Brain arteriovenous malformations and seizures: an Italian study.

OBJECTIVE: To evaluate seizures as first clinical manifestation of brain arteriovenous malformations (AVMs), in relation to angioarchitectural features of these vascular anomalies. METHODS: We performed a prospective observational study, collecting records of patients with AVMs consecutively admitted to the Neurological and Neurosurgery Units of Perugia University and to the Neurosurgery Unit of Terni Hospital, during a 10-year period (1 January 2002 to 1 June 2012). Two groups of patients, with or without seizures as AVM first presentation, were analysed to identify differences in demographic and angiographic features. A multivariate logistic regression model was also developed. RESULTS: We examined 101 patients with AVMs, 55 male and 46 female. Seizures were the initial clinical manifestation in 31 (30.7%) patients. We found a significant difference (p<0.05) between two groups of patients, with or without seizures as AVM first presentation concerning location, side, topography and venous drainage. A multivariate logistic regression model showed that clinical presentation with seizures was correlated with a location in the temporal and frontal lobes, and with a superficial topography. The strongest association (OR 3.48; 95% CI 1.77 to 6.85) was observed between seizures and AVM location in the temporal lobe. CONCLUSIONS: Vascular remodelling and haemodynamic changes of AVMs might create conditions for epileptogenesis. However, here we show that malformations with specific angiographic characteristics are more likely to be associated with seizures as first clinical presentation. Location is the most important feature related to epilepsy and in particular the temporal lobe might play a crucial role in the occurrence of seizure.

Prospective randomized comparison of ultrasound-guided and neurostimulation techniques for continuous interscalene brachial plexus block in patients undergoing coracoacromial ligament repair.

BACKGROUND: There are few data comparing the onset time of interscalene brachial plexus block performed using ultrasound (US) guidance or nerve stimulation (NS) technique for elective coracoacromial ligament repair. METHODS: Fifty ASA I-III patients were randomly allocated to receive a continuous interscalene brachial plexus block with 20 ml of 1% ropivacaine with either NS or US guidance. The time of block performance, number of skin punctures and needle redirections, inadvertent vascular punctures, and procedure-related pain scores were recorded. The onsets of sensory and motor blocks in the distribution of radial, axillary, and musculocutaneous nerves were blindly assessed every 5 min until 30 min from the end of local anaesthetic (LA) injection. Intraoperative fentanyl, general anaesthesia (GA) requirements, postoperative pain scores, LA consumption, and patients' requirements for subcutaneous morphine during the first 24 h were compared. RESULTS: Block onset times were similar. The time to complete the block and the number of skin punctures and vascular punctures were significantly lower in Group US. There were no differences in needle redirections, incidence of paraesthesiae, intraoperative fentanyl consumption, and requirements for GA or postoperative morphine. The US group required significantly less LA only at 16 h after surgery and had lower pain scores at rest at 24 h after surgery. CONCLUSIONS: Block onset times and success rate were similar whether NS or US was used, although US guidance allowed shorter procedural times, fewer needle punctures, and fewer vascular punctures.

Ultrasound vs nerve stimulation multiple injection technique for posterior popliteal sciatic nerve block.

In this prospective, randomised, observer-blinded study we evaluated whether ultrasound guidance can shorten the onset time of popliteal sciatic nerve block as compared to nerve stimulation with a multiple injection technique. Forty-four ASA I-III patients undergoing posterior popliteal sciatic nerve block with 20 ml of 0.75% ropivacaine were randomly allocated to nerve stimulation or ultrasound guided nerve block. A blinded observer recorded onset of sensory and motor blocks, success rates, the need for fentanyl intra-operatively, the requirement for general anaesthesia, procedure-related pain, patient satisfaction and side-effects. Onset times for sensory and motor blocks were comparable. The success rate was 100% for ultrasound guided vs 82% for nerve stimulation (p = 0.116). Ultrasound guidance reduced needle redirections (p = 0.01), were associated with less procedural pain (p = 0.002) and required less time to perform (p = 0.002). Ultrasound guidance reduced the time needed for block performance and procedural pain.

[Congenital arterio-venous coronary fistula associated with patent ductus arteriousus: description of a clinical case and review of the literature]. / Fistola artero-venosa coronarica congenita associata a dotto arterioso pervio: descrizione di un caso clinico e revisione della letteratura.

Congenital coronary artery fistulae are rare anomalies (0.27-0.4% of all congenital heart defects) and consist of a communication between a coronary artery and a cardiac chamber, a great artery or the superior vena cava. The association of these congenital anomalies with other congenital cardiovascular defects is unusual. The purpose of this paper is to report a case of congenital coronary fistula between the anterior descending coronary artery and the pulmonary artery associated with patent ductus arteriosus and to review the literature on the subject.

Nimodipine in acute ischemic stroke: a double-blind controlled study.

Nimodipine (BAY e 9736), a new dihydropyridine derivative, has been shown to reduce neurological deficits and mortality induced by acute cerebral ischemia in experimental studies. We investigated the effects of this calcium antagonist in patients with acute ischemic stroke through a randomized, double-blind, parallel-designed trial in which nimodipine was compared with placebo. Forty-one of 54 screened cases were found to fulfil the inclusion criteria (sudden occurrence of a focal neurological deficit secondary to an acute ischemic event in the carotid area diagnosed after a complete neurological work-up) and entered the study. Nineteen of them were treated with nimodipine (40 mg t.i.d. administered for 28 days) and the remaining 22 with placebo, given in identical tablets. In all patients the treatment started within 12 h after the onset of the symptoms. Course and intensity of the neurological deficit were evaluated by the Mathew Scale (slightly modified). Forty patients concluded the trial. Nimodipine was withdrawn in one case following the occurrence of a skin rash whose causative relation with the test drug could not be clarified. Altogether, however, nimodipine was well tolerated and no severe cardiovascular adverse reactions were observed. In terms of efficacy, the scores obtained by the Mathew Scale showed a higher rate of improvement on nimodipine than on placebo, thus indicating that patients receiving the latter drug did not fare as well as those receiving the test medication. Our data suggest that nimodipine may be beneficial in the treatment of acute stroke.

[The Italian Group for the Study of Streptokinase in Myocardial Infarct: Echocardiographic study]. / G.I.S.S.I.: Studio ecocardiografico.

Seventeen of the centres participating to the G.I.S.S.I. trial performed also, before discharge from the Hospital, an echocardiographic examination of patients (pts) included in the study. 561 pts were included, 280 assigned to the streptokinase (SK) treatment, and 281 to the control (CT) group. The echocardiographic asynergic area score index was lower in the SK pts than in the CT group (p less than 0.01). The difference was more evident in pts treated within 6 hours from the onset of symptoms (p less than 0.005), in pts without previous infarct (p less than 0.005), and in pts aged over 65 (p less than 0.005). The end diastolic (EDV) and the end-systolic (ESV) volumes were lower in SK pts (p less than 0.01 and p less than 0.025 respectively) than in the CT group; the ejection fraction (EF) did not differ. The reduction of EDV and ESV was more evident in pts treated within 6 hours, in pts without previous infarct, in pts aged over 65, and in anterior infarcts. At the 6-month follow-up examination, in SK pts the asynergic area score index, the EDV, the ESV and the EF were unmodified; in CT pts, on the contrary, the EDV and the ESV were significantly increased (p less than 0.05 and p less than 0.025 respectively).