Search

Hypertension is the most common and preventable risk factor for cardiovascular disease (CVD), accounting for 20% of deaths worldwide. However, 2/3 of people with hypertension are undiagnosed, untreated, or under treated. A multi-pronged approach is needed to improve hypertension management. Elevated blood pressure (BP) in childhood is a predictor of hypertension and CVD in adulthood; therefore, screening and education programmes should start early and continue throughout the lifespan. Home BP monitoring can be used to engage patients and improve BP control rates. Progress in imaging technology allows for the detection of preclinical disease, which may help identify patients who are at greatest risk of CV events. There is a need to optimize the use of current BP control strategies including lifestyle modifications, antihypertensive agents, and devices. Reducing the complexity of pharmacological therapy using single-pill combinations can improve patient adherence and BP control and may reduce physician inertia. Other strategies that can improve patient adherence include education and reassurance to address misconceptions, engaging patients in management decisions, and using digital tools. Strategies to improve physician therapeutic inertia, such as reminders, education, physician–peer visits, and task-sharing may improve BP control rates. Digital health technologies, such as telemonitoring, wearables, and other mobile health platforms, are becoming frequently adopted tools in hypertension management, particularly those that have undergone regulatory approval. Finally, to fight the consequences of hypertension on a global scale, healthcare system approaches to cardiovascular risk factor management are needed. Government policies should promote routine BP screening, salt-, sugar-, and alcohol reduction programmes, encourage physical activity, and target obesity control.

The present outbreak caused by SARS-CoV-2, an influenza virus with neurotropic potential, presents with neurological manifestations in a large proportion of the affected individuals. Disorders of the central and peripheral nervous system are all present, while stroke, ataxia, seizures, and depressed level of consciousness are more common in severely affected patients. People with these severe complications are most likely elderly with medical comorbidities, especially hypertension and other vascular risk factors. However, postinfectious complications are also expected. Neurological disorders as sequelae of influenza viruses have been repeatedly documented in the past and include symptoms, signs, and diseases occurring during the acute phase and, not rarely, during follow-up. Postinfectious neurological complications are the result of the activation of immune mechanisms and can explain the insurgence of immune-mediated diseases, including the Guillain-Barré syndrome and other diseases of the central and peripheral nervous system that in the past occurred as complications of viral infections and occasionally with vaccines. For these reasons, the present outbreak calls for the introduction of surveillance systems to monitor changes in the frequency of several immune-mediated neurological diseases. These changes will determine a reorganization of the measures apt to describe the interaction between the virus, the environment, and the host in areas of different dimensions, from local communities to regions with several millions of inhabitants. The public health system, mainly primary care, needs to be strengthened to ensure that research and development efforts are directed toward right needs and directions. To cope with the present pandemic, better collaboration is required between international organizations along with more research funding, and tools in order to detect, treat, and prevent future epidemics.

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.

Background: Neurological conditions are highly prevalent and disabling, in particular in the elderly. The Italian population has witnessed sharp ageing and we can thus expect a rising trend in the incidence, prevalence and disability of these conditions. Methods: We relied on the Global Burden of Disease 2019 study to extract Italian data on incidence, prevalence and years lived with a disability (YLDs) referred to a broad set of neurological disorders including, brain and nervous system cancers, stroke, encephalitis, meningitis, tetanus, traumatic brain injury, and spinal cord injury. We assessed changes between 1990 and 2019 in counts and age-standardized rates. Results: The most prevalent conditions were tension-type headache, migraine, and dementias, whereas the most disabling were migraine, dementias and traumatic brain injury. YLDs associated with neurological conditions increased by 22.5%, but decreased by 2.3% in age-standardized rates. The overall increase in prevalence and YLDs counts was stronger for non-communicable diseases with onset in old age compared to young to adult-age onset ones. The same trends were in the opposite direction when age-standardized rates were taken into account. Conclusions: The increase in YLDs associated with neurological conditions is mostly due to population ageing and growth: nevertheless, lived disability and, as a consequence, impact on health systems has increased. Actions are needed to improve outcome and mitigate disability associated with neurological conditions, spanning among diagnosis, treatment, care pathways and workplace interventions.

Migrainous infarction (MI) is a rare complication of migraines that accounts for 0.5-1.5% of all ischemic strokes. Although the pathogenesis of MI is still debated, cortical spreading depression and the consequent biochemical cascade and hemodynamic changes are presumed to play an important role. Here we describe a case of MI and systematically review the literature on the complex and possibly bidirectional relationship between migraine and stroke. A 44-year-old female with history of migraine with visual aura presented at the Emergency Department due to a sudden onset of left limb paresis and hypoesthesia. Brain magnetic resonance imaging revealed right fronto-parietal ischemic stroke. Two days after hospitalization, the patient experienced a prolonged visual aura and showed ultrasound evidence of intracranial artery vasospasm. To date, there have been 33 published articles on a total 119 patients with MI, although intracranial vasospasm has rarely been reported. Sustained hyperexcitability of cortical neurons, impairment of γ-aminobutyric acid inhibitory circuitry, altered serotonergic transmission, release of vasoconstrictive molecules, and cerebral blood flow changes have been proposed as pathogenic mechanisms of MI. The present case provides insight into the pathophysiological link between stroke and migraine, thus aiding clinicians in therapeutic decision-making although additional studies are needed to clarify the clinical, neuroradiological, and ultrasound findings that link MI and stroke-related migraine.

Background and Purpose— Despite treatment with oral anticoagulants, patients with nonvalvular atrial fibrillation (AF) may experience ischemic cerebrovascular events. The aims of this case-control study in patients with AF were to identify the pathogenesis of and the risk factors for cerebrovascular ischemic events occurring during non–vitamin K antagonist oral anticoagulants (NOACs) therapy for stroke prevention. Methods— Cases were consecutive patients with AF who had acute cerebrovascular ischemic events during NOAC treatment. Controls were consecutive patients with AF who did not have cerebrovascular events during NOACs treatment. Results— Overall, 713 cases (641 ischemic strokes and 72 transient ischemic attacks; median age, 80.0 years; interquartile range, 12; median National Institutes of Health Stroke Scale on admission, 6.0; interquartile range, 10) and 700 controls (median age, 72.0 years; interquartile range, 8) were included in the study. Recurrent stroke was classified as cardioembolic in 455 cases (63.9%) according to the A-S-C-O-D (A, atherosclerosis; S, small vessel disease; C, cardiac pathology; O, other causes; D, dissection) classification. On multivariable analysis, off-label low dose of NOACs (odds ratio [OR], 3.18; 95% CI, 1.95–5.85), atrial enlargement (OR, 6.64; 95% CI, 4.63–9.52), hyperlipidemia (OR, 2.40; 95% CI, 1.83–3.16), and CHA 2 DS 2 -VASc score (OR, 1.72 for each point increase; 95% CI, 1.58–1.88) were associated with ischemic events. Among the CHA 2 DS 2 -VASc components, age was older and presence of diabetes mellitus, congestive heart failure, and history of stroke or transient ischemic attack more common in patients who had acute cerebrovascular ischemic events. Paroxysmal AF was inversely associated with ischemic events (OR, 0.45; 95% CI, 0.33–0.61). Conclusions— In patients with AF treated with NOACs who had a cerebrovascular event, mostly but not exclusively of cardioembolic pathogenesis, off-label low dose, atrial enlargement, hyperlipidemia, and high CHA 2 DS 2 -VASc score were associated with increased risk of cerebrovascular events.

Aims Although oral anticoagulants (OACs) are effective in preventing stroke in older people with atrial fibrillation (AF), they are often underused in this particularly high-risk population. The aim of the present study was to assess the appropriateness of OAC prescription and its associated factors in hospitalized patients aged 65 years or older. Methods Data were obtained from the retrospective phase of Simulation-based Technologies to Improve the Appropriate Use of Oral Anticoagulants in Hospitalized Elderly Patients With Atrial Fibrillation (SIM-AF) study, held in 32 Italian internal medicine and geriatric wards. The appropriateness of OAC prescription was assessed, grouping patients in those who were and were not prescribed OACs at hospital discharge. Multivariable logistic regression was used to establish factors independently associated with the appropriateness of OAC prescription. Results A total of 328 patients were included in the retrospective phase of the study. Of these, almost 44% (N = 143) were inappropriately prescribed OACs, being mainly underprescribed or prescribed an inappropriate antithrombotic drug (N = 88). Among the patients prescribed OACs (N = 221), errors in the prescribed doses were the most frequent cause of inappropriate use (N = 55). Factors associated with a higher degree of patient frailty were inversely associated with the appropriateness of OAC prescription. Conclusions In hospitalized older patients with AF, there is still a high prevalence of inappropriate OAC prescribing. Characteristics usually related to frailty are associated with the inappropriate prescribing. These findings point to the need for targeted interventions designed for internists and geriatricians, aimed at improving the appropriate prescribing of OACs in this complex and high-risk population.

Objectives To determine the prognostic value of positive global left atrial strain (LA-GSA+), measured by two-dimensional speckle tracking echocardiography (2D-STE) in a population of acute ischemic stroke (AIS) patients without atrial fibrillation (AF), in the setting of Emergency Department (ED). Methods All consecutive AIS patients with sinus rhythm on ECG and without AF history entered this prospective study. All patients underwent complete blood tests and transthoracic echocardiography implemented with 2D-STE analysis of LA strain parameters within 6–12 h after symptoms onset. At 6-months follow-up, we evaluated the composite endpoint of all-cause mortality plus cardiovascular re-hospitalizations. Results A total of 102 AIS patients (76.4 ± 10.8 yrs, 47% males) were prospectively included. LA-GSA+ was markedly reduced in AIS patients (20.8 ± 7.7%), without any statistically significant difference between the stroke subtypes. At 6-months follow-up, 7 deaths and 27 re-hospitalizations occurred. On multivariate Cox regression analysis, variables independently associated with outcome were: LA-GSA+ (per unit) (HR 0.29, 95% CI 0.19–0.39) and C-reactive protein (CRP) (per 0.1 mg/dl) (HR 1.45, 95% CI 1.15–1.75) as continuous variables; statin therapy (HR 0.45, 95%CI 0.28–0.62), and type 2 diabetes (HR 1.65, 95% CI 1.15–2.35) as categorical variables. A LA-GSA+ ≤20.0% predicted the occurrence of the above-mentioned outcome at 6-months follow-up with 94% sensitivity and 81% specificity (AUC=0.84). Interestingly, GSA+ showed a strong inverse correlation with CRP levels (r = -0.86). Conclusions A LA-GSA+ ≤20% reflects a more advanced atrial cardiomyopathy and might provide a rapid and reliable prognostic risk stratification of AIS patients without AF history in the setting of ED.

Introduction Growing evidence has been published as to the impact of SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) on cerebrovascular events over the last few months, with considerable attention paid to ischemic strokes. Conversely, little is known about the clinical course of intracerebral haemorrhage (ICH) and simultaneous SARS-CoV-2 infection. Method The Italian Society of Hospital Neurosciences (SNO) promoted a multicentre, retrospective, observational study (SNO-COVID-19), involving 20 Neurological Departments in Northern Italy. Clinical data on patients with acute cerebrovascular diseases, admitted from March 1st to April 30th, 2020, were collected. A comparison was made of the demographical and clinical features of both SARS-CoV-2 positive and negative patients with ICH. Results 949 patients were enrolled (average age 73.4 years; 52.7% males); 135 patients had haemorrhagic stroke and 127 (13.4%) had a primary ICH. Only 16 patients with ICH (12.6%) had laboratory confirmed SARS-CoV-2 infection, both symptomatic and asymptomatic. SARS-CoV-2 related pneumonia or respiratory distress (OR 5.4), lobar location (OR 5.0) and previous antiplatelet or anticoagulant treatment (OR 2.9) were the only factors significantly associated with increased mortality in ICH. SARS-CoV-2 infection, regardless of respiratory involvement, led to a non-significantly increased risk of in-hospital death (37.5% vs 23.4%, p = 0.2). Discussion ICH patients with COVID-19 did not experience an increase in mortality as striking as ischemic stroke. The inflammatory response and respiratory complications could justify the slight increase of death in ICH. Bleeding sites and previous antiplatelet or anticoagulant treatment were the only other predictors of a worse outcome.

Space-occupying brain oedema is a potentially life-threatening complication in the first days after large hemispheric or cerebellar infarction. Several treatment strategies for this complication are available, but the size and quality of the scientific evidence on which these strategies are based vary considerably. The aim of this Guideline document is to assist physicians in their management decisions when treating patients with space-occupying hemispheric or cerebellar infarction. These Guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. A working group identified 13 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. An expert consensus statement was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high-quality evidence to recommend surgical decompression to reduce the risk of death and to increase the chance of a favourable outcome in adult patients aged up to and including 60 years with space-occupying hemispheric infarction who can be treated within 48 hours of stroke onset, and low-quality evidence to support this treatment in older patients. There is continued uncertainty about the benefit and risks of surgical decompression in patients with space-occupying hemispheric infarction if this is done after the first 48 hours. There is also continued uncertainty about the selection of patients with space-occupying cerebellar infarction for surgical decompression or drainage of cerebrospinal fluid. These Guidelines further provide details on the management of specific subgroups of patients with space-occupying hemispheric infarction, on the value of monitoring of intracranial pressure, and on the benefits and risks of medical treatment options. We encourage new high-quality studies assessing the risks and benefits of different treatment strategies for patients with space-occupying brain infarction.

Background: emotional processes and responses are underestimated in stroke patients because the massive clinical picture of large hemispheric strokes often hides these symptoms. We report on a patient with peculiar unpleasant emotional responses after temporal stroke. Case presentation: we describe a 62-years old man with significant unpleasant emotional responses that occurred after an acute episode of confusional state, disorientation, agitation, vertigo, postural instability, vomiting, and photophobia. Since then, he complained that vision of pictures containing curved/multicolored lines or tangles was associated with an uncomfortable feeling of fear and disgust, lasting few minutes, so that he avoided looking at them. Notably, he also showed an abnormal facial expression of disgust and fear, together with neurovegetative reaction and horripilation, at the presentation of pictures of objects or animals containing curved, multicolored, or tangled lines. A post-acute infarction of the right temporal-insular region, together with mild periventricular white matter changes, were evident at the brain magnetic resonance imaging. Conclusions: the anterior insula is crucial in transforming unpleasant sensory input into visceromotor reactions and the accompanying feeling of disgust. It is also known that temporal pole modulates visceral emotional functions in response to emotionally evocative perceptual stimuli. In the present case, the ischemic lesion of anterior part of the insula and temporal pole may have caused a decoupling of emotional and visceral response to complex visual stimuli. Further reports will provide a significant contribution to the taxonomy of these complex and relatively uncommon non-motor post-stroke symptoms that negatively affect quality of life.

Aims To assess the appropriateness of oral anticoagulant (OAC) prescription and its associated factors in acutely hospitalized elderly patients. Methods Data were obtained from the prospective phase of SIM-AF (SIMulation-based technologies to improve the appropriate use of oral anticoagulants in hospitalized elderly patients with Atrial Fibrillation) randomized controlled trial, aimed to test whether an educational intervention improved OAC prescription, compared to current clinical practice, in internal medicine wards. In this secondary analysis, appropriateness of OAC prescription was assessed at hospital admission and discharge. Results For 246 patients, no significant differences were found between arms (odds ratio 1.38, 95% confidence interval [CI] 0.84-2.28) in terms of appropriateness of OAC prescription. Globally, 92 patients (37.4%, 95% CI = 31.6-43.6%) were inappropriately prescribed or not prescribed at hospital discharge. Among 51 patients inappropriately prescribed, 82% showed errors on dosage, being mainly under-dosed (n = 29, 56.9%), and among 41 inappropriately not prescribed, 98% were taking an antiplatelet drug. Factors independently associated with a lower probability of appropriateness at discharge were those related to a higher risk of bleeding (older age, higher levels of aspartate aminotransferase, history of falls, alcohol consumption) and antiplatelet prescription at admission. The prescription of OACs at admission was the strongest predictor of appropriateness at discharge (odds ratio = 7.43, 95% CI = 4.04-13.73). Conclusions A high proportion of hospitalized older patients with AF remains inappropriately prescribed or nonprescribed with OACs. The management of these patients at hospital admission is the strongest predictor of prescription appropriateness at discharge.

To assess the pattern of use of Emergency Departments (EDs), factors contributing to the visits, geographical distribution and outcomes in people aged 65 years or more living in the Italian Lombardy Region in 2012. Based on an administrative database the study population was divided into groups according to the number of ED visits. A multinomial logistic regression model was performed to compare the characteristics of each group. The Getis–Ord’s G statistic was used to evaluate the clusters of high and low visit prevalence odd ratios (OR) at district level. To estimate the severity of the disease leading to ED attendance, visits were stratified based on the level of emergency and outcome. About 2 million older people were included in the analyses: 78 % had no ED visit, 15 % only 1, 7 % 2 or more. Male sex, age 85 years or more, high number of drugs, ED visits and hospital admissions in the previous year and the location of an ED within 10 km from the patient’s place were all factors associated with a higher risk to have more ED visits. Clusters of high and low prevalence of visits were found for occasional users. Overall, 83 % of ED visit with a low emergency triage code at admission had as visit outcome discharge at home. In older people several variables were associated with an increased risk to have a high number of ED visits. Most of the visits were done for non-urgent problems and significant geographic differences were observed for occasional users.

Purpose PROMISE study aimed to observe the safety and effectiveness of Penumbra System (PS) with ACE68 and ACE64 Reperfusion Catheters in patients with acute ischemic stroke (AIS) from large vessel occlusion (LVO), treated with ADAPT (A Direct Aspiration First Pass Technique) as front-line treatment. Materials and methods This was a prospective, single-arm, multicenter study across 20 European centers. Inclusion criteria were anterior circulation LVO within 6 hours of ictus; NIHSS≥2; CT-ASPECTS ≥6; or MR-ASPECTS ≥5. Primary endpoints included success in angiographic revascularization (mTICI 2b-3), and clinical independence (mRS 0–2) at 90 days. Secondary endpoints included safety events, functional improvement at 7–10 days, procedural metrics and quality of life. mTICI scores and safety endpoints were adjudicated by core laboratory and clinical events committee, respectively. Results A total of 204 patients were enrolled. Median age was 74 [IQR 65–80]. Primary occlusion vessels were 17.2% (35/204) patients with ICA occlusion, 3.9% (8/204) with Carotid T, 60.8% (124/204) with M1% and 18.1% (37/204) with M2. Median baseline CT ASPECT score was 9 [IQR 8–10]. Median baseline and 7–10 day NIHSS scores were 16 [IQR 11–20] and 3 [IQR 1–8], respectively. A reduction of ≤10 points or 7–10 days NIHSS of 0–1 was reported in 67.9% (127/187) patients. Prior to endovascular procedure, IV rtPA was administered in 61.8% (126/204) patients. After PS treatment, 70.3% (142/202) patients achieved mTICI 2b/3. Final revascularization (mTICI 2b/3) was achieved in 93.1% (188/202). Revascularization to mTICI 2 c/3 was achieved 63.9% (129/202). Median time from stroke to revascularization (mTICI 2b/3) was 245.5 min [IQR 192–305]. Median time from puncture to revascularization (mTICI 2b/3) was 31 min [IQR 20–53]. Day-90 mRS of 0–2 was achieved in 61.0% (122/200). In the subgroup analysis by occlusion location, final revascularization (mTICI 2b/3) in the ICA/Carotid T was 95.2% (40/42) and 90 day mRS of 0–2 was achieved in 64.3% (27/42), final revascularization (mTICI 2b/3) in the MCA M1 was 92.7% (114/123) and 90 day mRS of 0–2 was achieved in 57.0% (69/121) and the final revascularization (mTICI 2b/3) in the MCA M2 was 91.9% (34/37) and 90 day mRS of 0–2 was achieved in 70.3% (26/37). There was no significant difference in the safety rates by treatment location. Safety rates were favorable (sICH=2.9%; ENT=1.5%). 90 day morbidity, defined as mRS score (3–5), was observed in 31.5% (63/200). 90 day all cause-mortality was observed in 7.5% (15/200). Device and procedure-related SAEs were reported in 2.0% (4/204) and 4.9% (10/204), respectively. No deaths were device-related. Conclusion PROMISE study demonstrated safety and efficacy with latest generation of PS Reperfusion Catheters (ACE68/64) in patients with acute ischemic stroke from large vessel occlusion, using ADAPT as front-line treatment. Disclosures P. Navia: 2; C; Penumbra Inc. P. Schramm: 2; C; Penumbra Inc. R. Papa: None. J. Parra: None. A. Weitz: None. W. Weber: None. J. Fiehler: None. P. Michel: None. V. Pereira: None. T. Krings: None. L. Pierot: None. J. Gralla: None. P. Santalucia: None. T. Lo: None.

The purpose of the study was to determine whether low‐high fidelity medical simulation improves learning and long‐lasting retention of pharmacology knowledge, compared to lecture alone, in undergraduate medical students. Ninety students, before a 45‐minute lecture, were randomized into three groups ‐ sham (S), low (LF), and high fidelity (HF) simulation ‐ to participate in an interactive simulation session. To evaluate immediate and long‐lasting retention, a 20‐item structured questionnaire on inotropic agents was administered to 90 students before and after a 45‐minute lecture, after simulation, and 3 months later. In all groups, the rate of correct answers increased after lecture, while no difference was observed between different groups (P = 0.543). After simulation, students in the HF group provided more correct answers compared to S or LF group (P > 0.001). After 3 months, a significant decrease in the number of correct answers was observed in S (P

Introduction: Safe and complete recanalization is important to reduce clot burden and determines functional prognosis of patients with cerebral infarction from large vessel occlusions (LVO). The aim of PROMISE is to evaluate the safe and effective use of the aspiration-based Penumbra System with the latest generation of ACE Reperfusion Catheters in a real world population with acute ischemic stroke from anterior circulation LVO, treated with the ADAPT technique in routine practice. Methods: The prospective, single-arm, multicenter PROMISE registry evaluated the Penumbra System with ACE64 and ACE68 catheters across 20 European centers. Criteria for inclusion include presentation of anterior circulation LVO within 6 hours of ictus, NIHSS ≥ 2, ASPECTS ≥ 6 and wherein intervention was proceeded with ADAPT as frontline. Primary endpoints include angiographic revascularization to TICI 2b-3, and clinical independence (mRS 0-2) at 90 days. Secondary endpoints include safety events, functional improvement at 7-10 days, procedural metrics and quality of life. Results: A total of 202 patients were enrolled for evaluation of this interim analysis. Table I details patient history and baseline characteristics. Prior to endovascular procedure, IV rtPA was administered in 61.9% of patients. A final revascularization mTICI 2b-3 was achieved in 96.5% (194/201), per investigator assessment. Of these, mTICI 3 was achieved in 68.2% (137/201). Mortality was observed in 15 of the 141 (10.6%) patients at this interim analysis. Patient follow-up data collection, including clinical outcome, will be completed by the end of 2017. Core lab adjudicated results will be available at time of presentation. Conclusion: Interim analysis of the PROMISE registry demonstrated safe and effective utility of the Penumbra System with the novel ACE64 and ACE68 Reperfusion Catheters using ADAPT as frontline treatment. All follow up visits and final results will be presented at the ISC conference.

To describe the incidence of ischemic stroke, short-term mortality, recurrences, and prescription patterns.Data from administrative health databases of the Lombardy Region from 2002 to 2010 (about 4 million people) were analyzed for stroke incidence and recurrence, mortality, and drug prescriptions after an ischemic stroke.A total of 43,352 patients with a first hospital admission for ischemic stroke were identified. During 8 years, stroke incidence decreased from 3.2 of 1000 to 2.4 of 1000 (P.001) in people aged 65-74 years, from 7.1 of 1000 to 5.3 of 1000 (P.001) at ages 75-84 years and from 11.9 of 1000 to 9.4 of 1000 (P.001) at age 85 years or older. Stroke recurrences dropped by 30% (from 10.0% to 7.0%, P.001) and 30-day mortality rate also decreased. Prescription trends showed linear increase in antiplatelets and lipid-lowering drugs, respectively, from 60.2% to 65.0% (P.001) and from 19.1% to 34.6% (P.001), whereas antihypertensive prescriptions did not change appreciably. Anticoagulant prescription increased in patients with atrial fibrillation, from 64.8% to 72.1% in the 65-74 years age group, (P = .004) and from 40.2% to 53.7% in the 75-84 years age group (P.001); less than 20% of the 85 years or older age group were treated with anticoagulants (P.0001).Stroke incidence, recurrence, and 30-day mortality decreased from 2002 to 2010 concomitant with an increase in prescriptions of secondary stroke prevention drugs.

Simulation is a frontier for disseminating knowledge in almost all the fields of medicine and it is attracting growing interest because it offers a means of developing new teaching and training models, as well as of verifying what has been learned in a critical setting that simulates clinical practice. The role of simulation in neurology, until now limited by the obvious physical limitations of the dummies used to train students and learners, is now increasing since, today, it allows anamnestic data to be related to the instrumental evidence necessary for diagnosis and therapeutic decision-making, i.e., to the findings of neurophysiological investigations (EEG, carotid and vertebral echography and transcranial Doppler, for example) and neuroradiological investigations (CT, MRI imaging), as well as vital parameter monitoring (ECG, saturimetry, blood pressure, respiratory frequency, etc.). Simulation, by providing learners with opportunities to discuss, with experts, different profiles of biological parameters (both during the simulation itself and in the subsequent debriefing session), is becoming an increasingly important tool for training those involved in evaluation of critical neurological patients (stroke, Guillan Barrè syndrome, myasthenia, status epilepticus, headache, vertigo, confusional status, etc.) and complex cases. In this SIMMED (Italian Society for Simulation in Medicine) position paper, the applications (present and, possibly, future) of simulation in neurology are reported.

We describe the current and future objectives of the Women Stroke Association, a nonprofit multidisciplinary organization promoting research awareness on medical, psychological, and social issues concerning women affected by cerebro-cardiovascular disease. In this paper, we deal with only cerebrovascular disease, whereas cardiovascular disorders will be addressed in a future paper. Gender differences in the clinical presentation of cerebrovascular diseases have been repeatedly suggested, and some treatment options may not be as effective and safe in men and women. For many years, women have either been underrepresented or excluded from randomized clinical trials, and the majority of therapeutic research has been carried on predominantly male populations. Furthermore, gender differences have been shown to contribute to different responses to cerebrovascular drugs in women when compared with men, regarding pharmacokinetics, pharmacodynamics, and physiology. In this statement, we discuss main research fields relevant to Women Stroke Association's mission and commitment, highlighting opportunities and critical from the women's health perspective. Future directions and goals of the Women Stroke Association arise from these considerations and represent the association's commitment to combating stroke. © 2013 World Stroke Organization.

Rivaroxaban, an inhibitor of Factor Xa, is a direct oral anti-coagulant that has been found to be non-inferior to warfarin in preventing cerebral ischemia in patients with non-valvular atrial fibrillation and in the subgroup of patients with a history of the previous stroke or transient ischemic attack. Vascular neurologists in daily clinical practice may encounter patients taking rivaroxaban or patients who may benefit from its use. In this paper, we review the current clinical indications, contraindications, and clinical management guidelines for rivaroxaban while providing a special focus on neurological aspects and expert opinions on rivaroxaban therapy management in various situations that a neurologist may encounter when treating patients with an ischemic stroke (including those requiring intravenous or intra-arterial reperfusion therapy) and patients with an intracerebral hemorrhage. Since data from clinical trials and real-life data are missing in some clinical situations, strong recommendations are not always available. Nevertheless, practical guidelines should be adopted to maximize benefits from this oral anti-coagulant.

Hypertension is the major modifiable risk factor for ischaemic stroke other than cardioembolic and for haemorrhagic stroke. In primary prevention, regular BP monitoring and appropriate treatment of hypertension are firmly recommended by every guidelines, based on the strong evidence of stroke risk reduction through correct management of blood pressure (BP) whether systolic blood pressure (SBP) or diastolic blood pressure (DBP). Furthermore, the treatment of hypertension is one of the leading preventive strategies for both ischemic and haemorrhagic stroke. Guidelines from scientific societies and organizations deal with the management of blood pressure for primary prevention of cardiovascular diseases including stroke. Guidelines are periodically revised and released and, in some cases, do not take into account the latest evidences from clinical studies.

Evaluation of: Pan A, Okereke OI, Sun Q et al. Depression and incident stroke in women. Stroke 42(10), 2770–2775 (2011). In the Nurses' Health Study, 80,574 women aged between 54 and 79 years, without a history of stroke, were followed-up from 2000 to 2006. In this cohort, depressive symptoms were assessed at multiple time points utilizing the Mental Health Index score (1992, 1996 and 2000), and clinically significant depressive symptoms were defined as a score ≤52. A survey was carried out regarding antidepressant medication use biennially beginning in 1996, and physician-diagnosed depression was reported biennially from 2000. During this 6-year follow-up, 1033 incident strokes were documented. Having a history of depression was associated with an increased risk for total stroke, as well as the use of antidepressant medications with or without history of depression.

Background and Scope. Early etiologic diagnosis of ischemic stroke subtype guides acute management and treatment. We aim to evaluate if plasma biomarkers can predict stroke subtypes in the early phase from stroke onset.Methods. Plasma N-terminal prohormone of brain natriuretic peptide (NT-proBNP), D-dimer, C-reactive protein, serum albumin, and globulin levels have been investigated in 114 consecutive patients presenting at the emergency room within 6 hours of the ischemic stroke onset. Plasma levels of biomarkers have been correlated with stroke aetiology (based on TOAST criteria) by multivariable logistic regression analysis, adjusted for several covariates.Results. Of the 114 patients, 34 (30%) had cardioembolic stroke, 27 (23%) atherothrombotic stroke, 19 (17%) lacunar stroke, and 34 (30%) stroke of undetermined origin. Patients with cardioembolic stroke had significantly higher levels of NT-proBNP and lower globulin/albumin (G/A) ratio compared with the other subgroups. At multiple logistic regression NT-proBNP>200 pg/mL, G/A ratio>0.70,and NIHSS score were independent predictors of cardioembolic stroke with high accuracy of the model, either including (AUC, 0.91) or excluding (AUC, 0.84) atrial fibrillation.Conclusions. A prediction model that includes NT-proBNP, G/A ratio, and NIHSS score can be useful for the early etiologic diagnosis of ischemic stroke.

Background The impact of diabetes on cardiovascular disease in both sexes is known, but the specifics have not been fully clarified. We investigated whether sex-related differences exist in terms of management and hospitalization in patients with newly diagnosed diabetes. Methods We examined the rates of hospitalization for cardiovascular causes, mortality, treatments and management of patients with diabetes compared to subjects without, from administrative database. Interaction between sex and diabetes on clinical outcomes were calculated using a Cox regression model. Pharmacological treatments and recommended examinations by sex were calculated using logistic regression. Results From 2002 to 2006, 158,426 patients with diabetes and 314,115 subjects without were identified and followed up for a mean of 33 months (± 17.5). Diabetes confers a higher risk for all clinical outcomes. Females with diabetes have a risk profile for hospitalization for coronary heart disease comparable to males without (4.6% and 5.3%). Interaction between sex and diabetes shows that females with diabetes had an added 19% higher risk of total death (95% CI 1.13–1.24). No differences were observed in hospitalizations, although females with diabetes were less likely to undergo revascularization after myocardial infarction. Females received cardiovascular prevention drugs less frequently than males and had a slight tendency to get fewer examinations. Conclusion Diabetes is linked to a higher increase of mortality in females relative to males. This might reflect sex differences in the use of revascularization procedures or therapeutic regimens. Closer attention and implementation of standard care for females are necessary from the onset of diabetes.

BACKGROUND AND PURPOSE: Sex related differences in cardiovascular disease and stroke are issues of increasing interest. The aim of this study was to evaluate for sex differences in clinical presentation, severity of stroke and outcome in a population of patients admitted to 4 public and 1 private hospitals in three different regions of Italy. METHODS: All hospital admissions for ischemic and haemorrhagic stroke (ICD-IX code 434 and 431 respectively) between January 1st and December 31st, 2011 at five different hospitals located in three different regions of Italy: Milan (North), Rome and Perugia (Center), and Palermo (South) have been recorded and sex-differences have been evaluated. RESULTS: A total of 1272 stroke patients were included in the analysis: 1152 ischemic and 120 haemorrhagic strokes, 567 women and 705 men. Compared to men, women were significantly older (mean age 75.2 SD 13.7 vs 71.5 SD 12.5 years, P

Clinical evaluation is the cornerstone of any cardiac diagnosis, although excessive over-specialisation often leads students to disregard the value of clinical skills, and to overemphasize the approach to instrumental cardiac diagnosis. Time restraints, low availability of "typical" cardiac patients on whom to perform effective bedside teaching, patients' respect and the underscoring of the value of clinical skills all lead to a progressive decay in teaching. Simulation-guided cardiac auscultation may improve clinical training in medical students and residents. Harvey(©) is a mannequin encompassing more than 50 cardiac diagnoses that was designed and developed at the University of Miami (Florida, USA). One of the advantages of Harvey(©) simulation resides in the possibility of listening, comparing and discussing "real" murmurs. To objectively assess its teaching performance, the capability to identify five different cardiac diagnoses (atrial septal defect, normal young subject, mitral stenosis with tricuspid regurgitation, chronic mitral regurgitation, and pericarditis) out of more than 50 diagnostic possibilities was assessed in 523 III-year medical students (i.e. at the very beginning of their clinical experience), in 92 VI-year students, and in 42 residents before and after a formal 10-h teaching session with Harvey(©). None of them had previously experienced simulation-based cardiac auscultation in addition to formal lecturing (all three groups) and bedside teaching (VI-year students and residents). In order to assess the "persistence" of the acquired knowledge over time, the test was repeated after 3 years in 85 students, who did not repeat the formal 10-h teaching session with Harvey(©) after the III year. As expected, the overall response was poor in the "beginners" who correctly identified 11.0 % of the administered cardiac murmurs. After simulation-guided training, the ability to recognise the correct cardiac diagnoses was much better (72.0 %; p0.001 vs. baseline). Rather unexpectedly, before the tutorial, the performance of VI-year students and of residents was not significantly different from their III-year colleagues, since the two groups correctly identified 14.2 and 16.2 % of the diagnoses, respectively. After the tutorial, the VI-year students and the residents also improved their overall performance (to 73.1 and 76.1 %, respectively; p0.001 for both when compared to before the tutorial). The persistence of this capability after 3 years was remarkable, since the 85 students who repeated the test without any further exposure to the 10-h teaching session with Harvey(©) correctly identified 68.4 % of the possible cardiac diagnoses (p0.001 vs. baseline). These data underscore the importance of clinical training in order to improve auscultation skills in our academic setting, prompting to redesign teaching curricula. Simulation-based cardiac auscultation should be considered as the "missing link" between formal lecturing and bedside teaching of heart sounds and murmurs.

Posterior circulation stroke accounts for about 20% of all ischemic strokes in a variety of syndromic pictures ranging from lacunar and limited infarcts to more extensive involvement. Furthermore, infarcts in the vertebrobasilar (VB) region are frequently multiple and not univocally identifiable in one single clinical entity; the prognosis is sometimes unpredictable and very often is unfavorable having a high early mortality rate. The basilar artery (BA), which is the main vessel of the posterior circulation, supplies most of the brainstem and occipital lobes and part of the cerebellum and thalami, its occlusion (BAO) is the most severe occurrence in the posterior circulation infarct context. The optimum management of BAO is still under debate and in the absence of randomized studies the most appropriate approach is still unclear. In the previous chapters, single territory infarcts involving the posterior circulation have been discussed. The present chapter will discuss extended infarcts in the VB territory due to different degrees of VB involvement or to BAO.

Posterior circulation stroke accounts for about 20% of all ischemic strokes in a variety of syndromic pictures ranging from lacunar and limited infarcts to more extensive involvement. Furthermore, infarcts in the vertebrobasilar (VB) region are frequently multiple and not univocally identifiable in one single clinical entity; the prognosis is sometimes unpredictable and very often is unfavorable having a high early mortality rate. The basilar artery (BA), which is the main vessel of the posterior circulation, supplies most of the brainstem and occipital lobes and part of the cerebellum and thalami, its occlusion (BAO) is the most severe occurrence in the posterior circulation infarct context. The optimum management of BAO is still under debate and in the absence of randomized studies the most appropriate approach is still unclear. In the previous chapters, single territory infarcts involving the posterior circulation have been discussed. The present chapter will discuss extended infarcts in the VB territory due to different degrees of VB involvement or to BAO.

In a meta-analysis of results from 21 randomized trials comparing antiplatelet therapy with placebo in 18,270 patients with prior stroke or transient ischemic attack, antiplatelet therapy was associated with a 28% relative odds reduction in nonfatal strokes and a 16% reduction in fatal strokes, while another trial for secondary prevention with atorvastastin 80 mg showed a 16% risk reduction in time to first occurrence of stroke (adjusted hazard ratio: 0·84, 95% CI: 0·71–0·99). However, few studies have examined the sex differences regarding the efficacy of these treatments. Specifically, recent studies have reported higher rates of perioperative complications during endarterectomy in women. Nonetheless, to date, the data on the effects of carotid artery stenting in women, coming from diverse studies and meta-analyses, have been limited owing to the small number of female patients examined. Owing to this, the evidence of the benefit for women is unclear. Peculiar pathophysiological aspects of stroke, the higher stroke risk in some specific periods in life (e.g., pregnancy, puerperium and older age) and worse documented stroke outcome in women suggest that sex does matter in stroke management. Thus, future randomized controlled trials need to be sex-balanced, in order to better understand the efficacy of appropriate secondary stroke prevention therapy in women.

Intracerebral hemorrhage (ICH) accounts for between 10% to 30% of first-ever strokes; outcomes are significantly worse than with ischemic stroke with a 30-day mortality rate up to 50%, furthermore, half of the deaths occur in the acute phase. Intracerebral hemorrhage (ICH) is classified as primary or secondary according to the underlying etiology. Primary ICH (about 80%) comes from the spontaneous rupture of small vessels more often in relation to long-standing or uncontrolled arterial hypertension and is generally located in the basal ganglia and internal capsula. Secondary ICH (about 20%) is often associated with vascular abnormalities, tumors, and anticoagulant therapy or coagulation disorders, more frequently located in cerebral lobes or subtentorial (cerebellum or pons). Rapid recognition and diagnosis of ICH as well as identification of early prognostic indicators are essential for planning the level of care and avoiding acute rapid progression during the first hours. Hematoma size has been identified as one of the most important predictors of 30-day mortality and its expansion is highly predictive of neurological deterioration. Blood pressure management remains, although controversial, the first-line medical approach along with possible new and effective treatments coming from the numerous between pilot and larger randomized medical trials for ICH completed in the past decade.

Background Polypharmacy, common in the elderly, is an important risk factor for drug-related problems. In this context, the hospital pharmacist can contribute to supporting clinicians in promoting the safe use of medicines. Purpose To identify the need for an appropriate medicines reconciliation system in a sample of hospitalised elderly patients. Material and methods Medical records of patients ≥65 years taking ≥5 drugs admitted during a one-month period to 5 general medicine and geriatric wards were retrospectively reviewed. The following data were collected by a hospital pharmacist: number of drugs prescribed, dose omission, frequency, administration route, pharmaceutical form and potential drug-drug interactions. Results We analysed the medical records of 75 patients (36 men, 39 women, mean age 81 years). Overall, patients were admitted with 634 drugs used at home; in the first 24 h after admission and at discharge, 723 and 645 drugs were prescribed, respectively. At the recognition stage, the dosage form was omitted in 17% of prescriptions, the dose in 12%, route of administration in 20%, frequency in 26%. At discharge rates of omission decreased to 2% for dosage form, 2% for route of administration, 7% frequency. Overall, 816 potential drug-drug interactions were identified. In 13 medical records medicines were not prescribed in accordance with the hospital formulary; allergies/intolerances were not taken into account in 2 discharge letters and in 2 inpatient prescriptions, while 9 suspected adverse drug reactions were not notified. Conclusion The review of the actual process of accuracy of drug recording in the patient’s medical record highlights the need for a more structured procedure. An active role for hospital pharmacists is foreseen, in order to ensure the safe use of medicines. References and/or acknowledgements No conflict of interest.

Background and Purpose Changes in stroke incidence are likely to occur as a consequence of aging of the population, but evidence for this hypothesis is lacking. Methods A prospective community-based registry of first-ever strokes (1994 to 1998) classified according to the International Classification of Diseases, 9th Revision (ICD-9) was established in the L’Aquila district, central Italy, with a total population of 297 838 (1991 census). Patients were identified by active monitoring of multiple sources, including general practitioners. Results In 1994, 819 patients (398 men and 421 women; mean±SD age, 74.8±11.3 years) suffered from a first-ever stroke. Eighty-nine percent of the patients had neuroimaging studies of the brain and were reclassified with the recent Application of the International Classification of Diseases to Neurology (ICD-10 NA). The occurrence of subarachnoid hemorrhage, intracerebral hemorrhage, cerebral infarction, and ill-defined events was 2.9%, 14.9%, 80.2%, and 2.0%, respectively. Crude annual incidence of first-ever stroke was 2.75/1000 (95% confidence interval [CI], 2.57 to 2.94) and 24.23/1000 (95% CI, 21.65 to 27.10) in patients older than 80 years. Incidence rates were higher in men and steeply increased with age. The standardized rate was 2.37/1000 for the Italian and 2.28/1000 for the European population. The 30-day case-fatality rate was 25.6% (95% CI, 22.8% to 28.7%). The occurrence of death, disability, and full recovery at 1 year was 36.9%, 38.9%, and 24.2%, respectively. No differences were found in stroke incidence and case-fatality according to income and urban or rural residences. Conclusions In our population-based study, we found a high stroke incidence notably in the older age subgroups, suggesting that rather than declining, stroke is only being postponed until later in life.

Meterological factors influence several biological functions. Geomagnetic activity (GMA) can be considered a trigger factor of migraine attacks. We studied the possible relationship between 40 migraine patients and some meteorological factors: humidity, temperature and geomagnetic activity in particular. All frequency changes of geomagnetic activity, temperature and humidity values are recorded daily. The study was performed from March to June 1988 over a geographically small area in order to avoid climatic and environmental influences. Our results indicate a significant correlation between geomagnetic activity and migraine attack frequency. Controversial opinions concerning the modalities of data collection and the possible relationships between environment and headache raise the need of further studies.

Although proof-based medicine has generated much valid evidence for the drawing up of guidelines and recommendations for best clinical practice in symptomatic and asymptomatic carotid stenosis, whether and when it is better to employ endarterectomy or stenting as the intervention of choice still remain matters of debate. Moreover, guidelines have been targeted up to now to the ‘representative’ patient, as resulting from the statistical analyses of the studies conducted on the safety and efficacy of both interventions as well as on medical therapy alone. The Italian Stroke Organization (ISO) and Stroke Prevention and Awareness Diffusion (SPREAD) group has thus decided to update its statements for an 8th edition. To this end, a multidisciplinary team of authors representing Italian scientific societies in the neurology, neuroradiology, vascular and endovascular surgery, interventional cardiology, and general medicine fields re-examined the literature available on stroke. Analyses and considerations on patient subgroups have allowed to model the risks/benefits of endarterectomy and stenting in the individual. Accordingly, the guideline's original methodology has been revised to follow the new SIGN (Scottish Intercollegiate Guideline Network) Grade-like approach, integrating it with new considerations on Precision, or Personalized Medicine. Therefore, this guideline offers recommendations on precision medicine for the single patient, and can be followed in addition to the more standard guidelines.