Cerebellar mutism syndrome: the importance of preoperative language assessment

Children undergoing surgical removal of tumors in the posterior cranial fossa can encounter a varied and complex constellation of neurological symptoms, called cerebellar mutism, defined as a disturbance in the planning and programming of motor language with preserved understanding, behavioral disorders such as inattention, visual-spatial disorganization, personality change, as well as ataxia and dysmetria. In the last years, several groups have been trying to establish risk factors or even predictive scores in order to be able at least in part to predict the appearance of speech disorders before surgery. We report on a child with pilocytic astrocytoma of the cerebellar vermis who had already been diagnosed with developmental linguistic delay two years earlier. This disorder initially worsened after surgery and later improved in the following 12 months. The aim of this paper is to emphasize the importance of preoperative neuropsychological evaluation. The present case, along with those reported in the literature, suggests that the risk of long-term cerebellar mutism is higher in children with preoperative speech disorders. In these patients a thorough assessment of cognitive and linguistic functions is therefore necessary to better evaluate the risk of cerebellar mutism after surgery.

Degenerative cervical myelopathy: Neuroradiological, neurophysiological and clinical correlations in 27 consecutive cases

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New insight into prognostic factors for recovery of clinical function following posterior decompression for degenerative cervical myelopathy.

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An increase of IOM amplitude of at least 50% coupled with preoperative T2-only and diffuse T2 signal changes on MRI is a positive prognostic factors for clinical improvement 6 months after surgery.

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Clinical improvement at 6 months follow-up can be expected in patients with T1 hypo intensity if a diffuse border of the lesion on T2 images is present.

Intramedullary spinal cord metastasis from an adenoid cystic carcinoma of the external auditory canal: case report

BACKGROUND AND IMPORTANCE

Intramedullary spinal cord metastases (ISCMs) are rare and no cases of ISCM from an adenoid cystic carcinoma (ACC) of the external auditory canal (EAC) have been reported.

CLINICAL PRESENTATION

We report a 54-year old man complaining backpain and worsening myelopathy. He had an ACC of the EAC resected years prior. A spinal MRI demonstrated a contrast-enhancing intramedullary lesion within the conus medullaris. The histopathological diagnosis of the patient was consistent with the patient's primary cancer. At 3 months follow-up, the neurological condition of the patient was unchanged.

CONCLUSIONS

This is the first reported case of ISCM from a primary ACC of the EAC.

A snapshot of European neurosurgery December 2019 vs. March 2020: just before and during the Covid-19 pandemic

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19), which began as an epidemic in China and spread globally as a pandemic, has necessitated resource management to meet emergency needs of Covid-19 patients and other emergent cases. We have conducted a survey to analyze caseload and measures to adapt indications for a perception of crisis.

Methods

We constructed a questionnaire to survey a snapshot of neurosurgical activity, resources, and indications during 1 week with usual activity in December 2019 and 1 week during SARS-CoV-2 pandemic in March 2020. The questionnaire was sent to 34 neurosurgical departments in Europe; 25 departments returned responses within 5 days.

Results

We found unexpectedly large differences in resources and indications already before the pandemic. Differences were also large in how much practice and resources changed during the pandemic. Neurosurgical beds and neuro-intensive care beds were significantly decreased from December 2019 to March 2020. The utilization of resources decreased via less demand for care of brain injuries and subarachnoid hemorrhage, postponing surgery and changed surgical indications as a method of rationing resources. Twenty departments (80%) reduced activity extensively, and the same proportion stated that they were no longer able to provide care according to legitimate medical needs.

Conclusion

Neurosurgical centers responded swiftly and effectively to a sudden decrease of neurosurgical capacity due to relocation of resources to pandemic care. The pandemic led to rationing of neurosurgical care in 80% of responding centers. We saw a relation between resources before the pandemic and ability to uphold neurosurgical services. The observation of extensive differences of available beds provided an opportunity to show how resources that had been restricted already under normal conditions translated to rationing of care that may not be acceptable to the public of seemingly affluent European countries.

Electronic supplementary material

The online version of this article (10.1007/s00701-020-04482-8) contains supplementary material, which is available to authorized users.

Combined circular external fixation and flexible intramedullary nailing for pediatric bilateral open tibia fractures in blast injury

Management of blast injuries with open fractures and extensive soft tissue damage in pediatric patients is a challenging task even in experienced hands. This article reports the case of an 8-year-old boy with bilateral open tibia fractures and soft tissue loss due to the accidental explosion of a skyrocket. After the emergency procedures with lavage, debridement and temporary bone stabilization, we performed the definitive reconstruction surgery using a combined circular external fixation and flexible intramedullary nailing technique on both legs. This technique allowed easy access to the wounds for plastic surgery procedures and early bilateral weight bearing. All implants were removed within 6 months, the fractures healed with good axial alignment and the patient returned to his preinjury activities one year after the trauma. In this case, the combined use of circular external fixation and flexible intramedullary nailing ensured optimal fractures stabilization, minimizing the damage to the soft tissues and the obstruction for plastic surgeons. We believe that this technique should be considered in pediatric patients with open fractures of the lower limbs and extensive soft tissue injuries.

Bbr 2778, an Aza-anthracenedione Endowed with Preclinical Anticancer Activity and Lack of Delayed Cardiotoxicity

With the aim to provide second-generation anthracenedione analogues endowed with reduced side effects and a wider spectrum of action than mitoxantrone and doxorubicin, a large number of new molecules bearing nitrogen atoms in the chromophore was synthesized and screened in vitro and in vivo. From this screening, BBR 2778 (6,9-bis[(2-aminoethyl)amino] benzo[g]isoquinoline-5,10-dione dimaleate) emerged as the most interesting compound. BBR 2778 was tested in vitro on several murine and human tumor cell lines and showed cytotoxic potency lower than that of mitoxantrone and doxorubicin. BBR 2778 was more cytotoxic in leukemia and lymphoma cell lines than in solid tumor cell lines. Although against in vivo models BBR 2778 was less potent than mitoxantrone and doxorubicin, its antitumor activity was equal or superior (in certain tumor models) to that of the above standard compounds. In particular, BBR 2778 was curative against L1210 murine leukemia and YC-8 murine lymphoma. Moreover, it showed an antitumor activity comparable to that of mitoxantrone and doxorubicin on solid tumors. No cardiotoxic effect of BBR 2778 in animals not pretreated with anthracyclines was observed compared to standards. In light of its spectrum of activity and marked efficacy against lymphomas and leukemias over a wide dose range, together with its lack of delayed cardiotoxicity, BBR 2778 has been entered in clinical studies.

Evaluation of Levothyroxine Bioavailability after Oral Administration of a Fixed Combination of Soy Isoflavones in Post-menopausal Female Volunteers

BACKGROUND

Post-menopausal women under treatment with levothyroxine for their medical conditions may take concomitantly dietary supplements containing soy isoflavones in combination to treat their post-menopausal symptoms. The aim of this study was to investigate the effect of a fixed combination of soy isoflavones on the oral bioavailability of levothyroxine in post-menopausal female volunteers.

METHODS

12 healthy post-menopausal female, who were on stable oral levothyroxine as replacement/supplementation therapy for hypothyroidism, received a single recommended oral dose of a food supplement containing 60 mg of soy isoflavones (>19% genistin and daidzin) concomitantly with (test) and 6 h later (reference) the administration of levothyroxine in a randomized, open label, crossover fashion. Plasma concentrations of levothyroxine and soy isoflavones (daidzin, daidzein, genistin, genistein, S-equol) were determined by LC-MS/MS. Pharmacokinetic (PK) parameters were determined by non-compartmental analysis. No effect of soy isoflavones was assumed if the 90% confidence intervals (CIs) for the estimated ratio test/reference was included in the acceptance limits 0.80-1.25 for PK parameters Cmax and AUCt.

RESULTS

The test/reference ratios Cmax and AUCt of levothyroxine were very close to unity (1.02 and 0.99, respectively) and the corresponding 90% CIs (0.99-1.04 and 0.88-1.12, respectively) fell entirely within the acceptance bioequivalence limits.

CONCLUSION

The combination of soy isoflavones used in the present investigation does not affect the rate and extent of levothyroxine absorption when administered concomitantly in post-menopausal women.

Intraoperative neurophysiological monitoring for the resection of brain tumors in pediatric patients

Intraoperative neurophysiology (ION) is the gold standard to map and monitor brain functions during supratentorial surgery in critical areas. This is of great value for the surgery of brain gliomas in adults, but the same ION techniques can be used in the pediatric population with respect to both epilepsy and brain tumor surgery. While the principles of most ION techniques are the same for adults and children, the developing nervous system has peculiar characteristics in terms of anatomical and physiological maturation of afferent and efferent pathways within the brain and the spinal cord. Accordingly, some adjustments, particularly with regards to stimulation parameters, are needed in younger children. This paper will review current ION techniques to assist during the resection of brain tumors in children, focusing on the aspects peculiar to mapping and monitoring of sensori-motor functions in the pediatric population. On the other hand, awake surgery, of common use in adult patients when aiming to identify cortical and subcortical cognitive functions, is of very limited use in children and will not be discussed here.

The Italian validation of the Anosognosia Questionnaire for Dementia in Alzheimer's disease

Although the Anosognosia Questionnaire-Dementia (AQ-D) is one of the main instruments for assessing awareness in Alzheimer's disease (AD), the normative data were until now limited to people from Argentina and Japan. This study aims to validate this instrument in an European context, in particular in an Italian sample. In a multicenter project (Verona, Padova, and Trapani), 130 patients with AD and their caregivers participated in the study. Psychometric characteristics of AQ-D are confirmed indicating that the scale permits the early identification of anosognosia and the correct care management of patients. Indeed, anosognosia results to be present also in patients with very mild AD (moderate: 44.44%; mild: 47.17%; and very mild: 23.73%). Moreover, the results indicate that deficits in awareness may vary in severity and that different types of anosognosia may be identified.

Intraoperative mapping and monitoring in supratentorial tumor surgery

With the increasing strive for complete resections of supratentorial low or high-grade gliomas, the necessity for intraoperative electrical stimulation methods to map and monitor functional important cortical or subcortical brain areas increased. While many brain functions can be assessed during awake surgery using electrical stimulation, motor function as well as visual function can be mapped and monitored in the asleep patient, as well. Several different methods reviewed in this article are available which lead to an improved functional outcome while increasing the extent of tumor resection and thereby potentially the oncological outcome of the patient.

Awareness of cognitive deficits and clinical competence in mild to moderate Alzheimer's disease: their relevance in clinical practice

Awareness of cognitive deficits and clinical competence were investigated in 79 mild to moderate Alzheimer's disease patients. Awareness was assessed by the anosognosia questionnaire for dementia, and clinical competence by specific neuropsychological tests such as trail making test-A, Babcock story recall test, semantic and phonemic verbal fluency. The findings show that 66 % of the patients were aware of memory deficits, while the 34 % were unaware. Deficit in awareness correlated with lower scores on the Mini Mental State Examination test that, in the score range from 24.51 to 30 and from 19.50 to 24.50, appeared to be a significant predictor of level of awareness. None of the AD patients had fully preserved clinical competence, only 7 patients (9 %) had partially preserved clinical competence and 72 patients (91 %) had completely lost clinical competence. All the patients with partially preserved clinical competence (9 %) were aware of their memory deficit. The study indicates that neuropsychological tests used for the assessment of executive functions are not suitable for investigating clinical competence. Therefore, additional and specific tools for the evaluation of clinical competence are necessary. Indeed, these might allow clinicians to identify AD patients who, despite their deficits in selected functions, retain their autonomy of choice as well as recognize those patients who should proceed to the nomination of a legal representative.

Cognitive stimulation in a-MCI: an experimental study

Nowadays, preventing the effects of mental decline is an international priority, but there is little research into cognitive training in mild cognitive impairment (MCI). We present the results of a program aimed at teaching memory strategies and improving metacognitive abilities. This was associated with training to ameliorate caregivers' assistance. Two groups (A and B) were compared in a crossover design. After the first evaluation, group A (but not B) participated in a 6-month cognitive stimulation program. After a second assessment, only B received treatment and then a final evaluation was carried out on both the groups. The results show that (1) both the groups improved their performance as an effect of training; (2) improvements are specific to the functions trained; (3) in the interval without intervention, performance of group B worsened; and (4) group A has maintained their results over time. In conclusion, our results show that specific training may reduce memory impairment in MCI.

Characterization of a new trabectedin-resistant myxoid liposarcoma cell line that shows collateral sensitivity to methylating agents

Myxoid Liposarcomas (MLS), characterized by the expression of FUS-CHOP fusion gene are clinically very sensitive to the DNA binding antitumor agent, trabectedin. However, resistance eventually occurs, preventing disease eradication. To investigate the mechanisms of resistance, a trabectedin resistant cell line, 402-91/ET, was developed. The resistance to trabectedin was not related to the expression of MDR related proteins, uptake/efflux of trabectedin or GSH levels that were similar in parental and resistant cells. The 402-91/ET cells were hypersensitive to UV light because of a nucleotide excision repair defect: XPG complementation decreased sensitivity to UV rays, but only partially to trabectedin. 402-91/ET cells showed collateral sensitivity to temozolomide due to the lack of O(6) -methylguanine-DNA-methyltransferase (MGMT) activity, related to the hypermethylation of MGMT promoter. In 402-91 cells chromatin immunoprecipitation (ChIP) assays showed that FUS-CHOP was bound to the PTX3 and FN1 gene promoters, as previously described, and trabectedin caused FUS-CHOP detachment from DNA. Here we report that, in contrast, in 402-91/ET cells, FUS-CHOP was not bound to these promoters. Differences in the modulation of transcription of genes involved in different pathways including signal transduction, apoptosis and stress response between the two cell lines were found. Trabectedin activates the transcription of genes involved in the adipogenic-program such as c/EBPα and β, in 402-91 but not in 402-91/ET cell lines. The collateral sensitivity of 402-91/ET to temozolomide provides the rationale to investigate the potential use of methylating agents in MLS patients resistant to trabectedin.

Circumscribed palmar or plantar hypokeratosis: report of an italian case

Circumscribed palmar or plantar hypokeratosis is a rare benign epidermal malformation of the skin. Clinically it shows asymptomatic, well-circumscribed, and depressed erythema persisting for many years on the palms or soles. Its main histopathologic feature shows a characteristic epidermal depression with an abrupt decrement in the thickness of the stratum corneum, with a sharp stair between normal and involved skin. We describe a case of a 68-year-old woman who presented with an erythematous, asymptomatic, well-circumscribed, depressed patch, on the right thenar eminence which had been present for years.

Latency time in cutaneous leishmaniasis

Latency period in cutaneous leishmaniasis was very rarely studied so far. We describe three patients, aged 71, 50 and 32 years, respectively, who contracted cutaneous leishmaniasis in Sicily. In all patients, clinical diagnosis was confirmed by histopathological examination and polymerase chain reaction: the latter was positive for Leishmania infantum in two patients and Leishmania canis in one. All cases were characterized by a very long period of latency, ranging from 11 to 16 months. These cases suggest that latency time of cutaneous leishmaniasis acquired in Sicily may be sometimes very long. The reasons of this latency time are unknown: latency depends neither by the involved species of sandflies and Leishmania nor by the immunological response of the patients: all laboratory tests, including immunological ones, were normal.

Influenza A (H1N1) encephalitis with severe intracranial hypertension

The swine-origin influenza A (H1N1) virus was responsible for the pandemic infection in 2009. We report a case of encephalitis diagnosed as the H1N1 virus infection in a young child. The H1N1 virus infection can be causative of the encephalitis, as with other influenza virus infections. For patients presenting with influenza-like illness accompanied by mental status changes or seizures, high suspicion for unusual presentations of influenza A virus infection and careful monitoring, including EEG and intracranial pressure monitoring, are essential for reducing complications.

Wild grapevine: silvestris, hybrids or cultivars that escaped from vineyards? Molecular evidence in Sardinia

Vitis vinifera ssp. silvestris, the spontaneous subspecies of V. vinifera L., is believed to be the ancestor of present grapevine cultivars. In this work, polymorphism at 13 SSR loci was investigated to answer the following key question: are wild plants (i) true silvestris, (ii) hybrids between wild and cultivated plants or (iii) or 'escapes' from vineyards? In particular, the objective of the present study was to identify truly wild individuals and to search for possible hybridization events. The study was performed in Sardinia, the second largest island in the Mediterranean Sea, which is characterized by a large and well-described number of both grape cultivars and wild populations. This region was ideal for the study because of its spatial isolation and, consequently, limited contamination from outside material. The results of this study show that domesticated and wild grapevine germplasms are genetically divergent and thus are real silvestris. Pure lineages (both domesticated and wild) show very high average posterior probabilities of assignment to their own clusters, with a low level of introgression.

Intracranial pressure monitoring in pediatric bacterial meningitis: a fancy or useful tool? A case report

Childhood meningitis is associated with high mortality and morbidity. In selected cases, the prompt institution of invasive intracranial pressure (ICP) monitoring and therapy may improve survival but few studies have evaluated the indications for ICP monitoring in this specific neurological disease. This article examines the case of a five-year-old child who was comatose when admitted to the hospital with unilateral dilated pupil, neck stiffness and fever (T 39 degrees C). The initial brain computed tomography scan was unremarkable. Dexamethasone and empirical antibiotic therapy for suspected meningitis was started and a lumbar puncture (LP) was performed. The LP opening pressure was 45 mmHg. Cerebrospinal fluid microscopy demonstrated Meningococcal meningitis. The likelihood of raised ICP, associated with third nerve palsy, prompted insertion of an intraparenchymal catheter for ICP monitoring. Intracranial hypertension was treated with medical therapy. ICP was controlled within 72 hours. On day nine, the ICP device was removed. On the same day, the child started to obey commands, was rapidly weaned from mechanical ventilation and was extubated. He was discharged from the Department on day 13 and after two weeks went home with residual dysmetria and mild motor impairment. This study indicates that ICP-targeted treatment in children improves the outcome of severe cases of bacterial meningitis. ICP monitoring could particularly be useful to optimize brain perfusion and provide relief from severe neurological impairment, which is associated with the clinical signs of meningitis and increased ICP levels.

Operative classification of brain arteriovenous malformation. Part two: validation

SUMMARY

The most important issue when dealing with a patient with a brain AVM is the decision whether to treat or not. Only after this decision has been made, taking into consideration a number of factors depending on both the patient and the specific type of AVM, can the best option for treatment be chosen. An operative classification of brain AVMs, previously adopted in the Department of Neuroradiology and Neurosurgery of Verona (Italy) and published in this journal, was subjected to validation in a consecutive group of 104 patients clinically followed for at least three years after completion of treatment. This classification, slightly modified from the original version concerning the importance of some specific items, allowed us to assess the indication to treat in each case, whatever type of treatment was offered to the patient.

Haplotype richness in refugial areas: phylogeographical structure of Saxifraga callosa

This paper illustrates the phylogeographical structure of Saxifraga callosa in order to describe its genetic richness in refugial areas and to reconstruct its glacial history. S. callosa is a species spread throughout south-east France and Italy with a high distribution in the Maritime Alps. Four chloroplast microsatellite and AFLP markers were analyzed in populations of S. callosa. The size variants of all tested loci amount to 11 different haplotypes. Intrapopulational haplotype variation was found in two of the populations analyzed: on the Mt. Toraggio in the Maritime Alps, and in the Apuan Alps. On the other hand, no intrapopulational variation was found in 25 populations, most of which were sampled from isolated areas. Analysis of the haplotype distribution showed that population subdivision across all populations was high (G (ST) = 0.899). Moreover, its genetic structure was studied using AMOVA and STRUCTURE analysis. The study legitimated inferred conclusions about the phylogeographical structure of the species and identified centers of diversity. Considerations concerning genetic structure and divergence among three major clades (Maritime Alps, Apuan Alps and Apennines), the patchy distribution of haplotypes, and the high number of private haplotypes support the proposal that S. callosa survived in some refugia within the Italian Peninsula refugium, and that mainly northern populations of refugia were involved in postglacial recolonization.

Management of distal tibial intra-articular fractures with circular external fixation

The treatment of tibial plafond fractures requires careful management of the soft tissue envelope, reconstruction of the articular surface and stable fixation with minimal additional damage. Thirty cases of AO type 43 C tibial fractures were treated by transosseous osteosynthesis (Ilizarov technique). The external fixator constructs used were Ilizarov (Transosseous osteosynthesis: theoretical and clinical aspects of the regeneration and growth of tissue, Springer, Berlin, 1992) and Sheffield (Classification AO des fractures, Springer, Berlin, 1987) circular fixator systems. All tibial plafond fractures healed. Using radiological criteria for assessment of reduction of the articular fragments and the clinical scoring system described by Teeny and Wiss, there were excellent and good restoration of articular structure in 27 cases and good clinical results in 14. This treatment method compares well with previous published series and is to be recommended for this group of difficult fractures.

Investigating the role of protein folding and assembly in cell-type dependent expression of alpha7 nicotinic receptors using a green fluorescent protein chimera

To test the hypothesis that cell-dependent expression of alpha7 receptors is due to differences in protein folding or assembly, we constructed a chimeric rat alpha7 subunit with green fluorescent protein (GFP) at the receptor C-terminal. Expression of alpha7-GFP in Xenopus oocytes resulted in currents that were indistinguishable from wild type receptors but were only 33% of control. (125)I-alpha-bungarotoxin (alphaBGT) binding at the oocyte surface was reduced to 23% of wild type. Transfection of alpha7-GFP into GH4C1 cells produced fluorescence that was less intense than GFP alone, but showed significant alpha-BGT binding compared to transfection with GFP. In contrast, alpha7-GFP transfection in SH-EP1, HEK293 and CHO-CAR cells produced fluorescence without alphaBGT binding. Flow cytometry of cells transfected with alpha7-GFP indicated fluorescence in both SH-EP1 and GH4C1 cells, but surface toxin binding sites and sites immunoprecipitated using anti-GFP antibodies were undetectable in SH-EP1 cells, suggesting a problem in folding/assembly rather than trafficking. Surprisingly, integrated fluorescence intensities in GH4C1 cells transfected with alpha7-GFP did not correlate with amounts of cell surface or immunoprecipitable alphaBGT binding. Therefore, GFP folding at the C-terminal of the alpha7-GFP chimera is cell-line independent, but toxin binding is highly cell-line dependent, suggesting that if altered protein folding is involved in the cell-type dependence of alpha7 receptor expression, the phenomenon is restricted to specific protein domains. Further, C-terminal GFP-labeled alpha7 receptors decreased the efficiency of folding/assembly not only of chimeric subunits, but also wild-type subunits, suggesting that the C-terminal is an important domain for alpha7 receptor assembly.

Nicotinic acetylcholine receptors of adrenal chromaffin cells

In the adrenal medulla, acetylcholine released by the sympathetic splanchnic nerves activates neuronal-type nicotinic acetylcholine receptors (nAChRs) on the membrane of chromaffin cells which liberate catecholamines into the bloodstream in preparation for the fight and flight reactions. On adrenal chromaffin cells the main class of nAChRs is a pentameric assembly of alpha3 and beta4 subunits that forms ion channels which produce membrane depolarization by increasing Na+, K+ and Ca2+ permeability. Homomeric alpha7 nicotinic receptors are expressed in a species-dependent manner and do not contribute to catecholamine secretion. Chromaffin cell nAChRs rapidly activate and desensitize with full recovery on washout. nAChR activity is subjected to various types of dynamic regulation. It is allosterically modulated by the endogenous neuropeptide substance P that stabilizes receptors in their desensitized state, thus depressing their responsiveness. The full-length peptide CGRP acts as a negative allosteric modulator by inhibiting responses without changing desensitization, whereas its N-terminal fragments act as positive allosteric modulators to transiently enhance nAChR function. nAChR expression increases when cells are chronically exposed to either selective antagonists or agonists such as nicotine, a protocol mimicking the condition of chronic heavy smokers. In this case, large upregulation of nAChRs occurs even though most of the extra nAChRs remain inside the cells, creating a mismatch between the increase in total nAChRs and increase in functional nAChRs on the cell surface. These findings highlight the plastic properties of cholinergic neurotransmission in the adrenal medulla to provide robust mechanisms for adapting catecholamine release to acute and chronic changes in sympathetic activity.

[Experience and results of acute lymphoblastic leukaemia treatment in children between 1989-2005 in Navarre]

BACKGROUND

The determination of prognostic factors in acute lymphoblastic leukaemia (ALL) is increasingly important in establishing a correct treatment. We analyse the overall survival (OS), event free survival (EFS) and prognostic factors in our 16 years experience of treating acute lymphoblastic leukaemia.

METHODS

We performed univariate and multivariate analyses of the prognostic factors we considered most significant in our serie of patients.

RESULTS

From January 1989 to December 2005, 50 cases of ALL were reported in 58 patients with LA. We analysed a subgroup of 41 patients with LLA as they were included in standard protocols. In this group the EFS was 78% and OS 87.8%. Inmunophenotype is a predictor of prognosis when we compare Common with Others, with a HR of 13.82 (CI95%: 1.019-166.008) p<0.05; Protocol of Treatment of the Paediatric Haematology Oncology Society (SHOP) (94-99/89) with HR of 0.065 (CI95%: 0.005-0.008) p<0.02; and Age (>120 months/12-120 months) with a HR of 13.82 (CI95%: 0.58-329.48) p=0.1.

CONCLUSIONS

The OS in our series is similar to that reported in the literature. Inmunophenotype and protocols of treatment are the most significant prognostic factors.

How to improve ischemic stroke treatment in the fibrinolysis era

In the last 15 years new therapeutic approaches have influenced the treatment of ischemic stroke victims. Aim of this review is to point out the elements of a modern approach to the acute stroke patient. The likelihood of saving ischemic cerebral tissue is time-dependent and the treatment goal is to minimise brain damage. The NINDS trial has documented a higher likelihood of better outcome if the fibrinolytic therapy is administered within 3 h of onset of symptoms. To reach this target several interventions are necessary. First of all, education is needed to diffuse public awareness of stroke warning signs. Moreover, out-of-hospital treatment should be optimised with rapid triage and transport to an hospital with a comprehensive stroke approach. The early hospital phase should comprehend a rapid evaluation and an urgent CT scan. After the verification of the inclusion/exclusion criteria, in a authorised SITS-MOST centre, the patient should receive fibrinolytic therapy. The diagnostic and the therapeutic phase should include rapid identification and treatment of secondary insults, as hyperthermia and hyperglycaemia, that have a negative influence on outcome. Despite advances in diagnosis and monitoring, fibrinolytic therapy is the only treatment with a proven efficacy in achieving a higher functional outcome. The narrow time-window is the reason for the need of rapid and well-organised out-of-hospital and in-hospital systems.