Background and Aims:

Covert cognition may be present in around 15% of patients with Disorder of Consciousness (DoC). The lack of overt behavioural responsiveness may be due to many confounding factors, including diffuse pain. Aim of the present study was to compare, in non-communicative DoC patients, NCS-R scores obtained with the pressure on fingernail bed (standard stimulus, SS) versus other personalized painful stimuli (PS), shared with the rehabilitation staff and to verify possible correlations between NCS-R and Coma Recovery Scale-Revised (CRS-R).

Methods:

From a population of 66 patients (35 M and 31 F) enrolled in the study (mean age 42,74 years, range 14-69) diagnosed with DoC, according to the CRS-R, we selected a subgroup of 22 patients [10 M and 12 F; mean age =40,72 years (range 14-69); etiology: 10 TBI; 3 anoxia; 7 vascular (hemorrhagic or ischemic); 1 encephalitis], and assessed by means of NCS-R with PS (NCS-R-PS) versus SS (NCS-R-SS).

Results:

NCS-R-PS reached higher scores as compared to the NCS-R-SS, both for the total score and for motor and facial expression subscores (p<0.05). Significant correlation with CRS-R were found for both NCS-R-SS (r=0.613, p=0.0031) and NCS-R-PS (r=0.539, p=0.0117).

Conclusions:

Standard painful stimulation may be affected by sensory deficits of central and peripheral etiology and by the different pain sources. A personalized painful stimulation may be of some support to unveil covert cognition in non-communicative patients and to alleviate their possible sufferance by pain killers, improving responsiveness and quality of life.

Background and Aims:

Stroke is one of the leading causes of death and disability in the western world. The term embolic stroke of undetermined source (ESUS) indicates those nonlacunar strokes in which the most common causes have been excluded. It is thought that covert atrial fibrillation (AF) is the main etiology of ESUS. However, there are no definitive data about the actual prevalence of AF in ESUS.

Methods:

Fifty-four (n=54) patients with transient ischemic attack (TIA) or mild ischemic stroke (NIHSS < 3) - in which no causes had been identified with the usual diagnostic work-up - were recruited. All patients received a new generation smartwatch capable of reliably detecting AF through a single-lead electrocardiogram (ECG). Participants were instructed to use the ECG app to record at least 2 ECGs per day.

Results:

Patients’ median age was 68,5 year (IQR: 53,5-73). Thirty-three (61,1%) were female. Twenty-seven patients (50,9%) recorded the ECG twice a day as prescribed, forty-eight (88,9%) recorded the ECG at least once a day. Six patients (11,3%) had at least an episode of AF detected by the smartwatch app. One patient (1,9%) had a recurrent cerebrovascular event.

Conclusions:

New generation smartwatches offer the chance to augment the ability to detect covert AF and could represent a valid aid in the diagnostic work-up of ESUS. This pilot study demonstrated that available technologies could be readily implemented even with the current population’s technical and intellectual resources.

Background and Aims:

Delirium is an acute fluctuating disorder of attention and awareness. The endpoints of our study were: 1) incidence of delirium in acute stroke; 2) risk factors for delirium; 3) impact of delirium on the outcome of stroke.

Methods:

Patients were consecutively enrolled in a stroke unit from April to October 2020. Inclusion criteria were: age ≥18 years, acute stroke and NIHSS≥1. Exclusion criteria were: negative neuroimaging, stroke mimics, and need for ICU treatment. All patients were evaluated by means of Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Method-Intensive Care Unit (CAM-ICU) scores at baseline, within 72 hours or when patients developed symptoms suggesting delirium. The outcome was assessed by means of modified Rankin Scale at 90 days.

Results:

The overall incidence of delirium was 36/120 (30%). Delirium was associated with aphasia (OR 9.77; CI 1.2-79.6), chronic obstructive pulmonary disease (COPD) (OR 16.67; CI 1.1-263.0), deep Fazekas score (OR 5.05; CI 1.7-14.8), and physical restraint (OR 45.02; CI 1.4-1411.5). At 3 months follow-up evaluation, patients with delirium had more disability (DLR+: mRS=4; DLR–: mRS=1; Beta=1.43; CI 0.61-2.24; p=0.001) and shorter survival (DLR+: 84±20 days; DLR–: 87±13 days; p=0.048).

Conclusions:

Nearly one-third of patients (30%) had delirium in the acute phase of stroke. This finding supports the notion that delirium is a common complication of stroke. Delirium was associated with speech disorder, leukoencephalopathy, COPD and early use of physical restraint. Delirium was associated with increased risk of disability and shorter survival after stroke.

Background and Aims:

Longitudinal changes in carotid intima-media thickness (IMT) and plaque are considered markers of atherosclerosis progression and predictors of cardio and cerebrovascular events. However, a clinical predictive risk score of plaque progression is currently lacking. We aimed to investigate if a new proposed risk score (HAD₂S score) composed by the sum of single vascular risk factors (Hypertension, Age ≥ 75 years, Diabetes, Dyslipidemia and Smoking) and baseline IMT were predictive of plaque progression.

Methods:

We performed a retrospective analysis on real-life prospectively collected data. We include all patients with any detectable carotid plaque. The plaque score was defined as 0: no plaque or stenosis <30%; 1: stenosis between 30-49%; 2: stenosis between 50-69%; 3: stenosis between 70-99% and 4: occlusion. Vascular risk factors, stenosis progression, IMT, Peak Systolic Velocity and End Diastolic Velocity were investigated in all patients at baseline and at a median follow-up of 36.6 months (IQR 39.6-34.3). HAD₂S score was calculated for all patients.

Results:

The 340 included patients were aged 69.9 (9.1) years (52% men). 25% of subjects had plaque progression. Mean IMT at baseline was associated with plaque progression (p<0.0001). Patients with progression had a mean IMT at baseline of 0.86 (0.17) while those who didn’t present progression had a mean IMT at baseline of 0.77 (0.18). The 87.2% of patients with plaque progression had a HAD₂S score ≥ 2 (p=0.044).

Conclusions:

Our data demonstrates that mean IMT at baseline and initial HAD₂S score ≥ 2 could be considered predictors of plaque progression.

Background and Aims:

This study aimed at identifying the incidence, predictors and impact on long-term mortality and new-onset dementia of early-onset delirium in a cohort of patients with spontaneous intracerebral hemorrhage (ICH).

Methods:

We prospectively recruited consecutive patients in the Prognosis of InTra-Cerebral Hemorrhage (PITCH) cohort and analyzed the incidence rate of early-onset delirium (i.e. during the first 7 days after ICH onset) with a competing risk model. We used a multivariable Fine-Gray model to identify baseline predictors, a Cox regression model to study its impact on the long-term risk of mortality and a Fine-Gray model adjusted for pre-specified confounders to analyze its impact on new-onset dementia.

Results:

The study population consisted of 248 patients (mean age 70 years, 54% males). Early-onset delirium incidence rate was 29.8% (95% confidence interval [CI] 24.3-35.6). Multivariable analysis showed that pre-existing dementia (subhazard ratio [SHR] 1.63, 95% CI 1.03-2.57, p=0.036) and heavy alcohol intake (SHR 2.43, 95% CI 1.49-3.95, p<0.001) were predictors of early-onset delirium. Median follow-up was 9.5 years (interquartile range 8.1-10). Early-onset delirium was associated with higher mortality rates during the first 5 years of follow-up (HR 1.54 95% CI 1.02-2.32, p=0.042), but not thereafter (HR 0.77, 95% CI 0.35-1.68). Early-onset delirium did not predict new-onset dementia (SHR 1.54 95% CI 0.81-2.92).

Conclusions:

Early-onset delirium is a frequent complication of ICH and it should be regarded as a marker of pre-existing brain vulnerability. After ICH, it is associated with a higher risk of mortality, but not of new-onset dementia on long-term follow-up.

Background and Aims:

The aim of this report is to investigate the changes in rate of hospitalization and treatment of ischemic stroke during the first wave of COVID19 outbreak in Liguria district, Italy.

Methods:

A multicenter study involving all the Neurology Units in Liguria was carried out to analyze data about hospital admissions for ischemic stroke from March 10 to May 18, 2020 (study period), and from March 10 to May 18, 2018 (control period).

Results:

During the study period, a significant reduction of hospital accesses for ischemic stroke within 24 hours from symptoms onset was observed (451 cases in the control period versus 248 in the study period). Onset-to-door time was significantly increased in 2020 (mean 267,9±249,43 versus 232.2±290,46 minutes, p<0,001) as well as the mean NIHSS on arrival (8.1 versus 6.9, p<0,016). In the study period, we observed a reduction of the number of intravenous (iv) thrombolysis (38 vs 324, p<0,001) and an increase of intraarterial thrombectomies (21 vs 7, p<0,001).

Conclusions:

Our data support the hypothesis that social isolation and fear of being infected by SARS-CoV-2 played a crucial role in decreasing patients accesses to hospitals during the first Italian lockdown. In this scenario, mainly patients with more severe clinical presentations came to emergency rooms. Due to the decrease of hospital admissions and the increase of onset-to-door time, the number of iv thrombolysis performed was subsequently reduced. On the other hand, the number of mechanical thrombectomy was increased, as a result of the increase of patients not suitable for iv treatment and shift toward mothership model of organization.

Background and Aims:

Covid-19 disease is known to be associated with hypercoagulability state which is responsible for most of the clinical event. Among these, cerebrovascular accidents are frequently observed in affected patients, especially for those with cardiovascular comorbidity and severe respiratory symptoms. Radiological findings in Covid-19 related stroke show ischemic lesions in multiple cerebral vascular territories and large vessels occlusion. Thus, cardioembolism and thrombosis of large vessels seem to be the main etiologies. Other possible mechanisms include inflammation of vascular wall (vasculitis) and paradoxical embolism, supported by the non-rare occurrence of concomitant deep veins thrombosis. Little is known about the role of thromboprophylaxis for primary prevention of cerebrovascular events.

Methods:

We explored a cohort of 240 patients with Covid-19 recruited from March 2020 to March 2021 to estimate prevalence of stroke and to evaluate whether antithrombotic prophylaxis previously prescribed as secondary prevention could protect patients from the occurrence of stroke during Covid-19.

Results:

Eleven patients (median age was 80 years, 2 men and 9 women) developed ischemic stroke. 3 patients were under ASA treatment, 1 novel oral anticoagulant (NOAC) plus ASA, 1 warfarin, 3 patients EBPM at prophylaxic dose, 2 under ASA plus EBPM, 1 was untreated. No differences in comorbidities were reported among patients.

Conclusions:

We found that prophylactic antiaggregation and EBPM did not statistically reduce stroke risk in Covid-19 patients.

Background and Aims:

The development of post-stroke depression (PSD) is the most frequent neuropsychiatric post -stroke complication, with an estimated prevalence between 18and33%. This variations occours because of assesment of PSD take place with distinct time intervals from stroke. The diagnosis can be challenging due to the fact several symptoms of depression may overlap with deficits that are a direct consequence of strokes and tools for PSD screeening are not well defined.

Methods:

We analysed all consecutive patients hospitalized at Neurorehabilitation Department after their first ischaemic or haemorrhagic stroke from September 2018 to December 2019.

Out of 213, 46 subjects were excluded for aphasia and 1 due to illiteracy. Out of 166, all subjects was evaluated for cognitive functions (MoCA) and, after excluded 36 subjects due to severe cognitive impairment (raw score of MoCA≤10), 130 subjects were evaluated for depressive symptoms (BDI-II≥9).

Results:

Out of 213 (mean age: 74.54, SD: 10.51), 173 subjects showed ischemic stroke; 88 showed right lesions and 98 left lesion. Only 15 undergoing thrombolysis; 135 were hypertensive and only 49 were diabetic. Out of 166, 107 subjects showed a severe or moderate cognitive impairment (mean raw MoCA score: 12.27, SD: 5.39); out of 130 subject evaluated with BDI-II, 67 (mean age:72.83, SD: 9.47) showed mild to severe depressive symptoms and 22 were in-therapy with SSRI before stroke.

Conclusions:

PSD is vastly underdiagnosed, necessitating active screening in subjects underwent to rehabilitation after acute stroke. The high frequency can be related to acute loss of function but could be related to the brain damage.