IV thrombolysis plus thrombectomy versus IV thrombolysis alone for minor stroke with anterior circulation large vessel occlusion from the IRETAS and Italian SITS-ISTR cohorts

INTRODUCTION

The aim of this study was to compare the outcomes of patients treated with intravenous thrombolysis (IVT) <4.5 h after symptom onset plus mechanical thrombectomy (MT) <6 h with those treated with IVT alone <4.5 h for minor stroke (NIHSS ≤5) with large vessel occlusion (LVO) in the anterior circulation.

PATIENTS AND METHODS

Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analyzed.

RESULTS

Among the patients with complete data on 24-h ICH type, 236 received IVT plus MT and 382 received IVT alone. IVT plus MT was significantly associated with unfavorable shift on 24-h ICH types (from no ICH to PH-2) (OR, 2.130; 95% CI, 1.173-3.868; p=0.013) and higher rate of PH (OR, 4.363; 95% CI, 1.579-12.055; p=0.005), sICH per ECASS II definition (OR, 5.527; 95% CI, 1.378-22.167; p=0.016), and sICH per NINDS definition (OR, 3.805; 95% CI, 1.310-11.046; p=0.014). Among the patients with complete data on 3-month mRS score, 226 received IVT plus MT and 262 received IVT alone. No significant difference was reported between IVT plus MT and IVT alone on mRS score 0-1 (72.1% versus 69.1%), mRS score 0-2 (79.6% versus 79%), and death (6.2% versus 6.1%).

CONCLUSIONS

Compared with IVT alone, IVT plus MT was associated with unfavorable shift on 24-h ICH types and higher rate of 24-h PH and sICH in patients with minor stroke and LVO in the anterior circulation. However, no difference was reported between the groups on 3-month functional outcome measures.

Coexistent meningioma in a patient with primary familial brain calcification: A case report

Primary familial brain calcification (PFBC) is an idiopathic pathology characterized by the development of calcific deposits in the supratentorial region such as telencephalon and diencephalon but also, in more extensive forms, in the cerebellum. Meningiomas are among the most common central nervous system (CNS) tumors generally related to a good prognosis. The simultaneous presence of intracerebral or extra-axial tumors and PFBC represents an exceedingly rare occurrence. A 72-year-old female patient was admitted to our department because of anoculogyric crisis followed by generalized seizures. She performed a brain CT scan which showed widespread hyperdensities in the paraventricular supratentorial region, basal ganglia and at the level of bilateral cerebellar dentate nuclei, characteristics of PFBC. Concomitant left frontal and smaller right temporal extra-axial lesions were identified and then confirmed in a brain MRI. The patient underwent a microsurgical resection of the lesion and subsequent histological examination reported a meningothelial meningioma (WHO Grade I). According to our literature review, this is the first paper that reports the coexistence of both intracranial meningiomas and PFBC. To date, it is not possible to provide an exact correlation between pathogenesis and genetic mechanism underlying this association.

Spontaneous spinal epidural hematoma in a pediatric hemophiliac

Background

Spontaneous spinal epidural hematomas (SSEH), unrelated to trauma, epidural anesthesia, or surgery, are rare in the pediatric population. Here, a 1-year-old male with hemophilia presented with a magnetic resonance (MR)-documented SSEH and was successfully treated with a C5-T10 right hemilaminectomy.

Case Description

A 1-year-old male with hemophilia presented with quadriparesis. The holo-spine magnetic resonance imaging with contrast showed a posterior cervicothoracic compressive epidural lesion extending from C3 to L1 consistent with an epidural hematoma. He underwent a C5 to T10 right-sided hemilaminectomy for clot removal, following which his motor deficits fully resolved. A literature review of SSEH attributed to hemophilia revealed that 28 of 38 cases were effectively treated conservatively, while only 10 cases warranted surgical decompression.

Conclusion

Select patients with SSEH attributed to hemophilia with severe MR-documented cord/cauda equina compromise and significant accompanying neurological deficits may require emergent surgical decompression.

Case of incidental thoracic spinal dumbbell hemorrhagic arachnoid cyst and tentorial metastasis from breast carcinoma

Background

Spinal arachnoid cysts (SACs) in adults are typically acquired dural defects following trauma, inflammation, or infection. Brain metastases from breast cancer account for 5-12% of all CNS metastases and are mostly leptomeningeal. Here, the authors reported a 50-year-old female treated for a tentorial metastasis from breast carcinoma that underwent chemotherapy and radiotherapy. Three months later, she presented with a thoracic spinal extradural dumbbell hemorrhagic arachnoid cyst.

Case Description

A 50-year-old female underwent a left retrosigmoid suboccipital craniectomy for microsurgical removal of a tentorial metastasis attributed to poorly differentiated breast carcinoma (i.e., comedonic pattern). The patient subsequently underwent both chemotherapy and radiotherapy for accompanying bony metastases. Three months later, she experienced the onset of severe posterior thoracic pain. When the thoracic magnetic resonance imaging revealed a hyperintense "dumbbell" extradural T10-T11 lesion, she underwent a T10-T11 laminectomy for marsupialization and excision of the hemorrhagic lesion. The histological examination revealed blood and arachnoid tissue within a benign SAC, without accompanying tumor. Her postoperative course was uneventful, and she was discharged on postoperative day 3.

Conclusion

A 50-year-old female underwent a left retrosigmoid suboccipital craniectomy for removal of a tentorial metastasis from breast carcinoma, followed by radiation/chemotherapy. Three months later, she hemorrhaged into an MR-documented T10-T11 dumbell extradural SAC that was successfully treated with laminectomy, marsupialization, and excision.

Bilateral post-traumatic hygromas in patient with frontotemporal dementia

Background

Frontotemporal dementia (FTD) is a highly disabling neurologic disorder characterized by behavioral alterations and movement disorders, involving patients with a mean age of 58 years. We present a unique case of a patient suffering from FTD who developed post traumatic bilateral hygromas.

Case Description

A 52-year-old male patient, with an history of head trauma 3 months before, was admitted to our department for recurrent motor seizures. Anamnesis was positive for FTD with severe frontal syndrome. Brain computed tomography and magnetic resonance imaging (MRI) showed the typical "knife-blade" appearance of the cortical atrophy associated to bilateral hemispheric hygromas exerting mild mass effect. Brain MRI showed the signs of the cortical and "anti-cortical" vein. The two subdural collections were evacuated through two bilateral burr holes and controlled drainage. Despite anti-epileptic drugs therapy, in the early postoperative period, the patient presented further tonic-clonic seizures. The patient showed progressive recovery and was transferred to the neurorehabilitation center. After 6-month follow-up, he completely recovered.

Conclusion

In FTD, severe cortical atrophy leads to space increase between arachnoid and pia mater that could affect the anatomical integrity especially after trauma, with possible development of hygromas. The coexistence of radiological findings of the cortical vein and sign of the "anti-cortical" vein can make difficult an exact differential diagnosis between a primitive hygroma and a Virchow hygroma from resorption of previous blood collection. Surgical treatment may be indicated in selected patients, but it is burdened by higher postoperative risks compared to the general population.

Spontaneous anterior cervicothoracic spinal epidural hematoma extending to clivus in SARS-CoV-2 infection

Background:

The treatment of spontaneous spinal epidural hematomas (SSEHs), depending on the lesion size and myeloradicular involvement, can be surgical or conservative. Here, we present a 55-year-old patient who sustained a SSEH several months following a systemic SARS-CoV-2 infection.

Case Description:

A 55-year-old immunocompromised female (i.e., history 17 years ago of Hodgkin’s lymphoma, nodular sclerosis variant) recently developed a SARS-CoV-2 infection treated with nonsteroidal anti-inflammatory agents. She then reported the sudden onset of cervicodorsalgia after a slight cervical flexion/extension maneuver. The brain and cervicothoracic spine MRI studies documented a clival anterior spinal epidural hematoma with maximum spinal compression at the T1-T2 level; it also extended inferiorly to the T6 level. Two weeks later, the follow-up MRI showed a remarkable reduction in the anteroposterior diameter of the hematoma that correlated with significant neurological improvement and almost complete pain regression. She was discharged after a total 15-day hospital stay, with complete symptoms relief.

Conclusion:

We present a 55-year-old chronically immunocompromised (i.e., due to the history of Hodgkin’s lymphoma) female who, following a SARS-CoV-2 infection, developed an anterior SSEH extending from the clivus to the T6 spinal level that spontaneously regressed without surgical intervention.

European Multicenter Study of ET-COVID-19

BACKGROUND AND PURPOSE

Acute ischemic stroke and large vessel occlusion can be concurrent with the coronavirus disease 2019 (COVID-19) infection. Outcomes after mechanical thrombectomy (MT) for large vessel occlusion in patients with COVID-19 are substantially unknown. Our aim was to study early outcomes after MT in patients with COVID-19.

METHODS

Multicenter, European, cohort study involving 34 stroke centers in France, Italy, Spain, and Belgium. Data were collected between March 1, 2020 and May 5, 2020. Consecutive laboratory-confirmed COVID-19 cases with large vessel occlusion, who were treated with MT, were included. Primary investigated outcome: 30-day mortality.

SECONDARY OUTCOMES

early neurological improvement (National Institutes of Health Stroke Scale improvement ≥8 points or 24 hours National Institutes of Health Stroke Scale 0-1), successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2b), and symptomatic intracranial hemorrhage.

RESULTS

We evaluated 93 patients with COVID-19 with large vessel occlusion who underwent MT (median age, 71 years [interquartile range, 59-79]; 63 men [67.7%]). Median pretreatment National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were 17 (interquartile range, 11-21) and 8 (interquartile range, 7-9), respectively. Anterior circulation acute ischemic stroke represented 93.5% of cases. The rate modified Thrombolysis in Cerebral Infarction 2b to 3 was 79.6% (74 patients [95% CI, 71.3-87.8]). Thirty-day mortality was 29% (27 patients [95% CI, 20-39.4]). Early neurological improvement was 19.5% (17 patients [95% CI, 11.8-29.5]), and symptomatic intracranial hemorrhage was 5.4% (5 patients [95% CI, 1.7-12.1]). Patients who died at 30 days exhibited significantly lower lymphocyte count, higher levels of aspartate, and LDH (lactate dehydrogenase). After adjustment for age, initial National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and successful reperfusion, these biological markers remained associated with increased odds of 30-day mortality (adjusted odds ratio of 2.70 [95% CI, 1.21-5.98] per SD-log decrease in lymphocyte count, 2.66 [95% CI, 1.22-5.77] per SD-log increase in aspartate, and 4.30 [95% CI, 1.43-12.91] per SD-log increase in LDH).

CONCLUSIONS

The 29% rate of 30-day mortality after MT among patients with COVID-19 is not negligible. Abnormalities of lymphocyte count, LDH and aspartate may depict a patient's profiles with poorer outcomes after MT. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT04406090.

Cognitive Deficits and White Matter Alterations in Highly Trained Scuba Divers

Nitrogen gas (N2), present in the normal atmospheric air, is a potential source of risk for scuba divers. It seems probable that myelin can represent, in hyperbaric conditions, a preferential site for the accumulation of N2 in central nervous system (CNS). The purpose of this study is to verify whether the practice of the scuba diving is capable to determine a damage of the brain white matter (WM) in a dose dependent manner and, consequently, possible deficiency of their cognitive abilities. For this purpose, 54 professional scuba divers (35 men and 19 women), with at least 2,000 dives in their careers, were studied. Possible alterations of brain WM were evaluated in terms of Fractional anisotropy (FA) by using Diffusion Tensor Imaging, whereas possible cognitive impairments were verified by means of neuropsychological testing, by studying: (1) General mental capability (2) Executive functioning; (3) Visuospatial construction such as Rey Complex Figure; (4) Attention and orientation: (5) Selective attention capacity and processing speed ability; (6) Memory. The results showed alteration of the WM in terms of changes in FA; these alterations, statistically significant but quantitatively quite modest, were mainly observed in the WM of the anterior part of the brain, whereas no differences were observed between left and right hemisphere. The alterations of the WM were associated with changes, also in this case statistically significant but quantitatively quite modest, of the cognitive functions, in particular of those dependent on the prefrontal cortex, such as attention and memory function. The present study leads to the conclusion that repeated dives, even performed in compliance with the current decompression tables, can progressively lead in the CNS to the formation of micro-lesions in the myelin sheet capable of altering the functioning of the neuron.

Cyanidin and cyanidin 3-O-beta-D -glucoside as DNA cleavage protectors and antioxidants

Anthocyanins, colored flavonoids, are water-soluble pigments present in the plant kingdom; in fact they are secondary plant metabolites responsible for the blue, purple, and red color of many plant tissues. Present in beans, fruits, vegetables and red wines, considerable amounts of anthocyanins are ingested as constituents of the human diet (180-215 mg daily). There is now increasing interest in the in vivo protective function of natural antioxidants contained in dietary plants against oxidative damage caused by free radical species. Recently, the antioxidant activity of phenolic phytochemicals, has been investigated. Since the antioxidant mechanism of anthocyanin pigments is still controversial, in the present study we evaluated the effects of cyanidin and cyanidin 3-O-beta-D-glucoside on DNA cleavage, on their free radical scavenging capacity and on xanthine oxidase activity. Cyanidin and cyanidin 3-O-beta-D-glucoside showed a protective effect on DNA cleavage, a dose-dependent free radical scavenging activity and significant inhibition of XO activity. These effects suggest that anthocyanins exhibit interesting antioxidant properties, and could therefore represent a promising class of compounds useful in the treatment of pathologies where free radical production plays a key role.

DNA damage in astrocytes exposed to fumonisin B1

Fumonisins are a group of toxic metabolites mainly produced by Fusarium moniliforme and Fusarium proliferatum, fungi that commonly occur on corn throughout the world. Fumonisin B1 (FB1), structurally resembling sphingoid bases, is an inhibitor of ceramide synthase, a key enzyme involved in de novo sphingolipid biosynthesis and in the reacylation of free sphingoid bases derived from sphingolipid turnover. This inhibitory effect leads to accumulation of free sphinganine (SA) and sphingosine (SO), inducing cell death. However, little is known on the down stream effectors activated by these sphingolipids in the cell death signaling pathway. We exposed rat astrocytes to FB1 with the aim of evaluating the involvement of oxygen free radicals and of some other biochemical pathways such as caspase-3 activity and DNA damage. Our results indicate that FB1 treatment (48, 72 h and 6 days in vitro, DIV, and 10, 50, 100 microM) does not affect cell viability. Conversely, after 72 h of treatment, FB1 (50 and 100 microM) induced DNA damage and an enhancement of caspase-3 activity compared to controls. In addition, FB1 increased the expression of HSP70 at 10 and 50 microM at 48, 72 h, and 6 DIV of treatment. We conclude that DNA damage of apoptotic type in rat astrocytes is caused by FB1 and that the genotoxic potential of FB1 has probably been underestimated and should be reconsidered.

DNA damage in human fibroblasts exposed to fumonisin B(1)

Fumonisins are mycotoxins produced by several Fusarium species (Fusarium verticilloides and F. proliferatum) that infest corn and other cereals. Fumonisin B(1) (FB(1)), structurally resembling sphingoid bases, is an inhibitor of ceramide synthetase, a key enzyme involved in de novo sphingolipid biosynthesis and in the reacylation of free sphingoid bases derived from sphingolipid turnover. This inhibitory effect leads to accumulation of free sphinganine and sphingosine and subsequent induction of cell death. However, the downstream effectors activated by these sphingolipids in the cell death-signalling pathway are little known. The aim of this study was to evaluate, in FB(1)-exposed human fibroblasts, the involvement of oxygen free radicals and of some other biochemical pathways, caspase-3 activity, poly(ADP-ribose)polymerase (PARP) cleavage and DNA damage evaluated by comet assay. Our results indicate that FB(1) treatment (48, 72 h and 10, 50, 100 microM) does not affect cellular viability. Conversely, after 72 h of treatment, FB(1) (50 and 100 microM) induced DNA damage, an enhancement of caspase-3-activity and cleavage of PARP compared to controls. In addition, FB(1) increased the expression of HSP70 in a concentration and time-dependent manner. Our results indicate that DNA damage of apoptotic type in human fibroblasts is caused by exposure to FB(1) at high concentrations and for a prolonged time and that the genotoxic potential of FB(1) has probably been underestimated and should be reconsidered.

Activity and mechanism of the antioxidant properties of cyanidin-3-O-beta-glucopyranoside

In the present study, the antioxidant activity, the interaction with reactive oxygen species and the redox potential of cyanidin-3-O-beta-glucopyranoside (C-3-G), the main anthocyanin present in juice of pigmented oranges, were evaluated in detail. C-3-G effects on low density lipoproteins (LDL) oxidation induced by 40 microM Cu at a pH of 7.4 were compared with those of resveratrol and ascorbic acid, two other natural antioxidants. All cyanidin-3-O-beta-glucopyranoside concentrations used (1, 2, 5, 10, 20, 50, 100 and 200 microM) inhibited malondialdehyde (MDA) generation (an index of lipid peroxidation), the inhibition being significantly higher than that obtained with equal concentrations of resveratrol and ascorbic acid (IC50 = 6.5 microM for C-3-G, 34 microM for resveratrol and 212 microM for ascorbic acid). Experiments of LDL oxidation performed at a pH of 5.0 or 6.0 showed that C-3-G antioxidant activity is not influenced by pH variations between 5.0 and 7.4. This suggests that metal chelation, exerted by C-3-G through the eventual dissociation of its phenolic groups, plays a minor role in its protective mechanism. The presence of C-3-G produced significantly higher protective effects of pigmented orange juice (obtained from Moro cultivar) with respect to blond orange juice, when tested on copper-induced LDL oxidation. The evaluation of the direct interaction with reactive oxygen species (H2O2, -O2, OH*), demonstrated that C-3-G is quickly oxidized by these compounds and it is, therefore, a highly efficient oxygen free radical scavenger. The powerful C-3-G antioxidant activity is in excellent agreement with the very negative redox potential (-405 mV), determined through direct current cyclic voltammetry measurements. On the basis of these results, C-3-G should be considered as one of the most effective antioxidants that can be assumed with dietary plants; therefore, pigmented oranges represent a very relevant C-3-G source because of the high content of this anthocyanin in their juice.

Survey of the occurrence of aflatoxin M1 in dairy products marketed in Italy: second year of observation

During 1996, 161 samples of milk, 92 samples of dry milk for infant formula and 120 samples of yoghurt, were randomly collected in supermarkets and drug stores in four big Italian cities, and checked for aflatoxin M1 (AFM1) by immunoaffinity column extraction and HPLC. AFM1 was detected in 125 (78%) of milk samples (ranging from < 1 ng/l to 23.5 ng/l; mean level: 6.28 ng/l), in 49 (53%) of dry milk samples (ranging from <1 ng/l to 79.6 ng/kg; mean level: 32.2 ng/kg) and in 73 (61%) of yoghurt samples (ranging from <1 ng/kg to 32.1 ng/kg; mean level: 9.06 ng/kg). Altogether, only four samples of dry milk were over the legal limits established by the EC in 1999. It is concluded that during 1996, despite the widespread occurrence of AFM1, mean contamination levels in dairy products sold in Italy were not a serious human health hazard.

Dietary strategies to counteract the effects of mycotoxins: a review

We reviewed various dietary strategies to contain the toxic effects of mycotoxins using antioxidant compounds (selenium, vitamins, provitamins), food components (phenolic compounds, coumarin, chlorophyll and its derivatives, fructose, aspartame), medicinal herbs and plant extracts, and mineral and biological binding agents (hydrated sodium calcium aluminosilicate, bentonites, zeolites, activated carbons, bacteria, and yeast). Available data are primarily from in vitro studies and mainly focus on aflatoxin B1, whereas much less information is available about other mycotoxins. Compounds with antioxidant properties are potentially very efficacious because of their ability to act as superoxide anion scavengers. Interesting results have been obtained by food components contained in coffee, strawberries, tea, pepper, grapes, turmeric, Fava tonka, garlic, cabbage, and onions. Additionally, some medicinal herbs and plant extracts could potentially provide protection against aflatoxin B1 and fumonisin B1. Activated carbons, hydrated sodium calcium aluminosilicate, and bacteria seem to effectively act as binders. We conclude that dietary strategies are the most promising approach to the problem, considering their limited or nil interference in the food production process. Nevertheless, a great research effort is necessary to verify the in vivo detoxification ability of the purposed agents, their mode of action, possible long-term drawbacks of these detoxification-decontamination procedures, and their economical and technical feasibility.

Survey of the occurrence of aflatoxin M1 in dairy products marketed in Italy

During 1995, 159 samples of milk, 97 samples of dry milk for infant formula, and 114 samples of yogurt were randomly collected in supermarkets and drug stores in four large Italian cities and checked for aflatoxin M1 (AFM1) by immunoaffinity column extraction and HPLC. AFM1 was detected in 136 (86%) of the milk samples (in amounts ranging from < 1 ng/liter to 108.5 ng/liter; mean level: 10.19 ng/liter), in 81 (84%) of the dry milk samples (in amounts ranging from < 1 ng/liter to 101.3 ng/kg; mean level: 21.77 ng/kg), and in 91 (80%) of the yogurt samples (in amounts ranging from < 1 ng/liter to 496.5 ng/liter; mean level: 18.08 ng/liter). Altogether, only two samples of milk, two samples of yogurt, and one sample of dry milk had levels of AFM1 exceeding the Swiss legal limits, which are the most restrictive in the world. AFM1 contamination levels in milk and yogurt samples collected in the period of November to April were ca. four times as high as those in samples collected in the period of May to October. It is concluded that during 1995, despite the widespread occurrence of AFM1, the mean contamination levels in dairy products sold in Italy were not a serious human health hazard.