Functional and radiological outcomes after bridging therapy versus direct thrombectomy in stroke patients with unknown onset: Bridging therapy versus direct thrombectomy in unknown onset stroke patients with 10-point ASPECTS

BACKGROUND AND PURPOSE

The aim was to assess functional and radiological outcomes after bridging therapy (intravenous thrombolysis plus mechanical thrombectomy) versus direct mechanical thrombectomy (MT) in unknown onset stroke patients.

METHODS

A cohort study was conducted on prospectively collected data from unknown onset stroke patients who received endovascular procedures at ≤6 h from symptom recognition or awakening time.

RESULTS

Of the 349 patients with a 10-point Alberta Stroke Program Early Computed Tomography Score (ASPECTS), 248 received bridging and 101 received direct MT. Of the 134 patients with 6-9-point ASPECTS, 123 received bridging and 111 received direct MT. Each patient treated with bridging was propensity score matched with a patient treated with direct MT for age, sex, study period, pre-stroke disability, stroke severity, type of stroke onset, symptom recognition to groin time (or awakening to groin time), ASPECTS and procedure time. In the two matched groups with 10-point ASPECTS (n = 73 vs. n = 73), bridging was associated with higher rates of excellent outcome (46.6% vs. 28.8%; odds ratio 2.302, 95% confidence interval 1.010-5.244) and successful recanalization (83.6% vs. 63%; odds ratio 3.028, 95% confidence interval 1.369-6.693) compared with direct MT; no significant association was found between bridging and direct MT with regard to rate of symptomatic intracerebral hemorrhage (0% vs. 1.4%). In the two matched groups with 6-9-point ASPECTS (n = 45 vs. n = 45), no significant associations were found between bridging and direct MT with regard to rates of excellent functional outcome (44.4% vs. 31.1%), successful recanalization (73.3% vs. 76.5%) and symptomatic intracerebral hemorrhage (0% vs. 0%).

CONCLUSIONS

Bridging at ≤ 6 h of symptom recognition or awakening time was associated with better functional and radiological outcomes in unknown onset stroke patients with 10-point ASPECTS.

IER-SICH Nomogram to Predict Symptomatic Intracerebral Hemorrhage After Thrombectomy for Stroke

Background and Purpose—

As a reliable scoring system to detect the risk of symptomatic intracerebral hemorrhage after thrombectomy for ischemic stroke is not yet available, we developed a nomogram for predicting symptomatic intracerebral hemorrhage in patients with large vessel occlusion in the anterior circulation who received bridging of thrombectomy with intravenous thrombolysis (training set), and to validate the model by using a cohort of patients treated with direct thrombectomy (test set).

Methods—

We conducted a cohort study on prospectively collected data from 3714 patients enrolled in the IER (Italian Registry of Endovascular Stroke Treatment in Acute Stroke). Symptomatic intracerebral hemorrhage was defined as any type of intracerebral hemorrhage with increase of ≥4 National Institutes of Health Stroke Scale score points from baseline ≤24 hours or death. Based on multivariate logistic models, the nomogram was generated. We assessed the discriminative performance by using the area under the receiver operating characteristic curve.

Results—

National Institutes of Health Stroke Scale score, onset-to-end procedure time, age, unsuccessful recanalization, and Careggi collateral score composed the IER-SICH nomogram. After removing Careggi collateral score from the first model, a second model including Alberta Stroke Program Early CT Score was developed. The area under the receiver operating characteristic curve of the IER-SICH nomogram was 0.778 in the training set (n=492) and 0.709 in the test set (n=399). The area under the receiver operating characteristic curve of the second model was 0.733 in the training set (n=988) and 0.685 in the test set (n=779).

Conclusions—

The IER-SICH nomogram is the first model developed and validated for predicting symptomatic intracerebral hemorrhage after thrombectomy. It may provide indications on early identification of patients for more or less postprocedural intensive management.

Surgical Management of Adverse Radiation Effects After Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformations: A Population-Based Cohort Study

OBJECTIVE

The goal of this study is to report our experience in the surgical treatment of cerebral arteriovenous malformations (cAVMs) related permanent symptomatic adverse radiation effects (PSAREs), to clarify an appropriate surgical management and to identify the risk factors related to their development.

METHODS

We evaluated 549 patients treated with Gamma Knife radiosurgery (GKRS) for cAVMs with a follow-up of at least 8 years. Univariate and multivariate analyses were used to test different risk factors related to the development of PSARE. We retrospectively reviewed the records of these patients to analyze the clinical outcome.

RESULTS

Fourteen patients (2.5%) developed PSARE and were submitted to surgery. Higher average treated volume represents a significant risk factors for the development of PSARE (P < 0.05); on the other hand, older age and higher average dose reduce the risk of PSARE (P < 0.05). A favorable clinical outcome was achieved in 13 patients (93%) after surgery; in 1 patient, the unfavorable outcome was due to hemorrhage that occurred months after GKRS. Serial MRI scans following either surgical removal of the nodule or Ommaya reservoir positioning showed progressive reduction of brain edema in all cases.

CONCLUSIONS

The management of PSARE is controversial, especially for cAVMs treated with SRS. Surgical removal is rarely needed, but-if unavoidable-it can be a valuable option in experienced hands. A careful preoperative planning is always necessary to detect pathologic blood flow through the PSARE.

Surgical treatment of anterior cranial fossa dural arterio-venous fistulas (DAVFs): a two-centre experience

BACKGROUND

Anterior cranial fossa dural arterio-venous fistulas (DAVFs) represent 6% of all intracranial DAVFs; characteristically they show an aggressive behaviour with high risk of intracranial haemorrhage. Peculiar anatomical features, such as feeding by the ethmoidal arteries and the pattern of venous drainage (frequently with varices that mimic aneurysmal dilatation), can be evaluated in detail only by digital subtraction angiography (DSA), which represents the "gold standard" in the diagnosis of such cranial fistulas. Recent technological developments in endovascular management of this type of DAVF have partially reduced the morbidity risk related to this modality of treatment. Our purpose is to present our experience in the surgical management of 14 patients with anterior cranial fossa DAVFs, with attention paid to the possible role of preoperative embolisation in these cases and to the surgical technique.

METHOD

Between 1999 and 2015, 14 patients with anterior cranial fossa DAVFs were submitted to surgery in two neurosurgical departments; the mean age was 63 years old; nine DAVFs caused intracranial haemorrhage (subarachnoid haemorrhage in three cases, intracerebral haemorrhage in six cases). Pre-operative embolisation was attempted in an early case and was successfully done in one recent case. In all patients, the surgical approach chosen was a pterional craniotomy with a low margin on the frontal bone in order to gain the exposure of the anterior cranial fossa and especially of the olphactory groove region; the resection of the falx at its insertion on the crista galli was needed in five cases in order to get access to the contralateral afferent vessels. Cauterisation of all the dural feeders on and around the lamina cribrosa was needed in all cases; venous dilatations were evident in eight patients (in seven out of nine patients with ruptured DAVF and in one out of five patients with unruptured DAVF) and were removed in all cases. One patient harboured an ophthalmic artery aneurysm, which was excluded by clipping.

RESULTS

One patient died 5 days after surgery due to the severity of the pre-operative haemorrhage. Postoperative DSA showed the disappearance of the DAVF and of the venous pseudo-aneurysms in all cases. Clinical outcome was favourable (without neurological deficits) in 11 patients; three patients presented an unfavourable clinical outcome, due to the severity of the initial haemorrhage.

CONCLUSIONS

Surgical exclusion of the anterior cranial fossa DAVFs still represents the gold standard for such lesions, due to low post-operative morbidity and to complete protection against future rebleedings; endovascular techniques may help the surgeon in complex cases.

Cell Therapy for Parkinson's Disease: A Translational Approach to Assess the Role of Local and Systemic Immunosuppression

Neural transplantation is a promising therapeutic approach for neurodegenerative diseases; however, many patients receiving intracerebral fetal allografts exhibit signs of immunization to donor antigens that could compromise the graft. In this context, we intracerebrally transplanted mesencephalic pig xenografts into primates to identify a suitable strategy to enable long-term cell survival, maturation, and differentiation. Parkinsonian primates received WT or CTLA4-Ig transgenic porcine xenografts and different durations of peripheral immunosuppression to test whether systemic plus graft-mediated local immunosuppression might avoid rejection. A striking recovery of spontaneous locomotion was observed in primates receiving systemic plus local immunosuppression for 6 mo. Recovery was associated with restoration of dopaminergic activity detected both by positron emission tomography imaging and histological examination. Local infiltration by T cells and CD80/86+ microglial cells expressing indoleamine 2,3-dioxigenase were observed only in CTLA4-Ig recipients. Results suggest that in this primate neurotransplantation model, peripheral immunosuppression is indispensable to achieve the long-term survival of porcine neuronal xenografts that is required to study the beneficial immunomodulatory effect of local blockade of T cell costimulation.

Melanoma detection in Italian pigmented lesion clinics

AIM

Accuracy in melanoma detection is important to recognize early curable melanomas and to minimize the unnecessary excision of benign lesions. The aim of this paper was to evaluate melanoma screening accuracy of Italian pigmented lesion clinics in terms of number needed to excise (NNE), melanoma thickness, and number of melanomas diagnosed during patient follow-up.

METHODS

Information on all skin tumors excised in 2011 were extracted from the databases of the participating centers. Information whether the lesion was excised at the baseline examination or during patient follow-up was recorded, as well as the overall number of patients examined in each center in 2011.

RESULTS

After e-mail solicitation, 22 of 40 centers agreed to participate. A total of 8229 excised lesions were collected. The overall number of examined patients was 86.564, thus 9.5% of screened patients had a lesion removed. Of the excised lesions, 866 were diagnosed as melanoma (1% of examined patients) and 5311 (88.9%) were melanocytic nevi. Three NNE were calculated giving values of 7.9 excised lesions to find 1 melanoma, 7.1 melanocytic lesions to find 1 melanoma, and 3.7 lesions to find 1 skin malignancy. The median melanoma thickness was 0.6 mm, with only 15.1% of melanomas ≥ 1 mm of thickness. Melanomas detected over time were 96 (11.1%; mean thickness, 0.3 mm), with 15.6% of lesions excised after short-term follow-up and 84.4% after long-term follow-up.

CONCLUSION

The NNE values comparable to those achieved in specialized clinical settings and the high number of early melanomas diagnosed at the baseline examination or during patient follow-up indicate a high level of accuracy in melanoma screening achieved by Italian pigmented lesion clinics.

Operative classification of brain arteriovenous malformation. Part two: validation

SUMMARY

The most important issue when dealing with a patient with a brain AVM is the decision whether to treat or not. Only after this decision has been made, taking into consideration a number of factors depending on both the patient and the specific type of AVM, can the best option for treatment be chosen. An operative classification of brain AVMs, previously adopted in the Department of Neuroradiology and Neurosurgery of Verona (Italy) and published in this journal, was subjected to validation in a consecutive group of 104 patients clinically followed for at least three years after completion of treatment. This classification, slightly modified from the original version concerning the importance of some specific items, allowed us to assess the indication to treat in each case, whatever type of treatment was offered to the patient.

Gamma Knife radiosurgery for cerebral arteriovenous malformations in children/adolescents and adults. Part II: Differences in obliteration rates, treatment-obliteration intervals, and prognostic factors

PURPOSE

To evaluate and compare obliteration rates (OBRs) and treatment-obliteration intervals (TOIs) for cerebral arteriovenous malformations (cAVMs) treated with Gamma Knife radiosurgery in children/adolescents and adults; and to determine factors predicting the OBR and TOI in these two populations.

METHODS AND MATERIALS

This study concerned 62 children/adolescents and 193 adults observed for > or = 3 years. Fisher exact two-tailed and Wilcoxon rank-sum tests, multiple logistics, and Cox proportional hazard models were used for statistical analysis.

RESULTS

The overall OBR was 85.5% in children/adolescents and 87.6% in adults (p = 0.671), but children/adolescents showed higher 36-month actuarial OBRs (69.35%) and shorter median TOIs (25.7 months) than adults (66.84% and 28.2 months; p = 0.006 and p = 0.017, respectively). In children/adolescents, lower Spetzler-Martin grades (p = 0.043) and younger age (p = 0.019) correlated significantly with OBRs, and lower Spetzler-Martin grades (p = 0.024) and noneloquent cAVM locations (p = 0.046) with TOIs. In adults, low flow through the cAVM and < 6.2-cm3 volume were associated with both OBR and TOI (p = 0.012 and p = 0.002, respectively).

CONCLUSIONS

The differences in OBRs within 3 years and TOIs, although slight, seem to show that pediatric cAVMs behave differently from those in adults after Gamma Knife radiosurgery.

Gamma knife radiosurgery for cerebral arteriovenous malformations in children/adolescents and adults. Part I: Differences in epidemiologic, morphologic, and clinical characteristics, permanent complications, and bleeding in the latency period

PURPOSE

To compare the epidemiologic, morphologic, and clinical characteristics of 92 children/adolescents (Group A) and 362 adults (Group B) with cerebral arteriovenous malformations (cAVMs) considered suitable for radiosurgery; to correlate radiosurgery-related permanent complication and post-radiosurgery bleeding rates in the 75 children/adolescents and 297 adults available for follow-up.

METHODS AND MATERIALS

Radiosurgery was performed with a model C 201-source Co60 Leksell Gamma Unit (Elekta Instruments, Stockholm, Sweden). Fisher exact two-tailed, Wilcoxon rank-sum, and two-sample binomial exact tests were used for statistical analysis.

RESULTS

There were significant differences between the two populations in sex (p = 0.015), clinical presentation (p = 0.001), and location (p = 0.008). The permanent complication rate was lower in younger (1.3%) than in older patients (5.4%), although the difference was not significant (p = 0.213). The postradiosurgery bleeding rate was lower in Group A (1.3%) than in Group B (2.7%) (p = 0.694), with global actuarial bleeding rates of 0.56% per year and 1.15% per year, respectively.

CONCLUSIONS

The different characteristics of child/adolescent and adult cAVMs suggest that they should be considered two distinct vascular disorders. The similar rates of radiosurgery-related complications and latency period bleeding in the two populations show that gamma knife radiosurgery does not expose young patients to a higher risk of sequelae than that for older patients.

Leksell gamma knife radiosurgery for cerebral arteriovenous malformations in pediatric patients

OBJECTS

The authors report their experience of gamma knife radiosurgery (GKR) in a large series of pediatric cerebral arteriovenous malformations (cAVMs). The advantages, risks and failures of this approach are presented and discussed.

METHODS

Gamma knife radiosurgery was performed on 63 children aged < or =16 years. Haemorrhage was the clinical onset in 50 out of 63 cases. The mean pre-GK cAVM volume was 3.8 cm(3). Fifty-eight out of 63 cAVMs were Spetzler-Martin grades I-III. Most lesions (47 out of 63) were in eloquent or deep-seated brain regions.

CONCLUSION

Gamma knife radiosurgery-related complications occurred in 2 out of 47 cases with an available follow-up (1 had transient and 1 permanent morbidity). No bleeding occurred during the latency period. In 39 children with >36-month follow-up, complete cAVM occlusion was angiographically documented in 31, with a 3- and 4-year actuarial obliteration rate of 72 and 77% respectively. High rates of complete obliteration and very low frequency of permanent morbidity with no bleeding during the latency period encourage widespread application of GKR in the treatment of pediatric cAVMs.

Idiopathic thrombocytopenic purpura treated with steroid therapy does not prevent acute myocardial infarction: a case report

We report the case of a 65-year-old man affected by idiopathic thrombocytopenic purpura, who developed an acute myocardial infarction after 2 years of steroid therapy. Thrombocytopenia was initially recognized 11 years earlier, and became severe during the past 2 years [platelets (PLTS) 10000-30000/microl]. He was treated with steroids, initially to perform a surgical procedure (prednisone 75 mg/day), subsequently to maintain a platelet count of about 50000/microl (prednisone 12.5 mg/day). After 1 year of treatment, he began to complain about exertional angina and dyspnea. His blood pressure became elevated and cholesterol level raised. The exercise electrocardiogram, previously manifesting ischaemic changes, normalized after 1 month of steroid wash-out; however, steroid therapy was reinstituted (prednisone 5 mg per day). One year later, he suffered an infero-lateral non-Q-wave myocardial infarction. It seems likely that the severe coronary atherosclerosis present in our patient developed despite a low platelet count, under the spur of a heavier risk factor profile. Steroid therapy could have had a role as a precipitating agent of the acute event, and the opportunity of alternative treatments is considered.

[The diagnostic and therapeutic procedures in pulmonary embolism: a survey in the Veneto Region]

BACKGROUND

Pulmonary embolism is one of the most frequent cardiopulmonary diseases, but it is often under- or misdiagnosed. In order to address this issue and to identify flow charts that are commonly used in pulmonary embolism diagnosis and treatment, 191 clinical wards of internal medicine, cardiology, geriatrics, pneumology and intensive care units, located in the Veneto Region, were surveyed.

METHODS

An anonymous questionnaire was mailed to each ward in order to collect clinical diagnostic information on all pulmonary embolisms which occurred during 1993. Among the returned questionnaires, 114 (59.6%) had usable information for the analysis.

RESULTS

The vast majority of participating centers reported in 1993 less than 10 pulmonary embolism events. No significant differences were observed between internal medicine, geriatrics, pneumology wards and intensive care units. The reported events, however, were slightly higher in the divisions of cardiology with an annual average of 12 events per center. First level diagnostic procedures, such as ECG, chest X-ray and arterial blood gas analysis were chosen and performed in all patients. Interestingly, Doppler echocardiography, which is often not included in official guidelines for pulmonary embolism diagnosis, was performed in 56% of the participating centers. On the contrary, ventilation-perfusion lung scanning, which is considered highly predictive in many diagnostic algorithms, was underutilized (35% perfusion scan, 20% ventilation scan). This underuse was probably due to technical and organizational difficulties. Pulmonary angiography, the most accurate procedure for the diagnosis of pulmonary embolism, was performed in 28% of the patients. During the acute phase, intravenous heparin was commonly used; 91% of patients received the infusion continuously, 4% intermittently. Thrombolysis was performed in 25% of the patients. The preferred drugs were recombinant tissue-plasminogen activator (67%), followed by urokinase (20%) and streptokinase (13%). To start thrombolytic therapy, 20% of the interviewed clinicians considered sufficient the evidence of clinical manifestations of pulmonary embolism confirmed by echocardiographic data. At discharge, prescription of oral anticoagulant drugs was common (78%) for at least 6 months (47%). Standardized procedures for the diagnosis and treatment of pulmonary embolism were already implemented in 13% of the participating centers.

CONCLUSIONS

These data suggest a common effort to define unanimous conventional protocols in the management of pulmonary embolism. It should be underlined, however, that a particular attention to the clinical manifestations and a productive collaboration among clinicians with different expertise are required to improve the diagnosis and treatment of pulmonary embolism.

Pulmonary hypertension associated with human immunodeficiency virus infection. Report of two cases and review of the literature

Recent reports have suggested a possible association between HIV-1 infection and "idiopathic" pulmonary hypertension (PH), but the pathogenetic role of the viral agent has not been fully defined yet. We report the cases of two white males positive for human immunodeficiency virus type 1 (HIV-1) who presented with clinical and hemodynamic diagnosis of pulmonary hypertension. They were heterosexual, non-hemophiliac, heroin abusers with no signs of clinical AIDS. Neither one of the patients had opportunistic lung infections or any other cause of secondary pulmonary hypertension. In one case, peculiar clinical and electrocardiographic features of PH were associated with signs of thrombotic thrombocytopenic purpura (TTP). The association between PH and HIV-1 infection might be explained by a severe alteration of pulmonary endothelial cell homeostasis secondary to HIV-1 viral infection.

Carboplatin and teniposide concurrent with radiotherapy in patients with glioblastoma multiforme: a phase II study

BACKGROUND

The outcome after treatment for glioblastoma remains poor. Therefore, the authors evaluated the long term efficacy and toxicity of treatment with radiotherapy and concurrent carboplatin plus teniposide followed by three cycles of carmustine in patients who underwent resection for glioblastoma.

METHODS

Fifty-six newly diagnosed patients with glioblastoma underwent radiotherapy (1.8-2 gray [Gy]/day, 5 days a week using limited fields up to 60 Gy), and concurrent chemotherapy with carboplatin (350 mg/m2) on Days 1, 22, and 43, and teniposide (50 mg/m2) on Days 1, 2, 3, 22, 23, 24, 43, 44, and 45. Four weeks after the end of radiotherapy, patients were given carmustine (200 mg/m2) every 8 weeks for 3 cycles. Treatment then was suspended, but if disease progression was found, treatment was resumed using different drugs.

RESULTS

All 56 patients were evaluated for time to progression (TTP) and median survival time (MST). The TTP was 7.5 months and the MST was 12.5 months. Toxicity manifested as thrombocytopenia and in most cases was acceptable. Four patients (7.1%) had radiation necrosis at 2, 2, 7, and 9 months, respectively, from the end of radiotherapy.

CONCLUSIONS

The results obtained in the current study with concurrent radiochemotherapy in patients with glioblastoma are comparable to the best results reported using radiotherapy alone followed by chemotherapy with nitrosoureas.

Unusual nasal and orbital involvement of glioblastoma multiforme: a case report and review of the literature

We describe a case of glioblastoma treated with chemoradiotherapy that spread to the dura mater with direct invasion of the skull base, protrusion into the homolateral nasal fossa, and penetrated of the frontal sinus, the orbital wall and the ethmoidal sinuses. Only eight cases of glioblastoma showing this development have been described in the literature; one of these, however, had a sarcomatous component which was absent in our case.

Endovascular treatment of pial AVMs: technical options, indications and limits in pediatric age patients

Our study group consisted of 29 patients who underwent endovascular treatment for the presence of pial AVMs. The patients were treated with various embolization methods including "-free flow" embolization (2 cases); embolization with suture threads (2 mm long micro-emboli: 17 cases) and embolization with acrylic glue (10 cases). There were significant angio-architectural and AVM location differences between the pediatric and the adult patient groups. In pediatric patients, the more frequent AVMs were of the mono or few-pedunculated type, then simple direct fistulas and high-flow fistulous-plexiform AVMs and giant infra-tentorial or deep-seated malformations. In mono or few-pedunculated AVMs, the elected treatment was acrylic glue followed by radio-surgery achieving definitive cure in 3 cases. In direct AVFs and elevated flow AVMs, embolization with suture and acrylic glue offered definitive results. Treatment for infra-tentorial and deep-seated AVMs presented the greatest difficulty in pediatric patients. In two of them, embolization with glue enabled radiosurgery (giant cerebellar AVMs). Our experience did not confirm that current endovascular techniques provide definitive treatment in extensive, deep-seated AVMs. Each treatment, in children more so than in adults, requires a risk/benefit evaluation of the method taking into account the natural history data.

Incidence of risk of thromboembolism during treatment high-grade gliomas: a prospective study

A prospective study of a series of 77 patients on adjuvant radiochemotherapy following surgery for high-grade gliomas was conducted to evaluate the risk of deep vein thrombosis and identify risk factors. We found a 20.8% risk of deep vein thrombosis at 12 months (standard error = 4.8%) and a 31.7% risk (standard error = 7.4%) at 24 months (Kaplan-Meier method). Twenty patients (26%) developed deep vein thrombosis with a maximum incidence within the first 7 months after surgery when chemotherapy was still being administered, often with corticosteroids. The risk factors identified were histology (glioblastoma versus anaplastic astrocytoma, P = 0.032, log rank test; 0.0485 L-ratio) and the presence of paresis (P = 0.010, log rank test; 0.0161 L-ratio). A borderline tendency was found for an association between the deep vein thrombosis site and the side of paresis (P = 0.103, Fisher's exact test). Four patients (5%) had massive pulmonary embolism, which was fatal in 3 (4%).

Phase II trial with BCNU plus alpha-interferon in patients with recurrent high-grade gliomas

A Phase II study with a combination of BCNU and alpha-interferon (IFN) was conducted in patients with high-grade glioma recurrent after surgery and radiation treatment in order to investigate tumor control and toxicity. Twenty-one non-chemotherapy pretreated patients were administered 6 MU alpha-IFN in a 2-h infusion followed by 150 mg/m2 BCNU i.v. on day 1. Three MU alpha-IFN were subsequently administered subcutaneously on alternating days three times a week, until recycling of the whole procedure on day 42. Among 21 patients, partial remission was obtained in 7 (33%; 95% CI = 15-57) and stable disease in 6 (29%; CI = 11-52); overall Kaplan-Meier median time to progression (TTP) was 4.5 months (CI = 4-9) and the overall median survival time (MST) was 7 months (CI = 5-13). In patients who underwent surgical redebulking prior to chemotherapy, TTP and MST were 9 (CI = 7-14) and 15 months (CI = 11.0-39.0); in patients who were not operated on again before chemotherapy, these values were 4 (CI = 2-5; log rank test, p = 0.0026) and 5.5 months (CI = 4-7; log rank test, p = 0.0012) respectively. The results of this regimen in relapsing patients, especially following surgical redebulking, are encouraging; toxicity is acceptable, and further studies on combined alpha-IFN and multiple-agent chemotherapy are warranted.

Early chemotherapy and concurrent radio-chemotherapy in high grade glioma

PURPOSE

The poor results from treatment of high grade glioma prompted us to explore new protocols involving concurrent radio-chemotherapy. Our primary objective was to evaluate the feasibility of very early postoperative chemotherapy with BCNU, concurrent radio-chemotherapy with carboplatin and teniposide, and post-radiotherapy BCNU. Our secondary objectives were to evaluate time to progression, and overall survival.

PATIENTS AND METHODS

We treated 24 newly diagnosed patients (pts) with BCNU 150 mg/m2 seven days after surgery. Thirty days later, we started radiotherapy, 1.8 to 2 Gy/day for 5 days a week on limited fields up to 60 Gy, and concurrent chemotherapy with carboplatin 250 mg/m2 on days 1, 22, and 43, and teniposide 50 mg/m2 on days 1, 2, 3, 22, 23, 24, 43, 44 and 45. Two cycles of 150 mg/m2 BCNU were then given at 30 and 70 days, respectively, after the end of the radio-chemotherapy course. Therapy was then suspended, but if disease progression was evident, treatment was resumed with drugs that had not been previously employed. Surgical reintervention was not routinely considered.

RESULTS

Following radio-chemotherapy treatment in the 24 pts evaluable for response, we observed partial remissions in 8 cases (33%) and stable disease in 12 (50%). Actuarial estimates of progression free survival (PFS) were 33 weeks, with 56 wks for anaplastic astrocytoma and 31 weeks for glioblastoma. Median survival time (MST) of all pts was 58 weeks; 51 weeks for glioblastoma and was not reached for anaplastic astrocytoma. This regimen was feasible. Of 144 planned cycles, 139 were delivered, and among these only in 13 and 9 cycles the doses were reduced by 75 and 50%, respectively. We did not observe any gastrointestinal toxicity. Grade 2 hematological toxicity occurred in 25% of pts. grade 3 in 4% and neurological toxicity in 3% of the pts during BCNU delivery, probably due to a sharp increase in intracranial pressure.

CONCLUSION

Early chemotherapy, concurrent chemo-radiotherapy and brief post-radio-therapy chemotherapy are feasible and well tolerated. The objective response and disease stabilization rates appear similar to previous experiences.

Shape recovery and volume calculation from biplane angiography in the stereotactic radiosurgical treatment of arteriovenous malformations

PURPOSE

A model for calculating the three-dimensional volume of arteriovenous malformations from biplane angiography.

METHODS AND MATERIAL

Three-dimensional (3D) volume reconstruction is easily feasible with axial, coronal, or sagittal computer tomography (CT) and nuclear magnetic resonance (NMR) scans. On the other hand, radiosurgical treatment of arteriovenous malformations (AVM) is exclusively based on two orthogonal stereotactic projections, obtained with angiographic procedures. Most commonly, AVM volumes have been calculated by assimilating the nidus volume to a prolate ellipsoid. We present an algorithm dedicated to 3D structure reconstruction starting from two orthogonal stereotactic projections. This has been achieved using a heuristic approach, which has been widely adopted in the artificial intelligence domain.

RESULTS

Tests on phantom of different complexity have shown excellent results.

CONCLUSION

The importance of the algorithm is considerable. As a matter of fact: (a) it allows calculations of complex structures far away from regular ellipsoid; (b) it permits shape recovery; (c) it provides AVM visualization on axial planes.

Follow up after spontaneous coronary artery dissection: a report of five cases

Five cases of spontaneous coronary artery dissection (SCAD) are reported, three in women and two in men (mean age 44 years; range 28-65), all of whom suffered a myocardial infarction. Common risk factors for coronary artery disease were present in the two men; in the female group one patient was taking an oral contraceptive, one was in the postpartum period, and the third was a smoker. Only the three women received intravenous alteplase and their ejection fraction was normal; both men had impaired left ventricular function. Two patients had SCAD of the left anterior descending coronary artery and three of the right coronary artery. Only the two men had angiographic features of coronary atherosclerotic involvement. No patients required surgical revascularisation or percutaneous transluminal coronary angioplasty. At a mean follow up of 27 months (range 6 to 40) all patients were alive and all but one were asymptomatic.

Risk factors for cerebral glioma in adults: a case-control study in an Italian population

A case-control study on risk factors for cerebral tumors was conducted on an adult Italian population by the four Neurosurgical Departments of the Veneto Region, i.e. Padua, Treviso, Verona and Vicenza. The study recruited 195 cases of histologically-confirmed cerebral glioma. One hospital control was selected for each case. Cases and controls were matched for age, sex, data of hospitalization and residence. Information on both cases and controls was obtained from a relative. Uninvolved interviewers administered a structured questionnaire including items on the subject's education, occupation, lifestyle, medical history, exposure to radiation for diagnosis or therapy, head trauma and blood group and the medical history of family members. The series of cerebral tumors was first considered as an indistinct set: none of the risk factors examined showed a statistically significant association. A positive association was found with blood group A (OR = 6) when low-grade astrocytomas (n = 41) were considered separately. As for the malignant astrocytomas (n = 132), there was a suggestive but not statistically significant association with the presence of CNS tumors among first- and second-degree relatives (OR = 7.0). On the whole, this study yielded no clear and meaningful association for the various risk factors analyzed.

Ear disease is not a common complication in cystic fibrosis

Although upper respiratory tract involvement is a common finding in cystic fibrosis (CF), there is no agreement on whether hearing is affected in these patients. We studied 75 CF subjects and 50 healthy age-matched children with the same audiological protocol. An original scoring system was used to quantify the degree of hearing involvement (normal, mild, moderate and severe) in each subject. Prevalence of ear involvement in children with CF was similar to that in age-matched control subjects (25.4% and 18% respectively, P > 0.05). Ear disease in CF was not related to pulmonary disease, radiological sinusitis, nasal polyposis, or use of parenteral aminoglycosides. These data showed that the risk of ear disease in CF was not increased even if patients with severe audiological involvement were described only in the CF group.

The contribution of ultrasonography and computed tomography in the diagnosis of nonfunctioning islet cell tumors of the pancreas

The personal series of 12 nonfunctioning islet cell tumors (NFIT) of the pancreas is reported. The ultrasound and computed tomography features of NFIT are analyzed, and a few signs are identified that may be useful in the differential diagnosis vs ductal carcinoma. The necessity to complete the diagnostic work up by means of fine needle aspiration biopsy and cytologic smears is also emphasized.

Radiation-associated cerebral gliomas. A report of two cases and review of the literature

Two cases are reported in which a cerebral glioma developed after radiation therapy for a different primary tumor. The first case was a boy, who presented a right thalamic anaplastic astrocytoma 7 years after irradiation for a left temporal polymorphic cell sarcoma. The second case was a woman, with a right temporal anaplastic astrocytoma occurring 8 years after irradiation for a GH-secreting pituitary adenoma. Thirty-five other cases of radiation-associated cerebral gliomas had already been reported in the literature. The possible causal role of radiation therapy in inducing cerebral gliomas is discussed on the basis of these observations.

[Post-infarct rupture of the interventricular septum. 2-dimensional, continuous Doppler, pulsed and color-coded echocardiographic evaluation]

Rupture of the interventricular septum is an infrequent but always serious complication of acute myocardial infarction. It requires accurate timely diagnosis to decide the proper treatment and eventual surgical intervention. Echo-color-Doppler-cardiography appears to have such diagnostic capacities. In a total of 403 pts, with acute myocardial infarction we found 7 pts (1.7%) with suspected interventricular septum rupture; 5 with infero-posterior infarction and 2 with an anterior one. In 4 pts shock and death occurred rapidly, 2 pts were submitted to angiography and then to surgery with a good outcome, 1 pt died immediately after surgical repair. Echocardiographic findings were: 1) by 2-D (7 pts), direct visualization of septal rupture in 5/7, all with infero-posterior infarctions; 2) by pulsed wave Doppler (5 pts), detection of a typical systolic turbulence on the right septum in 5/5 pts, 3 with infero-posterior myocardial infarction, 2 with an anterior one; 3) by color Doppler (3 pts), detection of a "mosaic" color-jet expanding into the right ventricle in 3/3 pts, 2 with an anterior and 1 with an infero-posterior myocardial infarction. This technique immediately located two small ruptures which had not been easily detected by pulsed Doppler alone. In conclusion, echocolordopplercardiography appears to be a reliable method for the detection of ventricular septal rupture after myocardial infarction in so timely and accurately a manner as to rule out more aggressive procedures, angiography and surgery.

Distribution of amiodarone and desethylamiodarone in a patient with acute myocardial infarction after intravenous administration

The autopsy tissues concentration of amiodarone and desethylamiodarone of a man with acute myocardial infarction treated acutely with intravenous amiodarone is reported. Our data indicate that amiodarone is quickly distributed into all highly perfused tissues after intravenous administration with a high amiodarone/desethylamiodarone ratio. We also report here the autopsy case of a woman who died after 30 days of oral therapy with amiodarone. The increase in heart/plasma ratio of amiodarone and desethylamiodarone concentrations and the decrease in amiodarone/desethylamiodarone ratio after one month of therapy could explain the latency in the antiarrhythmic action of the drug.

Amiodarone and desethylamiodarone distribution in the atrium and adipose tissue of patients undergoing short- and long-term treatment with amiodarone

The time to onset of action of amiodarone is often long in patients treated for arrhythmias; one reason might be a slow entry of the drug into the target organ, the heart. Amiodarone and desethylamiodarone, its active metabolite, were measured in the plasma, atrial tissue and pericardial fat of patients undergoing cardiac surgery. Two groups were studied: patients treated with amiodarone for less than 28 days (short-term group) and those treated for 28 days or more (long-term group). Plasma levels of amiodarone in the two groups were not different, whereas levels of desethylamiodarone were significantly higher in the long-term group. Average concentrations of amiodarone in the atrium were higher with longer treatment periods (30.2 +/- 5.6 versus 13.2 +/- 2.5 micrograms/g wet weight of tissue); the same was true for desethylamiodarone (40.3 +/- 7.7 versus 15.7 +/- 3.7 micrograms/g). Amiodarone concentrations in fat were also significantly higher in the long-term than in the short-term group. Atrium/plasma concentration ratios of desethylamiodarone were higher than those of amiodarone, whereas fat plasma concentration ratios of desethylamiodarone were lower. In conclusion, the equilibration of amiodarone and desethylamiodarone concentrations between myocardium and plasma appears to occur slowly in patients undergoing long-term treatment with amiodarone.(ABSTRACT TRUNCATED AT 250 WORDS)

Severe head injury in children: early prognosis and outcome

The outcome is reported in 62 children with severe head injuries following a road traffic accident. All patients were comatose for at least 6 h; all patients were graded using the Glasgow Coma Score (GCS) or the Children Coma Score (CCS). Fifty-four patients were comatose immediately after injury, 8 after a lucid interval. Thirty patients had isolated head injuries and 32 had associated injuries, either long bone fractures or rupture of an abdominal organ. Additional information concerning main brainstem reflexes, posture and respiration was included in the study. The overall mortality was 32%. The goal of the study was to identify those clinical features available soon after injury which are important indicators of treatment and outcome.

The acromegaly--gigantism syndrome. Report of four cases treated surgically

Four cases of growth-hormone-secreting pituitary adenoma, with associated aspects of acromegaly and gigantism, are reported in patients aged 12-26. All of the patients had macroadenomas and were treated surgically, three by the transsphenoidal approach and one with a transfrontal craniotomy. Histologic examination revealed eosinophilic adenomas in three of the cases and a mixed eosinophilic--chromophobe adenoma in one, all with cellular irregularities (mitosis and cellular and nuclear polymorphism), local invasivity, or both. Because surgical treatment did not produce complete normalization of growth hormone levels, radiotherapy followed the operations in all four cases. In our opinion, the treatment of acromegalic gigantism poses more therapeutic problems than that of simple acromegaly, with combined treatment (surgical, radiation, and medical) often being necessary.

[Benign intracranial hypertension in infants]

B.I.H. or Pseudotumor is rare in children particularly under the first year of age. In addition, the syndrome at this age presents some peculiarities as compared with the adult form. This report describes the authors' experience with patients aged 4 to 12 months. Bulging fontanelle was the presenting symptom in all. Papilledema, strabismus, were present only in 1 case and vomiting in 4. Treatment was limited to lumbar puncture which was initially performed to rule out an acute CSN inflammatory process. In 8 patients the syndrome was precipitated by medications (sulfenazone - nalidixic acid); 3 had a prior history of 3 days of fever and roseola infantum, in 2 cases precipitanting factors were not found. Since the prompt remission of the intracranial hypertension (24 to 96 hours) neuroradiological investigations were not performed.

[A rare complication of ventriculo-peritoneal shunt: intracranial migration of the derivative system]

Two cases of intracranial migration of ventriculo-peritoneal shunt are described. The Authors discussed the possible pathogenesis and the surgical techniques required to prevent this rare complication.

Traumatic posterior fossa haemorrhage in children

We report ten cases of post-traumatic posterior fossa haemorrhage occurring in children. All patients were studied by CT scan. Five had an intracerebellar haemorrhage, three a brain stem haemorrhage, and two an extradural haematoma. In four cases we have found the coexistence of supratentorial and infratentorial haemorrhagic lesions. The incidence of posterior fossa haemorrhage in children, the importance of linear occipital fracture, the clinical course, the conservative or surgical treatment, and the prognosis are discussed.

Cervical rib syndrome: a neurosurgical experience with a series of 38 cases

A series of 38 patients with thoracic outlet syndrome caused by a cervical rib is reviewed after a postoperative follow-up period of 3 to 24 years. The outcome of the operation (anterior scalenotomy and partial to subtotal removal of the cervical rib) is not considered wholly satisfactory; three causes for this were identified: excessive duration of symptoms (mean almost 6 years), insufficient patient work-up and inadequacy of the incomplete removal of the cervical rib. In the presence of a cervical rib, other possible causes of compression of the neurovascular supply to the upper limb should always be considered.

Opto-chiasmatic arachnoiditis: a review of traditional neuroradiological diagnosis (82 cases, 1951--1976)

A retrospective appraisal of traditional neuroradiological techniques (such as direct röntgenograms, cerebral angiography RISA-cisternography, and pneumo-cisterno-encephalography, as opposed to the "new" technique of computer-assisted tomography) was carried out in a series of 82 cases of opto-chiasmatic arachnoiditis, all surgically verified. It is concluded that none of these examinations can provide a reliable diagnosis of opto-chiasmatic arachnoiditis, which preoperatively can only be a tentative diagnosis that becomes final only when confirmed by surgical findings. In the presence of certain progressive neuro-ophthalmological symptoms and signs, a negative neuro-radiological investigation should not deter the neurosurgeon from exploring the chiasmatic region. Computer-assisted tomography, of which the authors have no personal experience in these cases, may hold the future answer to the diagnostic problem.

Cystic suprasellar and retrosellar arachnoiditis: a clinical and pathologic follow-up case report

A patient, previously operated upon for a supra-and retrosellar arachnoid cyst, had again to undergo surgery for a recurrence and died in the early postoperative course. The gross and microscopic pathologic evidence obtained through necropsy is described: it seems to confirm the inflammatory nature of the arachnoid cyst, thus legitimating the term cystic optochiasmatic arachnoiditis used for the description of the same case in a previous report.