Retrospective Study of Complications Arising during Cerebral and Spinal Diagnostic Angiography from 1998 to 2003

SUMMARY

This retrospective study aimed to assess the percentage of complications in the daily practice of cerebral and spinal cord diagnostic angiography at our institution and to compare this with literature reports published in the last twenty years and guidelines for angiography. From 1(st) December 1998 to 1(st) December 2003 2154 patients underwent digital angiography for a total of 5996 vessels selected. Three neurological complications arose during angiographic procedures in the five year period. * Focal neurological deficit resolving within 24h in two patients, * Permanent neurological deficit in one patient. There were no adverse systemic reactions to contrast medium. Retrospective analysis of our cohort disclosed a complication rate of 0.1% for transient neurological complications and 0.05% for permanent deficits.

Brain AVM Embolization with Onyx(R): Analysis of Treatment in 34 Patients

SUMMARY

The endovascular approach to arteriovenous malformations (AVM) using different embolizing agents is a well-established treatment option. This report assesses the results of our experience using a non "glueing" embolic material available for several years, commercially known as Onyx(R). We used Onyx to treat 34 consecutive patients in the last four years. All patients were treated in the same department by the same neuroradiological team, with a strictly repetitive technical strategy and procedural protocol. All our patients presented AVMs with Spetzler Grade 3 or more, because in our Institution Grade 1 or 2 AVMs are directly treated by surgical approach. We adopt a multidisciplinary treatment approach (embolization, surgery, radiotherapy) by which embolization is construed as work in progress offering definitive treatment of AVMs without severe risks. Embolization is mainly undertaken as the first step before surgery, to reduce flow and size of the AVM by a "targeted" technique. In addition to reducing lesion size, endovascular treatment aims to seal off AVM areas anatomically or haemodynamically complex for surgical treatment. Occasionally, the reduction in size allows a radiosurgical approach. Embolization seldom results in a definitive cure of AVMs. At the end of multimodal approach, we obtained the complete and definitive cure of AVM in 21/34 patients (two complete obliteration with interventional technique, 19 in combination with surgery); to these were added 5/34 patients who received radiosurgical therapy. No major complications arose during endovascular treatment. One patient had transitory (36 hour) impaired right arm pronation. The CT scan disclosed an asymptomatic mild SAH in the left sylvian fissure but no ischaemic areas. One patient still in treatment died from fatal rebleeding (the clinical onset had been with haemorrhage two weeks before the session) 12 days after the embolization. Excellent or good clinical outcome was obtained in 23/26 patients who completed the therapeutic protocol. Outcome was conditioned by focal symptoms present on admission in three patients due to haemorrhagic onset, but only one patient presented a severe disability on discharge. In our view, the main problem of Onyx is that the apparently easier approach will probably lead to a wider diffusion of these procedures. AVMs are extremely difficult and dangerous to treat: this is not affected by the quality of the embolizing agents used and must be kept in mind at all times.

Endovascular treatment of basilar artery dissection by stent deployment. A case report

SUMMARY

We describe a 44 year-old woman with dissection of the distal third of the basilar artery presenting with subarachnoid haemorrhage. She was treated with a Neuroform stent (Boston Scientific), the first stent designed for intracranial navigation and recently approved by the FDA to treat wide-necked cerebral aneurysms and allow reconstruction of the internal lumen. In our patient, the dissection involved the origin of the anterosuperior cerebellar artery and the origin of the right posterior cerebral artery. The stent was positioned without complications during or after the procedure. Intra and periprocedural thrombolytic therapy was given followed by an antiaggregant (100 mg Aspirin) for a year after treatment. Subsequent angio-MR and angiographic monitoring disclosed resolution of the dissection and normalization of the basilar artery lumen. She currently lives a controlled but normal life.

Glubran 2((r)):a new acrylic glue for neuroradiological endovascular use: a complementary histological study

SUMMARY

Two Landrace Large White swine underwent angiography by the femoral route. In both cases, the superior left renal artery was embolized by injection of 2 ml of Glubran 2((R)), diluted with Lipiodol 1:1 thereby excluding the superior left kidney poles from blood flow. During the follow-up period, neither pig presented any clinical symptom correlated to the embolization procedure. Case 1 was sacrificed after 30 days and case 2 after 60 days. Macroscopic and microscopic analysis was performed in both animals. Long-term follow-up of the two cases after endovascular injection of Glubran 2((R)) showed that the embolization procedure was well-tolerated by the swine in terms of clinical symptoms and histological findings. Arterial occlusion was stable and a reasonable quantity of scar tissue appeared between 30 and 60 days, surrounding the ischaemic tissue. This follow-up experimental study offers further evidence that Glubran 2((R)) is a safe embolizing material for human use as far as its chemical activity is concerned.

Presurgical embolization of spinal tumours using glubran 2 acrylic glue

SUMMARY

This study aimed to define the indications, technique and results of presurgical embolization of spinal tumours using Glubran 2 acrylic glue. Embolization was performed prior to surgery in eight patients with benign tumours and 11 patients with malignant lesions. The main embolization agent used was Glubran 2, a new acrylic glue with the EC mark, suitable for permanent embolization of the pathological circulation of primary and secondary spinal tumours. All the procedures were technically feasible and achieved partial or complete embolization of the vascularized lesion without periprocedural complications. Glubran 2 proved easy to use with excellent intravascular penetration achieving permanent embolization. The degree of presurgical embolization in terms of surgical field haemostasis was correlated with the degree of vascular occlusion achieved.

3D Micrus Coil "Cage" in Wide-Necked Aneurysms

SUMMARY

We aimed to verify that Micrus 3D microcoils can be used as first coils in the treatment of saccular wide-necked aneurysms to provide stable protection to the neck by keeping the coil mesh inside the aneurysm. We selected 22 wide-necked aneurysms and calculated the ratio between sac diameter and neck width which was close to unity. The aneurysms were treated by endovascular approach using Micrus 3D (Spherical) microcoils as first coils. The coils proved stable during placement and detachment and compatible with both GDC and Micrus coils used for filling and packing. The endovascular procedure was suspended in only two out of 22 aneurysms selected for treatment. Aneurysm bleeding occurred in two endovascular procedures but was controlled. No complications were encountered in the remaining 18 patients treated. The percentage of technical failures has been reduced since the adoption of 3D Micrus microcoils in our practice.

Glubran 2: a new acrylic glue for neuroradiological endovascular use. Experimental study on animals

SUMMARY

A new acrylic glue, Glubran 2, is now available on the European market. It bears the CE mark with several surgical indications and the specific indication for neuroradiological endovascular use. Despite this approval, to our knowledge its use is still limited to surgery and no injections have been made in human patients. This study was designed to evaluate the behavior of Glubran 2 in endovascular injection in a simulation of brain AVM. Six sheep were operated on opening a fistula between the right common carotid artery and the jugular vein. This fistula modifies blood flow in the skull base rete mirabilis, which then functions as an AVM. In two sheep, the rete mirabilis was occluded by injection of 1.5 ml of Histoacryl diluted 1:1 and 1:3 with Lipiodol. In two sheep, the rete was embolized by injection of 1.5 ml of Glubran 2 diluted 1:1 with Lipiodol. The last two sheep were embolized by injection of Glubran 2 diluted 1:3 with Lipiodol. The procedures were documented by DSA angiographic acquisitions and by fluoroscopic VHS. The sheep were killed immediately after the procedures and the rete mirabilis isolated for histologic examination. Embolization was obtained with both kinds of glue. Glubran 2 diffuses in a very similar way to Histoacryl with an apparently more complete diffusion. Reflux in the ascending pharyngeal artery showed that Glubran 2 tended not to produce bubbles but diffused more homogeneously. The subjective conclusion of this work is that Glubran 2 can be used in endovascular embolizations. Before approaching brain AVMs, a further study will investigate embolization of the external carotid territory.

Three-Year Retrospective Study of Complications Arising during Interventional Procedures

SUMMARY

This retrospective study aimed to assess the percentage of complications arising in our daily practice of interventional procedures, comparing our findings with those of leading international reference centers and accepted guidelines for endovascular treatment. During the threeyear period considered (2000-2002), we performed 246 interventional procedures, divided into seven different pathological conditions: aneurysms, brain AVMs dural and carotid cavernous fistulae, spine-spinal cord tumours, headneck tumours, carotid stenosis and thrombolysis. Aneurysmal disease accounted for 45% of all endovascular procedures. In conclusion, four periprocedural complications arose in the course of 246 procedures resulting in one death and three cases of permanent neurological deficit (2%).

Analysis of proteins with caseinolytic activity in a human stratum corneum extract revealed a yet unidentified cysteine protease and identified the so-called "stratum corneum thiol protease" as cathepsin l2

Desquamation is described as a protease-dependent phenomenon where serine proteases with a basic pH optimum play a key role. Recently proteases with an acidic pH optimum were identified in the stratumcorneum and associated with desquamation, e.g., cathepsin D and the stratum corneum thiol protease. The purpose of this study was to investigate if human stratum corneum contains proteases different from the above, exhibiting similar properties. After gel filtration, we identified four distinct proteolytic activities in a human stratum corneum extract, a cathepsin-E-like activity (80 kDa), a cathepsin-D activity (40 kDa), a yet unknown cathepsin-L-like form (28 kDa) exhibiting the highest caseinolytic activity, and a chymotrypsin-like protein (24 kDa) containing the acidic activity of the well described stratum corneum chymotryptic enzyme. We named the new 28 kDa protease stratum corneum cathepsin-L-like enzyme. Characterization of stratum corneum cathepsin-L-like enzyme provided clear evidence that this new protease, despite its membership to the cathepsin-L-like family, is distinct from cathepsin L and from the recently described stratum corneum thiol protease. Its ability to hydrolyze corneodesmosin, a marker of corneocyte cohesion, was in favor of a role of stratum corneum cathepsin-L-like enzyme in the desquamation process. A more detailed analysis did not allow us to identify stratum corneum cathepsin-L-like enzyme at the molecular level but revealed that stratum corneum thiol protease is identical with the recently described cathepsin L2 protease. Reverse transcription polymerase chain reaction studies and the use of a specific antibody revealed that, in contrast to earlier reports, expression of stratum corneum thiol protease in human epidermis is not related to keratinocyte differentiation. Our results indicate that the stratum corneum thiol protease is probably expressed as a pro-enzyme in the lower layers of the epidermis and in part activated by a yet unidentified mechanism in the upper layers during keratinocyte differentiation.

Neuroradiology of spine degenerative diseases

Degenerative disease of the spine is one of the most common clinical entities and affects the intervertebral discs, including opposing vertebral endplates, the intervertebral posterior joints and the ligaments. The most severe primary spinal degenerative changes are found in the lower cervical and lumbar spine regions. The spine contains three different types of joints, each of which presents its own pattern of degenerative disease: (i) cartilaginous joints, represented by the intervertebral disc or, more specifically, the functional unit defined as the 'vertebro-disc connection'; (ii) synovial joints, represented by the posterior intervertebral joints, sacro-iliac and costovertebral joints; (iii) fibrous joints, mainly found in the principal ligaments such as the posterior longitudinal ligament and the yellow ligaments. With regard to radicular pain, root compression alone does not fully account for root pain following disc-root conflict, but it is, nevertheless, considered to be the main cause of pain. We will try to explain that the origin of pain is multi-factorial and that inflammation probably predominates over merely mechanical mechanisms. To conclude, we will consider whether vertebral arthrosis can be construed as the body's decision to favour the spine's static function over its dynamic role when joint 'hypermobility' linked to chronic load in old age could cause severe structural damage to the bony vertebral structures. This hypothesis should also embrace a further concept: ageing of the spine is not merelychronological. Themostaccurate interpretation tha tcan account for similar degenerative phenomena encountered in the young is that of abnormal static and dynamic loading stress.

Endovascular treatment of a distal aneurysm of the superior cerebellar artery by intra-aneurysmal injection of glue

SUMMARY

Aneurysms in the distal cerebellar arteries are rare events. They are associated with a poor prognosis, as surgery or embolisation with Guglielmi detachable coils (GDCs) is very difficult. The ability to treat them surgically depends on the location of the aneurysm, but surgery is considered difficult and is associated with a high morbidity/mortality rate. Embolisation with GDCs may be difficult or impossible because of the distal location of the aneurysm or the unfavourable ratio between the size of the aneurysm and the size of the parent vessel. We report our experience in one case treated with intra-aneurysmal injection of glue. The aneurysm, located in the distal right superior cerebellar artery, was catheterized with a flow-guided microcatheter, and glue was slowly injected into the aneurysmal sac. The treatment resulted in total occlusion of the aneurysm with preservation of the parent artery.

Purification and characterization of the endoglycosidase heparanase 1 from human plantar stratum corneum: a key enzyme in epidermal physiology?

A protein exhibiting endoglycosidase activity was purified from plantar stratum corneum to apparent homogeneity in two sequential column chromatographic steps. Protein sequencing revealed its identity with the recently cloned human heparanase 1, an enzyme, the expression of which is reported to be related to the metastasic potential of tumor cells. By using a heparanase 1 specific antibody we were able to demonstrate that, in the plantar stratum corneum, heparanase 1 exists in two forms, the active 50 kDa protein and the inactive 63 kDa form, probably a proform of the enzyme. The antibody also decorated numerous degradation fragments. Reverse transcription polymerase chain reaction studies as well as immunohistochemical analysis using reconstructed and normal human epidermis demonstrated clearly a keratinocyte differentiation related expression of heparanase 1. Interestingly, the antibody also strongly decorated dendritic cells, which after double labeling could be identified to be a subpopulation of the epidermal Langerhans cells. Based on our findings and the known history of this enzyme, we advanced the hypothesis that heparanase 1 has multiple physiologic functions in the epidermis: (i) it plays an important role in epidermal differentiation, possibly by modulating the liberation of heparan sulfate bound (growth) factors; (ii) in the stratum corneum, the endoglycosidase activity of heparanase 1 might be indispensable and represent the first step in the desquamation process; and (iii) in Langerhans cells, its catalytic activity is required for the trans-tissue migration of these cells.

Estrus synchronization in ewes treated with sponges impregnated with different doses of medroxyprogesterone acetate

The objectives of this study were to determine residual and absorbed levels of medroxyprogesterone acetate (MAP) after treatment with intravaginal sponges impregnated with different doses of MAP in an ewe herd and to determine the effects of such treatments upon estrus incidence, interval to estrus onset and pregnancy rate. Polyurethane sponges impregnated with 40, 50 and 60mg of MAP were prepared. Real amounts of progestagen on sponges were checked prior to sponge treatment insertion. During autumn 1999, 608 cyclic Merino ewes were treated with intravaginal sponges impregnated with different doses of MAP (groups I, 40; II, 50 and III, 60mg). After 14 days, sponges were removed and residual levels of MAP (RMAP) on removed sponges were measured by spectrophotometry. Real amounts for unused sponges were 39.60+/-1.10, 44.10+/-1.06 and 59.10+/-1.26mg for the intended doses of 40, 50 and 60mg MAP respectively. RMAPs were different (p<0.05) among groups (I: 17.98+/-1.97mg; II: 24.32+/-2.03mg; III: 34.25+/-3.23mg). Absorbed levels of MAP were not different among groups (I: 21.62+/-1.97mg; II: 19.78+/-2.03mg; III: 24.85+/-3.23mg). Artificial insemination was performed in 16 ewes from Group I, 17 ewes from Group II and 11 ewes from Group III, 12h after estrus onset. There were no differences among groups, neither for estrus incidence (I: 79.27%; II: 77.42%; III: 80.87%) nor interval to estrus onset (I: 55.94+/-1.87h; II: 56.74+/-1.13h; III: 57.70+/-1.02h). There were also no differences among groups for pregnancy rate (I: 43.75%; II: 52.94%; III: 45.45%). It was concluded that under similar conditions, a dose as low as 40mg MAP could be effectively used for estrus synchronization in cyclic Merino ewes.

Identification and cloning of a new calmodulin-like protein from human epidermis

After separating by two-dimensional gel electrophoresis an extract of total proteins from human stratum corneum, two spots were extracted and analyzed for their peptide sequence. The resulting internal protein sequences provided evidence for the identification of a new calcium-binding protein. Cloning of the corresponding full-length cDNA was achieved by reverse transcriptase-polymerase chain reaction using two keratinocyte libraries, one from proliferating cultured keratinocytes and one from differentiated keratinocytes of reconstructed human epidermis. The cDNA had an open reading frame encoding a new calcium-binding protein of 146 amino acids, a member of the calmodulin family. We named this new protein calmodulin-like skin protein (CLSP), since reverse transcriptase-polymerase chain reaction studies of CLSP expression in 10 different human tissues revealed that this protein was particularly abundant in the epidermis where its expression is directly related to keratinocyte differentiation. Expression of the cloned cDNA in Escherichia coli yielded a recombinant protein which allowed its further characterization. rCLSP is able to bind calcium, and similarly to calmodulin, exposes thereafter hydrophobic parts which most likely interact with target proteins. Epidermal proteins retained by CaM affinity column are quantitatively and qualitatively distinct from those of the rCLSP column. Sequencing of a rCLSP affinity purified protein revealed 100% identity with transglutaminase 3, a key enzyme in terminal differentiation, indicating an important role of CLSP in this process.

Endovascular Treatment of Vertebrobasilar Aneurysms

In posterior circulation aneurysms, GDC endosaccular occlusion is the treatment of choice, when indicated.

This report assessed anatomical, morphological and clinical criteria in the choice of vertebral or basilar artery occlusion in posterior circulation aneurysms, when CDC endosaccular treatment, with or without the “remodelling technique”, is not indicated, as in giant or wide-neck aneurysms.

Over five years we observed eleven patients harboring posterior circulation aneurysms with no indication for treatment with GDC, or only vertebral occlusion.

In our experience, the endovascular occlusion of a single or both vertebral arteries or basilar artery, following a detailed anatomical and clinical assessment, has proved a good, reliable treatment in large or giant vertebrobasilar aneurysms or those without a neck.

TNM glottic: role of the vocal muscle, arytenoid cartilage, and inferior paraglottic space in impaired vocal cord mobility (T2). An embryological and clinical study

The TNM classification is unsatisfactory regarding the impaired mobility of the vocal cord and/or the arytenoid. The authors have studied the intrinsic laryngeal musculature, with particular attention to the medial thyroarytenoid muscle, the lateral thyroarytenoid muscle, and the inferior paraglottic space. The study was conducted on serial sections of 4 embryonal and 9 fetal larynges at different stages of development. The embryological observations showed that the lateral and medial thyroarytenoid muscles have different maturation times and probably different functions: phonatory and sphincteric. The authors have found that the inferior paraglottic space is situated between these 2 muscles. It would represent a path of diffusion for glottic cancer and play a central role in impaired vocal cord and/or arytenoid mobility, according to the degree of diffusion. Embryological observations have suggested the existence of laryngeal morphofunctional units belonging to the subsites of the glottic region and related to tumoral spreading.

Potential biomarkers in predicting progression of epithelial hyperplastic lesions of the larynx

Factors contributing to malignant transformation of laryngeal pre-neoplastic lesions remain largely unknown. Potential etiologic factors may be related to a genetically controlled sensitivity to environmental carcinogens. In this study, we investigated bleomycin-induced chromosome fragility in 15 patients with laryngeal keratoses who experienced a malignant transformation of pre-neoplastic lesions during follow-up, as compared with chromosome fragility in 15 historical controls with no progression of laryngeal keratoses during a 10-year follow-up, in a match-paired analysis. Chromosomal analysis demonstrated a higher sensitivity to clastogens in patients with malignant progression of laryngeal pre-neoplastic lesions than that of control patients with no evolution of their original laryngeal keratoses (p < 0.01). Furthermore, in the attempt to identify possible prognostic markers we studied proliferative activity (MIB-1 expression) and p53 gene aberration in biopsy samples from non-invasive and invasive laryngeal lesions in both groups. p53 immunostaining was observed in 10/15 (66.7%) of pre-neoplastic lesions and in 11/15 (73.3%) of metachronous laryngeal cancers. No differences in terms of p53 expression were noted between transformed and not-transformed lesions. Mutations at p53 gene were observed in 3/15 (20%) of pre-invasive biopsies and in 4/5 (80%) of the laryngeal cancers analyzed. Our data suggest that p53 alteration is an early event in the genesis of a subset of laryngeal carcinomas and that there is no conclusive data about the possible clonal development of metachronous laryngeal carcinoma from a p53 mutated pre-invasive disease in the same patient. MIB-1 expression was found to progressively increase with degree of epithelial hyperplasia and dysplasia in both transformed (p = 0.007) and not-transformed (p < 0.1) lesions. Surprisingly, pre-invasive lesions with tumor evolution showed a lower proliferative activity when compared with laryngeal lesions without malignant transformation (p = 0.013). These data suggests that subjects with pre-neoplastic laryngeal lesion showing an increased susceptibility to carcinogens and with less proliferative disease could be at a higher risk for development of laryngeal carcinoma.

Loss of p53 gene mutation after irradiation is associated with increased aggressiveness in recurring head and neck cancer

The p53 gene plays a pivotal role in the control of a checkpoint during G1 and in the apoptotic program. It has been postulated that alterations of p53 may influence radio-sensitivity and prognosis in several malignancies. We studied the p53 gene status of 35 consecutive head and neck cancer patients who failed primary radiotherapy (RT) in preirradiated and postirradiated tumor samples using DNA single-strand conformational polymorphism analysis. Sixteen of 35 (46%) preirradiated samples presented with band shifts suggestive of point mutations in one or two exons. Eleven of these tumors (69%) showed the same shift even in the postirradiated samples. Exons 5 and 8 were prevalently affected in this group. Five tumors (31%) lost the mutation following RT. The missed mutations clustered in exon 7. All mutations were confirmed by sequencing. Actuarial analysis demonstrated increased survival in patients with tumors bearing a p53 gene mutation in both preirradiated and postirradiated samples (P = 0.05 and P = 0.01, respectively). We also found that loss of p53 gene mutation in postirradiated cancers is associated with a significantly shorter disease-free interval (P < 0.02) and a worse prognosis (P < 0.05). A possible explanation in such cases is clonal selection by RT of more aggressive and radioresistant cell subpopulations, which are wild-type for the p53 gene. Taken together, our data suggest that not only p53 gene status but also the pattern of mutations could modulate the response of tumor cell to RT in vivo.

bcl-2 protein expression correlates with recurrence and survival in early stage head and neck cancer treated by radiotherapy

Inherent cellular radioresistance plays a critical role in the failure of radiation therapy (RT). The proto-oncogene bcl-2 encodes a protein that inhibits apoptosis, a common mechanism of cell death induced by several genotoxic agents, including gamma-radiation. Thus, it is likely that bcl-2 gene expression could be involved in the complex mechanisms of radioresistance in human tumors with some prognostic implications. In this study, we analyzed the predictive relevance of bcl-2 expression on 5-year disease-free and overall survival in patients with early stage squamous cell carcinoma of the head and neck (SCCHN) primary treated with RT. The expression of bcl-2 was analyzed by immunohistochemistry on paraffin-embedded sections from 71 consecutive stage I-II SCCHN patients treated with curative RT. We detected bcl-2 protein in 21% of SCCHN studied. A suggestive association was observed between tobacco exposure and bcl-2 protein expression (P < 0.1); this association was stronger in those patients who failed primary RT (P = 0.03). Moreover, we documented a higher rate of bcl-2 immunoreactive tumors in postirradiated biopsies from relapsed patients than in preirradiated ones (P = 0.03). In both univariate and multivariate analyses, bcl-2 expression was the most important indicator for disease-free survival (P = 0.08 and P = 0.01, respectively) and overall survival (P = 0.004 and P = 0.05) within 5 years of RT. The present study indicates that the proto-oncogene bcl-2 is abnormally expressed in some SCCHN, and its expression may prove to be a useful tool in selecting patients for conventional RT with clear prognostic implications.

Neoplasms of the basal ganglia

Neoplasms of the basal ganglia are deep-seated and this markedly impacts on therapy, especially with respect to the surgical approach. However, neoplasms purely involving the basal ganglia are rare: more frequently, basal ganglia are secondarily involved by tumors originating in the cerebral hemispheres, the ventricles and the pineal or suprasellar regions. Following an anatomical and epidemiologic overview, most frequent CT and MR imaging findings of pediatric neoplasms of basal ganglia are described.

Giant aneurysm of the pericallosal artery

A rare case of a giant aneurysm of the pericallosal artery, evaluated by computed tomography, magnetic resonance imaging, and angiography, is reported, and the other 7 cases in the literature are reviewed. Giant aneurysms are exceptional in the distal segments of the anterior cerebral arteries, and may simulate a callosal tumor or hematoma on computed tomographic scan. The clinical, radiological, surgical, and pathological findings of giant aneurysms of this location are discussed and the other reported cases are analyzed. The role of magnetic resonance imaging in diagnosing and characterizing giant aneurysms is stressed.

Lipoma of the sylvian region

An exceptional case of lipoma of the sylvian region is described and the other seven reported cases are reviewed. The sylvian fissure is the most rare site of intracranial lipomas. Sylvian lipomas may be asymptomatic or present with epileptic seizures due to irritation of the cortex of the sylvian fissure. Only two previous cases have been diagnosed during life by computerized tomography and operated on; the deep location of these lipomas and their adherences to the sylvian cortex and the branches of the middle cerebral artery make radical removal impossible and dangerous.

[MR vs CT: which is the diagnostic advantage in neuroradiology]

The comparative adequacy was studied of the two main neuroradiological imaging methods, MR imaging and CT, through the analysis of 1500 MR examinations with a preliminary CT study. The comparison was made by giving a score to the diagnostic contribution of MR imaging, especially as far as changes in the therapeutical approach were concerned. The results varied according to the various pathologies, to the different anatomical regions explored, and to the site of the masses. The overall score was higher in the spine and the spinal cord than in brain pathology. In brain neoplastic pathology, eg, the diagnostic capabilities of CT and MR imaging were similar in most cases, especially in supratentorial locations, while MR imaging was clearly superior in the spinal cord district. In infratentorial location, the better anatomical details make MR imaging the method of choice. In conclusion, CT confirms its accuracy in the detection of brain pathology, while MR imaging proves more sensitive in white matter diseases, and in particular locations, e.g. the posterior fossa. In the spine and spinal cord districts, the very high average score mainly confirms MR capability to demonstrate spinal canal normal and pathological content. Moreover, the important role of MR imaging is stressed in pediatric pathology, together with CT primary role in emergency cases.

Intracranial lipomas. Diagnostic and therapeutic considerations

Fourteen cases of intracranial lipomas are reported and 200 cases from the literature are reviewed. Intracranial lipomas are rare lesions of developmental origin, which mainly occur in the region of the corpus callosum, more rarely in the ambient, interpeduncular, cerebellopontine angle and sylvian cisterns. Although they are usually asymptomatic, they can sometimes show neurological symptoms, mainly epileptic seizures. Computerized tomography and magnetic resonance imaging usually lead to the diagnosis, because of the very low-density attenuation values of lipomas on CT scan and the short T1 and T2 on magnetic resonance. A direct surgical approach is only rarely indicated, whereas cases associated to hydrocephalus require a CSF shunt. The anticonvulsivant therapy usually results in remission of the seizures.

Cross-sectional echocardiography with pulsed and continuous wave Doppler in the management of ventricular septal defects

We designed this study in order to evaluate those cross-sectional echocardiographic projections of most value in the diagnosis of ventricular septal defects and to compare the techniques of cross-sectional and Doppler echocardiography in these lesions. We studied 71 cases with ventricular septal defects confirmed by cross-sectional and/or pulsed Doppler echocardiography. The defect was imaged by cross-sectional echocardiography in 49 patients but not imaged in 22. In the group of 49 patients, except two with pulmonary hypertension, pulsed Doppler enabled us to detect a left-to-right shunt at ventricular level. In the second group of 22 patients, a positive pulsed Doppler signal was detected in the ventricles although no defect was visualized. Pulsed Doppler examination supplemented the information detectable from cross-sectional echocardiography in small defects; in the diagnosis of multiple septal defects; in the presence of aortic valve regurgitation in doubly committed and subarterial defects; in those having residual shunts after surgical correction; and in those with tricuspid valve regurgitation in the setting of perimembranous defects. Continuous wave Doppler cannot always be reliably employed in the evaluation of transventricular pressure gradient because of a failure to align with the jet in the presence of poor signals. The sub-costal oblique projections and the introduction of the right oblique sub-costal view proved, in our hands, to be the most important tools for identifying and classifying the various types of ventricular septal defect.

Lipoma of the ambient cistern causing obstructive hydrocephalus

A 62-year-old patient with lipoma of the ambient cistern and marked hydrocephalus is described. Intracranial lipomas are maldevelopmental lesions, which rarely produce neurological symptoms. The anatomopathological and clinical features of the lipomas of the ambient cistern are reviewed on the basis of the other reported cases. The importance of the computerized tomography and nuclear magnetic resonance for the diagnosis and the indications for the surgery are also discussed.

Lateral thoracic meningocele

A case of intrathoracic meningocele is reported, and 95 cases from the literature are reviewed. Thoracic meningoceles are usually associated with neurofibromatosis; nevertheless their etiology remains controversial. The authors postulate the role of spinal trauma in some patients and the origin of the meningocele from an abnormal prolongation of a nerve sleeve in nontraumatic cases. Thoracic meningoceles often are asymptomatic or produce radicular intercostal pain. Spinal computed tomography is the most useful investigation, particularly in the exploration of large meningoceles. Surgery is required in symptomatic cases and usually results in remission of the pain.

Ectopic pregnancies associated with low dose progestagen-releasing IUDs

Dimethyl-polysiloxane capsules containing pure progestagens were attached to Tatum's T IUDs and tested in 594 fertile women for contraceptive performance. The control group was represented by 71 women who received identical devices containing barium sulphate instead of steroid and 100 women who received a Copper T-200. The progestagens and the doses tested were megestrol acetate (4.8, 19.2, 26 and 32 micrograms/day; levonorgestrel (2.1, 3.4 and 8.5 micrograms/day); norethindrone (18 micrograms/day); R2323 (28.6 and 45 micrograms/day); and norgestrienone (26 micrograms/day). Twelve pregnancies were diagnosed during 5201 woman-months of exposure accumulated within the first year of use among users of the steroid-bearing IUDs. Five of these were ectopic gestations. Ten pregnancies, all uterine, were detected during 1701 woman-months of exposure in the control group. Intrauterine delivery of progestagens by means of a carrier IUD is effective in decreasing the pregnancy rate but it might effect postovulatory events in a way which increases the rate of tubal implantation. Because of this property, progestagen-releasing IUDs should be limited to doses that assure maximal effectiveness to avoid increasing the risk of ectopic pregnancy.