Recognizing Atypical Presentations of Alzheimer's Disease: The Importance of CSF Biomarkers in Clinical Practice.

Besides the typical amnestic presentation, neuropathological studies indicate that Alzheimer's disease (AD) may present with atypical clinical pictures. The relative frequencies of typical and atypical or mixed presentations within the entire spectrum of AD remain unclear, while some mixed or atypical presentations may have not received adequate attention for them to be included in diagnostic criteria. We investigated the spectrum of clinical presentations in patients with the AD CSF biomarker profile (high tau and phospho-tau, low Aß42 levels), hospitalized in a tertiary academic center. Among 98 patients with the CSF AD profile, 46% of patients had the typical presentation of "hippocampal" amnestic dementia. Additionally, 23.5% and 15.3% fulfilled the criteria of mixed or atypical presentations, respectively, as described in the IWG-2 criteria. The remaining 15.3% had unusual presentations, including non-logopenic (semantic and non-fluent agrammatic) primary progressive aphasia, corticobasal syndrome, and Richardson syndrome, or could be diagnosed with normal pressure hydrocephalus. Despite selection bias (academic center), atypical clinical presentations of AD may be more common than previously thought. CSF biomarkers seem to be a useful tool for antemortem identification of such patients, which is likely to affect therapeutic decisions. Some of the unusual presentations described above should be incorporated in diagnostic criteria.

Primary headache subtypes and thyroid dysfunction: Is there any association?

BACKGROUND: Primary headaches, and particularly migraine and tension-type headache (TTH) as well as hypothyroidism are common medical conditions. To date, numerous studies have suggested a possible bidirectional relationship between migraine and hypothyroidism, although certain studies had contradictory results. OBJECTIVE: To investigate whether there is any association between primary headache subtypes and thyroid disorders. METHODS: A retrospective study of consecutive patients aged ≥18 years referred to the Headache Outpatient Clinic of Aeginition Hospital and diagnosed with primary headache and any thyroid disorder. RESULTS: Out of 427 patients (males/females=76/351), 253 (59.3%) were diagnosed with migraine without aura, 53 (12.4%) with TTH, 49 (11.5%) with migraine with aura, 29 (6.8%) with medication-overuse headache, 23 (5.4%) with mixed-type headache (migraine with/without aura and TTH), nine (2.1%) with cluster headache, and 11 (2.6%) with other types of primary headaches. The prevalence of any type of thyroid disorder was 20.8% (89/427 patients). In the total sample, 27 patients (6.3%) reported hypothyroidism, 18 (4.2%) unspecified thyroidopathy, 14 (3.3%) thyroid nodules, 12 (2.8%) Hashimoto thyroiditis, 12 (2.8%) thyroidectomy, three (0.7%) thyroid goiter, and three (0.7%) hyperthyroidism. Further statistical analysis between categorical variables did not reveal any significant association between headache subtypes and thyroid dysfunction. CONCLUSIONS: No specific association was found between primary headache subtypes and specific thyroid disorder. However, a high prevalence of thyroid dysfunction in general and specifically hypothyroidism was demonstrated among patients with primary headaches, which lays the foundation for further clarification in prospective longitudinal studies.

Primary headache subtypes and thyroid dysfunction: Is there any association? / Subtipos de cefaleia primária e disfunção tireoidiana: existe alguma associação?

ABSTRACT Background: Primary headaches, and particularly migraine and tension-type headache (TTH) as well as hypothyroidism are common medical conditions. To date, numerous studies have suggested a possible bidirectional relationship between migraine and hypothyroidism, although certain studies had contradictory results. Objective: To investigate whether there is any association between primary headache subtypes and thyroid disorders. Methods: A retrospective study of consecutive patients aged ≥18 years referred to the Headache Outpatient Clinic of Aeginition Hospital and diagnosed with primary headache and any thyroid disorder. Results: Out of 427 patients (males/females=76/351), 253 (59.3%) were diagnosed with migraine without aura, 53 (12.4%) with TTH, 49 (11.5%) with migraine with aura, 29 (6.8%) with medication-overuse headache, 23 (5.4%) with mixed-type headache (migraine with/without aura and TTH), nine (2.1%) with cluster headache, and 11 (2.6%) with other types of primary headaches. The prevalence of any type of thyroid disorder was 20.8% (89/427 patients). In the total sample, 27 patients (6.3%) reported hypothyroidism, 18 (4.2%) unspecified thyroidopathy, 14 (3.3%) thyroid nodules, 12 (2.8%) Hashimoto thyroiditis, 12 (2.8%) thyroidectomy, three (0.7%) thyroid goiter, and three (0.7%) hyperthyroidism. Further statistical analysis between categorical variables did not reveal any significant association between headache subtypes and thyroid dysfunction. Conclusions: No specific association was found between primary headache subtypes and specific thyroid disorder. However, a high prevalence of thyroid dysfunction in general and specifically hypothyroidism was demonstrated among patients with primary headaches, which lays the foundation for further clarification in prospective longitudinal studies.

RESUMO Introdução: Cefaleias primárias e, particularmente, enxaqueca e cefaleia do tipo tensional (CTT), bem como hipotiroidismo, constituem condições médicas comuns. Até o momento, vários estudos sugeriram uma possível relação bidirecional entre enxaqueca e hipotireoidismo, embora alguns estudos tenham resultados contraditórios. Objetivo: Investigar se existe associação entre subtipos de cefaleia primária e distúrbios da tireoide. Métodos: Estudo retrospectivo de pacientes consecutivos com idade ≥18 anos encaminhados ao Ambulatório de Cefaleia do Hospital Aeginition, com diagnóstico de cefaleia primária e qualquer distúrbio da tireoide. Resultados: De 427 pacientes (homens/mulheres=76/351), 253 pacientes (59,3%) foram diagnosticados com enxaqueca sem aura, 53 (12,4%) com CTT, 49 (11,5%) com enxaqueca com aura, 29 (6,8 %) com cefaleia por uso excessivo de medicamentos, 23 (5,4%) com cefaleia mista (enxaqueca com/sem aura e CTT), nove (2,1%) com cefaleia em salvas e 11 (2,6%) com outros tipos de cefaleias primárias. A prevalência de qualquer tipo de distúrbio tireoidiano foi de 20,8% (89/427 pacientes). Na amostra total, 27 pacientes (6,3%) relataram hipotireoidismo, 18 (4,2%) tireoidopatia não especificada, 14 (3,3%) nódulos de tireoide, 12 (2,8%) tireoidite de Hashimoto, 12 (2,8%) tireoidectomia, três (0,7%) bócio da tireoide e três (0,7%) hipertireoidismo. Uma análise estatística posterior entre as variáveis categóricas não revelou qualquer associação significativa entre os subtipos de cefaleia e disfunção tireoidiana. Conclusões: Não encontramos associação entre subtipos de cefaleia primária e distúrbio específico da tireoide. No entanto, foi observada prevalência elevada de disfunção tireoidiana em geral e especificamente hipotireoidismo entre pacientes com cefaleia primária, o que estabelece base para maiores esclarecimentos em estudos longitudinais prospectivos.

Tenecteplase Averting Mechanical Thrombectomy in Emergent Large Vessel Occlusion.

INTRODUCTION: Tenecteplase has recently been studied as an alternative thrombolytic agent in acute stroke, with a possible superior effect in achieving reperfusion of large intracranial vessels. CASE REPORT: A 90-year-old female patient was admitted to our stroke unit because of acute onset of dysarthria, left-sided neglect, and hemiparesis. Brain computed tomography (CT) coupled with CT angiography and CT perfusion (postprocessed with the use of RAPID software) demonstrated right proximal middle cerebral artery occlusion with a large penumbra/small ischemic core pattern. The patient was subsequently treated with bolus tenecteplase infusion (0.25 mg/kg). Mechanical thrombectomy was abandoned because the patient has rapidly improved. The patient was discharged to her own home 4 days later with no neurological deficit and functionally independent (modified Rankin scale of 0). CONCLUSION: This case exemplifies the potential of tenecteplase in achieving swift reperfusion in patients with large vessel occlusion associated with a substantial mismatch penumbral pattern.

Biochemical diagnosis of vascular cognitive impairment associated with subcortical small vessels disease.

Subcortical small-vessel disease (SSVD) is a disorder that has been fully described in clinical, neuropathological and imaging aspects. It is considered as the most prevalent ischemic CNS disorder and has been associated to arterial hypertension, diabetes mellitus, dyslipidemia and obstructive sleep apnea. The hallmark of SSVD is the ischemic white matter lesions which can be presented as lacunar infracts and global brain hypoperfusion in a common and homogeneous subtype of vascular cognitive impairment (VCI) which is often unrecognized. The special nature and course of SSVD offers the opportunity of collecting knowledge at all stages of its pathogenicity. Arteriosclerosis, hypoxic hypo-perfusion and inflammation act synergistically, causing myelin degeneration and blood brain barrier alteration. Clinical diagnosis of SSVD includes early executive dysfunction manifested by impaired capacity to use complex information, to formulate strategies, and to exercise self-control. Brain imaging has advanced substantially the diagnostic tools for SSVD. Diagnostic biomarkers for Alzheimer Disease include reduction of cerebrospinal fluid amyloid-ß (Aß)42 and of the ratio Aß42/Aß40 sometimes with increased total tau levels. However, biomarkers specific for the diagnosis at all stages of SSVD are needed, especially because of the unsatisfactory treatment options at its late stages to date.