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Teleconsultation is a consultation between two or more physicians about the diagnostic work-up and therapeutic strategy in the treatment of an individual case by means of modern telematics. ‘Drip-and-ship’ teleconsultation model consists of the transfer of patients, through telematics stroke networks, with large arteries occlusions from primary to comprehensive stroke centers equipped for endovascular therapy. We retrospectively investigated appropriateness, safety, and effectiveness of ‘drip-and-ship’ teleconsultation model in a rural area of Tuscany. Outcome measures were: door-to-ship time (including door-to-needle time), ratio of number treated/total sent patients, adverse events/mortality during transfer, and mortality and modified Rankin scale at 90 days. Analysis of non-treated patients was also done. Seventy-eight patients were included; 16/78 patients were sent for endovascular therapy alone, and 62/78 for “drip-and-ship”; 12 patients were not treated. Door-to-ship, and door-to-needle times (mean ± SD) were 105 ± 29.8 and 62.5 ± 37.5 min, respectively. The ratio number of treated/total sent patients was 0.85. At 90 days, the global mortality rate was 21%, and 40% of patients showed favorable outcome. The main cause of non-treatment was spontaneous recanalization. The high value for treated/total sent patients’ ratio underlines that “drip-and-ship” teleconsultation model is appropriate and effective, with a few untreated patients. The model is safe, without adverse events during transfer. Taken together, our outcomes are in line with the previous reports. “Drip-and-ship” teleconsultation model is safe and effective in rural areas, allowing good selections and rapid treatments for stroke patients, based on the transfer from the primary to the comprehensive stroke center.

Paraneoplastic syndromes include, by definition, any symptomatic and non-metastatic condition associated with a neoplasm. Paraneoplastic movement disorders are a heterogeneous group of syndromes encompassing both hyperkinetic and hypokinetic conditions, characterized by acute/sub-acute onset, rapidly progressive evolution, and multifocal localizations with several overlapping features. These movement disorders are immune-mediated, as shown by the rapid onset and by the presence of antineuronal antibodies in biological samples of patients, fundamental for the diagnosis. Antineuronal antibodies could be targeted against intracellular or neuronal surface antigens. Paraneoplastic movement disorders associated with anti-neuronal surface antigens antibodies respond more frequently to immunotherapy. The underlying tumors may be different, according to the clinical presentation, age, and gender of patients. Our search considered articles involving human subjects indexed in PubMed. Abstracts were independently reviewed for eligibility criteria by one author and validated by at least one additional author. In this review, we sought to critically reappraise the clinical features and the pathophysiological mechanisms of paraneoplastic movement disorders, focusing on diagnostic and therapeutic strategies. Our main aim is to make clinicians aware of paraneoplastic movement disorders, and to provide assistance in the early diagnosis and management of these rare but life-threatening conditions.

Background: During Covid-19 pandemic, the Italian National Healthcare Service has faced increasing pressure, especially in Northern Italy. Even in less-affected regions, such as Tuscany, the changes in the healthcare system to prevent Covid-19 spread resulted in difficulty in treating time-dependent disorders like ischemic stroke rapidly. Objective: The aim of our study was to assess the outcome after acute ischemic stroke treatments during the Covid-19 spread in comparison with a similar period of the previous year in Siena-Hospital (Hub center in the South-East Tuscany). Method: We enrolled all patients admitted to Siena-Hospital for ischemic stroke and submitted them to acute treatments (intravenous and/or mechanical thrombolysis) between February 21st and May 18th, 2020 (study group, n:38) and compared the results with ischemic strokes acutely treated in a similar period in 2019 (control group, n:39). The modified Rankin scale score was assessed at 90 days to evaluate a 3-month clinical outcome. Conclusion: In the study group, the time from symptoms onset to hospital arrival and the door-to-groin puncture time were significantly more prolonged than in the control group. In moderate-severe strokes, the 3-month mortality was significantly higher in the study group (31% vs. 6%; p=0.01), and the number of patients with poor functional outcomes was significantly higher in the study group (73% vs. 44%; p=0.03). Results : During the lockdown period due to Covid-19 pandemic, patients with acute ischemic stroke had a worse prognosis. These findings suggest the need to improve the health system organization to guarantee an appropriate treatment during the pandemic, including the patients that are not affected by Covid-19.

Objectives To explore the impact of sex and age on relationship between prodromal constipation and disease phenotype in Parkinson’s disease at early stages. Methods A total of 385 Parkinson’s disease patients from the PRIAMO study were classified according to the presence of prodromal constipation and followed for 24 months. Multivariable mixed-effect models were applied. All analyses were performed separately for sex (64.1% men) and median age (different by sex: 67 years-old in men and 68 years-old in women). Results As for sex, prodromal constipation was associated with greater odds of attention/memory complaints and apathy symptoms in women only. As for age, prodromal constipation was associated with lower cognitive and higher apathy scores in older patients only. Conclusions Prodromal constipation anticipates lower cognitive performances and more severe apathy since the earliest stages in women and older patients. Sex- and age-related heterogeneity of prodromal markers of Parkinson’s disease may impact disease phenotype.

Supplemental Digital Content is available in the text., Background and Purpose: We aimed to investigate the rate of hospital admissions for cerebrovascular events and of revascularization treatments for acute ischemic stroke in Italy during the coronavirus disease 2019 (COVID-19) outbreak. Methods: The Italian Stroke Organization performed a multicenter study involving 93 Italian Stroke Units. We collected information on hospital admissions for cerebrovascular events from March 1 to March 31, 2020 (study period), and from March 1 to March 31, 2019 (control period). Results: Ischemic strokes decreased from 2399 in 2019 to 1810 in 2020, with a corresponding hospitalization rate ratio (RR) of 0.75 ([95% CI, 0.71–0.80] P

Cervical artery dissections may present with mild and misleading symptoms such as a headache or cervical pain. In the absence of early diagnosis and therapy, such patients may have a high risk of cerebrovascular events. In order to refine evaluation of cervical artery dissections, we report the experience of a single center, focusing on clinical findings (e.g., headache and pain-related features at onset). From 2012 to 2017, 49 patients with cervical arteries dissections were admitted to our institution; 28 out of 49 patients (57%) presented with a headache or cervical pain, which were evaluated according to the International Classification of Headache Disorders (ICHD-III beta). Item C3a of ICHD-III beta (“pain is severe and continuous for days or longer”) was present in all patients symptomatic for a headache. Another common characteristic was the recent onset, with an average (± SD) timing from the onset of a headache to the first neurologic evaluation of 3 (± 2) days (range 1–5). A refined clinical evaluation of patients presenting with a headache at the Emergency Department could improve the early detection and management of patients with cervical artery dissections, in particular when presenting without other associated neurological symptoms.

We read with interest the article by Messer et al[1][1] regarding the clinical outcome after IV thrombolysis and/or mechanical thrombectomy in patients with acute ischemic stroke due to large-vessel occlusion, presenting as minor stroke syndrome (MSS) (NIHSS score < 5). The authors retrospectively

The Fattori di Rischio Ambientali e Genetici Associati alla Malattia di Parkinson (FRAGAMP) study is a multicenter case-control study carried out to evaluate the possible role of environmental and genetic factors in Parkinson's disease (PD). Cases and controls were enrolled from five Movement Disorder centers in Central-Southern Italy. PD was diagnosed according to Gelb's criteria while the control groups consisted of the spouses of the enrolled patients or of healthy controls matched by age and area of residence. Cases and controls underwent a standardised questionnaire and a blood sample was taken for molecular analyses. At the end of the study 585 cases and 481 control subjects (287 spouse-controls and 194 generic-controls) were enrolled. Patients had a Hoehn-Yahr score of 2.3 +/- 0.8; 85% of them took levodopa and 47% had motor complications. The FRAGAMP study represents one of the largest case-control studies carried out in Europe to investigate the possible role of environmental and genetic factors in PD.

Several investigations have documented an increased incidence of right-to-left shunt (RLS) in migraine with aura (MA) and have emphasised its role in the physiopathology of aura; so far, however, no data are available concerning a possible correlation between the extent of the RLS and the clinical picture of MA patients. To investigate the possible relationship between the extent of the RLS, revealed by the number of microbubbles (MB) detected during transcranial Doppler with IV injection of ultrasound contrast (TCDc), and the clinical characteristics of MA (age at first onset of migraine, mean annual frequency of attacks and mean duration of the aura phase), 30 consecutive patients with typical aura and migraine headache positive on TCDc evaluation for RLS were enrolled. Permanent RLS was found in 12 patients and latent RLS was found in 18 patients; of these, 6 had a high-grade RLS, 5 medium-grade RLS and 7 low-grade RLS. No correlation has been documented between the number of MBs and the clinical parameters of both patients with latent shunts and those with permanent ones, nor between the clinical parameters of the two groups of patients. These data show that RLS does not seem to affect the clinical manifestation of MA and that the extent of RLS fails to correlate with the severity of the clinical picture of the disorder.

We read with great interest the study of Bejot et al1 evaluating the characteristics and outcomes of patients with single and multiple cervical artery dissection (CeAD). In particular, good outcome (with only 12% of moderate-to-severe handicap at 3 months and none had died) was observed irrespectively of single or multiple vessel involvement. As major ischemic stroke because of artery-to-artery embolism is reasonably the main cause of disability in such patients and its prevention with antithrombothic therapy is considered effective,2 early diagnosis of dissection plays a key role to administer proper therapy, to prevent major stroke, and to reduce long-term disability. Thus an efficient …

BACKGROUND Testicular lymphoma is an aggressive, extranodal, non-Hodgkin lymphoma, accounting for less than 10% of all testicular neoplasms and less than 1% of lymphoproliferative malignancies. A paraneoplastic syndrome has been reported and may precede diagnosis of testicular cancer. A delay in diagnosis results in more advanced stage at clinical presentation and resultant poor outcome. CASE SUMMARY We report here a case of testicular lymphoma associated with multiple cranial nerve palsies contributing to the diagnosis of an occult lymphoproliferative malignancy. CONCLUSIONS In elderly men, accurate urologic examination is mandatory, particularly when other malignancies have been ruled out, since timely diagnosis of testicular malignancy may allow successful treatment. Paraneoplastic syndromes secondary to extranodal malignancies should be always taken into account in the evaluation of patients with multiple nerve palsies with no apparent primary neurologic disease.

Recent investigations documented that the prevalence of right-to-left shunt (RLS) in patients with migraine with aura (MA) is significantly higher than in healthy controls and similar to prevalence of RLS in young patients with cryptogenic stroke (CS). Nevertheless, little data are available in the literature about RLS prevalence in the other forms of primary headache. The aim of this study was to investigate the occurrence of RLS in patients with cluster headache (CH). We enrolled 30 consecutive patients with CH diagnosis according to the IHS criteria and 40 controls. RLS was assessed with bilateral transcranial Doppler contrast (TCDc) monitoring of middle cerebral arteries. Eleven patients (37%) resulted positive to TCDc monitoring for evaluation of RLS. These data show that the presence of RLS in this group is more prevalent than in the general population and similar to that found in MA and in CS.

Some studies have suggested an overlap of clinical and genetic findings between essential tremor (ET) and Parkinson’s disease (PD). The first genome-wide association study in ET showed a significant association with the rs9652490 SNP of the leucine-rich repeat and Ig domain containing 1 (LINGO1) gene. Since patients with PD have higher LINGO1 expression levels compared to healthy controls, and animal models of PD show elevated LINGO1 protein levels after experimentally induced damage in the striatum, it can be inferred that LINGO1 is probably involved in PD pathophysiology. In this study, we performed a genetic association analysis of the rs9652490 and rs11856808 SNPs in Italian PD patients and controls to assess the role of these variants in our population. A total of 567 patients with PD and 468 control subjects were enrolled in five Movement Disorder centers located in Central-Southern Italy. Both variants were significantly associated with PD under a recessive model of inheritance before applying the Bonferroni correction. The GG genotype of rs9652490 and the TT genotype of rs11856808 were less frequent in patients than in controls, suggesting a protective effect against the disease. However, after stringent correction, only the P-values obtained from allele and genotype comparisons of the rs11856808 SNP remained significant. Our findings suggest that LINGO1 plays a certain role in the development of PD in the Italian population and represents an interesting candidate gene responsible for PD, due to its involvement in neurological processes.

We report the case of a young patient suffering from a severe ischaemic stroke due to basilar artery occlusion occurring during selective digital subtraction angiography. This examination was performed in order to assess an arteriovenous malformation in posterior cerebral artery territory responsible for haemorrhagic stroke occurring 17 days before. Intra-arterial thrombolysis with urokinase was performed and basilar artery recanalization was obtained 8 h after stroke onset. Despite the severe neurological impairment, the prolonged symptoms of ischaemia and the high bleeding risk due to the recent cerebral haemorrhage in the same vascular territory involved in thrombolysis, the treatment determined a very favourable clinical outcome.

Lumbosacral radiculopathy is a very common pathology, frequently caused by degenerative spondyloarthropathies. However, radiculopathy may result from tumor in various locations within the spinal canal, more commonly extramedullary. Primary nerve root tumors are a rare cause of lumbosacral radiculopathy. The majority of primary spinal tumors are benign and slow growing, and their clinical manifestations may be difficult to distinguish from more common causes of radiculopathy, such as a disc herniation. To our knowledge, voluminous schwannomas with endoabdominal development have only rarely been observed. Lumbosacral radiculopathy is a common neurological syndrome which can be an important source of disability. Although the most common causes are disc herniation and chronic spinal arthropathy, physicians should be mindful of other causes, including neoplasms.

Hyperperfusion encephalopathy (HPE) is a condition due to increased perfusion of the brain which is clinically characterized by headache, seizures, and other neurologic signs associated with increased (or not) systemic blood pressures and edema in the subcortical white matter (predominantly in the occipital lobe). Patients with critical carotid stenosis treated with endarterectomy or carotid artery stenting may develop a HPE syndrome of the ipsilateral hemisphere which closely resembles the unilateral HPE and that usually involves the vascular area subjected ipsilaterally to the carotid stenosis. We present here a case of a 62-year-old woman who developed atypical hyperperfusion syndrome after a carotid stenting for high-grade carotid artery stenosis. In our patient, the HPE involved bilaterally both hemispheres, even though the treatment of the carotid stenosis was unilaterally. Some authors have hypothesized that a high dose of contrast, in combination with an unidentified personal vulnerability, may result in the rupture of the blood-brain barrier, carrying the CA into the cerebral parenchyma (both hemispheres), leading to the encephalopathy. The course and prognosis of HPE in post-carotid stenting are excellent with conservative treatment and full recovery usually occurs within 24 to 48 hours.

We read with interest Morelli et al.’s [1] article, “Intracranial hypotension syndrome following chiropractic manipulation of the cervical spine”, in the August 2006 issue of The Journal of Headache and Pain. We would like to take this opportunity to emphasise the following point. It is now recognised that most cases of intracranial hypotension result from spontaneous CSF leaks [2]. CT myelography with iodinated contrast has been shown to be the study of choice to accurately define the location and extent of a CSF leak [3, 4]. Radionuclide cisternography has been used extensively in the evaluation of spontaneous intracranial hypotension but is of relatively limited usefulness. Spinal MRI is not the primary diagnostic modality for detection of dural leak because it is not particularly effective in localising the CSF leak. It can detect indirect spinal manifestations of intracranial hypotension such as dilated epidural veins, dural enhancement, extrathecal CSF collections and syringomyelia [3, 4]. In this case report, the authors did not use CT myelography (gold standard) or radionuclide cisternography for showing dural leak and fistula. They mentioned that total spine MR imaging performed with myelographic sequences documented an arachnoid cyst of the third cervical root and suggested the presence of a dural leakage. They showed this finding in Figure 2. However, I cannot see any objective imaging finding of dural leak or fistula in this image. I only noted small meningeal diverticula. The presence of meningeal diverticula is not an objective dural leak finding. We see many silent meningeal diverticula during routine lumber or cervical MR examination. Also, the authors said that Figure 2 is an axial contrast enhanced image. To me, this look likes an axial T2 image without contrast enhancement (CSF and fat are bright).

To the Editor: We read with great interest the study by Sztriha et al1 evaluating the early clinical outcome in a large sample of unprotected carotid artery stenting procedures. Although randomized studies comparing endovascular treatment with endarterectomy are showing encouraging results in favor of the endovascular approach,2,3 cerebrovascular complications can occur during and in the early period after the procedure. Whereas intraprocedural complications may be caused by carotid plaque embolization and then they may be affected by the expertise of the physicians performing the procedures and by the development in endovascular technologies such as the use of protection devices,4 the etiopathogenesis of the cerebrovascular symptoms occurring after the end of the procedure may be unclear. Sztriha et al1 observed cerebrovascular complications in 14 of 245 (5.4%) consecutive patients included in their study; most of these (9/14 [64.3%]) occurred after the procedure and involved the vascular territory of the carotid artery undergone to stenting (8/9 [88.9%]), but neither restenosis nor reperfusion damage was present. Also, Qureshi et al5 reported periprocedural cerebrovascular …

Transcranial Doppler monitoring shows a high prevalence of microemboli during carotid artery stenting (CAS); however, the occurrence of cerebrovascular symptoms (CVSs) does not seem to be related to the microembolic load.To evaluate embolic and hemodynamic transcranial Doppler monitoring findings and their relationships with the occurrence of procedural CVSs. Patients Fifty-four patients who had carotid stenosis of more than 70% underwent a total of 57 CAS procedures during transcranial Doppler monitoring of mean blood flow velocity and microembolic signals in the middle cerebral artery. The occurrence of transient ischemic attack, transient monocular blindness, and stroke during the CAS procedure was considered CVSs.Nine (15.8%) of the 57 patients had CVSs during the procedure (ie, 6 patients with transient ischemic attack, 1 with transient monocular blindness, 1 with a minor stroke, and 1 with a major stroke). The mean blood flow velocity median values were statistically significantly lower (P.001) in the group of 9 patients with CVSs (36 cm/s; interquartile range, 32.3-38.5) compared with the 48 without CVSs (48 cm/s; interquartile range, 41.5-52). The median number of isolated microembolic signals was similar in the 2 groups (72; interquartile range, 66-81 vs 75; interquartile range, 67-83.5). The median number of microembolic signal showers (clusters of too many signals to be counted separately in one cardiac cycle) presented a nonsignificant prevalence in the patients with CVSs (9; interquartile range, 7.5-11.2) compared with the ones without CVSs (8.2; interquartile range, 7-9).The low flow velocity in the middle cerebral artery may impair the clearance of the microembolic load and should be considered a precursor of CVSs during the CAS procedure.

Headache and cervical pain are common but not specific symptoms of carotid and vertebral arteries dissection. It is difficult to identify a specific pattern of pain due to dissection, useful to correctly address the diagnosis of dissection at first clinical evaluation, if other neurological signs (e.g., cranial nerves deficit, Horner's syndrome and other signs of cerebral ischemia) are not present. Recently, in the third edition of the International Classification of Headache Disorders (ICHD-III beta) diagnostic criteria for headache attributed to arterial dissection have been modified. Some Authors have suggested that this new classification is more reliable to detect carotid or vertebral arteries dissection at first clinical evaluation. Some headache features, such as, acute onset, continuous lasting and time-persistence, are currently emphasized. We have retrospectively investigated 34 patients diagnosed from January 2012 to March 2015 with cervical artery dissection. Our aim was to identify the main features of headache attributed to arterial dissection, in our cohort of patients, according to the new ICHD-III beta. We enrolled 34 patients (20 females; mean age 56 ± 11; age range 31-83), 20 of them with headache. In 10 of these 20 patients, headache was the unique symptom.