Trans-sulcal versus trans-parenchymal approach in supratentorial cavernomas. A multicentric experience

OBJECTIVES

Cavernous malformations (CM) are low-flow vascular lesions that can cause significant symptoms and neurological deficits. Different intraoperative surgical approaches have been developed. Aim of the present investigation is the comparison between the trans-sulcal approach (TS) and the trans-parenchymal neuronavigation-assisted approach (TPN) in a surgical series from two neurosurgical centers. The technique and clinical outcomes are discussed, with a specific focus on seizure outcome.

PATIENTS AND METHODS

Clinical and radiological data from two neurosurgical centers ("A. Gemelli" Hospital in Rome and A.O.U. Città della Salute e della Scienza in Turin) were retrospectively reviewed in order to evaluate the different outcome of TS and TPN approach for cavernous malformation treatment.

RESULTS

A total of 177 patients underwent surgical intervention for supratentorial CM, 130 patients with TPN approach and 47 with TS approach. TS approach was associated with higher rate of seizure in early post-operative period both in epileptic patients (p < 0,001) and in patients without history of seizures before surgery (p = 0,002). Moreover, length of incision (p < 0,001), area of craniotomy (p < 0,001) and corticectomy (p < 0,001) were bigger in TS than in TPN approach. Brain contusion (p < 0,001) and fluid collection (p < 0,001) were more likely to be discovered after TS approach.

CONCLUSIONS

TPN is a valuable approach for resection of CM. Minor complications are significantly lower in TPN approach when compared with TS approach. In addition, it is associated with lower rate of early post-operative seizure and shorter length of stay.

1203. Epidemiology of Respiratory Viruses in Influenza-Vaccinated Healthcare Workers During an H1N1-Dominant Season

Background

Respiratory pathogens are an important cause of morbidity and mortality in hospitalized patients and nosocomial spread of such pathogens is known to occur. However, little is known about the epidemiology of respiratory viruses in healthcare workers (HCW).

Methods

Between December 28, 2018 and April 26, 2019 enrolled HCW completed a weekly symptom diary, including presence or absence of respiratory symptoms, flu exposure history and whether they received medical attention. Vaccination and flu infection history were collected on enrollment. Participants self-collected flocked nasopharyngeal (NP) swabs every other week and if they reported any symptom on the weekly diary. These were tested using a multiplex PCR platform (Biofire, Salt Lake City, UT) with targets for 14 respiratory viruses. Symptomatic HCW with influenza or respiratory syncytial virus (RSV) were notified and followed policy regarding work restriction.

Results

66 HCWs provided baseline data and 57 continued data submission (9 withdrew). The active participants included 13 nurses (22.8%), 7 advanced practice providers (12.3%), 18 physicians (31.6%), and 19 other (33.3%). Participants received quadrivalent inactivated flu vaccine this season (2 self-reported/unknown type). Compliance was 89.8% (749 of 834) with weekly diary completion and 83.3% (378/454) for biweekly NP swabs. Thirty-nine unique participants reported symptoms on weekly diaries 100 times and submitted 88 total “symptomatic” NP swabs (88% compliance). Of these, 16 swabs revealed any pathogen (18.2%) and 3 had influenza H3N2 (18.8%) (only one reported fever). Other pathogens identified are detailed in Figure 1. 12 of the 366 asymptomatic swabs were positive for respiratory viruses (23.3%, see Figure 1). No participant had asymptomatic influenza.

Conclusion

Pauci-symptomatic influenza has been previously described by our group and others and is noted even in this small cohort. While asymptomatic flu was not found, there were several cases of other asymptomatic respiratory viruses in HCW. Analysis of the impact on patients is still underway from this cohort but the initial data suggest that patients are at risk of contracting healthcare-acquired respiratory infection even from health care providers.

Disclosures

All authors: No reported disclosures,

Assessing Restoration Effects on River Hydromorphology Using the Process-based Morphological Quality Index in Eight European River Reaches

The Morphological Quality Index (MQI) and the Morphological Quality Index for monitoring (MQIm) have been applied to eight case studies across Europe with the objective of analyzing the hydromorphological response to various restoration measures and of comparing the results of the MQI and MQIm as a morphological assessment applied at the reach scale, with a conventional site scale physical-habitat assessment method. For each restored reach, the two indices were applied to the pre-restoration and post-restoration conditions. The restored reach was also compared to an adjacent, degraded reach. Results show that in all cases the restoration measures improved the morphological quality of the reach, but that the degree of improvement depends on many factors, including the initial morphological conditions, the length of the restored portion in relation to the reach length, and on the type of intervention. The comparison with a conventional site scale physical-habitat assessment method shows that the MQI and MQIm are best suited for the evaluation of restoration effects on river hydromorphology at the geomorphologically-relevant scale of the river reach.

New tools for the hydromorphological assessment and monitoring of European streams

Hydromorphological stream assessment has significantly expanded over the last years, but a need has emerged from recent reviews for more comprehensive, process-based methods that consider the character and dynamics of the river with greater accuracy. With this as a focus, a series of hydromorphological tools have been developed and/or further extended in Europe within the context of the REFORM (REstoring rivers FOR effective catchment Management) project. The aim of this paper is to present the set of REFORM hydromorphological assessment methods and, based on some examples of their application, to illustrate and discuss their synergic use, specific features, limitations and strengths. This assessment and monitoring includes three tools: the Morphological Quality Index (MQI), the Morphological Quality Index for monitoring (MQIm), and the Geomorphic Units survey and classification System (GUS). These tools constitute the assessment phase of an overall multi-scale, process-based hydromorphological framework developed in REFORM. The MQI is aimed at an assessment, classification and monitoring of the current morphological state; the MQIm aims at monitoring the tendency of morphological conditions (enhancement or deterioration); the GUS provides a characterization, classification and monitoring of geomorphic units. A series of examples are used to illustrate the potential range of application, including: (i) an assessment of morphological conditions; (ii) an assessment of the morphological effects of restoration projects; (iii) an evaluation of the geomorphic impacts of interventions for risk mitigation; and (iv) an integrated use of MQI and GUS to assess and characterise morphological conditions. Finally, some of the main features, strengths and peculiarities of the three hydromorphological tools are discussed with the support of examples of their application.

Protective effect of external ventricular drainage on cerebral vasospasm. A retrospective study on aneurysmal SAH treated endovascularly

OBJECTIVE

Cerebral vasospasm (VS) is one of the factors that can most significantly worsen the prognosis after aneurysmal subarachnoid hemorrhage (SAH). A substantial body of evidence supports the idea that CSF diversion could prevent VS, even if this issue is still much debated. External ventricular drainage (EVD) is the recommended procedure for post-hemorrhagic hydrocephalus. In this study we analyzed whether EVD, placed for acute hydrocephalus, is effective in reducing the incidence of clinical and radiological cerebral vasospasm in patients who underwent endovascular treatment for aneurysmal SAH.

PATIENTS AND METHODS

We retrospectively studied the incidence of radiologically confirmed VS in 141 patients treated endovascularly for aneurysmal SAH: 80 underwent EVD for hydrocephalus, 61 did not undergo EVD.

RESULTS

VS occurred in 8.75% of cases (7 patients) in the first groups, while in 22.95% (14 patients) in the second group. In addition, patients not treated with EVD display a prevalence of VS in lower Fisher grades compared to the other group.

CONCLUSION

Our data indicate that CSF drainage reduces the risk of vasospasms in patients with endovascular treatment for aneurysmal SAH.

Anatomical variants of the basal vein of Rosenthal: prevalence in idiopathic subarachnoid hemorrhage

BACKGROUND

Spontaneous, non traumatic subarachnoid hemorrhage (SAH) is a significant clinical problem that occurs most commonly as a result of aneurysm rupture. In approximately 15 % of cases, nor aneurysm or other vascular malformation can be identified by cerebral angiography as origin of the hemorrhage, and these are commonly defined as idiopathic SAH (ISAH). Because of the negative angiography, limited extension of the bleeding with prevalent prepontine pattern and the benign prognosis, the venous causes has been preferred rather than the arterial ones. In the literature recent studies have suggested a possible contribution by primitive variants of Basal vein of Rosenthal (BVR) in its the pathogenesis of ISAH, commonly grouped according Watanabe classification (type A, B and C). In this paper we evaluated the prevalence of anatomical variants of BVR in ISAH.

METHODS

Venous drainage at angiography was retrospectively analyzed in 40 patients with ISAH and in 40 with unruptured aneurysms as controls.

RESULTS AND CONCLUSIONS

Previous studies displayed a significant prevalence of BVR type C variants in ISAH. Conversely in our study we recognized variant B as prevalent, in which the BVR bifurcates to drain anteriorly into the uncal vein and posteriorly into the Galenic system. Similarly to variant C (in which the BVR drains via perimesencephalic "bridging" veins into cavernous, sphenoparietal, petrosal sinus or directly into transverse sinus) also variant B might be subjected to those stress mechanisms and intrinsic system 'fragility' and for reasons yet to determine, sets off a consequent hemorrhage with clinical and radiological features typical of ISAH.

Transcriptional profile characterization for the identification of peripheral blood biomarkers in patients with cerebral aneurysms

We tried to identify molecular markers in peripheral blood to predict high risk of aneurysm rupture. Extraction of the total population of peripheral blood mononuclear cell (PBMC) from total blood volume, total RNA extraction from PBMC and Agilent One Color Gene-expression Oligo-Microarray were performed on peripheral venous blood samples from 45 patients with ruptured, unruptured cerebral aneurysms and control group (15). Mean foreground/ background signal intensities and A (log2(R*G)/2) values were calculated for each spot. Genes with absolute fold change (FC) greater than or equal to plus or minus 1.5 and p-value less than 0.05 were considered differentially expressed in the 3 groups (Student T-test). Genes coding for MMPs were strongly underexpressed in ruptured aneurysms group, suggesting a possible role in aneurysms development more than their rupture. Genes coding for adhesine proteins of the extracellular matrix (ICAM1) and cytoskeleton (WIPF1,TUBA4A) were underexpressed in ruptured aneurysms. Genes coding proteins involved in the regulation of apoptotic processes may be important in aneurysm development and rupture, resulting into an increased rate of remodeling processes in the arterial wall. Fas coding gene, SUMO1, ZFAT, BCL2, CCR5 genes were all over-represented in unruptured aneurysms. The coexisting over-representation of pro-apoptotic genes and the underexpression of cytoskeleton and extracellular matrix genes confirms that aneurysms development and evolution are part of a degenerative process of the arterial wall not involved in aneurysms rupture. MMPs may be involved in repairing chronic damages to the arterial walls and preventing SAH. Unexpectedly, Heat Shock Proteins (HSP90AA1, HSPA1A, HSPB1), G and RAS proteins, generally activated by stress situations were under-represented in aneurysmal walls. Further PCR and Western Blotting studies are needed to confirm such findings and to identify diagnostic and prognostic markers in order to define screening protocols for intracranial aneurysms.

Nanotechnology and vascular neurosurgery: an in vivo experimental study on microvessels repair using laser photoactivation of a nanostructured hyaluronan solder

Sealing tissues by laser in neurosurgical procedures may overcome problems related to the use of conventional suturing methods which can be associated with various degrees of vascular wall damage. Despite the significant experimental and clinical achievements of the past, a standardized clinical application of laser-welding technology has not yet been implemented. The main problem is related to the use of common organic chromophores. A substantial breakthrough in the laser welding of biological tissues may come from the advent of nanotechnologies. In this paper we describe an experimental study, to confirm the feasibility of an innovative laser-assisted vascular repair (LAVR) technique based on diode laser irradiation and subsequent photoactivation of a hyaluronan solder embedded with near infrared (NIR) absorbing gold nanorods (GNRs), and to analyze the induced closuring effect in a follow-up study performed in animal model. Twenty New Zealand rabbits underwent closure of a 3-mm longitudinal incision performed on the common carotid artery (CCA) by means of 810 nm diode laser irradiation, in conjunction with the topical application of an optimized GNR composite. Effective closure of the arterial wound was accomplished by using very low laser intensity (30 W/cm2). The average CCA occlusion time was as low as 50 sec. Animals underwent different follow-up periods (2, 8, 30 days). After follow-up, they were re-anesthetized, the patency of the treated vessels was tested (Doppler analysis) and then the irradiated vessels were excised and subjected to histological evaluations. Morphological examinations of the samples documented the integrity of the vascular wall. No host reaction to nanoparticles occurred. Collagen and elastic fibers returned to their normal architecture 30 days after treatment. A Scanning Electron Microscopy (SEM) examination and immuno-histochemical analysis demonstrated a full re-endothelization of the vessel walls. We thus confirmed that a laser-based approach is technically easy to perform, and provides several advantages, such as a simplification of the surgical procedure, a reduction in the operative time, and the suppression of bleeding. The use of GNRs improves the selectivity of welding and minimizes the surgical trauma to vessels, resulting in an optimal healing process.

A computational model to compare different investment scenarios for mini-stereotactic frame approach to deep brain stimulation surgery

Deep brain stimulation (DBS) alleviates symptoms of many neurological disorders by applying electrical impulses to the brain by means of implanted electrodes, generally put in place using a conventional stereotactic frame. A new image guided disposable mini-stereotactic system has been designed to help shorten and simplify DBS procedures when compared to standard stereotaxy. A small number of studies have been conducted which demonstrate localization accuracies of the system similar to those achievable by the conventional frame. However no data are available to date on the economic impact of this new frame.

AIM

The aim of this paper was to develop a computational model to evaluate the investment required to introduce the image guided mini-stereotactic technology for stereotactic DBS neurosurgery.

METHODS

A standard DBS patient care pathway was developed and related costs were analyzed. A differential analysis was conducted to capture the impact of introducing the image guided system on the procedure workflow. The analysis was carried out in five Italian neurosurgical centers.

RESULTS

A computational model was developed to estimate upfront investments and surgery costs leading to a definition of the best financial option to introduce the new frame. Investments may vary from Euro 1.900 (purchasing of Image Guided [IG] mini-stereotactic frame only) to Euro 158.000.000. Moreover the model demonstrates how the introduction of the IG mini-stereotactic frame doesn't substantially affect the DBS procedure costs.

[Plastic industry and exposure to carcinogenic chemical agents: an Italian Multicentric Study in Lombardy]

The potential carcinogenic risk at the workplaces is a primary interest of occupational health, but some questions are also controversially discussed. Particularly, in the plastic forming industry a great attention was directed to the hot processing and their possible exposure to monomers, some of which were classified as carcinogen by the International Agency for Research on Cancer (IARC) and/or the European Union (EU). In Lombardy, a study on occupational exposure to chemical carcinogens in the plastic forming industry was planned during last years. The aim was to recognize and promote preventive technical and medical solutions, basing on efficacy. By an investigation at workplace supported with standardized questionnaires, the presence of chemical carcinogens was registered in 59% of a representative sample of firms; but an effective possibility of exposure was found only for 34% of cases. The evaluation of exposure to monomers by air monitoring (acrylonitrile, 1,3-butadiene, styrene, formaldehyde), involving a representative sample of factory with ABS and formaldehydic resins processing, showed low level exposure, because the common hygienic prevention measures were applied; some particular occupation shoved greater exposure to formaldehyde.

Middle cerebral artery dolichoectasia in a young woman with a previous stroke

We observed a 32-year-old female who had suffered from a left hemisphere ischemic stroke with right hemiparesis at the age of seven. At that time, a CT scan demonstrated a left ischemic lesion in nucleo-capsular region and a cerebral angiogram documented a complete occlusion of the supraclinoid segment of the internal carotid artery. When we observed the patient neurological examination demonstrated a moderate right brachio-crural hemiparesis. A brain MRI showed an old ischemic lesion involving the left nucleo-capsular and 'flow voids' suggestive for a vascular malformation in the left sylvian region. A cerebral rotational angiogram with 3-D reconstructions demonstrated a dolichoectatic left middle cerebral artery with an unusual 'corkscrew' aspect. Middle cerebral artery dolichoectasia is a rare pathological condition that may manifest with a stroke. The patients with intracranial arterial dolichoectasia (IADE) are most often hypertensive elderly men, and, to the best of our knowledge, an ischemic stroke associated with IADE has never been reported in children.

Chronic anaemia and adhesion molecules in patients with liver cirrhosis. A preliminary report

AIM

The aim of our study was to investigate circulating levels of intercellular adhesion molecule-1 (sICAM-1) and vascular cellular adhesion molecule-1 (sVCAM-1) in cirrhotic patients, with and without chronic anaemia, to establish whether there was a relationship between inflammatory activity and anaemia.

METHODS

We investigated 14 anaemic (mean hemoglobin value 10.65+/-1.06 g/dL) and 14 non anaemic (mean hemoglobin value 13.8+/-0.89 g/dL) subjects affected by virus C-related liver cirrhosis comparable for sex, age and degree of liver dysfunction such as expressed by Child-Pugh classification. Circulating sICAM-1 and sVCAM-1 were measured by EIA commercial kit (R&D System Co, Abington, UK) and mean+/- standard deviation values in two groups were compared by t-test and Kruskall-Wallis test.

RESULTS

Mean+/-standard deviation sICAM-1 was 35.06+/-4.06 ng/mL in anaemic and 23.39+/- 6.1 ng/mL in non anaemic cirrhotic patients. Mean+/-standard deviation sVCAM-1 was 47.66+/-8.18 ng/mL in anaemic 31.77+/-6.08 ng/mL in non anaemic patients, respectively. Statistical analysis showed a significant difference between the two groups both in sICAM-1 (p=0.01) and sVCAM-1 (p=0.03) values.

CONCLUSIONS

Our study show that chronic anaemia, in liver cirrhosis, is associated to a greater increase of circulating adhesion molecules and suggests that inflammation may contribute to persistence of anaemic state, worsening the outcome of cirrhotic patients.

Pharmacogenomic analysis of rhIL-11 treatment in the HLA-B27 rat model of inflammatory bowel disease

Recombinant human interleukin-11 (rhIL-11) reduces the clinical signs and histological lesions of inflammatory bowel disease (IBD) in transgenic rats expressing the human major histocompatability complex (MHC) class I allele, HLA-B27. To elucidate the pharmacogenomic effects of rhIL-11 in this model, we examined the global gene expression pattern in inflamed colonic tissue before and following rhIL-11 treatment using oligonucleotide microarrays. In total, 175 disease-related genes were identified. Increased expression of genes involved in antigen presentation, cell death and inflammation, and decreased expression of metabolic genes was associated with disease. A total of 27 disease-related genes returned to normal expression levels following rhIL-11 treatment including the MHC class II gene RT1-DMbeta. rhIL-11 induced the expression of four intestinal epithelial growth factors. These gene expression patterns indicate that treatment of inflammatory bowel disease with rhIL-11 affects class II antigen processing and colonic epithelial cell proliferation and metabolism.

ICP and CBF regulation: effect of the decompressive craniectomy

The view of the intracranial system as a rigid and closed box has been criticised by many authors who take into account the possibility of a certain degree of elastic bulk accommodation, mainly in the spinal sac. In nine patients, who underwent decompressive craniectomy for treatment of life-threatening intracranial hypertension, when the clinical conditions improved, just before cranioplasty, the blood flow velocities at middle cerebral artery (MCA) and at superior sagittal sinus (SSS) level were simultaneously recorded. The measurements were repeated after cranioplasty. The blood flow velocity recorded from SSS in craniectomized patients appeared flat, without evident pulsation; after cranioplasty a clear-cut pulsatile wave became again evident. The disappearance of a pulsatile shape in the blood flow velocity recorded from the SSS when the intracranial system was "open" and the reappearance of a pulsatile blood flow waveform after the "closure" of the skull confirm that the venous bed acts as a bulk compensatory system in order to maintain the intracranial volume absolutely constant.

Neurodegeneration in the animal model of Menkes' disease involves Bcl-2-linked apoptosis

Copper plays a key role in brain development, function and survival. Alteration of its homeostasis is suggested to be an aetiological factor in several neurodegenerative diseases. However, the molecular mechanisms relating copper to neurodegeneration are still unknown. In the present report, using morphological analyses of brain sections of mottled/brindled mutant (Mo(br/y)) mice, the animal model of the human genetic copper deficiency associated with neurodegeneration (Menkes' disease), we demonstrated that a high degree of apoptotic cells is present in the neocortex and in the hippocampus. Biochemical characterisation revealed decreased levels of copper content and of the activity of the mitochondrial copper-dependent enzyme cytochrome c oxidase. Copper, zinc-superoxide dismutase activity also shows a slight decrease, while no change was observed for glutathione content. Lower levels of ATP were also found, indicative of a copper-dependent impairment of energy metabolism. Changes appear to be specific for the brain, since no alterations in the activity of liver enzymes were found, although the level of copper was strongly decreased. We also tested biochemical factors involved in cell commitment to apoptosis. The expression of the anti-apoptotic protein Bcl-2, which plays a fundamental role in brain development and morphogenesis, was dramatically decreased and the levels of cytochrome c released from mitochondria into the cytosol were significantly increased. On the basis of these findings, we propose that down-regulation of Bcl-2 can cause neurodegeneration triggered by mitochondrial damage due to copper depletion during brain development in Mo(br/y) mice.

Increased susceptibility of copper-deficient neuroblastoma cells to oxidative stress-mediated apoptosis

Treatment of neuroblastoma cells with the copper chelator triethylene tetramine tetrahydrochloride induced intracellular decrease of copper content paralleled by diminished activity of the enzymes Cu, Zn superoxide dismutase, and cytochrome c oxidase. This effect appears to be specific for copper-enzymes and the treatment affects neither viability nor growth capability of cells. However, molecular markers of apoptosis Bcl-2, p53, and caspase-3 were slightly affected in these cells. When copper-deficient cells were challenged with oxidative stress generated by paraquat or puromycin, they underwent a higher degree of apoptosis with respect to copper-adequate control cells. The mechanism underlying paraquat-triggered apoptosis implies dramatic activation of caspase-3 and induction of the transcription factor p53. These results demonstrate that impairment of copper balance predisposes neuronal cells to apoptosis induced by oxidative stress. Overall findings represent a contribution to the comprehension of the link between copper-imbalance and neurodegeneration, which has recently been repeatedly suggested for the most invalidating pathologies of the central nervous system.

Radial nerve palsy caused by spontaneously occurring nerve torsion. Case report

An 18-year-old man presented with a spontaneously occurring radial nerve palsy that spared the triceps muscle. At surgery, the portion of the radial nerve located at the midarm level had an hourglass-like appearance. Under magnification, an external-internal neurolysis of the narrowed portion of the hourglass-shaped portion revealed nerve torsion. Straightening of the twisted nerve and fixation accomplished using epiperineurium-fascia stitches to avoid a new torsion resulted in complete functional recovery of the radial nerve.

Decrease of cytochrome c oxidase protein in heart mitochondria of copper-deficient rats

Copper deficiency has been reported to be associated with decreased cytochrome c oxidase activity, which in turn may be responsible for the observed mitochondrial impairment and cardiac failure. We isolated mitochondria from hearts of copper-deficient rats: cytochrome c oxidase activity was found to be lower than in copper-adequate mitochondria. The residual activity paralleled copper content of mitochondria and also corresponded with the heme amount associated with cytochrome aa3. In fact, lower absorption in the alpha-band region of cytochrome aa3 was found for copper-deficient rat heart mitochondria. Gel electrophoresis of protein extracted from mitochondrial membranes allowed measurements of protein content of the complexes of oxidative phosphorylation, revealing a lower content of complex IV protein in copper-deficient rat heart mitochondria. The alterations caused by copper deficiency appear to be specific for cytochrome c oxidase. Changes were not observed for F0F1ATP synthase activity, for heme contents of cytochrome c and b, and for protein contents of complexes I, III and V. The present study demonstrates that the alteration of cytochrome c oxidase activity observed in copper deficiency is due to a diminished content of assembled protein and that shortness of copper impairs heme insertion into cytochrome c oxidase.

Purification of a fully metal-depleted Cu, Zn superoxide dismutase from copper-deficient rat liver

A copper-deprived form of the enzyme Cu, Zn superoxide dismutase was identified in the liver of rats made copper-deficient by dietary restriction. In homogenates of such livers Cu, Zn superoxide dismutase presents a dis-homogeneous electrophoretic profile with respect to the native enzyme. When rat liver extracts were treated with exogenous copper an electrophoretic pattern resembling the native one was observed. Enzyme purified by chromatography on DE-52 resin shows two major components, one corresponding to genuine, native enzyme and another one, eluting at higher ionic strength. The latter protein (Fraction II) consists of several isoforms which show the same characteristics of the native superoxide dismutase as far as immunoreactivity and molecular weight are concerned, but with decreased contents of copper and zinc. Its catalytic constant, referring to copper content, was 15 times lower than that obtained for the native enzyme. Moreover, the catalytic power of purified Fraction II was not regained upon incubation with copper. The occurrence of a superoxide dismutase void of metals confirms the hypothesis that this protein plays a dual physiological role: in metal metabolism and in superoxide anion dismutation.

[Cancer of the gallbladder]

Carcinoma of the gallbladder is the most frequent neoplasia of the biliary tract with an incidence of 2.5-4.4 cases for every 100,000 inhabitants; it more often affects females and elderly patients (60-70 years). It is an extremely malignant tumour with an often fatal prognosis owing to both its site and the generally late diagnosis; the majority of patients in fact undergo surgery at an advanced stage of the disease when surgery is only palliative. At the Surgical Division of S. Massimo Hospital in Penne (PE) a total of 897 operations on the gallbladder and biliary tract were performed between 1988 and 1994, revealing 21 cases of carcinoma of the cholecyst (2.3%). Sixteen patients were female (male-female ratio 1:3.2) with a mean age of 67.8 years (range 58-83 years). These patients were divided into 5 stages according to the UICC-1992 classification: 80.9% of cases were stage 3-4. Diagnosis was performed intraoperatively in 2 patients, whereas in 3 cases cancer had been diagnosed by the anatomo-pathologist. A total of 3 simple cholecystectomies were performed, 4 were associated with hepatic resection and lymphadenectomy of the hilus and hepatoduodenal ligament; surgery was enlarged in 2 cases due to the involvement of adjacent organs. After exploratory laparotomy, palliative surgery was performed in the remaining 12 patients in the form of biliary and derivation. Four system were implanted for intra-arterial chemotherapy. The most frequently found histological type was adenocarcinoma (76.2%). The mean survival rate of patients who died was 7.6 months. Six of the operated patients are still alive, of whom only one with a follow-up of 4 years. In conclusion, the authors agree with those who consider carcinoma of the gallbladder generally fatal in view of the rarity of early diagnosis and the difficulties of performing radical therapy.

Callosotomy for drug resistant generalized seizures

We report our series of drug resistant epileptic patients submitted to callosotomy. The 25 patients were affected by severe epilepsy with invalidating generalized seizures with fall, lacking of indication for ablative surgery. Nineteen patients, with at least 1 year of follow-up, were considered for this study. The surgical outcome was classified as: class A), seizure disappearance; class B) 80%, class C) 80-50%, class D) less than 50% seizure reduction; E) increase of seizure frequency. The follow-up analysis shows that the better results are obtained with the generalized seizures, in particular the GTA. Our surgical results are discussed considering the data of the literature: about the functional anatomy of the Corpus Callosum, the experimental studies and the clinical series published on callosotomized epileptic patients.

Metopic synostosis: in favour of a "simplified" surgical treatment

Metopic synostosis is a relatively simple form of craniosynostosis, resulting from premature fusion of the metopic suture. In this pathology different degrees of dysmorphia of the anterior cranial fossa and the presence of associated anomalies of the skull might enable specific subgroups to be identified. Since most functional and cosmetic anomalies benefit from early surgical treatment, over the last few years neurosurgeons have been forced to elaborate less drastic, but nonetheless effective, surgical techniques. In the present report we analyze the surgical results obtained in a series of 62 infants with trigonocephaly operated on within their 1st year of life. Patients were subdivided into two groups (group I: 8 patients; group II: 54 patients) according to the specific dysmorphic characteristics of the frontal bone and anterior cranial fossa, and the presence of compensatory deformities affecting the anterior cranial base and temporo-parietal region. All the patients were treated using one of two relatively simple surgical techniques (procedure A: inversion of two hemifrontal bone flaps--48 cases; procedure B: the "shell" operation--14 cases). Both surgical procedures appeared to be effective, allowing adequate functional and cosmetic correction of the cranial deformity. In patients operated on following procedure B surgical time and blood loss were dramatically reduced. Long-term outcomes were satisfactory in all cases, irrespective of the surgical technique used. In the group II patients, however, progressive normalization of the interorbital distance was constantly observed, suggesting a different degree of stenotic involvement at the level of the anterior cranial base in these patients.

Age-related changes in the binding and uptake of Cu, Zn superoxide dismutase in rat liver cells

The present paper reports the effect of aging on receptor mediated endocytosis of Cu, Zn superoxide dismutase in rat liver cells. The fate of bovine Cu, Zn superoxide dismutase conjugated to colloidal gold was followed by electron microscopy in young (2 months) and old (24 months) rats in situ, in vivo and in vitro experiments. The use of different models for the study of the binding and internalization of the enzyme allowed to discriminate the contribution of each different liver cell type. The data obtained demonstrate that aging of the liver affects binding and uptake of this enzyme. In particular both the number of binding sites and the rate of internalization were depressed in old rats. Therefore, the hypothesis of therapeutic application of superoxide dismutase for age-related diseases needs to be revalued in view of the fact that receptor-mediated endocytosis of this protein is a mechanism affected by senescence.

N-[5-nitro-2-furfurylidene]-3-amino-2-oxazolidinone activation by the human intestinal cell line Caco-2 monitored through noninvasive electron spin resonance spectroscopy

The pathways participating in the metabolism of the nitrofuran antimicrobial drug N-[5-nitro-2-furfurylidene]-3-amino-2-oxazolidinone (furazolidone) in intact cells were investigated in the human intestinal cell line Caco-2. One-electron reduction of furazolidone led to the formation of a free radical intermediate that could be monitored in dense cell suspensions by noninvasive electron spin resonance spectroscopy. The effects of enzyme inhibitors on the kinetics of radical production and decay were used to estimate the relative contribution of different enzymes to the reductive activation of the drug. Although many enzymes are known to reduce nitrofurans in vitro (e.g., xanthine oxidase, aldehyde oxidase, DT-diaphorase, mitochondrial redox chain components), their contributions were insignificant in living Caco-2 cells. The first reducing equivalent required for the formation of the nitroanion derivative of furazolidone appeared to be provided essentially by the microsomal cytochrome P450 reductase. This was confirmed through studies of the NADPH-dependent radical formation by microsomes. Differentiated Caco-2 cells, an established enterocyte model, showed only modestly increased radical formation and the same enzyme-specificity pattern as undifferentiated cells. Consistently, only a small increase in P450 reductase activity was found in differentiated cells, in contrast to the 10-fold increase seen in typical differentiation marker enzymes. With the electron spin resonance method that we describe, it is possible to distinguish between sites of bioactivation of redox active drugs in intact cells.

Callosotomy for severe epilepsies with generalized seizures: outcome and prognostic factors

The purpose of the present study was to verify the effect of callosotomy on generalized seizures, to check the effect on other seizure types and to search for possible prognostic factors. Twenty patients with a minimum follow-up of one year (mean 3.5 years) were available for our analysis. In six of them the callosotomy was performed in two stages (total: 26 surgical procedures). Age ranged from 14 to 40 years (mean 23 years). Different aetiologies were known in 15 patients. Duration of epilepsy ranged from 6 to 23 years (mean 15 years). The frequency of seizures ranged between 19 and 750 per month. The most significant effect of surgery was the complete suppression of the generalized seizures associated with falling in 9/19 and their reduction of more than 80% in 7/19 patients (total "good results": 16/19). The generalized tonic-clonic seizures were less affected. The surgical effect on the partial seizures was very variable, the partial simple seizures being the most affected. A positive statistical association with the outcome of the generalized seizures with fall was found for a presurgical seizure frequency below 90 per month, a prevalent bilateral EEG epileptic activity and, to a less extent, the absence of cerebral structural lesions. The role of age, aetiology, duration of the disease, single or more seizure types, mental impairment and extent of callosotomy remains uncertain. Disconnection syndrome does not appear if the splenium is spared. The present findings confirm that the main indication for callosotomy is the occurrence of generalized seizures with fall. Surgery can be initially limited to the anterior 2/3 of the corpus callosum; further posterior section of the corpus, excluding the splenium, should be regarded as a second step, when necessary.

Quantitative, morphological, and somatotopic nuclear changes after facial nerve regeneration in adult rats: a possible challenge to the "no new neurons" dogma

The anatomic reorganization of the subnucleus that controls the stylohyoid muscle (the stylohyoid subnucleus) within the brain stem facial nucleus was studied after regeneration of the facial nerve in adult rats. Horseradish peroxidase was injected into the right stylohyoid muscle 3 to 21 months after transection and repair of the right facial nerve at the level of the stylomastoid foramen. Position, number, and soma diameter of retrogradely horseradish peroxidase-labeled motoneurons were established, as well as the rostro-caudal extension of the stylohyoid subnucleus. In experimental rats, the stylohyoid subnucleus showed either an ipsilateral (50% of the rats) or a bilateral representation. In all of the experimental rats, the motoneurons composing the stylohyoid subnucleus had a more dispersed horizontal distribution pattern when compared with controls. More than 80% of the motoneurons were located outside the borders of the normal stylohyoid subnucleus, either ventrally or, especially in the rostral sections, dorsally closer to the floor of the fourth ventricle. The mean rostro-caudal length of the stylohyoid subnucleus was 2028.6 +/- 152.7 microns. The mean motoneuron number was 481.4 +/- 109.5 (2.20-fold greater than control values), and the motoneuron diameter distribution ranged from 7 to 43 microns. This study demonstrates that after regeneration of the facial nerve in adult rats, major changes occur in both the location and number of motoneurons that make up the stylohyoid subnucleus.(ABSTRACT TRUNCATED AT 250 WORDS)

["Uncompensated" small bowel obstruction in adults. Ultrasonographic findings of free fluid between loops and its prognostic value]

Plain abdominal film is the method of choice in the assessment of intestinal obstruction. This technique exhibits some limitations and must be frequently correlated with other diagnostic tools. Of them, US has been recently reported to allow the morphofunctional study of intestinal loops with high accuracy. Nevertheless, the literature on the usefulness of US disregards a sign of great interest, i.e., extraluminal fluid between bowel loops. Our personal experience in 56 adult patients with surgically confirmed small bowel obstruction suggests that this findings, demonstrated by US in 43 patients (73%), identifies early intestinal wall damage with high sensitivity. US, depicting fluid between bowel loops, can distinguish the various stages of obstruction, with major consequences on clinical management. US and plain abdominal film findings allowed us to distinguish three stages of obstruction: simple obstruction (15/56 patients, 27%), uncompensated obstruction (26/56 patients, 46%), and complicated obstruction (15/56 patients, 27%). These three evolutive stages exhibit different severity and require different surgical approaches.

[Tuberous sclerosis: neuropsychological implications]

The role of neurosurgical therapy in tuberous sclerosis is still controversial; generally, a surgical procedure is performed only to treat an increase in intracranial pressure secondary to an obstructive hydrocephalus caused by a neoplasm in the region of the foramen of Monro. The role of surgical treatment in the control of epileptic fits is much more limited because of multifocal EEG epileptogenic foci due to multiple cortical lesions. Recently some authors, however, have suggested that the surgical treatment may be useful in selected patients. In the present report 9 children affected by tuberous sclerosis who were operated on in the period 1982-1992, because of increased intracranial pressure are described. The neuroradiological examination showed tumors in the region of the foramen of Monro in all the patients, with secondary obstruction in the CSF shunt circulation. Operative procedures included CSF shunts and/or giant cell astrocytoma removal. The follow-up period ranged from 1 to 14 years (mean 6 years). According to our experience, tumor excision is the most satisfying therapy, allowing the removal of the cause of the hydrocephalus as well as the possibility of histological diagnosis. A CSF shunt procedure may resolve the symptomatology, but it is often weighted by frequent malfunctioning of the CSF shunt system due to catheter obstruction secondary to abnormally high CSF protein concentration; furthermore, in some patients the insertion of the ventricular catheter may induce intraventricular bleeding when the highly vascularized tumor is accidentally punctured during the procedure of shunt insertion or in cases in which the presence of the ventricular catheter causes chronic trauma on the tumoral surface.

On the treatment of subependymal giant cell astrocytomas and associated hydrocephalus in tuberous sclerosis

Between 1980 and 1992, 10 children affected by tuberous sclerosis and intraventricular subependymal giant cell astrocytomas were surgically treated at the Institute of Neurosurgery, Section of Pediatric Neurosurgery, Catholic University of Rome. Nine patients presented with signs and/or symptoms of intracranial hypertension; in all of them the neuroradiological investigations demonstrated the presence of a space-occupying lesion in the region of the foramen of Monro with secondary ventricular dilation. In the remaining patient, a 5-month-old male infant, an intraventricular mass was discovered by means of an ultrasound examination performed after the first epileptic fit. Three patients underwent a ventriculoperitoneal CSF shunt as first surgical procedure; in 2 of them it was subsequently necessary to remove the intraventricular tumor due to the frequent occlusion of the CSF shunt device. Seven subjects underwent the direct surgical excision of the lesion. In all of them the procedure resulted in the control of the associated hydrocephalus. On the basis of such an experience, the authors conclude that the surgical removal of the intraventricular tumors in patients with tuberous sclerosis and hydrocephalus is the most appropriate treatment. In fact, in the series considered here, the removal of the tumor was not accompanied by significant morbidity, and was followed by improvement in clinical conditions. In particular, in cases in whom the occurrence of hydrocephalus was associated with a worsening in the seizure disorder, the tumor removal and the correction of intracranial hypertension was followed by a significant reduction in frequency or even by the disappearance of the seizures. However, in no case presenting with mental impairment was a significant improvement observed in mental performances as a consequence of the surgical treatment.

Differential decrease of copper content and of copper binding to superoxide dismutase in liver, heart and brain of copper-deficient rats

Dietary copper-deficiency in rats produced a organ-specific decrease of copper content. This was paralleled by a decrease of the activity of the copper-enzyme superoxide dismutase. In liver such a decrease is partially due to the existence of an apo-form of superoxide dismutase, which can be reactivated by addition of exogenous copper to tissue extracts. These results demonstrate in vivo that superoxide dismutase is post-translationally modulated by copper in higher vertebrates as previously found for yeast and mammalian cells in culture.

A survey of the first complication of newly implanted CSF shunt devices for the treatment of nontumoral hydrocephalus. Cooperative survey of the 1991-1992 Education Committee of the ISPN

The results of an international multicenter study concerning the first complication of newly implanted cerebrospinal fluid shunts in nontumoral hydrocephalus are the subject of the present report. The authors have collected information on 773 cases from four continents. In particular, the following data were evaluated in relation to the general incidence of complications recorded in the first follow-up year: the patient's age at the operation, the etiology of hydrocephalus, the type of CSF shunt device used, and the modality of the surgical procedures. The overall complication rate in the series was 29%. Age and etiology of hydrocephalus appear to play a major role in influencing the complication rate; on the other hand, the choice of a specific CSF shunt device seems to be less important in this respect.

[Surgical treatment of epileptogenic hemimegalencephaly]

Thirteen children affected by hemimegalencephaly were observed in the Pediatric Section of the Institute of Neurosurgery of the Catholic University of Rome in the last six years. Nine of them were operated because of an intractable epilepsy. Seven were males and 2 females; the age at operation ranged between 7 months and 11 years (mean: three years and five months); the follow-up period varied between 1 and 6 years (mean 3 years and 10 months). All the patients had a clinical history of daily epileptic seizures not responsive to medical treatment; all of them presented with severely delayed psychomotor development. At neurological examination, six children showed a motor deficit of variable severity contralateral to the affected hemisphere and two patients a severe tetraparesis. The remaining child did not present with motor deficit. In all the cases the diagnosis had been obtained by CT scan and MRI. One of the cerebral hemispheres was abnormally enlarged with associated dilation of the lateral cerebral ventricle. The cortical architecture was obviously deranged with several areas of heterotopia of the gray substance suggesting an alteration of the neuronal cell migration. All the children underwent an extrathalamocaudato hemispherectomy. A post-operative ventriculo-peritoneal shunt was required in two cases. There were neither operative, nor late deaths. A dramatic reduction in the frequency and severity of epileptic seizures was observed in all but one of the patients of the series.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute phlegmonous appendicitis due to a villous adenoma in a hernial sac. A case report]

The authors report a case of a 93-year-old man with villous adenoma causing acute phlegmonous appendicitis. The appendicular localization, extremely uncommon, is the cause of an acute appendicitis in 50% of cases. Therefore, they analyse the anatomo-pathological, clinical, diagnostic and therapeutic aspects of this pathology with the help of the literature.

[Hemangioma of the masseter: a rare location of a pathology not always accurately diagnosed]

The hemangiomas of the skeletal muscles are rare. The authors describe a case of masseter muscle hemangioma, dwelling upon the problems of differential diagnosis that are present for the straight rapport that the muscle contract with the parotid gland. Thus, the surgeon is led to confuse the malformation with a neoplasm of the parotid gland.

[Acute torsion of the greater omentum]

Primary torsion of the greater omentum is an uncommon cause of acute abdomen and frequently it is misunderstood. In fact, from the analysis of the literature the authors can evict that the preoperative diagnosis is generally wrong. The authors write about the subject and they describe four cases come to their observation and all mistaken for acute appendicitis.

[Compression of the sigmoid of gynecological origin]

The authors report a case of extrinsic stenosis of the sigmoid colon due to inflammation of the uterus and adjoining parts. Attention is drawn to the possibility that the radiological images of this condition may be similar to neoplastic diseases.

Craniosynostosis: surgical treatment during the first year of life

Out of 276 children with craniosynostosis operated on in a 9 year period, 231 were operated on under 1 year of age. According to the sutures involved in the process of early fusion, two groups of infants were individuated. Patients belonging to the first group were characterized by the involvement of the sagittal suture, while infants of group II presented with a synostosis of the anterior or posterior sutural complex. Two different techniques were required for the 2 groups of subjects, the first of them being mainly based on linear craniectomies, the second requiring more complex reconstructive surgical procedures. The morbidity, mortality and recurrence rates of the series were low, demonstrating that infants can tolerate the procedure as well as older children. The advantage of the early treatment consists of a better cosmetic result with a more physiological growth of faciocranial skeleton.

Reconstruction of peripheral nerves: the phenomenon of bilateral reinnervation of muscles originally innervated by unilateral motoneurons

It is well known that after reconstruction of sectioned peripheral nerves in adult mammals, denervated muscles are reinnervated by the axotomized motoneurons lying in the original motonucleus. It is less well known that these muscles can also be reinnervated by uninjured motoneurons lying in the homologous contralateral motonucleus. Therefore, after nerve reconstruction, bilateral motoneuron reinnervation of muscles can occur. Contralateral motoneurons sprout axons that cross the midline, grow in the reconstructed nerve, and reach muscle targets. This phenomenon was observed after reconstruction of several different peripheral nerves in adult mammals, including the oculomotor nerve in guinea pigs and the facial and sciatic nerves in rats. The retrograde axonal transport of horseradish peroxidase was used for the study of the organization of the brainstem and spinal cord motonuclei. Horseradish peroxidase was injected into the medial rectus muscle, the stylohyoid muscle, and the trunk of the sciatic nerve. The distance between the homologous motonuclei of both sides influenced the occurrence of this phenomenon. In fact, bilateral reinnervation of muscles after nerve reconstruction was found in 36% (sciatic nerve), 50% (facial nerve), and 100% (oculomotor nerve) of the operated animals. The total number of contralateral motoneurons found were 14% (oculomotor nerve), 8% (facial nerve), and 5% (sciatic nerve). Bilateral reinnervation of muscles was evoked by both immediate and delayed peripheral nerve repair and was a stable phenomenon, seen between 3 and 21 months after facial nerve reconstruction.

Fibrous dysplasia of the skull in children

Early diagnosis of skull fibrous dysplasia in children is relatively easy, based on a history of painless progressive bony bulging. The therapeutic approach is still controversial, due to the benignity of the lesion. However, the clinical course may be unpredictable, with sudden appearance of symptoms, some of which can be important and irreversible. In pediatric patients, the possibility that an early surgical correction might positively interfere with the natural history of the lesion has to be evaluated by taking into account the obvious difficulties that will be encountered in reconstructing the skull after a wide excision of the pathologic bone. In the present report, we describe our personal experience on the surgical treatment of 9 children, ranging in age between 7 and 14 years. The patients were subdivided into two groups, according to the localization and extent of the disease. Patients in group 1 presented an involvement of the hair-covered cranium and/or the fronto-orbital region. Group 2 patients presented with a multizonal involvement of the skull, including the central cranial base (pterygoid, sphenoid, petrous and mastoid bone). The different surgical options, chosen for the two groups of patients, are discussed, together with the technical methodologies utilized, the cosmetic results and the long-term follow-up.

Experimental studies on spinal cord injuries in the last fifteen years

Experimental studies on spinal cord (SC) injuries published from 1975 to 1989 in some of the most widely circulating neurosurgical journals were reviewed. The relatively large number of animal species utilized as well as the intensely variable dynamic or static methods employed to induce SC injury represent elements of confusion more than objective necessities in this field of research. In fact, the objective of SC injury research should be to solve the problem of severe SC injuries by either preventing and/or repairing SC damage, rather than looking for modalities to provoke a large spectrum of SC injuries with the result of establishing a correlation between for example, the clinical picture and trauma magnitude. It should be time to study all variables and treatments mainly in only one experimental model. The rat with a permanent paraplegia should represent such a model; the abdominal aorta occlusion for 45 minutes, distal to the renal arteries in rabbits should be the experimental model of choice for ischaemia. If a significant result, such as reversing permanent paraplegia, were obtained in rats, it would be logical to repeat the study in higher mammals and if successful, in humans. For the last decade of this century it is necessary to further study all the mechanisms implied in secondary SC damage as well as to attempt to repair definitive SC damage by using grafts and enhancing the potential regenerative ability of the SC with known and new growth factors. Presently, methylprednisolone, dexametasone, thiopental, naloxone, and hypothermia seem to have some clinical potentials that require studies in humans.

Human interleukin 1 beta fused to the human growth hormone signal peptide is N-glycosylated and secreted by Chinese hamster ovary cells

A hybrid gene consisting of the sequences coding for the signal peptide of human growth hormone and the mature form of interleukin-1 beta (IL-1 beta) was chemically synthesized. This sequence was inserted into a eukaryotic expression vector and introduced into Chinese hamster ovary cells. The resulting stably transformed cell lines produced large amounts of recombinant IL-1 beta, which was secreted into the culture medium mainly as a 22-kDa form. Expression in the presence of tunicamycin, an inhibitor of N-glycosylation, led to the complete disappearance of the 22-kDa form and the appearance of a new form of 17.5 kDa, indicating that the hybrid protein had been both processed and N-glycosylated. However, transformed cells producing mature IL-1 beta without a signal peptide produced the predicted 17.5-kDa nonglycosylated form. These results suggest that fusion to a heterologous leader sequence allowed IL-1 beta to be translocated across the membrane of the endoplasmic reticulum and to be transported and secreted by the exocytotic pathway.