Evaluation of the anterior pituitary function in the acute phase after spontaneous subarachnoid hemorrhage.

BACKGROUND: Subarachnoid hemorrhage (SAH) is a potential cause of hypopituitarism. Most of the studies regarding the relationship between SAH and anterior pituitary function were retrospective and hormonal assessment was performed several months after SAH. AIM: To prospectively evaluate the prevalence of anterior pituitary hormone deficiencies in the acute phase after spontaneous SAH and their possible correlation with clinical and radiological parameters. METHODS: Pituitary function was tested in 60 patients within 72 h after spontaneous SAH. RESULTS: 56.9% of the patients showed at least one anterior pituitary hormone deficiency: gonadotropin and GH secretion failure represented the most prevalent hormonal deficiencies (33.3 and 22.0%, respectively), whereas ACTH and TSH deficiency was less frequent (7.1 and 1.8%, respectively). With the exception of secondary hypogonadism, the prevalence of other pituitary hormone deficiencies is in agreement with previous studies, which evaluated pituitary function on longterm follow up after SAH. No correlation was found between hypopituitarism and clinical status, as assessed with Hunt-Hess and Glascow Coma Scales. Moreover, no correlation was found between hypopituitarism and bleeding severity evaluated with Fisher's scale. CONCLUSIONS: We demonstrated a high prevalence of anterior pituitary hormone deficiencies acutely after SAH. Although part of GH and gonadotropin deficiencies might be a consequence of functional alteration due to SAH itself, the finding of low cortisol levels in this stressful condition strongly suggests the presence of true hypocortisolism. Therefore, an evaluation of pituitary function shortly after SAH might be useful to identify a subset of patients who deserve a more accurate follow-up.

A single-institution restrospective experience of brachytherapy in the treatment of pituitary tumors: transsphenoidal approach combined with (192)Ir-afterloading catheters.

BACKGROUND AND AIM: Radiotherapy may be used as an adjuvant treatment of pituitary adenomas. The aim of our study was to present our experience of multimodal treatment of pituitary adenomas, consisting in temporary implantation of (192)Ir-labeled wires following transphenoidal surgery. SUBJECTS AND METHODS: An observational investigation was performed on a series of 80 patients undergoing surgery (S) for pituitary adenomas between 1982 and 2000, some of whom received post-operative external beam radiotherapy (EBRT) (no.=19 between 1982 and 1990), brachytherapy (B) (no.=35, all after 1991), or both irradiation modalities (EBRT+B) (no.=14). The different treatments were compared in terms of hormonal normalization in the subgroup of patients with hypersecreting adenomas, tumor control, and side effects. RESULTS: Hormonal normalization was obtained in 84% of S+B patients and in 61% of S+EBRT patients. Tumor control was obtained in 74.3% of S+B patients and in 63.1% of S+EBRT patients. Anterior pituitary hormones deficits ranged from 8.6-34% in S+B patients and from 15.8-47.4% in S+EBRT patients, after a mean follow-up of 14 yr. The latter group also showed a higher rate of multiple deficits (42.1% vs 22.8%). Diabetes insipidus and other major complications were rare events in all groups. CONCLUSIONS: We presented one original experience regarding brachytherapy in the management of pituitary tumors, which turned out to be effective and safe. Additional prospective, and possibly randomized, studies should clarify whether in the era of 3-dimensional conformal radiotherapy and stereotactic radiotherapy this treatment modality may still have a role.

Inducible cyclooxygenase (COX-2) in glioblastoma--clinical and immunohistochemical (COX-2-VEGF) correlations.

Cyclooxygenase-2 (COX-2) is the inducible form of the enzyme responsible for the first step in the prostaglandin synthesis. COX-2 upregulation is demonstrated in different tumors. COX-2 products may modulate tumoral growth, apoptosis, metastasis, multidrug resistance and angiogenesis. Moreover, the antitumoral effect of the COX inhibitors has been documented. We studied the immunohistochemical expression and the prognostic value of COX-2 on 43 surgical specimens of glioblastoma-affected patients. Furthermore, we evaluated the correlation between the immunohistochemical expression of COX-2 and vascular endothelial growth factor (VEGF). Of the glioblastomas, 63% resulted as COX-2-positive. Median survival of the patients with COX-2-positive lesions was 10 months; median survival of the patients with COX-2 negative glioblastoma was 21 months (NS). All 4 patients who survived longer than 24 months had COX-2 negative lesions (p = 0.017). Concordance between COX-2 and VEGF was documented in 60% of the cases. Our findings show that glioblastoma can immunohistochemically express COX-2 and that its expression is unrelated with VEGF and significantly less frequent in the long survivors. Nevertheless, the absence of statistical correlation with survival time advises further studies on larger series to ascertain the concrete prognostic value of COX-2 in glioblastoma.

Oligodendrogliomas lacking O6-methylguanine-DNA-methyltransferase expression.

O6-Methylguanine-DNA-Methyltransferase (MGMT) is a DNA repair protein considered to be a chemosensitivity predictor. We evaluated the immunohistochemical MGMT expression in 28 consecutive oligodendroglial tumors (21 oligodendrogliomas, 5 mixed oligoastrocytomas, and 2 glioblastomas with prominent oligodendroglial features; 13 treated with CCNU) and compared it with that of 13 glioblastomas. Twenty-six (93%) oligodendroglial tumors were MGMT-negative, 2 (7%) were MGMT-positive. Twelve (92%) patients treated with CCNU had MGMT-negative lesions and their median survival was 73 months; 1 patient had an MGMT-positive oligodendroglioma and is alive at 28 months. Three (23%) glioblastomas were MGMT-negative and 10 (77%) MGMT-positive. The lower MGMT expression in oligodendroglial tumors compared to glioblastomas (P < 0.05), which have different chemosensitivity, suggests a possible role of MGMT in the determination of chemoresistance. Nevertheless, the heterogeneous outcome of our MGMT-negative oligodendroglial tumors treated with CCNU, indicates that MGMT expression alone is insufficient to predict the response to alkylating drugs, presumably because of the numerous mechanisms involved.

Atypical onset of antiphospholipid syndrome in pregnancy: a case report.

BACKGROUND: We present a case of an atypical onset of antiphospholipid syndrome (APS). CASE: A woman in her 15th week gestation had a thrombosis of an unknown cerebral cavernoma, which was successfully removed. Twenty-six days after, she was admitted for a severe pain in right hypochondrium and a second class HELLP syndrome was diagnosed. Two days after, she had a fetal loss. After 1 month, laboratory tests revealed high level of antiphospholipid antibodies. At the same time, she developed a spontaneous thrombosis at her right arm. After 6 weeks, antiphospholipid antibodies, tested again, result positive. CONCLUSION: Antiphospholipid antibodies often cause pregnancy complications, but, to our knowledge, this is the first report of an association of antiphospholipid antibodies, with cerebral cavernoma thrombosis and early onset HELLP syndrome.

Endovascular Coiling of Aneurysm Remnants after Clipping in Patients with Follow-up. A Single Center Experience.

SUMMARY: The vast majority of intracranial aneurysms can be obliterated completely with surgical clipping. However, postoperative remnants occur in about 4 to 8% of patients who undergo postoperative angiography. Endovascular embolization has been successfully performed in patients with postoperative aneurysm remnant and it may represent a therapeutic alternative to surgical reintervention. Twelve aneurysm remnants after surgical clipping were treated with endovascular embolization using GDC. All aneurysms were located in the anterior circulation. Our experience confirms the feasibility and relative safety of this treatment strategy that may be considered a valid alternative to reintervention.

Pregnancy and subarachnoid hemorrhage: a case report.

Cerebrovascular diseases are rare in pregnancy and mostly caused by rupture of an arterial aneurysm. We present the case of a pregnant woman at 36 weeks of gestation who had a subarachnoid hemorrhage resulting from rupture of an unknown aneurysm, and who underwent a Cesarean section and an endovascular treatment to embolize the aneurysm.

Results of surgical and endovascular treatment of intracranial micro-arteriovenous malformations with emphasis on superselective angiography.

BACKGROUND: The authors retrospectively reviewed the results of two different treatment modalities (surgery and endovascular approach) in patients with intracranial micro-arteriovenous malformations (micro-AVMs). The goal of this study is to evaluate the respective role of surgical treatment and superselective acrylic embolization in the management of micro-AVMs. METHOD: Fourteen patients with micro-AVMs who had been treated by surgical resection or endovascular acrylic embolization during a 6-year period were analyzed. The average age at presentation was 44.6 years (range, 24-65 yr) with no sex dominance. All patients presented with an intracranial haemorrhage, which was superficial in twelve patients and in eloquent brain areas in seven patients. Severe neurological deficits were observed in eleven patients. FINDINGS: Digital subtraction angiography (DSA) demonstrated micro-AVMs in eleven patients (78.5%) while in three patients (21.5%) the micro-AVM was detected only by superselective angiography (SA). Eight patients underwent surgical intervention which led to definitive resection in seven with no peri-operative morbidity. SA was performed in nine patients and followed by successful acrylic embolization of the micro-AVM in seven with haemorrhagic complications in two patients. All fourteen lesions were completely obliterated as demonstrated angiographically. Outcomes were classified according to the Modified Rankin Scale. With a mean long term clinical follow-up of 33 months (range, 8-75 mo), seven patients were Grade 0, six patients were Grade I and one patient was Grade IV. CONCLUSIONS: SA is deemed necessary to visualize micro-AVMs in case of questionable or negative findings also at delayed DSA in young healthy patients with otherwise unexplained intracranial haemorrhage. Obliteration of micro-AVM can be accomplished either surgically or endovascularly; however, the endovascular approach is associated with a defined procedural risk for haemorrhagic complications and long term angiographic follow-up is necessary.

[BCL-2 in primary central nervous system lymphomas. Immunohistochemistry and molecular biology]. / La BCL-2 nei linfomi primitivi del sistema nervoso centrale. Immunoistochimica e biologia molecolare.

BCL-2 is a membrane protein known to be an apoptosis inhibitor. It is the product of the bcl-2 gene located on chromosome 18. Several different tumors show BCL-2 over-expression as result of a translocation or independently from it. More than 85% of follicular lymphomas and a smaller number of diffuse large cell B lymphomas contain t(14;18) (q32;q21). The aim of this study was to investigate the immunohistochemical expression of the BCL-2 protein and to ascertain, by means of traditional PCR (Polimerase Chain Reaction), its possible dependence from t(14;18) (q32;q21) in 9 primary central nervous system lymphomas. Six cases (67%) shoved immunohistochemical BCL-2 over-expression and 3 cases (33%) had t(14;18). Precisely: 2 cases (22%) had immunohistochemical BCL-2 over-expression and t(14;18) (q32;q21); 4 cases (44%) had BCL-2 over-expression without translocation; 1 case (11%) did not show diffuse BCL-2 over-expression in presence of the traslocation; the remaining 2 cases (22%) did not demonstrate BCL-2 over-expression or t(14;18) (q32;q21). In conclusion, our results indicate primary central nervous system lymphomas frequently show BCL-2 over-expression that in some case may be related to t(14;18) (q32;q21). Nevertheless, t(14;18) (q32;q21), as evaluated by traditional PCR, may not correspond to diffuse immunohistochemical BCL-2 positivity.

Oligodendroglioma: CD44 as a possible prognostic opportunity.

CD44, in its standard form as well in its isoforms, is a cell surface adhesion glycoprotein which occurs in a wide variety of non-neoplastic and neoplastic cells. CD44 has been considered to be implicated in tumoral growth and in metastatic potential. We studied the immunohistochemical expression of CD44 standard in 30 oligodendrogliomas (19 primary lesions and 11 recurrences) in order to verify its possible prognostic role. Twelve primary oligodendrogliomas (63%) and 8 recurrences (73%) were CD44-positive. Three of 9 (33%) primary oligodendrogliomas with a Smith grade A-B and 9 of 10 (90%) primary oligodendrogliomas with a Smith grade C-D were found to be in CD44H-positive (p = 0.020). Three of 9 (33%) primary oligodendrogliomas that had not relapsed and 9 of 10 (90%) successively relapsed primary lesions were found to be CD44H-positive (p = 0.020). Median survival of the patients with a CD44H-positive lesion was 84 months; median survival of the patients with a CD44H-negative lesion was 91 months. We conclude that CD44H could have prognostic value regarding the occurrence of relapses.

[Atypical, aplastic, and unusual meningiomas. Morphology and incidence in 300 consecutive cases]. / Meningiomi atipici, anaplastici ed inusuali. Morfologia ed incidenza in 300 casi consecutivi.

We morphologically studied 300 consecutive and primitive meningiomas surgically treated between march 1997 and april 2002 in order to evaluate the incidence of atypical, anaplastic, and morphologically unusual meningiomas. Two hundred and fifty-five meningiomas (85%) were WHO I, 33 (11%) were WHO II, 9 (3%) were WHO III; the remaining 3 meningiomas (1%) showed clear and diffuse oncocytic differentiation without cytologic or architectural atypia (oncocytic meningiomas). Forty-five of 255 WHO I meningiomas (18%) were infrequent histological subtypes: 18 (7%) psammomatous, 9 (4%) metaplastic, 9 (4%) secretory, 6 (2%) angiomatous, and 3 (1%) microcystic. Thirty of 33 WHO II meningiomas (91%) were atypical, 2 (6%) were clear cell meningiomas, and 1 (3%) was chordoid meningioma. Seven of 9 WHO III meningiomas (78%) were anaplastic and 2 (22%) were papillary. We evidenced the high morphological variability and the discrete occurrence of WHO I and WHO II meningiomas.

Utility of balloon-assisted guglielmi detachable coiling in the treatment of cerebral aneurysms. A single center retrospective study.

SUMMARY: Balloon-assisted Guglielmi detachable coiling (BAGDC) is a new technical option developed to allow endovascular treatment of wide-necked aneurysms. Aim of the following work is to report a single center experience of BADGC of aneurysms with assessment of its efficacy and safety. BAGDC of wide-necked aneurysms (SNR close to 1) was retrospectively evaluated in 37 patients (28 females, nine males, mean age: 56.6 yrs, range: 27-81 yrs) who underwent the procedure between january 1999 and january 2002 for a total of 45 procedures on 41 aneurysms.Twenty- nine patients presented with SAH from an acutely ruptured aneurysm. In two patients BAGDC failed whereas 35 patients successfully underwent BADGC (39 aneurysms). Twenty-nine patients (31 aneurysms) were available for angiographic follow- up (mean: 10 mo, range: 3-24 mo). At the last angiographic follow-up 29/33 aneurysms (87%) resulted stable and occluded (22 aneurysms with dense and seven with loose packing of the sac and the neck), two aneurysms showed regrowth, one aneurysm showed a neck remnant and another one a sac and neck remnant. Complications directly related to the procedure occurred in five patients (three perforations, one thromboembolism, one femoral AV) with a mortality and morbility rate of 2.7 and 5.4 respectively. BAGDC is a promising adjunct to treatment of wide-necked aneurysms broadening the spectrum of indications for endovascular treament of challenging aneurysms.

Percutaneous transluminal cerebral angioplasty and stenting in acute vertebrobasilar ischemic stroke. Report of two cases.

SUMMARY: Reports of cerebral transluminal angioplasty and stenting in patients with vertebrobasilar ischemic stroke are scanty. Herein we report on the use of "monorail" coronary balloon angioplasty and stent balloon mounted catheters in two patients with acute vertebrobasilar ischemic stroke, focussing on the differences and possible advantages of the "monorail" technique in comparison with the "over-the-wire" technique. In both patients, the clinical picture was characterized by progressive brainstem symptoms followed by acute loss of consciousness related to an atherothrombotic occlusion and subocclusion of the dominant intracranial vertebral artery, respectively. In one patient, superselective thrombolytic therapy and balloon angioplasty resulted in a dissection flap at the vertebrobasilar junction. The latter was treated by successful deployment of a coronary stent. In the other patient, the subocclusive lesion was directly treated by angioplasty and stenting without thrombolytic therapy. The clinical outcome was poor for one patient ("locked in" syndrome) while the other had a complete clinical recovery. In acute atherothrombotic vertebrobasilar stroke transluminal cerebral angioplasty and stenting may be successfully performed allowing vessel recanalization.

Which target for DBS in Parkinson's disease? Subthalamic nucleus versus globus pallidus internus.

We selected 14 patients with advanced idiopathic Parkinson's disease (PD) and examined the clinical effects of STN DBS versus GPi DBS. Nine patients underwent bilateral STN DBS and five underwent bilateral GPi patients. All patients were followed for at least 12 months. The evaluation was performed on and off drug before surgery; on-drug/on-DBS and off-drug/on-DBS at 1, 3, 6 and 12 months after stereotactic surgery. At 1 and 3 months after surgery in off-drug/on-DBS condition, both groups showed an improvement in motor score (UPDRS III). Nevertheless, the results changed after long-term stimulation in the two groups. Chronic STN DBS is superior to GPi DBS in the amelioration of the clinical features and in the decrease of time spent in the off state. The efficacy in reduction of LID was comparable at 1 and 3 months after surgery, but the results were better in STN DBS after chronic stimulation. The L-dopa dose was reduced only in the STN group.

Oligodendroglioma: HMB-45 positivity using catalyzed signal amplification method: an immunohistochemical (HMB-45, CD31, p53, Mib-1) and ultrastructural study.

Although melanin synthesis and the presence of melanosomes are exceptionally reported in nervous system tumors, there is no record of melanotic oligodendrogliomas in the literature. The purpose of the current study was to evaluate whether melanosomes are immunohistochemically and ultrastructurally detectable in nonmelanotic oligodendrogliomas and to verify whether these data are related to prognosis. Thirty surgical specimens (19 primary lesions and 11 recurrences) from 19 patients were examined. Median survival was 80 months. Immunohistochemical studies were performed using the monoclonal antibodies HMB-45, CD31. Mib-1, and p53. Using catalyzed signal amplification (CSA), HMB-45 positivity was noticed in 3 (10%) of the oligodendrogliomas being studied. No correlation with survival was found. Ultrastructural examination displayed the presence of melanosomelike structures. Tumor vascularization, estimated by means of CD31 antibody, was increased in 6 of 19 primary lesions but there was no significant correlation with survival. Nine of the19 primary lesions were p53 negative. In these cases, survival was longer than in p53-positive tumors (P = 0.0213). Proliferation rate, evaluated with Mib-1, was unrelated to survival, but proved greater in recurrences (10 of 11 cases) than in primary tumors (7 of 19 lesions; P = 0.007).

[Metastatic brain tumors]. / I tumori cerebrali metastatici.

211 patients operated on for brain metastases have been selected through a review of specimens from the Department of Pathology of the University of Florence covering the period between 1980 to 1995. 140 patients (66%) are males and 71 (34%) are females. Average age is 59 years ranging from 33 to 79 years of age. Lung tumours (47%) and breast cancer (9%) are most frequently responsible for brain metastases. In 17% of the patients, the primary lesion was unknown. The average survival was 14 months and in 8 patients (4%) it was more 5 years. In 36 cases (17%) recurrence appeared 8 months after the first operation. Survival in these patients averaged 20 months from the diagnosis of brain metastases and 11 months after the discovery of the relapses. It is not significantly different from that of patients without evidence of relapsed metastases in the brain (13 months). Prognostically renal carcinoma behaves more favourably, average survival (27 months); on the contrary prognosis of metastatic melanoma is ominous (7 months). Metastases from unknown primaries do not have a significant different prognosis from all the other lesions.

Effectiveness of infection control program in controlling nosocomial Clostridium difficile.

OBJECTIVE: To report the effectiveness of use of comprehensive infection control measures to reduce the incidence of Clostridium difficile (CD) in an acute-care teaching hospital. METHODS: All CD infections were reviewed by the infection control coordinator from 1987 to 1996. The Centers for Disease Control and Prevention's nosocomial infection definition was used. CD-inclusion criteria remained unchanged during the study period. Interventions were started in 1990. INTERVENTIONS: The interventions used were: (1) Isolation policy-revision and enforcement, which included universal precautions policy, (2) educational program-monthly to all health care workers, (3) phenolic disinfectant for environmental cleaning, (4) triclosan (0.03%) soap for handwashing, (5) centralization of sterilization department, (6) cart-washer installation, and (7) aggressive surveillance activity. RESULTS: From 1987 to 1989, before the interventions, a total of 466 CD infections (mean 155 per year) occurred. From 1990 to 1996, after the interventions, 475 infections (mean 67 per year) occurred. Incidence of CD decreased by 60% from 1990 to 1996. CONCLUSION: The sustained decrease of nosocomial CD during the 7-year period demonstrated the effectiveness of aggressive infection control measures that involve multiple disciplines.

Surgical treatment of intracranial aneurysms in patients aged over 70: 25 years of experience.

Many references and communications regarding neurosurgical topics in elderly patients underline the interest of our Unit for this subject. We already presented in 1978 a series of 75 patients over 60 years of age operated on for intracranial aneurysms; we reported a 90% of success in all the cases operated with clinical grade 1 or 2 according to Botterel grading system on admission. In 1986, during the XXXV Congress of the Italian Neurosurgical Society, we presented other 15 cases operated for intracranial aneurysm over 70 years of age. We present an upgrading of our casistic.

Effect of a comprehensive program to reduce needlestick injuries.

The Arlington Hospital Needlestick Injury (NSI) Prevention Program was created to protect healthcare workers from NSI and to assess the effectiveness of our interventions. Interventions included revising NSI policy and procedures. The average NSI rate dropped from 109 to 43 per year after the interventions, over a period of 4 years.