Stroke units could be a valid alternative to intensive care units for patients with low-grade aneurysmal subarachnoid haemorrhage.

BACKGROUND AND PURPOSE: According to current guidelines, patients with aneurysmal subarachnoid haemorrhage (aSAH) are mostly managed in intensive care units (ICUs) regardless of baseline severity. We aimed to assess the prognostic and economic implications of initial admission of patients with low-grade aSAH into a stroke unit (SU) compared to initial ICU admission. METHODS: We reviewed prospectively registered data from consecutive aSAH patients with a World Federation of Neurosurgery Societies grade <3, admitted to our Comprehensive Stroke Centre between April 2013 and September 2018. Clinical and radiological baseline traits, in-hospital complications, length of stay (LOS) and poor outcome at 90 days (modified Rankin Scale score > 2) were compared between the ICU and SU groups in the whole population and in a propensity-score-matched cohort. RESULTS: Of 131 patients, 74 (56%) were initially admitted to the ICU and 57 (44%) to the SU. In-hospital complication rates were similar in the ICU and SU groups and included rebleeding (10% vs. 7%; P = 0.757), angiographic vasospasm (61% vs. 60%; P = 0.893), delayed cerebral ischaemia (12% vs. 12%; P = 0.984), pneumonia (6% vs. 4%; P = 0.697) and death (10% vs. 5%; P = 0.512). LOS did not differ between groups (median [interquartile range] 22 [16-30] vs. 19 [14-26] days; P = 0.160). In adjusted multivariate models, the location of initial admission was not associated with long-term poor outcome either in the whole population (odds ratio [OR] 1.16, 95% confidence interval [CI] 0.32-4.19; P = 0.825) or in the matched cohort (OR 0.98, 95% CI 0.24-4.06; P = 0.974). CONCLUSIONS: A dedicated SU, with care from a multidisciplinary team, might be an optimal alternative to ICU for initial admission of patients with low-risk aSAH.

Synthetic MRI in subarachnoid haemorrhage.

AIM: To evaluate the reliability of synthetic magnetic resonance imaging (SyMRI) for detecting complications associated with subarachnoid haemorrhage (SAH), such as ischaemic lesions, hydrocephalus, or bleeding complications. MATERIALS AND METHODS: Twenty patients with SAH, who underwent a conventional brain MRI and a SyMRI on a 3 T MRI machine. Comparable conventional and synthetic T2-weighted fluid attenuated inversion recovery (FLAIR) images were acquired. The presence of ischaemic lesions, hydrocephalus, extra-axial blood collections as well as the volumes of grey matter (GMv), white matter (WMv), and cerebrospinal (CSFv) were compared. The acquisition times of both sequences was also analysed. RESULTS: The concordance between the two techniques was excellent for the detection of ischaemic lesions and extra-axial collections (kappa = 0.80 and 0.88 respectively) and good for the detection of hydrocephalus (kappa = 0.69). No significant differences were detected in the number of ischaemic lesions (p=0.31) or in the Evans index (p=0.11). The WMv and CSFv measures were also similar (p=0.18 and p=0.94, respectively), as well as the volume of ischaemic lesions (p=0.79). Compared to conventional MRI, the SyMRI acquisition time was shorter regardless of the number of sections (32% and 6% time reduction for 4 or 3 mm section thickness, respectively). CONCLUSIONS: SyMRI allows the detection of potential complications of SAH in a similar way to conventional MRI with a shorter acquisition time.

Endoscopic endonasal surgery to treat intrinsic brainstem lesions: correlation between anatomy and surgery.

OBJECTIVE: The endoscopic endonasal approach (EEA) has been proposed as an alternative in the surgical removal of ventral brainstem lesions. However, the feasibility and limitations of this approach to treat such pathologies are still poorly understood. This study aimed to report our experience in five consecutive cases of intrinsic brainstem lesions that were managed via an EEA, as well as the specific anatomy of each case. METHODS: All patients were treated in a single center by a multidisciplinary surgical team between 2015 and 2019. Before surgery, a dedicated anatomical analysis of the brainstem safe entry zone was performed, and proper surgical planning was carried out. Neurophysiological monitoring was used in all cases. Anatomical dissections were performed in three human cadaveric heads using 0° and 30° endoscopes, and specific 3D reconstructions were executed using Amira 3D software. RESULTS: All lesions were located at the level of the ventral brainstem. Specifically, one mesencephalic cavernoma, two pontine ca- vernomas, one pontine gliomas, and one medullary diffuse midline glioma were reported. Cerebrospinal fluid leak was the major complication that occurred in one case (medullary diffuse midline glioma). From an anatomical standpoint, three main safe entry zones were used, namely the anterior mesencephalic zone (AMZ), the peritrigeminal zone (PTZ, used in two cases), and the olivar zone (OZ). Reviewing the literature, 17 cases of various brainstem lesions treated using an EEA were found. CONCLUSIONS: To our knowledge, this was the first preliminary clinical series of intrinsic brainstem lesions treated via an EEA presented in the literature. The EEA can be considered a valid surgical alternative to traditional transcranial approaches to treat selected intra-axial brainstem lesions located at the level of the ventral brainstem. To achieve good results, surgery must involve comprehensive anatomical knowledge, meticulous preoperative surgical planning, and intraoperative neurophysiological moni- toring.

[Causes of hospital mortality due to brain haemorrhage in patients with arteriovenous malformation]. / Causas de la mortalidad hospitalaria por hemorragia cerebral en pacientes con malformacion arteriovenosa.

AIM: To determine the causes of mortality in cases of brain haemorrhage among patients with arteriovenous malformations (AVM) treated in a tertiary hospital. PATIENTS AND METHODS: The patients with AVM who died over the period 1990-2014 were selected from a prospective register of vascular malformations. Demographic aspects, localisation of the AVM, associated aneurysms and previous treatments were reviewed. Three main causes of death were established: initial bleeding/rebleeding, those related with the treatment of the AVM and other causes not related with AVM. RESULTS: A total of 400 patients were treated for AVM, 216 (54%) with a ruptured AVM, of whom 26 (12.1%) died as a result of a brain haemorrhage. The mean age of the group of patients who died was 48.8 years (range: 8-78 years). Twenty (76.9%) were admitted in coma (Glasgow Coma Scale < 9). In five cases (19.2%), bleeding was due to an associated aneurysm. A very high percentage (38.5%) had the AVM in the posterior fossa. Three patients had previously received non-curative treatments for the AVM in other medical centres. Of the total number, six (23.1%) received endovascular/surgical treatment in our hospital, and we have assumed that, due to the indication or owing to the time in which it was carried out, the cause of death was treatment-related, although two young patients underwent surgery with bilateral mydriasis. One patient died due to an associated glioblastoma, and the others, 19 (76%), due to rebleeding or to the initial brain damage. CONCLUSION: Knowing the causes of mortality can help improve the clinical outcome, above all in cases in which an early treatment could be indicated.

TITLE: Causas de la mortalidad hospitalaria por hemorragia cerebral en pacientes con malformacion arteriovenosa.Objetivo. Conocer las causas de la mortalidad en la hemorragia cerebral de los pacientes con malformaciones arteriovenosas (MAV) tratadas en un hospital terciario. Pacientes y metodos. De un registro prospectivo de malformaciones vasculares se han seleccionado los pacientes que fallecieron con MAV en el periodo 1990-2014. Se han revisado aspectos demograficos, localizacion de la MAV, aneurismas asociados y tratamientos previos. Se han establecido tres causas principales de muerte: sangrado inicial/resangrado, relacionadas con el tratamiento de la MAV y otras causas no relacionadas con la MAV. Resultados. Se trato a 400 pacientes de MAV, 216 (54%) con MAV rotas, de los que fallecieron 26 (12,1%) por hemorragia cerebral. La media de edad del grupo de pacientes fallecidos fue de 48,8 años (rango: 8-78 años). Veinte (76,9%) ingresaron en coma (escala de coma de Glasgow < 9). En cinco casos (19,2%), el sangrado se debio a un aneurisma asociado. Un porcentaje muy elevado (38,5%) tenia la MAV en la fosa posterior. Tres pacientes habian recibido previamente en otros centros tratamientos no curativos de la MAV. Del total, seis (23,1%) recibieron tratamiento endovascular/quirurgico en nuestro hospital, y hemos asumido que, por la indicacion o por el momento en que se realizo, la causa de la muerte se relacionaba con el tratamiento, aunque dos pacientes jovenes se operaron con midriasis bilateral. Un paciente fallecio por un glioblastoma asociado, y el resto, 19 (76%), por el resangrado o el daño cerebral inicial. Conclusion. El conocimiento de las causas de mortalidad puede contribuir a mejorar el resultado clinico, sobre todo en los casos en que podria estar indicado un tratamiento precoz.

Epilepsy in patients with malignant middle cerebral artery infarcts and decompressive craniectomies.

UNLABELLED: Patients with malignant middle cerebral artery (MCA) infarctions who have undergone craniectomy are susceptible to the development of vascular epilepsy. Our objective was to study the factors that might influence the occurrence of seizures in this group of patients. MATERIALS AND METHODS: All patients who developed malignant MCA infarction and had undergone decompressive craniectomy in our center between November 2002 and January 2014 were evaluated. In the subsequent follow-up, we evaluated the clinical outcomes and attempted to identify the factors that were related to the occurrence of seizures. RESULTS: We evaluated a total of 80 patients. The median time at which the craniectomy was performed was 40.5h after the stroke. Seizures occurred in 47.5% of all patients. The mortality rate within the first week was 16%, and of those who survived 53.7% developed seizures; 9% of these seizures were acute symptomatic, and 44.8% were remote. The median onset of remote seizures was seven months, and the majority of these were motor seizures with generalization. Notably, the patients with seizures exhibited longer delays from stroke to craniectomy, greater involvements of the temporal lobe and a higher rate of post-craniectomy recanalization of the occluded artery. Regarding the timing of the surgeries, a significantly greater proportion of those who underwent surgery more than 42h after the stroke developed epilepsy (p=0.004). Logistic regression revealed that only prolonged delay (>42h) independently predicted the development of epilepsy (OR 5.166; IC 95% 1.451-18.389; p=0.011). CONCLUSIONS: More than half of patients with malignant MCA infarcts who underwent decompressive craniectomy developed epilepsy. The occurrence of seizures in these patients was related to the delay to the performance of the craniectomy.

[Cat-scratch disease. Histopathology of the primary skin lesion. Apropos of a case]. / Enfermedad por arañazo de gato. Histopatología de la lesión primaria cutánea. A propósito de un caso.

We report a case of cat-scratch disease. The histological findings of the primary cutaneous lesion were characterized by the presence of necrotic areas surrounded by epithelioid cells in a palisade arrangement and an infiltrate composed of lymphoid cells, plasma cells and giant cells foreign body type.

Hodgkin's disease presenting with superficial lymph nodes and tumors of the scalp.

Invasion of the skin by malignant cells in Hodgkin's disease is a rare occurrence and less common than skin involvement in non-Hodgkin's lymphoma. We describe a 36-year-old man with Hodgkin's disease who presented with superficial lymph nodes and tumors on the scalp as initial clinical findings. Biopsy of a tumor of the scalp showed a diffuse dermal infiltrate composed of polynuclear neutrophils and eosinophils, large lymphocytes, and Sternberg-Reed cells. Ultrastructural examination of the skin biopsy specimens demonstrated the characteristic morphology of the Sternberg-Reed cells.

Generalized lichen nitidus. Report of two cases treated with astemizol.

Two patients, one man aged 65 and one woman aged 48, presenting generalized lichen nitidus are reported. The clinical and histopathologic features of this uncommon presentation of lichen nitidus are illustrated as well as the excellent clinical response to the treatment with an H1-blocking antihistaminic (astemizol).

Generalized cutaneous B-cell pseudolymphoma. Report of a case studied by immunohistochemistry.

A 77-year-old woman presenting with multiple reddish infiltrated papulonodular lesions on her back is reported. Histologic studies revealed nodular aggregates of lymphoid cells in a B-cell pattern. Immunohistochemical studies of several lesions showed the immunoarchitecture of germinal centers. Generalized lesions of cutaneous B-cell pseudolymphomas are uncommon. Our case is one of the few reported, and the first studied by immunohistochemistry.

Skin lesions in carbon monoxide intoxication.

A 25-year-old man who survived carbon monoxide intoxication presented erythematous cutaneous lesions with blister formation in pressure areas. Histologic examination revealed subepidermal vesicles with extensive sweat gland necrosis. We discuss the clinicopathological findings of carbon monoxide poisoning. Similar cutaneous features have been observed in patients with various kinds of drug-induced coma.

Immunohistochemical classification of cutaneous pseudolymphomas: delineation of distinct patterns.

Because of the broad spectrum of clinical and histological features, cutaneous pseudolymphomas are difficult to classify. To delineate objective criteria for classification, we investigated the immunoarchitecture of 53 cases of pseudolymphomas; 29 were classified as T cell pseudolymphomas. The immunohistologic characteristics were the absence of B cell compartments, the predominance of T helper-inducer cells and the presence of Langerhans cells/indeterminate cells. Lymphomatoid contact dermatitis showed the bandlike (superficial) T cell pattern. Lymphocytic infiltration of the skin, lymphomatoid papulosis, lymphomatoid drug reactions, and persistent nodules following assaults by arthropods revealed a nodular T cell pattern. Twenty-four cases represented B cell pseudolymphomas containing a nodular arrangement of B lymphocytes. In 6 lesions, there were B cell aggregates without the association of dendritic reticulum cells (non follicular B cell pattern); in 18, the B cell clusters were associated with dendritic reticulum cells and a typical expression of IgM and IgD, thus forming fully developed germinal centers (follicular B cell pattern). The B cell clusters were always surrounded by distinct T zones. B cell patterns were present in lymphadenosis benigna cutis, large cell lymphocytoma and occasionally, in persistent nodules, following assaults by arthropods.

Transferrin receptor expression in normal skin and in various cutaneous tumors.

In the majority of human cells the transferrin receptor (TFR) plays an important role by mediating the cellular iron uptake. The TFR is especially expressed by proliferating cells and has been found in high amounts in malignant tumors. The distribution of the TFR in frozen sections of 89 skin biopsies of normal skin and of various cutaneous tumors was investigated using an anti-TFR monoclonal antibody (OKT9) and a 3-step immunoperoxidase method. Our results indicate that in normal human skin the TFR shows a characteristic microanatomical distribution in the basal cell layer correlated to the architectural pattern of the dermal-epidermal interface. In cutaneous lymphomas of high grade malignancy the TFR was expressed in virtually all cells compared to only 25-75% in low grade lymphomas. Malignant melanomas were strongly positive in the whole tumor tissue, whereas benign melanocytic nevi were largely negative. Obviously the immunohistochemical demonstration of the TFR may serve as prognostic indicator or diagnostic aid, respectively.

HLA-DR-positive keratinocytes are associated with suppressor lymphocyte epidermotropism. A biomathematical study.

The expression of HLA-DR antigen on keratinocytes has recently been described as a frequent finding in various dermatologic disorders without restriction to a particular entity or a peculiar histologic reaction pattern, except for the association with a mononuclear dermal infiltrate. To determine the relationship of HLA-DR+ keratinocytes and T lymphocyte epidermotropism in human disease in vivo, 82 skin specimens were investigated by immunohistologic and stereologic methods and by two- and three-dimensional linear regression analysis. In randomly selected cases of various dermatoses, HLA-DR+ keratinocytes were associated with T lymphocyte epidermotropism. Furthermore, HLA-DR+ keratinocytes correlated particularly with the proportion of epidermotropic suppressor/cytotoxic cells. Our findings demonstrate that HLA-DR+ keratinocytes are associated with a particular pattern of epidermotropism, which may suggest an interaction of keratinocytes and T suppressor/cytotoxic cells in vivo.

Clinicopathologic study of cutaneous plasmacytoma.

Eight patients with skin tumor lesions composed of dense, predominantly plasma cell infiltrates were studied. Primary cutaneous plasmacytoma can be reactive (polyclonal) or neoplastic (monoclonal). In four of the patients skin lesions were associated with multiple myeloma. Specific skin lesions usually consisted of reddish or purple nodules located on the trunk. In one case the cutaneous lesions developed at the site of previous herpes zoster. Histologically, the cutaneous plasmacytic infiltrate was mainly diffuse and monomorphous. Most of the plasma cells were mature, but in some cases immature immunoblasts and mitoses were observed. Serum immunoelectrophoresis findings correlated with the monoclonality or polyclonality of the plasmacytoma. Presence or absence of systemic involvement cannot be predicted from the appearance of clinical lesions or from maturity of plasma cell infiltration in the skin.

[Immunohistochemical classification of cutaneous lymphomas and pseudolymphomas]. / Immunhistochemische Klassifizierung von kutanen Lymphomen und Pseudolymphomen.

We investigated 46 cases of cutaneous lymphoma and pseudolymphoma by immunohistochemical methods using a panel of monoclonal antibodies. Of the cutaneous T cell lymphomas, 2 did not show the classic helper phenotype but revealed a predominance of suppressor cells in one case and of immature thymocytes in the other. Cutaneous B cell lymphomas of low-grade malignancy were characterized by the presence of completely developed T zones between the B cell areas. B cell lymphomas of high-grade malignancy revealed an immunohistologically homogeneous infiltrate. Cutaneous pseudolymphomas can be classified in T cell pseudolymphomas (lymphocytic infiltration, lymphomatoid papulosis) and B cell pseudolymphomas. Lymphadenosis cutis benigna with germinal center cell differentiation was clearly distinguishable from other B cell pseudolymphomas, which are considered to comprise mainly peripheral B lymphocytes. Immunohistological methods are obviously useful in the classification of lymphoproliferative diseases of the skin and can make a contribution to increasing our understanding of them.

Fisiopatología de las tormentas eléctricas en el encéfalo del paciente con una lesión cerebral aguda. Resultados preliminares de un estudio piloto / Pathophysiology of electrical storms in the brain of patients with acute brain injury. Preliminary results of a pilot study

Los fenómenos de despolarización cortical propagada (CSD y CSD-like) son despolarizaciones celulares que se extienden en forma de onda y están implicados en la progresión de las lesiones en pacientes con ictus y traumatismo craneoencefálico (TCE). Son detectables en el registro de electrocorticografía (ECoG). Experimentalmente inducen hipoxia cerebral e incrementa la permeabilidad de la barrera hematoencefálica. Objetivos: Determinar la frecuencia y duración de estos episodios en pacientes con TCE o infarto maligno de la arteria cerebral media (IMACM) que requieran craniectomía. Material y métodos: 20 pacientes a los que se les colocó, en el córtex perilesional, una tira de seis electrodos. Análisis del número y la duración de los episodios de CSD registrados. Resultados: En cuatro, de los ocho registros de ECoG analizados, se identificaron episodios de CSD o CSD-like de duración y frecuencia variable. Conclusiones: Se detectan frecuentemente episodios de CSD y CSD-like en pacientes con IMACM y TCE (AU)

The phenomena of cortical spreading depolarization (CSD and CSD-like phenomena) are cellular depolarization waves involved in the progression of lesions in patients with stroke and traumatic brain injury (TBI). Which are detected by an electrocorticographic (ECoG) recording. Experimentally, CSD induces cerebral hypoxia and increases the permeability of the blood-brain barrier. Objectives: To determine the frequency and duration of CSD episodes in patients with TBI and malignant middle cerebral artery infarction (MMCAI) requiring craniectomy. Material and methods: 20 patients were included. A strip of 6 electrodes was placed in the perilesional cortex. Analysis of the number and duration of CSD episodes in the ECoG recording was performed. Results: In four, of the eight ECoG recordings that was fully analyzed, CSD or CSD-like phenomena were identified with a variable frequency and duration. Conclusions: Episodes of CSD and CSD-like phenomena are frequently detected in patients with MMCAI and TBI (AU)