Hyperbaric Oxygen Therapy plus Hypofractionated Stereotactic Radiotherapy in Recurrent Glioblastoma

PURPOSE/OBJECTIVE(S)

Hypoxia is thought to play a role in tumor development, angiogenesis and growth, and resistance to chemotherapy, antiangiogenic therapy and radiotherapy (RT) in a large number of human cancers. Brain tumors, especially highly aggressive GBM with its necrotic tissue, are more likely to be affected by hypoxia. The median partial pressure of oxygen (PO2) of high-grade gliomas in patients under anesthesia was approximately 5-7 mmHg, with a significant proportion of PO2 values <2.5 mmHg. The radiosensitivity of brain tumors could potentially be increased by performing hyperbaric oxygenation (HBO) before the RT session. We propose an innovative approach to improve the efficacy of accelerated hypofractionated Stereotactic Radiotherapy (HSRT) after HBO (HBO-RT) for the treatment of recurrent HGG (rHGG). The primary objective of this study is to evaluate the disease control rate (DCR) at 3 months. The secondary Objectives are: - Safety assessment (acute and late toxicity). - Overall Survival (OS), - Progression Free Survival (PFS).

MATERIALS/METHODS

We enrolled 14 patients (aged >18 years) with rHGG detected using MRI. A total dose of 15-25 Gy was administered in daily 5-Gy fractions for 3-5 consecutive days after daily HBO.

RESULTS

Median follow-up from re-irradiation was 22.8 months (range: 2.0-24.2 months). The disease control rate 3-months after HBO-RT was 50% (23.0-76.9). Six- and 12-month Progression-free survival was 35.7% (95% CI: 13-59.4) and 10.7% (95% CI: 0.8-35.4), respectively. Median overall survival of HBO-RT was 10.7 months (95% CI: 6.6-24.2). No acute or late neurologic toxicity >grade (G)2 was observed.

CONCLUSION

HSRT combined to HBO seems effective and safe in the treatment of rHGG.

Diagnostic and Prognostic Potential of 18F-FET PET in the Differential Diagnosis of Glioma Recurrence and Treatment-Induced Changes After Chemoradiation Therapy

Background

MRI-based differential diagnosis of glioma recurrence (GR) and treatment-induced changes (TICs) remain elusive in up to 30% of treated glioma patients. We aimed to determine ¹⁸F-FET PET diagnostic performance in this clinical scenario, its outcome dependency on established prognostic factors, optimal ¹⁸F-FET semi-quantitative thresholds, and whether ¹⁸F-FET parameters may instantly predict progression-free survival (PFS) and overall survival (OS).

Methods

We retrospectively analyzed 45 glioma patients treated with chemoradiation therapy (32 males; mean age: 51 years, glioma grade: n=26 WHO4; n=15 WHO3; n=4 WHO2) who underwent ¹⁸F-FET PET to resolve differential diagnosis of GR and TICs raised by MRI performed in the preceding 2 weeks and depicting any of the following changes in their radiation field: volumetric increase of contrast-enhancing lesions; new contrast-enhancing lesion; significant increase in T2/FLAIR non-enhancing lesion without reducing corticosteroids. ¹⁸F-FET PET outcome relied on evaluation of maximum tumor-to-brain ratio (TBRmax), time-to-peak (TTP), and time-activity curve pattern (TAC). Metabolic tumor volume (MTV) and total tumor metabolism (TTM) were calculated for prognostic purposes. Standard of reference was repeat MRI performed 4–6 weeks after the previous MRI. Non-parametric statistics tested ¹⁸F-FET-based parameters for dependency on established prognostic markers. ROC curve analysis determined optimal cutoff values for ¹⁸F-FET semi-quantitative parameters. ¹⁸F-FET parameters and prognostic factors were evaluated for PFS and OS by Kaplan-Meier, univariate, and multivariate analyses.

Results

¹⁸F-FET PET sensitivity, specificity, positive predictive value, negative predictive value were 86.2, 81.3, 89.3, 76.5%, respectively; higher diagnostic accuracy was yielded in IDH-wild-type glioma patients compared to IDH-mutant glioma patients (sensitivity: 81.8 versus 88.9%; specificity: 80.8 versus 81.8%). KPS was the only prognostic factor differing according to ¹⁸F-FET PET outcome (negative versus positive). Optimal ¹⁸F-FET cutoff values for GR were TBRmax ≥ 2.1, SUVmax ≥ 3.5, and TTP ≤ 29 min. PFS differed based on ¹⁸F-FET outcome and related metrics and according to KPS; a different OS was observed according to KPS only. On multivariate analysis, ¹⁸F-FET PET outcome was the only significant PFS factor; KPS and age the only significant OS factors.

Conclusion

¹⁸F-FET PET demonstrated good diagnostic performance. ¹⁸F-FET PET outcome and metrics were significantly predictive only for PFS.

Role of Hyperbaric Oxygenation Plus Hypofractionated Stereotactic Radiotherapy in Recurrent High-Grade Glioma

Background

The presence of hypoxic cells in high-grade glioma (HGG) is one of major reasons for failure of local tumour control with radiotherapy (RT). The use of hyperbaric oxygen therapy (HBO) could help to overcome the problem of oxygen deficiency in poorly oxygenated regions of the tumour. We propose an innovative approach to improve the efficacy of hypofractionated stereotactic radiotherapy (HSRT) after HBO (HBO-RT) for the treatment of recurrent HGG (rHGG) and herein report the results of an ad interim analysis.

Methods

We enrolled a preliminary cohort of 9 adult patients (aged >18 years) with a diagnosis of rHGG. HSRT was administered in daily 5-Gy fractions for 3-5 consecutive days a week. Each fraction was delivered up to maximum of 60 minutes after HBO.

Results

Median follow-up from re-irradiation was 11.6 months (range: 3.2-11.6 months). The disease control rate (DCR) 3 months after HBO-RT was 55.5% (5 patients). Median progression-free survival (mPFS) for all patients was 5.2 months (95%CI: 1.34-NE), while 3-month and 6-month PFS was 55.5% (95%CI: 20.4-80.4) and 27.7% (95%CI: 4.4-59.1), respectively. Median overall survival (mOS) of HBO-RT was 10.7 months (95% CI: 7.7-NE). No acute or late neurologic toxicity >grade (G)2 was observed in 88.88% of patients. One patient developed G3 radionecrosis.

Conclusions

HSRT delivered after HBO appears to be effective for the treatment of rHGG, it could represent an alternative, with low toxicity, to systemic therapies for patients who cannot or refuse to undergo such treatments.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier NCT03411408.

Efficacy and Safety of Extracranial Vein Angioplasty in Multiple Sclerosis: A Randomized Clinical Trial

Question

What is the efficacy of venous percutaneous transluminal angioplasty (PTA) for chronic cerebrospinal venous insufficiency in patients with multiple sclerosis?

Findings

In the Brave Dreams trial, which included 115 patients with relapsing-remitting multiple sclerosis, venous PTA did not increase the proportion of patients who improved functionally nor did it reduce the mean number of new combined brain lesions on magnetic resonance imaging at 12 months. However, there was a tendency for more patients to become free of new lesions after venous PTA mainly because of a reduction in new lesions appearing 6 to 12 months after randomization.

Meaning

Venous PTA cannot be recommended for patients with relapsing-remitting multiple sclerosis.

Importance

Chronic cerebrospinal venous insufficiency (CCSVI) is characterized by restricted venous outflow from the brain and spinal cord. Whether this condition is associated with multiple sclerosis (MS) and whether venous percutaneous transluminal angioplasty (PTA) is beneficial in persons with MS and CCSVI is controversial.

Objective

To determine the efficacy and safety of venous PTA in patients with MS and CCSVI.

Design, Setting, and Participants

We analyzed 177 patients with relapsing-remitting MS; 62 were ineligible, including 47 (26.6%) who did not have CCSVI on color Doppler ultrasonography screening. A total of 115 patients were recruited in the study timeframe. All patients underwent a randomized, double-blind, sham-controlled, parallel-group trial in 6 MS centers in Italy. The trial began in August 2012 and concluded in March 2016; data were analyzed from April 2016 to September 2016. The analysis was intention to treat.

Interventions

Patients were randomly allocated (2:1) to either venous PTA or catheter venography without venous angioplasty (sham).

Main Outcomes and Measures

Two primary end points were assessed at 12 months: (1) a composite functional measure (ie, walking control, balance, manual dexterity, postvoid residual urine volume, and visual acuity) and (2) a measure of new combined brain lesions on magnetic resonance imaging, including the proportion of lesion-free patients. Combined lesions included T1 gadolinium-enhancing lesions plus new or enlarged T2 lesions.

Results

Of the included 115 patients with relapsing-remitting MS, 76 were allocated to the PTA group (45 female [59%]; mean [SD] age, 40.0 [10.3] years) and 39 to the sham group (29 female [74%]; mean [SD] age, 37.5 [10.6] years); 112 (97.4%) completed follow-up. No serious adverse events occurred. Flow restoration was achieved in 38 of 71 patients (54%) in the PTA group. The functional composite measure did not differ between the PTA and sham groups (41.7% vs 48.7%; odds ratio, 0.75; 95% CI, 0.34-1.68; P = .49). The mean (SD) number of combined lesions on magnetic resonance imaging at 6 to 12 months were 0.47 (1.19) in the PTA group vs 1.27 (2.65) in the sham group (mean ratio, 0.37; 95% CI, 0.15-0.91; P = .03: adjusted P = .09) and were 1.40 (4.21) in the PTA group vs 1.95 (3.73) in the sham group at 0 to 12 months (mean ratio, 0.72; 95% CI, 0.32-1.63; P = .45; adjusted P = .45). At follow-up after 6 to 12 months, 58 of 70 patients (83%) in the PTA group and 22 of 33 (67%) in the sham group were free of new lesions on magnetic resonance imaging (odds ratio, 2.64; 95% CI, 1.11-6.28; P = .03; adjusted P = .09). At 0 to 12 months, 46 of 73 patients (63.0%) in the PTA group and 18 of 37 (49%) in the sham group were free of new lesions on magnetic resonance imaging (odds ratio, 1.80; 95% CI, 0.81-4.01; P = .15; adjusted P = .30).

Conclusion and Relevance

Venous PTA has proven to be a safe but largely ineffective technique; the treatment cannot be recommended in patients with MS.

Trial Registration

clinicaltrials.gov Identifier: NCT01371760

[Encephalitis by type B influenza: a pediatric clinical case and literature review.]

We report the case of a 6-year-old girl who presented with encephalitis during type B influenza. The clinical picture was characterized by an alteration of the state of consciousness associated with focal neurological signs with electroencephalographic changes and brain MRI. Clinical improvement was rapid and without neurological outcomes. The clinical characteristics, the pathogenic mechanisms, the prognosis and the therapy of neuroinfluenza cases are described.

Safety of cardioversion in atrial fibrillation lasting less than 48 h without post-procedural anticoagulation in patients at low cardioembolic risk

Currently, there is no unified consensus on short-term anticoagulation after cardioversion of atrial fibrillation lasting less than 48 h in low-cardioembolic-risk patients. The aim of this study is to evaluate the rate of transient ischemic attacks, stroke and death in this subset of patients after cardioversion without post-procedural anticoagulation. In a prospective observational study, patients with recent-onset AF undergoing cardioversion attempts in the Emergency Department were evaluated over the past 3 years. Inclusion criteria were conversion to sinus rhythm, low thromboembolic risk defined by a CHA2DS2VASc score of 0-1 points for males (0-2 points for females aged over 65 years), and hospital discharge without anticoagulant treatment. Patients with severe valvular heart disease, underlying systemic causes of AF, and those discharged with anticoagulant therapy were excluded. The main outcomes measured were TIA, stroke and death at thirty days' follow-up after discharge. During the study period, 218 successful cardioversions, obtained both electrically and pharmacologically, were performed on 157 patients. One hundred and eleven patients were males (71%), the mean age was 55.2 years (±standard deviation 10.7), 99 patients (63%) reported a CHA2DS2VASc score of 0, and the remaining 58 (37%) had a risk profile of 1 point. Of these, latter 8 were females (5%) older than 65 years (risk score 2 points). At the thirty days outcome, none of the 150 enrolled patients who completed a follow-up visit has reported TIA or stroke, nor died, in the overall 211 successful cardioversions evaluated. In our study, the rate of thromboembolic events after cardioversion of recent-onset AF of less than 48 h duration, in patients with a 0-1 CHA2DS2VASc risk profile (females 0-2), appeared to be extremely low even in absence of post-procedural anticoagulation. These findings seem to confirm data from previous studies, and suggest that routine post-procedural short-term anticoagulation may be considered as an overtreatment in this very low-risk subset of patients.

Characterization of antibody response in neuroinvasive infection caused by Toscana virus

OBJECTIVES

Among sandfly-borne pathogens, Toscana virus (TOSV) is a prominent cause of summer meningitis in Mediterranean Europe. Here, we assessed the kinetics of anti-TOSV antibodies over time in 41 patients diagnosed with TOSV meningitis or meningoencephalitis in northeastern Italy.

METHODS

Acute and follow-up serum samples were collected up to 20 months after diagnosis of TOSV infection and tested for the presence of specific antibody using immunoenzymatic and indirect immunofluorescence assays. In addition, maturation of anti-TOSV IgG over time was evaluated as well as production of neutralizing antibodies.

RESULTS

Specific IgM and IgG response was present at diagnosis in 100% of patients; TOSV-specific IgM and IgG were detected in patients' sera up to 6 and 20 months after diagnosis, respectively. The avidity index (AI) increased over the first month after infection in 100% of patients and most cases exceeded 60% by Day 30 post infection. The AI subsequently plateaued then declined at 20 months after diagnosis. Finally, neutralization assay to TOSV was performed in 217 sera collected from 41 patients; 69.6% of tested samples resulted in reactive and moderate levels of neutralizing antibodies observed during all phases of infection despite high titres of total anti-TOSV IgG.

CONCLUSIONS

Specific antibody response develops rapidly and is long-lasting for neuroinvasive TOSV infection. Serodiagnosis of neuroinvasive TOSV requires simultaneous detection of specific IgM and IgG. Moderate levels of neutralizing antibodies were maintained over the study period, while the protective role of antibodies lacking neutralizing activity is unclear and requires further evaluation.

L'angio-TC nel riscontro e nell'analisi delle caratteristiche delle lesioni aneurismatiche intracraniche dei pazienti con ESA

È stato eseguito uno studio retrospettivo per valutare l'utilità dell'angio-TC nel riscontro e nell'analisi delle caratteristiche delle lesioni aneurismatiche intracraniche nei pazienti con ESA, usando l'angiografia digitale (AD) come “gold standard”.

È stato preso in esame un gruppo di 97 pazienti con emorragia sub-aracnoidea, e sono stati esaminati con angio-TC entro 12 ore dall'evento acuto; 23 hanno eseguito solo l'angio-TC, mentre 74 pazienti hanno eseguito sia l'angio-TC che l'AD; l'AD è stata eseguita mediamente entro 24 ore. Nei 74 pazienti hanno eseguito sia l'angio-TC che l'AD, abbiamo avuto un riscontro di 69 aneurismi (6 pazienti avevano una doppia lesione aneurismatica ed in una paziente ne sono state riscontrate quattro) e l'assenza di aneurismi in 14 pazienti. In cinque casi l'angio-TC non ha evidenziato l'aneurisma, riscontrato poi con l'AD.

I falsi negativi erano dovuti in un caso ad un errore nel calcolo del ritardo d'iniezione, in un secondo caso la lesione aneurismatica a carico della PICA non si è opacizzata. L'AD è stata eseguita il giorno dopo e nel frattempo le condizioni di circolo e dei vasi potrebbero essere cambiate. Nei restanti casi si trattava di aneurismi non ben visualizzati per la marcata tortuosità del vaso associata alle piccole dimensioni delle lesioni ed alla presenza di strutture ossee molto vicine alla lesione.

Pertanto la sensibilità e la specificità dell'angio-CT nel riscontro degli aneurismi sono rispettivamente del 96% e del 100%, ed il valore predittivo globale dell'esame è del 96%.

Tale metodica non invasiva è risultata quindi veloce, affidabile, ricca di informazioni e spesso conclusiva nell'iter diagnostico dei pazienti con ESA, con particolare utilità nella gestione della urgenza.

Severe symptomatic bradycardia after a dinner of spicy oleander soup

Introduction: Cardiac glycosides similar to digoxin are produced by different plants in nature. Nerium oleander, commonly grown as an ornamental shrub, can be found worldwide in temperate countries. Intentional or accidental ingestion of any part of the plant can lead to clinically relevant intoxication. Case report: A 63 year old woman came to the emergency department with acute dyspeptic symptoms after eating vegetable soup flavored with unfamiliar flowers she have collected herself. However, the ECG showed abnormalities that raised suspicions for an overdose of digoxin-like cardiac glycosides. The patient was not on treatment with digoxin and a careful anamnesis revealed that she had eaten oleander leaves. Digoxin specific Fab antibody fragments were administered for marked bradycardia that was not responding to atropine administration, after counseling with the reference toxicology center. The patient was also treated with activated charcoal and magnesium sulphate, intravenous fluids and pantoprazole. Four days later she was discharged as asymptomatic, with normal sinus rhythm. Conclusion: Emergency physicians should be aware of this type of poisoning, especially in cases with typical ECG alterations in patients not treated with digoxin and medical history of plants ingestion. Cardio-active glycosides are present in different plants, often used inappropriately, with potential toxic effects and harmful drug interactions.

Safety and feasibility of intravenous rt-PA in the Emergency Department without a neurologist-based stroke unit: an observational study

Early intravenous thrombolysis has proven to be a safe and effective therapy for selected patients with acute ischemic stroke (AIS). Nowadays, thrombolysis is usually delivered by neurologists in "hub" referral centers. However, only a few among eligible patients actually receive treatment. Barriers to early administration of thrombolysis are represented by delays in presentation to referral centers, in-hospital and transfer delays, as well as changes in symptoms during assessment time. The aim of this study is to evaluate the safety and rate of thrombolysis provided in Emergency Department (ED) of a district hospital without neurological stroke team. Consecutive patients with AIS treated with intravenous thrombolysis were prospectively enrolled in this observational study, conducted between May 2010 and December 2013. The main outcomes evaluated were: mortality, symptomatic intracerebral hemorrhage (ICH), systemic adverse events, and neurological recovery. Secondly, all patients admitted with ischemic stroke were retrospectively screened to assess the reasons for exclusion to treatment and the rate of thrombolysis delivered. During the study period, 43 patients with AIS received intravenous rt-PA treatment. The mortality rate at three months was 9.5 % (4/43; 95 % CI 2.6-22.1) and total ICH at any-time CT scan imaging was 18.6 % (8/43; 8.4-33.4). At seven days or at discharge, 35/43 patients (81.4 %; 66.6-91.6) presented a neurological improvement and 46.5 % (20/43; 31.2-62.3) a complete neurological recovery presenting a normal NIHSS, while 9.5 % of patients remained in steady conditions and other 9.5 % worsened (4/43; 2.6-22.1). Outcomes do not appear to be very different from those reported in SITS-MOST study cohort. Among the overall 732 patients with AIS, 117 (16.0 %; 13.4-18.8) were eligible for age and arrived within the three-hour window of time, and the thrombolysis rate was 5.9 % (43/732; 4.3-7.8). Administration of rt-PA in an ED setting without neurological specialized stroke unit seems to be feasible and safe after adequate training. Thrombolysis rate found seems to be favorably comparable with the national average in specialist stroke units. If such data were confirmed by studies of greater dimension, this may imply the ability to perform thrombolysis even in smaller centers without the neurologist, thus being able to treat a greater number of patients in the times proven effective for thrombolysis.

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.

Analysis of long-term survival in patients with glioblastoma

e13007

Background: Adult glioblastoma (GBM) is the most common type of malignant primary brain tumor. Despite advances made in treatment, median survival is between 12 and 15 months. Standard care is concomitant radiotherapy (RT)/temozolomide (TMZ) and adjuvant TMZ for 6 cycles (EORTC/NCIC trial 2005). At progression, subsequent treatments are left to the discretion of the treating physician. Methods: We evaluated retrospective data of GBM patients (pts) treated from 2003 to 2010, focusing on the treatment of patients with longer survival (over 24 months). Results: 139 pts with GBM were treated during the period. Thirty of these showed survival > 24 months: 20 were subjected to macroscopically radical neurosurgery, 9 to non-radical surgery and 1 to biopsy. All pts had a KPS 100%. 11 pts were treated in the period pre-EORTC/NCIC trial (Stupp et all) and 19 in the period “post-Stupp”. In the former group 10 pts underwent RT followed by TMZ ( 2-12cycles) and 1 patient received only RT. All pts in the latter group were treated with concomitant radio-chemotherapy followed by TMZ. 3 pts are currently disease stable. After the first documented evidence of disease progression (PD) 21 pts were treated, one with neurosurgery, 4 with neurosurgery plus chemotherapy (CT), 15 with only CT and 1 with CT and tomotherapy. With regard to chemotherapy, 14 pts received TMZ ( 2-21cycles), 3 fotemustine (4-16 cycles), 1 carboplatin and VP16 (2 cycles) and 1 irinotecan plus bevacizumab (2 cycles). Further progression was treated with another line of CT in only 8 pts, fotemustine in 5 (1-3 cycles), TMZ in 2 (2 cycles) and carboplatin plus VP16 In 1 (5 cycles). Median overall survival (mOS) of our long-term survivors was 36.18 months (CI 95% 28.32 – 42.01). Considering the two groups separately (pre- and post- Stupp), we observed a mOS of 36.18 months (CI 95% 26.45 – 42.01) (1 pt alive) for the first group and of 36.15 months (CI 95% 28.26 – 48.52) (7 pts alive) for the second. Conclusions: Our long-term survivors, independently of treatment, showed an mOS of 36.18 months (CI 95% 28.32 – 42.01). There was no significant difference in mOS between the 2 groups (p=0.6963). Further research is needed to identify the biomolecular and genetic pattern that is responsible for the long survival of some patients.

Efficacy and safety of venous angioplasty of the extracranial veins for multiple sclerosis. Brave dreams study (brain venous drainage exploited against multiple sclerosis): study protocol for a randomized controlled trial

Background

Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system with a disabling progressive course. Chronic cerebrospinal venous insufficiency (CCSVI) has recently been described as a vascular condition characterized by restricted venous outflow from the brain, mainly due to blockages of the internal jugular and azygos veins. Despite a wide variability among studies, it has been found to be associated with MS. Data from a few small case series suggest possible improvement of the clinical course and quality of life by performing percutaneous balloon angioplasty (PTA) of the stenotic veins.

Study design and methods

This is a multicenter, randomized, parallel group, blinded, sham-controlled trial to assess the efficacy and safety of PTA. Participants with relapsing remitting MS or secondary progressive MS and a sonographic diagnosis of CCSVI will be enrolled after providing their informed consent. Each participant will be centrally randomized to receive catheter venography and PTA or catheter venography and sham PTA. Two primary end points with respect to efficacy at 12 months are (1) a combined end point obtained through the integration of five functional indicators, walking, balance, manual dexterity, bladder control, and visual acuity, objectively measured by instruments; and (2) number of new brain lesions measured by T2-weighted MRI sequences. Secondary end points include annual relapse rate, change in Expanded Disability Status Scale score, proportion of patients with zero, one or two, or more than two relapses; fatigue; anxiety and depression; general cognitive state; memory/attention/calculus; impact of bladder incontinence; and adverse events. Six hundred seventy-nine patients will be recruited. The follow-up is scheduled at 12 months. Patients, treating neurologists, trained outcome assessors, and the statistician in charge of data analysis will be masked to the assigned treatment.

Discussion

The study will provide an answer regarding the efficacy of PTA on patients’ functional disability in balance, motor, sensory, visual and bladder function, cognitive status, and emotional status, which are meaningful clinical outcomes, beyond investigating the effects on inflammation. In fact, an important part of patients’ expectations, sustained and amplified by anecdotal data, has to do precisely with these functional aspects.

Trial registration

Clinicaltrials.gov NCT01371760

Carotid Stenting without Angioplasty and without Protection: The Advantages of a Less Invasive Procedure

SUMMARY

Endovascular stenting is a consolidated alternative to thrombendarterectomy in the treatment of extracranial carotid artery atheromasic stenosis. The most common complication of stenting is a distal embolism causing clinically silent orsymptomatic cerebral ischaemia. To prevent this complication distal embolism protection devices are often used but their effectiveness remains unsettled. In addition, there is some evidence that distal embolism may actually be triggered by the protection systems due to clot formationat their distal surface or in the intimal lesions these systems cause. Another rarer complicationis hyperperfusion syndrome arising during both stenting and thrombendarterectomy but more common in endovascular procedures. To avoid these complications the Neuroradiology Service at Bellaria Hospital (Bologna Local Health Trust) has devised a mini-invasive carotid stenting technique that does not require either distal embolism protection or angioplasty. The technique uses only the radial force exerted by the self-expanding stent to widen the atherosclerotic stenosis slowly and gradually. The goal of treatment has also changed from a prompt restoration of the atheromasic vessel's original calibre to slow transformation of the hemodynamic significance of the stenosis. The technique's success lies mainly in selecting the stenosis to treat using CT angiography to analyse plaque morphology and structure.We used the technique to treat 83 stenotic lesions in 75 patients. The study aims to describe and discussour experience.

Use of Glubran 2 acrylic glue in interventional neuroradiology

INTRODUCTION

Glubran 2 is a cyanoacrylate-based synthetic glue modified by the addition of a monomer synthesized by the manufacturer. With this material it is possible to obtain the stability of endovascular embolization that is needed to treat tumours and vascular disease.

MATERIAL AND METHODS

We report our 3-year experience of the use of Glubran for treating extracerebral tumours, spinal tumours, spinal arteriovenous malformations, and brain and spine dural fistulae. Glubran 2 was diluted with Lipiodol and injected in a continuous column with the flow rate monitored by seriography. The injection was stopped when retrograde flow was displayed in the afferent vessel.

RESULTS

There were no periprocedural or subsequent clinical complications and the glue resulted in successful selective permanent occlusion with intralesional penetration similar to the angiographic features of microcatheterization.

CONCLUSIONS

The embolization procedure was technically straightforward and relatively safe. However, Glubran 2 can be difficult to use and the procedure does carry major risks for patients. Glue injection requires in-depth study of the lesion, its circulation and the collateral circulation to avoid severe complications due to inappropriate use.

Intracranial stenting in the treatment of wide-necked aneurysms

SUMMARY

We positioned the following self-expanding stents certified for intracranial application: 16 Neuroform (Boston Scientific), three INX (Medtronic), one Leo (Balt). 6F calibre femoral introducers and guiding catheters were used for stent placement changing to 5F calibre introducers and guiding catheters (Envoy, Cordis) for the Neuroform 2 and 3 stents. All procedures were carried out under general anaesthesia and heparinization. Our pharmacological protocol consisted of adjunctive treatment with anti-aggregants during the interventional procedure and for the following six months, without premedication. From November 2000 to August 2006 we treated 28 patients (27 F/1M) with giant wide-necked aneurysms and one dissecting basilar artery aneurysm requiring the placement of 29 stents. We successfully positioned 20 stents: 11 stents combined with coils (8 immediate; 3 late) with complete exclusion of the aneurysm from the circulation in seven cases and subtotal exclusion in four; nine stents not followed by embolization with complete exclusion of the aneurysm from the circulation in six cases and subtotal exclusion in three. Stenting was not possible in nine cases due to extreme vessel tortuosity and the poor flexibility of release systems for the first stents. No late stent occlusion or subarachnoid haemorrhage were encountered after treatment.

Retrospective Study of Complications Arising during Cerebral and Spinal Diagnostic Angiography from 1998 to 2003

SUMMARY

This retrospective study aimed to assess the percentage of complications in the daily practice of cerebral and spinal cord diagnostic angiography at our institution and to compare this with literature reports published in the last twenty years and guidelines for angiography. From 1(st) December 1998 to 1(st) December 2003 2154 patients underwent digital angiography for a total of 5996 vessels selected. Three neurological complications arose during angiographic procedures in the five year period. * Focal neurological deficit resolving within 24h in two patients, * Permanent neurological deficit in one patient. There were no adverse systemic reactions to contrast medium. Retrospective analysis of our cohort disclosed a complication rate of 0.1% for transient neurological complications and 0.05% for permanent deficits.

Brain AVM Embolization with Onyx(R): Analysis of Treatment in 34 Patients

SUMMARY

The endovascular approach to arteriovenous malformations (AVM) using different embolizing agents is a well-established treatment option. This report assesses the results of our experience using a non "glueing" embolic material available for several years, commercially known as Onyx(R). We used Onyx to treat 34 consecutive patients in the last four years. All patients were treated in the same department by the same neuroradiological team, with a strictly repetitive technical strategy and procedural protocol. All our patients presented AVMs with Spetzler Grade 3 or more, because in our Institution Grade 1 or 2 AVMs are directly treated by surgical approach. We adopt a multidisciplinary treatment approach (embolization, surgery, radiotherapy) by which embolization is construed as work in progress offering definitive treatment of AVMs without severe risks. Embolization is mainly undertaken as the first step before surgery, to reduce flow and size of the AVM by a "targeted" technique. In addition to reducing lesion size, endovascular treatment aims to seal off AVM areas anatomically or haemodynamically complex for surgical treatment. Occasionally, the reduction in size allows a radiosurgical approach. Embolization seldom results in a definitive cure of AVMs. At the end of multimodal approach, we obtained the complete and definitive cure of AVM in 21/34 patients (two complete obliteration with interventional technique, 19 in combination with surgery); to these were added 5/34 patients who received radiosurgical therapy. No major complications arose during endovascular treatment. One patient had transitory (36 hour) impaired right arm pronation. The CT scan disclosed an asymptomatic mild SAH in the left sylvian fissure but no ischaemic areas. One patient still in treatment died from fatal rebleeding (the clinical onset had been with haemorrhage two weeks before the session) 12 days after the embolization. Excellent or good clinical outcome was obtained in 23/26 patients who completed the therapeutic protocol. Outcome was conditioned by focal symptoms present on admission in three patients due to haemorrhagic onset, but only one patient presented a severe disability on discharge. In our view, the main problem of Onyx is that the apparently easier approach will probably lead to a wider diffusion of these procedures. AVMs are extremely difficult and dangerous to treat: this is not affected by the quality of the embolizing agents used and must be kept in mind at all times.

Endovascular treatment of basilar artery dissection by stent deployment. A case report

SUMMARY

We describe a 44 year-old woman with dissection of the distal third of the basilar artery presenting with subarachnoid haemorrhage. She was treated with a Neuroform stent (Boston Scientific), the first stent designed for intracranial navigation and recently approved by the FDA to treat wide-necked cerebral aneurysms and allow reconstruction of the internal lumen. In our patient, the dissection involved the origin of the anterosuperior cerebellar artery and the origin of the right posterior cerebral artery. The stent was positioned without complications during or after the procedure. Intra and periprocedural thrombolytic therapy was given followed by an antiaggregant (100 mg Aspirin) for a year after treatment. Subsequent angio-MR and angiographic monitoring disclosed resolution of the dissection and normalization of the basilar artery lumen. She currently lives a controlled but normal life.

Glubran 2((r)):a new acrylic glue for neuroradiological endovascular use: a complementary histological study

SUMMARY

Two Landrace Large White swine underwent angiography by the femoral route. In both cases, the superior left renal artery was embolized by injection of 2 ml of Glubran 2((R)), diluted with Lipiodol 1:1 thereby excluding the superior left kidney poles from blood flow. During the follow-up period, neither pig presented any clinical symptom correlated to the embolization procedure. Case 1 was sacrificed after 30 days and case 2 after 60 days. Macroscopic and microscopic analysis was performed in both animals. Long-term follow-up of the two cases after endovascular injection of Glubran 2((R)) showed that the embolization procedure was well-tolerated by the swine in terms of clinical symptoms and histological findings. Arterial occlusion was stable and a reasonable quantity of scar tissue appeared between 30 and 60 days, surrounding the ischaemic tissue. This follow-up experimental study offers further evidence that Glubran 2((R)) is a safe embolizing material for human use as far as its chemical activity is concerned.

Presurgical embolization of spinal tumours using glubran 2 acrylic glue

SUMMARY

This study aimed to define the indications, technique and results of presurgical embolization of spinal tumours using Glubran 2 acrylic glue. Embolization was performed prior to surgery in eight patients with benign tumours and 11 patients with malignant lesions. The main embolization agent used was Glubran 2, a new acrylic glue with the EC mark, suitable for permanent embolization of the pathological circulation of primary and secondary spinal tumours. All the procedures were technically feasible and achieved partial or complete embolization of the vascularized lesion without periprocedural complications. Glubran 2 proved easy to use with excellent intravascular penetration achieving permanent embolization. The degree of presurgical embolization in terms of surgical field haemostasis was correlated with the degree of vascular occlusion achieved.

3D Micrus Coil "Cage" in Wide-Necked Aneurysms

SUMMARY

We aimed to verify that Micrus 3D microcoils can be used as first coils in the treatment of saccular wide-necked aneurysms to provide stable protection to the neck by keeping the coil mesh inside the aneurysm. We selected 22 wide-necked aneurysms and calculated the ratio between sac diameter and neck width which was close to unity. The aneurysms were treated by endovascular approach using Micrus 3D (Spherical) microcoils as first coils. The coils proved stable during placement and detachment and compatible with both GDC and Micrus coils used for filling and packing. The endovascular procedure was suspended in only two out of 22 aneurysms selected for treatment. Aneurysm bleeding occurred in two endovascular procedures but was controlled. No complications were encountered in the remaining 18 patients treated. The percentage of technical failures has been reduced since the adoption of 3D Micrus microcoils in our practice.

Three-Year Retrospective Study of Complications Arising during Interventional Procedures

SUMMARY

This retrospective study aimed to assess the percentage of complications arising in our daily practice of interventional procedures, comparing our findings with those of leading international reference centers and accepted guidelines for endovascular treatment. During the threeyear period considered (2000-2002), we performed 246 interventional procedures, divided into seven different pathological conditions: aneurysms, brain AVMs dural and carotid cavernous fistulae, spine-spinal cord tumours, headneck tumours, carotid stenosis and thrombolysis. Aneurysmal disease accounted for 45% of all endovascular procedures. In conclusion, four periprocedural complications arose in the course of 246 procedures resulting in one death and three cases of permanent neurological deficit (2%).

Reduced sympathetic outflow and adrenal secretory activity during a 40-day stay in the Antarctic

Human adaptation to unknown and extreme environments requires changes in the psychological and physical homeostasis. We previously reported a significant decrease of anterior pituitary and adrenal hormonal levels and a significant modification of psychophysiological correlates of stress, such as galvanic skin response, after exposure to Antarctica, suggesting a possible decrease of individual arousal. The latter was hypothesized to be correlated with a modification of autonomic balance, mainly represented by a possible reduction of adrenergic output. The aim of the present study was to assess the patterns of hormonal circadian rhythms and the autonomic nervous system balance by means of spectral analysis of heart rate variability (HRV). These parameters were evaluated during 3 sessions (baseline, session 1 and session 2), before, at the beginning and after a 40-day stay in Antarctica (Station of Terra Nova Bay; average temperature in the study period: -11 degrees C, 24 h of light, sea level). In each of the sessions, 6 healthy male subjects underwent a 24-h electrocardiogram and blood sampling (08.00, 12.00, 16.00, 20.00, 24.00 and 08.00 h) for hormonal determinations. The data showed a remarkable decrease of hormonal levels without significant changes in circadian rhythms. Spectral analysis of HRV showed an imbalance of the autonomic nervous system with a relative significant decrease of the low frequency band (0.1 Hz) in session 1 and 2 compared to baseline, which can be functionally interpreted as a relative decrement of the sympathetic component. In conclusion, the exposure to a cold and extreme environment seems to affect autonomic balance over a 40-day period. This is followed by a significant reduction of the anterior pituitary and adrenal hormonal secretory patterns with preserved hormonal circadian rhythms (within the same time period of 40 days). This pattern is suggestive of a trophotropic neurovegetative adaptive process.

[Malignant glial tumor with skeletal muscle differentiation. Description of a case]

A case of CNS gliomyosarcoma, in a 71-year-old female with skeletal muscle differentiation is presented. The tumor was composed by two cell types: one showed features typical of glial cells, the other was constituted by elements having immunohistochemical positivity with desmin, sarcomeric actin, myoglobin and myogenin antisera. It is postulated an origin from a cell capable of dual differentiation.

CT prognostic factors in acute subdural haematomas: the value of the 'worst' CT scan

The relationship between radiological findings and outcome in patients with acute posttraumatic subdural haematomas (SDH) has been based on CT obtained upon hospital admission. This study was undertaken to investigate the effects on prognosis of SDH patients of lesions not present on admission, but detected by subsequent CT. We have also studied those findings present on admission CT that could predict worsening of the associated lesions. From 1 May 1989 to 30 April 1996, we admitted 206 patients harbouring acute SDH of thickness 5 mm or more. The admission GCS score ranged from 3 to 15. Each patient underwent CT on admission (always within 3 h from injury). Follow-up CT was performed within 12-24 h after injury and in the following days (an average of 4.3 examinations for each patient). These examinations were reviewed by a neuroradiologist and the 'worst' CT was determined. We defined the 'worst' examination as that showing the largest haematoma thickness/midline shift and/or with the most extensive degree of parenchymal damage. Clinical factors related to prognosis in this series are age, hypoxia/hypotension, GCS motor score and pupillary abnormalities. Time from injury to treatment was found relevant only in patients with isolated SDH. CT findings on admission that correlated with outcome were haematoma thickness, midline shift and status of the basal cisterns. Prognosis was also worsened by the presence of associated lesions; SAH alone or associated with brain contusions. The last of these was the single most powerful predictor of worse outcomes (Odds ratio 0.37, p < 0.004). Whereas the first CT showed parenchymal associated damage in 56 patients, the 'worst CT' showed such damage in 105 patients. Presence of SAH on admission was found significant (p < 0.02) in predicting evolving parenchymal damage. Haematoma thickness, midline shift, status of the basal cisterns and presence of SAH are related to outcome when identified on the initial (early) CT examination. However, early (within 3 h from injury) CT under-estimates the ultimate size of parenchymal contusions. Patients with SAH on early CT are those at highest risk for associated evolving contusions. The use of sequential CT should be included in the routine management of head-injured patients.

Endocrine and psychophysiological aspects of human adaptation to the extreme

Human beings need to adapt to any extreme, unknown, or isolated environment. This adaptation requires changes in the normal regulation of psychophysiological homeostasis, as described in terms of stress reaction. The aim of the present study was to monitor the processes of human adaptation to cold and isolated areas in Antarctica during the 12th expedition of the Italian National Research Program. Nine healthy subjects (experimental subjects), members of the expedition, and nine controls in Italy, were studied over a period of 2 months. Anterior pituitary hormone secretion, insulin, and melatonin, plus routine blood test, blood pressure, and ECG were performed. In addition, psychophysiological correlates were also recorded before and after the expedition period. In experimental subjects results of metabolic data suggested the presence of an increased peripheral insulin sensitivity at the end of the permanence in the station and a significant increased of total cholesterol. Hematocrit also significantly increased due to the conditions of hypobaric hypoxia. Results of endocrine data showed a significant decrease (p < 0.05) of hormone levels, which was associated with a significant decrement of the Galvanic Skin Response (GSR) activity to a standardized cognitive stress. No significant differences were reported in the controls. The data suggest that the exposure to the extreme environment develops a possible psychophysiological mechanism(s) that decreases the individual arousal.

Importance of a reliable admission Glasgow Coma Scale score for determining the need for evacuation of posttraumatic subdural hematomas: a prospective study of 65 patients

BACKGROUND

Patients who have an acute subdural hematoma with a thickness of 10 mm or less and with a shift of the midline structures of 5 mm or less often can be treated nonoperatively. We wonder whether the knowledge of the clinical status both in the prehospital determination and on admission to the neurosurgical center can predict the need for evacuation of subdural hematomas as well as the computed tomographic (CT) parameters.

METHODS

From January 1, 1994, to May 31, 1996, 65 comatose patients harboring an acute subdural hematoma of 5 mm or more and not brain dead were admitted to our intensive care unit. Of the 65 patients, 15 patients were initially managed conservatively according to a protocol based on clinical, CT, and intracranial pressure parameters. During the study period, the use of long-lasting paralytic agents has been eliminated to allow detection of clinical deterioration in the Glasgow Coma Scale (GCS) score from the prehospital determination to the hospital admission assessment.

RESULTS

Of the 15 patients initially managed conservatively, two were subsequently operated on because of evolving parenchymal hematomas. When comparing demographic, clinical, and CT parameters between the surgical group of patients and the patients initially conservatively treated, hematoma thickness (mean, 17.1 mm vs. 7.5 mm, p < 0.0001) and shift of the midline structures (mean, 12.8 mm vs. 4.7 mm, p < 0.008) were predictive of the need for surgery. A statistically significant change in the GCS score between prehospital determination and admission assessment was shown in the surgical group of patients (mean GCS score, 8.4 vs. 6.7, p < 0.01), and it was not present (mean GCS score, 7.3 vs. 7.2) in the patients initially conservatively treated. Functional outcomes were present in 23 cases (35.4%); functional outcomes in the initially conservatively treated patients were reached by 10 patients (66.7%).

CONCLUSIONS

Nonoperative management for selected cases of acute subdural hematomas is at least as safe as surgical management. GCS scoring at the scene and in the emergency room combined with early and subsequent CT scanning is crucial when making the decision for nonoperative management. This strategy requires that administration of long-lasting sedatives and paralytic medications be avoided before the patient arrives at the neurosurgical center.

Emergency medical services in mass gatherings: the experience of the Formula 1 Grand Prix 'San Marino' in Imola

Mass gatherings are special situations for which mass medical care must be preplanned. Acute emergencies occur at public gatherings and medical coverage on site has proven benefit. Responsibility of general plan, management of specific problems, transport planning, communications system, guidelines and protocols, special situations management, ancillary supports, sources of extra help for unforeseen needs are the most important items to consider. In mass gatherings the whole emergency medical service (EMS) planning and management has to depend on the emergency department direction, with its authority on all aspects of patient care in the EMS system. This report concerns the planning of EMS and of medical care in a situation at risk for mass casualties at the Formula I Grand Prix-Championship Racing 'San Marino' of Imola.