Intraprocedural continuous saline infusion lines significantly reduce the incidence of acute kidney injury during endovascular procedures for stroke and myocardial infarction: evidence from a systematic review and meta-regression

BACKGROUND

Contrast media used in mechanical therapies for stroke and myocardial infarction represent a significant cause of acute kidney injury (AKI) in acute medical scenarios. Although the continuous saline infusion line (CSIL) is a standard procedure to prevent thrombus formation within the catheter during neurovascular interventions of mechanical thrombectomy (MT), it is not utilized in percutaneous coronary interventions (PCI).

METHODS

A systematic review of the incidence of AKI after MT for stroke treatment was performed. These data were compared with those reported in the literature regarding the incidence of AKI after PCI for acute myocardial infarction. A random-effect model meta-regression was performed to explore the effects of CSIL on AKI incidence, using clinical details as covariates.

RESULTS

A total of 18 and 33 studies on MT and PCI were included, respectively, with 69,464 patients (30,138 [43.4%] for MT and 39,326 [56.6%] for PCI). The mean age was 63.6 years±5.8 with male 66.6%±12.8. Chronic kidney disease ranged 2.0-50.3%. Diabetes prevalence spanned 11.1% to 53.0%. Smoking status had a prevalence of 7.5-72.0%. Incidence of AKI proved highly variable (I2=98%, Cochrane's Q 2985), and appeared significantly lower in the MT subgroup than in the PCI subgroups (respectively 8.3% [95% confidence interval: 4.7-11.9%] vs. 14.7 [12.6-16.8%], P<0.05). Meta-regression showed that CSIL was significantly associated with a decreased incidence of AKI (OR=0.93 [1.001-1.16]; P=0.03).

CONCLUSIONS

Implementation of CSIL during endovascular procedures in acute settings was associated with a significant decrease in the risk of AKI, and its safety should be routinely considered in such interventions.

The Pathophysiology of Collateral Circulation in Acute Ischemic Stroke

Cerebral collateral circulation is a network of blood vessels which stabilizes blood flow and maintains cerebral perfusion whenever the main arteries fail to provide an adequate blood supply, as happens in ischemic stroke. These arterial networks are able to divert blood flow to hypoperfused cerebral areas. The extent of the collateral circulation determines the volume of the salvageable tissue, the so-called "penumbra". Clinically, this is associated with greater efficacy of reperfusion therapies (thrombolysis and thrombectomy) in terms of better short- and long-term functional outcomes, lower incidence of hemorrhagic transformation and of malignant oedema, and smaller cerebral infarctions. Recent advancements in brain imaging techniques (CT and MRI) allow us to study these anastomotic networks in detail and increase the likelihood of making effective therapeutic choices. In this narrative review we will investigate the pathophysiology, the clinical aspects, and the possible diagnostic and therapeutic role of collateral circulation in acute ischemic stroke.

Lipid profiles and atrial fibrillation in ischemic stroke patients treated with thrombectomy: experience from a tertiary Italian stroke hospital

OBJECTIVES

To assess acute lipid profiles, atrial fibrillation and other cardiovascular risk factors in patients undergoing treatments by thrombectomy (EVT) with acute ischemic stroke (AIS).

METHODS

We performed a retrospective analysis of the lipid profile and vascular risk factor in 1639 consecutive patients with acute ischemic stroke between January 2016 and December 2021. To assess lipid profiles, laboratory tests, including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG), were obtained the day after admission. We also examined assessed the association between lipid profile, AF and EVT in multivariate logistic regression analysis.

RESULTS

Median age of patients was 74 years, 54.9% were males (95% CI 52.5-57.4%), and 26.8% (95% CI, 24.7-29.0%) had AF. EVT patients (n= 370; 22.57 %; 95% CI, 20.6-24.7) showed no difference in age (median 73 years [IQR; 63-80 ] versus 74 years [ QR; 63-82+ HbA1c levels (median 5.8 [IQR; 5.4-6.2] versus 5.9 [ IQR; 5.4-6.4+TG/HDL ratio (median 2.40 [IQR; 1.65-3.48#43; versus[IQR; 1.73-3.64)] diabetes (OR 0.82; 95% CI 0.61 to 1.08), hypertension (OR 0.87; 95% CI 0.68 to 1.12) and obesity (OR 1.06; 95% CI 0.78 to 1.42) compared to non-EVT patients. Conversely, EVT patients showed lower levels of TC (160 mg/dl[ IQR;139-187] versus 173 mg/dl [ IQR;148-202] P <0.001), LDL-C (105 mg/dl [ IQR; 80-133] versus 113 mg/dl [ IQR; 88-142] ; P <0.01), TG (98 mg/dl [ IQR; 76-126] versus 107 mg/dl [ IQR; 85-139] P <0.001), non-HDL-C (117 mg/dl[ IQR; 94-145] versus 127 mg/dl [ IQR; 103-154] P <0.001), HC (8.3[ mol/l [ IQR; 6-11] versus 10 µ mol/l[ IQR; 7.3-13.5] P <0.001) than non-EVT patients. Multivariate logistic regression analysis showed an independent association of EVT with TC (OR 0.99, 95% CI 0.98-0.99), AF (OR 1.79, 95% CI 1.34-2.38), age (OR 0.98, 95% CI 0.96-0.99), and NIHSS (OR 1.17, 95% CI 0.14-1.19).

CONCLUSION

Total cholesterol and all cholesterol-related measures were significantly lower in patients undergoing thrombectomy than in other stroke patients. Conversely, we found that AF was significantly high in patients with EVT, suggesting that hypercholesterolemia could be mainly linked to small-vessel occlusion stroke while large vessel occlusion (LVO) stroke could show different causes. AIS patients may have different pathogenesis and their understanding may improve enhance the discovery of specific and tailored preventive treatments.

Treating Post-stroke Epilepsy in a Patient With Multiple Comorbidities

Stroke is a major cause of seizures and epilepsy in adults. Stroke severity, younger age, hemorrhagic subtype of stroke, and alcohol use have been identified as risk factors for the development of stroke-related epilepsy. Despite being a common complication in stroke survivors, current guidelines do not provide strong recommendations about the optimal treatment of post-stroke seizures. No clear guidance is given about the preferred antiseizure medications (ASMs), primary and secondary prophylaxis, and ASMs withdrawal. The management of older patients is further complicated by the presence of comorbidities, pharmacokinetic alterations, and intake of several medications. We present a case of a 77-year-old man affected by epidermolysis bullosa and diabetes mellitus, who suffered from ischemic stroke and then developed post-stroke seizures. This case shows how complex it is to manage post-stroke seizures in an older patient with multiple comorbidities.

Recurrent paraneoplastic cerebral hemorrhage in lung cancer: A case report

Cerebral hemorrhage management in a patient requiring anticoagulant therapy is a therapeutic challenge also due to the absence of guidelines that convincingly define the best therapeutic strategy. Although the occurrence of cerebral hemorrhage in a patient with anticoagulant therapy seems to make the bleeding etiology obvious, sometimes, it is better to reflect on other possible causes and set up an adequate diagnostic workup. Herein, we describe a case of a 73-year-old male patient with atrial fibrillation, mechanical heart valve, and pacemaker that experienced an ischemic minor stroke during steady anticoagulation therapy with recurrent intracerebral haemorrhages (ICHs).

Is Mechanical Thrombectomy or Thrombolysis Universally Cost-Effective? A Systematic Review of the Literature

BACKGROUND

Thrombolysis (rTPA) and mechanical thrombectomy (MT) are cost-effective treatments for ischemic stroke. However, little is known about the impact of different types of health systems (HSs) on the outcome and cost of ischemic stroke.

METHODS

Literature search was performed on PubMed/OVID for studies without time limits. The year of publication, type of HS, cost of intervention treatment (rTPA/MT), cost of control strategy (conservative treatment or rTPA), quality-adjusted life years (QALYs) gained, and percentage of gross domestic product spent on health were recorded. The inclusion criteria were English literature, cost-effectiveness, and cost-utility analyses. The exclusion criterion was the absence of geographic coherence between the derived QALYs and the costs. The costs were inflated to 2021 and then converted to US dollar/euro. An analysis of variance or Kruskal-Wallis test was used to compare the percentage of cost reduction and the QALYs gained. Gross domestic product percentage was correlated with the QALYs gained.

RESULTS

Thirty-five studies were analyzed. No significant differences in the percentage of cost reduction were found among the different types of HS (Beveridge -14.74% [95% confidence interval {CI} -57.94/53.08] vs. Bismarck -2.27% [95% CI -122.73/118.18] vs. national insurance -0.015% [95% CI -16.96/51.00] vs. private insurance -4.05% [95% CI -32.62/13.18]). No differences were found in QALYs gained among the different HS (Beveridge 1021 [95% CI -36.37/1705.04] vs. Bismarck 440 [95% CI -2290.68/3870.68] vs. national insurance 643 [95% CI -137.54/2366.21] vs. private insurance 550 [95% CI 131.54/1128.06]). No differences were found among the QALYs gained between rTPA/conservative treatment versus rTPA/MT and rtPA + MT/MT. The percentage of gross domestic product spent on health did not correlate with the QALYs gained (rho = -0.16; P = 0.56).

CONCLUSIONS

MT and rTPA are independently cost-effective among different HS.

Thrombolysis after dabigatran reversal: A nation-wide Italian multicentre study, systematic review and meta-analysis

Introduction:

Recent anticoagulant intake represents a contraindication for thrombolysis in acute ischemic stroke. Idarucizumab reverses the anticoagulant effect of dabigatran, potentially allowing for thrombolysis. This nation-wide observational cohort study, systematic review, and meta-analysis evaluated the efficacy and safety of thrombolysis preceded by dabigatran-reversal in people with acute ischemic stroke.

Patients and methods:

We recruited people undergoing thrombolysis following dabigatran-reversal at 17 stroke centers in Italy (reversal-group), people on dabigatran treated with thrombolysis without reversal (no-reversal group), and age, sex, hypertension, stroke severity, and reperfusion treatment-matched controls in 1:7 ratio (control-group). We compared groups for symptomatic intracranial hemorrhage (sICH, main outcome), any brain hemorrhage, good functional outcome (mRS 0–2 at 3 months), and death. The systematic review followed a predefined protocol (CRD42017060274), and odds ratio (OR) meta-analysis was implemented to compare groups.

Results:

Thirty-nine patients in dabigatran-reversal group and 300 matched controls were included. Reversal was associated with a non-significant increase in sICH (10.3% vs 6%, aOR = 1.32, 95% CI = 0.39–4.52), death (17.9% vs 10%, aOR = 0.77, 95% CI = 0.12–4.93) and good functional outcome (64.1% vs 52.8%, aOR = 1.41, 95% CI = 0.63–3.19). No hemorrhagic events or deaths were registered in no-reversal group (n = 12). Pooling data from 3 studies after systematic review (n = 1879), reversal carried a non-significant trend for sICH (OR = 1.53, 95% CI = 0.67–3.50), death (OR = 1.53, 95% CI = 0.73–3.24) and good functional outcome (OR = 2.46, 95% CI = 0.85–7.16).

Discussion and conclusion:

People treated with reperfusion strategies after dabigatran reversal with idarucizumab seem to have a marginal increase in the risk of sICH but comparable functional recovery to matched patients with stroke. Further studies are needed to define treatment cost-effectiveness and potential thresholds in plasma dabigatran concentration for reversal.

Cluster analysis of weather and pollution features and its role in predicting acute cardiac or cerebrovascular events

BACKGROUND

Despite mounting evidence, the impact of the interplay between weather and pollution features on the risk of acute cardiac and cerebrovascular events has not been entirely appraised. The aim of this study was to perform a comprehensive cluster analysis of weather and pollution features in a large metropolitan area, and their association with acute cardiac and cerebrovascular events.

METHODS

Anonymized data on acute myocardial infarction (AMI) and acute cerebrovascular events were obtained from 3 tertiary care centers from a single large metropolitan area. Weather and pollution data were obtained averaging measurements from several city measurement stations managed by the competent regional agency for enviromental protection, and from the Metereological Center of Italian Military Aviation. Unsupervised machine learning was performed with hierarchical clustering to identify specific days with distinct weather and pollution features. Clusters were then compared for rates of acute cardiac and cerebrovascular events with Poisson models.

RESULTS

As expected, significant pairwise correlations were found between weather and pollution features. Building upon these correlations, hierarchical clustering, from a total of 1169 days, generated 4 separate clusters: mostly winter days with low temperatures and high ozone concentrations (cluster 1, N.=60, 5.1%), days with moderately high temperatures and low pollutants concentrations (cluster 2, N.=419, 35.8%), mostly summer and spring days with high temperatures and high ozone concentrations (cluster 3, N.=673, 57.6%), and mostly winter days with low temperatures and low ozone concentrations (cluster 4, N.=17, 1.5%). Overall cluster-wise comparisons showed significant differences in adverse cardiac and cerebrovascular events (P<0.001), as well as in cerebrovascular events (P<0.001) and strokes (P=0.001). Between-cluster comparisons showed that cluster 1 was associated with an increased risk of any event, cerebrovascular events, and strokes in comparison to cluster 2, cluster 3 and cluster 4 (all P<0.05), as well as AMI in comparison to cluster 3 (P=0.047). In addition, cluster 2 was associated with a higher risk of strokes in comparison to cluster 4 (P=0.030). Analysis adjusting for season confirmed the increased risk of any event, cerebrovascular events and strokes for cluster 1 and cluster 2.

CONCLUSIONS

Unsupervised machine learning can be leveraged to identify specific days with a unique clustering of adverse weather and pollution features which are associated with an increased risk of acute cardiovascular events, especially cerebrovascular events. These findings may improve collective and individual risk prediction and prevention.

Impact of weather and pollution on the rate of cerebrovascular events in a large metropolitan area

BACKGROUND

Despite mounting evidence, there is uncertainty on the impact of the interplay between weather and pollution features on the risk of acute cerebrovascular events (CVE). We aimed at appraising role of weather and pollution on the daily risk of CVE.

METHODS

Anonymized data from a hub CVE center in a large metropolitan area were collected and analyzed according to weather (temperature, pressure, humidity, and rainfall) and pollution (carbon monoxide [CO], nitrogen dioxide [NO2], nitrogen oxides [NOX], ozone [O3], and particulate matter [PM]) on the same and the preceding days. Poisson regression and time series analyses were used to appraise the association between environmental features and daily CVE, distinguishing also several subtypes of events.

RESULTS

We included a total of 2534 days, with 1363 days having ≥1 CVE, from 2012 to 2017. Average daily rate was 1.56 (95% confidence interval: 1.49; 1.63) for CVE, with other event rates ranging between 1.42 for stroke and 0.01 for ruptured intracranial aneurysm. Significant associations were found between CVE and temperature, pressure, CO, NO2, NOX, O3, and PM <10 µm (all P<0.05), whereas less stringent associations were found for humidity, rainfall, and PM <2.5 µm. Time series analysis exploring lag suggested that associations were stronger at same-day analysis (lag 0), but even environmental features predating several days or weeks were significantly associated with events. Multivariable analysis suggested that CO (point estimate 1.362 [1.011; 1.836], P=0.042) and NO2 (1.011 [1.005; 1.016], P<0.001) were the strongest independent predictors of CVE.

CONCLUSIONS

Environmental features are significantly associated with CVE, even several days before the actual event. Levels of CO and NO2 can be potentially leveraged for population-level interventions to reduce the burden of CVE.

625 Cluster analysis of weather and pollution features and its role in predicting acute cardiac or cerebrovascular events

Aims

The impact of the interplay between weather and pollution features on the risk of acute cardiac and cerebrovascular events has not been entirely appraised. The aim of this study was to perform a comprehensive cluster analysis of weather and pollution features in a large metropolitan area, and their association with acute cardiac and cerebrovascular events.

Methods and results

Anonymized data on acute myocardial infarction (AMI) and acute cerebrovascular events were obtained from three tertiary care centre from a single large metropolitan area. Weather and pollution data were obtained averaging measurements from several city measurement stations managed by the competent regional agency for environmental protection, and from the Meteorologic Center of Italian Military Aviation. Unsupervised machine learning was performed with hierarchical clustering to identify specific days with distinct weather and pollution features. Clusters were then compared for rate of acute cardiac and cerebrovascular events with Poisson models. As expected, significant pairwise correlations were found between weather and pollution features. Building upon these correlations, hierarchical clustering, from a total of 1169 days, generated four separate clusters: Cluster 1, including 60 (5.1%) days, Cluster 2 with 419 (35.8%) days, Cluster 3 with 673 (57.6%) days, and Cluster 4 with 17 (1.5%) days, with significant between-cluster differences in weather and pollution features. Notably, Cluster 1 was characterized by low temperatures and high ozone concentrations (P &lt; 0.001). Overall cluster-wise comparisons showed significant overall differences in adverse cardiac and cerebrovascular events (P &lt; 0.001), as well as in cerebrovascular events (P &lt; 0.001) and strokes (P = 0.001). Between-cluster comparisons showed that Cluster 1 was associated with an increased risk of any event, cerebrovascular events, and strokes in comparison to Cluster 2, Cluster 3, and Cluster 4 (all P &lt; 0.05), as well as AMI in comparison to Cluster 3 (P = 0.047). In addition, Cluster 2 was associated with a higher risk of strokes in comparison to Cluster 4 (P = 0.030). Analysis adjusting for season confirmed the increased risk of any event, cerebrovascular events, and strokes for Cluster 1 and Cluster 2.

Conclusions

Unsupervised machine learning can be leveraged to identify specific days with a unique clustering of adverse weather and pollution features which are associated with an increases risk of acute cardiovascular events, especially cerebrovascular events.

Acute Onset Focal Epilepsy Mimicking Stroke

A wide range of acute neurological disorders may present with symptoms similar to a stroke, so-called 'stroke mimics'. Migraine aura and seizures account for the most extensive stroke mimics population. A large number of patients with a definite stroke mimics diagnosis (most commonly those with psychiatric disorders or seizures) had been treated with IV alteplase without adverse related events. We report a case of a man aged 70 years admitted to the emergency room because of acute onset of delirium and a loss of strength in the left arm (National Institutes of Health Stroke Scale {NIHSS}: 10), severe hyponatremia (127 mEq/L), and no evidence of intracranial arterial occlusion at CT scan. He was eligible for intravenous thrombolysis and, after treatment, neurological symptoms improved (NIHSS: 2). The subsequent appearance of “clonus” in the left lower limb, the persistence of hyponatremia, and the presence of electroencephalogram (EEG) abnormalities led to the clinical suspicion of focal motor-onset seizure with impaired awareness. The patient was treated successfully with anti-seizure medications (ASMs): lacosamide 200 mg IV during the acute setting care, followed by oral lacosamide 200 mg bis in die (BID). Since two other focal seizures occurred, brivaracetam 25 mg BID has been added in therapy with subsequent clinical discontinuance and EEG normalization. Two consecutive magnetic resonance imaging (MRI) examinations showed several cortical lesions restricted in high signal in diffusion‐weighted imaging (DWI) which corresponding to T2‐weighted and fluid‐attenuated inversion recovery (FLAIR) hyperintensities, but without lesions evidence in apparent diffusion coefficient (ADC) map. These radiological changes disappeared at a follow-up MRI performed 20 days after the symptoms’ onset. The patient fully recovered was discharged home without developing pharmacological adverse events. In this case, MRI provided an opportunity for early identification of seizure-related alterations. Hence, we discuss how prospective MRI studies during seizures and interictal period would contribute to defining the relationship between the electroclinical characteristics and MRI alteration patterns, and therefore, the potential role of MRI in the differential diagnosis between seizures and stroke mimic.

An uncommon case of nonconvulsive status epilepticus successfully treated with enteral Brivaracetam

BACKGROUND AND AIM OF THE WORK

We present a case of a woman affected by nonconvulsive status epilepticus (NCSE) caused by cerebral hyperperfusion syndrome (CHS) after carotid endarterectomy (CEA) who was successfully treated with Brivaracetam (BRV) administered via nasogastric tube (NGT).

CASE PRESENTATION

An 82-years old woman was referred for increasing blood pressure, severe headache and two focal motor seizures on postoperative day four after right CEA. CT scan showed edema of the right hemisphere with a midline shift of 5 mm. The patient underwent daily Electroencephalography (EEG) monitoring which showed continuous epileptiform discharges over the right hemisphere, compatible with a diagnosis of status epilepticus. She was treated with standard antiepileptic drugs (Phenytoin, Lacosamide and Levetiracetam iv) without clinical response. A therapeutic trial with BRV 200mg administered via nasogastric tube (NGT) was tried which resulted in substantial clinical benefit.

CONCLUSIONS

The administration of new antiepileptic drugs (AEDs) such as BRV may result in significant clinical improvement in refractory cases of status epilepticus. The enteral administration of AEDs via NGT should always be considered for refractory cases of status epilepticus when standard iv treatment has failed or is not possible.

Ischemic Stroke in the Very Elderly: Experience from an Italian Stroke Unit Hub Over a Period of 8 Years in the Era of Thrombectomy

OBJECTIVE

The goal of this study is to understand how very elderly patients (VEP) after ischemic stroke are currently treated in a Stroke Unit (SU) Hub in Italy. We designed a retrospective monocentric study on patients admitted in the SU of "AO San Camillo Forlanini" over an 8-year period.

MATERIAL AND METHODS

Data were collected among patients with acute ischemic stroke admitted to SU between January 2012 and December 2019. Patients were divided into three sub-groups: Adults (18-65 years); Elderly (66-85 years); and VEP (>85 years). Vascular risk factors and clinical variables as predictors of short-term clinical outcome were compared among age groups.

RESULTS

A total of 1979 patients were enrolled, 254 were VEP (12.8%). The proportion of VEP showed no significant modifications during the 8-year period (11.9% in 2012-2015 and 13.7% in 2016-2019; p=0.93). The proportion of women, hypertension and atrial fibrillation was significantly higher in VEP compared to other age groups (p<0.001). The rate of VEP being treated with rt-PA increased from 2012-2015 to 2016-2019 (from 12.8% to 25.5%, p<0.001). Endovascular thrombectomy was rarely performed in VEP (1.5% of VEP). Rt-PA treatment was associated with favorable outcome for all three age groups (p<0.05).

CONCLUSIONS

We showed that VEP present different vascular risk factor profiles, clinical features, and prognostic elements for short-term stroke outcome. Future studies will reveal whether we will observe an increasing trend in the use of rt-PA and endovascular thrombectomy and whether it will result in improved functional outcome for VEP.

Tailored Vessel-Catheter Diameter Ratio in a Direct Aspiration First-Pass Technique: Is It a Matter of Caliber?

BACKGROUND AND PURPOSE

The aspiration technique has gained a prominent role in mechanical thrombectomy. The thrombectomy goal is successful revascularization (modified TICI ≥ 2b) and first-pass effect. The purpose of this study was to evaluate the impact of the vessel-catheter ratio on the modified TICI ≥ 2b and first-pass effect.

MATERIALS AND METHODS

This was a retrospective, single-center, cohort study. From January 2018 to April 2020, 111/206 (53.9%) were eligible after applying the exclusion criteria. Culprit vessel diameters were measured by 2 neuroradiologists, and the intraclass correlation coefficient was calculated. The receiver operating characteristic curve was used for assessing the vessel-catheter ratio cutoff for modified TICI ≥ 2b and the first-pass effect. Time to groin puncture and fibrinolysis were weighted using logistic regression. All possible intervals (interval size, 0.1; sliding interval, 0.01) of the vessel-catheter ratio were plotted, and the best and worst intervals were compared using the χ² test.

RESULTS

Modified TICI ≥ 2b outcome was achieved in 75/111 (67.5%), and first-pass effect was achieved in 53/75 (70.6%). The MCA diameter was 2.1 mm with an intraclass correlation coefficient of 0.92. The optimal vessel-catheter ratio cutoffs for modified TICI ≥ 2b were ≤1.51 (accuracy = 0.67; 95% CI, 0.58-0.76; P = 0.001), and for first-pass effect, they were significant (≤1.33; P = .31). The modified TICI ≥ 2b odds ratio and relative risk were 9.2 (95% CI, 2.4-36.2; P = 0.002) and 3.2 (95% CI, 1.2-8.7; P = .024). The odds ratio remained significant after logistic regression (7.4; 95% CI, 1.7-32.5; P = .008). First-pass effect odds ratio and relative risk were not significant (2.1 and 1.5; P > .05, respectively). The modified TICI ≥ 2b best and worst vessel-catheter ratio intervals were not significantly different (55.6% versus 85.7%, P = .12). The first-pass effect best vessel-catheter ratio interval was significantly higher compared with the worst one (78.6% versus 40.0%, P = .03).

CONCLUSIONS

The aspiration catheter should be selected according to culprit vessel diameter. The optimal vessel-catheter ratio cutoffs were ≤1.51 for modified TICI ≥ 2b with an odds ratio of 9.2 and a relative risk of 3.2.

Unsuccessful Endovascular Treatment in a Patient With Stroke Onset of Takayasu Arteritis and Positive Clinical Outcome

Takayasu's arteritis (TA) is a chronic progressive vasculitis affecting large and medium-sized vessels, mainly in young subjects. It is most common in women with a higher prevalence in the Asian population. Stroke is a rare complication of TA, and these patients usually have a poor therapeutic response to revascularization treatments (thrombolysis and/or thrombectomy). We report a case of a male patient aged between 40 and 50 years admitted to our Emergency Department's Stroke Unit for sudden left hemiplegia, hypoesthesia, and dysarthria caused by right internal carotid artery (ICA), middle cerebral artery (MCA), and anterior cerebral artery (ACA) occlusion. He was treated with intravenous thrombolysis (r-tPA), endovascular carotid stenting, and thromboaspiration. We also revealed subclavian stenosis, vascular bruit, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) elevation; therefore, a diagnosis of TA was made. Double antiplatelet therapy (DAPT) was started. Despite the early post-procedural carotid stent occlusion, the patient was discharged with a full recovery (neurological index of stroke scale [NIHSS] = 0). Thefive5-year clinical follow-up showed no clinical neurological relapses, and no arterial restenosis was found by further carotid artery echo-Doppler. Takayasu arteritis is a rare cause of ischemic stroke in young adults; however, stroke may be the first manifestation of the disease. Guidelines concerning the role of revascularization treatment in this type of patients are unclear. In this regard, the clinical experience and the multidisciplinary approach applied in our case had a pivotal role. Such an approach would eventually advocate for standardized treatment in patients with stroke and TA. 

Thrombolysis in elderly stroke patients in Italy (TESPI) trial and updated meta-analysis of randomized controlled trials

BACKGROUND

Since its approval, the use of alteplase had been limited to patients aged ≤80 years.

AIMS

TESPI trial had been designed to evaluate whether alteplase treatment within 3 h in patients with acute ischemic stroke aged >80 years resulted in favorable benefit/risk ratio compared with standard care. The meta-analysis of randomized controlled trials was updated to put findings in the context of all available evidence.

METHODS

TESPI was a multicenter, open-label with blinded outcome evaluation, randomized, controlled trial. Main clinical endpoints were 90-day favorable functional outcome (mRS score 0-2) and mortality and symptomatic intracerebral hemorrhage. The trial was prematurely terminated for ethical reasons after publication of IST-3 trial which provided evidence of treatment benefit in elderly.

RESULTS

Of the planned 600 patients, 191 (88 assigned to alteplase) were enrolled. Overall, 24/83 (28.9%) alteplase patients had a favorable outcome compared to 22/95 (23.2%) controls (non-significant absolute difference of 5.7% for alteplase; OR 1.35, 95% CI 0.69-2.64, P = 0.381). Rates of death were non-significantly lower in the alteplase patients (18.1% vs. 26.5%); rates of symptomatic intracerebral hemorrhage were similar between the two groups (5.9% vs. 5.1%). The updated meta-analysis showed consistent results with prior estimates and add weights.

CONCLUSIONS

The effects of alteplase observed in this interrupted trial did not reach statistical significance, probably for the small numbers, but are consistent with and add weight to the sum total of the randomized evidence demonstrating that alteplase is beneficial in patients with acute ischemic stroke aged over 80 years, particularly if given within 3 h.

Safety and efficacy of Rotigotine in hospedalized patients with Vascular Parkinsonism aged 75 and older: effects on movement, praxis capacities, time-space orientation, quality of life and adherence to medical therapy

In hospitals without stroke unit Department, the patients with acute ischemic stroke are stabilized in First Aid and sent to the Department of Internal Medicine. During the hospedalization period the patients undergo medical therapy for the stabilization of hemodynamic parameters and instrumental examinations for the determination of cardiovascular risk and thromboembolic evaluation. All patients are subjected to multidimensional evaluation of cognitive, praxis capacities, spatial-temporal orientation, quality of life and adherence to medical therapy. The aim of this study is evaluate the effect of Rotigotine patch on the impairment of neuro-cognitive capacity throught a continuous dopaminergic stimulation with transdermal administration. We have observed 19 patients (10 male and 9 female with range age 75-92 yrs) with Acute Ischemic Stroke stabilized in First Aid Depatment. The outcomes were the neurological changes from the baseline to 7 days in the clinical summury score on MMSE (on a scale from 0 to 30, with higher scores indicating fewer symtoms and lower physical limitations), Morinsky scale (on scale from 0 to 8, indicating adherence to therapy) and swallowing test (acts/minute). During the first week the patients were undergone to treatment with rotigotine 2 mg/24 hours. At the end of the treatment we obtained a statistically significant correlation about improvement of MMSE, Morinsky scale and swallowing test from a basal value. Rotigotine transdermal patches could be a new useful approach in the treatment of elderly hospetalized patients with acute ischaemic stroke correlated with cognitive impairment. Data shown that low dose of rotigotine patch could improves cognitive and praxis functions and therefore the quality of life of the hospitalized elderly patients. Rotigotine was effective and well-tolerated when used in routine clinical practice. Our data gave comfortable results but further evaluation are needed to have conclusive results. (www.actabiomedica.it)

The clinical spectrum of reversible cerebral vasoconstriction syndrome: The Italian Project on Stroke at Young Age (IPSYS)

Introduction

To describe clinical, neuroimaging, and laboratory features of a large cohort of Italian patients with reversible cerebral vasoconstriction syndrome.

Methods

In the setting of the multicenter Italian Project on Stroke at Young Age (IPSYS), we retrospectively enrolled patients with a diagnosis of definite reversible cerebral vasoconstriction syndrome according to the International Classification of Headache Disorders (ICHD)-3 beta criteria (6.7.3 Headache attributed to reversible cerebral vasoconstriction syndrome, imaging-proven). Clinical manifestations, neuroimaging, treatment, and clinical outcomes were evaluated in all patients. Characteristics of reversible cerebral vasoconstriction syndrome without typical causes (“idiopathic reversible cerebral vasoconstriction syndrome”) were compared with those of reversible cerebral vasoconstriction syndrome related to putative causative factors (“secondary reversible cerebral vasoconstriction syndrome”).

Results

A total of 102 patients (mean age, 47.2 ± 13.9 years; females, 85 [83.3%]) qualified for the analysis. Thunderclap headache at presentation was reported in 69 (67.6%) patients, and it typically recurred in 42 (60.9%). Compared to reversible cerebral vasoconstriction syndrome cases related to putative etiologic conditions (n = 21 [20.6%]), patients with idiopathic reversible cerebral vasoconstriction syndrome (n = 81 [79.4%]) were significantly older (49.2 ± 13.9 vs. 39.5 ± 11.4 years), had more frequently typical thunderclap headache (77.8% vs. 28.6%) and less frequently neurological complications (epileptic seizures, 11.1% vs. 38.1%; cerebral infarction, 6.1% vs. 33.3%), as well as concomitant reversible brain edema (25.9% vs. 47.6%).

Conclusions

Clinical manifestations and putative etiologies of reversible cerebral vasoconstriction syndrome in our series are slightly different from those observed in previous cohorts. This variability might be partly related to the coexistence of precipitating conditions with a putative etiologic role on disease occurrence.

What is the Current Role for Vitamin D and the Risk of Stroke?

INTRODUCTION

Increasing evidence supports the relationship between vitamin D and stroke. Vitamin D has now been proposed as a prognostic biomarker also for functional outcome in stroke patients.

METHODS

A revision of the data suggests that low vitamin D is associated more with ischemic than with haemorrhagic stroke, even if the role of optimal vitamin D levels for vascular wall is still unclear. Vitamin D deficiency induces with different mechanisms an alteration of vascular wall.

RESULTS

However, to date, the research supporting the effectiveness of vitamin D supplementation in stroke and in post-stroke recovery is still inadequate and conclusive evidences have not been published.

CONCLUSION

In this review, we provide a better understanding of the role of vitamin D in stroke.

Clinical skills or high-tech MR in TIA patients: what makes the difference?

BACKGROUND

TIA has been recently re-defined as "a transient episode of neurological dysfunction caused by ischemia without acute infarction." The gold standard to exclude the presence of ischemic lesions is acute brain MR. However, in many clinical settings, the 24/7 availability of MR is, at best, irregular. Being so, an appropriate adoption of this definition, which excludes the presence of ischemic lesions, can only be equally irregular. Our aim was to retrospectively compare the long-term outcomes of patients receiving acute care for TIA diagnosed with the new, tissue-based definition, and those diagnosed only on symptom duration.

METHODS

We analyzed 480 patients (227 males) from two centers: group 1 consisted of 162 patients with time-defined TIA; group 2 of 315 patients with negative brain DW-MRI (tissue-based TIAs). We considered the combined recurrence of TIA, stroke, myocardial infarction, and angina as endpoints.

RESULTS

Both groups had a similar mean follow-up duration (38.3 months vs. 37.2 months) and were comparable for vascular risk factors, clinical features, and etiology. The combined endpoint rates were 11.1% for both groups, and the rates for segregate endpoints did not differ between groups. Recurrence was correlated with atrial fibrillation, diabetes, and high diastolic blood pressure.

CONCLUSIONS

The long-term outcomes of TIA patients did not differ according to the definitions applied. Therein suggesting that, even without acute MRI results, a clinical diagnosis seemed to be enough to assure prompt medical treatment and similar long-term outcomes.

Charles Bonnet syndrome versus Occipital Epilepsy, a diagnostic challenge

Charles Bonnet Syndrome (CBS) is a disorder with visual deficit and complex recurrent visual hallucination in conscious patients, described for the first time by Charles Bonnet. It has been found in association with variable pathologic conditions of the eyes, central visual pathways and occipital lobe. Occipital lobe lesion is an important cause of visual field deficit associated with elementary simple hallucinations, whereas complex hallucinations are related to occipitotemporal and occipitoparietal visual association neocortex damage.

Five-Year Risk of Stroke after TIA or Minor Ischemic Stroke

BACKGROUND

After a transient ischemic attack (TIA) or minor stroke, the long-term risk of stroke and other vascular events is not well known. In this follow-up to a report on 1-year outcomes from a registry of TIA clinics in 21 countries that enrolled 4789 patients with a TIA or minor ischemic stroke from 2009 through 2011, we examined the 5-year risk of stroke and vascular events.

METHODS

We evaluated patients who had had a TIA or minor stroke within 7 days before enrollment in the registry. Among 61 sites that participated in the 1-year outcome study, we selected 42 sites that had follow-up data on more than 50% of their enrolled patients at 5 years. The primary outcome was a composite of stroke, acute coronary syndrome, or death from cardiovascular causes (whichever occurred first), with an emphasis on events that occurred in the second through fifth years. In calculating the cumulative incidence of the primary outcome and secondary outcomes (except death from any cause), we treated death as a competing risk.

RESULTS

A total of 3847 patients were included in the 5-year follow-up study; the median percentage of patients with 5-year follow-up data per center was 92.3% (interquartile range, 83.4 to 97.8). The composite primary outcome occurred in 469 patients (estimated cumulative rate, 12.9%; 95% confidence interval [CI], 11.8 to 14.1), with 235 events (50.1%) occurring in the second through fifth years. At 5 years, strokes had occurred in 345 patients (estimated cumulative rate, 9.5%; 95% CI, 8.5 to 10.5), with 149 of these patients (43.2%) having had a stroke during the second through fifth years. Rates of death from any cause, death from cardiovascular causes, intracranial hemorrhage, and major bleeding were 10.6%, 2.7%, 1.1%, and 1.5%, respectively, at 5 years. In multivariable analyses, ipsilateral large-artery atherosclerosis, cardioembolism, and a baseline ABCD² score for the risk of stroke (range, 0 to 7, with higher scores indicating greater risk) of 4 or more were each associated with an increased risk of subsequent stroke.

CONCLUSIONS

In a follow-up to a 1-year study involving patients who had a TIA or minor stroke, the rate of cardiovascular events including stroke in a selected cohort was 6.4% in the first year and 6.4% in the second through fifth years. (Funded by AstraZeneca and others.).

Anti-inflammatory Strategies in Stroke: a Potential Therapeutic Target

Stroke is an acute condition characterized by a sudden decrease in blood flow to brain tissue, resulting in immediate deprivation of both glucose and oxygen. Different mechanisms are involved in the pathogenesis of stroke, but increasing evidence suggests that one of the processes worsening clinical outcome is inflammation with the synthesis and the release of pro-inflammatory cytokines that activate several cells contributing to the progression of brain injury. Monoclonal antibody therapy has proved useful and safe for the treatment of several systemic diseases. In contrast, the evidence is limited for the treatment of stroke. More studies are needed in order to standardize the method of treatment and establish if it is safe and effective.

Effect of Cardioembolic Etiology on Intravenous Thrombolysis Efficacy for Acute Ischemic Stroke

Previous clinical studies suggest that intravenous (IV) recombinant tissue plasminogen activator (rt-PA) benefits stroke patients regardless of the underlying etiology. In this study, we assessed the possible differences in response to IV rt-PA between cardioembolic stroke and other stroke subtypes. A total of 303 consecutive stroke ischemic patients (from January 2005 to April 2014) admitted to our Stroke Unit and treated with IV rt-PA were retrospectively reviewed. All patients were classified in two groups: Cardioembolic (CE) and Non-Cardioembolic (NCE). We analyzed a total of 303 patients. Thirty patients died in the first hours after fibrinolysis and no statistically significant differences were found in two groups (14 CE vs 18 N-CE). We observed a significant differences in clinical outcome in terms of symptoms "improvement" (p< 0.01 .2) and symptoms" regression" (p<0.057 .2) even if this last result did not reach statistical significance in CE patients respect to N-CE patients. In conclusion, the intravenous fibrinolysis is more effective in CE group than in N-CE regarding symptoms "improvement" and the PFO-Stroke patients treated with fibrinolysis have better outcome than other patients and they have high rate of symptoms" regression". Moreover the main predictor of good outcomes were younger age and milder stroke severity on hospital admission.

Transient Ischemic Attack Fast-track and Long-Term Stroke Risk: Role of Diffusion-Weighted Magnetic Resonance Imaging

BACKGROUND

Acute ischemic lesions on diffusion-weighted magnetic resonance imaging (DWI-MRI) are reliable predictors of recurrent stroke at 90 days. However, to date, limited information on transient ischemic attack (TIA) patients with positive DWI lesions for stroke risk from 1 to 5 years is available. In this study, we evaluated the role of positive DWI lesions and vascular risk factors on stroke, cardiovascular death, and mortality at 90 days (T0), 1 year (T1), and 5 years (T2). Moreover, we also evaluated the association between stroke risk and the presence of DWI lesions.

METHODS

We performed an observational study on consecutive patients admitted to the emergency department of San Camillo-Forlanini Hospital, Rome, Italy, from January 2007 to November 2012. Over the study period, 4300 patients with TIA or ischemic stroke were examined by stroke specialists in an emergency room setting within 1 hour from admittance.

RESULTS

In 510 of 4300 patients (11.86%), a TIA was diagnosed, and 445 patients satisfy the study inclusion criteria. For all 445 patients, the mean ABCD2 score was 4.35 ± 1.30. Using DWI-MRI, we identified acute ischemic lesions in 185 patients (41.57%). We did not observe any correlation between duration of symptoms, ABCD2 score, and positive or negative DWI lesions. Positivity for DWI was not associated with the presence of diabetes mellitus, hypertension, smoking habit, or age; however, an association with weakness was observed. We documented a time-dependent increase in the absolute risk of stroke: T0: 1.35% (95% confidence interval [CI], .81-2.8); T1: 4.78% (95% CI, 2.88-7.47); T2: 9.02% (95% CI, 4.66-5.70). We did not record any difference in stroke risk in patients with positive DWI lesions: T0: hazard ratio [HR], 1.43; 95% CI, .35-5.88; log-rank P = .60; T1: HR, 1.04; 95%CI, .42-2.61; log-rank P = .91; T2: HR, .83; 95% CI, .25-2.67; log-rank P = .86.

CONCLUSIONS

This long-term follow-up study in TIA patients documents that both positive and negative DWI patients treated with fast-track had similar long-term risks of stroke.

Pulmonary arteriovenous malformation as a cause of embolic stroke: case report and review of the literature

BACKGROUND

Pulmonary arteriovenous malformation (PAVM) is an abnormal communication between pulmonary arteries and veins responsible for right-to-left shunting that could induce the development of embolic stroke.

SUMMARY

We describe an 82-year-old woman without history of respiratory or neurological diseases, who presented at our observation unit with acute onset of cerebral ischemia. Clinical, laboratory and radiological findings diagnosed a PAVM.

KEY MESSAGES

Usually, endovascular procedures based on embolization or, alternatively, surgery represent the recommended treatment. However, both hormonal therapy and thrombolytic therapy can be used. In our patient, treatment with warfarin induced a remission of symptoms. This strategy should be tested in larger studies.

A neuroleptic malignant-like syndrome (NMLS) in a patient with Parkinson's disease resolved with rotigotine: a case report

Neuroleptic Malignant-Like Syndrome (NMLS) is a rare, but potentially fatal complication of dopaminergic therapy in Parkinson's disease due to a sudden withdrawal of dopaminergic therapy. Here, we describe the case of a 79 years old woman, with 19 years history of Parkinson disease treated with L-dopa, dopamine agonists and MAO inhibitors, whose sudden withdrawal due to lack of therapeutic compliance, led to sudden onset of high fever, muscle rigidity, akinesia, autonomic dysfunction, impaired level of consciousness, respiratory distress and dysphagia with inability to take oral dopaminergic therapy. High blood levels of CPK and myoglobinaemia were found. The patient was treated with transdermal Rotigotine starting from a dose of 2 mg/24 hours, that was rapidly increased to 6 mg/24 hours, leading to resolution of the acute disturbances.

Women Stroke Association Statement on Stroke

We describe the current and future objectives of the Women Stroke Association, a nonprofit multidisciplinary organization promoting research awareness on medical, psychological, and social issues concerning women affected by cerebrocardiovascular disease. In this paper, we deal with only cerebrovascular disease, whereas cardiovascular disorders will be addressed in a future paper. Gender differences in the clinical presentation of cerebrovascular diseases have been repeatedly suggested, and some treatment options may not be as effective and safe in men and women. For many years, women have either been underrepresented or excluded from randomized clinical trials, and the majority of therapeutic research has been carried on predominantly male populations. Furthermore, gender differences have been shown to contribute to different responses to cerebrovascular drugs in women when compared with men, regarding pharmacokinetics, pharmacodynamics, and physiology. In this statement, we discuss main research fields relevant to Women Stroke Association's mission and commitment, highlighting opportunities and critical from the women's health perspective. Future directions and goals of the Women Stroke Association arise from these considerations and represent the association's commitment to combating stroke.

The cloud stroke unit: 24-hour acute stroke expertise-on-demand

The use of telemedicine, especially as it is relates to telestroke, has significantly expanded over the past one or two decades. The fact that stroke therapy is a time-critical disease process, coupled with the relative paucity of stroke-trained practitioners, makes telestroke an attractive technique of care. The authors' objective was to summarize the evidence that support the reliability of telemedicine for diagnosis and efficacy in acute stroke treatment in collaboration between hospitals in two different countries.

Sex differences in clinical presentation, severity and outcome of stroke: results from a hospital-based registry

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.

Muscle, peripheral nerve and autonomic changes

Muscle, peripheral nerve and autonomic disorders associated with acute cerebrovascular events are a large spectrum of conditions, their pathophysiology, clinical features, frequencies of occurrence, prognosis and treatment are diverse; the disturbances may be primary or secondary to acute cerebrovascular events. These disorders have been previously defined as multiple neurological complications as the underlying pathophysiological mechanism may largely differ; their characterization may need a full clinical, neuroradiological, neurophysiological, immunological, biochemical and genetic analyses assessment, and an autonomic function test may also be needed as well as nerve and muscle biopsy. In this chapter we present multiple neurological complications secondary to acute cerbrovascular events.

PKR is a novel functional direct player that coordinates skeletal muscle differentiation via p38MAPK/AKT pathways

Myogenic differentiation is a highly orchestrated multistep process controlled by extracellular growth factors that modulate largely unknown signals into the cell affecting the muscle-transcription program. P38MAPK-dependent signalling, as well as PI3K/Akt pathway, has a key role in the control of muscle gene expression at different stages during the myogenic process. P38MAPK affects the activities of transcription factors, such as MyoD and myogenin, and contributes, together with PI3K/Akt pathway, to control the early and late steps of myogenic differentiation. The aim of our work was to better define the role of PKR, a dsRNA-activated protein kinase, as potential component in the differentiation program of C2C12 murine myogenic cells and to correlate its activity with p38MAPK and PI3K/Akt myogenic regulatory pathways. Here, we demonstrate that PKR is an essential component of the muscle development machinery and forms a functional complex with p38MAPK and/or Akt, contributing to muscle differentiation of committed myogenic cells in vitro. Inhibition of endogenous PKR activity by a specific (si)RNA and a PKR dominant-negative interferes with the myogenic program of C2C12 cells, causing a delay in activation of myogenic specific genes and inducing the formation of thinner myofibers. In addition, the construction of three PKR mutants allowed us to demonstrate that both N and C-terminal regions of PKR are critical for the interaction with p38MAPK and Akt. The novel discovered complex permits PKR to timely regulate the inhibition/activation of p38MAPK and Akt, controlling in this way the different steps characterizing skeletal muscle differentiation.

Respiratory allergy to Cupressus sempervirens in Rome

Mediterranean Cypress pollen is the major aerospore component in winter and early spring. Several recent studies have assessed the incidence of respiratory allergy to this pollen. A personal series of patients encountered in 1994-96 revealed a 9.33% incidence of positive prick-test responses to Cypress pollen among a population with atopical status. That series included 16 (19.05%) single and 68 (80.95%) multiple allergy sufferers. Among the former the symptoms encountered were rhinitis (62.5%) and asthma (37.5%). Given the ever-increasing incidence of Cypress pollen allergy, there is a need to restrict the planting of the tree for ornamental purposes, especially in areas with a high pollen count.

[Study of spontaneous resolution of bronchial spasm after methacholine challenge. Comparison of patients with different degree of hyperreactivity]

The study was designed to assess the spontaneous recovery of bronchial spasm induced by methacholine in bronchial challenge tests and to examine the mechanisms and the modalities involved as well as the influence of dosage. The phenomenon was analysed in 32 hyperreactive patients diagnosed as asthmatics by measuring FEV1 as soon as maximum bronchial constriction (PD20) had been achieved and after 5, 10, 15, 30 and 60 minutes. The data obtained were subjected to variance analysis. Results show: 1) as regards duration of spontaneous recovery, that FEV1 returned to pre-challenge levels after 60 minutes in both the severely and moderately hyperreactive patients; 2) as regards onset of regression, that onset depended on the level of sensitivity, occurring after 30 minutes in the severely affected, after 15 minutes in the mild cases; 3) as regards recovery intensity, that in the moderated cases the recovery was more pronounced in the first 15 minutes than subsequently. Data show that the onset and intensity of the spontaneous recovery change according to the degree of sensitivity. That might reflect a greater affinity and/or bonding of methacholine in the muscarinic receptors of the severely affected, but the possibility of a difference in mediator metabolization speed cannot be excluded. In conclusion, research into the recovery of bronchial spasm may contribute to a better understanding of bronchial hypersensitivity and provide new information of value on the diagnosis, pathogenesis and treatment of the condition.

Time course of methacholine induced bronchoconstriction during drugs and spontaneous resolution

We examined the resolution of the bronchial spasm induced by methacholine after administration of a dose sufficient to provoke PD20 to study, in patients with bronchial asthma, how spontaneous resolution (as opposed to bronchodilator-induced resolution) takes place. According to a randomization criterion, the patients were divided into four groups: 1) resolution induced by salbutamol (S), 2) by ipratropium bromide (I), 3) after placebo (P) and 4) spontaneous resolution (R). In brief, we observed that variations in FEV1 after methacholine PD20, reach statistically significant levels after 15 minutes in patients from groups (S) and (I), after 30 minutes in patients from groups (P) and (R) (p < 0.05). Comparing the phenomenon at various intervals in the four experimental situation, we found a pairing trend: groups (S) and (I) on the one hand, and groups (P) and (R) on the other. On the whole, this phenomenon shows that pharmacological treatment accelerates the process of spontaneous resolution of the bronchial spasm induced by methacholine which, in our experience, beings to show after 15 minutes, and that after 60 minutes, there are no statistically significant differences in the four groups. It is our opinion that closer examination of this phenomenon may provide greater knowledge of the mechanisms that come into play during the phase after stimulation of the muscarinic receptors and that reasonably involve the system to eliminate the muscarinic drug.

Sensitivity of FEV1 and indices of flow volume curve in the methacholine test

Our aim was to asses the association between the decrease of FEV1 and the modifications of the indices (PEF, MEF25, MEF50 and MEF75% of FVC) during methacholine challenge. 105 patients of both sexes with mild bronchial asthma were included in this study and were subjected to methacholine test according to ATS standards. The results were analysed using analysis of variance (MANOVA), discriminant stepwise and multiple regression. The reduction of FEV1 induced by increasing dosage of methacholine was associated with a significant decrease of the other flow-volume curve indices but we can observe a different flow behaviour. The MEF50 was more significant during the first level of variations and the MEF75 and MEF25 being more significant during the subsequent phases. We conclude that the evaluation of the flow volume indices can be important for better study the site of action of methacholine.

Respiratory allergy to parietaria pollen in 348 subjects

We have revisited 348 records of allergic outpatients to Parietaria, ratio M/F 1:1 and mean age 29.46 +/- 12.49 yrs. 97 of them were skin positive to Parietaria only (A-group: M/F 37/60); 251 patients were skin positive also to other allergens (B-group: M/F 137/114). Mean age of A-group patients (35.41 +/- 12.91) was higher than B-group (27.16 +/- 11.54; p < 001). Dividing mono and polysensitized subjects by age decade, a different distribution was found between the two groups (p < 001): monosensitized patients showed an increasing number of subjects from the 3rd to the 4th decade and a decreasing trend in the following decades; polysensitized patients showed a prevalence in age < 20 yrs and a decreasing trend in the other decades. In B-group Gramineae were the most frequent allergens associated to Parietaria (84.8%) followed by Olea Europaea (41.1%), Dermatophagoides farinae (37.4%) and Dermatophagoides pteronyssinus (36.2%). Main symptoms were rhinoconjunctivitis (187 cases), rhinitis + asthma (141 cases) and bronchial asthma (20 cases). Comparing the clinical features of the two groups, we have found that monosensitized patients showed a female prevalence, a prevalence of rhinitis with late onset of symptoms while in patients suffering from isolated asthma the onset was early.