P113 Efficacy, safety and long-term durability of endovascular treatment of MCA aneuryms: a review of 161 treated aneurysms

Objectives

The aim of this study was to assess the long-term outcomes of endovascular treatment of MCA aneurysms and identify factors associated with recurrence.

Subjects

161 aneurysms in 147 patients treated between January 2008 and August 2011.

Methods

A retrospective case note review was performed. Aneurysm occlusion was assessed using the Raymond-Roy classification. Clinical outcome was graded using the mRS.

Results

The minimum period of follow up was 65 months, with a maximum follow up period of 120 months. 49% of aneurysms were ruptured at the time of treatment. Morbidity was observed in 15% of the unruptured aneurysms (6% permanent neurological deficit), and in 33% of ruptured aneurysms (15% permanent neurological deficit). 84% of aneurysms were fully occluded following first treatment. Of these, 34% demonstrated angiographic recurrence and 10% required re-intervention. 25% of aneurysms≤7 mm in maximal diameter demonstrated angiographic recurrence, as compared with 50% of aneurysms>7 mm. Aneurysm size >7 mm was associated with a significantly shorter time to recurrence (log rank=9.655, p=0.002).

Conclusions

This is a large series of MCA aneurysms with a long period of follow up. Our results demonstrate that endovascular treatment of MCA aneurysms is associated with a low morbidity and mortality. Given the increasing use of adjunctive devices (stents, web devices) full occlusion of ruptured aneurysms in the acute phase is not necessary, and deliberate staged treatment a reasonable strategy.

Pituitary tuberculoma: a rare cause of sellar mass

INTRODUCTION

Pituitary tuberculosis is an uncommon cause of sellar mass [1]; the estimated prevalence worldwide is not known, and there have been no reports of the condition occurring in Ireland. Tuberculosis of the pituitary gland may present as a sellar mass or with symptoms of hypopituitarism.

CASE PRESENTATION

A 41-year-old woman, with a short prodromal history without endocrine symptoms, was found to have pituitary tuberculosis after the demonstration of a sellar mass on MRI, and lumbar puncture findings consistent with lymphocytic meningitis.

CONCLUSION

To our knowledge, this is the first published case of pituitary tuberculoma in Ireland.

Paediatric cyclical Cushing's disease due to corticotroph cell hyperplasia

BACKGROUND

Cushing's disease is very rare in the paediatric population. Although uncommon, corticotroph hyperplasia causing Cushing's syndrome has been described in the adult population, but appears to be extremely rare in children. Likewise, cyclical cortisol hypersecretion, while accounting for 15 % of adult cases of Cushing's disease, has only rarely been described in the paediatric population. Here, we describe a very rare case of a 13-year old boy with cyclical cortisol hypersecretion secondary to corticotroph cell hyperplasia.

CASE PRESENTATION

The case is that of a 13-year old boy, presenting with a long history of symptoms and signs suggestive of hypercortisolism, who was found to have cyclical ACTH-dependent hypercortisolism following dynamic pituitary testing and serial late-night salivary cortisol measurements. The patient underwent endoscopic transsphenoidal resection of the pituitary. Early surgical remission was confirmed by undetectable post-operative morning plasma cortisol levels. Histology and immunocytochemistry of the resected pituitary tissue showed extensive corticotroph cell hyperplasia.

CONCLUSION

This report describes a rare case of cyclical Cushing's disease secondary to corticotroph hyperplasia in a paediatric patient. This highlights the challenging and varied nature of Cushing's disease and its diagnosis, and the need to keep a differential diagnosis in mind during the diagnostic process.

Chronic hypopituitarism is uncommon in survivors of aneurysmal subarachnoid haemorrhage

OBJECTIVE

The incidence of hypopituitarism after aneurysmal subarachnoid haemorrhage (SAH) is unclear from the conflicting reports in the literature. As routine neuroendocrine screening for hypopituitarism for all patients would be costly and logistically difficult, there is a need for precise data on the frequency of hypopituitarism and on factors which might predict the later development of pituitary dysfunction. We aimed to: (i) Establish the incidence of long-term hypopituitarism in patients with aneurysmal SAH. (ii) Determine whether data from patients' acute admission with SAH could predict the occurrence of long-term hypopituitarism.

DESIGN

One hundred patients were studied prospectively from the time of presentation with acute SAH. Plasma cortisol, plasma sodium and a variety of clinical and haemodynamic parameters were sequentially measured for the first 12 days of their acute admission. Forty-one patients then underwent dynamic pituitary testing at median 15 months following SAH (range 7-30 months), with insulin tolerance test (ITT) or, if contraindicated, a glucagon stimulation test (GST) plus short synacthen test (SST). If symptoms of cranial diabetes insipidus (CDI) were present, a water deprivation test was also performed.

RESULTS

Forty-one patients attended for follow-up dynamic pituitary testing. Although 14 of 100 had acute glucocorticoid deficiency immediately following SAH, only two of 41 had long-term adrenocorticotrophic hormone (ACTH) deficiency and four of 41 had growth hormone (GH) deficiency. None were hypothyroid or gonadotrophin deficient. None had chronic CDI or hyponatraemia. There was no association between acute glucocorticoid deficiency, acute CDI or acute hyponatraemia and long-term pituitary dysfunction.

CONCLUSION

Both anterior and posterior hypopituitarism are very uncommon following SAH and are not predicted by acute clinical, haemodynamic or endocrinological parameters. Routine neuroendocrine screening is not justified in SAH patients.

Presentation, management and outcomes in acute pituitary apoplexy: a large single-centre experience from the United Kingdom

OBJECTIVE

To study the presentation, management and outcomes and to apply retrospectively the Pituitary Apoplexy Score (PAS) (United Kingdom (UK) guidelines for management of apoplexy) to a large, single-centre series of patients with acute pituitary apoplexy.

DESIGN

Retrospective analysis of casenotes at a single neurosurgical centre in Liverpool, UK.

RESULTS

Fifty-five patients [mean age, 52·4 years; median duration of follow-up, 7 years] were identified; 45 of 55 (81%) had nonfunctioning adenomas, four acromegaly and six prolactinomas. Commonest presenting features were acute headache (87%), diplopia (47·2%) and visual field (VF) defects (36%). The most frequent ocular palsy involved the 3rd nerve (81%), followed by 6th nerve (34·6%) and multiple palsies (19%). Twenty-three patients were treated conservatively, and the rest had surgery either within 7 days of presentation or delayed elective surgery. Indications for surgery were deteriorating visual acuity and persistent field defects. Patients presenting with VF defects (n = 20) were more likely to undergo surgery (75%) than to be managed expectantly (25%). There was no difference in the rates of complete/near-complete resolution of VF deficits and cranial nerve palsies between those treated conservatively and those who underwent surgery. Endocrine outcomes were also similar. We were able to calculate the PAS for 46 patients: for the group treated with early surgery mean, PAS was 3·8 and for those managed conservatively or with delayed surgery was 1·8.

CONCLUSIONS

Patients without VF deficits or whose visual deficits are stable or improving can be managed expectantly without negative impact on outcomes. Clinical severity based on a PAS ≥ 4 appeared to influence management towards emergency surgical intervention.

Hyponatremia following mild/moderate subarachnoid hemorrhage is due to SIAD and glucocorticoid deficiency and not cerebral salt wasting

CONTEXT

Hyponatremia is common after acute subarachnoid hemorrhage (SAH) but the etiology is unclear and there is a paucity of prospective data in the field. The cause of hyponatremia is variously attributed to the syndrome of inappropriate antidiuresis (SIAD), acute glucocorticoid insufficiency, and the cerebral salt wasting syndrome (CSWS).

OBJECTIVE

The objective was to prospectively determine the etiology of hyponatremia after SAH using sequential clinical examination and biochemical measurement of plasma cortisol, arginine vasopressin (AVP), and brain natriuretic peptide (BNP).

DESIGN

This was a prospective cohort study.

SETTING

The setting was the National Neurosurgery Centre in a tertiary referral centre in Dublin, Ireland.

PATIENTS

One hundred patients with acute nontraumatic aneurysmal SAH were recruited on presentation.

INTERVENTIONS

Clinical examination and basic biochemical evaluation were performed daily. Plasma cortisol at 0900 hours, AVP, and BNP concentrations were measured on days 1, 2, 3, 4, 6, 8, 10, and 12 following SAH. Those with 0900 hours plasma cortisol<300 nmol/L were empirically treated with iv hydrocortisone.

MAIN OUTCOME MEASURES

Plasma sodium concentration was recorded daily along with a variety of clinical and biochemical criteria. The cause of hyponatremia was determined clinically. Later measurement of plasma AVP and BNP concentrations enabled a firm biochemical diagnosis of the cause of hyponatremia to be made.

RESULTS

Forty-nine of 100 developed hyponatremia<135 mmol/L, including 14/100<130 mmol/L. The cause of hyponatremia, and determined by both clinical examination and biochemical hormone measurement, was SIAD in 36/49 (71.4%), acute glucocorticoid insufficiency in 4/49 (8.2%), incorrect iv fluids in 5/49 (10.2%), and hypovolemia in 5/49 (10.2%). There were no cases of CSWS.

CONCLUSIONS

The most common cause of hyponatremia after acute nontraumatic aneurysmal SAH is SIAD. Acute glucocorticoid insufficiency accounts for a small but significant number of cases. We found no cases of CSWS.

Is stereotactic radiosurgery under-utilised in the treatment of surgically excisable cerebral metastases?

BACKGROUND/OBJECTIVE

Brain metastases are a significant cause of morbidity and mortality. Treatment options included surgery, whole brain radiotherapy and stereotactic radiosurgery alone or in combination. There has been a significant increase in stereotactic radiosurgery (SRS) provision in the UK over the last 5 years. We investigated the proportion of surgically resected brain metastases that would be suitable for SRS.

METHODS

We retrospectively collected data on 116 consecutive patients undergoing surgical resection of brain metastases. Suitable radiological targets for SRS were defined as solid tumours < 30 mm maximum diameter with no hydrocephalus and no symptomatic mass effect.

RESULTS

One hundred and two cases (88%) were solitary metastasis and fourteen (12%) had multiple metastases. Median maximum tumour diameter was 34 mm (range: 12-70 mm). Approximately one-third of patients (n = 41) had surgically resected brain metastasis suitable for SRS. Median OS was 7.7 months for those suitable for SRS and 5.4 months for those not suitable for SRS (Fig. 3; Log Rank: P = 0.52).

CONCLUSIONS

In surgically amenable tumours, day case SRS could also be used in approximately one-third of cases, thereby avoiding craniotomy and reducing length of stay. These data may be useful in planning service provision, and for drawing up business plans for a new SRS services. Nationally agreed guidelines for SRS for brain metastases have been developed and a full health economic analysis warrants further investigation to determine the cost effectiveness of SRS compared to craniotomy.

A clone of elusive parents: gonadotroph adenoma-female type

A 69-year-old woman presented with visual disturbance. Perimetry testing revealed a bitemporal hemianopia. Brain MRI demonstrated a 2.2-cm gadolinium-enhancing pituitary mass. Previously she had been treated for hypothyroidism, hypertension, and dyslipidemia. She had hyperprolactinemia. Endoscopic transsphenoidal debulking improved her visual field defects. Histology showed a chromophobic adenoma. Electron microscopy showed elongated, polar cells with long, slender processes. The small uniform secretory granules were peripherally disposed, collecting heavily within cell processes. Based on electron microscopical characteristics the tumor is consistent with an ACTH-negative female gonadotroph adenoma. The parent cell of this rare variant of a pituitary adenoma is yet unknown.

The influence of growth hormone replacement on peripheral inflammatory and cardiovascular risk markers in adults with severe growth hormone deficiency

BACKGROUND

Adult GHD syndrome is associated with clustering of adverse cardiovascular (CV) risk factors such as abnormal body composition, dyslipidemia, insulin resistance and abnormal haemostatic factors. There is a wealth of evidence linking CV events with elevated levels of inflammatory markers (hs-CRP and IL-6) in the general population; however data on their abnormalities in GHD and specially the effects of GH replacement (GHR) on these inflammatory markers are limited.

OBJECTIVE

To study the effects of GHR on inflammatory markers, glucose homeostasis and body composition in a cohort of adults with recently diagnosed severe GHD due to hypothalamic pituitary disease.

DESIGN

Fifteen hypopituitary adults (11 males, mean age 48.5 years) with recently diagnosed, severe GHD were recruited. Patients received GHR (in addition to other pituitary hormone replacements) titrated to clinical response and to normalize age and gender adjusted IGF-1 levels. Weight, waist hip ratio (WHR), body composition, fasting plasma glucose and insulin, insulin resistance index (HOMA-IR), fasting serum lipid levels, hs-CRP, IL-6 and TNF-alpha were measured at baseline and following a minimum 6 months of stable maintenance GHR.

RESULTS

GHR resulted in a physiological increase in IGF-1 SDS [median -0.6 to +0.39, P<0.0001], improved quality of life (mean pre-treatment AGHDA score 16 vs. post-treatment score 7, P<0.0001) and reduction in WHR (0.94 vs. 0.92, P=0.01). There were no significant changes in body weight and composition. Levels of hs-CRP (log transformed, mean (SD)) were significantly reduced following GHR (pre 1.21 (0.9) vs. post 0.27 (0.9), P<0.0001) but TNF-alpha and IL-6 levels remained unchanged. Fasting glucose (mmol/L) [4.6 (0.1) vs. 5.1 (0.1), P=0.003], fasting insulin (muU/mL) [9.4 (8.1) vs. 12.1 (9.2), P=0.03] and HOMA-IR [1.2 (1.0) vs. 1.5 (1.1) P=0.02] (all pre-GHR vs. post-GHR and mean (SD)) significantly increased following GHR indicating increased insulin resistance. Significant improvements were noted in fasting LDL-cholesterol (LDL-C) and HDL-cholesterol (HDL-C) levels following GHR [3.4 (0.9) vs. 2.9 (0.7), P=0.03 and 1.2 (0.2) vs. 1.3 (0.2), P=0.02, respectively] (all pre-GHR vs. post-GHR and mean (SD)). Levels of total cholesterol and triglycerides did not change following GHR.

CONCLUSIONS

Physiological GHR for at least 6 months in hypopituitary adults with recently diagnosed severe GHD resulted in favourable changes in hs-CRP, WHR, fasting LDL-C and HDL-C levels all of which are recognised CV risk markers. However, there remains a high prevalence of obesity in this population and given the worsening of insulin sensitivity in the short term with GHR, monitoring and aggressive treatment of established CV risk factors is essential to reduce premature atherosclerotic CVD in this patient population.

The d3/fl-GH receptor gene polymorphism does not influence quality of life and body composition in GH-deficient adults receiving GH replacement therapy

CONTEXT

The growth response to recombinant human growth hormone (rhGH) in GH deficient (GHD) patients may be influenced by polymorphisms in the growth hormone receptor (GHR) gene.

OBJECTIVES

To investigate adults with GHD who have been treated with rhGH for more than 1 year to determine the relationship between genomic deletion of exon 3 in the GHR gene and quality of life (QoL), body composition (BC) and serum IGF1 levels, and to compare these variables to a healthy adult control population.

DESIGN

Cross-sectional study.

METHODS

A total of 100 healthy adult controls and 131 patients were studied. Deletion of exon 3 in the GHR gene was determined in DNA that was isolated from peripheral blood. QoL was determined using the adult GHD assessment scale and three other validated QoL instruments.

RESULTS

In the control population, the frequency of the genotypes was 53% fl/fl, 40% d3/fl and 7% d3/d3, and in the patient population, 55, 39 and 6% respectively. There was no significant difference in QoL scores and BC in control subjects with the fl/fl genotype compared with those with the d3/d3 or fl/d3 genotype. There was no difference in the rhGH dose required to optimize serum IGF1, QoL or BC in patients with the fl/fl genotype compared with those with the d3/d3 or d3/fl genotype.

CONCLUSION

Deletion of exon 3 in the GHR gene does not influence adult height, QoL or BC of the normal adult population nor does it influence rhGH dose, QoL and BC in GHD adults treated with rhGH for more than 1 year.

Cerebral aneurysm associated with an intracranial tumour: staged endovascular and surgical treatment in two cases

Two cases are reported in which an anterior communicating artery aneurysm was associated with an intracranial tumour. The tumour was a suprasellar meningioma in one case and an optic chiasm/hypothalamic astrocytoma in the other. In both cases, the aneurysm was successfully embolized using Guglielmi detachable coils. Subsequently craniotomy was performed with complete excision of the meningioma and subtotal removal of the astrocytoma. Endovascular techniques can be employed to make the surgical excision of an intracranial tumour co-existing with an incidental aneurysm safer.

Dysphagia and hoarse voice: an unusual cause

We report an unusual presentation and successful treatment of an extracranial skull base carotid aneurysm. The patient presented with a combination of multiple cranial nerve dysfunction and local mass effect. After endovascular treatment of this rare condition her symptoms resolved. The radiological images submitted demonstrate this rare condition well.

The role of endoscopic third ventriculostomy in the management of hydrocephalus associated with cerebellopontine angle tumours

BACKGROUND

Progressive hydrocephalus secondary to cerebellopontine angle tumours has been traditionally managed with ventriculo-peritoneal shunting. Endoscopic third ventriculostomy provides an alternative treatment option and the success rate in this patient group has not previously been reported.

METHODS

We report a retrospective series of 11 patients with cerebello-pontine angle tumours who presented with symptomatic hydrocephalus, or developed hydrocephalus following radiosurgery, who underwent endoscopic third ventriculostomy.

RESULTS

Seven patients (63.6%) remain shunt free. There were no complications following endoscopy in any patient. Where the ventriculostomy failed there was no additional morbidity.

CONCLUSIONS

Endoscopic third ventriculostomy is a low morbidity procedure, which avoids the inherent problems of shunts, particularly infection and should be considered for patients with hydrocephalus and cerebello-pontine angle tumours.

Sudden death secondary to delayed closure of endoscopic third ventriculostomy

An 11-year-old boy who underwent an initially successful endoscopic third ventriculostomy (ETV) died 4 months later secondary to acute hydrocephalus. This is the first report of sudden death caused by delayed closure of ETV. Guidelines to patients, parents and primary caregivers should include the possibility of ETV failure and encourage early neurosurgical consultation when symptoms of raised intracranial pressure occur.

Microvascular Decompression for Trigeminal Neuralgia in Patients with Multiple Sclerosis

AIMS

To assess whether microvascular decompression (MVD) is a safe and efficacious treatment for patients with trigeminal neuralgia (TGN) and multiple sclerosis (MS).

METHODS

Case records were reviewed of all patients with TGN and MS who underwent posterior fossa exploration with a view to MVD between 1993 and 2001. In all patients, magnetic resonance tomoangiography (MRTA) demonstrated vascular compression.

RESULTS

Nine patients were included in the study. Seven patients underwent MVD alone; in 2 patients a partial sensory rhizotomy of the trigeminal nerve was added to the decompression. All patients had excellent initial pain relief. Recurrence of neuralgia was noted in 5 patients after MVD and in 1 of the 2 patients after partial sensory rhizotomy. Long-term pain relief was obtained in 1 patient who underwent a redo MVD after postoperative MRTA scans demonstrated recurrent vascular compression of the root entry zone (REZ). Thus only 4 out of 9 patients maintained pain relief. In addition, 3 patients experienced transient worsening of their MS.

CONCLUSIONS

Although MVD provides good initial pain relief, the recurrence rate is much higher than that obtained in 'idiopathic' TGN. Although all procedures for the treatment of TGN are worse than those for idiopathic TGN, it is concluded that because of the high recurrence rate together with the morbidity associated with the procedure MVD should not be offered to patients with TGN and MS.

Intracerebral abscess formation following embolisation of an internal carotid artery aneurysm using Guglielmi detachable coils

Infection following endovascular therapy for cerebrovascular disease is a potential but rare complication. A 70-year-old lady in whom an intracranial abscess formed secondary to GDC embolisation of a giant right internal carotid artery aneurysm is reported. Computed tomography (CT) showed the abscess and staphylococcus aureus was cultured from the cerebrospinal fluid and blood. The abscess was successfully treated by antibiotic therapy. Infected Guglielmi detachable coils (GDC) may result in abscess formation in the presence of underlying cerebral ischaemia.

Synchronous basal cell carcinoma and meningioma following cranial irradiation for a pilocytic astrocytoma

We report a case of synchronous radiation-induced meningioma and basal cell carcinoma in a 48-year-old man who presented to the plastic surgeons with a fixed scalp lesion sited over a craniotomy scar. Synchronous radiation-induced tumours are a rare occurrence.

Endoscopic treatment of suprasellar and third ventricle-related arachnoid cysts

OBJECTIVE

To evaluate the role of neuroendoscopy in the treatment of rare suprasellar and other third ventricle-related arachnoid cysts.

METHODS

A review of supratentorial midline arachnoid cysts treated by endoscopic fenestration.

RESULTS

Ten cases were identified. The median age of these ten patients was 7.5 years. In three a cysto- or ventriculoperitoneal shunt had previously been inserted. Six cysts were located in the suprasellar/prepontine area, one was a combined suprasellar/middle fossa cyst, and three were complex cysts arising mainly in the quadrigeminal cistern and extending into the third ventricle. Successful endoscopic fenestration to both the ventricular system and the basal cisterns ("bipolar" fenestration) was achieved in all cases. In seven cases a cystoventriculostomy and cystocisternostomy was performed, while in three a cystoventriculostomy was combined with a third ventriculostomy, achieving additional communication to the subarachnoid space. The previously inserted shunts were removed at the end of the procedure. The median follow-up period was 17 (range 1-30) months. The clinical outcome was excellent in all cases, despite only marginal reduction in the cyst size and persistence of ventriculomegaly in some cases. No further treatment to the cyst was required during the period of follow-up.

CONCLUSION

Third ventricle-related arachnoid cysts can be satisfactorily and safely treated by endoscopy. This approach leaves the patient shunt independent.

The impact of endoscopic third ventriculostomy on the management of newly diagnosed hydrocephalus in infants

OBJECTIVES

To evaluate the role of endoscopic third ventriculostomy (ETV) as a primary treatment for hydrocephalus in children less than 1 year old and to determine its impact as a whole on the reduction of shunts necessary in a new population of hydrocephalic infants.

METHODS

Data were collected prospectively on 47 infants with newly diagnosed hydrocephalus of all aetiologies who were referred between 1st April 1998 and 30th September 2000. Twenty-one patients (median age 6 weeks, range 34 weeks of gestation to 10 months) underwent ETV, while the remaining 26 patients had insertion of a ventriculoperitoneal shunt. Anatomical criteria and demonstration of third ventricle outflow obstruction on preoperative magnetic resonance imaging were used to select patients for ETV.

RESULTS

There was no mortality or major morbidity following ETV. The median follow-up period was 18 (range 8-36) months. During the follow-up period, the ETV remained patent in 7 (33%) of the 21 patients. Of the 14 patients with failed ETV, 11 had insertion of a ventriculoperitoneal shunt, while 3 have undergone successful redo ETV. Therefore, in total 10 patients (48%) of the ETV group remain shunt independent. The best results were obtained in patients with congenital aqueduct stenosis with 71% (5 of 7 patients) success rate, while patients with posthaemorrhagic hydrocephalus did particularly badly with only 1 of 10 patients having a successful ETV. Overall, 10 of 47 (21%) infants with newly diagnosed hydrocephalus have avoided a shunt.

CONCLUSIONS

Our results suggest that the selective use of ETV as the primary treatment in infants with hydrocephalus is safe and can lead to a reduction in the shunted population of all newly diagnosed hydrocephalic infants by up to 21%. Success of ETV is aetiology, not age dependent.

Craniovertebral abnormalities in Type VI mucopolysaccharidosis (Maroteaux-Lamy syndrome)

INTRODUCTION

The craniovertebral abnormalities found in patients with Type VI mucopolysaccharidosis (Maroteaux-Lamy syndrome) are described, and the indications for and outcomes of surgery in this group are assessed.

METHODS

The clinical histories and radiological findings in all patients with Type VI mucopolysaccharidosis treated at Royal Manchester Children's Hospital during the past 10 years were reviewed.

RESULTS

The typical findings in patients with this disease are of canal stenosis at the level of the foramen magnum and upper cervical spine with or without cord compression. The stenosis is secondary to thickening of the posterior longitudinal ligament. Atlantoaxial instability is rare. Of nine patients under regular clinical review, four underwent decompressive surgery for cervical cord compression. Three of the four showed improvement in their neurological symptoms and signs postoperatively. Of the children reviewed, six had radiological evidence of cord compression, although only those with neurological signs or symptoms were treated surgically.

DISCUSSION

Despite the often formidable anesthetic challenge, surgery is indicated in those patients who present with progressive neurological deficit due to cervical myelopathy. Surgery can be undertaken safely if the associated medical problems in these children are recognized and managed appropriately.

Solitary exostosis of the thoracic spine. Early diagnosis and treatment

STUDY DESIGN

A case report.

OBJECTIVE

To highlight the importance of early diagnosis and treatment of vertebral exostosis.

SUMMARY OF BACKGROUND DATA

Few cases of spinal cord compression caused by solitary thoracic exostoses have been reported.

METHOD

A solitary exostosis in the midline of the neural arch of the fifth thoracic vertebra, causing compression of the spinal cord documented on both magnetic resonance and computed tomographic examinations, is reported in a 51-year-old woman who had normal findings in a neurologic examination.

RESULTS

The exostosis was successfully excised.

CONCLUSION

Accurate preoperative diagnosis of vertebral exostoses is possible using magnetic resonance and computed tomography. Early excision avoids the development of a permanent neurologic deficit.

Herbimycin-A attenuates ischaemia-reperfusion induced pulmonary neutrophil infiltration

OBJECTIVES

To determine whether pharmacological induction of heat shock proteins (HSPs) by herbimycin-A (a tyrosine-kinase inhibitor) would protect against neutrophil-mediated lung injury in an animal model of lower torso ischaemia-reperfusion.

MATERIALS AND METHODS

Sprague-Dawley rats were randomised into three groups: the control group underwent midline laparotomy only; the ischaemia-reperfusion (IR) group underwent laparotomy and clamping of the infrarenal abdominal aorta for 30 min followed by 2 h of reperfusion; the third group (HerbIR) was pretreated with herbimycin-A 18 h prior to IR insult. Wet to dry lung weight ratio (W:D), bronchoalveolar lavage protein concentration (BALprot), tissue myeloperoxidase activity (MPO) and bronchoalveolar lavage neutrophil count (BALPMN) were measured. Heat shock protein 72 (HSP72) expression in lung, intestine, mesentery and liver was measured using Western immunoblotting.

RESULTS

IR resulted in acute lung injury with tissue oedema (W:D) and neutrophil infiltration (PMO, BALPMN). Herbimycin-A, in vivo, induced HSP expression and attenuated neutrophil infiltration (MPO, BALPMN).

CONCLUSION

These data indicate that herbimycin-A protects against ischaemia-reperfusion induced pulmonary neutrophil infiltration, possibly by increasing the expression of heat shock proteins.

Thermotolerance induces heat shock protein 72 expression and protects against ischaemia-reperfusion-induced lung injury

BACKGROUND

Ischaemia-reperfusion injury is mediated by neutrophil-endothelial interaction. Induction of heat shock proteins attenuates neutrophil-endothelial interactions. The aim of this study was to determine whether thermal preconditioning could have a protective effect on neutrophil-mediated lung injury in an animal model of lower torso ischaemia-reperfusion.

METHODS

Sprague-Dawley rats were randomized into: control, ischaemia-reperfusion, and ischaemia-reperfusion preconditioned with hyperthermia groups. Ischaemia-reperfusion injury was induced by infrarenal aortic clamping for 30 min and reperfusion for 120 min. Thermotolerance was induced by raising the core body temperature to 40.5-41.5 degrees C for 15 min, 18 h before ischaemia-reperfusion. Wet:dry lung (W:D) weight ratio, bronchoalveolar lavage protein (BALprot) concentration, tissue myeloperoxidase (MPO) activity and bronchoalveolar lavage polymorphonuclear neutrophil (BAL PMN) count were measured. Heat shock protein 72 (hsp72) expression in lung, intestine and mesentery was measured using Western immunoblotting.

RESULTS

Ischaemia-reperfusion resulted in a significant increase in tissue oedema (W:D weight ratio) and BALprot concentration. In addition there was a marked increase in tissue neutrophil infiltration (MPO activity, BAL PMN concentration). Preconditioning with hyperthermia resulted in increased expression of hsp72 and significantly reduced tissue oedema and neutrophil infiltration.

CONCLUSION

Thermal preconditioning protects against neutrophil-mediated ischaemia-reperfusion-induced lung injury, possibly by increasing the expression of heat shock proteins.

Studies of in vitro gamma-interferon production in coeliac disease as a response to gliadin peptides

The effects of certain fractions of a peptic-tryptic-pancreatinic (PTP) digest of wheat gliadin and of synthetic peptides on the production of gamma interferon (gamma-IFN) in cultures of whole blood from adult patients with coeliac disease (CD) have been studied using a sandwich enzyme immunoassay. The most active peptides were fraction 9, its two principal sub-fractions (sub-fractions 1 and 2) and a synthetic peptide of sequence RPQQPYPQPQPQ (peptide V) corresponding to the principal peptide obtained from reversed-phase HPLC of fraction 9. Results with blood from the control group of subjects also indicated some response to these antigens, in most cases at similar levels to those observed with the coeliacs. Fraction 1 of the PTP digest and the other nine synthetic peptides tested were inactive with both coeliacs and controls. These results are in agreement with the results of in vivo and in vitro toxicity tests. They provide evidence of a link between toxicity and cell-mediated immune response in CD, and suggest that peptide V represents one of the active parts of the gliadin molecule.