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Increasing evidence shows that migraine, typically considered as an episodic disease, is a chronic and, in some patients, progressive disorder. Among neuromodulators used for migraine prevention, topiramate has a high level of evidence-based efficacy. Through its wide range of mechanisms of action topiramate increases the activation threshold resulting in neuronal stabilization and thereby reducing cortical neurons hyperexcitability, which is believed to be an important electrophysiological feature underlying the pathogenesis of epilepsy and migraine. Recent studies show that migraineurs have subclinical structural brain changes and persistent alteration of pain perception, in some cases correlated with the duration of the disease and the frequency of attacks that might play a role in the transformation of episodic migraine to chronic forms. An early and prolonged preventive treatment might reduce the risk of such transformation. Recent evidence suggests that topiramate, by reducing migraine frequency and use of acute medication, may prevent the negative progression of migraine. Furthermore, two recently completed multicenter, randomised, placebo-controlled trials have shown that treatment with topiramate 100 mg/day is effective and well tolerated in patients already progressed to chronic migraine and difficult to treat conditions associated with medication-overuse. Topiramate seems to be a preventive treatment, which might be able to act at different levels of the migraine cycle: reduction of frequency in episodic migraine, prevention, and treatment of chronic migraine.

The main pathways played by COVID-19 while affecting the CNS are likely represented by a combination of direct viral pathogenicity, immune-mediated tissue damage, inflammatory vascular involvement and intravascular coagulation [1,5]. To this effect, we encourage searching signs of spinal cord involvement in COVID-19 patients, whose incidence could have been underestimated but could play a major role in determining post-acute functional outcome.Authors’ contribution Isabella Canavero*: study conception and authors' coordination, clinical data collection, data interpretation, literature search, writing. The corresponding author had full access to all the data in the study and takes full and final responsibility for the decision to submit for publication.Ethics and patient consent All clinical procedures were performed in accordance with the national and international ethical standards. Case 1 Case 2 Case 3 Subject demographics Female, 25 y-o Female, 50 y-o Male, 69 y-o Medical history – Essential tremor Hypertension, dyslipidemia COVID-19 symptoms Mild (fever, anosmia, dysgeusia) Mild (fever) Moderate (fever, asthenia, interstitial pneumonia) Exposure to proven COVID-19 cases Untraceable Workmates Wife COVID-19 treatment Acetaminophen HCQ 200 mg bid for 7 days, azithromycin 500 mg for 5 days, amoxicillin/clavulanate 875/125 mg bid for 7 days and celecoxib Amoxicillin/clavulanate 875/125 mg bid for 2 days CNS Neurological features Sub-acute paraplegia, sensory impairment with upper thoracic level, bladder dysfunction Sub-acute sensorimotor impairment to the lower limbs with gait ataxia Acute flaccid paraplegia, sensory impairment with mid thoracic level, bladder and bowel dysfunction Latency/Overlap between infectious and neurological onset 15 days/No 15 days/No 3 days/Yes Lab tests (at admission) Normal Normal WBC 6,6/mmc Ly 1,2/mmc CRP 151 mg/l Ferritin 1422 ng/ml LDH 592 U/L Chest imaging during hospitalization Negative Negative Interstitial pneumonia SARS-CoV-2 RT-PCR (swab) – performed after symptom onset:

BackgroundAlthough early mobilization (EM) is recommended by most guidelines in acute stroke patients, there is a paucity of tools to perform a standardized patient risk assessment prior to EM in stroke units (SUs).ObjectiveThis survey aimed at assessing (1) the usefulness of an ad hoc checklist for a standardized approach to EM in SUs and (2) the relationship between EM achieved by this checklist and SU characteristics.MethodsThis survey was carried out in 10 SUs in Piedmont, Italy. The EM checklist was based on 15 “items”, including quantitative/qualitative, clinical and management features.ResultsA total of 250 completed checklists were assessed. EM, defined as out-of-bed activity within 72 h of admission, was reached by 174 patients (69.6%), according to the checklist. There was a statistically significant association between the admission NIHSS score and EM. Hypotension at mobilization was observed in 29/250 patients (11.6%) and was significantly associated with EM. A total of 6 falls (2.4%) were reported. Nurses were most frequently involved in EM, either alone (40.8%) or with another professional.ConclusionA large percentage of acute stroke patients managed to achieve a safe EM in the SUs that adopted the novel checklist. These results suggest that this checklist may well be a user-friendly, reliable tool to assist SU professionals in deciding whether to mobilize or not, by means of a standardized approach.

We aimed to examine the association between Careggi Collateral Score (CCS) and radiological outcomes in a large multicenter cohort of patients receiving thrombectomy for stroke with occlusion of middle cerebral artery (MCA). We conducted a study on prospectively collected data from 1785 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. According to the extension of the retrograde reperfusion in the cortical anterior cerebral artery-MCA territories, CCS ranges from 0 (absence of retrograde filling) to 4 (visualization of collaterals until the alar segment of the MCA). Radiological outcomes at 24 h were the presence and severity of infarct growth defined by the absolute change in ASPECTS from baseline to 24 h; presence and severity of cerebral bleeding defined as no ICH, HI-1, HI-2, PH-1, or PH-2; presence and severity of cerebral edema (CED) defined as no CED, CED-1, CED-2, or CED-3. Using CCS = 0 as reference, ORs of CCS grades were significantly associated in the direction of better radiological outcome on infarct growth (0.517 for CCS = 1, 0.413 for CCS = 2, 0.358 for CCS = 3, 0.236 for CCS = 4), cerebral bleeding grading (0.485 for CCS = 1, 0.445 for CCS = 2, 0.400 for CCS = 3, 0.379 for CCS = 4), and CED grading (0.734 for CCS = 1, 0.301 for CCS = 2, 0.295 for CCS = 3, 0.255 for CSS = 4) shift in ordinal regression analysis after adjustment for pre-defined variables (age, NIHSS score, ASPECTS, occlusion site, onset-to-groin puncture time, procedure time, and TICI score). Using CCS = 4 as reference, ORs of CCS grades were significantly associated in the direction of worse radiological outcome on infarct growth (1.521 for CCS = 3, 1.754 for CCS = 2, 2.193 for CCS = 1, 4.244 for CCS = 0), cerebral bleeding grading (2.498 for CCS = 0), and CED grading (1.365 for CCS = 2, 2.876 for CCS = 1, 3.916 for CCS = 0) shift. The CCS could improve the prognostic estimate of radiological outcomes in patients receiving thrombectomy for stroke with MCA occlusion.