Deep brain stimulation in patients with long history of drug resistant epilepsy and poor functional status: Outcomes based on the different targets

BACKGROUND

Deep brain stimulation (DBS) is a widely used surgical procedure for the treatment of patients with drug resistant epilepsy (DRE) and several anatomical target have been described. Indications for DBS includes patients with focal, partial seizure and those for which resective or disconnective surgery are contraindicated, such as involvement of eloquent cortex or significant comorbidities. Despite the SANTE trial has clearly indicated the efficacy of DBS of anterior nucleus of the thalamus (ANT), specific indications regarding the best anatomical target and outcome in patients with severe disability are lacking. Here we described our case series of patients underwent DBS of three different target including ANT, centromedian thalamic nucleus (CMN) and subthalamic nucleus (STN).

METHOD

Six patients with DRE have been treated with DBS of ANT (n = 3), STN (n = 2) and CMN (n = 1). Outcome has been expressed as seizures frequency reduction and patients functional status after surgery with a follow-up of 5-11 years.

RESULTS

Four out of six patients show no reduction of seizures frequency after DBS implant with one case of increasing atypical absence. Two cases, one ANT and one CMN, show a significant reduction of seizures frequency of 50-60%. No patients improve relative to functional outcome and one showed psychiatric symptoms worsening.

CONCLUSIONS

For patients with DRE and severe functional disability, DBS may reduce seizure frequency in some cases, but it does not improve functional outcome.

Diabetic Retinopathy and Cerebral Hemodynamic Impairment in Type II Diabetes

PURPOSE

To assess whether a screening method based on transcranial Doppler (TCD) examination could detect signs of brain hemodynamic impairment in non-insulin-dependent diabetic patients with retinal microangiopathy of varying severity, asymptomatic for cerebrovascular diseases.

METHODS

We studied 86 patients stratified according to the presence of proliferative diabetic retinopathy (PDR: 29 cases), background retinopathy (BDR: 32 cases) and no diabetic retinopathy (NDR: 25 patients). TCD was performed to record mean flow velocity and pulsatility index values in the middle cerebral (MCA), anterior cerebral (ACA) and ophthalmic arteries (OA), at rest. It was also employed to evaluate the cerebral vasodilatory response to a breath-holding test: the maximum percentage MCA flow velocity increase during the test was taken as an index of cerebrovascular reactivity. Fifty healthy subjects were studied to establish control values. Analysis of variance was used to test inter-group differences. The regression test was applied to define the relationship between TCD parameters and age and disease duration.

RESULTS

No significant differences were found between controls and the whole group of patients with respect to TCD parameters. However, subgroup analysis showed PDR patient had a significantly higher pulsatility index and lower cerebrovascular reactivity than BDR and NDR patients. This difference was not explained by the effect of age or disease duration, being greatest in patients under sixty.

CONCLUSIONS

These findings seem to confirm the hypothesis of a silent cerebral microangiopathy affecting diabetic patients, with concomitant signs of microangiopathic damage in other districts.

A tool for home-based rehabilitation allowing for clinical evaluation in a visual markerless scenario

This work deals with the design of an interactive monitoring tool for home-based physical rehabilitation. The software platform includes a video processing stage and the exercise performance evaluation. Image features are extracted by a Kinect v2 sensor and elaborated to return the exercises score. Furthermore the tool provides to physiotherapists a quantitative exercise evaluation of subject's performances. The proposed tool for home rehabilitation has been tested on 5 subjects and 5 different exercises and results are presented. In particular both exercises and relative evaluation indexes were selected by specialists in neurorehabilitation.

Accuracy evaluation of the Kinect v2 sensor during dynamic movements in a rehabilitation scenario

In this paper, the accuracy evaluation of the Kinect v2 sensor is investigated in a rehabilitation scenario. The accuracy analysis is provided in terms of joint positions and angles during dynamic postures used in low-back pain rehabilitation. Although other studies have focused on the validation of the accuracy in terms of joint angles and positions, they present results only considering static postures whereas the rehabilitation exercise monitoring involves to consider dynamic movements with a wide range of motion and issues related to the joints tracking. In this work, joint positions and angles represent clinical features, chosen by medical staff, used to evaluate the subject's movements. The spatial and temporal accuracy is investigated with respect to the gold standard, represented by a stereophotogrammetric system, characterized by 6 infrared cameras. The results provide salient information for evaluating the reliability of Kinect v2 sensor for dynamic postures.

Intra- and inter-observer variability of basal flow velocity and vascular reactivity measurements using transcranial Doppler sonography

The reliability of blood flow velocity measurements performed using transcranial Doppler sonography was investigated with regard to the intra- and inter-observer variability. We compared the flow velocity values recorded in the intracranial vessels by two experienced investigators both under rest conditions and during hypercapnia induced by an apnea test. The results showed how flow velocity values measured at the level of the middle cerebral artery, anterior cerebral artery, ophthalmic artery and basilar artery were not significantly influenced by intra- or inter-examiner variability. The flow velocity increases recorded from the middle cerebral artery during the activation test proved to be reproducible when the measurements were repeated by the same examiner, but more variable when detected by different investigators. On the basis of the available data, the clinical relevance of transcranial Doppler results must take into account the degree of reliability of its measurements.

Features and predictors of activity limitations and participation restriction 2 years after intensive rehabilitation following first-ever stroke

BACKGROUND

Although stroke-related disability has been extensively studied, only few studies have investigated Participation restriction in chronic stroke survivors.

AIM

To identify features and predictors of Activity limitation and Participation restriction in the chronic phase of a first-ever stroke.

DESIGN

Cross-sectional observational study.

SETTING

Comprehensive stroke unit with outpatient rehabilitation facility.

POPULATION

Subjects submitted to intensive rehabilitation after first-ever stroke, from 1st January 2009 to 31st December 2010.

METHODS

Participation was investigated through the Frenchay Activity Index (FAI) and the Functional Status Questionnaire (FSQ) at 2.4±0.5 years after the event. Basic activities of daily living (ADL) and mood were also assessed through the Modified Barthel Index (MBI) and the Beck Depression Inventory (BDI). A retrospective search of the medical records looked for: type/side of brain lesion, stroke clinical syndromes, comorbidities and functional condition at discharge from intensive rehabilitation (upper limb motricity index-ULMI-, Functional Ambulation Category-FAC, MBI, cognitive deficits).

RESULTS

Forty-five subjects (17 female, age 70.1±11.5 years) were enrolled. They showed a striking restriction in their Participation, mainly for FAI-outdoor activities (median FAI score was <50% of the theoretical maximum). A poor gait function (FAC) and an impaired mood (BDI) were the only independent predictors of FAI indoor (F=6.1; p=,005; R^2= 64%) and outdoor activities (F=4.1; P=0.01; R^2=48%), respectively. The univariate analysis showed a strong dependence of all FSQ scores from global disability (MBI), motor function impairment (ULMI and FAC) and cognitive deficits. Depression influenced "psychological function" score, whereas gait capacity was the only factor significantly associated with the "work performance" score. The gait function level, achieved after intensive rehabilitation, was extrapolated by the multivariate analysis, as the most powerful independent predictor of the chronic activity limitations, as measured by MBI (F=33.8, P<0.0001, R2=0.539).

CONCLUSION

Gait dysfunction is the main factor of Activity limitations and Participation restriction in chronic stroke. Participation is restricted by global disability, depression, older age and dementia. More than 50% variance of Participation measures cannot be explained by the quoted factors.

CLINICAL REHABILITATION IMPACT

The study results support the need to integrate the standard rehabilitation approach with vocational rehabilitation in order to reduce Participation restriction.

A stereophotogrammetric-based method to assess spatio-temporal gait parameters on healthy and Parkinsonian subjects

Generally, the study of gait requires the detection of successive heel contacts and toe-off instants. Traditional gait analysis methods obtain these gait events using dynamometric platforms together with stereophotogrammetric data. Usually, are kept valid only those walking trials where the subjects step on each platform by only one foot. For subjects suffering from walking impairments it is very difficult or sometimes impossible to walk naturally and step properly on the dynamometric platforms. The aim of the present study is to propose a new method to identify, in an automatic manner, the initial contact (IC) and the toe-off (TO) time instants using only stereophotogrammetric data and a classic gait analysis protocol. The assessment of spatio-temporal gait variables during natural walking is also performed. The study consisted in analyzing healthy and Parkinsonian elderly subjects. The reliability of the proposed stereophotogrammetric-based method was tested by direct comparison with the IC and TO instants determined by the dynamometric platform data. The absence of any statistically significant differences between the values estimated by the two different modalities, highlights the reliability of the proposed method in the assessment of these two gait events. Results underline, as expected, the reduction of walking velocity in pathological patients during free ambulation. The present study proposes this method as a valid alternative to the traditional technique that use dynamometric platforms to identify main gait events, for subjects unable to walk naturally and to step properly on the platforms.

Action observation as a useful approach for enhancing recovery of verb production: new evidence from aphasia

BACKGROUNDS

Evidence exists that the observation of actions performed by others enhance word retrieval and can be used in aphasia rehabilitation to treat naming impairments.

AIM

The aim of the present study was to assess to what extent action observation treatment may improve verb retrieval in chronic aphasics.

DESIGN

This was an observational study.

SETTING

Patients were recruited from the Neurorehabilitation Centre of Ancona Hospital.

POPULATION

Six aphasic patients underwent an intensive language training to improve verb naming.

METHODS

Language evaluation was carried out before and after the treatment. A rehabilitation therapy based on observation of actions was administered daily to each patient for two consecutive weeks. Four different rehabilitation procedures were adopted: 1) "observation of action performed by the examiner"; 2) "observation and then execution of action"; 3) "observation of videoclips of actions"; and, as a control condition; 4) "observation of action and execution of meaningless movement".

RESULTS

In four participants, a significant improvement in verb retrieval was found for the three experimental procedures (χ² (3)=75.212, P<0.0001), with respect to the control condition. No significant improvement was observed in the two patients with severe deficits in verb semantics (χ² (3)=0.592, P=0.892).

CONCLUSIONS

Action observation therapy may become a useful intervention strategy to promote verb retrieval in aphasic patients.

CLINICAL REHABILITATION IMPACT

The observation of videoclips of actions may be an efficacious alternative approach to traditional rehabilitation programs for lexical deficits. This finding endorses the planning of innovative low-cost interventions in language rehabilitation.

A randomised controlled cross-over trial of aerobic training versus Qigong in advanced Parkinson's disease

AIM

To investigate the effects of an aerobic training in subjects with Parkinson's disease (PD) as compared to a medical Chinese exercise (Qigong).

METHODS

DESIGN

randomized controlled trial with a cross over design.

SETTING

PD out-patients referred to a Neurorehabilitation facility for the management of motor disability.

SUBJECTS

26 PD patients in Hoehn and Yahr stage II to III under stable medication were randomly allocated to either Group AT1+QG2 (receiving 20 aerobic training sessions followed by 20 ''Qigong'' group sessions with 2 month interval between the interventions), or Group QG1+AT2 (performing the same treatments with an inverted sequence).

MAIN OUTCOME MEASURES

clinical effects of treatment were sought through the Unified Parkinson's Disease Rating Scale (UPDRS), Brown's Disability Scale (B'DS), six-Minute Walking Test (6MWT), Borg scale for breathlessness, Beck Depression Inventory (BDI) and Parkinson's Disease Questionnaire-39 items (PDQ-39). A spirometry test and maximum cardiopulmonary exercise test (CPET) were also performed to determine the pulmonary function, the metabolic and cardio-respiratory requests at rest and under exercise. All measures were taken immediately before and at the completion of each treatment phase.

RESULTS

The statistical analysis focusing on the evolution of motor disability and quality of life revealed a significant interaction effect between group and time for the 6MWT (time x group effect: F: 5.4 P=0.002) and the Borg scale (time x group effect: F: 4.2 P=0.009). Post hoc analysis showed a significant increase in 6MWT and a larger decrease in Borg score after aerobic training within each subgroup, whereas no significant changes were observed during Qigong. No significant changes over time were detected through the analysis of UPDRS, B'DS, BDI and PDQ-39 scores. The analysis of cardiorespiratory parameters showed significant interaction effects between group and time for the Double Productpeak (time x group effect: F: 7.7 P=0.0003), the VO(2peak) (time x group effect: F: 4.8 P=0.007), and the VO(2)/kg ratio (time x group effect: F: 4.3 P=0.009), owing to their decrease after aerobic training to an extent that was never observed after Qigong treatment.

CONCLUSIONS

Aerobic training exerts a significant impact on the ability of moderately disabled PD patients to cope with exercise, although it does not improve their self-sufficiency and quality of life.

Functional improvement after subthalamic stimulation in Parkinson's disease: a non-equivalent controlled study with 12-24 month follow up

OBJECTIVE

This study aimed to assess the effectiveness of chronic bilateral STN-S in improving the functional status of PD patients compared with patients treated with drugs alone.

METHODS

Controlled study of disability index changes over 12 and 24 month chronic STN stimulation. Of 39 patients with advanced PD meeting CAPSIT criteria for STN-S, 23 underwent surgery; 16 patients decided against surgery and continued on drug schedule adjustments. Functional status was measured using the Activities of Daily Living section of the Unified Parkinson's Disease Rating Scale (UPDRS-ADL), Brown's Disability Scale, and Functional Independence Measure. UPDRS motor score and subscores for selected items, levodopa equivalent daily dose, and Beck Depression Inventory scores were also monitored.

RESULTS

T12 follow up data were available for all 39 patients and T24 data for 13 STN-S and 8 control subjects. Compared with controls, STN-S patients experienced significant or highly significant improvements in all independence measures at both 12 and 24 months (time x treatment effect T12: F = 19.5, p = 0.00008; T24: F = 6.2, p = 0.005). Forward stepwise regression for independent predictors of the yearly rate of UPDRS-ADL score modification in the entire sample showed that treatment was the only factor significantly associated with functional status change (beta coefficient -0.54, t value -2.5, p = 0.02), whereas other variables-UPDRS motor score, BDI, and age at disease onset and enrolment-were not in the equation.

CONCLUSION

STN-S is an effective therapeutic option in advanced PD. It induced a consistent improvement of functional abilities over two years to an extent that was not achieved with drug therapy alone.

Microalbuminuria, brain vasomotor reactivity, carotid and kidney arterial flow in Type 2 diabetes mellitus

Diabetic microangiopathy produces widespread small vessel impairment which particularly affects renal glomeruli functions. Microalbuminuria is the earliest marker of microangiopathic kidney disease and has also recently been recognised as a marker of macroangiopathic cardiovascular involvement. To determine correlations between daily microalbuminuria, local microangiopathic kidney damage, systemic macroangiopathic involvement and functional brain microcirculation, 70 Type 2 diabetic subjects who were diagnosed more than 5 years ago underwent carotid (to determine index of macro- and microangiopathy) and interlobar kidney artery color Doppler (to determine microangiopathic involvement), transcranial Doppler (to determine alterations in brain vasomotor reserve), and evaluation of daily albumin excretion rate. All the indices of microcirculatory involvement in the kidney, brain and small vessels downstream-from the carotid arteries were closely related (for all p<0.001) but never correlated with the macroangiopathy index. Daily microalbuminuria correlated with all the micro- (p<0.0001) and macroangiopathic (p<0.005) Doppler indices. These findings confirm that microangiopathy is the main cause of the diabetic increase in the albumin excretion rate and support the view that microalbuminuria can be considered a powerful biomarker of widespread macroangiopathy. Our results suggest microalbuminuria may also identify cerebrovascular diabetic involvement, as it predicts both macroangiopathic carotid alteration and microvascular brain impairment.

A randomised controlled trial on the efficacy of hydroelectrophoresis in acute recurrences in chronic low back pain patients

AIM

Physical therapy efficacy in the treatment of low back pain (LBP) has been widely debated and is far from achieving high levels of evidence. Hydroelectrophoresis (Hydrofor) is a novel method of driving drugs through the dermal tissue, which has been proposed for muscle pain treatment. Aim of this randomised placebo-controlled study was to ascertain the efficacy of Hydrofor treatment on acute relapsing episodes of pain in chronic LBP subjects.

METHODS

Eighteen under-50 adults (M/F: 7/11; age 35+/-8 years) suffering from chronic LBP were enrolled within 3 to 4 days of back pain relapse. After a complete clinical and functional assessment patients were randomly divided into 2 equal groups. Group A received 3 Hydrofor applications of a mixture containing both NSAIDs and muscle relaxants, whereas Group B received 3 Hydrofor applications of a drug-free solution. Afterwards, both groups performed the same rehabilitation treatment consisting of 7 group sessions of standard physiotherapy, including stretching, range of motion and extension exercises. The Oswestry disability index (ODI), the Million instrument scale and a visual analogue scale (VAS) were chosen as outcome measures and applied at baseline, after Hydrofor/placebo applications, after completion of rehabilitation sessions and, at last, 2 months later. The two-way Friedman test was used to analyse within-group (time effect) and between-group (time x group effect) differences.

RESULTS

All subjects declared a significant pain reduction since the first Hydrofor application. Pain evolution overlapped in the 2 groups until the 3rd session, after which Group A significantly diverged from Group B, as they affirmed a greater symptom reduction than controls (time x group effect: VAS: F = 7.4, p <0.01). Such difference disappeared after the physiotherapy sessions as well as 2 months later (time x group effect: VAS: F = 2.1, p =0.08). Pain-related disability showed a greater reduction in Group A than B immediately after Hydrofor application (time x group effect: ODI: F=3.9 p <0.05; Million: F=4.1 p<0.05), but the mean scores almost overlapped at the 2 month follow-up (time x group effect: ODI: F=2.3 p =0.08; Million: F=1.3 p=0.26).

CONCLUSIONS

Hydrofor treatment relieves relapsing LBP and could be recommended to active adults as a safe technique shortening the time needed to achieve functional restoration.

Influence of early high-dose steroid treatment on Bell's palsy evolution

The objective of this double-blind, randomized, placebo-controlled study was to test the efficacy of high-dose prednisone, administered as early as possible, in modifying the natural progression of Bell's palsy. Sixty-two consecutive patients, enrolled within 72 hours of facial palsy onset, were assigned to high dose intravenous prednisone in combination with intramuscular polyvitaminic therapy (group A) or polyvitaminic therapy alone (group B). Clinical grading of facial muscle strength and length of absence from work were evaluated. An early worsening of facial muscle strength was observed in controls, leading to the divergence in the trends of the grading scores in the two groups; this result was not confirmed in the long-term follow-up. Treated patients returned to work earlier than controls. In conclusion, early treatment based on high-dose corticosteroids slightly accelerates spontaneous improvement in Bell's palsy.

Post-stroke spasticity management with repeated botulinum toxin injections in the upper limb

OBJECTIVE

Although the botulinum toxin A (BTX-A) treatment has proved effective in spasticity management, no information is available with regard to the effects of repeated injections over time.

DESIGN

To evaluate the effects of BTX-A on moderate or severe upper limb spasticity, an exploratory investigation was performed on 28 stroke patients treated for 2 yr or longer and observed for 3 yr. Every 3 to 5 mo, each patient received BTX-A injections in upper limb muscles. The assessment, performed before and 1 mo after each injection for a median of 28 mo, included technical and functional objectives and the burden of care. The former were evaluated by using the modified Ashworth Scale for spasticity and the goniometric measurement of rest position and range of motion; functional objectives were evaluated by means of the Frenchay Arm Test and a patient/caregiver goals assessment scale.

RESULTS

BTX-A treatment was followed by an improvement in all technical outcome measures. Motor dexterity scores improved in only 8 of 28 patients, vs. daily living activities, which increased in all subjects. Although the average dosage injected per session did not change, intervals between injections became longer. No relationship between either spasticity onset or residual motoricity and response to treatment could be found.

CONCLUSIONS

This investigation is relevant clinically because repeated BTX-A injections show unchanging effectiveness in the management of focal spasticity after stroke.

A multidimensional assessment of multiple sclerosis: relationships between disability domains

OBJECTIVE

To test the feasibility of a multidimensional assessment based on both task-related and self-evaluation questionnaire scores in patients with multiple sclerosis (MS); ii) to correlate the results from selective measures with the severity of illness in terms of the Expanded Disability Status Scale (EDSS) score; iii) to assess the relationships between different domains of MS-related disability and handicap.

PATIENTS AND METHODS

Eighty-three MS patients (M/F 31/52; age 43.26 +/- 10.9 years, range 21-72) underwent a standard clinical evaluation of motor abilities (by means of the Rivermead Mobility index, Timed Walking Test, Nine Hole Peg test and Hauser Ambulation Index) and cognitive performances (using Digit Symbol, Buschke-Fuld selective remind test, "FAS"-Word Fluency, Wisconsin Card Sorting test and Block design test). The Beck Depression inventory, MS Specific Fatigue Scale, Functional Assessment of MS and London Handicap Scale were applied to evaluate mood, fatigue, quality of life and handicap, respectively. Minimal Record of Disability measures - MRD (i.e. EDSS, Inability Status Scale and Environmental Status Scale) were also applied to test the criterion validity of the selected disability and handicap scales. The Kruskal-Wallis H-test for independent samples tested differences between subgroups with an increasing EDSS score (<3.5, 3.5-6.0, >6.0). The covariance and redundancy of measures included in the multidimensional assessment were evaluated through Factor Analysis. The Multiple Regression Analysis was used to detect the relative impact of either motor or cognitive disabilities and depression on handicap and quality of life.

RESULTS

The multimodal assessment took 70 min on average to be performed, being well accepted by patients. Motor abilities worsened as the EDSS score rose, unlike cognitive performances which proved to be similarly impaired at different severity levels. Measures of fatigue and depression were not related to EDSS values. The chosen measures were assigned by Factor Analysis to 4 domains corresponding to motor performance, executive performance, cognitive abilities and quality of life, respectively. Regression analysis showed how handicap and depression independently affect quality of life. While the handicap score is mostly influenced by motor ability, as measured by the Rivermead Mobility Index, the depression score grows independently of any physical or cognitive disability and seems to be related to fatigue self-assessment scores.

CONCLUSIONS

A multidimensional approach to MS patient assessment allows a more detailed and sensitive evaluation of their disability profile and perceived difficulties, leading to a care programme tailored to the patient's needs.

Transcranial Doppler sonographic monitoring during cerebral aneurysm embolization: a preliminary report

BACKGROUND AND PURPOSE

The wide application of embolization in the treatment of aneurysms has created the need for an intraprocedural means to anticipate a poor outcome by monitoring hemodynamic changes in the brain.

METHODS

Transcranial Doppler sonography was used to monitor flow velocity in the middle cerebral artery (MCA) in 23 patients undergoing embolization with Guglielmi detachable coils (GDCs) of either incidental or symptomatic intracranial aneurysms. Sonographic values were recorded from the ipsilateral MCA at the beginning, middle, and end of the interventional procedure and 24 hours afterward.

RESULTS

No complications occurred in 15 patients. In these cases, sonography showed an average decrease in MCA flow velocity of 2.7% after GDC application, returning to baseline at the end of treatment and then increasing by about 17% 24 hours later. In four patients with vasospasm on posttreatment angiograms, MCA flow velocity increased to values higher than 120 cm/s after GDC application, returning to baseline after 24 hours. In four patients with ischemic complications (two transient ischemic attacks, one stroke, one vascular death), MCA flow velocity decreased more than 30% and did not return to preoperative values within 24 hours.

CONCLUSION

The application of transcranial Doppler sonographic monitoring during endovascular treatment may help to identify patients at risk for posttreatment cerebral ischemia.

Predictive value of clinical indices in detecting aspiration in patients with neurological disorders

OBJECTIVES

(1) To evaluate the predictive value of a detailed clinical screening of aspiration in patients with neurological diseases, both with and without symptoms of dysphagia taking videofluoroscopy as the gold standard; (2) to assess the existence of risk factors for silent aspiration, measuring the cost-benefit ratio of radiological examination.

METHODS

93 consecutive patients meeting the diagnostic criteria for a neurological disease with a risk of swallowing dysfunctions (cerebrovascular accidents, brain injury, Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, myotonic dystrophy, and abiotrophic diseases) underwent a detailed clinical assessment using a 25 item form to check for symptoms of dysphagia and impairment of the oropharyngeal swallowing mechanism. The 3 oz water swallow test was also performed to assess the aspiration risk. Sensitivity, specificity, positive predictive, and negative predictive values (NPV) of dysphagia, history of cough on swallowing, and 3 oz test positivity, versus videofluoroscopy documented aspiration, taken as the gold standard, were measured in all the patients and in subgroups with different neurological disorders.

RESULTS

Non-specific complaints of dysphagia showed a very poor predictive value, whereas the symptom "cough on swallowing" proved to be the most reliable in predicting the risk of aspiration, with 74% sensitivity and specificity, 71% positive predictive, and 77% negative predictive value. The standardised 3-oz test had a higher predictive potential than the clinical signs, but had low sensitivity. The association of cough on swallowing with the 3 oz test gave a positive predictive of 84%, and an negative predictive value of 78%. In cases where the clinical tests failed to detect any impairment, videofluoroscopy documented only a low risk (20%) for mild aspiration.

CONCLUSIONS

The association of two clinical items (such as history of cough on swallowing and 3 oz test positivity) provides a useful screening tool, the cost:benefit ratio of which seems very competitive in comparison with videofluoroscopy in aspiration risk evaluation.

Inter-examiner variability of transcranial Doppler procedure and reports: a multicenter survey. Italian Transcranial Doppler Group

OBJECTIVE

To assess the clinical use of Transcranial Doppler (TCD) and the reproducibility of TCD reports.

METHODS

A multicenter survey involving 45 Italian laboratories (the Italian Transcranial Doppler Group-ITDG) was carried out by investigating the examination procedure, the parameters and normative data, and the interpretation criteria applied to reach diagnostic conclusions. The inter-examiner agreement on 10 TCD reports was computed using Kappa statistics. Results. Investigators consider both qualitative (flow direction, signal detectability) and quantitative measurements (mean flow velocity and pulsatility index values), applying their own normative criteria reference which may differ slightly between centers. TCD reports appear to be highly reproducible when based upon the interpretation of qualitative data (Kappa index: 0.95-1.00), whereas a moderate agreement is obtained when considering alterations in quantitative parameters (Kappa: 0.44-0.81).

CONCLUSIONS

The application of the same criteria in different laboratories may facilitate the standardization of TCD examinations and support the reproducibility of clinical reports based on TCD parameters.

[Therapeutic objectives in the subacute phase after stroke]

The aim of this study was to identify the most appropriate clinical management of the subacute stage after stroke, in order to reduce mortality and control disability following cerebrovascular disease. Data were collected from international journals, books and guidelines written by accredited agencies and scientific societies. Reviews and clinical investigations written by authors operating in stroke assistance facilities have been selected among those submitted to accredited scientific journals, spontaneously or upon request by editors of specific sections or supplements. Furthermore, the guidelines proposed by either scientific or lay associations have been considered. The following elements have been considered: i) prevention of morbidity and treatment of complications in the subacute phase; ii) identification of uncommon stroke causative factors in order to prevent recurrent events; iii) prognosis of survival and disability; iv) activation of rehabilitation. Results show that a careful evaluation of stroke etiology and the direct management of cerebrovascular problems by specialized utilities bring about an increase in survival rate and reduce disability. The treatment of complications, the evaluation of recovery capacity and the accomplishment of rehabilitation strategies, based on accredited criteria of organization, allow an increase in the efficiency of assistance facilities. Involvement of the family has a positive influence on autonomy. In conclusion, the qualified management of stroke patients can reduce mortality and disability, even if there is still no effective therapy, capable of reducing cerebral damage.

Influence of vigabatrin on cognitive performances and behaviour in patients with drug-resistant epilepsy

INTRODUCTION

The aim of this research was to evaluate changes in cognitive performances, mood and quality of life in drug-resistant epileptic patients, after the introduction of Vigabatrin (VGB) as additional treatment.

MATERIAL AND METHODS

A four-step evaluation was carried out in two groups of 20 patients each, randomly assigned to VGB or placebo treatment. A battery of neuropsychological tests investigating attention, memory and adaptive abilities, associated with inventories concerning depression, quality of life and the concern of families upon patient behaviour, were utilised. For each subject, four evaluations were performed, two before and two after VGB/placebo administration.

RESULTS

No relevant side-effects regarding cognition and behavior were detected in the VGB group. The intra-group comparison between pre- and post-treatment phases showed a slight improvement in cognitive performances of VGB patients and a positive change in their overall psychological status. The inter-group comparison confirmed the selective improvement occurring in the trend of a few neuropsychological test scores in the VGB group.

CONCLUSION

Such results help to reject the hypothesis that the addition of VGB to the current antiepileptic treatment may affect cognitive performances and behaviour.

Multimodal treatment to prevent the late whiplash syndrome

In order to assess the long-term efficacy of a multi-modal rehabilitation approach on whiplash injury, 60 patients were recruited within two months after neck injury. They were randomly allocated either to an experimental multimodal treatment (A) consisting of postural training, manual technique and psychological support or to a control treatment (B), using physical agents only, such as electrical and sonic modalities. Pain level, range of movement, self-rating scale of treatment efficacy and return-to-work delay were evaluated before and at the end of treatment, and later, 30 and 180 days after randomisation. The benefit obtained with treatment "A" was greater and longer lasting than that experienced using "B", despite the fact that the same benefit was obtained in joint mobility in the two groups. Patients undergoing the experimental treatment returned to their usual occupations sooner than the controls. The results seem to confirm the hypothesis of a multifactorial involvement as a possible mechanism for the late whiplash syndrome.

Thrombolysis in ischemic stroke: evaluation of operative difficulties

A few on-going international trials aim to investigate the effectiveness of early fibrinolytic treatment for ischaemic stroke to assist cerebral reperfusion. This operative strategy depends on clinical parameters such as haemorrhagic lesions, coma, pre-existent impairment and disability, and the efficiency of the sanitary organization receiving the patients (availability of CT scan, hospitalization within 6 h of onset of symptoms). We report data on the operative efficiency of a Regional Hospital Centre without a stroke unit: we observe that 142 patients did not receive early stroke treatment because of organizational problems whose prevalence exceeded the incidence of theoretical contraindications to fibrinolytic use. These elements suggest the necessity to organize a specific ward for the management of acute stroke.

Electrophysiological and cognitive effects of lumbar myelography with iopamidol: comparison with diagnostic lumbar puncture

To assess the influence of contrast medium on cortical function, we studied 20 patients undergoing lumbar myelography with iopamidol and 10 patients undergoing diagnostic lumbar puncture (controls). The examinations performed before and 6 and 24 h after myelography (or lumbar puncture) included a neuropsychological battery and an electrophysiological evaluation. In the patients cranial CT was performed thrice to assess passage of contrast medium from the cerebrospinal fluid into the brain. Neither patients nor controls had significantly different scores on neuropsychological testing after the diagnostic examinations. A transient slowing of basal EEG activity could be detected in 2 patients and 3 controls 6 h after the lumbar puncture. In 3 patients CT showed a transient increase in density of the brain. None of the parameters studied was significantly affected by myelography with iopamidol. CT findings support the hypothesis of early clearance of iopamidol from brain tissue, explaining its low neurotoxicity.

Haemodynamic changes following carotid occlusion: MRI angiography and transcranial Doppler patterns

To see the signal changes in MR angiography (MRA) when occlusions or severe stenoses of carotid arteries occur and to relate these data with the velocity values provided by transcranial Doppler sonography (TCD), 20 patients showing symptomatic or asymptomatic unilateral carotid obstructions underwent both MRA and TCD after digital angiography investigation. No MRA signal was recorded immediately downstream from the carotid occlusion. Low flow velocity values in the carotid siphon and middle cerebral artery (MCA) ipsilateral to the carotid obstruction were associated with altered MRA signals corresponding to the same vessels. Turbulence phenomena induced by reversed flow in the anterior cerebral artery induced MRA signal impairments. In carotid occlusions, there may be a relationship between the MRA patterns and the flow velocity variations detected by TCD, but the two approaches have to be applied together since they provide complementary information.

Was it infarction or haemorrhage? A clinical diagnosis by means of the Allen score

Since the clinical distinction between haemorrhagic and ischaemic stroke cannot be achieved with a simple clinical evaluation, and it is virtually impossible to submit all stroke patients to CT, a weighted clinical score may offer some advantages to physicians who are involved in stroke management. The Allen score (also referred to as the Guy's Hospital score), a validated clinical score, has been tested in two different clinical settings, comprising 289 patients. When only the values under 4 and those over 24 are taken into account (i.e. greater than 90% probability of ischaemia and haemorrhage), the global accuracy of the score is 97%, and the diagnostic gain (given a pretest probability for haemorrhage of 11% and a likelihood ratio of 194) is 85%. Therefore, we conclude that this simple clinical method can be used for epidemiological studies of stroke incidence and outcome, as well as for a first bedside screening to decide which patients should have priority for CT.