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Anti-myelin oligodendrocyte glycoprotein antibody-associated disorders (MOGAD) are new emerging diseases with heterogeneous course, treatment, response, and prognosis. We herein present 2 cases with antibodies to MOG, one with a cerebellar/brainstem monophasic syndrome which partially improved after treatment, and the other with an optic neuritis onset then relapsed with cortical encephalitis and presented a subsequent complete recovery. We further discuss elements possibly associated with disease heterogeneity and influencing treatment choices. MOGAD is an extremely variable disease which can relapse and accumulate disability over time. An early diagnosis and correct timely treatment is fundamental to improve clinical outcome.

Background Dabigatran is a direct competitive thrombin inhibitor approved for stroke prevention in non-valvular atrial fibrillation. At full-dose, dabigatran showed similar rates of bleedings and higher efficacy compared to warfarin. Case summary We report a case of acute ischaemic stroke in a patient treated with dabigatran 150 mg b.i.d. for atrial fibrillation. After an off-label treatment with idarucizumab, a humanized monoclonal antibody approved for dabigatran reversal, we performed a successful intravenous thrombolysis (IVT). Transoesophageal echocardiography showed a left atrial appendage (LAA) thrombus, despite full-dose dabigatran and an adequate therapy adherence. Discussion There are few cases of LAA thrombus during dabigatran treatment reported in literature till date. We analyse the possible pathogenetic mechanisms involved in dabigatran failure, including drug interactions and unexpected genetic variations interfering with dabigatran serum levels suggesting periodical assessment of direct Oral Anticoagulant levels. Furthermore, we confirm initial reports of safety and efficacy of intravenous thrombolysis after idarucizumab, in case of dabigatran failure.

A 68-year-old man with a 9-year history of relapsing-remitting multiple sclerosis previously treated with natalizumab and fingolimod achieved clinical and radiologic stability with alemtuzumab. Sixteen months after administration of the second cycle, he developed behavioral changes and focal seizures, characterized by aphasia and motor automatisms. Seizures were refractory to multiple antiepileptic drugs and evolved into epilepsia partialis continua and, after 1 week, into generalized status epilepticus (see timeline, [doi.org/10.5061/dryad.pvmcvdnht][1]). EEG showed bilateral temporal slowing and epileptiform discharges. Brain MRI revealed new large multifocal nonenhancing cortical/subcortical abnormalities involving bilaterally the frontal and temporal lobes (figure 1, A and B). Routine blood analyses were unremarkable, except for a reduced lymphocyte count (730/μL; B cells 50%, T cells 36%). CSF analysis showed pleocytosis (12 cells/μL) and increased proteins (53.8 mg/dL), whereas extensive screening for infections (including JC virus, herpes simplex virus 1-2-6, varicella-zoster virus, cytomegalovirus, Enterovirus , Listeria , Haemophilus , Cryptococcus , and bacterial and fungi cultures) yielded negative results. Fixed cell-based and Western Blot commercial assays (Euroimmun, Lubeck) excluded the presence of neuronal antibodies, including Hu, Yo, Ri, Tr, GAD65, CV2/CRMP5, Ma2, SOX1, amphiphysin, N-methyl-D-aspartate receptor, LGI1, CASPR2, AMPAR1/2, gamma-aminobutyric acid-B receptor, and dipeptidyl peptidase-like protein 6. Whole-body computed axial tomography did not show any malignancies. A right parietal brain biopsy showed unspecific gliosis without inflammatory infiltrates. [1]: https://doi.org/10.5061/dryad.pvmcvdnht

Objectives The enforcement of complete lockdown with home confinement has been necessary to limit SARS-CoV-2 contagions in Italy, one the most affected countries worldwide. Simultaneously, in several Emergency Departments, a reduction in cardio- and cerebrovascular presentations was noticed. This study analyses the impact of Covid-19 pandemic and lockdown measures on the incidence of stroke, in Campania, the most densely-populated region in Italy. Materials and Methods We retrospectively analyzed data regarding acute stroke patients presenting at 5 Campania stroke hubs, before and after the issue of lockdown in Italy on March 9th, 2020. Results Compared to the pre-lockdown, we observed a significant reduction in the number of acute reperfusion treatments in stroke (P for interact 0.001); however the global number of patients presenting with acute stroke did not significantly differ. The time to reach medical attention was significantly longer in the lockdown phase (230 versus 154 min, P 0.016). For patients who underwent acute reperfusion treatment we also observed significantly longer time-to-imaging (30 versus 40 min, P 0.0005) and a trend to longer time-to-needle (75 versus 90 min P 0.23), but not time-to-groin. Conclusions This study showed the reduction in acute reperfusion treatments for acute ischemic stroke and the slowdown of stroke pathways, during the lockdown phase of Covid-19 pandemic, in Campania, the third-most-populous and the most-densely populated Italian Region. In the next future, the risk for high-grade disability and death, due to delayed or even avoided hospital presentation due to fear of contagion, may be high.