[Show abstract][Hide abstract] ABSTRACT: Aim: The aim of our study was to compare characteristics of stroke patients who presented Obstructive Sleep Apnea/Hypopnea (OSAH) to those of cases that presented Central Sleep Apnea/Hypopnea (CSAH) events at PSG, and to investigate relationships between the type of breathing disturb during sleep and the location of brain damage. Methods: Thirty four patients were submitted to clinical, neuroradiological and polisomnographyc study (PSG) after 4 months of stroke. A Sleep Disordered Breathing (SDB) was diagnosed in all cases with an AHI > 5. Patients were classified as affected by pre-dominantly OSAH (pOSAH), or predominantly CSAH (pCSAH). Comparisons were made among the groups and correlation analyses were done in each group. Significance was set at p < 0.005. Results: Twenty six patients with ischemic strokes had a SDB during sleep (56% embolic, 31% lacunar, 8% large artery, 8% with undeter-mined cause). The 61% of them showed pOSAH. Except for age, no statistical differences were found between the two groups as to clinical findings, risk factors for stroke, PSG data, or location of brain lesion. Correlation analysis outlined that in pOSAH cases the time interval from stroke to PSG (∆t) was inversely related to both TST (p = 0.017) and TSP (p = 0.039); in pCSAHs it was inversely related to SE Index (p = 0.021) and directly related to both ODI (p = 0.016) and with the n. of arrhythmias/h sleep (p = 0.033). In pCSAH, AHI did not correlate with ODI. Con-clusions: Our data suggest that among cases with post stroke SDB is included 3 different subgroups of cases: OSAHs who terminate the obstruction by arousal, OSAHs who do not arise and alternate obstructive to central events, and CSAHs due to the direct effect of stroke on the breathing network; in a forth subgroup of cases， the microstructure of sleep might be altered, with the consequent occurrence of sleep-related events. Further studies are needed to clarify these hypotheses as well as the role of post-stroke depression on the nature and occurrence of SDB after stroke.
[Show abstract][Hide abstract] ABSTRACT: Imaging of a 29-year-old man with seizures showed a frontal lobe mass with curvilinear narrow calcifications, cystic components and multiple flow-voids. An AVM was considered. A DSA confirmed the hypervascular nature of the lesion. It was resected and microscopic examination showed an anaplastic oligodendroglioma remarkable for a diffuse and hypertrophic vasculature with areas of frank vascular proliferation. The marked vascularity seen on the MRI, the gyriform calcifications and the cystic degeneration are all features which can be encountered in an AVM. This case illustrates that highly vascular malignant gliomas can simulate vascular lesions by radiology and may require an angiogram for diagnosis.
[Show abstract][Hide abstract] ABSTRACT: Aim: In order to define the clinical and instrumental profile of patients with Obstructive Sleep Apnea/Hypopnea (OSAH) and to compare them with that of cases with Central Sleep Apnea/Hypopnea (CSAH), a series of stable strokes were studied.
Methods: Thirty four patients were submitted to both clinical and polisomnographyc study (PSG) after 4 months
of stroke. A Sleep Disordered Breathing (SDB) was diagnosed in all cases with an AHI>5. Patients were classified
as affected by predominantly OSAH (pOSAH), predominantly CSAH (pCSAH), or normal patients. Comparisons were made among the groups and correlation analyses were done in each group. Significance was set at p<0.005.
Results: Thirty-four ischemic strokes were enrolled (55% embolic, 6% large artery, 32% lacunar, 9% with
undetermined cause). The 76% of them had a SDB ( pOSAH=61%; pCSAH=39%). Nearly the 47% of cases had an obstruction of the upper airways alone or combined with an increase in pharyngeal tissue. No significant differences were found between pOSAH and pCSAH. In pOSAH cases, 8 cases (50%) had an obstruction of the upper airways; in 4 of them it was combined with an increase in pharyngeal tissue; the time interval from stroke to PSG (Δ t), was
inversely related to both TST (p 0.017) and TSP (p 0.039); the NIH-SS at entry was directly related to the number of arousals /h of sleep (p 0.044); the more severe AHI the higher is ODI (p 0.000). In the pCSAH group, 4 cases (40%) had an obstruction of the upper airways combined with an increase in pharyngeal tissue; two of these 4 cases had also a BMI>30. In CSAH, Δt was inversely related to SE Index (p 0.021), and directly related to both the number of arrhythmias/h sleep (p 0.016) and ODI (p 0.033). No correlations were found between the number of arrhythmias/h
sleep and causes of stroke both in pOSAH and in pCSAH groups.
Conclusions: Our data suggest a direct effect of stroke on the peripheral breathing system with subsequent
alteration of loop gain and CSAH phenotype, at least in a subgroup of cases. To confirm this hypothesis multicenter clinical sleep studied are needed.
Journal of Sleep Disorders and Therapy. 01/2013; 2:113.
[Show abstract][Hide abstract] ABSTRACT: Aim of the study: in order to characterise sleep disordered breathing (SdB) in patients with stable stroke, a prospective observational study is ongoing in Rome. We report the results of the first 55 cases studied. Methods: a consecutive series of patients with acute stroke, admitted to the stroke unit of two different Roman university hospitals, were screened. Participants were submitted to both clinical and instrumental evaluations at stroke onset and then at 4 months. The diagnostic tests included polisomnographyc (PSG) study and brain MRi. SdB, either central or obstructive, was diagnosed in presence of an apnoea/hypopnoea index (ahi) value ≥5. Statistical analysis was performed with SPSS version 18.0 for Windows. comparisons were done by χ2 tests or via Fisher's exact test depending on which was more appropriate. correlations were done with non-parametric tests (Spearman's rho). Statistical significance was set at p<0.05. Results: Fifty-five PSG studies were performed. Forty-two cases (76.4%) had a SdB. Twenty-eight out of the 42 (67%) cases with an ahi ≥5 had an obstructive sleep apnoea-hypopnoea (oSah) and 12 (29%) cases had a central sleep apnoea-hypopnoea (cSah). Patients affected by cSah were significantly older than those affected by oSah (p=0.052). in the group of patients affected by predominantly oSah, the longer the time interval from stroke to PSG, the shorter both the total sleep period and the total sleep time. Patients with predominantly cSah were more frequently arrhythmic and more frequently affected by increase in pharyngeal tissue and referred significantly more frequently inattention or unrefreshing sleep. Discussion and Conclusions: The hypothesis we postulate is that, in a subgroup of patients with stroke, stroke moves to worsen patients' pre-existing breathing condition, causing ventilatory instability. in these cases, central apnoea may take precedence over the obstructive one, in a loop gain circuit over than one, that gives rise to alternating obstructive and central events (possible complex-sleep apnoeas). Multicentre studies, capable of enrolling larger cohorts, are needed to confirm this hypothesis.
[Show abstract][Hide abstract] ABSTRACT: Sleep Disordered Breathing (SDB) is a negative prognostic factor for stroke patients. In order to reveal: (1) the frequency of Sleep Apnea-Hypopnea Syndrome (SAHS) in the stable phase of the illness; (2) the type of SAHS, either obstructive (OSAHS) or central (CSAHS); (3) the possible association between SAHS and daily sleepiness, cardiac arrhythmias, stroke / TIA recurrence and location of the brain lesion, an observational study is on-going at Sapienza University of Rome. We report here the results of cases included in the feasibility study.
clinical evaluations, brain images and polisomnographic study were performed at discharge and after 4 and 9 months of stroke.
Eleven out of the 12 patients included (91.6%) had an Apnea/Hypopnea Index-AHI >= 5. In 5 cases, the majority of total respiratory events were purely central in origin. In 3 of these 5 cases, a concomitant obstruction of the upper airways was revealed; the 2 remaining had risk factors for OSAHS (smoke, hypertension, BMI > 25). A significant association was found between central apnea/hypopnea events and cardiac arrhythmias (p value 0.017).
These findings confirm the high prevalence of SDB, either obstructive or/and central, even in the stable phase of the illness, which in those patients who had accumulated risk factors for OSAHS result in Complex-sleep apnea/hypopnea syndrome (CompSAHS). As patients with CompSAHS are left with very disrupted breathing on continuous positive airway pressure, in order to select cases with stable stroke who benefit from continuos-positive airway pressure (C-PAP) treatment, further and more detailed clinical studies are needed to better distinguish CompSAHS from mixed SAHS.
European review for medical and pharmacological sciences 09/2012; 16(9):1295-300. · 1.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We evaluated the feasibility and clinical utility of transesophageal echocardiography (TEE) in the early management of ischemic stroke. TEE was performed in consecutive patients with acute cerebral ischemia within 48 hours of symptoms onset. The data were analyzed by age (<55 vs ≥55 years), and the baseline stroke etiology was classified (determined vs undetermined). TEE was feasible in 660 (61%) of 1,080 patients. Left atrial abnormalities and complicated aortic plaques prevailed in older patients (p <0.05), irrespective of the stroke etiology. A patent foramen ovale prevailed in younger patients (p <0.05) but even in older patients was present in 13% of the determined and 31% of the undetermined stroke subgroups. Overall, high-risk and potentially high-risk cardioembolic sources were detected in 47% of the patients, and stroke etiology was consequently reviewed: 40% of the baseline undetermined strokes were reclassified as cardioembolic, and 29% of lacunar, 42% of large artery, and 30% of other determined-cause strokes were reclassified as concurrent etiology. Subsequently, according to the current guidelines, 12% of patients were reassigned from antiplatelet to anticoagulant therapy and 17% of patients were treated with high-dose statins; overall, secondary prevention treatment was modified in 26% of patients. In conclusion, TEE was feasible in about 2/3 of the patients investigated within 48 hours of the index event, contributed to stroke classification in 1/3 of cases, and guided secondary prevention therapy in 1/4 of patients. Therefore, TEE is useful for defining patients' risk profile for stroke recurrence.
The American journal of cardiology 11/2010; 106(9):1339-44. · 3.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A 35-year-old man presented with one month history of vomitus, dizziness and headache. CT and MR imaging revealed a 3.5 x 3.2 cm solitary extra-axial midline mass arising from the frontal falx cerebri; radiological findings were diagnostic of meningioma of the falx. At surgery, the tumour appeared as an extra-axial lesion and was removed via a left midline frontal craniotomy. Macroscopically, the surgical specimen was whitish, soft, well circumscribed and measured 1.6 cm in diameter; microscopic features showed a neoplasm with high cellularity, presence of mitotic figures, without necrosis or microvascular proliferation; the neoplasm was reactive for glial fibrillary acidic protein and MIB-1 index was about 15%. Given the localization, microscopic features were diagnostic of primary intracranial solitary leptomeningeal astrocytoma (PLA), WHO grade 3. PLA is a very rare lesion that arises in the leptomeninges of the brain or spinal cord with no involvement of intraparenchymatous tissue. Fifteen cases of PLA are reported in the literature. Retrospective neuroradiological analysis of this case failed to detect any findings to help in the differential diagnosis, thus confirming the fundamental role of the neuropathologist even in what can firstly appear to be a straightforward radiological diagnosis.
[Show abstract][Hide abstract] ABSTRACT: Lymphomatosis cerebri (LC) is a rare form of primary central nervous system lymphoma; we report a case of LC mainly involving the brainstem and cerebellum. This diagnosis should be considered in patients presenting with diffuse white matter disease, and a subacute clinical history of cognitive deficits, ataxic gait, and personality changes. We present our findings along with a review of the neuroradiological literature.
Journal of neuroimaging: official journal of the American Society of Neuroimaging 03/2010; 21(2):e183-6. · 3.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Myotonic dystrophy type 1 (DM1) is a multisystemic disease involving multiple organ systems including central nervous system (CNS) and muscles. Few studies have focused on the central motor system in DM1, pointing to a subclinical abnormality in the CNS. The aim of our study was to investigate patterns of cerebral activation in DM1 during a motor task using functional MRI (fMRI). Fifteen DM1 patients, aged 20 to 59 years, and 15 controls of comparable age were scanned during a self-paced sequential finger-to-thumb opposition task of their dominant right hand. Functional MRI images were analyzed using SPM99. Patients underwent clinical and genetic assessment; all subjects underwent a conventional MR study. Myotonic dystrophy type 1 patients showed greater activation than controls in bilateral sensorimotor areas and inferior parietal lobules, basal ganglia and thalami, in the ipsilateral premotor area, insula and supplementary motor area (corrected P<.05). Analysis of the interaction between disease and age showed that correlation with age was significantly greater in patients than in controls in bilateral sensorimotor areas and in contralateral parietal areas. Other clinical and MR characteristics did not correlate with fMRI. Functional changes in DM1 may represent compensatory mechanisms such as reorganization and redistribution of functional networks to compensate for ultrastructural and neurochemical changes occurring as part of the accelerated aging process.
Magnetic Resonance Imaging 08/2009; 28(2):226-34. · 2.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The National Institutes of Health Stroke Scale (NIHSS) is a basic component of the assessment of patients with acute stroke. To foster and standardize the use of the NIHSS among Italian health professionals, we translated the scale, dubbed into Italian the training and test videotapes devised by the National Institutes of Health researchers, and conducted a series of certification courses using the translated videos.
Translation, text adaptation, video dubbing, and editing of the Italian NIHSS videotapes relied on a team of bilingual stroke neurologists. Three waves of training courses were organized for mixed classes of medical and nonmedical health professionals. The certification test was based on the usual set of 5 videotaped patients. Scoring rules were those provided by the National Institutes of Neurological Disorders and Stroke. Reliability of the Italian NIHSS was assessed using kappa statistics and compared with that of the original NIHSS.
During 3 years, 850 nurses, 460 nonneurologist physicians, and 246 neurologists were trained. Pass rates were respectively 44%, 75%, and 87%, respectively. Overall, 80% of scale items showed moderate to excellent reliability. Independent significant predictors of test failure at multivariate logistic regression were nurse profession (OR, 5.41; 95% CI, 4.07 to 7.20), older age (OR, 1.03; 95% CI, 1.02 to 1.05), and first edition of the course (OR, 3.13; 95% CI, 2.43 to 4.05). The agreement across all items between NIHSS and the Italian NIHSS was 80% (kappa=0.70+/-0.18, z<0.001).
The Italian translation, supervised by experienced vascular neurologists, did not influence the clinimetric characteristics of the NIHSS. Our findings support the implementation of NIHSS video training in languages other than English.
[Show abstract][Hide abstract] ABSTRACT: Although many patients with multiple sclerosis (MS) complain of trigeminal neuralgia (TN), its cause and mechanisms are still debatable. In a multicentre controlled study, we collected 130 patients with MS: 50 patients with TN, 30 patients with trigeminal sensory disturbances other than TN (ongoing pain, dysaesthesia, or hypoesthesia), and 50 control patients. All patients underwent pain assessment, trigeminal reflex testing, and dedicated MRI scans. The MRI scans were imported and normalised into a voxel-based, 3D brainstem model that allows spatial statistical analysis. The onset ages of MS and trigeminal symptoms were significantly older in the TN group. The frequency histogram of onset age for the TN group showed that many patients fell in the age range of classic TN. Most patients in TN and non-TN groups had abnormal trigeminal reflexes. In the TN group, 3D brainstem analysis showed an area of strong probability of lesion (P<0.0001) centred on the intrapontine trigeminal primary afferents. In the non-TN group, brainstem lesions were more scattered, with the highest probability for lesions (P<0.001) in a region involving the subnucleus oralis of the spinal trigeminal complex. We conclude that the most likely cause of MS-related TN is a pontine plaque damaging the primary afferents. Nevertheless, in some patients a neurovascular contact may act as a concurring mechanism. The other sensory disturbances, including ongoing pain and dysaesthesia, may arise from damage to the second-order neurons in the spinal trigeminal complex.