Guideline on carotid surgery for stroke prevention: updates from the Italian Society of Vascular and Endovascular Surgery. A trend towards personalized medicine.

BACKGROUND: This guideline (GL) on carotid surgery as updating of "Stroke: Italian guidelines for Prevention and Treatment" of the ISO-SPREAD Italian Stroke Organization-Group, has recently been published in the National Guideline System and shared with the Italian Society of Vascular and Endovascular Surgery (SICVE) and other Scientific Societies and Patient's Association. METHODS: GRADE-SIGN version, AGREE quality of reporting checklist. Clinical questions formulated according to the PICO model. Recommendations developed based on clinical questions by a multidisciplinary experts' panel and patients' representatives. Systematic reviews performed for each PICO question. Considered judgements filled by assessing the evidence level, direction, and strength of the recommendations. RESULTS: The panel provided indications and recommendations for appropriate, comprehensive, and individualized management of patients with carotid stenosis. Diagnostic and therapeutic processes of the best medical therapy, carotid endarterectomy (CEA), carotid stenting (CAS) according to the evidences and the judged opinions were included. Symptomatic carotid stenosis in elective and emergency, asymptomatic carotid stenosis, association with ischemic heart disease, preoperative diagnostics, types of anesthesia, monitoring in case of CEA, CEA techniques, comparison between CEA and CAS, post-surgical carotid restenosis, and medical therapy are the main topics, even with analysis of uncertainty areas for risk-benefit assessments in the individual patient (personalized medicine [PM]). CONCLUSIONS: This GL updates on the main recommendations for the most appropriate diagnostic and medical-surgical management of patients with atherosclerotic carotid artery stenosis to prevent ischemic stroke. This GL also provides useful elements for the application of PM in good clinical practice.

Anesthetic management of carotid endarterectomy: an update from Italian guidelines.

BACKGROUND AND AIMS: In order to systematically review the latest evidence on anesthesia, intraoperative neurologic monitoring, postoperative heparin reversal, and postoperative blood pressure management for carotid endarterectomy. The present review is based on a single chapter of the Italian Health Institute Guidelines for diagnosis and treatment of extracranial carotid stenosis and stroke prevention. METHODS AND RESULTS: A systematic article review focused on the previously cited topics published between January 2016 and October 2020 has been performed; we looked for both primary and secondary studies in the extensive archive of Medline/PubMed and Cochrane library databases. We selected 14 systematic reviews and meta-analyses, 13 randomized controlled trials, 8 observational studies, and 1 narrative review. Based on this analysis, syntheses of the available evidence were shared and recommendations were indicated complying with the GRADE-SIGN version methodology. CONCLUSIONS: From this up-to-date analysis, it has emerged that any type of anesthesia and neurological monitoring method is related to a better outcome after carotid endarterectomy. In addition, insufficient evidence was found to justify reversal or no-reversal of heparin at the end of surgery. Furthermore, despite a low evidence level, a suggestion for blood pressure monitoring in the postoperative period was formulated.

Sex influence in ischemic stroke severity and outcome among metabolically unhealthy overweight patients.

INTRODUCTION: The role of metabolically unhealthy (MU) overweight in influencing stroke prognosis has not been fully assessed and conclusive data about the impact of sex are lacking. Aim of this study was to evaluate the possible correlations among MU overweight, sex and ischemic stroke severity and outcome. METHODS: All consecutive patients with acute non-lacunar ischemic stroke observed over a one-year period were considered. MU subjects were selected and classified according to the body mass index (BMI) values. The relationships among sex, BMI and National Institutes of Health Stroke Scale (NIHSS) score at admission and modified Rankin scale (mRS) score at discharge were analysed with multivariate models. RESULTS: 180 patients were included. A significantly increasing trend in the NIHSS (p = .030) and in the mRS (p = .001) scores along with the increase of the BMI category was detected in women. Men showed a significantly decreasing trend in the NIHSS (p = .040) and a non-significant decreasing trend in the mRS (p = .290) scores with increasing BMI category. CONCLUSIONS: Our findings show that sex can influence stroke severity and outcome among MU patients. The worse outcome observed in women suggest the need of considering differential sex-based clinical approaches in stroke overweight patients.

The neural bases of discourse semantic and pragmatic deficits in patients with frontotemporal dementia and Alzheimer's disease.

Neuropsychological research on language has largely focused on how the brain processes single words and sentences whose meaning does not depend on the context or on the intentions of the speaker. Fewer studies have investigated the neurobiological bases of discourse semantics and pragmatics in patients and healthy individuals. We studied discourse semantic and pragmatic skills in patients with behavioral variant frontotemporal dementia (bvFTD) or Alzheimer's disease (AD) in comparison to healthy controls. Our goal was to assess whether and how the two patient groups differ in their cognitive and behavioral profiles, and whether these differences may be traced back to disease-specific patterns of neuronal hypometabolism. We combined PET imaging with standard neuropsychological assessment tools and a dedicated test battery designed to evaluate discourse semantics and pragmatics in patients with brain lesions or neurological disorders. We found that AD and bvFTD patients were both impaired compared to controls in discourse comprehension, but largely spared in single word comprehension. Importantly, we also found evidence for behavioral impairments specific to each disease, associated with different brain damage patterns. Compared to AD and controls, bvFTD patients had, behaviorally, more difficulty in evaluating whether certain inferences follow from discourse and in identifying humorous completions of stories; neurally, they had greater damage to medial and lateral regions of PFC. AD patients showed a different pattern of errors in a humor comprehension task than bvFTD patients and controls, and they showed greater posterior temporal and parietal cortical depletion. Both groups had comparable difficulties with understanding idioms and indirect requests. Finally, bvFTD-specific errors were correlated with the severity of hypometabolism in bvFTD. We discuss these results in light of previous research on the dementias as well as consequences for models of semantics and pragmatics in the brain.

Insight in frontotemporal dementia and progressive supranuclear palsy.

INTRODUCTION: Progressive supranuclear palsy (PSP) and behavioural variant frontotemporal dementia - (bv-FTD) share common neuropsychological features except for online monitoring awareness. Therefore, the aim of our study is to explore if this assessment could be used in standard clinical practice. MATERIALS AND METHODS: We retrospectively analyse 93 subjects (27 FTD, 25 PSP, 42 healthy controls). Neuropsychological and instrumental examinations were performed for each patient. RESULTS: FTD patients made fewer self-corrections than PSP patients despite a similar number of total errors. We also performed ROC curves: the area under the curve (AUC) is 0.79. A model for a logistic regression was also developed: the only significant predictor is the number of self-corrections (p = 0.004 ß = 1244). DISCUSSION AND CONCLUSIONS: In conclusion, our findings show online awareness is more compromised in FTD patients than in PSP patients. This difference could be useful for making a differential diagnosis between the two diseases: for each extra point in number of self-corrections the probability of suffering from PSP increases by about three and a half times (OR 3.47).

Inter-rater reliability of primitive signs in dementia.

OBJECTIVES: The aim of the present study is to explore inter-rater reliability of primitive signs in a group of patients assessed for dementia. PATIENTS AND METHODS: 97 patients admitted to our University Hospital for cognitive impairment were enrolled in the study. The mean age was 73.04 ±â€¯8.68 (53 females and 44 males). All patients were examined by two cognitive neurologists in a blind fashion. The grasp reflex, the snout reflex, the glabella tap reflex and the palmomental reflex were elicited according to the current literature. Moreover, we add a stretch reflexes (the masseter reflex) to our battery. RESULTS: The most frequent primitive reflex was the palmomental reflex followed by the glabella tap, snout, and grasp. The inter-rater reliability was measured for each primitive reflex: grasp reflex (0.884) have a strong correspondence; the glabella tap (0.556), the palmomental (0.516) and the snout reflex (0.445) have otherwise a weak correspondence. The masseter reflex reaches a moderate agreement (0.662). All the measurements reached statistical significance (p < 0.005). CONCLUSION: The results of the study show weak to substantial agreement for primitive signs and the masseter reflex as expressed by the low-to-high kappa values.

Acute Occlusion of the Percheron Artery during Pregnancy: A Case Report and a Review of the Literature.

OBJECTIVES: The Percheron artery (PA) is a rare variant vessel. Its acute occlusion can cause a bilateral symmetrical thalamic stroke, clinically manifested as a sudden alteration of consciousness that could vary from sleepiness to coma. In this paper, we illustrate a case of acute PA occlusion in a young, pregnant woman and present a review of the literature, focusing on the possible causes of the acute occlusion. METHODS: A 35-year-old woman, at the fourth week of pregnancy, came to the emergency department of our hospital because of a sudden onset and persistent loss of consciousness. Brain magnetic resonance imaging (MRI) showed a symmetrical and bilateral thalamic infarction without evidence of other ischemic lesions, compatible with an acute PA occlusion. RESULTS: The patient, who showed full clinical recovery within a few hours of symptom onset, received a short-term anticoagulant treatment followed by aspirin for long-term prevention. CONCLUSIONS: We reviewed the literature about the possible causes of acute PA occlusion. This ischemic condition is usually associated with cardioembolic or small-vessel disease. However, in our patient, we did not find any element supportive for coagulative alteration or embolyzing conditions. PRACTICE: The presence of this type of thalamic stroke should be considered in the management of persistent loss of consciousness. PA occlusion is rare, but it needs a brain MRI examination for a correct diagnosis, a narrow evaluation of all the possible causes, and a long-term anticoagulant therapy. Pregnancy itself should constitute a rare but possible cause of a PA occlusion.