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Background: Detection of atrial fibrillation (AF) after ischemic stroke (IS) is crucial for starting anticoagulant therapy to prevent IS recurrence. Strategies to identify patients who might benefit the most from extended electrocardiography (ECG) monitoring would be highly desirable. Objectives: We aimed to investigate the role of brain natriuretic peptide (BNP) and echocardiographic parameters as biomarkers for predicting new AF detection in a large cohort of patients with acute IS. Design: We retrospectively analyzed data of 2411 consecutive patients admitted for IS to a single Stroke Center from January 1, 2018, to May 31, 2023. Methods: BNP levels were measured within 48 h of onset. Clinical and echocardiographic variables were evaluated. Single or multiple 12-lead ECG and continuous monitoring with external or implantable devices were used to detect new AF. The outcome measure was new AF detection at 3 months. Results: Of 2337 included patients, 1907 (81.6%) had not previously known AF, and new AF was detected in 422 (22%) patients. In the multivariate analysis, older age (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.02–1.05, p < 0.001), higher National Institutes of Health Stroke Scale score (OR 1.05, 95% CI 1.03–1.07, p < 0.001), BNP ⩾150 pg/ml (OR 4.10, 95% CI 2.95–5.69, p < 0.001), and left atrium (LA) enlargement (OR 2.88, 95% CI 1.99–4.18, p < 0.001) were independently associated with new AF detection. The combination of both BNP ⩾150 pg/ml and LA enlargement showed a strong association (adjusted OR 4.74, 95% CI 3.47–6.48, p < 0.001) and a good discriminative performance for predicting new AF detection at 3 months (area under the receiver operating characteristic curve 0.74, 95% CI 0.71–0.77, sensitivity 0.70 (95% CI 0.65–0.74), specificity 0.78 (95% CI 0.76–0.80)). Conclusion: BNP ⩾150 pg/ml within 48 h of IS onset and LA enlargement, especially if combined, may be valuable biomarkers for predicting new AF detection and identifying patients who might benefit the most from extended ECG monitoring.

Background Occlusion of the internal carotid artery (ICA), whether isolated or in the setting of a tandem lesion (TL) have a poor response to treatment with intravenous thrombolysis. Previous studies ​​have demonstrated the superiority of mechanical thrombectomy in the treatment of acute ischemic stroke (AIS) following large vessel occlusion, compared to standard intravenous fibrinolysis. The aim of our study was to describe endovascular treatment (EVT) in AIS due to isolated ICA occlusion or TL. Methods We assessed the association between 90-day outcome and clinical, demographic, imaging, and procedure data in 51 consecutive patients with acute isolated ICA occlusion or TL who underwent EVT. We evaluated baseline NIHSS and mRS, ASPECTS, type of occlusion, stent placement, use of stent retrievers and/or thromboaspiration, duration of the procedure, mTICI, postprocedural therapy and complications. Results A favorable 90-day outcome (mRS 0–2) was achieved in 34 patients (67 %) and was significantly associated with the use of dual antiplatelet therapy after the procedure ( p  = 0.008), shorter procedure duration (p = 0.031), TICI 2b-3 ( p  < 0.001) and lack of post-procedural hemorrhagic transformation ( p  = 0.001). Four patients did not survive, resulting in a mortality rate of 8 %. Conclusions Our study has shown that EVT in the treatment of AIS due to ICA occlusion is safe, and effective in determining a good functional outcome. ICA stenting led to good angiographic results and therapy with a glycoprotein IIb / IIIa inhibitor immediately after stent release did not result in a greater risk of hemorrhage. The use of post-procedural dual antiplatelet therapy was associated with favorable outcome, without a significant increase in hemorrhagic transformation.

Background: To describe high-resolution brain vessel wall MRI (VW-MRI) patterns and morphological brain findings in central nervous system (CNS) vasculitis patients. Methods: Fourteen patients with confirmed CNS Vasculitis from two tertiary centers underwent VW-MRI using a 3T scanner. The images were reviewed by two neuroradiologists to assess vessel wall enhancement characteristics and locations. Results: Fourteen patients were included (six females; average age 48 ± 19 years). Diagnoses included primary CNS vasculitis (PCNSV) in six patients and secondary CNS vasculitis (SCNSV) in eight, half of which were infection-related. Thirteen patients showed vessel wall enhancement, which was intense in eleven patients (84.6%) and concentric in twelve (92.3%), affecting the anterior circulation in nine patients (69.2%), posterior in two patients (15.4%), and both circulations in two patients (15.4%). The enhancement patterns were similar across different CNS vasculitis types. DWI changes corresponded with areas of vessel wall enhancement in 77% of patients. Conclusions: CNS vasculitis is often associated with intense, concentric vessel wall enhancement in VW-MRI, especially in the anterior circulation. The consistent presence of DWI alterations in affected territories suggests a possible link to microembolization or hypoperfusion. These imaging findings complement parenchymal brain MRI and MRA/DSA data, potentially increasing the possibility of a clinical diagnosis of CNS vasculitis.

Many investigations were carried out on the association between viruses and multiple sclerosis (MS). Indeed, early studies reported the detections of neurotropic virus footprints in the CNS of patients with MS. In this study, sera from patients affected by MS, other inflammatory (OIND) and non-inflammatory neurologic diseases (NIND) were analyzed for antibodies against the polyomavirus, Simian Virus 40 (SV40). An indirect enzyme-linked immunosorbent assay (ELISA), with two synthetic peptides, which mimic SV40 antigens, was employed to detect specific antibodies in sera from patients affected by MS, OIND, NIND and healthy subjects (HS). Immunologic data indicate that in sera from MS patients antibodies against SV40 mimotopes are detectable with a low prevalence, 6%, whereas in HS of the same mean age, 40 yrs, the prevalence was 22%. The difference is statistically significant (P = 0.001). Significant is also the difference between MS vs. NIND patients (6% vs. 17%; P = 0.0254), whereas no significant difference was detected between MS vs OIND (6% vs 10%; P>0.05). The prevalence of SV40 antibodies in MS patients is 70% lower than that revealed in HS.

Introduction: Topiramate was serendipitously synthesized in 1979 during research aimed at developing a fructose-1,6-diphosphatase inhibitor that might be used in the treatment of diabetes mellitus. Some investigators have suggested it might be used in the treatment of binge eating disorder (BED). The aim of this review was to evaluate current knowledge and opinions on this topic. Materials and methods: We conducted a search of five electronic databases (PubMed, Embase, Nice, Cochrane, Cinahl) using the search strategy ‘‘topiramate’’ AND ‘‘binge’’, ‘‘binge eating disorder.’’ No time limits were applied, and only reports of randomized controlled trials were included in our analysis. Results: In clinical studies, topiramate use has been associated with significant weight loss mediated by reductions in the frequency of bingeing episodes. The most common side effects of the drug are paresthesias, but nephrolithiasis, oligohydrosis, and dizziness have also been described. Conclusions: Available data are limited, but the literature we reviewed suggests that topiramate can be useful in the medical treatment of BED, reducing both body weight and binge episodes. Side effects are not negligible. Before topiramate can be regarded as a good tool for the treatment of BED, further data must be obtained from longer, methodologically correct studies of larger populations.

BackgroundProgressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by a reactivation of the human polyomavirus 2 (HPyV-2, previously known as JCV) in immunosuppressed individuals. Few cases of PML have been described in multiple myeloma (MM) patients.MethodsWe described a case of PML in a patient with MM with fatal worsening that occurred during SARS-CoV-2 infection. We also performed a literature review to update the 16 cases series of MM patients with PML already collected until April 2020.ResultsA 79-year-old female patient with refractory IgA lambda MM in Pomalidomide- Cyclophosphamide-Dexamethasone regimen developed gradual lower limbs and left arm paresis along with a decreased consciousness 3.5 years after the MM diagnosis. Symptoms developed shortly after the recognition of hypogammaglobulinemia. After SARS-CoV-2 infection, her neurological status quickly worsened until she deceased. MRI features and JCV-positive PCR on CSF confirmed the PML diagnosis.Our literature review adds sixteen clinical cases of PML in MM published between May 2020 and March 2023 to the 16 cases already collected in the previously published review by Koutsavlis.DiscussionPML has been increasingly described in MM patients. It remains questionable if the HPyV-2 reactivation is determined by the severity of MM itself, by the effect of drugs or by a combination of both. SARS-CoV-2 infection may have a role in worsening PML in affected patients.

Introduction Medium vessel occlusion (MeVO) accounts for 30% of acute ischemic stroke cases. The risk/benefit profile of endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) or the combination of the two (bridging therapy (BT)) is still unclear in MeVO. Here, we compare reperfusion strategies in MeVO for clinical and radiological outcomes. Methods This prospective single center study enrolled consecutive patients with AIS due to primary MeVO undergoing IVT, EVT, or BT at a comprehensive stroke center. Primary outcome was good functional status, defined as modified Rankin Scale (mRS) 0–2 at 3-month follow-up. Additional outcomes included mortality, successful recanalization, defined as mTICI ≥ 2b, stroke severity at discharge, and symptomatic intracerebral hemorrhage (sICH) according to SITS-MOST criteria. Logistic regression was modeled to define independent predictors of the primary outcome. Results Overall, 180 consecutive people were enrolled (IVT = 59, EVT = 38, BT = 83), mean age 75. BT emerged as independent predictor of primary outcome (OR = 2.76, 95% CI = 1.08–7.07) together with age (OR = 0.94, 95% CI = 0.9–0.97) and baseline NIHSS (OR = 0.88, 95% CI = 0.81–0.95). BT associated with a 20% relative increase in successful recanalization compared to EVT (74.4 vs 56.4%, p  = 0.049). Rates of sICH (1.1%) and procedural complications (vasospasm 4.1%, SAH in 1.7%) were very low, with no difference across groups. Discussion BT may carry a higher chance of good functional outcome compared to EVT/IVT only in people with AIS due to MeVO, with marginally higher rates of successful recanalization. Randomized trials are needed to define optimal treatment tailoring for MeVO.

ObjectiveTo explore the impact of antithrombotic therapy discontinuation in the postacute phase of cervical artery dissection (CeAD) on the mid-term outcome of these patients.MethodsIn a cohort of consecutive patients with first-ever CeAD, enrolled in the setting of the multicentre Italian Project on Stroke in Young Adults Cervical Artery Dissection, we compared postacute (beyond 6 months since the index CeAD) outcomes between patients who discontinued antithrombotic therapy and patients who continued taking antithrombotic agents during follow-up. Primary outcome was a composite of ischaemic stroke and transient ischaemic attack. Secondary outcomes were (1) Brain ischaemia ipsilateral to the dissected vessel and (2) Recurrent CeAD. Associations with the outcome of interest were assessed by the propensity score (PS) method.ResultsOf the 1390 patients whose data were available for the outcome analysis (median follow-up time in patients who did not experience outcome events, 36.0 months (25th–75th percentile, 62.0)), 201 (14.4%) discontinued antithrombotic treatment. Primary outcome occurred in 48 patients in the postacute phase of CeAD. In PS-matched samples (201 vs 201), the incidence of primary outcomes among patients taking antithrombotics was comparable with that among patients who discontinued antithrombotics during follow-up (5.0% vs 4.5%; p(log rank test)=0.526), and so was the incidence of the secondary outcomes ipsilateral brain ischaemia (4.5% vs 2.5%; p(log rank test)=0.132) and recurrent CeAD (1.0% vs 1.5%; p(log rank test)=0.798).ConclusionsDiscontinuation of antithrombotic therapy in the postacute phase of CeAD does not appear to increase the risk of brain ischaemia during follow-up.

BackgroundsSeveral neurological manifestations, including stroke, have been reported in COVID-19 patients. The putative role of the COVID-19-related hyperinflammatory state in cerebrovascular disorders remains unclear.MethodsFrom March 2020 to September 2021, we searched for patients who exhibited an ischemic stroke related to carotid free-floating thrombus (CFFT) to investigate its incidence and relationship with COVID-19.ResultsOf 853 ischemic strokes referred to our Stroke Centre during the study period, 5.7% (n = 49) were positive for SARS-CoV-2. Six had CFFT, of which two tested positive for SARS-CoV-2 (2/49 = 4.1%), and four did not (4/802 = 0.5%). The former were two middle-aged men suffering from COVID-19 pneumonia. Floating thrombi were promptly extracted by endarterectomy and endovascular thrombectomy, respectively, with no early and long-term complications. Notably, our COVID-19 patients exhibited little or no atherosclerosis burden on CT angiography, markedly elevated D-dimer levels, and extensive thrombus length.ConclusionsCOVID-19-induced immunothrombosis possibly played a significant pathogenic role in CFFT.

Watershed infarcts can involve the brainstem, with lesions distributed across the terminal supply from the vertebral and cerebellar arteries. Brain imaging can highlight a comma-shaped lesion at the edge of vertebral and posteroinferior cerebellar artery vascularization territory. Such peculiar MRI lesion shape might suggest a watershed hypoperfusion etiology and direct workup towards causes of hemodynamic impairment, including postural hypotension, cardiac failure, or vertebral artery origin occlusion.