SARS-CoV-2 mRNA vaccination and short-term changes in viral load and CD4/CD8 T-cell counts in people living with HIV

OBJECTIVES

To investigate whether SARS-CoV-2 messenger RNA (mRNA) vaccination has an impact on HIV-related viro-immunological parameters.

METHODS

People with HIV (PWH) in the VAXICONA-ORCHESTRA cohort who received one or more doses of SARS-CoV-2 mRNA vaccine and for whom paired measures of immuno-virological markers (viral load, clusters of differentiation [CD]4, and CD8 count 1 month before and after a vaccine dose [VD]) were available were included. Paired t-test and generalized estimating equation linear regression analyses were used to study changes over ± 1 month around the VD. Subgroup analyses were performed.

RESULTS

A total of 510 PWH were enrolled: the median age was 55 years (interquartile range 46-60 years), the CD4 and CD8 count were 489 (287-719) and 790 (59-1104) cells/mm3, respectively, and 81% received three VDs. After a median of 28 (3-53) days from VD, CD4 count increased by +15 cells/mm3 (SD ± 129.7, P = 0.001) and CD8 by +12 (±250.5, P = 0.199) and the viral load decreased by -0.11 log10 (±0.88, P = 0.001). Similar results were observed after restricting the analysis to viro-suppressed PWH, with CD4 ≤200/mm3, more than 6 months of antiretroviral therapy before VD and after excluding previous COVID-19.

CONCLUSIONS

A small significant increase in CD4 count and a negligible drop in HIV RNA were observed. Our findings are consistent with the hypothesis that SARS-CoV-2 mRNA vaccine can prime CD4 T spike-specific cells, even in the more immuno-compromised PWH.

New treatment strategies for HIV-positive cancer patients undergoing anticancer medical treatment: update of the literature

The introduction of highly active antiretroviral therapy (ART) has deeply modified the outcome of HIV patients by improving their overall survival and ameliorating their quality of life (QoL). The prolongation of these patients' survival has led to an increased risk of highly diffused non-infectious diseases, e.g., cardiovascular diseases, endocrine disease, neurological diseases, and cancer. The management of antiretroviral therapy and anticancer agents (AC) can be challenging, due to the possible drug-drug interactions (DDI) between AC and ART. For this reason, a multidisciplinary approach is always preferred as demonstrated by the GICAT (Italian Cooperation Group on AIDS and Tumors). This review aims to analyze the current scientific data regarding the possible effects of ART on the management of HIV-positive cancer patients and to evaluate the possible DDIs that must be taken into consideration when co-administrating ART and AC. A collaboration between all the involved professional figures, particularly infectious disease specialists and oncologists, represents the key to the correct managing of these patients in order to guarantee the best oncological outcome possible.

Growing old with antiretroviral therapy or elderly people in antiretroviral therapy: two different profiles of comorbidity?

Background

In persons living with HIV (PLWH), the burden of non-communicable chronic diseases increased over time, because of aging associated with chronic inflammation, systemic immune activation, and long-term exposure to the combination antiretroviral therapy (ART).

Methods

To explore the association of chronological age, age at first ART, and exposure to ART with non-communicable chronic diseases, we performed a cross-sectional analysis to evaluate the prevalence of comorbidities in patients enrolled in the SCOLTA Project, stratified by groups of chronological age (50–59 and 60–69 years) and by years of antiretroviral treatment (ART, ≤ 3 or > 3 years).

Results

In 1394 subjects (23.8% women), mean age at enrollment was 57.4 (SD 6.5) years, and at first ART 45.3 (SD 10.7). Men were older than women both at enrollment (57.6 vs 56.8, p = 0.06) and at first ART (45.8 vs 43.6, p = 0.0009). ART duration was longer in women (13.1 vs 11.7 years, p = 0.01). The age- and sex-adjusted rate ratios (aRRs, and 95% confidence interval, CI) showed that longer ART exposure was associated with dyslipidemia (aRR 1.35, 95% CI 1.20–1.52), hypertension (aRR 1.52, 95% CI 1.22–1.89), liver disease (aRR 1.78, 95% CI 1.32–2.41), osteopenia/osteoporosis (aRR 2.88, 95% CI 1.65–5.03) and multimorbidity (aRR 1.36, 95% CI 1.21–1.54). These findings were confirmed in strata of age, adjusting for sex.

Conclusions

Our data suggest that longer ART exposure was associated with increased risk of dyslipidemia, hypertension, and osteopenia/osteoporosis, hence the presence of multimorbidity, possibly due to the exposition to more toxic antiretrovirals. We observed different comorbidities, according to ART exposure and age.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07739-y.

Non-discogenic low back pain treated with oxygen-ozone: outcome in selected applications

Low back pain and sciatica are highly debilitating conditions affecting all socioeconomic groups at an increasingly early age. They are caused by different often concomitant spinal disorders: disc or facet joint disease, spondylolysis (with or without listhesis), vertebral body and interapophyseal arthrosis, spinal stenosis, radicular and synovial cysts and, more rarely, infections and primary or metastatic cancer. Treatment of low back pain and/or sciatica requires an accurate diagnosis based on thorough history-taking and physical examination followed by appropriate imaging tests, namely computed tomography, and/or magnetic resonance scans in addition to standard and morphodynamics X-rays of the spine. In recent years, several reports have demonstrated the utility of oxygen-ozone therapy in reducing the size of herniated discs. The present study reports on the outcome of oxygen-ozone treatment in 576 patients with non-discogenic low back pain caused by degenerative disease of the posterior vertebral compartment (facet synovitis, Baastrup syndrome, spondylolysis and spondylolisthesis, facet degeneration).

Body fat changes in HIV patients on highly active antiretroviral therapy (HAART): a longitudinal DEXA study

OBJECTIVE

We aimed to quantitatively evaluate body fat composition in a group of HIV patients treated with Highly Active Anti-retroviral Therapy (HAART) to ascertain both fat loss and fat distribution changes and to identify possible therapeutic and host related associated risk factors.

PATIENTS AND METHODS

A total of 180 patients with available total body DEXA scan were assigned to a) Group 1, with clinically evident body fat changes, (BFC) and b) Group 2, without BFC. Clinical and immunovirologic data were collected. We used Student t-test and x2 or Fisher exact test to compare the characteristics of the two groups. Paired t-test was used to compare basal and follow-up data. The relationships between variables were evaluated by calculating Pearson's correlation coefficient and its significance.

RESULTS

HAART duration was significantly (p<0.0001) higher for patients in Group 1 than in Group 2, as well as PI (p<0.02) and NRTI (p<0.002) therapy duration. Current CD4 count and CD4 rise from nadir resulted significantly higher in Group 1 than in Group 2 (p<0.02 and 0.006, respectively). Whole Body Fat (WBF), Peripheral Fat (PF) and Leg (L) fat negatively correlated with PI and NRTI therapy duration, while Trunk Fat (TF)/PF positively correlated with PI and NNRTI duration. No significant correlation was found, instead, with NNRTI therapy duration. At 5-year follow-up, we registered a further increase in TF, Arms (A) and L fat, especially in PI-treated patients.

CONCLUSIONS

Body fat changes should always be considered when dealing with HIV-affected patients on HAART. The fat loss seemed to involve mainly peripheral regions, while fat accumulation tendency occurred in the trunk.

Lipid profile improvement in virologically suppressed HIV-1-infected patients switched to dolutegravir/abacavir/lamivudine: data from the SCOLTA project

Introduction: Metabolic disorders are common amongst HIV-infected patients. Data from real-life setting on the impact of DTG/ABC/3TC in virologically suppressed HIV-infected patients are scarce.

Methods: We investigated the modification of metabolic profile including fasting glucose, lipid profile and markers of insulin resistance (IR) in experienced patients switching from a boosted protease inhibitors (bPI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen to DTG/ABC/3TC in a prospective, observational, multicenter study.

Results: We enrolled 131 HIV-infected patients, of whom 91 (69.5%) males, mean age was 50.5±10.6 years. CDC stage was A in 66 (50.4%) patients, of whom 91 (69.5%) had acquired HIV through sexual contacts. The previous regimen was bPI-based in 79 patients (60.3%) and NNRTI-based in 52 (39.7%). Patients switching from NNRTI showed a significant reduction at week 24 in total cholesterol (TC) and low-density lipoprotein cholesterol (LDL). Triglycerides/high-density lipoprotein cholesterol (TG/HDL) ratio, HDL, median TG and TG/HDL ratio did not show significant modification during follow-up times. Among patients switching from a bPI, we observed a significant reduction in TC and LDL at both follow-up times and a slight increase in HDL. Triglycerides/HDL ratio, median TG and TG/HDL ratio showed a decrease over time that became significant at weeks 24 and 48. Blood glucose levels did not significantly vary during the observation period in patients switching from both bPI and NNRTI-based regimens.

Conclusion: Our data suggest an improvement in lipid profile and TG/HDL ratio in pretreated HIV-1-infected patients who switched to DTG/ABC/3TC over 48 weeks, especially in those previously receiving a bPI-based regimen.

Serum interleukin-6 levels are increased in HIV-infected patients that develop autoimmune disease during long-term follow-up

BACKGROUND

Elevated IL-6 levels have been associated with both autoimmune diseases and treated HIV-seropositive (HIV⁺) subjects. However, few data on classic and trans-signaling IL-6 in autoimmune thyroid diseases and HIV⁺ subjects developing autoimmune disorders are currently available.

MATERIALS AND METHODS

A total of 102 patients were included in the study. They were subdivided into two groups. Group A consisted in 51 HIV⁺ patients, who were followed-up for a period of five years in search of possible occurrence of autoimmune diseases. Ten of them, treated with antiretroviral therapy (ART), developed an autoimmune disorder, namely Hashimoto's thyroiditis, and psoriasis. Group B consisted in 51 patients affected by Hashimoto's thyroiditis (HT). Serum levels of the free form of IL-6 were analyzed by ELISA in all patients and for HIV⁺ patients at the beginning of the follow-up, before initiation of ART.

RESULTS

Mean serum levels of IL-6 were similar in Group A and in Group B. In Group B, IL-6 levels showed a 5.8% increase compared with assay minimum detectable dose corresponding to 1% of full serum IL-6 level. However, serum levels of free IL-6 were increased in those HIV⁺ patients who developed autoimmune disorders (5.8±2.8pg/ml) and in these patients, the highest levels of free IL-6 correlated with age and CD4 cellular counts.

CONCLUSIONS

The present study indicates a correlation between serum free IL-6 levels and the occurrence of autoimmune disease in HIV⁺ population, treated with ART during a long-term follow-up. The increased levels of serum free IL-6 were observed before ART treatment was initiated, indicating that IL-6 measurement in such patients may represent an early predictor of development of autoimmune disease.

Il ruolo della TC e dell'Angio-TC

La Tomografia Computerizzata, grazie alle continue innovazioni tecnologiche, consente oggi di poter studiare accuratamente le biforcazioni carotidee, in tempi rapidi, con elevata risoluzione spaziale dopo somministrazione a bolo di dosi non elevate di mezzo di contrasto. Le apparecchiature ad acqusizione spirale permettono un ulteriore incremento qualitativo delle immagini e delle successive ricostruzioni. L'esame viene effettuato con strati sottili di 1–3 mm di spessore, con tempi di scansione rapidi ed una quantità totale di contrasto d 100–150 ml. Nel caso di acquisizione con apparecchio spirale l'inizio dell'esame avviene 20 sec dopo il termine della somminitrazione del contrasto a bolo con iniettore.

Molteplici sono gli algoritmi ricostruttivi sia multiplanari che tridimensionali; quelli più comunemente usati sono il Multiplanar Reformatting per le ricostruzioni sui vari piani dello spazio, il Maximum Intensity Projection per la ricostruzione esclusivamente delle strutture vascolari, e lo Shaded Surface Display per ottenere immagini tridimensionali.

Nel caso di steno-occlusioni aterosclerotiche la TC identifica con precisione la sede della lesione e fornisce importanti informazioni sulla natura della placca:ciò permettere di distinguere le placche calciche, «dure», ad elevata densità da quelle fibrolipidiche, «molli» che risultano ipodense rispetto al lume opacizzato dal contrasto. Nelle placche «miste» entrambe le componenti vengono ben rilevate, cosi come la loro disposizione lungo la parete del vaso. È inoltre agevole l'analisi della superficie endoluminale della placca con la possibilità, in alcuni casi, di evidenziare piccole ulcerazioni superficiali punto di partenza di microemboli. Con TC viene anche misurata la percentuale di stenosi sia applicando i criteri del NASCET, sia come rapporto tra area totale del vaso e area del lume residuo come rapporto tra diametro massimo del vaso e diametro del lume residuo.

Le ricostruzioni multiplanari e tridimensionale forniscono la visione longitudinale del vaso ed ulteriori dati sulla disposizione e dimensione dell'ateroma. Anche nel caso di dissecazione carotidea la TC consente il rilievo della lesione e la sua evoluzione nel tempo: nella fase acuta all'esame diretto, l'ematoma sottointimale è leggermente iperdenso; diventa poi isodenso rispetto al lume e per tale motivo il reperto più significativo e quello di riduzione del calibro vasale. La TC è in grado agevolmente di rilevare la presenza di aneurismi e pseudo-aneurismi carotidei nonchè le compressioni ab estrinseco di questi vasi fornendo importanti informazioni sia morfologiche che di natura.

Single forearm radius and ulna asymmetric lengthening in multiple cartilaginous exostoses: a case report and a long-term follow-up

We describe one case of forearm deformity in a patient affected by multiple cartilaginous exostoses - also known as the forearm 'candy stick deformity'. Surgical treatment usually focuses on the correction of the wrist deformity without correcting the forearm shortening, the latter not being given the same consideration as lower limb shortening. In the presented case, radius and ulna corticotomies were performed and distal forearm deformity and shortening were corrected by two independent monoaxial external fixators, with full pronosupination. It is our belief that simultaneous treatment of forearm shortening and deformity not only results in an improved clinical and functional result but also provides significant psychological benefit. We recommend a long-term follow-up.

Forearm post-traumatic deformities: classification and treatment

INTRODUCTION

There is no classification for acquired forearm deformities. A clinical-radiographic study was conducted to classify these deformities and evaluate the results.

MATERIALS AND METHODS

Thirteen patients with forearm deformities following traumas or their treatment were included (11 men and two women, from 2000 to 2010). Mean age was 31 years (range 10-75 years). Initial treatment was conservative in five patients and surgical in eight patients. One segment was affected in seven patients (the radius in four patients, the ulna in three), and both segments were affected in six patients. Location assessment: 2 projections X-rays, including wrist and elbow. Deformity location: proximal, diaphisary, distal, defined with the abbreviation, in distal sense, R1, R2, R3 for the radius, and U1, U2, U3 for the ulna. Primary and secondary deformities were distinguished: secondary deformities occurred later in a different location than the primary one. Six patients were treated with plate and screws. An external fixator was used in six patients. One patient was treated with bone resection. Iliac crest bone graft was used in 10 patients, and vascularised fibula graft in one patient.

RESULTS

The primary deformity affecting the radial diaphysis (R2) determined a secondary deformity in four patients: in the distal ulna (U3) with ulnocarpal dislocation in three patients and in the distal radius (R3) in one patient. Results of osteosynthesis treatment were excellent in one patient, satisfactory in four and unsatisfactory in one. External fixation was excellent in one patient and satisfactory in five. Bone resection was satisfactory in one patient.

DISCUSSION

Surgical treatments with osteosynthesis are the major cause of acquired forearm deformities in adults. Location and aetiology of the deformities are essential for the surgical indication and the result. It is important to restore the length of the deformed segment, realigning the anatomical axis. X-rays enable clinicians to distinguish between primary and secondary forearm deformities.

CONCLUSION

Characteristics and locations of post-traumatic deformities were identified. The major location is diaphisary and distal, the elbow is rarely affected. The functional consequence is a limitation in the range of motion of the hand. The best results are achieved with short-term treatment.

High prevalence of undiagnosed anxiety symptoms among HIV-positive individuals on cART: a cross-sectional study

INTRODUCTION

Anxiety disorders are frequent in HIV-infected individuals, can pre-exist or occur during HIV infection. We evaluated with a self-reported questionnaire whether anxiety is related to HIV clinical status and therapeutic success in a cohort of HIV-positive subjects in Sicily.

PATIENTS AND METHODS

We enrolled 251 patients on combination antiretroviral therapy (cART) for at least six months; Self Rating Anxiety State SAS 054 was used to diagnose anxiety and a Z score ≥ 45 points was considered diagnostic.

RESULTS

47% of patients were diagnosed with anxiety. Patients showing symptoms related to anxiety had experienced a high number of therapeutic switches (fourth line or more).

CONCLUSIONS

These data confirm a high prevalence of anxiety symptoms among subjects with HIV infection in Eastern Sicily. Physicians should be aware of the extent of the problem and should be able to adequately manage anxiety in the setting of HIV infection.

Bioenergetics of T cell activation and death in HIV type 1 infection

Regressive morphological lesions, found in peripheral lymphocytes from HIV(+) patients, clearly conflict with normal cycle progression and with the execution of basic housekeeping and immune functions. With these lesions, circulating lymphocytes are destined to spontaneous and energy-independent cell lysis. By means of confocal microscopy and morphometry, we have quantified the rate of circulating T cells that are probably destined to emocatheresis in vivo. This rate includes lymphocytes in which nucleolin fragments have been scattered out of the nuclear region as a result of prelethal alterations in the nuclear membrane permeability. In terms of bioenergetics, these cells show evident anomalies in the energy production machinery that make them unable to carry out ATP-requiring functions. The extent of damaged cell fraction in peripheral blood reflects the frequency with which T lymphocytes leave lymphoid tissue to be cleared in hemocatheretic processes.

96 Week follow-up of HIV-infected patients in rescue with raltegravir plus optimized backbone regimens: a multicentre Italian experience

BACKGROUND

Long term efficacy of raltegravir (RAL)-including regimens in highly pre-treated HIV-1-infected patients has been demonstrated in registration trials. However, few studies have assessed durability in routine clinical settings.

METHODS

Antiretroviral treatment-experienced patients initiating a RAL-containing salvage regimen were enrolled. Routine clinical and laboratory follow-up was performed at baseline, week 4, 12, and every 12 weeks thereafter. Data were censored at week 96.

RESULTS

Out of 320 patients enrolled, 292 (91.25%) subjects maintained their initial regimen for 96 weeks; 28 discontinued prematurely for various reasons: death (11), viral failure (8), adverse events (5), loss to follow-up (3), consent withdrawal (1). Eight among these 28 subjects maintained RAL but changed the accompanying drugs. The mean CD4+ T-cell increase at week 96 was 227/mm(3); 273 out of 300 patients (91%), who were still receiving RAL at week 96, achieved viral suppression (HIV-1 RNA <50 copies/mL). When analyzing the immuno-virologic outcome according to the number of drugs used in the regimen, 2 (n = 45), 3 (n = 111), 4 (n = 124), or >4 (n = 40), CD4+ T-cell gain was similar across strata: +270, +214, +216, and +240 cells/mm(3), respectively, as was the proportion of subjects with undetectable viral load. Laboratory abnormalities (elevation of liver enzymes, total cholesterol and triglycerides) were rare, ranging from 0.9 to 3.1%. The mean 96-week total cholesterol increase was 23.6 mg/dL.

CONCLUSIONS

In a routine clinical setting, a RAL-based regimen allowed most patients in salvage therapy to achieve optimal viral suppression for at least 96 weeks, with relevant immunologic gain and very few adverse events.

Intracellular accumulation of cell cycle regulatory proteins and nucleolin re-localization are associated with pre-lethal ultrastructural lesions in circulating T lymphocytes: the HIV-induced cell cycle dysregulation revisited

The HIV-induced demise of CD4-T cells is thought to be a result of the execution of genetically programmed cell death that occurs in lymphoid tissue, where many resident T cells are chronically hyperactivated. Since HIV-induced alterations of cell cycle control has been often indicated as prominent mechanism of immune hyper activation and cause of apoptotic death, the signal pathway involved in cell cycle dysregulation of T lymphocytes from HIV infected patients was extensively studied. Here, we also demonstrate that circulating T lymphocytes leave lymphoid tissues with diffused regressive lesions (vacuolization, blebbing, nuclear evanescence and organelle swelling). Equally diffused are biochemical anomalies that accompany the overall disarrangement of cell structure, particularly the fragmentation and diffusion into the cytoplasm of C23/nucleolin, the intracellular accumulation of short lived regulatory proteins and the decrease in expression of membrane proteins. All this is something more than a cell cycle-related remodelling of cell morphology and biochemical mechanisms, and rather recalls a necrotic/oncotic cell damage. Since these changes are associated with adaptive mechanisms to hypoxia, we give evidence for alteration of cell cycle control developing in conditions of scarce energy supply.

Changes in aqueductal CSF stroke volume in shunted patients with idiopathic normal-pressure hydrocephalus

BACKGROUND AND PURPOSE

Aqueductal CSF stroke volume (ACSV) measured by phase-contrast MR imaging is a tool for selection of surgical patients with idiopathic normal-pressure hydrocephalus (iNPH). The aim of the present study was to investigate whether there is a relationship between clinical outcome and changes in ACSV in patients with iNPH who have been shunted.

MATERIALS AND METHODS

Sixty-five shunted patients with iNPH underwent clinical evaluation and ACSV measurements 7-30 days before and 1, 3, 6, and 12 months after surgery.

RESULTS

Two patients were excluded from the study for the occurrence of a perioperative complication. In a group of 35 clinically improved patients, the mean preoperative ACSV (157.01 microL) decreased to 18% one month after ventriculoperitoneal shunt (VPS) and < or =49% at 12 months post-VPS. In a group of 15 unimproved patients, the lower mean preoperative ACSV (84.2 microL) decreased to 14.3% one month post-VPS and < or =34% at 12 months post-VPS. In the other 8 improved patients who developed a subdural fluid collection (SDFC), ACSV values decreased by 43%-75% in the 3 months post-VPS. A postoperative ACSV increase was noted in 6 patients with a shunt system malfunction. One patient experienced both SDCF and shunt malfunction.

CONCLUSIONS

ACSV decreases in all patients in whom the VPS system works properly, with the rate of ACSV decrease being higher in the patients who show clinical improvement. Postoperative ACSV increase suggests shunt malfunction. A precipitous drop of ACSV values after VPS may be the consequence of increased drainage and herald the occurrence of SDFC.

Short-term evolution of autoreactive T cell repertoire in multiple sclerosis

T cells reactive to self-antigens are present in the peripheral blood of patients with autoimmune diseases as well as in healthy subjects. Although T cell-response to the self-myelin antigen myelin basic protein (MBP) has been widely investigated in multiple sclerosis (MS) patients, very little is known about the evolution over time of this response and its correlation with the disease activity. In recent years magnetic resonance imaging (MRI) techniques have provided new tools for following the inflammatory activity in the central nervous system (CNS) of MS patients. In the present study the T cell response to MBP was longitudinally investigated in terms of frequency, epitope specificity, and cytokine production profile in four patients with relapsing-remitting MS enrolled in a gadolinium-enhanced MRI serial study. In spite of different profiles of inflammatory activity within the CNS, all the patients examined showed major changes in their reactivity to MBP during the follow-up period in terms of both frequency and epitope specificity. Episodic expansions of MBP-specific T cell populations were observed in each patient, and overall they did not correlate with disease activity. In these patients the expansions: 1) occurred in the context of a steady level of disease activity, 2) correlated with a burst of CNS inflammation, 3) followed the appearance of a new active lesion, and 4) were observed even in the absence of detectable signs of CNS inflammation during the entire follow-up period. These results suggest that the evolution over time of the T cell response to a self-antigen such as MBP is more complex than previously expected. The short-term repertoire dynamics of autoreactive T cells in MS underscore the importance of longitudinal studies for evaluating autoreactivity to myelin antigens and probably to any self-antigen in other autoimmune diseases.

[Diffusion weighted MR: principles and clinical use in selected brain diseases]

PURPOSE

To define the principles and technical bases of diffusion weighted MR imaging of the brain and report our experience in the evaluation of selected brain disorders including age-related ischemic white matter changes (leukoaraiosis), neoplastic and infective cysts and wallerian degeneration.

MATERIAL AND METHODS

Between May 1999 and June 2000 we examined seventeen patients: 10 patients with leukoaraiosis and deterioration of cognitive and motor function, 5 patients with focal cystic lesions (one anaplastic astrocytoma, one glioblastoma, one metastasis from squamous cell lung carcinoma, one pyogenic abscess and one case with cerebral tubercolosis) and 2 patients with wallerian degeneration (one with post-hemorrhagic degeneration of right corticospinal tract and one with post-traumatic degeneration of left optic tract). All patients underwent a standard cranial MR examination including SE T1-, proton density, T2-weighted, FLAIR and diffusion weighted images. Post-contrast T1-weighted sequences were also obtained in the patients with cystic lesions. Diffusion weighted images were acquired with double shot echoplanar sequences. Diffusion sensitizing gradient along the x, y and z axes and b values ranging 800 to 1200 s/mm2 were used. For each slice a set of three orthogonal diffusion "anisotropic" images, an "isotropic" image and a standard T2-weighted image were reconstructed. Postprocessing included generation of the apparent diffusion coefficient maps and of the "trace" image that reflects pixel by pixel the diffusional properties of water particles only. Values of mean diffusivity within regions of interest were computed in the "trace" image and compared with those obtained in contralateral brain areas. In patients with leukoaraiosis the diffusivity in posterior periventricular white matter was compared with that measured in 10 age-matched control subjects without leukoaraiosis.

RESULTS

In patients with leukoaraiosis the areas of increased periventricular signal intensity on T2-weighted images showed a significantly higher (p < 0.001) diffusivity (mean values 124.7 +/- 21.3 x 10(-5) mm2/s) as compared to control subjects (mean values 85 +/- 7 x 10(-5) mm2/s). Diffusion weighted images in 2 patients revealed the presence of a small focal area of increased signal and reduced diffusivity in "trace" images consistent with recent ischemic lesion. In neoplastic cystic lesions the central necrotic/cystic content was always hypointense on diffusion weighted images and showed increased diffusivity on "trace" images. On the other hand the central necrotic content of the pyogenic brain abscess was hyperintense and showed low diffusivity. In patients with wallerian degeneration diffusion weighted images and "trace" images demonstrated loss of anisotropy and increased diffusivity in the affected white matter tract relative to the contralateral.

DISCUSSION

The increased diffusivity observed in areas of leukoaraiosis and the identification of subclinical acute ischemic lesions by diffusion weighted images might be more useful than standard MR sequences for monitoring the disease progression. Diffusion weighted images allow differentiation of the different parts of focal cystic lesions (edema, solid and cystic/necrotic portion) and are useful to differentiate pyogenic brain abscess from necrotic tumors. In patients with wallerian degeneration the loss of anisotropy and the increase of diffusivity values in the affected tract are probably related to myelin breakdown and allow better recognition of the affected tract relative to standard MR images.

CONCLUSIONS

Diffusion weighted MR imaging can be performed during a standard cranial MR examination and add useful clinical information in several brain disorders besides acute ischemic stroke.

Ascending myelopathy in the early stage of spinal cord injury

A 30-year-old healthy woman was involved in a road traffic accident. She sustained a fracture dislocation of T11/12 with a complete Frankel A paraplegia below T11. She had no associated injuries. High Dose Methylprednisolone was administered according to the NASCIS III protocol (48 h) together with low molecular weight Heparin and gastroprotected medication. Complete transection of the spinal cord and an anterior haematoma from T11 to T12 were confirmed on X rays, CT's and MRI scans. Posterior surgical stabilisation was performed using Isola instrumentation, starting 8 h post injury. Her post surgical period was uneventful except for some episodes of low blood pressure (85/60 mmHg) from which she had no symptoms. On the 12th post operative day, while in the physiotherapy department, she complained of right scapular pain. This occurred every time she was sat up and was associated with paraesthesia of both upper limbs. Two days later she deteriorated neurologically and her level ascended initially to T8 and then to T3. MRI of the spine with and without gadolinium showed spinal cord oedema between C3 and T1. There was no evidence of haemorrhage or syringomyelia. The authors discussed this case making different hypotheses. They are mainly the following: (1) Gradually ascending ischaemia due to a vascular disorder; (2) Double spinal trauma; (3) Ischaemia related to repeated hypotensive episodes; (4) Low grade intramedullary tumour; and (5) Thrombus of the Radicularis Magna artery. The case has been recognised as being very rare and interesting. In the conclusions, the presenting author stresses the importance of adopting MRI-compatible instrumentation for the surgical stabilisation of the spine, and careful monitoring of blood pressure during the acute phase of spinal cord injury. Dr Aito agrees with Mr El Masry about the opportunity of forming a group of clinicians in order to discuss protocols to cope with this devastating complication.

Phase-contrast MR angiography of intracranial dural arteriovenous fistulae

MRI and phase-contrast MR angiography (PC MRA) were obtained in 13 patients with angiographically confirmed intracranial dural arteriovenous fistulae (DAVF). Three- and two-dimensional PC MRA was obtained with low (6-20 cm/s) and high (> 40 cm/s) velocity encoding along the three main body axes. MRI showed focal or diffuse signal abnormalities in the brain parenchyma in six patients, dilated cortical veins in seven, venous pouches in four with type IV DAVF and enlargement of the superior ophthalmic vein in three patients with DAVF of the cavernous sinus. However, it showed none of the fistula sites and did not allow reliable identification of feeding arteries. 3D PC MRA enabled identification of the fistula and enlarged feeding arteries in six cases each. Stenosis or occlusion of the dural sinuses was detected in six of eight cases on 3D PC MRA with low velocity encoding. In six patients with type II DAVF phase reconstruction of 2D PC MRA demonstrated flow reversal in the dural sinuses or superior ophthalmic vein.

Extraventricular neurocytoma with ganglionic differentiation associated with complex partial seizures

We report an unusual case of extraventricular ("cerebral") neurocytoma with ganglion cells located in the right temporal lobe in a 9-year-old girl with complex partial seizures and precocious puberty. CT showed a calcified mass with central cystic zones. MR imaging showed a markedly hyperintense predominately solid tumor on both T1- and T2-weighted images, without appreciable contrast enhancement. Cerebral neurocytomas are histologically benign and radical surgery is curative; they should be included in the differential diagnosis of temporal lobe tumors in children.

Magnetic resonance in the study of cranial nerves

The course of cranial nerves was studied by means of magnetic resonance (MR), which allowed a multiplane visualization of the investigated structures. The obtained results showed that MR was an excellent method for visualization of the optic, trigeminal, facial and acoustica nerves. The oculomotor and the abducent nerves were detectable only in some regions where the contrast with the surrounding structures was greater. The glossopharingeus, vegus and accessory nerves were identifiable only in the first tract of emergency from the encephalic trunk and they could no be distinguished separately. The trochlear nerve was seldom visible whereas the olfactory nerve failed to be revealed. Further technological progress will allow for additional advances as regards the acquisition of knowledge concerning these important nerves.

Quantitation of brain perfusion with 99mTc-bicisate and single SPECT scan: comparison with microsphere measurements

This study describes and validates in a preliminary manner a method to measure the steady-state influx constant (Ki) of 99mTc-bicisate with one single photon emission computed tomography (SPECT) scan. The method is based on the analysis of the arterial concentration of the radioactivity. The results of this quantitation procedure were compared with regional CBF (rCBF) measurements made using 99mTc-microspheres (MI). Two quantitative indexes of perfusion, fractional brain uptake (FBU) and normalized (with cerebellum) brain uptake (NBU), were also evaluated. Two SPECT studies were performed on seven cardiovascular patients who had no signs of neurological disease. In the first of these, 99mTc-bicisate was used, while in the other, which was performed 2 days later, MI were injected into the left heart ventricle. The values of the FBU, NBU, and Ki of 99mTc-bicisate were calculated in several gray and white matter brain regions of interest (ROIs) and compared with the rCBF values measured with MI in coupled ROIs. Mean FBU values were 0.00008 +/- 0.00002 and 0.00004 +/- 0.00001 in the gray and the white matter, respectively. Mean NBU values were 0.99 +/- 0.04 and 0.54 +/- 0.05, mean Ki values were 0.36 +/- 0.06 and 0.19 +/- 0.03 ml g-1 min-1 and mean rCBF values were 0.51 +/- 0.04 and 0.27 +/- 0.04 ml g-1 min-1 in gray and white matter, respectively. Analysis of variance of the regression gave different F values for the regressions with rCBF of FBU (F = 19, n = 126), NBU (F = 289, n = 112), and Ki (F = 117, n = 126).(ABSTRACT TRUNCATED AT 250 WORDS)

[Computer-assisted interactive didactic system in radiology]

A computer-assisted didactic interactive system for radiology is described; it was implemented on a widely available, cost-effective personal computer with advanced graphic features. A set of suitable CT images was selected and digitized with a specific software that also allowed to process the acquired images. After adding graphic and textual comments, the images were ready to be put in the tutorial. A second software tool was used to manage the image display and to control the correct sequence of the interactive steps of the tutorial. A series of computer-driven multiple-choice questions was prepared to provide the user with a tool improving his/her knowledge of the topics covered by the system, in a simple and unconventional way. The tutorial was designed so that both the absolute number and the percentage of correct answers can be displayed and the critical evaluation of incorrect answers is automatically performed; in the end, the system goes back to the first screen and the tutorial can be run again. The system performance is good with standard hardware; it can be markedly improved with the integration of peripherals--i.e. hard disk. In the next future, the commercial availability of more advanced storage media (videodisks and optical disks) will dramatically improve the archiving capacity and will reduce access times.

[Ultrasonography and computerized tomography in giant Baker's cyst]

The US study of the posterior compartment of the knee usually allows the clinical suspicion of popliteal cyst to be confirmed. Nevertheless, in case of giant Baker's cysts--which are, at any rate, less frequent--US diagnosis is more difficult. CT can help determine the benign nature of the lesion, and allow an accurate spatial evaluation. Moreover CT, when accurately performed, demonstrates the caudal or cranial cystic spread, together with its clear separation from adjacent muscular tissues. Direct coronal scans are more useful to obtain better spatial definition than reformatted images.

[Side effects of spinal nerve root radiography. How to reduce them?]

Contrastographic techniques with intrathecal injections (SRG, Myelo-CT) are widely employed in the diagnostic approach to lumbar pathologic conditions. These techniques allow pathologic changes to be demonstrated and the information they yield helps plan the correct surgical approach. However, these invasive examinations are seldom employed for the high incidence of side-effects. The latter are related to various causes, the identification of which can help reduce the side-effects themselves. The authors analyzed a study population of 522 patients subjected to radiculography, using needles of different gauges (18-23 G), and injected non-ionic contrast medium in doses ranging 5-10 ml. The incidence of side-effects was significantly higher in the patients suffering from usual headache (79/237 = 33%), in those under 40 (87/238 = 37%), and in female patients (86/221 = 39%). The incidence of side-effects was lower with fine needles (41/139 = 17%) and contrast medium in doses less than 8 ml (80/337 = 24%). The patients were divided into 4 subgroups according to the different doses of contrast medium administered and to needle gauges: the above parameters exhibited a percentage decrease (21/161 = 14%) with 21-23 G needles and 8 ml of contrast medium. The authors believe it possible to reduce side-effects by using fine needles and smaller doses of contrast medium.

For an elective surgical management in lumbar intervertebral disc herniation. Experience of 25 years of surgery

On the base of a wide clinical experiences, the Authors report some consideration about relationship between clinical findings and neuroradiological pictures (plain film, myelography, CT and NMR) of the lumbar vertebral and disc diseases. It's pointed out the useful aspect of each imaging technique that contribute to obtain the more complete informations about anatomy of the lesion; such considerations allows the surgeon to plain the more adequate surgical technique. The Authors think myelography, still today, is the investigation of choice in this kind of pathology.