9 S p r i n g e r - V e r l a g 1998

SPONTANEOUS TRASOUND

INTERNAL

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CAROTID

DISSECTION:

UL-

FINDINGS

ANALYSIS OF STROKE REHABILITATION MANAGING: PRELIMINARY STUDY AMONG

PHYSIOTHERAPIST

F Accorsi General Medicine E, Ospedale Maggiore, Lal\go Nigrisoli 2, 40100 Bologna, Italy

T. Boschi, L. Paviotti Physical Medicine and Rehabilitation Institute, Udine, Italy

Spontaneous internal carotid artery (ICA) dissection is an unusual finding. ICA dissection is a dynamic process that may cause rapid lumen obliteration but also early recanalization. Angiography has been always regarded as the gold standard for the diagnosis of arterial dissection but its role will probably decline in the future. The favorable natural history of ICA dissection enphasizes the need for a noninvasive approach to detection and follow-up. Therefore ultrasound may play an important role in the early diagnosis and follow-up providing an ideal non invasive procedure for monitoring patients with ICA dissection. Ultrasound findings may be: (1) echo poor thrombus with or without lumen narowing, (2) Luminal flap with or without thrombus formation, but a double lumen cannot be identified in most cases. Usually absence of atheroma is observed. ICA occlusion located above the carotid bifurcation in a patient free of atheroma suggests dissection. Doppler ultrasound waveform findings may be: (1) normal, (2) damped or biphasic, (3) absent,(4) High velocity. In this study ultrasound monitoring of spontaneous ICA dissection is reported. In particular a three stages evolution is presented: 1) alteration in the flow and tapering of thc ICA lumen, 2) early recanalization, 3) normalization of the blood stream. In conclusion ultrasound examination is an ideal method for a diagnosis and follow up of patients with ICA dissection because of its not invasive nature and its diagnostic validity.

The aim of this work is to point out and describe what professional help can be offered to patients suffering from strokes by physiotherapists working in the Friuli Venezia Giulia region in north east Italy. To this end a questionnaire was circulated to gather information on training in the neurologic field and the adoption of systems for evaluation which are important both from the methodological point of view and in verifying the success of the treatment. 230 questionnaires were completed and the average age of those questioned was 37.2, with 14 years experience. To show how representative this illness is in the daily workload of a physiotherapist, it should be pointed out that 91% of physiotherapists treat stroke patients with 35.8% dealing with them on a daily basis, treatment times range from 60 minutes for patients in the sub-acute phase to 45 minutes for those in the chronic phase. Regarding professional qualifications and experience, 85% of physiotherapists had followed specific post-diploma courses with 51% having consulted specialist hooks and literature, 38% participated in conferences and 10% having done related work experience. The most well-known and widely used methods are those of Bobath and Perfetti. Physiotherapists evaluate patients at the beginning of treatment using, above all, a spontaneous observation of the patient (66%) and evaluation scales (35%). The methods adopted for recording an evaluation are: personal notes (50%) and a rehabilitation card (18%). The last data reveals a negative aspect but is alleviated by a large request for the adoption of a new system of evaluation which includes the drafting of a plan of treatment (95%) and verification of its success. Other important data regards the impossibility of a personal verification about the efficiency of treatment because of the lack of coordination between the various professional figures involved in the rehabilitation of the patient. In fact, it becomes evident that in 23% of cases it is impossible to make a significant verification as either the rehabilitation cycle is insufficient or the patient is released without the knowledge of the physiotherapist.

THE QUEST FOR EARLY PREDICTORS

THE ROLE OF ULTRASOUND

OF STROKE EVOLU-

INVESTIGATION

IN TAKAYA-

T I O N . IS T C D A G U I D I N G L I G H T ?

SU'S ARTERITIS

C. Baracchini, R. Manara, S. Marengon, G. Meneghetti Department of Neurological Sciences, Universi(v of Padova, Padova, ltaly

N. Carraro, M. Bardelli*, P. Dolso, S. Ros, B. Cruciatti Neurology Clinic, Clinical Medicine*, University of Trieste, Trieste, Italy

A very early detection of the site and size of cerebral ischemia is a fundamental parameter, yet difficult to achieve. This preliminary study was conducted on 10 patients with acute cerebral ischemia in the middle cerebral artery (inca) territory, clinically identified as TACI according to Bamford's classification. We compared cerebral hemodynamic data gathered by TCD serial examinations (at admittance, at 24 hours, on the 7th day) with cerebral CT findings (at admittance, between the 7th and 10th day). Acute and chronic clinical assessments were performed by the Unified Neurological Stroke Scale. The results are as follows: the first TCD showed no flow in the symptomatic mca in 6 patients, an asymmetry of the inca flow velocity (A velocity > 20%) in 2 patients, normal values in the remaining 2 patients. The serial TCD showed persis tently normal blood flow velocities in 2 subjects, persistent asymmetry in 2 cases and no flow in 2 patients, while 4 cases that previously presented an inca occlusion had a partial restoration of blood flow. The 2 patients with persistent occlusion on the 7tb day from clinical onset had the worst outcome. The first cerebral CT scan demonstrated an early hypodensity in only 2 patients. The follow-up CT showed a complete infarction in 8 and a partial infarction in 2 cases. From these preliminary data acute TCD seems to be a useful predictive parameter of the site and extension of the iscbemic damage while the clinical outcome is better depicted by TCD serial examinations.

In our opinion the diagnostic value of ultrasound examination in vasculitis is not yet clearly definite. We try to identify the contribute of the neurnsonology to the knowledge of this kind of disease dealing with a case of Takayasu's Arteritis (TA). As case study we describe a patient affected by TA since the age of 15. The neurovascular investigations (CW Doppler, Echo-Doppler or B-Mode Ultrasonography, Transcranial Doppler- and Echo-Tracking System) were executed 2 years after the beginning of the disease. On the base of the results of our investigation on the patient we note that: CW Doppler can show waveform modification, or the hemodynamic consequence, of the affected vessels, B-Mode Ultrasonography can show hyperechogenicity of the inner arterial wall and/or circumferential, diffuse, homogeneous, hyperechogenic arterial wall thickening with the peculiar axial pulsation of the vessel that slides on bordering tissue. Transcranial Doppler can show the hemodynamic changes due to the extracranial vessels modifications, Echo-Tracking System can show the modification of the pulse wave and high values of Peterson Index and Stiffness Parameter, which are related to the rigidity of the arterial wail. Owing to the fact that the gold standard examination remains to date the angiography, we emphasized the importance of noninvasive investigation to support the diagnosis and follow up of TA. We underline the role of dynamic evaluation of ED with the peculiar axial pulsation of the affected artery. We think that this movement is characteristic of this kind of pathology and differs from that we find in atheromatous lesions.

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NEUROLOGICAL OUTCOME AFTER CARDIAC SURGERY M. CasarolY, C. Vinci~, I. Pittard, E. Zappoli ~, F Giacomuzzi-', UJ~ Guerra: , G. Molinis', D. Tuniza, M. Valentd, R. Frassani 4, C. Puricelli ~, P. Prati' ' Neurology Departement Gervasutta Hospital, Udine, Italy 2Nuclear Medicine Departement S. Maria Misericordia Hospital, Udine, Italy Cardiac Rehabilitation Centre Gervasutta Hospital, Udine, Italy ' Cardiothoracic Surgery Unit S. Maria Misericordia Hospital, Udine, holy After cardiac operation, Transitory Ischaemic Accident (TIA) and stroke occur in varying percentages (0.8-5%), while the alteration of neuropsychological function is a common condition. The causative parameters are subject variables (age, concomitant cerebrovascular disease, heart disease) or surgery variables (duration of extracorporal circulation, temperature and pH, mean arterial pressure). This study is undertaken to evaluate the complete neurological outcome after cardiac surgery, its extent and duration and whether neuro-psychological alterations do or do not recover spontaneously. DESIGN of study: prospective study. PARTICIPANTS: patients undergoing cardiac surgery on extra-corporal circulation. The exclusion criteria were type I diabetes mellitus, atherosclerosis with > 70% carotid stenosis (duplex sonography) or stenosis of intracranial arteries (Transcranial Doppler, TCD). INTERVENTIONS: valve repair or replacement, replacement of the thoracic aorta, Coronary Artery Bypass Graft surgery (CABG), closure of Atrial Septal Defect (ASD) and Ventricular Septa] Defect (VDS) or heart transplantation. NEUROPSYCHOLOGICAL TEST BATTERY: a neuropsychological test battery was used to assess mnestic, cognitive and personality variables. The tests were performed 1 day preoperatively and 10 days, and 3, 6 and 12 months postoperatively. CARDIAC EVALUATION: all patients were submitted at clinical evaluation to echocardiography, Holter monitoring and exercise testing. After discharge, patients were enrolled in a cardiac rehabilitation program. The focal interventions were: exercise training, health information and education, counselling and psychological assistance, prognostic evaluation and long-term care. NEUROLOGICAL EXAMINATION: a neurological clinical examination, a neurophysiological study (NI00 and P300 evoked potentials, computed EEG) and a neurosonological examination to study embolus detection with bilateral transcranial detection of high intensity transient signal (HITS) and Duplex sonography of supra-aortic arteries, were performed before surgery and 10 days, 3, 6 and 12 months postoperatively. SPECT: regional blood flow by 99mTc-ECD-SPECT was evaluated before and after surgery and was correlated with number of HITS.

REPORT OF A PATIENT WITH POSSIBLE HEREDITARY MULTIPLE ANEURYSMS M. Cavallo, D. Decima, P. Pinelli Division of Neuromotor Rehabilitation Villa Salus Hospital, Mestre, Italy The aims of the study were: (1) To check the existence of cerebral aneurysms in a cephalalgic patient with family history of uneurysmal subaracnoid haemorrhage (2), and to detect in the same patient extracranial aneurysms. We report a 56-year old woman, with anamnesis of hypertension, smoke, headache and family history of aneurysmal subaracnoid baemorhrage who came to our hospital for mnesic disorders. Computed tomography showed two cerebral aneurysms (right MCA and left MCA), although the patient never had symptoms suggesting cerebral haemorrhage. Further exams performed to detect extracranial aneurysms, showed an aneurysm of the left popliteal artery. We consider if a deficiency of alpha-sub 1 antitrypsin could play a role in the pathogenesis of arterial aneurysms.

9 Springer-Verlag 1998

MOTOR EVOKED POTENTIALS IN STROKE PATIENTS DURING NEUROREHABILITATIVE APPROACHES P. Cicinelli, M.M. Filippi, M.G. Palmieri, M. Oliveri, t~ Pasqualetti, R. Traversa, P.M. Rossini I.R.C.C.S. S. Lucia, Rome, Italy Excitability and conductivity of the central motor system were evaluated through transcrunial magnetic stimulation in stroke patients. We followed-up two rehabilitation approaches having a different theoreucal frame ("peripheral" i.e. Bobath versus "central" i.e. Perfetti approach). According to perceptual theories, voluntary movement and relaxation act at a "central" level activating brain mechanisms of perceptual awareness and purposeful behaviour (cortical facilitation). On the other hand, "peripheral" facilitatory techniques utilise movement control strategies acting at a spinal level. Twenty patients were selected: 11 and 9 were following a neurorehabilition treatment based on Bobath or Perfetti approaches, respectively. Functional and neurological status was evaluated. MEPs was bilaterally recorded from five upper limb muscles (Deltoid, FCR, EDC, FDI, ADM) in 5 different sessions, from admittance (TO) to 3-4 months away from TO (T4). In Perfeni-treated patients, a MEPs amplitude increment was present in most muscles at rest and during contraction. On the other hand, considering mean MEP latencies, it was possible to find shorter latencies, either at rest or during contraction in the Bobath-treated population. After a vascular monohemispheric lesion, the analysis of 5 different MEP recording session, showed some differences between Bobathand Perfetti-treated patients: in Perfetti group, a pattern of amplitude increment and SP shortening was evident, while on Bobath group there was a shortening of latencies. Excitability thresholds were not different in the two groups. It seems that an approach based on "peripheral" afferences modulation (Bobath) induces some recovery of the lost tonic facilitatory sensory feed-back from the affected arm. The "central" method (Perfetti), acting at a cortical level, could contribute to a decrement of inhibition from the affected hemisphere coupled with a more synchronized recruitment of the motoneuronal population (temporal summation) as well as of an increased number of the activated cortical efferents (spatial summation).

FACTOR V RS06Q MUTATION ASSOCIATED WITH FIBRINOLYTIC DERANGEMENTS IN PATIENTS WITH ATHEROTHROMBOTIC STROKE D. De Lucia ~, D. d'Alessio ~, i( Del Giudicd, F. Ammendola ~, G. Maistd, R. Marotta ~, F. Demurtas', R. Mamone', S. Pezzella', M.L. Papal. 'Institute of General Pathology and Oncology, H University of Naples, ;Hemophilia and Thrombosis Center, Pellegrini Hospital, Naples, Italy Stroke is the third leading cause of death and a leading cause of serious disability. The prothrombotic conditions promoting cerebrovascularthrombosis are normally due to hypercoagulability in the arteries that supply blood to the brain. APC-resistance may increase endothelial cell fibrinolysis and produces a procoagulant state. The aim of our study was to determine the prevalence of Factor V (FV) R506Q mutation and fibrinolysis plasma levels in ischemic cerebrovascular disease. We genotyped 50 patients who had suffered from atherothrombetic ischemic stroke (mean age +SD, 52.5+17.5 years, 12 females and 38 males). All subjects were from Southern Italy and all the cerebral ischemic episodes occurred 12-15 months previously and had been documented by NMR and CT scan. One hundred controls were enrolled by age-matched healthy volunteers. Eleven (22%) patients showed FV Leiden mutation (10 heterozygous and 1 homozygous) while 2 (2%) healthy subjects had the same mutation. In patients with stroke, results of fibrinolytic proteins were significantly different from controls. Increased plasma levels oft-PAand PAI-I were found in cerebrovascular patients as compared to healthy subjects (12.5+3.5 ng/rnl vs. 3.5:t:1.2 ng/ml; 22.5-1-4.7ng/ml vs. 8.5_-f.5.2nod'ml,respectively,p< .001 Fisher Exact Test). Notably, the highest values in t-PA and PAI-I were found in patients with FV:R506Q mutation (I6.5:.+3.5 ng/ml and 36.5+11.5 nghnl, respectively). F,.~-was significantly higher in patients compared to control group (l.15_+0.25nM vs. 0.45• nM, p< .00l). However, the highest values in F,§ were found in patients with FV:RS06Q mutation (1.55-20.25nM vs 1.05:2,'0.35riM, p< .001). In agreement with other authors our data suggest a state of hypercoagulabiliry in cerebrovascular ischemic disease. Our findings also showed that mutation in FV gene was significantly more frequent among cases and significantly discriminate subjects with a stroke history. On the basis of these results, it is conceivable that APC-resistance may affect endothefial cell fibfinolysis, expecially in response to enviromental stimufi such as high thrombin plasma levels. The observation that the extent of in vivo blood clotting activation, as assessed by F~.2 and tPA/PAI-1 determinations, is higher in patients carryingthis defect as compared to patients with normal APC-responses, indicates that APC-resistance may contribute, at least in part, to the occurrence of the hypercoagulable slate encountered in this clinical condition. These findings have raised the exciting possibility of using these hemostatic factors as markers for selecting high-risk subjects in cerebrovascular ischemic disease.

9 Springer-Verlag 1998

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PROGRESSION OF CAROTID ATHEROSCLEROSIS ASSOCIATED WITH HYPERCOAGULABILITY IN PATIENTS SUFFERING FROM ISCHEMIC STROKE D. De Lucia', D. d'Alessic;, L. Lieto-', V. Del Giudice', A. Durante/, R. Mamone', R. Marotta ~, G. Maisto l, F. Demurtas ~, S. Pezzella~, M.L. PapaJ. 'Institute of General Pathology and Oncology, I[ University of Naples, :Hospital "G. Moscati", Avellino, -~Hemophiliaand Thrombosis Center, Pellegrini Hospital, Naples, Italy Introduction. Early atheroscterosis progression may be studied by the thickness of the common carotid intima-media using B-mode ultrasonography. We aimed at investigating the relationship between markers of hypercoagulable state and the thickness of common carotid intima-media. Methods. We studied over 12 months 75 patients (mean age _+SD, 60.5+17.5 years, 47 males and 28 females) belongIng to unrelated families of Southern Italy, and consecutively admitted to our hemostasis laboratory for a diagnosis of ischemic stroke. The patients were selected according to the World Health Organization criteria for the diagnosis of ischemic stroke. Blood sampling from 45 (60%) patients who showed increases in thickness of common carotid intima-media (Group A) were compared with those from 30 (40%) in which the progression in thikness of common carotid intima-media (Group B) was not observed. Results. PT, AP"fT, TT, antithrombin III (AT III), protein C (PC), protein S/PS (total-and free) and APC-resistance were similar in the two groups of patients. High fibrinogen (Fg), t-PA, PAI-I and FI+2 plasma levels were found in the group of patients with increased thickness of common carotid intima-media (387-+45 mg/dl vs. 315+57 mg/dl, t= 6.096, p <.001; 12.7+2.8 IU/ml vs 9.7-+3.5 IU/ml, t= 4.11, p < .001; 27.5+9.7 AU/mL vs. 18.7:t I 1.5 AU/mL, t= 3.572, p < .001; 2.25+0.75 nm vs 1.35_+0.85nM, t= 4.826, p < .001, respectively). The thickness of common carotid intima-media correlated positively with plasma levels of Fg (r=0.78, p < .001) and Fl+2 (t-'=0.69,p < .001). Interpretation. Our findings suggest that high plasma concentration of Fg, t-PA/PAI- 1 and Fl+2 may be associated with the progression of early carotid atherosclerosis in patients with a history of ischemic stroke. To our knowledge, there are only few reports describing to what extent the thickness of common carotid intima-media will affect further outcome in patients with a history of ischemic stroke or whether there wilt be associated hypercoagulable state. Thus, our prospective study confirmed the possible correlation between the thickness of common carotid intima-media and markers of hypercoagulability.

PROGRESS IN NEUROLOGICAL SURVEILLANCE DURING CAROTID ENDARTERECTOMY V. Fregonese, N. Gonano, R. Santarelli, G. Biasi, G. Andolfato, P. Pfeiffer, L. Mozzon Vascular Surgery Unit, Udine Regional Hospital, Udine, Italy From 1981 to April 1998, the Vascular Sugery Unit of Udine Regional Hospital performed 1258 surgical procedures on epiaortic vessels: carotid endarterectomies were 1187 (1123 patients, both sides operated in 135 cases; age range 32-86 years, symptomatic cases 835, 70.35%). A temporary intraluminal shunt was inserted in 79 procedures (6.65%). Perioperafive overall complication raIe is here referred: Mortality 0.67%, TIAs 1.68%, major strokes 1.09%, cerebral hemorrhage 0.50%. We have had a complete experience in the most common neurological monitoring techniques during carotid endarterectomy: continous EEG, stump pressure, transcranial Doppler. Unfortunately, none of them showed a complete accuracy. On the basis of our experience, we finally adopted a newly conceived inlraoperative surveillance method together with oar anesthesiological team. Immediately before the operation, the patient received an epidural anesthesia in the C5-C6 space: a rubber toy was placed in patient's controlateral hand and pushed on command. Then, a complete pharingo-laryngo-tracheal treatment (lidocaine) was performed and the patient underwent general endotracheal anesthesia (propofol+fentanyl+mivacurinm). Afxerthe surgical procedure begins, patient was awaken and maintained consciousness under mild sedation (lorazepam). During a carotid clamping test (3 min), patient is able to listen to the operator and to push rubber toy, thus demostrating at once his neurological status. In case of change of cerebral function (like a lack of consciousness and/or a sudden neurological deficit of the ann), a temporary endoluminal shunt is selectively positioned. Therefore, the surgical procedure can go on without any functional or anatomic damage. Few months later, a change in anesthesiological procedure was made: instead of epidural cervical injection, a superficial and deep cervical plexus block was preferred, because of its lesser risk degree. Until April 1998, 109 patients underwent carotid endarterectomy according to this new method: 57 had an epidural injection and 52 a cervical plexus block. In 15 cases (13.76%) intraluminal shunt had to be used for a neurological deficit. Neverthless no fatal complication occurred (Mortality rate 0%, TIAs 0.9%, major stroke 0.9%). The new intraoperative management we suggest combines the advantages of general and regional anesthesia: surgeon can easily evaluate neurological status of a conscious,co-operative patient at any moment. If symptoms of cerebral ischemia occur, the patient could safely be treated. In oar preliminar experience, the overall ratio of shunt insertion is much higher ( 13.76%, 6.65%) than in the previous series. We consider that further experience will lead to a decrease of this ratio. In conclusion, we underline the cheapness and the safety of the procedure.

A NEW INDEPENDENT RISK FACTOR FOR ISCHEMIC STROKE: SERUM PARAOXONASE ACTIVITY

FROM STROKE TO HANDICAP: MULTIDISCIPLINARY INTEGRATED MANAGEMENT HOSPITAL PHASE

R. Del CoUe', E. De Fanti", M Turazzini', L. Targa:, P. Battaglia:, D. Giavarina ~, M. Silvestri~, R. Schiavon'-. ~Department of Neurology, 2Clinical Chemistry Laboratory - Legnago Hospital, Vecvna, Italy

A. Gaffuri', L. Granella', R. Frediani :; C. Foglia~, B. Quercia', M. Vacca Arleri' ; L. Ferrero ~, S. Lombardo ~. Region of Piedmont ASLS Moncalieri, S. Croce Hospital, 'Rehabilitation Autonomous Operating Unit and 2Stroke Unit, Department of lnternal Medicine, Moncalieri, Italy

Paraoxonase (PON) is an enzyme linked to HDL particles. Recently PON was identified as a genetic risk factor for coronary heart disease patients. We have investigated whether the 191 polymorphism, linked to high PON activity (B allele) was associated with ischemic stroke. 31 consecutive patients with history of ischemic stroke were tested for PON activity and some other important risk factors, namely homocyst(e)ine (HCY), fibrinogen (FBG), lipoprotein (a) Lp(a), and total cholesterol (TC). Results:

The new focus of health care must be on curing the individual (not only the organs), thus improving both life quality and life expectancy. The implementation of the ASL8Moncalieri Stroke Service will provide multidisciplinary, integrated, and continuous management of stroke patients through all stages of their clinical course: from the acute phase (curing the disease), to impairment and disability (medical rehabilitation), to handicap (social rehabilitation). Professional figures involved in the project are: physicians, nurses, physical therapists, speech therapists, family doctors, social workers, as well as voluntary associations and patients' family members. Co-ordinated interventions in the Hospital phase will go from medical treatment, to nursing, rehabilitation, social and environmental re-adjustment. All these specialist activities will be differently balanced and harmonised according to the progress of patients' condition. The Hospital phase of the Stroke Service will provide a stroke unit, a medical ward, a rehabilitation ward, plus an integrated medical and rehabilitation day hospital. There will be specific protocols, internal guidelines and physical characteristics for each one of these units. Criteria for moving patients from one unit to the other will be defined by specific protocols. Co-ordination toward common goals of the stroke service team members will be obtained through interdisciplinary meetings aimed at sharing discipline-specific skills, at optimising work processes and at developing a strong team-working attitude. The Hospital phase will be strictly linked to the Community phase.

Parameter

Stroke patients

Control group

HCY (tool/l) ' FBG (g/l) b Lp(a) (g/l)" PON (IU/1) TC (mmol/l) b

16.5 4.08 0.33 209 6.08

12.5 3.51 0.14 116 5.18

(6.1-89.2) (1.11) (0.01-1.5) (1.09)

(4.5-26.6) (0.79) (0.01-0.59) (0.94)

Median (range); bMean (SD) PON activity showed a trimodal curve of distribution (low-AA, intermediate-AB and high-BB allele activity) in both groups; however in stroke group intermediate and high activity peaks prevailed, accounting for an increased median value. HCY, FBG, Lp(a) and TC levels were significantly elevated in stroke patients compared with the control group. HCY and FBG levels were reciprocally correlated (r=0.42, p 0.05), whereas PON was not correlated with any parameters. In conclusion, this preliminary study confirms the association of FBG, HCY, Lp(a) with ischemic stroke and point out to high PON activity as an independent risk factor for ischemic stroke. Further studies are needed to define the importance of the latter observation.

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9 Springer-Verlag 1998

DYSPHAGIA I N A C U T E S T R O K E

PATIENTS

A. Gaffuri t, L. Granelld, R. Frediani2; C. Foglia', B. Quercia', M. Vacca Arleri'; L. Ferrero ~, S. Lomhardoq Region of Piemonte ASL8 Moncalieri, $. Croce Hospital, ~RehabilitationAutonomous Operating Unit and 2Stroke Unit, Department of lnternal Medicine, Moncal&ri, Italy

RECOVERY FROM STROKE: THE ROLE OF I D E O M O T O R APRAXIA O N F U N C T I O N A L O U T C O M E F Giunmli, M. Bulkaen, C. Quiriconi, S. Lange, O. Renucci, M. Campioni, L. Gatardini, E. Tommasi, R. Muceiacito, N. Borrelli Rehabilitation Department, Valdinievole Hospital, Pescia, USL 3, Pistoia, Italy

Dysphagia and associated malnutrition are serious risk factors of functional disability and mortality among acute stroke patients. It has been estimated that 40% of hospitalised patients suffer from malnutrition caused by dysphagia. Despite recognition of the problem, no approach has been devised to prevent bronchopulmonary infections or complications due to inadequate hydration and nutrition in the acute phase of stroke. In our multidisciplinary team (including physicians, nurses, dieticians, physiotherapists and speech therapists), the speech therapist evaluates the swallowing function within 48 hours from stroke in order to predict possible physiological swallowing recovery. It has been demonstrated that dysphagia is present in 13% of patients with unilateral stroke and in 71% of patients with bilateral stroke. Patients for whom dysphagia is diagnosed during the first swallowing assessment, receive daily treatment by the speech therapist and are submitted to subsequent clinical evaluations aimed at choosing the most appropriate nutritional intervention: 1) Facilitated and controlled mouth feeding, using dietary, postural or compensatory techniques, 2) Enteral feeding (through naso gastric tube or PEG), while stimulating functional recovery. The purpose of such an approach is to reduce medical complications due to a late treatment of dysphagia.

Among the predictive factors of neurological and functional recovery after stroke, a smaller attention, in comparison with aphasia and unilateral spatial neglect, has been payed to ideomotor apraxia (A) that rarely appears in clinical evaluation protocols of post-stroke patients. Targets of our study are the following: 1) To evaluate the incidence of A, in stroke and respectively on left and right side lesions; 2) To weigh the change in A, during the stay in a second level rehabilitation unit; 3) To survey the difference of score values, on Fim scale, between A and not-A subjects. A perspective study on 80 patients (46 males, average age 76+9 years), at their first stroke, consecutively admitted to our unit from January 1997 to May 1998. All the patients were subjected to internistic, angiological and neurological examinations, laboratory routine, cerebral computed tomography (CT) or magnetic resonance (MR). Patients with history of previous stroke, subarachnoid hemorrhage, or with an onsetadmission time > 30 days were excluded from the study. The lesion proved left hemisferic in 52 cases (65%), fight in 24 cases (30%) and bilateral or of the trunk in 4 cases (5%). Ischemia was found in 90% of cases. The FIM scale and Apraxia test (De Renzi test by checking the healthy limb) were completed within 72 h from admission or discharge, by accreditated personal. In 8 cases, De Renzi test was not assessable. The onset-admission time was 21+10 days; the length of stay 50+10 days. At admission, A was found in 26 cases (33%), of which 14 males (52%). In A subjects, lesion was located on the left in 17 cases (70%). By comparing mean values of apraxic and non apraxix patients no difference in the distribution of the readings of the average age was evident. There was no significant differences between the two groups in the onset-admission time, in the length of stay and in the mean values of motor, cognitive and total scores of FIM. In conclusion our study does not seem to indicate, at least in the early rehabilitation period, a negative prognostic role of A in the functional recovery from stroke.

FROM STROKE TO HANDICAP: M U L T I D I S C I P L I N A R Y

DISABILITY

TEGRATED

MANAGEMENT

HOSPITAL

IN-

PHASE

A. Gaffur?, L. Granella j, R. Fredian?; C. Foglia', B. Quercid, M. Vacca Arleri~; L. Ferrer&, S. Lombardo ~. Region of Piemonte ASL8 Moncalieri, S. Croce Hospital, 'Rehabilitation Autonomous Operating Unit and ~Stroke Unit, Department of Internal Medicine, Moncalieri, Italy Between 1989 and 1998, 380 patients with cerebrovascular disease and associated sensorymotor/communication disabilities received domiciliary physiotheraphy by our Rehabilitation UOA once discharged from the S. Croce Hospital Medicine UOA. The domiciliary service, started in 1989 as a sheer rehabilitation therapy, was integrated with AD1 (Domiliciary Integrated Assistance) in 1996 and with a Rehabilitation Day Hospital in 1998; the aim was to broaden the range of "out-patient" activities through the co-operation of various medical and non-medical professionals, thus ensuring therapeutical continuity while providing an interdisciplinary customised and comprehensive domiciliary approach. From the assessment of our past home-based activities, the following critical areas emerge: 9 Communication problems among the different acute hospital operating units, the District Health and Social Services, the voluntary associations and the patient's family members. 9 Little flexibility and interaction among rehabilitation, nursing, and social funcions. 9 Difficult home management of disables patients because of family and care problems. 9 No specialised training programme for the professionals involved. 9 No strong team-working attitude, nor designated project leader. 9 Extemporary follow-up and efficiency/efficacy audits. The ASLS-Moncalieri Stroke Service project is designed to integrate the Hospital phase (Stroke Unit, Medical Ward, Rehabilitation Ward, Rehabilitation Day Hospital) with the Community phase (Discrict, Family Doctor, ADI, Social Services, Out-patient Rehabilitation, etc.) through a disease management modality ingluding: A communicaton protocol among Hospital and Community functions. A wide range of customised out-patient services. A set of internal guidelines. Efficacy, efficiency and quality indicators. A prevention and indicators analysis oriented follow-up. The development of a "Learning Organisation" culure within the working team.

IN HEMIPLEGIA.

HEMINEGLECT

INDEPENDENT

EFFECT

OF

AND MOTOR I M P A I R M E N T

M. Lamponi, G. Zeloni, S. Fruzzetti, B. Frascella, G. Gori INRCA, Hospital 1, Fraticini, Florence, Italy Both hemineglect and motor impairment strongly influence the severity of disability in performing the activities of daily living (ADL) in stroke patients. However, the independent effect of hemineglect on disability in stroke patients with motor impairment is still disputed. The aim of this study was to verify whether the presence of hemineglect independent of motor impairment influences performances in the activities of daily living. Two groups of thirteen patients each, with vascular fight brain lesion, were studied. The patients in the first group were affected by hemineglect (Bell's Cancellation Test). Patients in the second group were free of hemineglect and were matched with age, gender, onset of illness and level of motor impairment. ADL was measured according to Barthel Index. The Bartbel Index was significantly worse in the patients with hemineglect, suggesting that the presence of hemineglect in patients with stroke has important functional consequences, independent of the effects of physical impairment.

9 Springer-Verlag 1998

PATHOGENESIS AND PROGNOSIS OF ISCHAEMIC STROKE IN ELDERLY PATIENTS: ANALYSIS OF 149 CONSECUTIVE HOSPITALIZED CASES G. Landini, G. Regoli, A. Stefanini, L. Guastella, M.T. Passaleva, A. Ghetti Internal Medicine Operating Unit H, Hospital S.M. Annunziata, Florence, Italy

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MICROEMBOLIC SIGNALS IN PATIENTS WITH PROSTHETIC HEART VALVES: ARE THEY HARMLESS? G. Mal[errari ~, C. Bernardi j, R. MorattJ ~Emergency Medicine, Modena Civil Hospital, Modena, Italy 2Vascular Surgery, Modena Civil Hospital, Modena, Italy

Despite the high prevalence of ischaemic stroke in the elderly, there is a relative lack of studies concerning these patients. A retrospective analysis of 149 consecutive patients with ischaemic stroke aged 70 years and older admitted in our unit between January 1997 and June 1998 was carried out. We classified stroke with TOAST study criteria partially modified in: atherosclerosis (ATS), cardioembolic (CE), lacunar (LAC), uncertain (UNC), and undetermined (UND). Patients were also grouped into four clinical subtypes according to Bamford criteria (TACS, PACS, POCS, LACS). The mean age was 82 years (females 84 years; males, 60 years). Mortality at the tenth day was 13%. Pathogenetic subgroup rate was: UND 40%, CE 29%, LAC 14%, ATS 10%, UNC 7%. The incidence of CE strokes was significantly higher in patients aged over 80 years compared to patients aged 70-80 (p= 0.005). Atrial fibrillation occurred in 80% of CE strokes. Mortality rates for pathogenetics subgroups were: CE 21%, UND 15%, UNC 9%, ATS 6%, LAC 0%. The most severe clinic subgroup (TACS) had CE pathogenesis in 47% cases, UND in 47% and UNC 6% (ATS and LACS, 0%). These data confirm the high incidence of CE stroke in the elderly and underline the severe nature of this type of stroke both for disability and mortality. Surely these data are undervalued because many patients classified as UND were suspected of CE pathogenesis for clinical and radiological assets, but could not be studied with TEE both for their advanced age and severity of disease. Conclusion. Primary and secondary ischaemic stroke prophylaxis in elderly should not only control cardiovascular risk factors, but also and mainly treat the sources of cardioembolism (particulary atrial fibrillation) by establishing an appropriate anticoagulant therapy.

The aim of our study was to investigate the added effect of antiplatelet therapy on the number of microembolic signals (MES) in patients with prosthetic valves taking anticoagulants and who suffered one or more T1As and had no significant carotid disease, by means of recording MES in middle cerebral artery (MCA). We studied 8 patients, 3 men and 5 women, aged 42-82 years, addressed to our laboratory for a recent neurological hemisphere deficit, who were carriers of mechanical valve protheses placed at mitral (4) or aortic (4) sites and were anticoagulated with warfarin. All subjects received a full-color duplex investigation of their neck arteries and echocardiography. We performed a 30 rain transcranial Doppler (TCD) sonography recording from the MCA contralateral to the neurological deficit. The recording was performed both at basal conditions and after inspiration of oxygen 6 1/min via not closely fitting facial mask. Consistent with previous experience of Georgiaides and Droste, we found in our patients MES, which significantly decreased during 02 inhalation. Surprisingly, we did not find a close relation between MES and valve type. Afterwards, in all patients antiplatelet therapy (Aspirin, 100 rag/day) was added to the usual oral anticoagulant regimen because of TIA occurrence. After 4-6 months we performed a second TCD monitoring of MES and found a further decrease of MES in basal condition and after 02 inhalation. The patients were free of symptoms and had no history of TIAs since the first visit. In five patients there were no major risks of embolism (atrial fibrillation, dilated cardiomyopathy, or diffuse atherosclerosis) and the gaseous nature of the majority of MES was confirnaed by the result of 02 inhalation which showed a marked decrease of MES number. Howewer, at six month control with aspirin addiction we recorded a further reduction of the number of MES. In 3 patients who had dilated cardiomynpathy, atrial fibrillation, and diffuse atherosclerosis, we recorded minor reduction of MES with 02 and major reduction of MES with aspirin with respect to the first group, so we can suppose that microaggregates coming from heart and vessels were added to the bubbles. Presently, we only partially know the nature and pathogenicity of MES. By adding oxygen there is a drastic reduction of the gaseous portion. Aspirin has a platelet antiaggregating action even on those platelets tha might stick to a bubble cluster, therefore creating a dangerous mixture.

THE USE OF TRANSCRANIAL COLOR DOPPLER IN INTRACRANIAL STENOSES. EXPERIENCE WITH CONTRAST-ENHANCED COLOR DOPPLER

SPONTANEOUS CAROTID ARTERY DISSECTION AFTER RECENT INFECTIOUS DISEASE

G. Malferrari ~, C. Bernardi ~,R. Moratto 2, N. Tusini:, A. Pisanello ~, G.Copp? 'Emergency Medicine, Modena Civil Hospital, Modena, Italy -'Vascular Surgery, Modena Civil Hospital, Modena, Italy JNeurology, Modena University, Modena, ltaly Transcranial Doppler ultrasonography may be used by clinicians as a noninvasive screening tool for the diagnosis of intracranial arterial stenosis. Data regarding the sensitivity and specificity of transcranial doppler (TCD) in the diagnosis of middle cerebral artery (MCA) stem (M1) and intracranial vertebral artery and basilar artery stenoses have been published elsewhere. In our study we used velocity criteria to predict intracranial stenoses of MCA, MI, intracranial vertebral and basilar artery segments. The TCD criteria for stenosis are: (1) stenosis of 50% or greater in diameter gives a peak systolic frequency shift of 2 KHz or greater, using a 2 MHz probe, (2) stenosis of 75% produces severe flow disturbances combined with direct and reverse low frequency, high energy signals or with damped velocity beyond the stenosis. We assume that asymmetry in arterial velocity (> 30%) is an important parameter. We know from previous works that, using velocity criteria alone, TCD with pulsed wave probe may miss up to 17% of M 1 stenoses of any degree and up to 20% of intracranial vertebral and basilar 50% stenoses. With the use of transcranial color-coded (TCCD) ultrasonography, we can define the direction of the vessel and calculate the Doppler shift together with angle incidence with better estimate of velocities. TCCD may better define the exact site of the junction of the two verterbral arteries and the origin of the basilar artery, allowing a better identification of this part of the vertebrobasilar system, often the site of abnormality. TCCD can also solve the problem of inverted direction of flow due to tortuosity of vertebral artery, allowing vision of the whole artery course. Recently we experienced contrast-enhanced TCCD both in vertebrobasilar and MCA study: this method allows complete vision of intracranial arteries overcoming the difficulties of insufficient temporal bone window and a deeper and clearer identification of vertebrobasilar system. With contrast-enhanced TCCD we were able to identify intracranial stenoses in seven patients (4 vertebrobasilar, 3 MCA). This finding was confirmed by digital arteriography.

R. Manara, C. Baracchini, S. Marengon, C. Carollo and G. Meneghetti Department or Neurological Sciences and Neuroradiology, University of Padova, Padova, Italy Internal carotid artery dissection occurs either spontaneously or post-traumatically and is not an uncommon cause of carotid occlusion, since highly sensitive and noninvasive tools such as cervical MRI, MRA, duplex color flow and transcranial doppler sonography are available and allow not only the diagnosis, but also the monitoring of its natural course. We report two cases of unilateral and bilateral carotid artery dissection preceded by a definite infection (a pharyngitis and a flu-like syndrome, respectively) within one week of stroke onset. Both patients were investigated by computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), duplex color flow and transcranial doppler sonography (TCD). In the first patient we observed a complete recanalization of the internal carotid artery with regression of neurological symptoms and signs. In the second patient the ultrasound followup revealed a complete recanalization in one carotid artery with partial clinical recovery and a persistent occlusion in the contralateral vessel. We emphasize the pivotal role of MRI and ultrasound in the diagnosis and follow-up of acute internal carotid artery dissection and suggest that an infection may act as a trigger factor.

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9 Springer-Verlag 1998

HEPARIN IN CEREBRAL ISCHEMIA

SIGNAL TRANSDUCTION PATHWAYS OF NEURONAL INJURY

S. Manzoni, A. Gasparotto, A. Villacara, L.C. Bergamo, R. Busato, E. Scapolo, A. Lovascio Neurological Division, General Hospital Camposampiero (PD), Italy

P.D. Piraino Institute of Thoracic and Cardiovascular Surgery and Biomedical Technologies, General Hospital "Le Scotte", Siena, Italy

Among the patients with cerebral ischemia admitted in our hospital in the period March 1997-March 1998, 21 were treated with heparin i.v. in acute after a CT scan ruled out hemorrhagic stroke. No bolus was used, and heparin infusion was adjusted to maintain PTT twice basal value. Heparin infusion was maintained until clinical resolution or stabilization. Afterwards all patients were put on therapy with oral anticoagulant or antiaggregant drugs. At least a second cerebral CT scan was performed on each patient during hospitalization. All patients underwent Doppler examination of supra-aortic arteries, a complete cardiological evaluation, and selected cases were studied with transesophageal echocardiography. Functional neurological impairment was measured using Unified Neurological Stroke Scale (UNSS) both at admission and at patient discharge. No sustantial worsening or complications were observed in any case; even in 3 patients in which a further cerebral CT scan showed some degree of hemorrhagic infarction, no clinical worsening was evident. Complete recovery was reached in 8 patients while in other 8 cases recovery was partial. In 2 patients in which neurological imimpairment was very heavy at admission and the first cerebral CT scan suggested precocious signs of massive iscbemic damage, no clinical improvement was observed. In 1 case full recovery was gained in 48 hours, and a following CT scan remained normal: the patient was then classified as having had a reversible ischemic attack. In 2 patients, the choice of heparin i.v. therapy was taken because of subsequent transient ischemic attacks. UNSS was normal at admission, no more TIAs were observed after starting therapy. Conclusions: 1. No clnical progression was verified; 2. No systemic hemorrhages or cerebral hematoma were observed. 3. No definite criteria can help to distinguish cases potentially evolving hemorrhage. 4. Patients showing heavy neurological impairment at the beginning, with tomografic images suggesting extensive cerebral ischemic damage, do not benefit from anticoagulant therapy i,v.

It is now clear that modulation of particular signal transduction pathways in the CNS can profoundly influence the extent of neuronal degeneration following injury. For example, the therapeutic window for the treatment of cerebral ischemia is narrow, less than 10 hours, and requires rapid reversal of the toxic cellular events. Although the core of an ischemic insult suffers from loss of cerebral blood flow and metabolism, the penumbral zone, i.e., the region surrounding the ischemic core, is characterized by decreased blood flow and patchy areas of hypermetabolism. Protection during neuronal injury also is thought to be a result of preserving calcium homeostasis. Yet, subsequent neuronal degeneration appears to be ultimately dependent on nitric oxide (NO) pathway. Generation of NO, by a mechanism that may require intracellular calcium release, can lead to the death of neurons. During neurodegenerafion, agents that decrease PKC activity can prevent neuronal damage. Inhibition of PKC activity also has been shown to protect neurons during periods of glutamate and kainate toxicity. In addition, we have demonstrated that modulation of PKC activity and PKA activity is protective against both anoxia and NO exposure in primary hippocampal neuronal cultures and that these signal transduction pathaways mediate, at least in part,the protective effects of bFGF and EGE NO production also has been linked to neuronal death that occurs with cerebral injury. NO, a free radical, has recently been shown to decrease neuronal survive. NO is generated from the enzyme nitric oxide synthase (NOS) and has a half-life approximately 30 s. NOS oxidizes the substrate L-arginine to yield NO and citrulline. NO also modulates the short-term effects of excitatory amino acids on brain development, learning, and memory. Studies have documented reduction in glutamate neurotoxicity in cortical and hippocampal neurons by the addition of inhibitors of NO production. NO also has been implicated as a mediator of neurodegenemtion during in vivo models of cerebral ischemia. In addition, we have shown that NO contributes to anoxic death and that peptide growth factors are protective against NO toxicity.

PRINCIPLES OF SWALLOWING REHABILITATION IN PATIENTS WITH STROKE: AN UPDATE

INTERNAL CAROTID ARTERY DISSECTION AFTER VIRAL RESPIRATORY INFECTION AND SPONTANEOUS RECANALIZATION

M. Piemonte, S. Palma, M.G. Rugiu, E. Cavallo, M. Zanellato U.O. O.R.L., Hospital S. Maria della Misericordia, Udine, Italy Cerebrovascular disease and ischemic stroke often raise important swallowing problems mainly due to the anatomo-functional impairment of oral and pharyngeal components and to the central nervous regulation of deglutition. Site and extension of ischemic disease bear the utmost importance in this field, while a good general psychophysical condition of the patient seems less important with reference to swallowing post-ischemic impairment but very important for a faster and easier recovery of deglutition. A spontaneous compensation of functional damages usually occurs within some time in many patients, but a timely swallowing rehabilitation can improve and quicken the recovery of the patients with obvious clinical, psychological and economical advantages. Since 1989, at the E.N.T. Department. of Udine Civil Hospital (Italy), the swallowing rehabilitation program has followed: (a) an attentive evaluation of swallowing function and of the causes of dysphagia; and (b) the information and active involvement of the patient in the rehabilitation program. Only then a personalized swallowing rehabilitation program is activated, which is usually timed in four phases: general preparation of the patient and his apparatuses, learning of a new voluntary swallowing reflex, learning of a new involuntary swallowing reflex, strengthening and stabilization of the new swallowing mechanism. Indications, different techniques and results of the rehabilitation program are presented and discussed. The authors underline the importance of a timely and correct rehabilitation program of swallowing in dysphagic patients after stroke by personalized treatment, which actually offers the best chances of a good and often successful functional recovery of the patient.

lschemia Excitatoryamino acid release Cellular calcium influx Protein kinase C Nitric oxide synthase activation Nitric oxide Protein Kinase C Cell death

G. Pistollato, M. Masato Neurology Operating Unit, Department of Neurological Sciences, Hospital of Mestre, Mestre, Italy Extracmnial internal carotid artery (ICA) dissection is an uncommon cause of cerebral ischemia. Some cases are associated with cervical trauma or have evidence of an underlying vascular disease; many occur without any history of injury or detectable arterial disease. We describe a case of a 52-year-old male patient who developed a dissection of ICA at the conclusion of an acute febrile illness reaching 39~ with coryza, sore throat, hoarseness, cough, myalgia and malaise, and diagnosed as viral infection of respiratory tract. He suffered a TIA characterized by aphasia and right-side motor deficit with partial regression after a few minutes and complete recovery within two hours. EEG showed bilateral and synchronous discharges of slow waves without focal activities. An echo Doppler demonstrated a patent left carotid bifurcation and proximal ICA with short systolic flow signal and tapering of ICA lumen distal to the bulb; TCD highlighted a clear reduction of left MCA flow, an inversion of left ACA signal and an increased flow in the anterior communicating artery. Posterior communicating artery was not activated. A digital venous angiography did not confirm the picture and 20 days after the onset of the disease a traditional angiography showed a high-grade stenosis of left ICA three centimeters after the bifurcation; distal portion of ICA was very narrow up to one centimeter from the carotic hole, where a dilation was present. No atherosclerosis risk factors nor coagulation disorders were present. One year later, echo Doppler and TCD showed a normalization of left ICA district flow. Two years after the onset of TIA, MR angiography confirmed the recanalization of ICA, with only a little reduction of internal lumen. MRI excluded parenchymal damage and EEG was normal. After five years, the patient enjoys good health. The reason of interest of this case is the possible role of a viral infection in the pathogenesis of arterial dissection and the confirmation of frequent spontaneous recanalizations in comparison with the different evolution of carotid atherosclerotic lesions.

9 Springer-Verlag 1998

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TRAUMATIC THROMBOSIS OF INTERNAL JUGULAR VEIN WITH TAPIA'S SYNDROME

ISCHEMIC STROKE IN YOUNG ADULTS: A RETROSPECTIVE ANALYSIS OF 43 CASES

G. Pistollato, M. Haefefe, C. Ravenna Neurology Division, Mestre Hospital, Mestre, Italy

A. Rinaldi , P. Dolso , M. Zamagni, G.L.Gigli Neurology and Neurophysiopathology Operating Unit, Hospital S. Maria della Misericordia, Udine, Italy

Tapia first described in 1905 a syndrome characterized by paralysis and wasting of the tongue, ipsilateral paralysis of the vocal cord and sometimes involvement of the sternocleidomastoid and trapezius muscles or of the cervical sympathetic nerves (Homer's Syndrome). The syndrome is due to a lesion of the 12th and 10th cranial nerve below the inferior ganglion. The commonest cause is trauma behind the angle of the jaw. We report the case of a 50-year-old male without any atherosclerosis risk factors. He abruptly complained of a neuralgic pain between the left outer ear and the base of the tongue, two days after supporting heavy pieces of furniture on his shoulders, bending his head sideways. Five days later he developed a poor control of tongue movements and a slight left palpebral ptosis. Neurologic examination showed a deficit of left hypoglossal and vagus nerves, associated with an ipsilateral palpebral ptosis indicative of cervical sympathetic nerve involvement and extracranial localization of the disease. ACT scan identified an annular filling defect of the left internal jugular vein, like an inside wall thrombus. No brain parenchymal damage was detectable. MR angiography showed no visualization of left transverse, and part of sigmoid and petrous venous sinuses; jugular vein was not visible except for a faint laminar flow signal. Neurotogic signs recovered slowly over two months. Six months later a second MRA showed the persistence of previous findings. Brain MR][was quite normal again. A two-time symptomatology characterized the clinical course: initial trauma was followed by an asymptomatic period and, two days after, palpebral ptosis and cranial nerves paresis came out. This evolution resembles the one often seen in arterial dissection. The most acceptable hypothesis is that traumatism injured the jugular vein with endothelial damage and a consequent endovascular thrombosis; a progressive parietal edema and perhaps a venous engorgement may have determined little by little an involvement of cervical sympathetic and cranial nerves on the site described by Tapia's first report. In the case, a second reason of interest is represented by the remarkable diagnostic accuracy recent imaging tecniques have reached.

RECOVERY FROM APHASIA: A STUDY OF 58 PATIENTS U. Raiteri, R. Rissotto, L. Bosia, G. Regesta Department of Neurology, San Martino Hospital, Genoa, Italy Fifty-eight aphasic patients (28 men, 30 women, mean age 64.8 years) with left hemispheric vascular lesions were assessed by an extensive language battery (Aaehener Aphasic Test) two weeks after the stroke. Sixteen patients had global aphasia, 20 Wemicke aphasia, 6 Broca aphasia, 14 amnestic aphasia. Two patients could not be classified within the traditional syndromes. A total score as performance index was calculated, summing the single scores of the five sub-tests (the items of spontaneous language were not considered). All patients were treated with intensive language therapy. A second assessment was performed after an interval of 4-6 months (mean, 5.5). The extent of recovery (calculated as the difference between the first and second scores) was age-correlated but did not show any correlation with the length of the interval between the two assessments. Furthermore, it was higher in patients with Wernicke and Broca aphasia. None of the partial scores of the five sub-tests (Token Test, Repetition, Written Language, Denomination, Comprehension) improved significamiy in comparison with the other ones. The possible prognostic role of the site of the lesion has also been evaluated.

Ischemic stroke in young adults is uncommon; its etiologies and prognosis are different from those verified in the cerebrovascular disease of old age. Atherothrombotic stroke is only 33% and the origin remains unknown or undeterminated in almost onethird of cases. A specific diagnostic protocol for a pathogenetic and etiological determination is useful in these patients. We retrospectively studied 43 patients (22 females and 21 males aged 26-45 years) hospitalized for ischemic stroke identified with computed tomography or magnetic resonance, between January 1994 and May 1998. The standard diagnostic protocol included: laboratory tests (with coagulation and immunological studies), ECG, echo-Doppler, neuroimaging in all patients and additional exams in selected patients (trans-thoracic and trans-esophageal echocardiography, MR-angiography, angiography, transcranial Doppler). Thirty-eight patients were evaluated in a 1-53 month follow-up period. Cases were classified into four groups: 13 atherothrombotic (30.2%), 5 cardioembolic (11.6%), 11 of other determined etiology (25.6%), and 11 of undeterminated origin (25.6%). In 3 patients (7%), the etiology remained unknown. Outcomes (Glasgow Outcome Scale) were favorable: 39.4% of patients reported severe or moderate disability and 57.8% were not disabled. In one case the stroke was fatal. Recurrent stroke occurred in 2 patients with successive good recovery. It is important for a correct etiopathogenetical evaluation to define a specific diagnostic protocol for young patients because of the specific therapeutic possibilities and remarkable recovery. The high percentage of unidentified origin of ischemic stroke confirms the importance of further studies about etiological mechanisms.

PHYSIOTHERAPIST INTERVENTION IN THE HOME MANAGEMENT OF STROKE SURVIVORS G. Saccavino Physiatry Rehabilitation Unit South, I.M.F.R. Gervasutta Hospital, Udine, Italy Reduction in number of beds and hospitalization time, following the revision of national and local health planning - in a more general level-based action - will aim more than in the past at the early discharge of stroke patients to their families. Literature on the matter emphasizes the active presence of family members in the recovering of the hemiplegic patient. Wrong involvement of relatives and home care assistants after discharge would compromise on the medium- and long-term results, which have been established during the rehabilitation process. This could cause important economic loss in the health management and community. Apart from the re-education techniques used, the physiotherapist is always a basis that can be referred to. He is able to inform/educate relatives adopting caring roles, because of his good clinical and personal patient's acquaintance. To get a better idea of the relationship between rehabilitating personnel and families of stroke patients, a voluntary and anonymous questionnaire was given to the physiotherapists working in some medical facilities of Friuli Venezia Giulia (northeastern Italy). 117 questionnaires were obtained (some were not completely filled out). The most important questions were in regard to: (a) presence/absence of specific physiotherapist's education in managing stroke patients (89.5% positive answers), (b) importance of involving relatives in the rehabilitation process (99.1% positive answers), (c) level of intervention towards the families (73.6% declare a whole and complex intervention, 23.6% offer verbal information and 2.8% delegate others to perform the task). Co-operation from families was finally tested (a hyper-protective attitude seems to prevail). In spite of these results, a more profound analysis of the received data reveals contrasting perception that raises doubts about the effect of a poorly verified and codified approach towards the families receiving patients with stroke outcome at home.

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9 Springer-Verlag 1998

SPEECH REHABILITATION IN APHASIC PATIENTS: EXPERIENCE OF THE APHASIA CENTRE AT THE E.N.T. DEPARTMENT OF UDINE CIVIL HOSPITAL

THE NEUROLOGICAL OUTCOME AFTER A FIRST-EVER STROKE IN DIABETIC SUBJECTS WITH SILENT BRAIN INFARCTIONS

E. Sandrin, D. Morassi, M.G. Rugiu, M. Pescatore, M. Piemonte Aphasia Center U.O. O.R.L., Hospital S. Maria della Misericordia, Udine, Italy

A. Seneghini ~, G. Regesta', T. Regesta', G.A. Ottonello z, A. De Michel?. E, Corti4 ' Departments of Neurology, -'Neurophysiopathology, 'Diabetology, and ~Cardiology, San Martino Hospital, Genoa, Italy

Speech rehabilitation is a demanding challenge in any phoniatrics department, both for otolaryngologists/phoniatricians and for speech therapists. At the Aphasia Centre of E.N.T. Department, Udine Civil Hospital (Italy), in the 1980-1997 period, 831 patients suffering speech problems underwent standard language examinations: 721 (86.7%) resulted aphasic and I I0 (13.3%) non-aphasic. Cerebrovascular accidents were the first cause of aphasia, in 632/721 patients (87.7%), while other causes of aphasia were cranial traumas (54, 7.5%), CNS tumors (17, 2.3%) or any other pathology (18, 2.5%). The highest aphasia rate was observed in patients aged 65-74 years (249 cases, 34.5%), followed by patients aged 55-64 years (153, 21.2%) and 75-84 years (i23, 17%). The patients got in touch with the Aphasia Centre mainly thanks to Neurology departments in 336/721 cases (46.6%) or Rehabilitation departments in 141/721 (19.6%), but in 131 cases (18.1%) they were referred to the speech rehabilitation centre by their general practitioner. Overall, 241/721 aphasic patients (33.4%) underwent speech rehabilitation with personalized treatment, in orcler to overcome the comprehension barrier between patient and therapist. Some different rehabilitation techniques and results are presented and discussed, mainly underlining how difficult the objective results evaluation is in the speech rehabilitation of aphasic patients

ACUTE PSEUDOBULBAR SYNDROME: CLINICAL EVALUATION AND DIAGNOSTIC REHABILITATIVE MANAGEMENT OF A CASE F Schiavd, A. Rinaldi ~, E. Del Zotto', P. FilF, M.G. Rugiu:, GL. Gigl? ~Neurotogy and Physiopathotogy Operating Unit, and :Otorhinolaryngology Opertating Unit, Phonetics Centre, Hospital S.M. della Misericordia, Udine, italy Pseudobulbar syndromes are determined by bilateral interruption of cortico-bulbar tracts, caused usually by vascular isehemic events, sometimes subclinical, which typically have a subtle and progressive course. We describe a patient who developed acute onset anarthria and absolute dysphagia, without other motor deficits in musuolar districts outside those controlled by cranial nerves. The clinical symptoms were provoked by an acute ischemic subcortieal parietal stroke: a similar event had occurred three weeks before on the other hemisphere, causing onIy slight symptoms and signs and with complete clinical recovery. We discuss the particular examinations performed for diagnosis (videofluoroscopy) and techiniques used for rehabilitation of speech and swallowing.

Silent brain infarcts (SBIs) are asymptomatic infarcts detected by CT and/or MRI imaging. The data concerning the relationship between diabetes mellitus (DM), one of the most important risk factors for stroke, and SBIs are contradictory, and the matter is still under debate. In our previous studies, a statistically significant relationship was found between diabetic state (history of DM plus the cases defined during the hospital stay) and presence of SBIs. The role of the unknown DM on the neurological outcome was also evaluated. The aim of the present study has been to investigate the role of the two associated conditions (SBIs and DM) on the final neurological outcome in a consecutive series of patients admitted to the Stroke Unit for a first-ever ischemic stroke. The statistical method used was multiple linear regression. Independent variables were hypertension, diabetic condition, SBIs, and DM plus SBIs. Dependent variable was Scandinavian Stroke Scale at six weeks. The p value resulted significant (p=0.05) for the variable DM (all known diabetic subjects plus the newly diagnosed) and for the subgroup of diabetic subjects with SBIs (p=0.0I). We conclude that DM (when thoroughly defined) constitutes an important risk factor for poor neurological outcome in ischemic stroke patients. Moreover, we are allowed to underline the importance of the combined condition of DM plus SBIs, which seems to represent an important risk factor worsenine the final neurological outcome.

INFLUENCE OF POLYMORPHISM OF ANGIOTENSINCONVERTING ENZYME AND APOLIPOPROTEIN E GENES ON CAROTID WALL THICKNESS IN ASYMPTOMATIC ADULTS M. Tonizzo ~, M. Fisicaro 2, L. Cattin ~, G.M. Danekj, M. Fonda ~, M. VaIenti ~, S. Casagrande', A. Petrucco ~, M. Bovenzi', I
9 Springer-Verlag 1998

PREVALENCE

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AND CLINICAL CORRELATES

CEREBROVASCULAR

DISORDERS

OF PREVIOUS

IN THE GENERAL POPU-

LATION: RESULTS OF THE VITA PROJECT

Backgraund. Limited data are available on the prevalence of previous cerebrovascular disorders (stroke and transient ischemic attacks, TIAs) in the general population.

Aim oJthe study. To evaluate the prevalence of previous cerebrovascular disorders and their clinical correlates in a population-based study.

Methods. We analyzed the data of the VITA (Vicenza Thrombophilia and Atherosclerosis) project, a large epidemiological investigation on the prevalence of thrombophilia in the general population. Caucasian subjects aged 18-65 years were randomly enrolled from the census list. In all participating subjects, a detailed history of previous arterial and venous thrombotic events was collected using validated questionnaires. Anthropometric and laboratory measurements were collected as previously described. Blood samples (plasma and DNA) were stored at 80 ~ C for all subjects. Results. From May 1993 to June 1997, we collected data from 15 109 subjects, 8 017 females and 7 092 males, with a median age of 43 years. The prevalence of previous stroke was 28.7 cases/10 000 subjects; the prevalence of previous TIAs was 42.0 cases/10 000 subjects. The combined prevalence of cerebrovascular disorders was 70.8 cases/10 000 subjects. In a multivariate logistic model, past cerebrovascular disorders were associated with hyperglycemia (p=0.019), increased waist/hip ratio qn<0./)01), increased white blood cell count (p<(l.(101)and with history of venous thromboembolism (p=0.024). Conclusions. This study shows that cerebrovascular disorders may be a common finding even in a young, active population. Given the cross-sectional design of the study, risk factors in the cohort could not be easily identified. These preliminary results form, however, the basis for future, prospective studies.

ROLOGICALLY

WELFARE

COURSE

POTENTIALS

OF CORTICAL

SOMATOSENSORY

TO TIBIAL NERVE IN ISCHEMIC

EVOKED

STROKE

M. Turazzini, R. Bassi, B. Costa, R. Del Colle, M. Silvestri Department of Nemvlogy, City Hospital, LEGNAGO, Verona, Italy

A. Tosetto, M. Frezzato, S. Dal Santo, F. Rodeghiero Hematology Department, S. Bortolo Hospital, Vieenza. Italy

THE REHABILITATIVE

INVOLVEMENT

OF THE NEU-

INJURED PATIENT

A.A. Troisi, l. Quarto. C. De Cesare. M. Sollo Rehabilitation Unit. Cardarelli Hospital, Naples, Italy The Republic Presidential Decree n~ dated 5 October 1994, related to the National Health Plan 1994-1996, classified the rehabilitative welfare centres into: 1. Health services of rehabilitation (hospital and district services); 2. Social-health services of rehabilitation; 3. Social rehabilitative services. In details, the rehabilitative welfare course, in hospital or at home, is shared first in hospital time and after in territorial rehabilitative welfare time. This sharing provides for different financial needs and for the following different hospital rehabilitative services: 9 Intensive Rehabilitative Unit for acute patients (code 56 11 level); 9 Spinal Unit (code 28 [11 level); 9 Cerebral Brain Injured Unit (code 75 III level). The above units mean the rehabilitative services for the treatment of the acute patients with a hospitalization time not exceding 60 days. Furthermore, the patient is deverted into the Rehabilitative District Units of II and I level to complete rehabilitative course. Moreover, the authors intend to develop the more appropriate and actual systems in neurorehabilitalion, in light of the present Prime Ministeral Decree which regulates the health rehabilitative welfare in Italy.

The value of somatosensory evoked potentials (SEPs) in predicting functional recovery in stroke patients has been assessed in several studies. In an attemp to reveal an involvement of the large diameter sensory tracts, most authors have focused their attention on assessment of central conduction time without taking possible alterations in the cortical response into account. A 9-month longitudinal study has been performed on 15 subjects following first-ever ischemic stroke to determine the changes in cortical SEPs to tibial posterior nerve stimulation using multiple scalp derivations. The SEPs were recorded within 1 week, 6 weeks, and 9 months after the onset of the symptoms and were correlated to MEPsl clinical parameters, NIHSS and Barthel index. The main change regarded the latency, the amplitude and the field distribution of the early cortical potentials. In the patients, the presence of these potentials in the acute period or in the first control showed a significant clinical recovery compared to the others. The use of neurophysiological parameters compared with stroke degree of recovery had value in predicting the outcome of disease.