The role of emergency neurology in Italy: outcome of a consensus meeting for a intersociety position

A possible definition of clinical, educational and organizing aspects of emergency neurology in Italy is reported in this position paper of Emergency Neurology Intersociety Group, created in 2008 among the two neurological Societies in Italy: Società Italiana di Neurologia and Società di Neuroscienze Ospedaliere. The aim of this Group has been the evaluation of the role of neurologist in the emergency setting of Italian hospitals, as well as of the description of different scenarios in which a ward dedicated to a semi-intensive care of neurological emergencies could have a role in the actual organization of academic or general hospitals in our Country. The actual great relevance of neurologist activity in the inpatients treatment, in fact, is actually misleaded as it is the considerable significance of neurological expertise, techniques and support in hospital care pathways also involving neurological manifestations throughout the course of other diseases. Finally, the possible contents of educational programs orienting neurological specialty towards a better comprehension and management of emergency neurological problems either in terms of specific formation or of techniques to be learned by emergency neurologist, are reported as a results of the Consensus Workshop hold in Castiglioncello (LI) in September 12th, 2009

Efficacy and Safety of Intravenous Immunoglobulin as Adjuvant Treatment for Refractory Neuropathic Pain. Results of an Open-Label, Multicenter Study

Introduction. Neuropathic pain is frequently associated with many peripheral nervous system diseases and its successful treatment is an area of significant and critical unmet need. Methods. Twenty adult outpatients of both sexes who had been suffering from painful polyneuropathy resistant to conventional therapies for at least 6 months and up to a maximum of 5 years and who reported severity of pain >60 units on a visual analog scale (VAS) at baseline were included in this open-label pilot study. Patients were randomly 1:1 allocated to receive adjuvant intravenous immunoglobulin (IVIG) (Flebogamma (R), 2 g/kg) in addition to their regular therapy or to continue with the previous therapy (control group). Results. The mean value of pain intensity (VAS) in the IVIG group dropped from 88 at baseline to 49 after the first week, and to 28 after 4 weeks, while values in the control group only slightly changed, from 85 to 78 after 1 week and to 75 after 4 weeks (P < 0.01). Almost 100% of patients reported strong/medium pain (Short Form McGill Pain Questionnaire) in both groups at baseline, while after 48 weeks, pain was reduced to moderate/light in 90% of patients in the IVIG group, whereas no improvement was reported in the control group (P < 0.01). In patients' quality of life, scores of the IVIG group (Short Form 36, Clinical Global Impression of Change, and Patient Global Impression of Change questionnaires) in all the follow-up were significantly higher than those of the control group (P < 0.01). Conclusion. This unblinded pilot study showed a beneficial effect of IVIG on neuropathic pain intensity and quality of life in patients resistant to conventional treatments

Exploring somatosensory hemineglect by vestibular stimulation

The effects of vestibular stimulation upon somatosensory deficits or tactile extinction contralateral to a hemispheric lesion were investigated in 20 right brain-damaged patients and 11 left brain-damaged patients. After stimulation, right brain-damaged patients showed a temporary partial recovery from left hemianaesthesia or extinction. Conversely, right somatosensory deficits associated with left brain damage were virtually unaffected by vestibular stimulation. Temporary recovery from somatosensory deficits was independent of the presence of visuo-spatial hemineglect. The suggestion is made that somatosensory deficits and extinction produced by right brain damage have an important non-sensory or perceptual component, that may be positively affected by vestibular stimulation. The mechanisms whereby this treatment may ameliorate somatosensory deficits may involve the restoration of the normal correspondence between somatotopic and egocentric representations of the body

Cryptogenic stroke

Although in the last few years emerging conventional and unconventional radiological and laboratory techniques have shed light on different pathophysiologic causes of stroke, nowadays almost 25% of ischemic strokes results of undetermined etiology. Different diagnostic criteria have been developed to define cryptogenic stroke and to establish its prevalence in stroke units. Different studies tried to unravel mechanisms of cryptogenic stroke and to evaluate adequate primary and secondary preventive measures, but standardized diagnostic and therapeutic strategies are still missing. In this review we report the most relevant updated notions in cryptogenic stroke providing an overview of the definition, the recommendations for diagnostic evaluation and the updated treatment strategies for secondary prevention

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of tension-type headache in adults

Background: This is an updated version of the Cochrane review published in 2005 on selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headache. The original review has been split in two parts and this review now only regards tension-type headache prevention. Another updated review covers migraine. Tension-type headache is the second most common disorder worldwide and has high social and economic relevance. As serotonin and other neurotransmitters may have a role in pain mechanisms, SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been evaluated for the prevention of tension-type headache. Objectives: To determine the efficacy and tolerability of SSRIs and SNRIs compared to placebo and other active interventions in the prevention of episodic and chronic tension-type headache in adults. Search methods: For the original review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2003, Issue 4), MEDLINE (1966 to January 2004), EMBASE (1994 to May 2003), and Headache Quarterly (1990 to 2003). For this update, we revised the original search strategy to reflect the broader type of intervention (SSRIs and SNRIs). We searched CENTRAL (2014, Issue 10) on the Cochrane Library, MEDLINE (1946 to November 2014), EMBASE (1980 to November 2014), and PsycINFO (1987 to November 2014). We also checked the reference lists of retrieved articles and searched trial registries for ongoing trials. Selection criteria: We included randomised controlled trials comparing SSRIs or SNRIs with any type of control intervention in participants 18 years and older, of either sex, with tension-type headache. Data collection and analysis: Two authors independently extracted data (headache frequency, index, intensity, and duration; use of symptomatic/analgesic medication; quality of life; and withdrawals) and assessed the risk of bias of trials. The primary outcome is tension-type headache frequency, measured by the number of headache attacks or the number of days with headache per evaluation period. Main results: The original review included six studies on tension-type headache. We now include eight studies with a total of 412 participants with chronic forms of tension-type headache. These studies evaluated five SSRIs (citalopram, sertraline, fluoxetine, paroxetine, fluvoxamine) and one SNRI (venlafaxine). The two new studies included in this update are placebo controlled trials, one evaluated sertraline and one venlafaxine. Six studies, already included in the previous version of this review, compared SSRIs to other antidepressants (amitriptyline, desipramine, sulpiride, mianserin). Most of the included studies had methodological and/or reporting shortcomings and lacked adequate power. Follow-up ranged between two and four months. Six studies explored the effect of SSRIs or SNRIs on tension-type headache frequency, the primary endpoint. At eight weeks of follow-up, we found no difference when compared to placebo (two studies, N = 127; mean difference (MD) -0.96, 95% confidence interval (CI) -3.95 to 2.03; I2= 0%) or amitriptyline (two studies, N = 152; MD 0.76, 95% CI -2.05 to 3.57; I2= 44%). When considering secondary outcomes, SSRIs reduce the symptomatic/analgesic medication use for acute headache attacks compared to placebo (two studies, N = 118; MD -1.87, 95% CI -2.09 to -1.65; I2= 0%). However, amitriptyline appeared to reduce the intake of analgesic more efficiently than SSRIs (MD 4.98, 95% CI 1.12 to 8.84; I2= 0%). The studies supporting these findings were considered at unclear risk of bias. We found no differences compared to placebo or other antidepressants in headache duration and intensity. SSRIs or SNRI were generally more tolerable than tricyclics. However, the two groups did not differ in terms of number of participants who withdrew due to adverse events or for other reasons (four studies, N = 257; odds ratio (OR) 1.04; 95% CI 0.41 to 2.60; I2= 25% and OR 1.55, 95% CI 0.71 to 3.38; I2= 0%). We did not find any study comparing SSRIs or SNRIs with pharmacological treatments other than antidepressants (e.g. botulinum toxin) or non-drug therapies (e.g. psycho-behavioural treatments, manual therapy, acupuncture). Authors' conclusions: Since the last version of this review, the new included studies have not added high quality evidence to support the use of SSRIs or venlafaxine (a SNRI) as preventive drugs for tension-type headache. Over two months of treatment, SSRIs or venlafaxine are no more effective than placebo or amitriptyline in reducing headache frequency in patients with chronic tension-type headache. SSRIs seem to be less effective than tricyclic antidepressants in terms of intake of analgesic medications. Tricyclic antidepressants are associated with more adverse events; however, this did not cause a greater number of withdrawals. No reliable information is available at longer follow-up. Our conclusion is that the use of SSRIs and venlafaxine for the prevention of chronic tension-type headache is not supported by evidence