La nucleoaspirazione secondo Onik nel trattamento dell'ernia discale lombare analisi multicentrica dei primi risultati su oltre 650 trattamenti

Gli autori espongono i risultati ottenuti applicando la nucleotomia percutanea secondo Onik al trattamento dell'ernia discale lombare. Le casistiche sommate complessivamente ammontano a oltre 600 pazienti. Nel complesso i risultati sono buoni o ottimi nel 72% circa dei casi. I risultati insoddisfacenti, considerando globalmente i modest e gli invariati, corrispondonoal 26% circa. Eccezionali le complicanze (meno dell' 1 %): 1 discite (risolta con intervento chirurgico). La metodica di Onik può già essere serenamente considerata una possibilitanon trascurabile nel campo vasto e variegato dei trattamentidisponibili per l'ernia discale lombare

Pattern of care and effectiveness of treatment for glioblastoma patients in the real world: Results from a prospective population-based registry. Could survival differ in a high-volume center?

BACKGROUND

As yet, no population-based prospective studies have been conducted to investigate the incidence and clinical outcome of glioblastoma (GBM) or the diffusion and impact of the current standard therapeutic approach in newly diagnosed patients younger than aged 70 years.

METHODS

Data on all new cases of primary brain tumors observed from January 1, 2009, to December 31, 2010, in adults residing within the Emilia-Romagna region were recorded in a prospective registry in the Project of Emilia Romagna on Neuro-Oncology (PERNO). Based on the data from this registry, a prospective evaluation was made of the treatment efficacy and outcome in GBM patients.

RESULTS

Two hundred sixty-seven GBM patients (median age, 64 y; range, 29-84 y) were enrolled. The median overall survival (OS) was 10.7 months (95% CI, 9.2-12.4). The 139 patients ≤aged 70 years who were given standard temozolomide treatment concomitant with and adjuvant to radiotherapy had a median OS of 16.4 months (95% CI, 14.0-18.5). With multivariate analysis, OS correlated significantly with KPS (HR = 0.458; 95% CI, 0.248-0.847; P = .0127), MGMT methylation status (HR = 0.612; 95% CI, 0.388-0.966; P = .0350), and treatment received in a high versus low-volume center (HR = 0.56; 95% CI, 0.328-0.986; P = .0446).

CONCLUSIONS

The median OS following standard temozolomide treatment concurrent with and adjuvant to radiotherapy given to (72.8% of) patients aged ≤70 years is consistent with findings reported from randomized phase III trials. The volume and expertise of the treatment center should be further investigated as a prognostic factor.

A diagnostic flowchart, including TCD, Xe-CT and angiography, to improve the diagnosis of vasospasm critically affecting cerebral blood flow in patients with subarachnoid haemorrhage, sedated and ventilated

The aim of this study was to prospectively evaluate a clinical protocol including transcranial doppler (TCD), Xenon-CT (Xe-CT) and angiography, for the detection of vasospasm leading to critical reductions of regional cerebral blood flow (rCBF) in both ventilated and sedated SAH patients, i.e. patients in whom clinical evaluation was not possible. Seventy-six patients were prospectively included in a surveillance protocol for daily TCD vasospasm monitoring. When TCD showed a V(mean) above 120 cm/sec in the middle cerebral artery (MCA), patients underwent Xe-CT study. If rCBF in the MCA was reduced to below 20 ml/100 g/min or if there was a reduction in the rCBF with significant asymmetry between the two MCAs, angiography was performed. Conversely, further Xe-CT and angiography were not obtained unless the TCD V(mean) values reached values above 160 cm/sec. In 35 patients, V(mean) attained values above 120 cm/sec, but only in five of them, rCBF was suggestive of vasospasm, and angiography confirmed the diagnosis in four. The protocol suggests that in sedated and ventilated patients, detection of a critical rCBF reduction due to vasospasm is possible to allow for more specific treatment and to reduce undue medical complications.

237 ACoA aneurysms clipped or embolized. Outcomes measurement using the De Santis-CESE assessment tool

AIM

The aim of this retrospective study was to demonstrate the difference in patient outcomes after treatment for bleeding endocranial aneurysms when evaluated with methods based on different assessment criteria.

METHODS

The outcome of 237 patients, 141 of which were operated on for anterior communicating artery aneurysm and 96 embolized, was assessed by a new method developed by De Santis. The patients operated on were assessed by the Glasgow Outcome Scale (GOS) and Rank Disability Scale (RDS) and the results of the latter were compared with the new method, the De Santis-CESE (Clinical Emotional Social Evaluation) method, which consists of a clinical evaluation and a numeric scoring system based on seven standard points. Comparison between the three methods showed significantly different outcomes. Patients who underwent surgical operation showed changes in character and behaviour, whereas the others showed cognitive, emotional and sexual habit changes.

CONCLUSION

Compared with the GOS and RDS instruments, the CESE method showed significant differences in patient outcome assessment, particularly regarding best outcomes. These differences may be due to the greater sensitivity of the CESE method over the other two scales. Furthermore, surgical patients seemed to achieve a better outcome than endovascular patients. The authors intend to conduct a prospective study to test the results obtained in this retrospective study.

Transcranial Doppler sonographic monitoring during cerebral aneurysm embolization: a preliminary report

BACKGROUND AND PURPOSE

The wide application of embolization in the treatment of aneurysms has created the need for an intraprocedural means to anticipate a poor outcome by monitoring hemodynamic changes in the brain.

METHODS

Transcranial Doppler sonography was used to monitor flow velocity in the middle cerebral artery (MCA) in 23 patients undergoing embolization with Guglielmi detachable coils (GDCs) of either incidental or symptomatic intracranial aneurysms. Sonographic values were recorded from the ipsilateral MCA at the beginning, middle, and end of the interventional procedure and 24 hours afterward.

RESULTS

No complications occurred in 15 patients. In these cases, sonography showed an average decrease in MCA flow velocity of 2.7% after GDC application, returning to baseline at the end of treatment and then increasing by about 17% 24 hours later. In four patients with vasospasm on posttreatment angiograms, MCA flow velocity increased to values higher than 120 cm/s after GDC application, returning to baseline after 24 hours. In four patients with ischemic complications (two transient ischemic attacks, one stroke, one vascular death), MCA flow velocity decreased more than 30% and did not return to preoperative values within 24 hours.

CONCLUSION

The application of transcranial Doppler sonographic monitoring during endovascular treatment may help to identify patients at risk for posttreatment cerebral ischemia.

Electrophysiological and cognitive effects of lumbar myelography with iopamidol: comparison with diagnostic lumbar puncture

To assess the influence of contrast medium on cortical function, we studied 20 patients undergoing lumbar myelography with iopamidol and 10 patients undergoing diagnostic lumbar puncture (controls). The examinations performed before and 6 and 24 h after myelography (or lumbar puncture) included a neuropsychological battery and an electrophysiological evaluation. In the patients cranial CT was performed thrice to assess passage of contrast medium from the cerebrospinal fluid into the brain. Neither patients nor controls had significantly different scores on neuropsychological testing after the diagnostic examinations. A transient slowing of basal EEG activity could be detected in 2 patients and 3 controls 6 h after the lumbar puncture. In 3 patients CT showed a transient increase in density of the brain. None of the parameters studied was significantly affected by myelography with iopamidol. CT findings support the hypothesis of early clearance of iopamidol from brain tissue, explaining its low neurotoxicity.

Reversible multifocal encephalopathy following tuberculous infection

Tuberculous encephalic infection is commonly reported as confined to Asians or Africans or people living in poor hygienic conditions; very often it follows meningitis in patients with lung TB infection. We describe three western patients coming from good social environment and suffering from multifocal tuberculous encephalopathy. Two of them showed neither meningitis or lung TB when CNS involvement appeared. Complete recovery after therapy is described, together with the evolution of brain CT and, in 1 case, MRI features. The instrumental findings accompanying the complete recovery suggest that the lesions described in these cases are a localized form of encephalitis responsive to medical treatment, unlike tuberculomas, which often need surgical treatment. The occurrence of tuberculous encephalic infection in western, middle-class patients with or without meningitis emphasizes that tuberculous encephalopathy must be considered in the differential diagnosis of multifocal brain lesions.

Evidence of central nervous system involvement in chronic demyelinating neuropathies associated with "benign" gammopathies

Recent papers underline the possible involvement of the central nervous system when an acquired peripheral demyelinating disease occurs and vice-versa. We describe five patients with chronic polyneuropathy and "benign" gammopathy, monoclonal (IgM-K, IgA-k, IgG-k) in three cases and polyclonal (IgG, IgM) in two cases; the monoclonal gammopathies were detected in cases of peripheral nerve disease. Three patients showed tremor and signs of pyramidal system impairment when the peripheral damage had improved or was stable. All cases underwent a longitudinal assessment according to clinical, CSF, EMG-ENG, neuroradiological and pathological criteria. The MRI finding always showed multiple alterations of encephalic white matter. When related to neurophysiological and pathological data supporting a chronic demyelinating neuropathy, such results point to possible encephalic involvement in chronic polyneuropathies due to a pathogenetic mechanism common to both.

Lumbar myelography with iopamidol: a methodological approach to the investigation of side effects

Pathophysiology of adverse reactions occurring during myelography with non-ionic contrast agents, such as iopamidol, seem related to their direct action on the nervous system. The authors try a multivariate approach, involving neurophysiological, neuropsychological and neurochemical parameters on a pilot group of twelve subjects. Any possible change in the above examinations is thoroughly analyzed and correlated to the postulated neurotoxic properties of contrast media.

Onset of primary brain T-lymphoma simulating a progressive leukoencephalopathy

We describe the clinical, CT and MRI evolution of a patient with a primary T-lymphoma of the brain showing features similar to those of leukoencephalopathy. We report the findings that led to the cerebral biopsy performed and we discuss the striking features of this case in the light of previous reports in the literature.

Ultrasound-computerized tomography in neonatal encephalic pathology

The echoencephalographic examinations of 127 neonates were analysed to verify the role of US in the study of neonatal cerebral pathology, and to compare it with CT. US was of value in identifying the existence of a cerebral lesion and for follow-up. CT was more reliable for the characterization of the lesion and in establishing the surgical indications.

Immediate and late effects of ventricular shunting in infantile hydrocephalus

This paper analyzes our findings in a series of 1900 CT examinations carried out on 950 children after ventricular drainage. Blood in the ventricles is a relatively frequent findings in the immediate postoperative course, and gliotic or poroencephalic phenomena are often found in the late course. Persistence of ventricular dilatation and periventricular lucency has been observed several times. Extracerebral collections and septic complications are not rare findings, but trapped fourth ventricle and choroidal-ependymal reactions are only rarely observed.

Cerebral damage following ventricular shunt for infantile hydrocephalus evaluated by computed tomography

The result of a late CT control of infantile hydrocephalus is reported with an analysis of effects of the catheter on the cerebral tissue in the immediate and late postoperative course. The most frequent finding is blood in the ventricle and/or subependymal or intraparenchymal along the catheter or near its tip.

CT findings of atypical forms of phakomatosis

Three cases with unusual manifestations of phakomatosis are reported. The first two had clinical symptoms of neurofibromatosis but CT disclosed nodular subependymal calcifications as in tuberous sclerosis. The third one presented with cerebral calcifications as found in both tuberous sclerosis and Sturge-Weber syndrome, though he had no clinical symptoms of phakomatosis.

Traumatic cerebral mass lesions: correlations between clinical, intracranial pressure, and computed tomographic data

After surveying the different phases of their previous experience with the diagnosis and management of traumatic cerebral mass lesions, the authors analyze the correlation between clinical, computed tomographic (CT), and intracranial pressure (ICP) data in 29 patients with traumatic intracerebral hematomas and/or brain lacerations. Clinically, the patients are classified in three groups: (a) deeply comatose patients (Glascow coma scale (GCS), 4 to 5); (b) patients with intermediate disturbances of consciousness (GCS, 6 to 10); and (c) patients with minor impairment of consciousness (GCS, more than 10). Sixteen patients were operated upon. Operation was ineffective in the patients who were already deeply comatose in the first hours after injury, even though elevated ICP was definitely reduced after operation in some of them. Conversely, patients with well-limited lesions, moderate disorders of consciousness, and persisting intracranial hypertension despite medical therapy seemed to be good candidates for delayed operation by limited procedures. In patients with intermediate disturbances of consciousness and no tendency to improvement or deterioration, ICP monitoring correlated with CT scan appearance may be of practical use for making the decision to operate. However, most cases diagnosed on CT scan have a benign course; the patients recover uneventfully with conservative management. In such patients careful clinical observation is usually sufficient. (Neurosurgery, 7: 337-346, 1980).

The reliability of computerized axial tomography in the diagnosis of infratentorial mass lesions. A neurosurgical appraisal

The accuracy of CAT in the diagnosis of infratentorial expanding lesions is analysed on the basis of 224 personal cases. The posterior fossa lesions are classified in four groups according to the reliability of CAT as the only pre-operative examination. The present indications for conventional neuroadiological procedures are also outlined. Particular emphasis is laid on the information supplied by CAT in postoperative follow up to detect both immediate and delayed complications.

Metrizamide demonstration of the subarachnoid space surrounding the optic nerves

Intrathecal instillation of metrizamide has provided a useful tool for the in vivo evaluation of smaller structures adjacent to or within the subarachnoid cisterns. The authors report a case in which metrizamide filled the thin subarachnoid space surrounding the optic nerve in its course through the orbit. The finding appears to be infrequent, however, since it was not observed in any instance in a review of 80 metrizamide computed tomographic cisternograms in patients with normal intracranial pressure.

Computed tomography of the optic nerve: part I. Normal results

In vivo visualization of the optic nerve (ON) by computed tomography (CT) has important clinical applications, both realized and potential. An accurate CT analysis of the ON is, however, hampered by a number of technical limitations. Sinuosity and gaze-shift-related motility of the ON tend to increase the difficulties of demonstrating in a consistently satisfactory fashion this anatomical structure. Nevertheless, if rigid imaging criteria are followed, adequate visualization of the ON may be attained in the majority of patients. Simultaneous visualization of the ON and the eyeball permits establishment of a neuroocular index for clinical use.

Computed tomography of the optic nerve: part II. Size and shape modifications in papilledema

Increase in the caliber and course tortuosity of the optic nerve (ON) can be demonstrated by computed tomography (CT) in cases of papilledema due to intracranial tumors, hydrocephalus, pseudotumor cerebri, and other conditions causing increased intracranial pressure. The enlargement of the ON in these conditions is generally bilateral, although one of the nerves, usually of the side of the tumoral pathology, may be thicker. Enlargement on the ON may also be demonstrated by CT in papilledema due to optic neuritis. Occasionally, the thickened ON also display increased attenuation coefficient values.

Role of computed tomography in the postoperative evaluation of infantile hydrocephalus

The value of CT for the diagnosis and followup of infantile hydrocephalus is discussed. The ventricular volume, subependymal periventricular hypodensity, sbudural hygroma or hematoma, position of catheter in the ventricles, ependymal inflammation and other occasional findings are considered.

Periventricular hypodensity in hydrocephalus: a clinico-radiological and mathematial analysis using computed tomography

The computed tomography (CT) scans carried out in hydrocephalic patients before and after surgical treatment [cerebrospinal fluid (CSF) shunting] were assessed by analysis of the densities. The numerical data were compared to the pictorial record on the display console. The periventricular hypodensity was correlated to the clinical parameters and to the time lapse after surgical treatment. The subependymal hypodensity shows good direct correlation to the transit of CSF from the ventricles to the white matter, and to the clinical status of the patients. The mathematical analysis supplies objective data and comparable indices. It constitutes the starting point for an automatic evaluation of the CT images of the process of transependymal CSF resorption in non-treated and treated hydrocephalus.

[Preliminary observations on computerized axial tomography (CAT) in 32 patients with various epileptic syndromes (author's transl)]

Thirty-two subjects affected by various types of epilepsy have been studied as follows: 1) from the clinical point of view with careful case history or by direct observation of the seizures; 2) from the EEG point of view by means of prolonged recordings during wakefulness and nocturnal sleep or with pharmacological activations; 3) from a radiological point of view with standard skull radiography, air-encephalography (PNX), brain scanning and, when necessary, with cerebral angiography, mono or bilateral. Furthermore, all the patients underwent a CAT at least once; in the majority of cases this examination was repeated after administration of contrast medium. The following results were obtained by comparing the various examinations: 1) anatomo-elector-clinical correlation was present only in some cases; 2) only in patients with cerebral neoplasms was there proof of an agreement in site between EEG, CAT and PNX; 3) it was not possible to detect in a definite manner epileptic glial lesions with CAT; 4) the EEG analysis, when repeated several times with different methods of investigations, whoed epileptic foci in a higher number compared to the anatomical focal lesions proved by CAT; 5) compared with air-encephalography and morphological brain scanning, CAT usually pointed out a higher number of focal and/or diffused cerebral lesions with a higher degree of precision; viceversa cerebral angiography proved to be irreplaceable in cases where it was necessary to study possible circulatory alterations.