Venous outflow as a criterion of impairment of cerebral vascular reserve

AIM

The purpose of this work is to evaluate if the asymmetry of venous outflow between the two hemispheres is a reliable criterion of impairment of the cerebral vascular reserve among symptomatic patients harbouring a spontaneous atherosclerotic occlusion of internal carotid artery.

METHODS

From January 1995 to December 2007, 7 symptomatic patients, affected from occlusion of internal carotid artery, were submitted to a low-flow by-pass between the superficial temporal artery and the middle cerebral artery owing to the presence of an impairment of cerebral vascular reserve diagnosed by TC-Doppler, SPECT or perfusion-CT with acetazolamide challenge. Conventional angiography was always performed. Angiographic studies of these patients were reviewed in order to find out the presence of asymmetry of the venous outflow. In the same period 35 patients harbouring an occlusion of the carotid artery in the neck and a normal cerebral reserve underwent cerebral angiography in our departments in Monza. Angiographic studies, of this latter group of patients, were also retrospectively analyzed with the same purpose.

RESULTS

All patients, with a poor cerebral reserve, showed an asymmetry of venous outflow >3 s omolateral at the carotid occlusion. Patients, with a normal cerebral reserve, showed an asymmetry of venous outflow <2 s.

CONCLUSIONS

Asymmetry of venous outflow were correlated to an impaired cerebral reserve also in chronic conditions as atherosclerotic spontaneous occlusion of internal carotid artery. Our data are a further support to the reliability of this criterion in case of therapeutic sacrifice of internal carotid artery.

Hemodynamic instability after extracranial carotid stenting

OBJECTIVE

Hemodynamic instability (hypertension, hypotension and bradycardia) is a well-known complication of carotid endarterectomy. Carotid angioplasty and stenting (CAS) is becoming a valuable alternative treatment for patients with severe carotid stenosis and increased surgical risk. CAS implies instrumentation of the carotid bulb, so baroceptor dysfunction may provoke hemodynamic instability. The aim of this work was to calculate the incidence of this complication and to detect factors to predict it.

METHODS

Medical records and angiograms of 51 consecutive patients submitted to CAS for severe atherosclerotic stenosis (40 cases) or postsurgical restenosis (11 cases) were retrospectively reviewed in order to detect the occurrence of intra- and post-procedural hypertension (systolic blood pressure >160 mmHg), hypotension (systolic blood pressure <90 mmHg) and bradycardia (heart rate <60 beats/min). The relationship between clinical, procedural and angiographic factors and the occurrence of hemodynamic instability was assessed with univariate and multivariate analysis (logistic regression).

RESULTS

Transient mild systolic post-procedural hypertension occurred in five cases (10%); preprocedural hypertension, asymptomatic stenosis and ipsilateral post-surgical restenosis predicted this. Hypotension with bradycardia also occurred in five cases (10%), one with neurological sequelae. Transient periprocedural bradycardia occurred in 19 cases (37%). Severe bradycardia without hypotension arose in one case only. Factors predicting post-procedural hypotension included the presence of a fibrous plaque and the ratio between the pre- and post-stenting diameter of the internal carotid artery. Peri-procedural bradycardia predicted post-procedural bradycardia. None of these factors were confirmed by multivariate analysis as a significant prognostic predictor.

CONCLUSION

Mild systolic hypertension may occur after CAS, but is resolved by medical treatment. Prolonged hypotension and bradycardia may also arise and this can be dangerous because it may cause neurological deterioration due to hypoperfusion. These complications cannot be predicted by clinical, procedural, and angiographic factors.

APOE influences vasospasm and cognition of noncomatose patients with subarachnoid hemorrhage

OBJECTIVE

To determine the influence of the APOE genotype on functional and cognitive outcome and on the incidence and prognosis of clinical vasospasm (delayed ischemic neurologic deficit [DIND]) in noncomatose patients with aneurysmal subarachnoid hemorrhage (SAH).

METHODS

The authors reviewed the data of patients admitted for SAH to the Neurosurgical Departments of the San Gerardo Hospital of Monza (January 1996 to December 2001) and the Ospedali Riuniti of Bergamo (January 2002 to September 2003). The authors considered only noncomatose patients and evaluated outcome by means of the Rankin Disability Index and the Mini-Mental State Examination at least 6 months after the SAH.

STATISTICAL ANALYSIS

Uni- and multivariate logistic regression.

RESULTS

The authors included 101 patients. They found the epsilon4 allele in 26 patients (25.7%). The presence of the epsilon4 allele negatively affected the overall outcome (functional morbidity or cognitive morbidity, or both) (p = 0.0087) and, particularly, cognitive morbidity (p = 0.0028). Those with an epsilon4 allele had delayed ischemic neurologic deficit DINDs more frequently (p = 0.024) and, in the presence of DIND, they were more likely to show permanent neurologic deficits (p = 0.0051).

CONCLUSIONS

ApoE4 negatively affects cognitive morbidity and delayed ischemic neurologic deficit recovery. The presence of an epsilon4 allele increases the risk of delayed ischemic neurologic deficit.

The headache in the Emergency Department

The headache is a very frequent symptom and represents the 0.36%-2.5% of all reasons of claim to Emergency Department. Even if it is rarely related to high risk diseases, it is mandatory to promptly differentiate life-threatening conditions. In order to establish a correct diagnostic and therapeutic pathway and ask for aimed specialistic consultation, the emergency physician must be familiar with the various categories of headache. It is important to distinguish between essential headache and secondary headache. All patients presenting to the emergency department with the complaint of headache should be interviewed carefully regarding their history. The quality of pain associated with the intensity, location, rate, duration, modality of onset, relieving or worsening conditions, response to drugs, symptoms or signs associated must be investigated as well. Careful neurological examination including the vision of fundus oculi and the evaluation of rigor nucalis can provide further important diagnostic information. Laboratory exams do not usually give significant issues in the majority of patients with headache. However, dosage of inflammation index can be useful when an infective or inflammatory disease is suspected. CT scan can rule-out the suspicion of organic intracranial causes. When the physician suspects meningitis or subarachnoid hemorrhage (SAH) not showed by CT scanning, rachicentesis can turn out diagnostic. The modality of onset, clinical characteristics and differential diagnosis of subarachnoid hemorrhage, intracranial hypertension, colloidal cyst of the third ventricle, trigeminal neuralgia, temporal arteritis and pituitary adenomas and apoplexy will be discussed. These diseases are not only of neurological and neurosurgical interest, but involve also the physician in the Emergency Department.

Clinical characteristics and factors predicting evolution of asymptomatic IgM monoclonal gammopathies and IgM-related disorders

We evaluated the prognostic features of 384 asymptomatic IgM-monoclonal gammopathies (aIgM-MGs) and 74 IgM-related disorders (IgM-RDs), two clinically distinct groups as proposed by the Second International Workshop on Waldenström's Macroglobulinemia (WM). The cumulative probability of evolution to lymphoid malignancy at 5 and 10 years was 8% (95% CI, 5-13%) and 29% (95% CI, 21-38%), respectively, in aIgM-MGs; it was 9% (95% CI, 4-20%) and 16% (95% CI, 7-31%), respectively, in IgM-RDs (P=0.26). At a median follow-up of 45 months (12-233), 45 aIgM-MGs (11.7%) evolved to symptomatic WM (n=41), non-Hodgkin's lymphoma (NHL) (n=2), IgM multiple myeloma (n=1), and primary amyloidosis (n=1). At a median follow-up of 60 months (13-195), seven IgM-RDs (9.5%) evolved to symptomatic WM (n=6), and B-chronic lymphocytic leukaemia (n=1). At univariate analysis, in aIgM-MGs bone marrow lymphoplasmacytic infiltration, high erythrocyte sedimentation rate (ESR), haemoglobin level, IgM size, and lymphocytosis significantly correlated with evolution probability. At multivariate analysis, the latter two parameters strongly correlated with prognosis, haemoglobin being associated with a trend for a higher progression risk. In IgM-RDs IgM size, neutropenia, lymphocytosis, detectable Bence Jones proteinuria, and high ESR were associated with evolution probability. In conclusion, asymptomatic IgM-MGs and IgM-RDs are distinct clinical entities with similar probability of transformation to lymphoid malignancy.

Peripheral blood progenitor cell mobilization in healthy donors receiving recombinant human granulocyte colony-stimulating factor

OBJECTIVE

We analyzed the incidence of primitive (LTC-IC) and committed (CFU-mix, BFU-E, CFU-GM) hematopoietic progenitors detected under steady-state conditions and upon progenitor cell mobilization in a cohort of healthy donors receiving recombinant human granulocyte colony-stimulating factor (rhG-CSF).

MATERIALS AND METHODS

Healthy donors (n = 30) of HLA-mismatched or -matched stem cell transplants were mobilized with rhG-CSF (8 microg/Kg body weight subcutaneously twice daily until completion of leukapheresis). PBPC collections were started after 4 days of rhG-CSF therapy.

RESULTS

Steady-state incidence of bone marrow LTC-IC, but not committed progenitors, significantly correlated with the numbers of mobilized CD34+ cells (r = 0.6, p = 0.004), CFU-GM (r = 0.79, p = 0.0005) and CFC (r = 0.76, p = 0.001) detected after 4 days of rhG-CSF therapy. Statistically significant correlations were also found between steady-state blood CFU-GM and peak numbers of CD341 cells (r = 0.68, p = 0.001), numbers of day 4 CD341 cells (r = 0.52, p = 0.005), CFU-GM (r = 0.63, p = 0.002), and CFC (r = 0.61, p = 0.003).

CONCLUSION

Our data show that in normal volunteers baseline marrow LTC-IC and blood CFU-GM correlate with rhG-CSF-mobilized PBPC. The potential clinical relevance of these findings in the identification of poor mobilizers will be tested in a prospective study.

Clonogenic potential and phenotypic analysis of CD34+ cells mobilized by different chemotherapy regimens

BACKGROUND AND OBJECTIVE

Since limited data concerning quantitative and qualitative differences of CD34+ cells collected after different mobilization schedules are available, we investigated phenotype, proliferative capacity and primitive progenitor cell content of CD34+ cells mobilized with four different regimens.

DESIGN AND METHODS

The number, phenotype, and progenitor cell content of CD34+ cells were investigated in 46 patients mobilized with cyclophosphamide (CY) 7 g/m(2) plus granulocyte colony-stimulating factor (G-CSF, 5 microg/kg) (CY7+G-CSF) (n=16), CY 4 g/m(2) plus G-CSF (CY4+G-CSF) (n=8), IVE [ifosphamide (2.5 g/m(2) for 3 d), etoposide (150 mg/m(2) for 3 d), epirubicin (100 mg/m(2) on day 1)] plus G-CSF (IVE+G-CSF) (n=9), or G-CSF (10 microg/kg) alone (n=13).

RESULTS

The number of CD34+ cells collected per liter of processed blood was significantly higher in the CY7+G-CSF group than in the CY4+G-CSF and G-CSF groups (p </= .005), but not the IVE+G-CSF group. As compared to patients in the CY4+G-CSF group, those mobilized with CY7+G-CSF and IVE+G-CSF produced significantly lower percentages of CD34+ cells lacking CD38, CD33, CD45RA, and HLA-DR (p </= .016, at least). In addition, CY4+G-CSF mobilized CD34+ cells had a significantly higher plating efficiency than the cells mobilized in other ways (p </= r .036). In the G-CSF group, colony-forming cells and long-term culture-initiating cells were significantly lower than in the CY groups (p </= .0014 and </= 013, respectively).

INTERPRETATION AND CONCLUSIONS

Our data demonstrate that: (i) different mobilization regimens allow the collection of CD34+ cells with distinct phenotypic and proliferative features; (ii) evaluation of the absolute number of CD34+ cells by itself is not a reliable indicator of the clonogenic content of blood mobilized with different chemotherapy regimens; (iii) because of the substantial impact that chemotherapy regimens have on the quantity and quality of collected CD34+ cells, anticancer effects and optimal blood progenitor cell yields should be evaluated for each chemotherapy schedule.

Ocular presentation and successful outcome of invasive sphenoid sinus aspergillosis in acute myelogenous leukemia

We report the case of a 73-year-old male with acute myelogenous leukemia, who progressively developed a cavernous sinus syndrome during the aplastic phase after induction chemotherapy. Although the clinical, serological and radiological findings suggested an invasive sphenoid sinus aspergillosis, endoscopic ethmoido-sphenoidectomy allowed definitive diagnosis of the infection. After surgery, fungal eradication and reversal of the neurophtalmological damage paralleled complete hematologic remission. The differential diagnoses of the patient ocular symptoms are discussed. Early recognition, prompt intervention and immunologic reconstitution are essential for successful outcome of paranasal mycoses in immunosuppressed patients.

CD34+ cells mobilized by cyclophosphamide and granulocyte colony-stimulating factor (G-CSF) are functionally different from CD34+ cells mobilized by G-CSF

Mobilized peripheral blood progenitor cells (PBPC) are increasingly used as an alternative to bone marrow for autografting procedures. Currently, cyclophosphamide (CY) followed by granulocyte colony-stimulating factor (G-CSF) or G-CSF alone are the most commonly used PBPC mobilization schedules. In an attempt to investigate whether the use of these two mobilization regimens could result in the collection of functionally different CD34+ cells, we analyzed nucleated cells (NC), CD34+ cells, committed progenitor cells and long-term culture initiating-cells (LTC-IC) in 52 leukaphereses from 26 patients with lymphoid malignancies, mobilized either by CY+G-CSF (n=16) or G-CSF alone (n=10). Thirty-four aphereses from the CY+G-CSF group and 18 aphereses from the G-CSF group were investigated. According to the study design, leukaphereses were carried out until an average number of 7 x 10(6) CD34+ cells/kg body weight were collected. The mean (+/-s.e.m.) numbers of CD34+ cells mobilized per apheresis by CY+G-CSF and G-CSF were not significantly different (2.76+/-0.6 x 10(8) vs 2.53+/-0.4 x 10(8), P < or = 0.7). This resulted from a mean number of NC that was significantly lower in the CY+G-CSF products than in the G-CSF products (12.4+/-1.7 x 10(9) vs 32+/-5.4 x 10(9), P < or = 0.0001) and a mean incidence of CD34+ cells that was significantly higher in the CY+G-CSF products than in the G-CSF products (2.9+/-0.6% vs 0.9+/-0.2%, P < or = 0.0018). The mean (+/-s.e.m.) number of CFU-GM collected per apheresis was significantly higher in the CY+G-CSF group than in the G-CSF group (37+/-7 x 10(6) vs 14+/-2 x 10(6), P < or = 0.03). Interestingly, CY+G-CSF-mobilized CD34+ cells had a significantly higher plating efficiency than G-CSF-mobilized CD34+ cells (25.5+/-2.9% vs 10.8+/-1.9%, P < or = 0.0006). In addition, the mean number of LTC-IC was significantly higher in the CY+G-CSF products than in the G-CSF products (6.3+/-1 x 10[6] vs 3.3+/-0.3 x 10[6], P < or = 0.05). In conclusion, our data provide evidence that CY+G-CSF and G-CSF induce the mobilization of CD34+ cells with different clonogenic potential. As mobilized PBPC containing large numbers of progenitors lead to safer transplantation, this issue may have implications for planning mobilization strategies.

Clonogenic capacity and ex vivo expansion potential of umbilical cord blood progenitor cells are not impaired by cryopreservation

Umbilical cord blood (UCB) progenitor cells have been demonstrated to possess significant advantages over bone marrow (BM), in terms of proliferative capacity and immunologic reactivity. Therefore, UCB has been recently considered an attractive potential alternative to BM as a source of hematopoietic progenitor cells for clinical applications. Since several programs throughout the world are currently evaluating the feasibility of large-scale UCB banking for unrelated transplants, it was the aim of this study to evaluate whether cryopreservation procedures might heavily impair the clonogenic capacity, the feasibility of CD34+ selection and the ex vivo expansion potential of UCB progenitor cells. UCB samples were collected and cryopreserved as unseparated (n = 21) or mononuclear (MNC) cells (n = 15) within 12 h from delivery, and evaluated for viability, immunophenotype, cell and progenitor numbers after a minimum stay in liquid nitrogen of 6 months (range 6-14 months). Viability was always > 97% and no statistically significant difference was detected by flow cytometric analysis. Clonogenic recovery from unseparated cells was 80-87% for HPP-CFC, CFU-GEMM, BFU-E and CFU-GM, and from MNC cells ranged from 82 to 91% for LTC-IC, CFU-GEMM, BFU-E and CFU-GM. CD34+ selection (n = 8) was performed on fresh and cryopreserved MNC cells using the MiniMACS immunomagnetic separation device, showing no difference in yield (68 +/- 7% vs 57 +/- 4%, P < or = 0.4) or in purity (89 +/- 2% vs 81 +/- 6%, < or = 0.4), for fresh in comparison to cryopreserved MNC cells. After 14 days of liquid culture in the presence of different combinations of SCF, IL-3, IL-6 and G-CSF no statistically significant difference was detected in CFC fold-expansion for fresh or cryopreserved MNC cells and for CD34+ cells, either selected and cultured from fresh or cryopreserved MNC cells. In conclusion we can state that UCB is a potential source of primitive progenitor cells that can be cryopreserved unmanipulated or after physical separation without major losses in clonogenic capacity and immunophenotypic composition. Moreover, CD34+ selection from cryopreserved MNC cells is feasible and ex vivo expansion is not impaired. These results have important implications in the large scale UCB banking, in view of the potential applications of ex vivo expanded hematopoietic progenitor cells for the engraftment of adult patients.

In vitro growth of mobilized peripheral blood progenitor cells is significantly enhanced by stem cell factor

The existence of primitive hematopoietic progenitors in mobilized peripheral blood is suggested by clinical, phenotypic and in vitro cell culture evidences. In order to quantify primitive progenitors, 32 leukaphereses from 15 patients with lymphoid malignancies were investigated for the growth of multilineage colony-forming units (CFU-Mix), erythroid burst-forming units (BFU-E) and granulocyte-macrophage colony-forming units (CFU-GM) in the absence or presence of recombinant stem cell factor (SCF), a cytokine which selectively controls stem cell self-renewal, proliferation and differentiation. Primitive progenitors were also quantitated by means of a long-term assay which allows the growth of cells capable of initiating and sustaining hematopoiesis in long-term culture (LTC-IC). Addition of SCF (50 ng/ml) to methyl-cellulose cultures stimulated with maximal concentrations of G-CSF, GM-CSF, interleukin 3 and erythropoietin significantly increased the growth (mean +/- SE) of CFU-Mix (7.7 +/- 1.7 versus 2.4 +/- 0.6, p < or = 0.0001), BFU-E (47 +/- 10 versus 32 +/- 6, p < or = 0.002) and CFU-GM (173 +/- 31 versus 112 +/- 20, p < or = 0.0001). Mean (+/- SE) percentages of SCF-dependent CFU-Mix, BFU-E and CFU-GM were 60 +/- 5%, 19 +/- 5%, and 33 +/- 4%, respectively. Mean (+/- SE) LTC-IC growth per 2 x 10(6) nucleated cells was 221 +/- 53 (range, 2 to 704). Linear regression analysis demonstrated a statistically significant correlation (r = .87; p < or = 0.0001) between LTC-IC and SCF-dependent progenitors. In conclusion, our data suggest that: A) the optimal quantification of mobilized progenitors requires supplementation of methylcellulose cultures with SCF, and B) in vitro detection of SCF-dependent progenitors might represent a reliable and technically simple method to assess the primitive progenitor cell content of blood cell autografts. Such in vitro evaluation of immature hematopoietic progenitors might be clinically relevant for predicting the reconstituting potential of autografts.

Transfusion-transmitted human parvovirus B19 infection in a thalassemic patient

BACKGROUND

Human parvovirus (HPV) B19 infection has been shown to be transmissible by clotting factor concentrates, most often resulting in asymptomatic seroconversion. So far, no case of B19 transmission due to single-donor transfusion has been documented.

CASE REPORT

A case of transfusion-transmitted HPV B19 infection in a 22-year-old female thalassemia major patient is described. She presented with an aplastic crisis; this was followed 1 week later by transitory heart failure and acute tricuspid incompetence. The echocardiogram revealed a grade III tricuspid regurgitation and a floating vegetation on the atrial face of the tricuspid lateral leaflet. The tricuspid regurgitation and vegetation spontaneously disappeared within 15 days. Blood cultures for bacteria were repeatedly negative. IgM anti-HPV B19 seroconversion was documented in the acute phase. B19 DNA was detected by polymerase chain reaction and remained detectable up to 4 months after diagnosis. High-titer IgM anti-HPV and B19 DNA were also found in serum samples collected at the time of donation from one of the donors of the blood transfused before the onset of clinical symptoms.

CONCLUSION

This case documents the transmission of HPV B19 by the transfusion of 1 red cell unit and the occurrence of possible transient cardiac involvement in this infectious complication.