Commentary: Early screening parameters for dysphagia in acute ischemic stroke

We read with great interest the article by Henke et al. (1) aimed to identify early assessable predictors of dysphagia in the acute phase of ischemic stroke. A multivariate logistic regression analysis revealed higher age, male gender, and higher stroke severity [as assessed by NIH stroke scale (NIHSS)] to be independent predictor of poststroke dysphagia. Moreover, ROC analysis showed that in the acute phase of stroke NIHSS score of 4.5 was the best cut-off between dysphagic and non-dysphagic patients. This research field certainly has a remarkable clinical interest, because it may lead to individuate those acute stroke patients who may benefit from a more detailed assessment of their swallow function (i.e., using fiberoptic endoscopic evaluation of swallowing or videofluoroscopy). However, an NIHSS cut-off for dysphagia of 4.5, by excluding only stroke patients with a very mild deficit, is probably of limited clinical usefulness. In other words, since the majority of stroke is of moderate-severe degree, it appears to be of little help in detecting only those patients who may benefit from a more detailed assessment of their swallowing function

Letter by toscano et al regarding article. association of leukoaraiosis with convalescent rehabilitation outcome in patients with ischemic stroke

Given the aforementioned link between leukoaraiosis and swallowing impairment, and the burden of poststroke dysphagia on rehabilitation outcome, it could be of some interest to analyze the relationships between leukoaraiosis, recovery, and dysphagia in your large population

Alice in wonderland syndrome. a clinical and pathophysiological review

Alice in Wonderland Syndrome (AIWS) is a perceptual disorder, principally involving visual and somesthetic integration, firstly reported by Todd, on the literary suggestion of the strange experiences described by Lewis Carroll in Alice in Wonderland books. Symptoms may comprise among others aschematia and dysmetropsia. This syndrome has many different etiologies; however EBV infection is the most common cause in children, while migraine affects more commonly adults. Many data support a strict relationship between migraine and AIWS, which could be considered in many patients as an aura or a migraine equivalent, particularly in children. Nevertheless, AIWS seems to have anatomical correlates. According to neuroimaging, temporoparietal- occipital carrefour (TPO-C) is a key region for developing many of AIWS symptoms. The final part of this review aims to find the relationship between AIWS symptoms, presenting a pathophysiological model. In brief, AIWS symptoms depend on an alteration of TPO-C where visual-spatial and somatosensory information are integrated. Alterations in these brain regions may cause the cooccurrence of dysmetropsia and disorders of body schema. In our opinion, the association of other symptoms reported in literature could vary depending on different etiologies and the lack of clear diagnostic criteria

Cerebral venous hemodynamic abnormalities in episodic and chronic migraine

Alterations of cerebral venous drainage have been demonstrated in chronic migraine (CM), suggesting that cerebral venous hemodynamic abnormalities (CVHAs) play a role in this condition. The aim of the present study was to look for a correlation between CM and CVHAs. We recruited 33 subjects suffering from CM with or without analgesic overuse, 29 episodic migraine (EM) patients with or without aura, and 21 healthy subjects as controls (HCs). CVHAs were evaluated by transcranial and extracranial echo-color Doppler evaluation of five venous hemodynamic parameters. CVHAs were significantly more frequent in the CM and EM patients than in the HCs. In the migraine patients, CVHAs were not correlated with clinical features. Cerebral venous hemodynamic abnormalities in episodic and chronic migraine The significantly greater frequency of CVHAs observed in the migraineurs may reflect a possible relationship between migraine and these abnormalities. Prospective longitudinal studies are needed to investigate whether CVHAs have a role in the processes of migraine chronification

Optic nerve sheath diameter ultrasound evaluation in intensive care unit. possible role and clinical aspects in neurological critical patients' daily monitoring

Background. The increase of the optic nerve sheath diameter (ONSD) is a reliable, noninvasive sonographic marker of intracranial hypertension. Aim of the study was to demonstrate the efficacy of ONSD evaluation, when monitoring neurocritical patients, to early identify malignant intracranial hypertension in patients with brain death (BD). Methods. Data from ultrasound ONSD evaluation have been retrospectively analyzed in 21 sedated critical patients with neurological diseases who, during their clinical course, developed BD. 31 nonneurological controls were used for standard ONSD reference. Results. Patients with neurological diseases, before BD, showed higher ONSD values than control group (CTRL: RT  cm; LT  cm; pre-BD: RT  cm; LT  cm; ) even without intracranial hypertension, evaluated with invasive monitoring. ONSD was further significantly markedly increased in respect to the pre-BD evaluation in neurocritical patients after BD, with mean values above 0.7 cm (RT  cm; LT  cm; ), with a corresponding dramatic raise in intracranial pressure. Logistic regression analysis showed a strong correlation between ONSD and ICP ( 0,895, ). Conclusions. ONSD is a reliable marker of intracranial hypertension, easy to be performed with a minimal training. Routine ONSD daily monitoring could be of help in Intensive Care Units when invasive intracranial pressure monitoring is not available, to early recognize intracranial hypertension and to suspect BD in neurocritical patients

Treating Chronic Migraine With Neuromodulation: The Role of Neurophysiological Abnormalities and Maladaptive Plasticity

Chronic migraine (CM) is the most disabling form of migraine, because pharmacological treatments have low efficacy and cumbersome side effects. New evidence has shown that migraine is primarily a disorder of brain plasticity and migraine chronification depends on a maladaptive process favoring the development of a brain state of hyperexcitability. Due to the ability to induce plastic changes in the brain, researchers started to look at Non-Invasive Brain Stimulation (NIBS) as a possible therapeutic option in migraine field. On one side, NIBS techniques induce changes of neural plasticity that outlast the period of the stimulation (a fundamental prerequisite of a prophylactic migraine treatment, concurrently they allow targeting neurophysiological abnormalities that contribute to the transition from episodic to CM. The action may thus influence not only the cortex but also brainstem and diencephalic structures. Plus, NIBS is not burdened by serious medication side effects and drug–drug interactions. Although the majority of the studies reported somewhat beneficial effects in migraine patients, no standard intervention has been defined. This may be due to methodological differences regarding the used techniques (e.g., transcranial magnetic stimulation, transcranial direct current stimulation), the brain regions chosen as targets, and the stimulation types (e.g., the use of inhibitory and excitatory stimulations on the basis of opposite rationales), and an intrinsic variability of stimulation effect. Hence, it is difficult to draw a conclusion on the real effect of neuromodulation in migraine. In this article, we first will review the definition and mechanisms of brain plasticity, some neurophysiological hallmarks of migraine, and migraine chronification-related (dys)plasticity. Secondly, we will review available results from therapeutic and physiological studies using neuromodulation in CM. Lastly we will discuss the results obtained in these preventive trials in the light of a possible effect on brain plasticity

A horse, a horse, my kingdom for a horse. Saddle thrombosis of carotid bifurcation in acute stroke

Background: Saddle thrombosis is less frequently detected in carotid arteries than in peripheral arterial embolism. The clot and the distal vessel patency have to be promptly recognized in these cases, because if the carotid vessel is open distally, chances may arise for successful emergent surgical procedures to remove the thrombus. At conventional static imaging, mobile floating thrombi may be difficult to differentiate from thrombosis on carotid complicated lesions of atherosclerotic origin. High-resolution ultrasound (US), with its unique capability of real-time imaging, adds fundamental data for interpretation of the findings. Methods: Carotid ultrasound has been performed in acute stroke patients with high-resolution probes. Real-time clips are analyzed and imaging is presented. Results: Saddle carotid bifurcation thrombosis of cardiac origin has been identified in 2 patients with acute homolateral ischemic stroke, with prompt successful surgical removal in one case. Moreover, an example of a thrombus attached on the ruptured surface of a complicated atherosclerotic plaque in an acute symptomatic stroke patient that was successfully operated in emergency is presented. Conclusions: Early high-resolution ultrasound with real-time imaging can easily identify peculiar characteristics of carotid vulnerable diseases in acute stroke phase. Different clinical implications result from the early identification of these different conditions, modifying the therapeutical strategies. © 2012 Elsevier GmbH

Ageusia, hyposmia, dizziness and tinnitus as presenting symptoms of multiple sclerosis

Multiple Sclerosis (MS) is a chronic inflammatory and neurodegenerative disease of the central nervous system characterized by the destruction of myelin sheaths and axonal loss. Presenting symptoms of multiple sclerosis may vary and if not promptly identified may lead to a delayed diagnosis of Multiple sclerosis. In this paper, we present a rare case of a patient with ageusia as presenting symptom of Multiple sclerosis; the symptom spontaneously resolved after two weeks and was followed by hyposmia, dizziness, tinnitus and facial paraesthesia that eventually led to a clinical diagnosis of Multiple sclerosis. The presence of gustatory, olfactory and audio-vestibular symptoms has been associated with disease activity and progression of several inflammatory and neurodegenerative diseases of the central nervous system including Multiple sclerosis. Gustatory alterations may be due to the presence of demyelinating lesion in the brain area of taste; the progression of the disease may explain the additional olfactory and audio-vestibular symptoms described in this patient. Even if taste alteration is an extremely rare presenting symptom of Multiple sclerosis, its presence in young women should always be carefully investigated as it could be an early sign of Multiple sclerosis

Migraine-specific quality of life questionnaire and relapse on medication overuse headache

Background: The management of Medication overuse headache (MOH) represents a difficult challenge for clinicians and headache experts, particularly for the responder rate after a successful withdrawal treatment. The purpose of this study was to investigate the role of demographic and clinical characteristics as well as the score of Migraine-Specific Quality of Life Questionnaire (MSQ), Migraine Disability Questionnaire and Leeds Dependence Questionnaire in predicting a response after a successful withdrawal treatment in patients with MOH. Methods: This ancillary study is part of a randomized trial that demonstrated the safety and the efficacy of a 3-month treatment with sodium valproate (VPA) (800 mg/day vs placebo) in MOH. Demographic and clinical characteristics and questionnaire results were obtained from the entire sample. Results: A significant correlation was found only between MOH relapse and the total MSQ score, the Role Preventive sub-scale and the Emotional Function sub-scale, suggesting a poorer quality of life in non responders. Conclusion: A high MSQ score could be associated with a poor short-term outcome in MOH patients after a successful treatment with detoxification followed by a new treatment

Le trasformazioni dello spazio urbano: la quarta dimensione nella georeferenziazione dell’iconografia storica di Rome

Se si considera la componente fisica del sistema città come espressione materiale dell’insieme dei fenomeni evolutivi dei luoghi, appare evidente come la sua rappresentazione possa essere considerata come sistema di conoscenza generale in grado di manifestare una convergenza di informazioni di natura altamente eterogenea. Le vaste trasformazioni che hanno interessato le città nella storia hanno determinato una evoluzione non solo nelle modifiche morfologiche degli assetti territoriali e nella stratificazione architettonica delle strutture urbane, ma anche nella percezione e fruizione degli spazi urbani. Se si considera l’organizzazione dello spazio urbano come ambito di relazione tra gli uomini, i contributi che provengono dalle fonti bibliografiche, iconografiche e cartografiche in particolare possono consentire la ricostruzione diacronica dei tessuti urbani. Questa ricostruzione è resa possibile dalla lettura delle diverse rappresentazioni che della città sono state date nel tempo, come rappresentazioni iconografiche o pittoriche, talvolta simboliche se non addirittura metaforiche, che consentono di acquisire conoscenze dei luoghi, anche quando presentano uno scarso grado di attendibilità. L’introduzione dell’informatica nel rilevamento e nella rappresentazione cartografica e la realizzazione dei sistemi informativi territoriali hanno aperto nuove possibilità non solo nella realizzazione di database collegati e georeferenziati, che possono contenere una notevole quantità di informazioni di diversa natura progressivamente incrementabili, ma soprattutto rendendo agevoli sia le molteplici interrogazioni sia le successive elaborazioni. Lo sviluppo della cartografia digitale dalla quale si possono derivare direttamente modelli tridimensionali, si pone quindi come punto di partenza per una corretta rappresentazione della complessità del fenomeno urbano e per un ripensamento dello spazio non più sulla base di esplorazioni planimetriche, ma tramite la creazione di modelli virtuali generati in maniera più o meno automatica a partire dalla cartografia stessa. In questo senso, il modello di derivazione cartografica costituisce l’aspetto metrico-quantitativo della rappresentazione della città, aspetto che risulta tanto più esatto, obiettivo e verificabile in quanto ottenuto con strumenti che rendono le misurazioni sufficientemente attendibili. Si tratta dunque di esplorare la cartografia tridimensionale cogliendone le peculiarità e la ricchezza nella restituzione dello spazio urbano, caratteristiche, queste, che suggeriscono immediatamente di tentare di ricostruire con la stessa vivacità rappresentativa anche tutti i trascorsi storici della città o, quanto meno, di alcuni dei suoi momenti topici, con particolare attenzione alle trasformazioni di natura orografica ed edilizia. In questo quadro emergono due distinti aspetti di natura metodologica, l’uno concernente la generazione del modello urbano e le implicazioni tecniche che questo comporta (implementazione di dati, automatismi, studi tipo-morfologici, scala del modello, …), l’altro relativo all’evoluzione della città attraverso il confronto tra modelli cartografici diversi (bi e tridimensionali). La realizzazione di un modello virtuale basato sulla cartografia digitale 3D, che fotografa lo stato attuale della struttura urbana, può rappresentare la griglia tridimensionale di riferimento per una visualizzazione delle trasformazioni spaziali attuata con una procedura che ripercorre a ritroso il cammino della storia. Si tratta di riferire a questa griglia orientata sulla base di capisaldi topografici certi i dati cartografici e iconografici provenienti dalla ricerca storico-documentaria, sulla base della individuazione di elementi invarianti della struttura urbana, come assetti orografici, vuoti urbani o edifici esistenti, etc., che non hanno mutato la loro localizzazione e le loro caratteristiche morfologiche. Così concepito, il modello tridimensionale di derivazione cartografica si caratterizza per la capacità di recepire e valorizzare documenti molto diversi e non necessariamente “scientifici” ai fini di una visualizzazione interattiva della storia del singolo brano di città o del singolo edificio per valutarne le trasformazioni sul piano morfologico e dimensionale, ma anche percettivo.Peer Reviewe