Intravenous thrombolysis in acute ischemic stroke: Our experience

Stroke is a major health problem worldwide and nationally: the second leading cause of death and dementia, the most common cause of epilepsy in the elderly, and a common cause of depression. Stroke is associated with an increased rate of morbidity, but it is also the leading cause of long-term morbidity and disability in industrialized countries. Thrombolysis by administering intravenous recombinant tissue plasminogen activator (IV-rtPA) is the only treatment method "in the therapeutic window" recognized in international protocols. The benefit-risk ratio should be evaluated on a case-by-case basis, with the neurologist's decision being individual and often difficult. The aim of our study was to analyze the outcome of this procedure in our hospital since 2015. We performed a retrospective clinical study of 77 patients with acute ischemic stroke subjected to IV-rtPA. Most patients with ischemic stroke undergoing intravenous thrombolysis did not receive chronic antithrombotictherapy. In most cases (76%) there was a decrease in the NIHSS score at 24 hours after thrombolysis and especially after 7 days (between 3 and 19 points), reflecting a reduction in poststroke disability in thrombolyzed patients. In the series of patients undergoing i.v. thrombolysis 5 deaths (10%) were recorded, the lowestrate of data/death ratereported in the literature (14-18%)

First episode of consciousness loss: setting new standards in acute care management

There is a high prevalence of patients addressed to the emergency department presenting a first episode of consciousness loss. The high prevalence of patients admitted to the emergency departments (ED) with a first episode of consciousness loss (ECL) is well established. Although there are studies assessing acute management in these patients, there is still need for more data on clinical and paraclinical characteristics which may prompt early etiological diagnosis, especially in countries where integrated medical procedures are lacking and access to specialized medical care is still limited. Sudden death syndrome, early cerebral morphological changes emerging in chronic epilepsy is the main motivation for an early diagnosis of epilepsy. The aim of our study was to evaluate demographic, clinical and paraclinical data in adult patients referred to our emergency hospital presenting a first episode of consciousness loss, in order to avoid misdiagnosis (with personal and social high impact) and unnecessary anti-epileptic treatment versus underestimation of epilepsy diagnosis. Conclusion: There is a clear need to improve multidisciplinary circuits in patients with a first episode of consciousness loss at a local level, in order to promote accurate and prompt diagnosis. We consider necessary to build a unitary online platform in order to establish an early and complete diagnosis

Primary Headaches and their Relationship with the Autonomic Nervous System

Headache disorders, described as early as 3000 BC, represent both a treatment challenge and a serious public health concern, with impact on the individual and society. Existing research in primary headache syndromes (not being caused by any underlying problem) focuses mainly on pain mechanisms. However, the painful symptomatology is the main encounter for the decreased quality of life and discomfort, the vegetative manifestations that frequently accompany the cephalalgic syndromes represent an important source of distress. Despite the advancement of the understanding of the molecular basis of headache disorders and neurovascular complex interactions, there is still lack of a cohesive understanding of the neurovegetative modulation in different types of primary cephalalgic syndromes. The aim of this chapter is to present an overview of the neurochemical mechanisms and pathways, which subtend dysautonomic manifestations in headache

Cardiac autonomic modulation in drug-resistant epilepsy patients after vagus nerve stimulation therapy

The positive effect of vagus nerve stimulation (VNS) in patients with drug-resistant epilepsy is considered to be mediated by the afferent pathways of the vagus nerve, but the efferent pathways may influence the cardiac autonomic activity.Aim of the study. To assess the effects of VNS on cardiac autonomic modulation in epilepsy patients, over three months of neurostimulation.Clinical rationale for the study. Linear and non-linear heart rate variability (HRV) analysis can provide information on the sympathovagal balance and reveal particularities of the central control of the autonomic cardiovascular function.Materials and Methods. Using Biopac Acquisition System, we analysed HRV parameters in resting condition and during sympathetic and parasympathetic activation tests in five patients with drug-resistant epilepsy, who underwent VNS procedure.Results. During the sympathetic and vagal activation tests, all five patients presented normal responses of cardiac autonomic activity, reflected in RMSSD, HFnu and LF/HF dynamics in both HRV evaluations. No bradycardia, cardiac arrhythmia or orthostatic hypotension was registered during the two evaluations.Conclusions. Our results indicate that VNS appears not to alter the cardiac autonomic function after three months of neurostimulation. HRV analysis is a useful tool for evaluating cardiac autonomic modulation in epilepsy patients during VNS therapy.Clinical Implications. Patients with decreased HRV should be periodically monitored. Cardiac changes in patients with epilepsy are important because of the additional risk of arrhythmias mediated through the autonomic dysfunction

Default mode function in patients with generalised epilepsy syndromes: from generalised to focal findings

Introduction. Many recent studies have suggested that generalised epilepsy is associated with cortical epileptogenic focus, and therefore distinguishing between focal and generalised often becomes difficult. Aim of study. We aimed to detect differences between default mode function in patients with idiopathic generalised epilepsy who have discharges on EEG, and healthy persons. Material and methods. This was a case-control study; we performed EEG analysis with LORETA in 17 patients with a type of generalised epilepsy and a control group represented by 17 healthy age-matched persons. We performed statistical non- -parametric tests for current density electrical distribution for our two groups (‘t-statistic on Log transformed data’) and we defined regions of interest (ROIs) from the default mode network. In the second part, we compared the average activation for each ROI for each timeframe in the epoch for the group with epilepsy, and for controls (we performed a Wilcoxon rank-sum test for two means). Results. In the first part, we obtained that in the medial frontal gyrus (BA 9) delta oscillations significantly differed in patients with epilepsy who had electrical discharges on EEG in resting state conditions compared to healthy controls (medial frontal gyrus in this group had a greater number of synchronously oscillating neurons than did the controls). In the second part, we ran statistics on our localised activity from the default mode network (defined ROIs) and we obtained statistically significant differences in the left medial frontal gyrus (the values were higher for the group with epilepsy, p-value = 0.0066). Conclusions and clinical implications. It may be possible to move from a ‘generalised theory’ about epilepsy to a ‘focused theory’ by understanding how various areas of interest are activated within default mode networks. Insights into the pathophysiology of generalised epilepsy may lead to new treatment options

Effect of Antiseizure Medication on the Salience Network in Patients with Epilepsy with Generalized Tonic-Clonic Seizures Alone

This study aimed to investigate the effects of antiepileptic drugs on salience network regions in patients with epilepsy with generalized tonic-clonic seizures alone (EGTCSa). A retrospective observational case-control study was performed on 40 patients diagnosed with epilepsy with EGTCSa and 40 healthy age-matched controls. In LORETA, a voxel-by-voxel analysis between regions from the salience network was performed for both hemispheres, specifically between the anterior cingulate (BA 32 and BA 24) and the sublobar insula (BA 13). Subsequently, a Wilcoxon rank-sum test (the Mann-Whitney U test) was conducted for the equality of medians in the transformation matrix. A comparison was then made between each region of interest as defined by the salience network and the controls. Marked differences were found in the brain regions assessed in patients with EGTCSa treated with valproic acid and carbamazepine compared to the control group; few differences in patients treated with levetiracetam; and no difference was found in the group without treatment compared with those in the control group. These results suggest that ASMs can influence cognitive processes, which provide novel insights toward understanding the neural mechanisms underlying the effects of ASMs administration