- Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy.
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12
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Micheli S, Paciaroni M, Corea F, Agnelli G, Zampolini M, Caso V. Cervical Artery Dissection: Emerging Risk Factors~!2009-05-11~!2010-12-31~!2010-06-14~! Open Neurol J 2010. [DOI: 10.2174/1874205x01004020050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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13
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Micheli S, Paciaroni M, Corea F, Agnelli G, Zampolini M, Caso V. Cervical artery dissection: emerging risk factors. Open Neurol J 2010; 4:50-5. [PMID: 21270941 PMCID: PMC3026338 DOI: 10.2174/1874205x01004010050] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Revised: 12/31/2009] [Accepted: 12/31/2009] [Indexed: 01/13/2023] Open
Abstract
Cervical artery dissection (CAD) represents an increasingly recognized cause of stroke and the most common cause of ischemic stroke in young adults. Many factors have been identified in association with CAD such as primary disease of arterial wall (fibrodysplasia) and other non-specific diseases related to CAD like Ehlers Danlos-syndrome IV, Marfan's syndrome, vessel tortuosity. Moreover, an underlying arteriopathy which could be in part genetically determined, has been suspected. The rule of emerging risk factors for CAD such as recent respiratory tract infection, migraine and hyperhomocysteinemia are still a matter of research. Other known risks factors for CAD are major head/neck trauma like chiropractic maneuver, coughing or hyperextension injury associated to car. We examined emerging risks factors for CAD detected in the last years, as CAD pathogenesis is still not completely understood and needs further investigations.
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Affiliation(s)
- S Micheli
- Department of Rehabilitation, SC Riabilitazione Intensiva Neuromotoria, Trevi, Italy
| | - M Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - F Corea
- Department of Rehabilitation, UO Gravi Cerebrolesioni Acquisite, Ospedale San Giovanni, Foligno, Italy
| | - G Agnelli
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - M Zampolini
- Department of Rehabilitation, UO Gravi Cerebrolesioni Acquisite, Ospedale San Giovanni, Foligno, Italy
| | - V Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
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14
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Teive HA, Munhoz RP, Paciaroni M, Bogousslavsky J. HOW DID STROKE BECOME OF INTEREST TO NEUROLOGISTS? A SLOW 19TH CENTURY SAGA. Neurology 2010; 74:1006; author reply 1006. [DOI: 10.1212/wnl.0b013e3181d2b715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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15
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Abstract
Strokes that remain without a definite cause even after extensive work-up are classified as cryptogenic. These constitute about 30-40% of all strokes. Stroke aetiology may remain undetermined for the following reasons: (i) the cause of stroke is transitory or reversible and the diagnostic work-out is not therefore performed at the appropriate time; (ii) all known causes of stroke are not fully investigated; (iii) some causes of stroke remain unknown. Recent studies have challenged the previous view that cryptogenic stroke is a relatively benign cerebrovascular event, and have shown that cryptogenic stroke is associated with a higher rate of recurrence and adverse outcome at long-term follow-up. The determination of stroke aetiology is a valuable procedure to avoid the risk of stroke recurrence, especially in young patients. In this review, we discuss new evidence on the aetiology of cryptogenic stroke, specifically focusing on patients with patent foramen ovale and atheroma of the aortic arch.
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Affiliation(s)
- F Guercini
- Stroke Unit and Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy.
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16
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Abstract
Synergy between hyperhomocysteinaemia and conventional risk factors for stroke
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17
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Paciaroni M, Agnelli G, Caso V, Venti M, Alberti A, Milia P, Silvestrelli G, Biagini S. Prior use of antithrombotic agents and neurological functional outcome at discharge in patients with ischemic stroke. J Thromb Haemost 2006; 4:1957-61. [PMID: 16961603 DOI: 10.1111/j.1538-7836.2006.02095.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Studies in experimental animals have suggested that antithrombotic agents may have a neuroprotective effect after an ischemic injury. The aim of this study was to analyze the effect of prior use of antithrombotic agents (antiplatelets or anticoagulants) on neurological functional outcome in patients with acute ischemic stroke. SUBJECTS AND METHODS Consecutive patients included in the Perugia Stroke Registry were considered for this analysis. Neurological functional outcome was evaluated at discharge using the modified Rankin Scale (mRS >or= 3 disabling stroke). RESULTS Of the 1921 patients included in the analysis (mean age 76.3 +/- 12.5 years; 53% males), 662 (34.5%) were on antithrombotic treatment (581 antiplatelets, 71 anticoagulants and 10 antiplatelets associated with anticoagulants). One hundred and twenty-two patients (6.4%) died in hospital; at discharge 712 patients (37.1%) were disabled and 1,087 patients (56.6%) were non-disabled. Fifty-four (44.3%) of the deceased patients and 270 (37.9%) of disabled patients were on antithrombotic treatment, while 338 (31.1%) non-disabled patients were taking antithrombotic agents. From multivariate analysis, age and stroke severity were associated with an adverse outcome. Male gender, dyslipidemia, stroke due to small vessel disease and no history of previous stroke were associated with an improved outcome, while no correlation was found between prior use of antithrombotic agents and outcome (mortality odds ratio; OR = 1.32, 95% confidence interval; CI 0.85-2.04; P = 0.20, mortality or disability OR = 0.95, 95% CI 0.72-1.25; P = 0.80). CONCLUSION Prior use of antithrombotic agents does not improve the functional outcome in patients with acute ischemic stroke.
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Affiliation(s)
- M Paciaroni
- Stroke Unit and Division of Internal and Cardiovascular Medicine, University of Perugia, Italy.
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18
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Paciaroni M, Georgiadis D, Arnold M, Gandjour J, Keseru B, Fahrni G, Caso V, Baumgartner RW. Seasonal variability in spontaneous cervical artery dissection. J Neurol Neurosurg Psychiatry 2006; 77:677-9. [PMID: 16614034 PMCID: PMC2117448 DOI: 10.1136/jnnp.2005.077073] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We examined the seasonal variability of spontaneous cervical artery dissection (sCAD) by analysing prospectively collected data from 352 patients with 380 sCAD (361 symptomatic sCAD; 305 carotid and 75 vertebral artery dissections) admitted to two university hospitals with a catchment area of 2,200,000 inhabitants between 1985 and 2004. Presenting symptoms and signs of the 380 sCAD were ischaemic stroke in 241 (63%), transient ischaemic attack in 40 (11%), retinal ischemia in seven (2%), and non-ischaemic in 73 (19%) cases; 19 (5%) were asymptomatic sCAD. A seasonal pattern, with higher frequency of sCAD in winter (31.3%; 95% confidence interval (CI): 26.5 to 36.4; p=0.021) compared to spring (25.5%; 95% CI: 21.1 to 30.3), summer (23.5%; 95% CI: 19.3 to 28.3), and autumn (19.7%; 95% CI: 15.7 to 24.1) was observed. Although the cause of seasonality in sCAD is unclear, the winter peaks of infection, hypertension, and aortic dissection suggest common underlying mechanisms.
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MESH Headings
- Adult
- Aortic Dissection/epidemiology
- Aortic Aneurysm/epidemiology
- Carotid Artery, Internal, Dissection/diagnosis
- Carotid Artery, Internal, Dissection/epidemiology
- Carotid Artery, Internal, Dissection/etiology
- Cerebral Infarction/diagnosis
- Cerebral Infarction/epidemiology
- Cerebral Infarction/etiology
- Cohort Studies
- Comorbidity
- Cross-Sectional Studies
- Female
- Hospitals, University
- Humans
- Hypertension/epidemiology
- Incidence
- Infections/epidemiology
- Magnetic Resonance Angiography
- Male
- Middle Aged
- Neurologic Examination/statistics & numerical data
- Prospective Studies
- Risk Factors
- Seasons
- Statistics as Topic
- Switzerland
- Tomography, X-Ray Computed
- Ultrasonography, Doppler, Transcranial
- Vertebral Artery Dissection/diagnosis
- Vertebral Artery Dissection/epidemiology
- Vertebral Artery Dissection/etiology
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Affiliation(s)
- M Paciaroni
- Stroke Unit, University Hospital Perugia, Italy
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19
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Abstract
An improvement in patient arrival time to stroke unit (SU) is recommended, since earlier stroke management seems to improve 'per se' functional outcome. The objective of this study was to determine if early admission influences the outcome, reduces disability and mortality at discharge and three months later independent of tlirombolytic treatment. Consecutive acute stroke patients admitted to SU between January 1st 2000 and December 31st 2003 were studied in order to analyze the actual role of acute management independent specific pharmacological treatment, we excluded subjects who underwent rt-PA. 35.8% of 2,041 consecutive stroke patients arrived within 3 hours; 62.4% within 6 hours; 37.6% arrived later. Approximately 80% of the <6 hour patients presented a National Institutes of Health Stroke Scale (NIHSS) >4 and modified Rankin Scale (mRS) score >2 in comparison with 60% of the >6 hour patients. In hospital (8.7%) and three-month (7.3%) mortality in <3 hour patients were not significantly different from what observed in >3 hour patients (6.8% and 6.1% respectively) while functional outcome after three months was better in <3 hour patients (NIHSS: 34.6 vs 15.2; mRS: 32.9% vs 16.8%). Old age, history of TIA, cardioembolic etiology, severity of neurological deficit and hemorrhagic stroke type all led to earlier arrival time. Admission within 3 hours 'per se' improves outcome and reduced disability at three months.
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20
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Pezzini A, Caso V, Zanferrari C, Del Zotto E, Paciaroni M, Bertolino C, Grassi M, Agnelli G, Padovani A. Arterial hypertension as risk factor for spontaneous cervical artery dissection. A case-control study. J Neurol Neurosurg Psychiatry 2006; 77:95-7. [PMID: 16361604 PMCID: PMC2117399 DOI: 10.1136/jnnp.2005.063107] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2005] [Revised: 03/23/2005] [Accepted: 04/04/2005] [Indexed: 11/04/2022]
Abstract
Because of the presumed non-atherosclerotic pathogenesis, the potential link between spontaneous cervical artery dissection (sCAD) and common risk factors for atherosclerosis has never been investigated systematically. Therefore, this prospective, multicentre, case-control study compared the frequency of tobacco use, hypertension, diabetes mellitus, and hypercholesterolaemia among a group of consecutive patients with sCAD (n = 153), a group of patients with ischaemic stroke, not related to CAD (non-CAD), and a group of controls. As opposed to the other variables, a trend towards a significant association was seen when the prevalence of hypertension was compared among patients with sCAD and controls (26.8% v 17.0%; odds ratio (OR) 1.79; 95% confidence interval (CI), 0.98 to 3.27; p = 0.058). Hypertension was also significantly associated with the subgroup of patients with sCAD and cerebral infarction (OR, 1.94; 95% CI, 1.01 to 3.70; p = 0.045), particularly when involving the vertebral arteries (OR, 2.69; 95% CI, 1.20 to 6.04; p = 0.017). These findings might help define the spectrum of pathogenic conditions predisposing to sCAD and provide information to help investigate the combined effect of such susceptibility factors in future studies.
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Affiliation(s)
- A Pezzini
- Clinica Neurologica, Università degli Studi di Brescia, P. le Spedali Civili, 1, 25100 Brescia, Italia.
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21
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Paciaroni M, Caso V, Acciarresi M, Baumgartner RW, Agnelli G. Management of asymptomatic carotid stenosis in patients undergoing general and vascular surgical procedures. J Neurol Neurosurg Psychiatry 2005; 76:1332-6. [PMID: 16170071 PMCID: PMC1739358 DOI: 10.1136/jnnp.2005.066936] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Current available data do not seem to support the strategy for carotid endarterectomy prior to surgical intervention in patients with asymptomatic carotid stenosis. However, in patients with coronary artery disease, synchronous carotid endarterectomy and coronary artery bypass grafting should be considered where there is a proven surgical risk of <3% with unilateral asymptomatic stenosis >60% or bilateral carotid stenosis >75% on the same side as the most severe stenosis. Clarification of the optimal strategy requires an adequately powered, multicentre, randomised clinical trial.
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Affiliation(s)
- M Paciaroni
- Stroke Unit, University of Perugia, Ospedale Silvestrini, Sant'Andrea delle Fratte, Perugia 06126, Italy.
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22
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Paciaroni M, Agnelli G, Caso V, Venti M, Milia P, Silvestrelli G, Parnetti L, Biagini S. Atrial fibrillation in patients with first-ever stroke: frequency, antithrombotic treatment before the event and effect on clinical outcome. J Thromb Haemost 2005; 3:1218-23. [PMID: 15892862 DOI: 10.1111/j.1538-7836.2005.01344.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSES Atrial fibrillation (AF) is an independent risk factor for stroke. The aims of this study were to assess: (i) the frequency of known or unknown AF in patients admitted to the hospital for a first-ever ischemic stroke and whether AF is associated with an adverse outcome at discharge (death or disability); (ii) the rates and determinants for the use of antithrombotic agents before stroke in patients with known AF and the adherence to the current treatment guidelines; and (iii) whether the lack of adherence to the current guidelines is associated with adverse outcome at discharge. METHODS Consecutive patients with acute first-ever stroke admitted to an individual Stroke Unit between January 2000 to December 2003, were included in the study. Twelve-lead electrocardiogram (ECG) was performed in all patients on admission. Functional outcome was measured at discharge according to modified Rankin Score. RESULTS A total of 1549 patients were included in the study: 238 patients (15.4%) were known to have AF and 76 (4.9%) were diagnosed with AF (unknown) on ECG performed on admission. At discharge 91 patients (5.9%) had died and 605 patients (39.0%) had died or were functionally dependent. Multivariate analysis showed that AF on admission was correlated with mortality or disability (OR = 1.58, 95% CI 1.09-2.30, P = 0.015). Before stroke, 124 out of 238 patients with known AF (52.1%) were not on antithrombotic therapy, 83 (34.9%) were receiving antiplatelet and 31 (13.0%) anticoagulant treatment. Previous transient ischemic attack, history of ischemic heart disease and hyperlipidemia were associated with the use of antithrombotic therapy. Only 24 out of 114 patients on antithrombotic treatment on admission were adequately treated according to the current guidelines. Of the adequately treated patients, 41.7% died or were disabled at discharge respect to 52.3% of the patients non-adequately treated (RR = 0.80, 95% CI 0.48-1.30). CONCLUSIONS AF (on history or new diagnosis) was present in 20.3% of the patients with first-ever stroke admitted to a Stroke Unit and it was associated with increased mortality or disability. Only 10% of patients with known AF were previously receiving an adequate antithrombotic treatment according to current guidelines.
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Affiliation(s)
- M Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy.
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23
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Abstract
BACKGROUND Some investigators have stated that monoparesis is almost never the result of a lacunar infarct or cerebral haemorrhage. OBJECTIVE To describe the topography and aetiology in a consecutive population where first ever stroke was manifested by isolated monoparesis. METHODS Patients with motor paresis of only one limb were included consecutively in the study. A neuroradiologist determined stroke location, while a neurologist reviewed the clinical records to assign stroke subtype. Both physicians worked blind to each other's findings. RESULTS 51 of 2003 patients (2.5%) had isolated monoparesis, and of these 39 (76.5%) were ischaemic strokes and 12 (23.5%) were haemorrhagic. Cardioembolism was the cause of stroke in 15.7%, atherosclerosis in 9.8%, and small artery disease in 39.2%. Most of the haemorrhages were in the thalamic-capsular region (5/12). Most of the ischaemic lesions were in the deep territory of the middle cerebral artery, the corona radiate, or the centrum semiovale (20/39); 16 of 39 were in the cortical territories or the watershed region. CONCLUSIONS Isolated monoparesis is a rare symptom in stroke patients and is often caused by small artery disease or a small haemorrhage.
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Affiliation(s)
- M Paciaroni
- Stroke Unit, Department of Neuroscience, University of Perugia, Via Enrico dal Pozzo, 06126 Perugia, Italy.
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24
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Paciaroni M, Caso V, Agnelli G. Magnetic resonance imaging, magnetic resonance and catheter angiography for diagnosis of cervical artery dissection. Front Neurol Neurosci 2005; 20:102-118. [PMID: 17290116 DOI: 10.1159/000088155] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Catheter angiography has been considered the standard of reference for the diagnosis of spontaneous cervical artery dissection (CAD), but carries a risk of complications and does not demonstrate the arterial wall. The most common angiographic finding is a relatively smooth or slightly irregular tapered arterial narrowing. Conversely, angiographic appearance of cervical artery occlusion due to CAD is nonspecific, because other causes such as thromboembolism or atherosclerotic disease may present very similar angiographic characteristics. Magnetic resonance imaging (MRI) is an alternative noninvasive approach and the only reliable possibility to diagnose occlusive dissection. MRI demonstrates the hyperintense, crescent- shaped wall hematoma and an eccentric flow void of the patent lumen. Intramural hematoma shows a typical evolution of signal intensity over time with intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images in the first 3 days. In the following days, most intramural hematoma show slightly or definitively increased signal intensity on T1- and T2-weighted images. After this, signal intensity of the hematoma increases and remains high for approximately 2 months. Magnetic resonance angiography shows the same findings as catheter angiography, and allows in combination with MRI to determine the extent of CAD.
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Affiliation(s)
- M Paciaroni
- Stroke Unit, University of Perugia, Perugia, Italy
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25
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Abstract
A history of a minor precipitating event is frequently elicited in patients with a spontaneous dissection of the carotid or vertebral artery. Other precipitating events associated with hyperextension or rotation of the neck include practicing yoga, painting a ceiling, coughing, vomiting, sneezing, the receipt of anesthesia, and the act of resuscitation. Chiropractic manipulation of the neck has been associated with carotid artery dissection and, particularly, vertebral artery dissection. Another risk factor for spontaneous dissections seems to be a recent history of a respiratory tract infection. The possibility of an infectious trigger is supported by the finding of a seasonal variation in the incidence of spontaneous dissections, with a peak incidence in fall. A potential link with common risk factors for vascular disease, such as tobacco use, hypertension, and the use of oral contraceptives, has not been systematically evaluated, but atherosclerosis appears to be distinctly uncommon in patients with a dissection of the carotid or vertebral arteries. In conclusion, although any hypotheses on the pathogenic mechanisms linking environmental factors and dissection remain speculative at present, we believe that these hypotheses may contribute to better define the spectrum of pathogenic conditions predisposing a cervical artery to dissection and provide arguments to better investigate the single or combined effect of such susceptibility factors in future studies.
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Affiliation(s)
- V Caso
- Stroke Unit, Division of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
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Mazzotta G, Sarchielli P, Caso V, Paciaroni M, Floridi A, Floridi A, Gallai V. Different cytokine levels in thrombolysis patients as predictors for clinical outcome. Eur J Neurol 2004; 11:377-81. [PMID: 15171733 DOI: 10.1111/j.1468-1331.2004.00798.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Thrombolytic therapy not always improves clinical outcome in ischemic stroke patients. This could cause lymphomonocyte accumulation in the infarcted brain area. These produce an excessive amount of proinflammatory cytokines, such as IL-1 beta, IL-6 and TNF-alfa. The aim of our study was to determine ILs levels in fibrinolytic therapy treated patients, compared with healthy controls and to evaluate if the varying levels can predictors of neurological outcome. Eighteen patients underwent thrombolytic treatment with t-PA within 3 h. Plasma levels of IL-1 beta, IL-6, TNF-alfa and IL-10 were determined by ELISA method before and within 24 h after t-PA infusion and compared with controls. Significantly higher levels of IL-1 beta and Il-6 emerged in stroke patients before treatment compared with the control group (P < 0.05 and 0.04, respectively). Slightly higher plasma levels of TNF-alfa and lower plasma levels of IL-10 were also found at base line in stroke patients. After thrombolytic treatment no significant variations were observed in the levels of TNF-alfa and IL-6, whereas a trend toward lower values for IL-1 beta and higher levels for IL-10 was observed. Positive correlations among the values of IL-6, TNF-alfa and National Institute of Health Stroke Scale (NIHSS) at discharges were observed. A similar correlation with modified Rankin scale score at 3 month was found. Pre-treatment cytokine status seems to influence pre-and long-term clinical outcome. Therefore an investigation into the possible predictor of cytokines seem worthy.
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Affiliation(s)
- G Mazzotta
- Stroke Unit, Department of Neuroscience, University of Perugia, Italy
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Paciaroni M, Silvestrelli G, Caso V, Corea F, Venti M, Milia P, Tambasco N, Parnetti L, Gallai V. Neurovascular territory involved in different etiological subtypes of ischemic stroke in the Perugia Stroke Registry. Eur J Neurol 2003; 10:361-5. [PMID: 12823486 DOI: 10.1046/j.1468-1331.2003.00646.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED We studied the correlation between the potential causes of stroke (TOAST etiological groups) and the involvement of different vascular territories seen on computed tomography (CT) scans in patients with ischemic stroke. Information from consecutive patients with a first-ever stroke have been prospectively coded and entered into a computerized data bank (Perugia Stroke Registry). A population of 1,719 patients were evaluated: 1,284 patients (74.7%) had ischemic stroke. Large artery disease was the main cause of entire middle cerebral artery (MCA) territory infarcts (40.9%), superficial MCA territory infarcts (35.7%), and watershed infarcts (68.2%). The highest presence of emboligenic heart disease was found in the entire MCA territory infarcts (28.8%) or superficial (29.4%) supratentorial infarcts and in cerebellar infarcts (36.8%). Small artery disease was the most common presumed cause of deep MCA infarcts (75.0%) and posterior cerebral artery (PCA) territory infarcts (52.1%). IN CONCLUSION stroke location could depend on its etiology. Lacunar infarcts are the most prevalent (36.7%), being mostly localized in the deep MCA territory; large artery disease includes more than two-thirds of watershed infarcts; the most prevalent territories involved in cardioembolic stroke are the entire MCA and posterior fossa.
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Affiliation(s)
- M Paciaroni
- Stroke Unit, Department of Neuroscience, University of Perugia, Perugia, Italy.
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Tambasco N, Pelliccioli GP, Chiarini P, Montanari GE, Leone F, Mancini ML, Paciaroni M, Gallai V. Magnetization transfer changes of grey and white matter in Parkinson's disease. Neuroradiology 2003; 45:224-30. [PMID: 12687305 DOI: 10.1007/s00234-002-0925-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2002] [Accepted: 11/25/2002] [Indexed: 11/28/2022]
Abstract
Since the attempt to evidence structural brain damage in Parkinson's disease (PD) by conventional magnetic resonance imaging (MRI) is usually disappointing, we have investigated whether the magnetization transfer ratio (MTR) can reflect changes in grey and white matter of PD patients. MTR was quantified in 44 regions of interest (ROIs) in both grey and white matter of 11 non-demented PD patients, ranging from 2 to 4 on the Hoehn and Yahr Scale, and eight age-matched healthy subjects. MTR differences between patients and controls were found in the supratentorial white matter and in the brainstem. In particular, lower MTR values were found in the paraventricular white matter of PD patients (p<0.05) while no differences were observed in corpus callosum, frontal, parietal, occipital lobes or centrum semiovalis. Lower MTR values were found in substantia nigra (p<0.001), red nucleus (p<0.05) and pons (p<0.05) of the patient group. No differences were discovered in basal ganglia and thalamus. These findings suggest that MTR measurements in the paraventricular white matter and brainstem may help to recognize a marker for probable PD.
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Affiliation(s)
- N Tambasco
- Department of Neuroscience, University of Perugia, via Enrico dal Pozzo, 06126 Perugia, Italy.
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Caso V, Paciaroni M, Parnetti L, Cardaioli G, Biscarini L, Acciarini AE, Rubino S, Gallai V. Stroke related to carotid artery dissection in a young patient with Takayasu arteritis, systemic lupus erythematosus and antiphospholipid antibody syndrome. Cerebrovasc Dis 2002; 13:67-9. [PMID: 11810014 DOI: 10.1159/000047749] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Autoimmune diseases are rarely the cause of stroke even in the young age group in association with cervical artery dissection and collagen vascular diseases. Takayasu arteritis is a chronic, idiopathic, inflammatory disease that primarily affects large vessels, such as the aorta and its main branches. Takayasu arteritis rarely coexists with systemic lupus erythematosus, and only few cases have been reported in association with the presence of antiphospholipid antibodies. We describe a young patient with right internal carotid artery dissection and subsequent stroke who presented with all three syndromes. Although this patient met the diagnostic criteria for each syndrome, systemic lupus erythematosus, Takayasu arteritis and the antiphospholipid antibody syndrome, it remains unlikely that the three disorders are not related. We suggest a single disimmune disorder may have led to carotid artery dissection.
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Affiliation(s)
- V Caso
- Stroke Unit, Department of Neuroscience, Unit of Internal Medicine and Oncological Sciences, University of Perugia, Italy
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Gallai V, Caso V, Paciaroni M, Cardaioli G, Arning E, Bottiglieri T, Parnetti L. Mild hyperhomocyst(e)inemia: a possible risk factor for cervical artery dissection. Stroke 2001; 32:714-8. [PMID: 11239192 DOI: 10.1161/01.str.32.3.714] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The pathogenesis of cervical artery dissection (CAD) remains unknown in most cases. Hyperhomocyst(e)inemia [hyperH(e)], an independent risk factor for cerebrovascular disease, induces damage in endothelial cells in animal cell culture. Consecutive patients with CAD and age-matched control subjects have been studied by serum levels of homocyst(e)ine and the genotype of 5,10-methylenetetrahydrofolate reductase (MTHFR). METHODS Twenty-six patients with CAD, admitted to our Stroke Unit (15 men and 11 women; 16 vertebral arteries, 10 internal carotid arteries), were compared with age-matched control subjects. All patients underwent duplex ultrasound, MR angiography, and/or conventional angiography. RESULTS Mean plasma homocyst(e)ine level was 17.88 micromol/L (range 5.95 to 40.0 micromol/L) for patients with CAD and 6.0+/-0.99 micromol/L for controls (P:<0.001). The genetic analysis for the thermolabile form of MTHFR in CAD patients showed heterozygosity in 54% and homozygosity in 27%; comparable figures for controls were 40% (P:=0.4) and 10% (P:=0.1), respectively. CONCLUSIONS Mild hyperH(e) might represent a risk factor for cervical artery dissection. The MTHFR mutation is not significantly associated with CAD. An interaction between different genetic and environmental factors probably takes place in the cascade of pathogenetic events leading to arterial wall damage.
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Affiliation(s)
- V Gallai
- Neuroscience Department, University of Perugia, Perugia, Italy.
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31
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Affiliation(s)
- M Paciaroni
- Department of Neuroscience, University of Perugia, Italy
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Affiliation(s)
- J Bogousslavsky
- Department of Neurology, University of Lausanne, Switzerland
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Abstract
We studied 25 patients with an acute thalamic stroke (infarct or hemorrhage) on CT or MRI scan and sensory dysfunction, among the 3,628 patients with first-time stroke included in the Lausanne Stroke Registry. Twelve patients had a right-sided infarct, 11 a left-sided infarct, and 2 a left-sided thalamic hemorrhage. Sensory symptoms or signs were the only clinical abnormality. The presumed causes of stroke were small artery disease in 21 patients including both cases of hemorrhage, emboligenic heart disease in 2, while the etiology of ischemic stroke was undetermined in 2 patients. Nine patients had a loss of all modalities of sensation with faciobrachiocrural distribution, 5 patients suffered dissociated sensory loss with faciobrachiocrural distribution and 11 patients showed a dissociated involvement of sensation with a partial distribution pattern. The inferolateral region (thalamogeniculate arteries) was involved in all patients. Six patients complained of pain and/or dysesthesias during the stroke; 5 of them had involvement of the nucleus ventrocaudalis (in 3 with damage to the nucleus ventro-oralis intermedius, and in one to the pulvinar) and 1 patient had involvement of the nucleus ventro-oralis intermedius. Eighteen patients complained of paresthesias in the contralateral part of the body; 16 of them had involvement of the nucleus ventrocaudalis (in 4 with damage to the nucleus ventro-oralis intermedius, in 1 with damage to the nucleus ventro-oralis intermedius, and nucleus ventro-oralis externus, and in one with damage to the nucleus parvocellularis and pulvinar). Four patients developed delayed pain and/or dysesthesias; all of them had involvement of the nucleus ventrocaudalis (in 1 with damage to the nucleus parvocellularis and pulvinar). Time lag from stroke onset to developing pain ranged from 2 to 15 days (mean 10.5 days). One patient with dissociated involvement of sensation with a partial distribution pattern had paresthesias and dissociated hemisensory loss involving position sense without pain and temperature sensations. This patient had involvement of the posterolateral part of the nucleus ventrocaudalis. In conclusion, sensory dysfunction and delayed pain are more often found in thalamic lesions that involve the nucleus ventrocaudalis, and nucleus ventro-oralis intermedius. Restricted sensory abnormalities correlate with very small lesions located in critical areas within these nuclei.
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Affiliation(s)
- M Paciaroni
- Service de Neurologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Paciaroni M, Eliasziw M, Sharpe BL, Kappelle LJ, Chaturvedi S, Meldrum H, Barnett HJ. Long-term clinical and angiographic outcomes in symptomatic patients with 70% to 99% carotid artery stenosis. Stroke 2000; 31:2037-42. [PMID: 10978026 DOI: 10.1161/01.str.31.9.2037] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In 1991, the North American Symptomatic Carotid Endarterectomy Trial (NASCET) reported the benefit of carotid endarterectomy for 659 patients with 70% to 99% stenosis. Follow-up continued until 1997. METHODS The present study examined the risks and causes of ipsilateral stroke in the randomized groups and in those who had delayed endarterectomy or continued on medical therapy and also examined the evolution of carotid disease on follow-up imaging. RESULTS By on-treatment (efficacy) analysis, the risk of any ipsilateral stroke at 3 years was 28.3% for medically randomized and 8.9% for surgically randomized patients (19.4% absolute risk reduction, P:<0.001). For combined disabling or fatal ipsilateral stroke, the risks were 14.0% and 3.4%, respectively (10. 6% absolute risk reduction). In medical patients, >80% of the first strokes at 3 years were of large-artery origin. After February 1991, 116 suitable medical patients underwent endarterectomy within 6 months, and 115 continued on medical therapy. The 3-year risk of any ipsilateral stroke in the groups of 116 and 115 patients was 7.9% and 15.0%, respectively (7.1% absolute risk reduction). During follow-up, 81 patients had angiograms comparable to the baseline images. Progression by >/=10% occurred in 7 patients; regression, in 8; no change, in 39; and occlusion, in 27. By use of both angiography and ultrasound, 63 (25.5%) of the 247 medically treated patients progressed to occlusion, of whom 31.7% had an ipsilateral stroke before or on the day of occlusion. CONCLUSIONS Endarterectomy for patients with 70% to 99% stenosis and recent symptoms was efficacious in the long term. Compared with patients who continued on medical therapy, medical patients with delayed endarterectomy experienced a moderate benefit. Medically treated patients experienced a high risk of occlusion.
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Affiliation(s)
- M Paciaroni
- Department of Neuroscience, University of Perugia, Perugia, Italy
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35
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Abstract
BACKGROUND Several studies have attempted to identify criteria for predicting functional prognosis after stroke, but often with contradictory results. The purpose of this study was to predict the functional outcome at discharge of first-time stroke patients included consecutively in the Lausanne Stroke Registry. METHODS We studied 3,628 sequential patients with first-ever stroke who were admitted consecutively to the Centre Hospitalier Universitaire Vaudois. Functional status was evaluated using the Rankin disability scale at discharge. We studied the prognostic value of historical, clinical and instrumental variables related to functional outcome at discharge. The factors studied were age, sex, risk factors, ECG results, occurrence of transient ischemic attacks (TIAs), extension of cerebral infarction, presumed cause of stroke, clinical findings and demographic characteristics. Univariate analysis was performed on each variable by comparing the number of functionally independent with that of dependent patients at the moment of discharge. The significant variables of the univariate analysis were subjected to multivariate analysis with a backward logistic regression procedure to find those with an independent effect on the outcome. RESULTS A total of 3,156 patients, excluding 117 patients with ischemic stroke who died during hospitalization and 355 with brain hemorrhage, were included; 2,867 patients belonged to the nil, mild or moderate disability groups (modified Rankin score 1-4; functionally at least partially independent patients), while 291 patients belonged to the severe disability group (modified Rankin score 5; functionally dependent patients). The mean duration of stay in hospital of the severe disability group was 31.2 days (SD = 16.2). Multivariate analysis showed that impaired consciousness on admission, limb weakness, progressive worsening, infarct in the superficial and deep territory of the middle cerebral artery, ischemic heart disease and cardiac arrhythmia were predictors of severe disability at discharge. Age was not an independent predictor of poor outcome. Hypercholesterolemia was significantly related to a better outcome. CONCLUSIONS Some prognostic indicators associated with functional outcome at discharge are available during the first few hours after onset of stroke. This is important for the management of the individual stroke patient and for organizing suitable rehabilitation planning.
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Affiliation(s)
- M Paciaroni
- Service de Neurologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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36
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Paciaroni M, Eliasziw M, Kappelle LJ, Finan JW, Ferguson GG, Barnett HJ. Medical complications associated with carotid endarterectomy. North American Symptomatic Carotid Endarterectomy Trial (NASCET). Stroke 1999; 30:1759-63. [PMID: 10471420 DOI: 10.1161/01.str.30.9.1759] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Carotid endarterectomy (CE) has been shown to be beneficial in patients with symptomatic high-grade (70% to 99%) internal carotid artery stenosis. To achieve this benefit, complications must be kept to a minimum. Complications not associated with the procedure itself, but related to medical conditions, have received little attention. METHODS Medical complications that occurred within 30 days after CE were recorded in 1415 patients with symptomatic stenosis (30% to 99%) of the internal carotid artery. They were compared with 1433 patients who received medical care alone. All patients were in the North American Symptomatic Carotid Endarterectomy Trial (NASCET). RESULTS One hundred fifteen patients (8.1%) had 142 medical complications: 14 (1%) myocardial infarctions, 101 (7.1%) other cardiovascular disorders, 11 (0.8%) respiratory complications, 6 (0.4%) transient confusions, and 10 (0.7%) other complications. Of the 142 complications, 69.7% were of short duration, and only 26.8% prolonged hospitalization. Five patients died: 3 from myocardial infarction and 2 suddenly. Medically treated patients experienced similar complications with one third the frequency. Endarterectomy was approximately 1.5 times more likely to trigger medical complications in patients with a history of myocardial infarction, angina, or hypertension (P<0.05). CONCLUSIONS Perioperative medical complications were observed in slightly fewer than 1 of every 10 patients who underwent CE. The majority of these complications completely resolved. Most complications were cardiovascular and occurred in patients with 1 or more cardiovascular risk factors. In this selected population, the occurrence of perioperative myocardial infarction was uncommon.
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Affiliation(s)
- M Paciaroni
- John P. Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
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37
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Abstract
Ischemic stroke, myocardial infarction and peripheral arterial disease are different clinical manifestations commonly due to the same underlying disease, i.e. atherosclerosis with subsequent thrombosis/embolism (atherothrombosis). Many clinical trials of secondary prevention after stroke or TIA have evaluated the benefit of long-term use of antiplatelet drugs in reducing the risk of subsequent vascular events. Aspirin and triclopidine have been shown to be effective in placebo-controlled studies for the composite outcome of stroke, myocardial infarction, or vascular death. Contrasting with these benefits, there were potentially serious, though rare, adverse effects. These considerations certainly justify the development of new antiplatelet agents. Clopidogrel is a new ADP-receptor antagonist, with a greater activity in animal models of thrombosis. CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events) was a randomized, blinded, international trial designed to assess the relative efficacy of clopidogrel and aspirin in reducing the risk of the outcome cluster of ischemic stroke, myocardial infarction, or vascular death, as well as to assess their relative safety. 19,185 patients were recruited. The intention-to-treat analysis showed that the relative risk reduction was 8.7% (95% CI 0.3-16.5, p = 0.043) in favor of clopidogrel from an overall annual event rate of ischemic stroke, myocardial infarction, or vascular death, ranging from 5.83% in the aspirin group to 5.33% in the clopidogrel group. The percentage of adverse events reported was higher in the aspirin group for all categories except rash, diarrhea, and abnormal liver function. It seems likely that clopidogrel will replace ticlopidine for stroke prevention, because of its better safety profile, and comparable efficacy. Clopidogrel probably will not replace aspirin as the first line therapy for many clinicians because of its higher cost and lack of widespread experience. However, other clinicians have already decided that they will use clopidogrel as first choice, because of the significant advantage over aspirin demonstrated in the CAPRIE study.
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Affiliation(s)
- M Paciaroni
- Service de Neurologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Affiliation(s)
- G Devuyst
- Department of Neurology, CHUV, Lausanne, Switzerland
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39
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Mazzotta G, Alberti P, Sarchielli A, Paciaroni M, Gallai V. Electromyographical Ischemic Test and Intra and Extracellular Mg++ Concentration in Young Headache Patients. Cephalalgia 1995. [DOI: 10.1177/0333102495015s1692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- G. Mazzotta
- Interuniversity (Perugia-Rome-Sassari-Bari) Centre for the Study of Headache and Neurotransmitter Disorder of the CNS. Italy
| | - P. Alberti
- Interuniversity (Perugia-Rome-Sassari-Bari) Centre for the Study of Headache and Neurotransmitter Disorder of the CNS. Italy
| | - A. Sarchielli
- Interuniversity (Perugia-Rome-Sassari-Bari) Centre for the Study of Headache and Neurotransmitter Disorder of the CNS. Italy
| | - M. Paciaroni
- Interuniversity (Perugia-Rome-Sassari-Bari) Centre for the Study of Headache and Neurotransmitter Disorder of the CNS. Italy
| | - V. Gallai
- Interuniversity (Perugia-Rome-Sassari-Bari) Centre for the Study of Headache and Neurotransmitter Disorder of the CNS. Italy
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Rassu S, Carboni F, Zoroddu F, Ganau G, Milia A, Mastropaolo C, Poddighe M, Gallai V, Sarchielli P, Firenze C, Paciaroni M. Preliminary Report on the use of a Structured Interview for Headache in the Emergency Department. Cephalalgia 1995. [DOI: 10.1177/0333102495015s1638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- S Rassu
- Emergency Department, General Hospital of Sassari, Italy
| | - F Carboni
- Interuniversity Center for the Study of Headache and Neurotransmitter Disorders - Universities of Perugia and Sassari; Italy
| | - F Zoroddu
- Interuniversity Center for the Study of Headache and Neurotransmitter Disorders - Universities of Perugia and Sassari; Italy
| | - G.F. Ganau
- Emergency Department, General Hospital of Sassari, Italy
| | - A Milia
- Emergency Department, General Hospital of Sassari, Italy
| | - C Mastropaolo
- Interuniversity Center for the Study of Headache and Neurotransmitter Disorders - Universities of Perugia and Sassari; Italy
| | - M Poddighe
- Emergency Department, General Hospital of Sassari, Italy
| | - V Gallai
- Interuniversity Center for the Study of Headache and Neurotransmitter Disorders - Universities of Perugia and Sassari; Italy
| | - P Sarchielli
- Interuniversity Center for the Study of Headache and Neurotransmitter Disorders - Universities of Perugia and Sassari; Italy
| | - C Firenze
- Interuniversity Center for the Study of Headache and Neurotransmitter Disorders - Universities of Perugia and Sassari; Italy
| | - M Paciaroni
- Interuniversity Center for the Study of Headache and Neurotransmitter Disorders - Universities of Perugia and Sassari; Italy
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Abstract
We determined the plasma levels of ET1, both interictally and ictally, in 50 migraine patients, 20 with aura (MPA) and 30 without aura (MPWA), comparing them with the levels of 40 age-matched tension-type headache patients (20 episodic and 20 chronic) (ETTHP and CTTHP) and the levels of a group of 20 healthy control subjects (CS). No statistically significant difference was evident between the mean ET1 plasma levels of MPA and those of MPWA, assessed in headache-free periods. The mean ET1 plasma levels of MPA and MPWA, assessed interictally, were significantly higher than those of CS. However, the values of plasma ET1 in ETTP and in CTTHP did not differ statistically from those of CS. MPA and MPWA ET1 plasma levels increased significantly within 2 h from the onset of attacks (p < 0.0001) and remained significantly higher between 4 and 6 h from the onset. The ET1 plasma levels of ETTHP and CTTHP assessed during attacks did not differ statistically from those of the same patients assessed in the headache-free periods. The increase in ET1 levels in MPA and MPWA patients when assessed ictally, suggests that this peptide is involved in the haemodynamic changes and vascular tone modifications observed during migraine attacks, particularly in the first phase of the ictal period.
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Affiliation(s)
- V Gallai
- Interuniversity Center for the Study of Headache and Neurotransmitter Disorders, Perugia, Italy
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Abstract
Neuropeptide Y (NPY) is widely distributed throughout sympathetic nerve endings where it is co-stored and co-secreted with noradrenaline. It is considered a marker of noradrenergic function. To determine the role of NPY in the pathogenesis of juvenile headache, we determined its plasma levels in two groups of young migraine patients (with and without aura), in a group of episodic tension-type headache patients and in a group of age and sex-matched healthy subjects. Significantly lower plasma levels of NPY were evident in the migraine patients with aura (P < 0.001) and, to a lesser extent, in the migraine patients without aura (P < 0.02), both assessed in the interictal period, with respect to the control group. Plasma NPY levels tended to significantly increase during attacks in migraine patients with aura (P < 0.0009). A less evident, though significant increase was also present during attacks in migraine patients without aura (P < 0.02). No significant variations were observed between headache-free periods and attacks in tension-type headache patients. Reduced NPY levels in the interictal period can be considered further evidence of the derangement of the sympathetic function in the course of migraine, particularly that with aura. The increase in NPY levels during migraine attacks could be an expression of sympathetic activation, even though the functional status of this system is less efficient.
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Affiliation(s)
- V Gallai
- Interuniversity Center for the Study of Headache and Neurotransmitter Disorders, Perugia, Italy
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Gallai V, Sarchielli P, Trequattrini A, Paciaroni M. Monocyte chemotactic and phagocytic responses in migraine and tension-type headache patients. Ital J Neurol Sci 1993; 14:153-64. [PMID: 8509270 DOI: 10.1007/bf02335750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Monocyte chemotactic and phagocytic responses were assessed in two groups of migraine patients (with and without aura) and in two groups of tension-type headache patients (episodic and chronic). The chemotactic but not the phagocytic response, assessed interictally, is significantly lower in migraine patients (p < 0.006) and in episodic tension-type headache patients, though not so significantly in the latter (p < 0.05), than in the control individuals. The chemotactic response tends to increase significantly during attack in migraine patients both with and without aura (p < 0.008 and p < 0.007 respectively). The same was evident for the phagocytic response in both migraine patient groups (p < 0.007 and 0.0004). No modifications of monocyte functions were found during attacks neither in episodic nor chronic tension-type headache patients. These findings suggest that one or more mediators of neurogenic inflammation having phagocytic and chemotactic enhancing properties (substance P, prostaglandin E and thromboxane A2 etc.) are implicated in the modification of monocyte function. The demonstration of a defect in monocyte function during the interictal period in migraine patients confirms the results of recent research which evidenced reduced capacity of monocyte to phagocyte and kill microorganisms in the course of migraine.
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Affiliation(s)
- V Gallai
- Centro Interuniversitario, Unità di Perugia
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Gallai V, Gaiti A, Sarchielli P, Coata G, Trequattrini A, Paciaroni M. Evidence for an altered dopamine beta-hydroxylase activity in migraine and tension-type headache. Acta Neurol Scand 1992; 86:403-6. [PMID: 1455988 DOI: 10.1111/j.1600-0404.1992.tb05108.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Sympathetic dysfunction is often present in migraine. It has been suggested that serum dopamine-beta-hydroxylase (D beta H) can be taken as an index of peripheral sympathetic activity. We studied the serum D beta H activity in migraine with and without aura and in tension-type headache patients compared with healthy control subjects. The serum D beta H activity was significantly lower in migraine and tension-type headache patients than in the control group. No significant difference was observed among the three groups of patients studied. These findings suggest that patients with migraine and tension-type headache have a sympathetic hypofunction that may play an important role in the pathogenesis.
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Affiliation(s)
- V Gallai
- Interuniversity Center for the Study of Headache and Neurotransmitter Disorders, University of Perugia, Italy
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