Neurologic manifestations in 1760 COVID-19 patients admitted to Papa Giovanni XXIII Hospital, Bergamo, Italy.

OBJECTIVES: Evidences from either small series or spontaneous reporting are accumulating that SARS-CoV-2 involves the Nervous Systems. The aim of this study is to provide an extensive overview on the major neurological complications in a large cohort of COVID-19 patients. METHODS: Retrospective, observational analysis on all COVID-19 patients admitted from February 23rd to April 30th, 2020 to ASST Papa Giovanni XXIII, Bergamo, Italy for whom a neurological consultation/neurophysiological assessment/neuroradiologic investigation was requested. Each identified neurologic complication was then classified into main neurologic categories. RESULTS: Of 1760 COVID-19 patients, 137 presented neurologic manifestations that manifested after COVID-19 symptoms in 98 pts and was the presenting symptom in 39. Neurological manifestations were classified as: (a) cerebrovascular disease [53 pts (38.7%)] including 37 ischemic and 11 haemorrhagic strokes, 4 transient ischemic attacks, 1 cerebral venous thrombosis; (b) peripheral nervous system diseases [31 (22.6%)] including 17 Guillain-Barrè syndromes; (c) altered mental status [49 (35.8%)] including one necrotizing encephalitis and 2 cases with RT-PCR detection of SARS-Cov-2 RNA in CSF; (d) miscellaneous disorders, among whom 2 patients with myelopathy associated with Ab anti-SARS-CoV-2 in CSF. Patients with peripheral nervous system involvement had more frequently severe ARDS compared to patients with cerebrovascular disease (87.1% vs 42%; difference = 45.1% 95% CI 42.0-48.2; χ2= 14.306; p < 0.0002) and with altered mental status (87.1% vs 55.6%; difference = 31.5% 95% CI 27.5-37.5%; χ2= 7.055; p < 0.01). CONCLUSION: This study confirms that involvement of nervous system is common in SARS-CoV-2 infection and offers clinicians useful information for prevention and prompt identification in order to set the adequate therapeutic strategies.

Migraine improves after ischemic stroke.

OBJECTIVE: To assess if migraine frequency spontaneously changes after stroke. BACKGROUND: Patent foramen ovale (PFO) closure has been reported to decrease migraine attacks. Because many closures are carried out after an ischemic stroke, it is possible that migraine spontaneously improves after stroke. METHODS: We have prospectively collected all patients with ischemic stroke and active migraine admitted to our stroke unit and have compared their migraine frequency before and 6, 12, and 24 months after stroke. RESULTS: We studied 43 patients. Mean follow-up was 1.3±.5 years. The mean number of migraine attacks per month decreased from 2.9±2.2 before stroke to .7±1.4 six months after stroke (P<.0001), and to .6±.6 one year after stroke (P<.0001). Migraine attacks completely disappeared in 23 of 43 patients at 6 months after stroke (53.5%) and in 22 of 40 at 1 year (55.0%). Improvement of 50% or more or total disappearance of attacks occurred in 34 of 43 patients at 6 months after stroke (79.1%) and in 33 of 40 at 1 year (82.5%). CONCLUSIONS: Ischemic stroke is very often followed by a marked and persistent improvement of prestroke migraine. The causes of improvement are unclear and may involve changes in lifestyle and psychological status, drugs, platelet activation, or modifications of vasoreactivity after stroke. These data suggest that studies reporting the efficacy of PFO closure for migraine in stroke patients are probably biased by the lack of a control group.

Common carotid artery duplex for the bubble test to detect right-to-left shunt.

We prospectively compared the bubble test with agitated saline for right-to-left shunt using transcranial Doppler (TCD) of the right middle cerebral artery and second harmonic imaging duplex of the right common carotid artery (CCA) in 100 consecutive patients. Microembolic signals (MES) were counted offline. MES were classified into 6 classes: absent (class 0), 1-10 MES (class 1), 11-20 MES (class 2), 21-30 MES (class 3), 31-50 MES (class 4) and >50 MES or "curtain effect" (class 5). For TCD, classes 2-5 combined (i.e., "large" shunts), the sensitivity of duplex with the Valsalva maneuver was 95.3%, the specificity was 100%, the positive predictive 100%, the negative predictive value 96.6% and accuracy 98.0%. Second harmonic imaging duplex of the CCA may substitute TCD for the bubble test when an adequate cranial bone window is not available. This technique may also greatly increase the number of facilities where the bubble test can be carried out. However, tests with few or no MES need to be confirmed by TCD or transesophageal echocardiography.