Transcranial Doppler, electroencephalography, and single photon emission computed tomography were performed in a case of basilar migraine during the different phases of the attack. In the aura phase, the patient had bilateral blindness and ataxia. Doppler ultrasound studies showed a reduction in the mean flow velocity of the posterior cerebral arteries, electroencephalography showed slow activity confined to the posterior regions, and single photon emission computed tomography, an area of hypoperfusion in the right parietal and occipital regions. During the headache phase, when the neurological examination was normal, transcranial Doppler showed an increase in the mean flow velocity of both posterior cerebral arteries and the electroencephalogram revealed an increase: in the slow activity over the occipital regions. When the pain subsided, the electroencephalogram showed a progressive reduction of the slow abnormalities and transcranial Doppler was reported as normal. After a week, single photon emission computed tomography and cranial magnetic resonance imaging were normal. After a month, a follow-up electroencephalogram was also normal. All these findings indicated a transient focal reduction of cerebral blood flow during the aura phase. Transcranial Doppler (TCD) is an effective technique for the study of cerebral blood flow (CBF) in patients with migraine. The available data refer to the pain phase and the intericta period. 1,2 The possibility of documenting the CBF variation starting with the aura phase is a rare event limited to cases with prolonged aura. 3 In this case, the data suggest a decrease of CBF in the cortical area responsible for the neurological manifestations during the aura phase.Determinations of regional cerebral blood flow (rCBF) with Xenon-133 during migraine with aura have already demonstrated initial focal hypoperfusion followed by hyperemia. 4 More recently, the use of technetium Tc 99m hexamethyl propylenamine oxime (Tc 99m HMPAO) single photon emission computed tomography (SPECT) in patients with migraine without aura has failed to show evidence of CBF focal alterations. 5 A relative rCBF reduction during migraine attacks might account for the different electroencephalographic abnormalities described in these patients, the meaning of which is uncertain.We performed an EEG, TCD, and cerebral SPECT using Tc 99m HMPAO, during all phases of a basilar migraine attack in order to correlate the focal electroencephalographic abnormalities with the dynamic alterations of the rCBF.In view of the neurological deficit in the aura phase, we evaluated the TCD parameters with respect to the posterior cerebral arteries (PCAs) and compared them with those of the middle cerebral arteries (MCAs). The normal values for mean flow velocity (MFV) suggested by the Italian Society of Neurosonology 6 (PCA 51 to 26 cm/ sec, MCA 76 to 44 cm/sec, pulsatility index [PI] 0.99 to 0.69 cm/sec) were taken into account. CASE HISTORYA 25-year-old woman was hospitalized with complaints of positive scotomata and bilater...

Background and Purpose: Early treatment (i.e. thrombolysis) is crucial for a successful care of ischemic stroke. In the management of stroke, two phases are crucial: the pre-hospital and the in-hospital interval. This work investigated factors influencing pre- and in-hospital delay in a large geographic area of Northern Italy. Methods: Enrolled were patients presenting with ischemic stroke in four administrative districts of Northern Italy (Como, Lecco, Sondrio and Varese) over a 4-month period. Pre-hospital time and in-hospital time with single management steps were recorded prospectively. Age, gender, recruiting hospital, EMS transport and triage codes, clinical severity and thrombolytic treatment were also recorded. Univariate and multivariate analysis of factors predicting pre- and in-hospital delay were performed. Results: Median pre-hospital time and in-hospital time were, respectively, 120 min (interquartile range, IQR 62-271) and 150 min (IQR 80-214). Pre-hospital time was halved in patients hospitalized via EMS (p < 0.001) and clinically more severe (p < 0.001). At multivariate analysis, transport code was associated with delay at any time (p < 0.05). Conclusions: EMS use and transport code predicted treatment delay in patients with ischemic stroke. A more intensive use of EMS and high urgency codes could help increase the number of stroke patients treated appropriately.

The objective of this study was to assess the efficacy and safety of Gabapentin as the sole analgesic in patients with HIV-related painful neuropathy. Nineteen patients with HIV-related painful neuropathy were administered Gabapentin. Efficacy was evaluated with two 100-mm Visual Analogue Scales (VAS) (0: no symptom; 100: worst symptom), rating pain and interference of pain with sleep, performed at baseline and monthly intervals. Main Pain VAS score decreased from a baseline of 55.7 +/- 19.1 mm to a final 14.7 +/- 18.6 mm (ANOVA P = 0.0001) and mean Sleep Interference VAS score decreased from a baseline of 60.4 +/- 31.9 mm to a final 15.5 +/- 27.7 mm (ANOVA P = 0.0001). Gabapentin provided significant pain relief in our patients with HIV-associated painful sensory neuropathy.

Transcranial Doppler sonography (TCD) was performed in a case of migraine with aura during the different phases of the attack. In the prodromic period our patient showed a slight central deficit of the seventh right cranial nerve and hypesthesia in her right arm. TCD indicated a remarkable decrease of the mean flow velocity (MFV) of the left middle cerebral artery (MCA). During the headache phase and when the signs and symptoms subsided, TCD showed an increase in MFV of both middle cerebral arteries with normal symmetry. An electroencephalogram (EEG) demonstrated a left temporal disorder. A month later a cranial CT scan, an EEG, and TCD were normal. In our opinion all these findings suggest a focal reduction in cerebral blood flow in the prodromic phase.

Stroke is the leading cause of disability in adulthood, and the principal aim of care in cerebrovascular disease is the reduction of this negative outcome and mortality. Several studies demonstrated the efficacy of thrombolytic therapy in ischemic stroke, but up to 80% of cases could not be treated because the diagnostic workup exceeds the time limit. In this article, we described the design of a study conducted in the northern Lombardy, within the district of Sondrio, Lecco, Como, and Varese. The awaited results of this study are reduction of avoidable delay, organization of an operative stroke emergency network, and identification of highly specialized structures. The study schedules education and data registration with implementation and training of acute stroke management algorithms. The use of standardized protocols during prehospital and in-hospital phase can optimize acute stroke pathways. The results of this study could contribute to the assessment of an effective and homogeneous health system to manage acute stroke.