BACKGROUND:The sleep-wake cycle and the autonomic nervous system (ANS) can be impaired in neurodegenerative diseases. OBJECTIVES:To describe sleep-wake cycle and circadian rhythms of body core temperature (BcT) and cardiovascular parameters in Progressive Supranuclear Palsy (PSP). METHODS:We prospectively recorded 48 hour video-polysomnography, BcT and blood pressure (BP) in 14 PSP patients (disease duration 5.9 ± 2.6 years) under controlled environmental conditions. We analyzed wake-sleep parameters and state-dependent modulation for BcT, BP and heart rate from the last 24 h of recording. Twelve healthy younger controls were used for comparison. RESULTS:Patients slept less than 5 hours/night with frequent awakenings, daytime naps were shorter than 60 minutes and mainly represented by light sleep resulting in a 24 h sleep deprivation. Patients with PSP slept less compared to younger controls and normative values for age. Only two patients reported excessive daytime sleepiness. There were no significant differences in sleep parameters according to the presence of sleep disorders. Compared to controls, patients showed significantly higher BcT values during wake and sleep. Twelve patients presented an abnormal BP pattern at nighttime. CONCLUSION:PSP patients experienced profound sleep deprivation across the 24 h study period. An imbalance between sympathetic and parasympathetic function with sympathetic predominance may be associated with this alteration. Whether this autonomic dysfunction is the primary drive for the sleep-wake cycle disruption or the consequence of sleep loss needs to be elucidated.

Purpose Autonomic dysfunction is a distinctive but undervalued feature of hereditary transthyretin amyloidosis (ATTRv). It may predate the onset of polyneuropathy and cardiomyopathy, thereby providing crucial prognostic and therapeutic information. The objective of this study was to assess autonomic function by means of the standardized cardiovascular autonomic reflex tests (CRTs) in a cohort of subjects with genetically proven ATTRv from non-endemic areas who were in the symptomatic and pre-symptomatic stages. Methods All subjects enrolled in this cross-sectional study had genetically proven ATTRv. They underwent the head-up tilt test, Valsalva manoeuvre, deep breathing test, cold face test and handgrip test while under continuous blood pressure and heart rate monitoring. Based on the results of the nerve conduction study, the subjects were divided into two groups: those with polyneuropathy (ATTRv-wPN) and those without polyneuropathy (ATTRv-woPN). Age- and sex-matched healthy controls (HC) were used for comparison. Results Thirty-seven ATTRv subjects (19 with ATTRv-wPN, 18 with ATTRv-woPN) and 41 HC performed the CRTs. Of these 37 subjects with ATTRv, four (11%) presented neurogenic orthostatic hypotension the during head-up tilt test. Based on the results of the CRTs, autonomic dysfunction characterized by either sympathetic or parasympathetic impairment was detected in 37% and 63% of ATTRv-wPN subjects, respectively. Subjects with ATTRv-woPN presented a significant impairment of autonomic responses to the Valsalva manoeuvre compared to the HC (overshoot p = 0.004; Valsalva ratio p = 0.001). Conclusion Autonomic dysfunctions are frequent in subjects with ATTRv when investigated by means of standardized CRTs, and are also relevant in the pre-symptomatic stage. Cardiovagal functions are the primary functions affected, among others. This may be crucial in defining the proper diagnostic workout for early diagnosis and improving the likelihood of providing the patient with prompt administration of disease-modifying treatments.

Background The degree of involvement of the autonomic nervous system in progressive supranuclear palsy (PSP) has been investigated in several studies, often providing conflicting results. There is a need for a better characterization of autonomic dysfunction in PSP, to enhance our understanding of this highly disabling neurodegenerative disease including patients’ needs and possibly be of value for clinicians in the differential diagnosis among Parkinsonian syndromes. Methods We applied a systematic methodology to review existing literature on Pubmed regarding autonomic nervous system involvement in PSP. Results PSP reported quite frequently symptoms suggestive of autonomic dysfunction in all domains. Cardiovascular autonomic testing showed in some cases a certain degree of impairment (never severe). There was some evidence suggesting bladder dysfunction particularly in the storage phase. Dysphagia and constipation were the most common gastrointestinal symptoms. Instrumental tests seemed to confirm sudomotor and pupillomotor disturbances. Conclusions PSP patients frequently reported visceral symptoms, however objective testing showed that not always these reflected actual autonomic impairment. Further studies are needed to better delineate autonomic profile and its prognostic role in PSP.

The association of movement disorders with structural or functional hepatic disease occurs in three principal scenarios: (1) combined involvement of both organ systems from a single disease entity, (2) nervous system dysfunction resulting from exposure to toxic compounds in the setting of defective hepatic clearance, or (3) hepatic and/or neurological injury secondary to exposure to exogenous drugs or toxins. An important early step in the workup of any patient with combined movement disorders and liver disease is the exclusion of Wilson's disease. Diagnostic delay remains common for this treatable disorder, and this has major implications for patient outcomes. Thereafter, a structured approach integrating variables such as age of onset, tempo of progression, nature and severity of liver involvement, movement disorder phenomenology, exposure to drugs/toxins and laboratory/neuroimaging findings is key to ensuring timely diagnosis and disease-specific therapy. Herein, we provide an overview of disorders which may manifest with a combination of movement disorders and liver disease, structured under the three headings as detailed above. In each section, the most common disorders are discussed, along with important clinical pearls, suggested diagnostic workup, differential diagnoses and where appropriate, treatment considerations.

Parkinson's disease (PD) is frequently associated with autonomic dysfunction as well as sleep disorders, resulting from neurodegeneration of autonomic nervous system structures and central areas involved in sleep control. In addition, PD patients may be affected by other sleep disorders encountered also in the general population such as obstructive sleep apnea and restless legs syndrome. Sleep and the autonomic nervous system are closely related from an anatomical and physiological point of view. The hypothalamus and brainstem harbor crucial regions of the central autonomic network and sleep-wake cycle regulation, and autonomic functions are physiologically modulated according to the state (wake and sleep stages). Hence, autonomic dysfunction may influence sleep and, in turn, sleep disorders may alter the sympathetic/parasympathetic balance. This chapter will focus on the complex association between autonomic dysfunction and sleep in PD. Firstly, we will give an overview on general principles of sleep and associated autonomic characteristics, briefly discussing the anatomical and physiological background. Secondly we will examine sleep disorders that may be associated with or cause autonomic dysfunction. Thirdly we will consider how autonomic dysfunction commonly associated with PD may alter sleep.

Objectives: The prevalence of neurogenic orthostatic hypotension (NOH, due to cardiovascular autonomic failure) at early stage of Parkinson's disease (PD) is unknown. The aims of this study are to prospectively evaluate in a cohort of PD patients recruited within 3 years from motor onset (1) cardiovascular autonomic functions by means of cardiovascular reflex tests (CRTs) and the occurrence of NOH; (2) the frequency of orthostatic symptoms with a validated questionnaire. Methods: We included the first 105 PD patients of the prospective "BoProPark" study. Each patient underwent CRTs (head up tilt test; Valsalva manoeuvre; deep breathing; cold face test and handgrip test) under continuous blood pressure monitoring according to standardized procedures and SCOPA-Aut questionnaire at baseline (T0) and after 16 months (T1). A group of 50 age- and sex-matched controls was used for comparison. Results: At T0 (mean age 61 +/- 9 years, disease duration 19 +/- 9 months) NOH was detected in 4/105 (3.8%) patients, whereas at T1 in 8/105 (7.6%). CRTs responses assessing sympathetic function were impaired at T0 in PD patients compared to controls and progressively worsened at T1. Only 1 patient at T0 and 3 at T1 with NOH reported orthostatic symptoms with low frequency, while the majority of patients reporting these symptoms did not have OH at testing. Conclusions: Our prospective study shows that NOH is not common at early PD stage. Asymptomatic mild sympathetic impairment was observed at first evaluation and progressed with disease evolution. Secondary OH may account for the higher prevalence of OH in PD reported so far.

The Coronavirus Disease 2019 (COVID-19) pandemic required a thorough re-organization of every sector of the healthcare system. Sleep laboratories need to renew protocols in order to guarantee the safety of patients and healthcare staff while providing exams. Polysomnography (PSG) examinations are essential for the diagnosis and treatment management of several sleep disorders, which may constitute a public or personal safety issue such as obstructive sleep apnea syndrome. Here we provide some practical advice on how to perform sleep studies after the COVID-19 outbreak based on our experience, the review of the existing literature and current national and international recommendations by Health Authorities. We believe that with appropriate precautions it is possible to guarantee a safe restart of PSG and other sleep studies.

Autonomic dysfunction is a key feature of hereditary transthyretin amyloidosis (hATTR). In addition to causing prominent and disabling heterogenic manifestation (orthostatic hypotension, sweating disturbances, erectile and voiding dysfunction, etc.), it carries important prognostic value. The objective of this study was to assess in detail cardiovascular autonomic function throughout a battery of standardized autonomic tests in patients with genetically proven hATTR and healthy controls (HC).

Background: According to expert opinion, orthostatic hypotension (OH) associated to a change in heart rate (Delta HR) less than 15 bpm suggests neurogenic OH (NOH). Recently, the ratio between HR and systolic blood pressure changes at 3 min of tilt test (Delta HR/Delta SBP) has been proposed as a better index than the Delta HR cut-off of 17 bpm. Our aim was to validate these indexes based on HR in an independent cohort of patients who performed cardiovascular reflex tests according to standardized procedures at our Institution. Methods: We applied the HR indexes to all cardiovascular reflex tests that fulfilled the following criteria: (1) presence of classical OH at tilt test, (2) reliable Valsalva manoeuvre (VM), (3) absence of heart disease. We classified OH according to VM (absence of overshoot = NOH), and verified how many were correctly identified by Delta HR/Delta SBP (<= 0.49 neurogenic) and Delta HR (<= 17 and <= 15 neurogenic). Results: We identified 369 tests with OH. Based on VM, 335 were NOH. The Delta HR/Delta SBP <= 0.49 identified NOH with a sensitivity of 91% and a specificity of 59%, the Delta HR <= 17 bpm with 88% sensitivity and 38% specificity, and the Delta HR <= 15 bpm with 84% sensitivity and 50% specificity. Conclusion: In our cohort, the Delta HR/Delta SBP ratio had a good sensitivity but a limited specificity to identify NOH. This easily applicable test may represent a valuable screening tool in a clinical setting to identify patients who need further detailed autonomic testing to confirm the neurogenic origin of OH.

Study design Prospective cohort study. Objectives To analyze the circadian rhythm and state-dependent modulation of core body temperature (Tcore) in individuals with spinal cord injury (SCI) under controlled environmental conditions. Setting Institute of the Neurological Sciences of Bologna, Italy. Methods We assessed 48-h rectal Tcore and sleep–wake cycle by means of video-polygraphic recording in five cervical SCI (cSCI), seven thoracic SCI (tSCI), and seven healthy controls under controlled environmental conditions. Results cSCI showed higher night-time Tcore values with reduced nocturnal decrease, higher MESOR and earlier acrophase compared with tSCI and controls ( p < 0.05 in all comparisons). The mean Tcore values during wake and non-rapid eye movement (NREM) and rapid eye movement (REM) sleep stages were higher in cSCI compared with tSCI and controls ( p < 0.05). Tcore variability throughout the 24 h differed significantly between cSCI, tSCI, and controls. Conclusions cSCI had higher Tcore values without physiological night-time fall compared with controls and tSCI, and a disrupted Tcore circadian rhythm. Furthermore, SCI individuals did not display the physiological state-dependent Tcore modulation. The disconnection of the sympathetic nervous system from its central control caused by the SCI could affect thermoregulation including Tcore modulation during sleep. It is also possible that the reduced representation of deep sleep in people with SCI impairs such ability. Further studies are necessary to evaluate whether improvement of sleep could ameliorate thermoregulation and vice versa.

Introduction. Intracerebral haemorrhage (ICH) is characterised by a high risk of mortality and disability. Studies on sex differences in ICH characteristics and outcomes have been inconclusive. The aim of our observational study is to investigate the demographics, aetiology, location, stroke care, and intra-hospital mortality of ICH patients, in order to evaluate sex differences. Methods. Consecutive patients with primary ICH admitted to the Santa Maria della Misericordia Hospital in Perugia, Italy, between 1st January 2009 and 31st March 2017 were included. All patients were classified according to SMASH-U. Intra-hospital mortality rates and their timings were recorded for each included patient. Results. 1,441 patients were identified on the basis of the 431 ICD-9 code. A total of 727 patients were included in the study; 322 (44.3%) were females. Females were older than males (73.9 vs 70.5, p = 0.001). Hypertensive angiopathy was the most common aetiology for both sexes. Amyloid angiopathy was more frequent in females, whereas drug-induced ICH was more frequent in males. Additionally, NIHSS was slightly higher for females. No sex difference was observed for intra-hospital mortality. Multivariate analysis performed separately on the sexes suggested that hypertension-related ICH was independently associated with an increased risk of mortality in females. For both sexes, ICH severity, evaluated using the NIHSS, correlated with an increased risk of intra-hospital mortality. Conclusions. In our study, no sex differences in intra-hospital mortality were detected. At ICH onset females tended to be older than males. Hypertension-related ICH tended to be more severe in females and correlated with a higher risk of intra-hospital mortality.

It has been 30 years since Quinn, referring to Graham and Oppenheimer’s proposal, suggested multiple system atrophy (MSA) as a unifying term for the conditions previously described as striatonigral degeneration, olivopontocerebellar atrophy, and ShyDrager syndrome, and outlined the first set of diagnostic criteria. Despite our advances in understanding this disease, today there is still no reliable biomarker for a definite diagnosis in life, which is still neuropathological. Miki and colleagues analyzed the clinical records and pathology of 203 patients diagnosed in life with MSA. The aims of this article were: (1) to identify clinical features predictive of MSA pathology and thus useful in differentiating MSA from its lookalikes, and (2) to evaluate the utility of red flags (which were previously validated only as differentiators of MSA with predominant parkinsonism (MSA-P) from Parkinson’s disease) in the differential diagnosis between MSA-P as well as MSA with predominant cerebellar ataxia (MSA-C) and its mimics. The main findings were: (1) diagnosis of MSA was confirmed at postmortem examination in 79% of the cases; misdiagnosed patients mainly had Lewy body disease (LBD) or progressive supranuclear palsy (PSP) pathology; (2) pill-rolling tremor was highly unusual in pathologically confirmed MSA and PSP; (3) positive pull test was not useful in distinguishing between MSA and MSA lookalikes; (4) early ataxia, stridor, early dysphagia and early falls were reasonable differentiators between MSA and LBD, whereas ataxia and stridor between MSA and PSP; (5) early autonomic dysfunction favored MSA over PSP; (6) severe orthostatic hypotension and/or urinary incontinence requiring urinary catheter in patients with atypical parkinsonism should prompt consideration of MSA; (7) several red flags (orofacial dystonia, inspiratory sighs, contractures of hands or feet, polyminimyoclonus) proved useful in predicting MSA pathology, even when applied to MSA-C patients; (8) cognitive impairment and hallucinations were less common in MSA than in other forms of atypical parkinsonism, and this may account for the lower rate of institutionalization; however, when cognitive impairment was present, MSA patients reached that disability milestone earlier than LBD; (9) 40% of MSA patients presented a beneficial response to levodopa, and it was not significantly different when compared to other conditions. This study is important first because it validated clinical criteria including red flags in a large population of autopsy-proven MSA patients against a cohort of atypical LBD and PSP that resembled MSA in life, thus reinforcing the diagnostic power of these features and reminding clinicians to make an effort to look for and pick all these signs. The differentiating value of the red flags is likely to be even greater when compared to typical LBD and PSP patients. Second, it challenged the reliability of some features that have been considered so far highly suggestive of MSA, such as poor levodopa response and preserved cognition, which were instead found to be the best predictors of MSA in the retrospective analysis of 38 autopsy-proven cases by Wenning and colleagues. These topics were also discussed in an article by the Movement Disorder Society MSA Study Group, suggesting a need for revisions in the current diagnostic criteria. In conclusion, although the mainstays of “the beast” have not changed during 30 years of research, we have certainly broadened our knowledge about it. Despite the changes in the two consensus criteria that followed since 1989, we are currently no better at predicting MSA pathology, and the variant presentations of both MSA and other atypical parkinsonisms further increase the clinical overlap and potential for misdiagnosis. Therefore, MSA diagnostic criteria need to be implemented to better define this highly complex and multifarious disease.

Circadian rhythms of blood pressure and heart rate are regulated by a biological clock located in the suprachiasmatic nucleus (SCN) of the hypothalamus, which modulates the autonomic nervous system activity directed to the heart and blood vessels. Humoral mediators released with periodicity induced by the SCN as well as sleep are also important factors. Disruption of physiological cardiovascular circadian rhythms has important clinical implications, as it is associated with increased morbidity and mortality. In this review, firstly we will give an overview on the neuroanatomic and physiologic aspects of cardiovascular circadian rhythms. Secondly we will examine how to assess them in clinical practice. Finally we will discuss certain neurodegenerative diseases in which there is an alteration of these rhythms, such as Parkinson's disease and Alzheimer's disease.

The MRI evidence of persistent black holes (pBHs) on T1-weighted images reflects brain tissue loss in multiple sclerosis (MS). The evolution of contrast-enhancing lesions (CELs) into pBHs probably depends on the degree and persistence of focal brain inflammation. The aim of our retrospective study was to evaluate the effect of a single cycle of intravenous methylprednisolone (IVMP), as for MS relapse treatment, on the risk of CELs’ evolution into pBHs.

HomeStrokeVol. 49, No. 12Gender-Based Approaches for the Prevention and Control of Noncommunicable Diseases Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBGender-Based Approaches for the Prevention and Control of Noncommunicable DiseasesKeep an Eye on Stroke Francesca Baschieri, MD, Monica Acciarresi, MD and Valeria Caso, MD, PhD Francesca BaschieriFrancesca Baschieri From the Clinica Neurologica, Dipartimento di Medicina, Università degli Studi di Perugia, Ospedale S. Maria della Misericordia, Italy (F.B.) , Monica AcciarresiMonica Acciarresi Stroke Unit, Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Italy (M.A., V.C). and Valeria CasoValeria Caso Correspondence to Valeria Caso, MD, PhD, Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia 06156, Italy. Email E-mail Address: [email protected]. Stroke Unit, Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Italy (M.A., V.C). Originally published8 Nov 2018https://doi.org/10.1161/STROKEAHA.118.023633Stroke. 2018;49:2810–2811Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 8, 2018: Ahead of Print On September 27, 2018, the United Nations General Assembly will stage the third High-level Meeting on the prevention and control of noncommunicable diseases (NCDs) where a comprehensive review of the global and national progress to reach target 3.4 of the Sustainable Development Goals will be undertaken. Target 3.4 aims to reduce by one-third premature mortality from NCDs within 2030 through prevention and treatment and to promote mental health and well-being. Earlier in 2018, a report by the Secretary-General had outlined that actions produced by governments in 2011 and 2014 were inadequate, and without a significant scaling up of efforts before 2020, the 2030 goals risk not to be met.1 Therefore, the Secretary-General recommended redoubling efforts to engage sectors beyond health, in order to obtain greater health gains by influencing public policies. These efforts include a review of current gender-based approaches for the prevention and control of NCDs.1Stroke is a leading cause of mortality among NCDs for both sexes. However, data reveals that stroke is more detrimental to women in several ways. Specifically, women have higher overall lifetime risks of stroke along with higher rates of mortality and disabilities.2 These higher risks have been shown to be driven by women living in low and middle-income countries,3 residing in countries with higher gender inequality index4 and with significant ethnic disparities.5 About risk factors for stroke, atrial fibrillation leads to a higher incidence and more severe thromboembolic events for women. Other crucial sex-specific risk factors include oral contraceptive therapy, pregnancy, postpartum period, and migraine with aura.6 Likewise, long-term sequelae in the form of depression, dementia, and epilepsy have been reported to increase disability and mortality. Moreover, women tend to seek medical attention later than men as they are more likely to be living alone.7 Women have more cortical associated symptoms which are not always recognized in a general care emergency room, leading to delays in acute stroke treatment. Gender differences have also been reported about prehospital and hospital management. The German Stroke Registry data have suggested that women >80 are less likely to be admitted to specialized stroke unit care.8 To date, women have been under-represented in major randomized clinical trials, and this has led to accusations that their results on safety and efficacy may not accurately reflect realities and in turn distort the drafting of both recommendations and guidelines.9 This under-representation has been suggested as a reason for women having more drug-related adverse events.10Overall, gender and sex differences in virtually every aspect—from epidemiology to treatment—demand more focused research on women-personalized stroke care. Considering that women have a longer life expectancy and will represent the majority of patients affected by stroke this issue cannot be overlooked during the 2018 United Nations General Assembly in September.So, when the Secretary-General admonishes a greater promotion of gender-based approaches for the prevention and control of NCDs, the authors could not be in greater agreement. This need to be realized in the form of more dedicated pathways for stroke taking into account the following:Dedicated awareness stroke campaign for women.Research on the hurdles for women to undergo regular screening for stroke risk factors, seek acute care, and receive less poststroke care.More inclusion of women >80 years in stroke randomized controlled trials.Stop male randomized controlled trials enrollment after achieving 50% of the sample size.A past model of health care reform that could be used as a template for gender-specific stroke healthcare is the one for Breast Cancer. It led to improved screening imaging modalities that allowed earlier detection, adjuvant and neoadjuvant chemotherapy, hormonal therapy, radiotherapy, immunotherapy, breast-conservative surgery with a better aesthetic outcome, and a greater awareness among young women on the importance of screening. All of these resulted in a considerable and accelerated reduction in mortality and morbidity.11,12 Outpatient care of breast cancer patients has been improved, explicitly targeting those pitfalls and inefficiencies in the health care system, and promoting specialized professional figures dedicated to the specific needs of women.13 In the 1970s, the breast cancer awareness campaign caught the public eye. The collective aims of the multitude of nonpolitical organizations were to promote medical knowledge, share experiences, increase funding for research, and take a more central role in medical decision-making, including an active part in the therapeutic surgical approach.14 Pressure driven by these campaigns was so high that by 1990s breast cancer became a favorite social cause in American culture, and the medical profession, governments, and researchers were committed to the cause.15In conclusion, as suggested by the current Secretary-General in promoting gender-based approaches for NCDs, additional resources need to be catalyzed. The authors urge to move forward with the declared 2030 goals, by adopting a more gender-focused approach to stroke based on the breast cancer model.Nikola Tesla, one of the greatest scientists of the past century, in an interview in 1926 predicted the emergence of women as one of the main developments of the future: "But the female mind has demonstrated a capacity for all the mental acquirements and achievements of men, and as generations ensue that capacity will be expanded; the average woman will be as well educated as the average man, and then better educated, for the dormant faculties of her brain will be stimulated to an activity that will be all the more intense and powerful because of centuries of repose."16DisclosuresDr Caso received speakers fees from Daiichi Sankyo, Ever-NeuroPharma, Boehringer-Ingelheim, Pfizer/BMS, Bayer, Mindmaze and is member of advisory boards Boehringer-Ingelheim, Pfizer/BMS, Bayer (All Honoraria are paid to ARS Umbria); chair of the adjudication for Respect ESUS. The other authors report no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Valeria Caso, MD, PhD, Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia 06156, Italy. Email [email protected]com.References1. United Nations General Assembly. Progress on the P revention and Control of Non-Communicable Diseases. Report of the Secretary-General.2017. https://ncdalliance.org. Accessed August 12, 2018.Google Scholar2. Reeves MJ, Bushnell CD, Howard G, Gargano JW, Duncan PW, Lynch G, et al. Sex differences in stroke: epidemiology, clinical presentation, medical care, and outcomes.Lancet Neurol. 2008; 7:915–926. doi: 10.1016/S1474-4422(08)70193-5CrossrefMedlineGoogle Scholar3. Arnao V, Acciarresi M, Cittadini E, Caso V. Stroke incidence, prevalence and mortality in women worldwide.Int J Stroke. 2016; 11:287–301. doi: 10.1177/1747493016632245CrossrefMedlineGoogle Scholar4. Kim YD, Jung YH, Caso V, Bushnell CD, Saposnik G; Women's Disparities Working Group. Countries with women inequalities have higher stroke mortality.Int J Stroke. 2017; 12:869–874. doi: 10.1177/1747493017694389CrossrefMedlineGoogle Scholar5. Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart disease and stroke statistics-2017 update: a report from the American Heart Association.Circulation. 2017; 131:e29–e322.Google Scholar6. Cordonnier C, Sprigg N, Sandset EC, Pavlovic A, Sunnerhagen KS, Caso V, et al; Women Initiative for Stroke in Europe (WISE) Group. Stroke in women - from evidence to inequalities.Nat Rev Neurol. 2017; 13:521–532. doi: 10.1038/nrneurol.2017.95CrossrefMedlineGoogle Scholar7. The Lancet Neurology. Sex differences and stroke prevention.Lancet Neurol. 2014; 13:339. doi: 10.1016/S1474-4422(14)70057-2CrossrefMedlineGoogle Scholar8. Krogias C, Bartig D, Kitzrow M, Weber R, Eyding J. Trends of hospitalized acute stroke care in Germany from clinical trials to bedside. Comparison of nation-wide administrative data 2008-2012.J Neurol Sci. 2014; 345:202–208. doi: 10.1016/j.jns.2014.07.048CrossrefMedlineGoogle Scholar9. Tsivgoulis G, Katsanos AH, Caso V. Under-representation of women in stroke randomized controlled trials: inadvertent selection bias leading to suboptimal conclusions.Ther Adv Neurol Disord. 2017; 10:241–244. doi: 10.1177/1756285617699588CrossrefMedlineGoogle Scholar10. United States Government Accounting Office (GAO). Drug Safety: Most Drugs Withdrawn in Recent Years Had Greater Health Risks For Women. GAO-01-286R, 2001.www.gao.gov/new.items/d01286r.pdf. Accessed August 4, 2014.Google Scholar11. Zurrida S, Veronesi U. Milestones in breast cancer treatment.Breast J. 2015; 21:3–12. doi: 10.1111/tbj.12361CrossrefMedlineGoogle Scholar12. Toriola AT, Colditz GA. Trends in breast cancer incidence and mortality in the United States: implications for prevention.Breast Cancer Res Treat. 2013; 138:665–673. doi: 10.1007/s10549-013-2500-7CrossrefMedlineGoogle Scholar13. Shockney LD. The evolution of breast cancer navigation and survivorship care.Breast J. 2015; 21:104–110. doi: 10.1111/tbj.12353CrossrefMedlineGoogle Scholar14. Lukong KE. Understanding breast cancer - The long and winding road.BBA Clin. 2017; 7:64–77. doi: 10.1016/j.bbacli.2017.01.001CrossrefMedlineGoogle Scholar15. Sulik G, Zierkiewicz E. Gender, power, and feminisms in breast cancer advocacy: lessons from the United States and Poland.J. Gend Power. 2014; 1:111–145.Google Scholar16. Cheney M. Tesla: Man Out of Time. 1st ed. New York, NY: Simon & Schuster; 2001.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Saleh S, Muhieddine D, Hamadeh R, Dimassi H, Diaconu K, Noubani A, Arakelyan S, Ager A and Alameddine M (2022) Outpatient use patterns and experiences among diabetic and hypertensive patients in fragile settings: a cross-sectional study from Lebanon, BMJ Open, 10.1136/bmjopen-2021-054564, 12:5, (e054564), Online publication date: 1-May-2022. December 2018Vol 49, Issue 12 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.118.023633PMID: 30571452 Originally publishedNovember 8, 2018 Keywordswomenatrial fibrillationdementiastrokeEditorialsmortalityPDF download Advertisement SubjectsIschemic StrokeWomen, Sex, and Gender

Pure autonomic failure is challenging as it can be the presenting feature of a central nervous system syncleinopathy such as Parkinson’s disease (PD) or multiple system atrophy (MSA). Because the prognosis of MSA and PD is so different, predictive features for a possible conversion can be extremely valuable. In this paper, we report three cases (two with autopsy-proven diagnosis) that had isolated AF for many years before converting to MSA or PD. Of all the tests that were performed during the premotor stage, Iodine-123-meta-iodobenzylguanidine (MIBG) myocardial scintigraphy was predictive of the conversion to MSA. We suggest that MIBG myocardial scintigraphy, when performed in patients with isolated AF, may be a valuable predictor of conversion to MSA. On the contrary, the role of such test in parkinsonian patients irrespective of the presence of AF is still to be clarified.