Abstract Background The Boston Criteria v2.0 represent the gold standard for diagnosing Cerebral Amyloid Angiopathy (CAA), but their application is currently precluded in mixed small vessel disease (SVD), where deep and lobar hemorrhages coexist. The aims of this study are: (i) to determine which cerebrospinal fluid (CSF) biomarker (Aβ42, Aβ40, Aβ42/40 ratio) is the best candidate to support the CAA diagnosis; (ii) to define a data-driven cut-off, and (iii) to explore if a biomarker-integrated classification significantly improves the phenotypical concordance with the suspected predominant SVD (CAA vs. arteriosclerosis). Methods We analyzed data from a retrospective multicenter cohort of patients with suspected CAA, defined as probable CAA (Boston criteria v2.0) but allowing deep hemorrhagic lesions, and with available CSF biomarkers. We visually quantified MRI-visible SVD markers (e.g., cerebral microbleeds [CMB], cortical superficial siderosis [cSS], lacunes) and their association with MRI-visible SVD features. We employed a Gaussian Mixture Model (GMM) to identify a data-driven threshold for amyloid positivity (A + ). Then, we compared the prevalence of MRI-visible manifestations of SVD between subgroups applying different frameworks, namely the current MRI-based classification (probable CAA vs. mixed SVD) and a CSF biomarker-integrated classification (A + vs. A - ). Results We enrolled 121 patients (age: 72 [66-77] years; 60% probable CAA, 40% mixed SVD with suspected CAA). The CSF Aβ42/40 ratio showed a bimodal distribution and consistent associations with all CAA-specific radiological features. The CSF biomarker-integrated reclassification, particularly using the GMM cut-off, significantly improved the distinction between subgroups regarding CAA- and arteriosclerosis-related MRI features (e.g., cSS presence: probable CAA vs. mixed SVD: aOR=2.84 [95%CI 1.27-6.39], p=0.011; A+ vs. A-: aOR=12.68 [95%CI 4.31-37.32], p<0.001; deep lacunes presence: probable CAA vs. mixed SVD: aOR=0.20 [95%CI 0.08-0.50], p<0.001; A + vs. A - : aOR=0.04 [95%CI 0.01-0.11], p<0.001). Notably, patients classified as A + never demonstrated more than four deep CMBs. Discussion A CSF biomarker-integrated classification may improve the classification of CAA compared with the current MRI-based framework. These findings are cohort-specific and would benefit from further validation, especially with a neuropathological reference. Still, these results support a future transition toward an integrated biological-radiological framework, which may refine in vivo CAA diagnosis, particularly in mixed SVD.

BACKGROUND AND AIMS:Hereditary transthyretin amyloidosis (ATTRv) is a multisystemic disease where early neuropathy signs are challenging to detect conventionally. This study aimed to evaluate hand motor performance in ATTRv using the Hand Test System (HTS) across disease stages and examine correlations with standard measures. METHODS:A total of 113 individuals were enrolled: 74 patients with ATTRv (divided according to Familial Amyloid Polyneuropathy [FAP] stage into FAP0: pre-symptomatic with confirmed TTR mutations, n = 16; FAP1: mild sensory/motor symptoms, n = 40; FAP2: ambulatory with assistance, n = 18) and 39 healthy controls. All participants underwent HTS evaluation; 9-Hole Peg Test (9HPT); handgrip and tripod pinch strength testing; Thumb Opposition Test (TOT); Neuropathy Impairment Score (NIS); Disabilities of the Arm, Shoulder and Hand questionnaire (DASH); and Quality of Life Diabetic Neuropathy (Norfolk QoL-DN) questionnaire. Group differences were analyzed with analysis of covariance and correlations with Pearson's coefficients. RESULTS:HTS parameters (Touch Duration, Inter-Tapping Interval, Movement Rate) significantly differed across stages between the FAP2 and all other groups, with some parameters distinguishing the FAP1 from the control and FAP0 groups. 9HPT impairment was observed only in the FAP2 group. Grip strength showed subtle changes, especially in the right hands of the FAP1 group, while tripod pinch strength declined during advanced stages. Several HTS parameters were correlated with NIS, DASH, Norfolk QoL-DN, and hand strength. Subclinical carpal tunnel syndrome possibly influenced early-stage results. INTERPRETATION:HTS detected stage-related motor differences in ATTRv and correlated them with standard measures, offering increased sensitivity to early neuropathic changes.

Amyotrophic Lateral Sclerosis (ALS) phenotyping is a challenging task due to its heterogeneous nature and low prevalence. In this paper, we introduce a data-driven approach to support the characterization of ALS phenotypes based on clinical data from a battery of examinations. A consensus clustering method is proposed to identify stable clusters across multiple random data sub-samples, with the objective of discovering whether the retrieved patients' groups and related features align with clinical phenotypes and medical knowledge. Results suggest consistent profiles for bulbar onset ALS patients, driven by onset characteristics, whereas spinal onset ALS patients exhibit greater within-phenotype heterogeneity.

Background and Objectives:Biallelic intronic repeat expansions in the replication factor C subunit 1 (RFC1) gene are a common cause of cerebellar ataxia, neuropathy, vestibular areflexia syndrome and other late-onset ataxias. Recent evidence suggests a broader phenotypic spectrum. This systematic review and meta-analysis evaluated the prevalence and features of motor neuron, extrapyramidal, and cognitive involvement in RFC1 disease. Methods:We systematically searched PubMed, Scopus, and Web of Science for studies reporting motor neuron, extrapyramidal, or cognitive involvement in RFC1 disease from inception to March 2025. Eligible sources comprised research articles and case reports/series on genetically confirmed cases. Extracted data included publication details, study design, location, and individual participant data (IPD) covering demographics, signs, and symptoms. When needed, IPD were obtained from corresponding authors. Random-effects models were used to estimate pooled prevalences (95% CIs). Univariable mixed-effects logistic regression accounted for clustering within studies, with multivariable models including variables with p < 0.10 in univariate analyses. Results:Of 729 articles, 37 were included in the systematic review and 36 (874 patients) in the proportion meta-analyses. For IPD meta-analysis, 30 cohorts provided data on 312 patients (mean age 66.91 ± 10.76 years; median disease duration 12 [interquartile range 7-18] years; 51.5% male). Upper and lower motor neuron signs were present in 18% (95% CI 6%-34%) and 11% (95% CI 2%-24%). Patients with the ACAGG pentanucleotide repeat expansion (biallelic or compound heterozygous with an AAGGG expansion) had higher odds of muscle atrophy (OR 17.90, p 0.001) and weakness (OR 11.69, p 0.001); men had an increased likelihood of muscle atrophy (OR 2.71, p = 0.038). The pooled prevalence of parkinsonism and cognitive impairment was 8% (95% CI 1%-18%) and 31% (95% CI 13%-53%), with prominent executive-attention deficits. Cognitive decline was more likely with longer disease duration (OR 1.04, p = 0.047) and in biallelic AAGGG carriers vs ACAGG (ACAGGexp: OR 0.13, p = 0.041). Discussion:Motor neuron, extrapyramidal, and cognitive involvement may extend the phenotypic spectrum of RFC1 disease. Still, their true prevalence remains uncertain due to heterogeneity across studies, with potential overestimation from publication bias favoring atypical cases and underestimation when subtle signs are not systematically investigated. Larger multicenter cohorts with standardized assessments are needed to clarify their clinical relevance.

Objectives. Despite the body of literature on genetic risk factors for dementia, little is known on protective genetic factors associated with favourable cognitive ageing in the oldest population. In Europe, Italy has a leading position with a swelling population of centenarians, and the urban area of Genoa in the Liguria region has one of the highest prevalence of centenarians. The COOL study is a not-for-profit, multicentric study involving a cohort of centenarians (aged >99) living in the Genoa area. The ultimate aim is the identification of genomic biomarkers associated with cognition in the oldest old population. Results. Participants underwent a semi-structured interview on personal, disease and family history, and a neuropsychological assessment of the main cognitive domains. As of July 2025, we enrolled 88 centenarians (age range: 99-108, median 100.56) with and without cognitive impairment; 32 subjects were followed up. All participants were of Italian ancestry, 81% were female. The cognitive profile in assessed subjects showed a wide range of cognitive health measures (CDR 0-5; MMSE 3-30, median 24). Whole peripheral blood and DNA samples from 67 participants were stored. Conclusions. We demonstrated that the protocol is feasible, and acceptable by participants and their families. A comprehensive phenotype dataset was established, and DNA samples were stored. Centenarians exhibited a broad spectrum of cognitive profiles, from preserved cognition to severe dementia. These findings will eventually allow to interpret the profiles of genomic variants as associated with variability of cognitive performance in centenarians. The molecular underpinnings of healthy cognitive ageing could inform health policy strategies in the general population. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The COOL project was partially funded by the Galliera Hospital (EO Ospedali Galliera, fondo Sper 41). EM is a fellow of the Department of Health Sciences, University of Genoa, supported by the fund 'donazioni per ricerca scientifica su coronavirus', University of Genoa. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was approved by the Local Ethics Committee (Comitato Etico Territoriale, Regione Liguria, approval ID CER Liguria 91/2021). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data that support the findings of this study are available from the corresponding author upon reasonable request. University of Genoa, https://ror.org/0107c5v14, fund “donazioni per ricerca scientifica su coronavirus”, Department of Health Sciences Ente Ospedaliero Ospedali Galliera, https://ror.org/05bs6ak67, fondo Sper 41

IntroductionImmune checkpoint inhibitors have markedly improved outcomes in advanced malignancies by enhancing antitumor immunity, but they may also disrupt immune tolerance and induce immune-related adverse events involving multiple organs; among these, the overlap of myositis, myocarditis, and Myasthenia Gravis (triple-M syndrome) represents a rare but potentially fatal condition with limited evidence guiding its management.MethodsWe performed a systematic review of case reports and case series published until July 2025 to describe the clinical characteristics, diagnostic findings, treatments, and outcomes of patients developing triple-M syndrome after immune checkpoint inhibitor therapy.ResultsThe syndrome typically occurred early after treatment initiation and presented with rapidly progressive and heterogeneous features, including ocular and bulbar symptoms, muscle involvement, and cardiac manifestations; diagnosis was often challenging due to low sensitivity of routine tests, variable antibody positivity, and limited feasibility of advanced investigations, making clinical suspicion crucial. High-dose corticosteroids were the most frequently used first-line treatment, often combined with intravenous immunoglobulins or plasma exchange, although steroid monotherapy was associated with clinical worsening in some cases; emerging therapies, including targeted monoclonal antibodies and next-generation immunomodulatory agents, have the potential to provide more rapid and effective disease control. Overall prognosis remains poor, with high rates of respiratory failure, severe complications, and oncologic progression following treatment discontinuation. Triple-M syndrome is a severe and under-recognized complication requiring early diagnosis and prompt multidisciplinary management, and further studies are needed to improve diagnostic strategies and optimize treatment while preserving oncologic benefit.

Background and Objectives:Anesthetic management for Charcot-Marie-Tooth disease (CMT) is still controversial and source of concerns for both anesthetists and patients. We explored the frequency of self-reported complications following anesthesia in a large cohort of patients with CMT compared with unaffected controls. Methods:We administered an online ad hoc questionnaire to patients enrolled in the Italian CMT Registry and to unaffected controls. The questionnaire collected self-reported adverse events following any anesthetic procedure undergone during the participants' lifetime. Anesthetic procedures were categorized as general anesthesia (including endotracheal intubation or deep sedation), central neuraxial anesthesia (epidural or spinal anesthesia), and peripheral regional anesthesia (plexus or peripheral nerve blocks). Results:Overall, the questionnaire was completed by 290 patients with CMT (160 female patients; mean age 47.8 ± 13.1 years) and 94 controls (46 female patients; mean age 47.5 ± 13.2 years), and a total of 508 and 161 procedures, respectively, were analyzed. The rate of self-reported complications following general, central neuraxial, and peripheral regional anesthesia did not differ between patients with CMT and controls. All reported events in the CMT cohort were transient and fully resolved, with a favorable anesthetic outcome in all cases. Demyelinating CMT subtypes were not more likely to report complications than axonal subtypes. Moreover, experienced complications following anesthesia for cesarean delivery occurred with similar frequency in patients with CMT and controls. Discussion:Anesthesia-related complications are not reported more frequently in patients with CMT compared with controls. However, longitudinal studies incorporating objective clinical assessments and detailed information on anesthetic agents are warranted.

Background:Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a treatable immune-mediated neuropathy, yet real-world evidence on therapeutic strategies and their evolution over time remains limited. This study aimed to characterise prescription patterns across Italian centres, assess adherence to international guidelines, and identify clinical, structural, and temporal determinants of therapeutic decision-making. Methods:This multicentre, combined prospective and retrospective observational study used data from the Italian CIDP registry, including 653 patients from 24 tertiary centres from 2015 to 2025. Detailed treatment histories were collected for induction and maintenance regimens, including intravenous immunoglobulin (IVIg), corticosteroids, plasma exchange (PE), subcutaneous immunoglobulin (SCIg), and immunosuppressants. A structured questionnaire assessed centre-level factors influencing treatment choices. Findings:Marked inter-centre heterogeneity across all treatment options was observed (p < 0.001). Over time, IVIg and SCIg use increased, while corticosteroids, PE, and traditional immunosuppressants declined. Independent determinants of induction therapy included patient characteristics, treatment period, and treating centre. Lower IVIg induction doses and oral corticosteroids were associated with worse long-term outcomes. Over time, induction response rates, residual disability, and therapy suspension rates improved. Questionnaire data revealed that although guideline recommendations strongly influenced decisions, organisational constraints, local prescribing culture, and patient preferences independently shaped treatment allocation. Interpretation:CIDP management in routine clinical practice is highly heterogeneous and influenced by both clinical and structural factors. These findings underscore the need for standardised, evidence-based, and sustainable treatment pathways to reduce unwarranted variability and ensure equitable access to optimal care as therapeutic options continue to expand. Funding:Grant from Regione Lombardia, Italy; Grant from Ministero della Salute, Ricerca Finalizzata; Kedrion Biopharma (Italy); CSL Behring (Italy); Humanitas Research Institute (Milan, Italy); GBS-CIDP Foundation International (USA).

Peripheral nerve injury induces inflammatory and stress-related remodeling in downstream skeletal muscle before overt atrophy develops, yet non-invasive approaches capable of detecting and anatomically localizing early muscle involvement remain limited. The 18-kDa translocator protein (TSPO), a marker of inflammatory activation and mitochondrial stress, is a molecular target for PET imaging with [1⁸F]DPA-714. This study aimed to determine whether TSPO-targeted PET imaging enables early and spatially resolved detection of denervation-induced skeletal muscle injury distal to a peripheral nerve lesion. Adult mice underwent unilateral sciatic nerve crush. One-week post-injury, static [1⁸F]DPA-714 PET imaging was performed to assess tracer uptake in hindlimb skeletal muscle. Uptake was quantified and compared between injured and contralateral limbs as well as with sham-operated mice. Ex vivo validation included CD68 immunofluorescence, Western blot analysis of TSPO expression, and laminin-based muscle fiber morphometry. [1⁸F]DPA-714 uptake was significantly increased in distal hindlimb of crush-injured mice compared with contralateral and sham models. PET signal was selectively confined to denervated muscle distal to the lesion. Tracer uptake ratio between injured and contralateral hindlimb clearly discriminated crush-injured from sham animals without overlap. Immunofluorescence demonstrated marked macrophage infiltration, Western blot confirmed increased TSPO protein levels, and laminin morphometry revealed reduced muscle fiber size consistent with early atrophic remodeling. TSPO-targeted PET with [1⁸F]DPA-714 enables an early and anatomically selective detection of denervation-induced skeletal muscle injury distal to the nerve lesion, supporting its role as a translational imaging biomarker of peripheral nerve-muscle interaction during acute reversible nerve damage.

Background: Demyelination and remyelination are major issues for scientists dealing with myelin disorders in both clinical and research fields. Despite that, rapid, reliable and convenient tools to monitor myelin changes still lack both in central and peripheral nervous system. Given that myelin is enriched in specific lipids and proteins, it is reasonable they could represent eligible candidates as structural damage biomarkers for this characteristic membrane. Among them, we focused on sphingomyelin (SM) due to the enrichment in myelin and because it is easily measurable in different biological matrices. Objective: Depicting the roadmap to identify and validate SM dosage as a myelin biomarker useful for pre-clinical and clinical practice. Design: This study adheres to STROBE guidelines for observational cross-sectional studies on human patients and to ARRIVE guidelines for animal models. Method: Following the recommendations of the Society for CSF Analysis and Clinical Neurochemistry, we describe the stepwise process to validate SM as a myelin biomarker, starting from the optimization of the fluorescence-based assay and analytical validation in experimental models until clinical and pathological validation in biological fluids of neurological patients. Results: SM dosage monitors myelination, demyelination, remyelination and even small myelin changes associated to myelin pathology and pharmacological treatments in experimental models. SM is detectable in human biological fluids and informative of myelin damage in the CSF of neurological patients. SM dosage identifies myelin breakdown in the CSF of patients affected by Guillain-Barrè Syndrome (GBS) and Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP), identifying disease activity, axonal from demyelinating variants, and avoiding misdiagnosis. Conclusion: SM dosage displayed extremely promising real-word performances being able to identify, monitor and stage myelin pathology. Given that it is simple, inexpensive and easily adaptable to routine use in any hospital setting, it might rapidly progress to the implementation and impact on clinical outcomes.

IntroductionRituximab (RTX) is a widely used treatment for anti-MAG polyneuropathy, though standardized maintenance strategies are lacking. We aimed to compare two RTX retreatment protocols: (1) a full course (375 mg/m2/week for 4 weeks) administered at clinical relapse, and (2) a single infusion (375 mg/m2) at reappearance of peripheral CD27+ B cells—to evaluate their impact on disability progression over time.Patients and methodsWe retrospectively enrolled 29 patients with anti-MAG polyneuropathy, dividing them into two cohorts: (1) relapse (n = 19), treated with a full course at clinical relapse, or (2) Kim's protocol (n = 10), treated based on peripheral CD27+ B cell monitoring. Changes in INCAT, MRC sum score, and ISS from baseline to last follow-up were assessed.Results and discussionNo significant changes in MRC scores were observed in either cohort. Both cohorts showed a significant reduction in INCAT scores at last follow-up, with a tendency toward greater improvement in Kim's protocol cohort. ISS scores were significantly lower in Kim's protocol cohort compared to the relapse cohort (p < 0.01). Importantly, patients treated according to Kim's protocol received a cumulative RTX dose ~2.5 times lower than those treated upon relapse (p < 0.0001), despite showing comparable or better clinical outcomes.ConclusionA tailored maintenance strategy guided by peripheral CD27+ memory B-cell monitoring enables reduced cumulative RTX exposure while preserving clinical efficacy. This approach may improve cost-effectiveness and reduce treatment burden in patients with anti-MAG polyneuropathy.

Objectives: Cognitive impairment (CI) is frequently observed in motor neuron diseases (MNDs), and the Edinburgh Cognitive and Behavioral ALS Screen (ECAS) represents the most widely used measure to evaluate it. For the Italian ECAS, two norming approaches are currently available: the "regression-based" (R) and the "2 standard deviation-based" (2SD). In this study, we therefore aimed at comparing those two methods for the detection of CI in MNDs. Methods: Raw ECAS scores from 160 MND patients were corrected using both the R and the 2SD methods. According to Strong's criteria, patients were then categorized as either cognitively normal (CN), with CI (ALSci), with behavioral impairment (ALSbi), or both (ALScbi). Results: Using the R approach, the frequency of below-cutoff performances was 3.12% for the ECAS total, 4.37% for the ALS specific, and 3.75% for the ALS nonspecific score. Using the 2SD method, the prevalence increased to 25.62% for the ECAS total, 21.25% for the ALS specific, and 23.12% for the ALS nonspecific score. The same increase was observed across all single tasks except for the digit span backward. The R-based frequency of Strong's diagnoses was 7.50% for ALSci, 15.62% for ALSbi, and 3.14% for ALScbi, which became 24.38% for ALSci, 8.75% for ALSbi and 10% for ALScbi with the 2SD method. Conclusions: The norming approach has a significant impact on the estimated prevalence of CI in MNDs, with the R method representing the most conservative one. These findings highlight the need for harmonized protocols in future studies evaluating CI in MNDs.

Purpose: The skeletal muscle has been proposed to contribute to the progressive loss of motor neurons typical of amyotrophic lateral sclerosis (ALS). However, this mechanism has not yet been clarified due to the lack of suitable imaging tools. Here, we aimed to verify whether PET imaging of the translocator protein 18 kDa (TSPO) can detect a muscular abnormality in an experimental model of ALS. Methods: In vivo biodistribution and kinetics of [18F]DPA-714 were analyzed in skeletal muscle and brain of SOD1G93A transgenic mice and in wildtype (WT) littermates. Both cohorts were divided into three groups (n = 6 each) to be studied at 60, 90 and 120 days. After microPET imaging, animals were sacrificed to evaluate inflammatory infiltrates by hematoxylin/eosin staining and TSPO expression by immunohistochemistry and Western blot in both quadriceps and brain. Results: [18F]DPA-714 uptake was higher in the skeletal muscles of SOD1G93A than in WT mice in the preclinical phase (60 and 90 days) and further increased up to the symptomatic late stage (120 days). Inflammatory cells were absent in the quadriceps of SOD1G93A mice whose myocytes, instead, showed a progressive increase in TSPO expression with advancing age. By contrast, brain tracer uptake and TSPO expression were comparably low in both groups, regardless of age and genotype. Conclusion: Upregulation of TSPO expression is characteristic of skeletal muscle, but not the brain, in the experimental SOD1G93A mouse model of ALS. Tracers targeting this pathway have been mostly proposed for the evaluation of inflammatory processes within the central nervous system. Nevertheless, the ubiquitous nature of TSPO expression and its responsiveness to various signals may broaden the diagnostic potential of these tracers to include disease conditions beyond inflammation.

Charcot-Marie-Tooth (CMT) disease is the most common hereditary neuropathy, characterized by progressive distal muscle weakness and gait abnormalities, impacting patients mobility and quality of life. Despite efforts to develop effective treatments, pharmacological options remain limited. Evaluation of gait function is crucial for assessing disease progression and treatment efficacy. This study compared the sensitivity of clinical and instrumental outcome measures (OM) in discriminating CMT patients and identifying key spatio-temporal gait parameters and their correlations with clinical measures. Eighteen CMT patients and 18 healthy age-matched subjects (HS) were evaluated using clinical scales and instrumental gait analysis. Clinical measures included the 10 m walk test (10MWT), 6-minutes walk test (6MWT), Berg balance scale (BBS), Short Physical Performance Battery (SPPB), CMT Examination Score (CMTES), and Walk12 scale. Instrumental evaluation utilized the GAITRite electronic walkway system to assess spatio-temporal parameters. Correlations between clinical and instrumental parameters were examined. CMT patients exhibited significantly lower performance in clinical scales compared to HS. Instrumental evaluation revealed significant differences in stride length, velocity, stance percentage, and swing percentage between CMT patients and HS. Correlation analysis demonstrated associations between clinical and instrumental measures, particularly with stride length, gait speed, and balance assessments. The GAITRite system demonstrated sensitivity in discriminating CMT patients and controls, highlighting gait abnormalities consistent with previous literature findings. Correlations between instrumental and clinical measures suggest potential for objective gait assessment in CMT management. Further research with larger cohorts is warranted to validate these findings and assess longitudinal gait changes in CMT.