Increased age and male sex are independently associated with higher frequency of blood–cerebrospinal fluid barrier dysfunction using the albumin quotient

Background: The cerebrospinal fluid (CSF)/serum quotient of albumin (QAlb) is the most used biomarker for the evaluation of blood–cerebrospinal fluid barrier (B-CSF-B) permeability. For years QAlb was considered only as an age-related parameter but recently it has also been associated to sex. The aim of the present study was to explore the impact of sex in the determination of B-CSF-B dysfunction. Methods: The analysis was retrospectively conducted on subjects consecutively admitted to the neurological ward. CSF and serum albumin levels were measured by immunonephelometry and pathological QAlb thresholds were considered: 6.5 under 40 years, 8.0 in the age 40–60 and 9.0 over 60 years. Results: 1209 subjects were included in the study. 718 females and 491 males (age: 15–88 years): 24.6% of patients had a diagnosis of multiple sclerosis, 23.2% suffered from other inflammatory neurological diseases, 24.6% were affected by non-inflammatory neurological diseases, and for 27.6% of patients the final neurological diagnosis could not be traced. Dysfunctional B-CSF-B was detected more frequently (44 vs. 20.1%, p < 0.0001) and median QAlb value were higher (7.18 vs. 4.87, p < 0.0001) in males than in females in the overall study population and in all disease sub- groups. QAlb and age were positively correlated both in female (p < 0.0001) and male (p < 0.0001) patients, however the slopes of the two regression lines were not significantly different (p = 0.7149), while the difference between the elevations was extremely significant (p < 0.0001) with a gap of 2.2 units between the two sexes. Finally, in a multivari- able linear regression analysis increased age and male sex were independently associated with higher QAlb in the overall study population (both p < 0.001) and after stratification by age and disease group. Conclusions: Accordingly, identification and validation of sex-targeted QAlb thresholds should be considered as a novel tool in an effort to achieve more precision in the medical approach

Cerebral blood volume ASPECTS is the best predictor of clinical outcome in acute ischemic stroke: A retrospective, combined semi-quantitative and quantitative assessment

INTRODUCTION:The capability of CT perfusion (CTP) Alberta Stroke Program Early CT Score (ASPECTS) to predict outcome and identify ischemia severity in acute ischemic stroke (AIS) patients is still questioned. METHODS:62 patients with AIS were imaged within 8 hours of symptom onset by non-contrast CT, CT angiography and CTP scans at admission and 24 hours. CTP ASPECTS was calculated on the affected hemisphere using cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) maps by subtracting 1 point for any abnormalities visually detected or measured within multiple cortical circular regions of interest according to previously established thresholds. MTT-CBV ASPECTS was considered as CTP ASPECTS mismatch. Hemorrhagic transformation (HT), recanalization status and reperfusion grade at 24 hours, final infarct volume at 7 days and modified Rankin scale (mRS) at 3 months after onset were recorded. RESULTS:Semi-quantitative and quantitative CTP ASPECTS were highly correlated (p<0.00001). CBF, CBV and MTT ASPECTS were higher in patients with no HT and mRS ≤ 2 and inversely associated with final infarct volume and mRS (p values: from p<0.05 to p<0.00001). CTP ASPECTS mismatch was slightly associated with radiological and clinical outcomes (p values: from p<0.05 to p<0.02) only if evaluated quantitatively. A CBV ASPECTS of 9 was the optimal semi-quantitative value for predicting outcome. CONCLUSIONS:Our findings suggest that visual inspection of CTP ASPECTS recognizes infarct and ischemic absolute values. Semi-quantitative CBV ASPECTS, but not CTP ASPECTS mismatch, represents a strong prognostic indicator, implying that core extent is the main determinant of outcome, irrespective of penumbra size

Treatment with recombinant tissue plasminogen activator (r-TPA) induces neutrophil degranulation in vitro via defined pathways.

AbstractThrombolysis is recommended for reperfusion following acute ischemic stroke (AIS), but its effects on stroke-associated injury remain to be clarified. Here, we investigated the effects of recombinant tissue plasminogen activator (r-tPA) on neutrophil pathophysiology in vitro and in a case–control study with AIS patients submitted (n=60) or not (n=30) to thrombolysis. Patients underwent radiological and clinical examination as well as blood sampling at admission and after 1, 7 and 90days. In vitro, 30-min incubation with 0.1–1mg/ml r-tPA induced neutrophil degranulation in different substrate cultures. Pre-incubation with kinase inhibitors and Western blot documented that degranulation was associated with activation of PI3K/Akt and ERK1/2 pathways in Teflon dishes and PI3K/Akt in polystyrene. In thrombolysed patients, a peak of neutrophil degranulation products (matrix metalloproteinase [MMP]-9, MMP-8, neutrophil elastase and myeloperoxidase), was shown during the first hours from drug administration. This was accompanied by serum augmentation of protective tissue inhibitor of metalloproteinase (TIMP)-1 and TIMP-2. An increased rate of haemorrhagic transformations on day 1 after AIS was shown in thrombolysed patients as compared to non-thrombolysed controls. In conclusion, r-tPA treatment was associated with in vitro neutrophil degranulation, indicating these cells as potential determinants in early haemorrhagic complications after thrombolysis in AIS patients

Affidabilità delle mappe TC perfusionali nel definire il core infartuale e la penombra ischemica in pazienti con ictus ischemico acuto

INTRODUZIONE L’ictus ischemico rappresenta l’80% di tutti gli eventi cerebrovascolari acuti; è responsabile del 10-12% dei decessi (circa 6 milioni) per anno, rappresentando la seconda causa di morte a livello mondiale e la principale causa di disabilità nei paesi industrializzati. Il 70% di tutti gli infarti cerebrali è secondario ad occlusione dell’arteria cerebrale media. Nell’ambito del tessuto ipoperfuso si distinguono 3 regioni: - core infartuale (al centro dell’area ischemica): severamente ipoperfuso e non più vitale; evolve sempre verso l’infarto anche se viene riperfuso (danneggiato in modo irreversibile) - penombra ischemica (attorno al core): severamente ipoperfusa ma ancora vitale; evolve progressivamente verso l’infarto se non viene riperfusa (danneggiata in modo reversibile) - oligoemia benigna (attorno alla penombra ischemica): moderatamente ipoperfusa e di solito non a rischio di infarto; di solito recupera spontaneamente anche in assenza di riperfusione. Attualmente, le principali terapie di fase acuta comprendono la trombolisi endovenosa ed i trattamenti endovascolari e sono volti a ricanalizzare il vaso occluso e riperfondere il tessuto ischemico (penombra), con conseguente miglioramento dei sintomi neurologici e della prognosi. Tuttavia, il principale parametro su cui si basa la possibilità di accedere alle terapie di riperfusione è attualmente rappresentato dal tempo intercorso dall’esordio clinico con una finestra di intervento molto rigida. Pertanto, solo una ridotta percentuale (15-20%) dei pazienti con ictus ischemico acuto risulta eleggibile, per il momento, a questo tipo di terapie. E’ stato osservato inoltre, come, nonostante la ricanalizzazione, molti di questi pazienti (25-50%) non raggiungano comunque un buon outcome clinico, anzi, nel 35% di essi si abbia addirittura un’espansione dell’infarto cerebrale. E’ quindi evidente come esistano altri fattori (oltre al dato temporale) potenzialmente in grado di condizionare la prognosi dei pazienti con ictus ischemico acuto. In tale contesto, il Neuroimaging, mediante l’analisi degli aspetti fisiopatologici più rilevanti della patologia cerebrovascolare acuta, si pone come obiettivo quello di contribuire all’implementazione dell’efficacia e della sicurezza delle strategie terapeutiche, guidando e migliorando la selezione dei pazienti candidati alle terapie di riperfusione. Al fine di rispondere a queste esigenze è stato proposto pertanto un protocollo TC multimodale che, avvalendosi dell’utilizzo di TC standard senza mezzo di contrasto (NCCT), angio-TC (CTA) e TC-perfusionale (CTP), è in grado di fornire informazioni relativamente alla presenza/assenza di emorragie (ICH), alla pervietà dei vasi, allo stato della circolazione collaterale di supplenza alla regione ischemica (CTA) ed alle conseguenze emodinamiche dell’occlusione vasale (CTP). Tale protocollo è relativamente rapido e disponibile in molti centri. La CTP è l’unico strumento in grado di descrivere i principali aspetti dell’emodinamica cerebrale studiando il primo passaggio attraverso i capillari cerebrali di un bolo di mezzo di contrasto (m.d.c.) iodato somministrato per via endovenosa (e.v.). I dati densitometrici sono quindi analizzati secondo un modello matematico definito di deconvoluzione attraverso cui è possibile ricavare una curva densità/tempo definita Funzione Residua dove l’altezza del picco quantifica il CBF (flusso ematico cerebrale espresso in ml sangue/100 g di tessuto/min) e l’area sotto la curva rappresenta il CBV (volume ematico cerebrale a livello capillare-tissutale espresso in ml di sangue/100 g di tessuto). L’MTT (il tempo di transito medio capillare, ovvero il tempo intercorso tra l’immissione arteriosa nel letto capillare ed il deflusso venoso del m.d.c., espresso in secondi) è quindi calcolato sulla base del “principio del volume centrale” (CBF=CBV/MTT) dal rapporto CBV/CBF. Sulla base dei calcoli di deconvoluzione, il software genera infine le cosiddette mappe parametriche perfusionali pixel per pixel su scala colorimetrica. “Classicamente”: 1) ipoperfusione totale (core + penombra) = estensione della lesione CBF o MTT 2) core infartuale = dimensioni della lesione CBV 3) penombra ischemica = volume CBF o MTT - volume CBV (mismatch CBF o MTT – CBV). PRESUPPOSTI ED OBIETTIVI DELLO STUDIO Recenti evidenze hanno messo in discussione la validità del “classico” approccio CTP nel definire i parametri emodinamici cerebrali e quindi la sua affidabilità nel descrivere le caratteristiche delle regioni in cui notoriamente è suddivisa l’area ischemica e nel fornire indicazioni sulla prognosi dei pazienti con ictus ischemico acuto. Complessivamente pertanto, scopo di questo studio è stato quello di verificare: 1) se un approccio basato sull’analisi visiva dei classici parametri CTP sia accurato nell’identificare e nel descrivere i principali elementi dell’emodinamica cerebrale in corso di ictus ischemico acuto e pertanto ancora utilizzabile nella pratica clinica 2) se il classico mismatch tra CBF o MTTe CBV (the “penumbral hypothesis”) possa ancora avere un valore nel predire l’outcome di questi pazienti. Per questo motivo abbiamo deciso di misurare e descrivere i valori assoluti di CBF, CBV ed MTT ed il volume della lesione ischemica totale, del core infartuale e della penombra ischemica in una larga popolazione di pazienti affetti da ictus cerebrale acuto e di metterli in relazione con: - il carico trombotico e lo stato dei circoli collaterali leptomeningei di compenso (condizioni presenti all’esordio e contemporaneamente predittori di outcome), - la ricanalizzazione e la riperfusione (condizioni legate all’esito delle terapie messe in atto) - il volume dell’infarto finale e la disabilità (mRS) (indicatori di outcome a lungo termine). Dato che, il core infartuale è stato misurato sulla mappa CBV e, la penombra ischemica mediante il mismatch MTT - CBV, il nostro studio si propone di verificare se in effetti un approccio qualitativo di questo tipo può essere ancora utilizzabile ed utile nel predire il destino del tessuto ischemico e la prognosi dei pazienti. MATERIALI E METODI Selezione dei pazienti e disegno dello studio Abbiamo valutato retrospettivamente 200 pazienti con ictus ischemico nel territorio dell’arteria cerebrale media. Tutti i pazienti hanno eseguito un protocollo TC multimodale pre-trattamento comprendente: TC standard senza m.d.c. (NCCT), angio-TC (CTA) e CTP. E’ stato ottenuto il consenso informato dal paziente/familiari e il comitato etico locale ha approvato il protocollo. La scala NIHSS (National Institute of Health Stroke Scale) è stata calcolata al momento del ricovero e dopo 3 mesi. La scala di Rankin modificata (mRS) è stata calcolata a 3 mesi; un punteggio mRS ≤ 2 e > 2 è stato classificato come buono e cattivo outcome clinico, rispettivamente. Protocollo di imaging Gli studi CTP sono stati condotti secondo il modello del tracciante cinetico, analizzando il primo passaggio di m.d.c. a livello tissutale con un’apparecchiatura TC a 64 banchi (Lightspeed VCT 64, GE Helthcare) in accordo con il seguente protocollo di acquisizione: una scansione continua (cine) di 50 secondi ricostruita ad intervalli di 0.5 secondi al fine di ottenere una sequenza di 99 immagini per ciascuna delle 8 sezioni in cui è suddiviso lo spessore totale di 4 cm (dai gangli della base ai ventricoli laterali). La scansione CTP cine (80 kVp; 100 mAs; matrix size = 512 x 512; FOV = 25-cm; scan type = cine full 1 sec.; rotation = 0.5 sec.; total scan time 50 sec) è stata avviata 5 secondi dopo l’iniezione automatica di 40 ml di mezzo di contrasto non ionico (Iomeron 300 mg/ml, Bracco Imaging SpA) alla velocità di 4 ml/sec. Elaborazione dei dati Tutte le scansioni CTP sono state valutate con un algoritmo di deconvoluzione sensibile al ritardo utilizzando una stazione di elaborazione delle immagini (Advantage Windows; GEHelthcare). Sono state generate mappe CTP (CBF, CBV ed MTT) per ogni paziente. I valori di CBF, CBV e MTT sono stati espressi in ml/100g/min, ml/100g e secondi rispettivamente. Dopo averle identificate mediante analisi visiva sulle mappe MTT e CBV, l’ipoperfusione totale, il core infartuale e la penombra ischemica sono state calcolate disegnando manualmente tali lesioni rispettivamente sulle mappe MTT, CBV ed MTT-CBV (mismatch CTP). Il punteggio relativo al carico trombotico (clot burden score – CBS) ed allo stato dei circolai collaterali di compenso (regional leptomeningeal collaterals – rLMC) sono stati calcolati sulla CTA all’esordio. Un CBS ≤ 7 e> 7 (range 0-10) ed un rLMC ≤ 10 e> 10 (range 0-20) sono rispettivamente stati classificati come poveri e buoni. La ricanalizzazione è stata valutata a 24 sulla CTA secondo i criteri TICI. La riperfusione è stata definita come riduzione percentuale > 80% della lesione MTT basale rispetto a quella documentata a 24 ore. Il volume dell'infarto finale è stato delineato manualmente sulla TC di controllo (NCCT) eseguita a 7 giorni. Analisi statistica La distribuzione dei dati di ciascuna variabile è stata verificata attraverso il test di Kolmogorov-Smirnov. In caso di distribuzione normale dei dati, le differenze fra i valori medi di ciascuna variabile (valori assoluti di CBF, CBV, MTT e volume di lesione totale, core e penombra) sono state valutate mediante il t test di Student per campioni indipendenti. Nel caso invece di distribuzione non normale, i valori medi di ogni variabile sono stati confrontati utilizzando il Mann-Whitney U test. Dato che almeno una variabile presentava una distribuzione non normale, le correlazioni fra il volume della lesione totale, del core e della penombra e il Clot Burden Score (CBS), il Collateral Score (rLMC), il volume della lesione finale (calcolato dalla TC standard eseguita a 7 giorni) e l’outcome del paziente (calcolato mediante la mRS somministrata a 3 mesi) sono state valutate mediante il test del coefficiente di correlazione di Spearman.E’ stato considerato statisticamente significativo, un valore di p < 0.05. RISULTATI I valori CTP assoluti e volumetrici rilevati in tre differenti ROI analizzate, hanno mostrato che i valori assoluti di CBF e CBV misurati in core e penombra erano in accordo con quelli riportati in studi precedenti. Inoltre, un mismatch CTP indicativo della presenza di penombra ischemica è stato rilevato all'esordio in tutti i pazienti. Il volume della lesione totale, del core infartuale e della penombra ischemica erano significativamente inferiori (p < 0.0001) nei pazienti con basso carico trombotico rispetto a quelli con alto carico trombotico. Le dimensioni della lesione totale e del core infartuale si dimostravano significativamente più piccole nei pazienti con buona circolazione collaterale di compenso rispetto a quelli con scarsi circoli collaterali (p < 0.05 e p < 0.001, rispettivamente). Nessuna differenza statistica compariva per il volume della penombra in queste due categorie di pazienti. Il volume della lesione totale, del core infartuale e della penombra ischemica erano significativamente inferiori (p < 0.001, p < 0.01 e p < 0.001, rispettivamente) nei pazienti ricanalizzati rispetto a quelli con occlusione persistente. Le dimensioni della penombra risultavano significativamente più piccole (p < 0.02) nei pazienti riperfusi rispetto a quelli non riperfusi. Nessuna differenza statistica compariva per il volume della lesione totale e del core infartuale in queste due categorie di pazienti. Le dimensioni della lesione totale, del core infartuale e della penombra ischemica si dimostravano significativamente più piccole (p < 0.0001, p < 0.0001 e p < 0.01, rispettivamente) nei pazienti con outcome favorevole rispetto a quelli con outcome sfavorevole. Questi risultati sono stati confermati dalle correlazioni osservate tra i volumi CTP ed in parametri fisiopatologici, clinici e radiologici analizzati. DISCUSSIONE I nostri risultati suggeriscono che: -i valori assoluti misurati nel core infartuale e nella penombra sono sostanzialmente in accordo con i dati precedentemente riportati, indicando che l'identificazione di queste due regioni mediante analisi visiva è affidabile. -la TC perfusionale rappresenta uno strumento utile per predire la prognosi dei pazienti con ictus acuto; l'estensione dei volumi MTT (ipoperfusione totale) e CBV (core infartuale) è infatti fortemente legata ai parametri fisiopatologici ed alle misure di outcome clinico e radiologico; in particolare, la mappa CBV sembra essere il principale indicatore prognostico in accordo con alcuni studi precedenti. Complessivamente pertanto, la valutazione delle “classiche” mappe CTP (MTT, CBF e CBV) ed in particolare della mappa CBV, mediante un’analisi visiva rappresenta ancora un metodo affidabile per descrivere i principali aspetti dell’emodinamica cerebrale nell'ictus ischemico acuto. Questo è particolarmente importante nella pratica clinica quotidiana nell’ottica di implementare il più possibile il numero di pazienti trattati e di predire il loro esito funzionale a lungo termine.BACKGROUND Ischaemic stroke accounts for 80% of all acute cerebrovascular events. Stroke is responsible for 10-12% of deaths (about 6 million) per year, making it the second leading cause of death worldwide and the first leading cause of disability in developed countries. 70% of all cerebral infarctions is secondary to middle cerebral artery occlusion. Within the hypoperfused tissue 3 regions are identified: - the infarct core: strictly hypoperfused and not more vital tissue; it progresses to necrosis even if reperfused (irreversibly damaged) - the ischaemic penumbra (around the ischemic core): hypoperfused but still vital tissue; it progressively evolves to necrosis if not reperfused (reversibly damaged) - the benign oligoemia (around the ischemic penumbra): moderately hypoperfused tissue and usually not at risk for necrosis; it recovers spontaneously also without reperfusion. Currently, the major acute phase therapies include intravenous thrombolysis and endovascular treatments. Aim of these therapies is to recanalise occluded vessels and to reperfuse the ischaemic tissue (penumbra), resulting in an improvement of neurological symptoms and prognosis. However, the main parameter to get access to reperfusion therapies is represented by the clinical onset time with a strict time window. Therefore, only a small percentage (15-20%) of people with acute ischemic stroke is actually eligible for this kind of therapies; moreover, despite recanalization, many of these patients (25-50%) do not reach a good clinical outcome; on the contrary 35% of them have a cerebral infarction growth. Therefore, it is clear that other factors (in addition to time) are involved in clinical outcome of acute ischemic stroke patients. In this context, the Neuroimaging, through the analysis of the most relevant pathophysiological aspects of acute cerebrovascular diseases, aims to contribute to the efficacy and safety of therapeutic strategies, improving and leading patients selection for reperfusion therapies. In order to meet these needs a multimodal CT protocol has been proposed. This protocol, by using non contrast CT scan (NCCT), CT angiography (CTA) and CT-perfusion (CTP), tries to provide informations about the absence of an haemorrhage (ICH), vessels patency, regional leptomeningeal collateral state (CTA) and haemodynamic consequences of vascular occlusion (CTP). This protocol is relatively fast and available in many Centers. CTP is the only able to describe the main aspects of cerebral hemodynamics. It studies the first transit of a contrast bolus through brain capillaries. Densitometric data are then analyzed according to a mathematical model called deconvolution. Through deconvolution is possible to obtain a density/time curve called Residual Function. The height of the peak of this curve quantifies the CBF (cerebral blood flow – ml blood/100 g tissue/min) and the area under the curve the CBV (cerebral blood volume - ml blood/100g tissue). MTT (mean transit time - seconds) is then calculated on the basis of the "central volume principle " (CBF = CBV / MTT). Based on deconvolution, finally we obtain the so-called parametric perfusion maps. "Classically": 1) Total hypoperfusion (core + penumbra) = extension of CBF and MTT injury 2) Core infarct size = CBV injury 3) ischaemic penumbra volume = CBF or MTT - CBV volume (CBF/MTT - CBV mismatch). AIMS OF THE STUDY Several new findings have questioned the validity of "classic" CTP approach to define cerebral haemodynamics and its reliability in order to describe ischaemic regions (core and penumbra) and to predict outcome of acute ischaemic stroke patients. Therefore, aim of this study was to verify: 1) if a visual analysis approach of “classical” CTP parameters is reliable to identify and describe cerebral hemodynamics in acute ischaemic stroke and if it could be still used in clinical practice 2) if the classical mismatch (CBF/MTT – CBV) the so-called "penumbral hypothesis" can still has a value to predict patients outcome. For this reason we decided to measure CBF, CBV and MTT absolute value and the volume of the whole ischaemic lesion, infarct core and penumbra in a broad number of patients with acute ischaemic stroke. These measures were than coupled with: -the clot burden and the status of regional leptomeningeal collaterals (onset conditions and outcome predictors at the same time) -recanalization and reperfusion (conditions related to therapy issues) -final infarct volume and disability (mRS) (long-term outcome measures). As, infarct core was measured on CBV map and ischemic penumbra by the MTT - CBV mismatch, our study aims to verify whether a qualitative approach may still has a value to predict the fate of ischaemic tissue and patients prognosis. METHODS Patient selection and study design We retrospectively evaluated 200 patients having middle cerebral artery acute stroke. All patients performed pre-treatment multimodal CT protocol including non-enhanced CT (NECT), CT Angiography (CTA) and CTP. Informed consent was obtained from the patient/next of kin and local ethics committee approved the protocol. The National Institute of Health Stroke Scale (NIHSS) was recorded at admission and at 3 months. The modified Rankin scale (mRS) was recorded at 3 months; mRS ≤ 2 and > 2 were classified as good and poor outcomes, respectively. Imaging protocol CTP studies were performed with a dynamic first-pass bolus-tracking methodology on a 64-section CT scanner (Lightspeed VCT 64, GE Helthcare) according to a one-phase imaging protocol consisting of an acquisition of 50-seconds continuous (cine) scans reconstructed at 0.5 second intervals to produce a series of 99 sequential images for each of 8 sections which covered a total of 4 cm from the basal ganglia to the lateral ventricles. Cine CTP scanning (80 kVp; 100 mAs; matrix size = 512 x 512; FOV = 25-cm; scan type = cine full 1 sec.; rotation = 0.5 sec.; total scan time 50 sec) was initiated 5 seconds after the automatic injection of 40 ml of non-ionic contrast agent (Iomeron 300 mg/ml, Bracco Imaging SpA) at the rate of 4 ml/sec. Data processing All CTP scans were assessed with a deconvolution-based delay sensitive algorithm by using an imaging workstation (Advantage Windows; GEHelthcare). CBF, CBV and MTT CTP maps were generated for each patient. CBF, CBV and MTT values were expressed in ml/100g/min, ml/100g and seconds, respectively. After identification by visual inspection on MTT and CBV maps, total ipoperfusion, infarct core and ischemic penumbra volumes were calculated by manually drawing MTT, CBV and MTT-CBV (CTP mismatch) lesions, respectively. Clot Burden Score (CBS) and regional LeptoMeningeal Collateral (rLMC) score were calculated on CTA at onset. CBS ≤ 7 and > 7 (range 0-10) and rLMC ≤ 10 and > 10 (range 0-20) were classified as poor and good, respectively. Recanalization was assessed on 24 hour CTA according to TICI criteria. Reperfusion was defined as a percentage reduction > 80% in the baseline-24 hour MTT lesion. The final infarct volume was manually outlined on follow-up 7 days unenhanced CT (NECT). Statistical analysis The normality of each variable was checked by using the Kolmogorov-Smirnov test. When normality of data distribution was found in all variables, statistical analysis was performed by a parametric approach. Conversely, when normality of data distribution was rejected in several variables, a non-parametric analysis was applied. Accordingly, continuous variables were compared by t-test, whereas their correlation were assessed by linear regression or Spearman's rank correlation coefficient, respectively. A value of p < 0.05 was accepted as statistically significant. RESULTS CTP volumetric and absolute values detected in the three different ischemic ROI analyzed, showed that the absolute values of CBF and CBV measured in core and penumbra were in agreement with those reported in previous studies. Furthermore, a CTP mismatch indicative of salvageable penumbra was detected at onset in all patients. MTT total hypoperfusion, CBV infarct core and (MTT/CBF-CBV) penumbra volumes were smaller (P<0.0001) in good than in poor CBS. Total hypoperfusion and infarct core were smaller in in good than in poor rlMC (p < 0.05 e p < 0.001, respectively). No differences were detected between MTT-CBV penumbra volumes in patients with good and poor rLMC. Total hypoperfusion, infarct core and penumbra volumes were smaller (p < 0.001, p < 0.01 e p < 0.001, respectively) recanalized than occluded patients. Penumbra volumes were smaller (p < 0.02) in reperfused than not reperfused patients. No differences were detec

Epstein-Barr virus-specific antibody response in cerebrospinal fluid and serum of patients with multiple sclerosis

Cerebrospinal fluid and serum levels and intrathecal synthesis of anti-Epstein-Barr virus (EBV) IgG were measured by enzyme-linked immunosorbent assay in 80 relapsing-remitting multiple sclerosis patients grouped according to clinical and magnetic resonance imaging (MRI) evidence of disease activity. Eighty patients with other inflammatory neurological disorders (OIND) and 80 patients with non-inflammatory neurological disorders (NIND) served as neurological controls. Cerebrospinal fluid concentrations were higher in OIND than in multiple sclerosis (p &lt; 0.0001) and NIND (p &lt; 0.01) for anti-viral-capsid-antigen (anti-VCA) IgG, in multiple sclerosis than in NIND (p &lt; 0.01) and in OIND than in NIND (p &lt; 0.05) for anti-EBV nuclear antigen-1 (EBNA-1) IgG. Serum levels were more elevated in OIND than in multiple sclerosis (p &lt; 0.05) and in MRI inactive than in MRI active multiple sclerosis (p &lt; 0.0001) for anti-VCA IgG, and in multiple sclerosis than in OIND and NIND (p &lt; 0.01) for anti-EBNA-1 IgG. Serum titres of anti-VCA and anti-EBNA-1 IgG were also positively (p &lt; 0.05) and inversely (p &lt; 0.001) correlated, respectively, with the Expanded Disability Status Scale. An intrathecal IgG production of anti-VCA and anti-EBNA-1 IgG, as indicated by Antibody Index, was present only in a limited number of multiple sclerosis patients and controls (range from 1.3 to 6.3%). These findings do not support a direct pathogenetic role of EBV-targeted humoral immune response in multiple sclerosis

AbobotulinumtoxinA: A New Therapy for Hip Osteoarthritis. A Prospective Randomized Double-Blind Multicenter Study

Hip Osteoarthritis (OA) causes pain and disability. Here we evaluate abobotulinumtoxinA (Dysport®) (AboBoNT-A) injections versus placebo as a novel treatment option to improve hip range of motion, pain and quality of life. This prospective randomized double-blind multicenter study (EudraCT # 2012-004890-25) recruited 46 outpatients with hip OA who were randomized 2:1 to the Treatment Group (TG; 31 subjects), or the Placebo Group (PG; 15 subjects). The TG received 400 U of AboBoNT-A injected into the adductor muscles, and the PG received placebo solution. The primary endpoints were the difference in Harris Hip Score (HHS) and Visual Analogic Scale for pain (VAS) at Week 4 between groups (TG vs. PG). Secondary endpoints were the change from baseline in HHS, VAS pain, Medical Research Council scale for muscle strength (MRC) and Short Form scale (SF-36) scores. In TG at Week 4, the HHS and VAS score were significantly improved compared to PG, and pairwise assessments showed significant improvements in HSS and VAS pain at each time point compared to baseline for TG. No significant changes were observed in MRC and SF-36 over time, though SF-36 showed a positive trend. There were no significant differences from baseline in the PG. No adverse events were detected in either treatment group. AboBoNT-A injections in hip OA improve range of motion and pain without any significant side effects

CEREBROSPINAL FLUID AND SERUM LEVELS OF ANTI-CHLAMYDIA PNEUMONIAE IGA IN PATIENTS WITH MULTIPLE SCLEROSIS - ERMES: EMILIA ROMAGNA MULTIPLE SCLEROSIS. REGIONAL NETWORK FOR IMPLEMENTING A BIOLOGICAL BANK TO IDENTIFY MARKERS OF DISEASE ACTIVITY RELATED TO CLINICAL VARIABLES.

Objectives: Chlamydia pneumoniae (C. pneumoniae) is currently believed to be a potential co-factor in Multiple Sclerosis (MS) pathogenesis. In fact, intrathecally synthesized anti-C. pneumoniae high-affinity IgG and C. pneumoniae-specific CSF-restricted oligoclonal IgG bands were found in patients with MS progressive forms (1). In the setting of C. pneumoniae-specific humoral immune response, anti-C. pneumoniae IgA can be implicated in the reactivation as well as in the protection against C. pneumoniae infection. However, CSF and serum concentrations of anti-C. pneumoniae IgA have not yet been intensively investigated in MS. Materials: We analyzed 59 relapsing-remitting (RR), 9 secondary progressive (SP) and 15 primary progressive (PP) MS patients grouped according to clinical and Magnetic Resonance Imaging (MRI) evidence of disease activity. Seventy-two patients with other inflammatory neurological disorders (OIND) and 59 with non-inflammatory neurological disorders (NIND) were used as controls. Methods: CSF and serum levels of anti-C. pneumoniae IgA were measured by ELISA technique. Quantitative intrathecal synthesis of anti-C. pneumoniae IgA was determined by Antibody Specific Index (ASI). Results: CSF and serum concentrations of anti-C. pneumoniae IgA were higher in OIND (p < 0.0001, and p < 0.02, respectively) and NIND (p < 0.01 and p < 0.02, respectively) than in MS patients. Abnormal ASI values indicative of a C. pneumoniae-specific intrathecal IgA synthesis were more elevated in OIND (16/72; 22.2%) than in MS (3/83; 3.6%; p < 0.001) and NIND (3/59; 5.1%; p < 0.02). Anti-C. pneumoniae IgA CSF levels were greater in SP and PP than in RR MS (p < 0.02). No significant differences were found for CSF and serum mean concentrations of anti-C. pneumoniae IgA and for abnormal ASI values between MS patients categorized according to clinical forms and appearance of clinical and MRI activity. Discussion: Our findings suggest that anti-C. pneumoniae IgA may play a dual role in MS. First, lower CSF and serum levels of anti-C. pneumoniae IgA detected in MS compared to controls could reflect an increased susceptibility for C. pneumoniae infection in MS. Second, higher CSF IgA concentrations measured in SP and PP than in RR MS could indicate persistent and repeated C. pneumoniae infection in patients with MS progressive forms. Conclusions: C. pneumoniae IgA antibodies are considered the most relevant and clinically significant marker for ongoing C. pneumoniae infection or reactivation compared to the other Ig classes (2). Their detection in larger extent in SP and PP forms may have clinical significance in MS pathogenesis. Tipo presentazione: Progetto giovani: Malattie infettive 1. Fainardi E, Castellazzi M, Tamborino C, Seraceni S, Tola MR, Granieri E, Contini C. Chlamydia pneumoniae-specific intrathecal oligoclonal antibody response is predominantly detected in a subset of multiple sclerosis patients with progressive forms. J Neurovirol. 2009;15:425-33 2. Contini C, Seraceni S, Cultrera R, Castellazzi M, Granieri E, Fainardi E. Chlamydophila pneumoniae Infection and Its Role in Neurological Disorders. Interdiscip Perspect Infect Dis. 2010; 273573. Epub 2010 Feb 21

Effects of anticoagulants on the activity of gelatinases.

OBJECTIVES: To identify the best procedure for preanalytical blood collection in the determination of matrix metalloproteinase (MMP)-2 and -9 by testing the effects of anticoagulants on their activity. DESIGN AND METHODS: Active forms of both gelatinases were measured by specific activity assay systems in serum, plasma EDTA, plasma-heparin and plasma-citrate obtained from 20 healthy volunteers, as well as in a pooled serum sample before and after anticoagulant treatment. RESULTS:: Active MMP-2 and MMP-9 mean concentrations were similar in serum and in plasma-citrate, higher in plasma EDTA than in serum, in plasma-heparin and in plasma-citrate, and lower in plasma-heparin than in serum and plasma-citrate. A similar trend was observed in untreated and treated pooled serum samples. CONCLUSIONS: Our results indicate that MMP-2 and MMP-9 in their active forms are not released by platelets during blood clotting, whereas the use of calcium chelating anticoagulants can profoundly alter the activity of endogenous gelatinases. This suggests that the determination of active forms of MMP-2 and MMP-9 in serum samples represents a suitable procedure