Changes in body composition in early breast cancer patients treated with aromatase inhibitors.

PURPOSE: The aim of the study was to analyze the modification of total and regional body composition in early breast cancer patients treated with aromatase inhibitors (AIs). METHODS: This is a prospective, single-center, observational, longitudinal study. Four-hundred and twenty-eight patients treated with adjuvant aromatase inhibitors were enrolled at the Medical Oncology and Breast Unit of Spedali Civili Hospital in Brescia from September 2014 to June 2022. Several body composition parameters including total and regional fat and lean body mass were investigated with dual-energy X-ray absorptiometry (DXA) scan at baseline and after 18 months of treatment with aromatase inhibitors. RESULTS: A significant increase in fat body mass (mean + 7.2%, 95% confidence interval [CI]: 5.5;8.9%) and a reduction in lean body mass (mean -3.1%, 95% CI -3.9; -2.4) were documented in this population. The changes in fat and lean body mass varied considerably according to different body districts ranging between + 3.2% to + 10.9% and from-1.3% to -3.9%, respectively. CONCLUSION: Aromatase inhibitor adjuvant therapy in early breast cancer is associated with changes in body composition, with a wide variability among different body districts, leading to a risk of sarcopenic obesity. Supervised physical exercise that focuses on single body parts that may display detrimental variations may be beneficial for AIs treated patients.

Metronomic chemotherapy (mCHT) in metastatic triple-negative breast cancer (TNBC) patients: results of the VICTOR-6 study.

PURPOSE: Triple-negative breast cancer (TNBC) represents a subtype of breast cancer which lacks the expression of oestrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor-2 (HER2): TNBC accounts for approximately 20% of newly diagnosed breast cancers and is associated with younger age at diagnosis, greater recurrence risk and shorter survival time. Therapeutic options are very scarce. Aim of the present analysis is to provide further insights into the clinical activity of metronomic chemotherapy (mCHT), in a real-life setting. METHODS: We used data included in the VICTOR-6 study for the present analysis. VICTOR-6 is an Italian multicentre retrospective cohort study, which collected data of metastatic breast cancer (MBC) patients who have received mCHT between 2011 and 2016. Amongst the 584 patients included in the study, 97 were triple negative. In 40.2% of the TNBC patients, mCHT was the first chemotherapy treatment, whereas 32.9% had received 2 or more lines of treatment for the metastatic disease. 45.4% out of 97 TNBC patients received a vinorelbine (VRL)-based regimen, which resulted in the most used type of mCHT, followed by cyclophosphamide (CTX)-based regimens (30.9%) and capecitabine (CAPE)-based combinations (22.7%). RESULTS: Overall response rate (ORR) and disease control rate (DCR) were 17.5% and 64.9%, respectively. Median progression free survival (PFS) and overall survival (OS) were 6.0 months (95% CI: 4.9-7.2) and 12.1 months (95% CI: 9.6-16.7). Median PFS was 6.9 months for CAPE-based regimens (95% CI: 5.0-18.4), 6.1 months (95% CI: 4.0-8.9) for CTX-based and 5.3 months (95% CI: 4.1-9.5) for VRL-based ones. Median OS was 18.2 months (95% CI: 9.1-NE) for CAPE-based regimens and 11.8 months for VRL- (95% CI: 9.3-16.7 and CTX-based ones (95%CI: 8.7-52.8). Tumour response, PFS and OS decreased proportionally in later lines. CONCLUSION: This analysis represents the largest series of TNBC patients treated with mCHT in a real-life setting and provides further insights into the advantages of using this strategy even in this poor prognosis subpopulation.

Comparison of genioglossus muscle activity and efficiency of dexmedetomidine or propofol during drug-induced sleep endoscopy in patients with obstructive sleep apnea/hypopnea syndrome.

OBJECTIVE: The purpose of this study is to evaluate the haemodynamic and respiratory effects of dexmedetomidine vs. propofol in patients with OSAHS during the drug-induced sleep endoscopy (DISE), and analyze simultaneously the electromyography of genioglossus muscle. PATIENTS AND METHODS: We conducted a study on 50 patients with OSAHS; patients were subjected to DISE with simultaneous polygraphic cardiorespiratory measurement and electromyography of genioglossus muscle. Patients undergoing DISE were divided in two groups: in Group A (19 M; 8 W) was administered propofol TCI and in Group B (16 M; 7 W) was administered dexmedetomidine TCI. RESULTS: In Group A, a mean minimal SpO2 decreasing of 3.7% (p=0.000) and a mean SpO2 decreasing of 1.6% (p 0.001) was noticed, while there was an increase in BP20 of 14.8% (p=0.000) and HR20 of 11.1% (p=0.000). In Group B, it was showed a decreasing of mean minimal SpO2 and mean SpO2 values, about 1.8% (p=0.000) and 1.1% (p 0.009) respectively, while there was an increase of BP20 and HR20, about 8.7% (p=0.000) and 8% (p 0.002), respectively. Despite EMG activity comparing spontaneous sleep with propofol-DISE, there is a statistically significative change for the amplitude (p=0.040) and an increase of 7.01% for the area under the curve (AUC). Comparing spontaneous sleep with dexmedetomidine-DISE induced one, there is only an increase of 25.87% in the AUC. CONCLUSIONS: A greater worsening of the cardio-respiratory basal values was noted after sleep induction with Propofol and same results were obtained confronting EMG of genioglossus muscle data.

Emerging and re-emerging infectious disease in otorhinolaryngology.

SUMMARY: Emerging and re-emerging infectious disease in otorhinolaryngology (ENT) are an area of growing epidemiological and clinical interest. The aim of this section is to comprehensively report on the epidemiology of key infectious disease in otorhinolaryngology, reporting on their burden at the national and international level, expanding of the need of promoting and implementing preventive interventions, and the rationale of applying evidence-based, effective and cost- effective diagnostic, curative and preventive approaches. In particular, we focus on i) ENT viral infections (HIV, Epstein-Barr virus, Human Papilloma virus), retrieving the available evidence on their oncogenic potential; ii) typical and atypical mycobacteria infections; iii) non-specific granulomatous lymphadenopathy; iv) emerging paediatric ENT infectious diseases and the prevention of their complications; v) the growing burden of antimicrobial resistance in ENT and the strategies for its control in different clinical settings. We conclude by outlining knowledge gaps and action needed in ENT infectious diseases research and clinical practice and we make references to economic analysis in the field of ENT infectious diseases prevention and care.

Papillary squamous cell carcinoma of the palatine tonsil: a rare cancer of the head and neck.

Papillary squamous neoplasms of the upper respiratory tract are rare variants of squamous cell carcinomas. They are characterised by an exophytic, papillary growth and generally have favourable prognosis. The tumour has been described in the upper aerodigestive tract. In this context, most common sites of involvement are the larynx and hypopharynx, and rarely the oral cavity and oropharynx. The limited studies and small number of published cases of papillary squamous cell carcinoma of the palatine tonsil led us to make a complete analysis of this tumour by analysing the clinical, histological, radiological, virological and therapeutic aspects that are not always present in the literature. A case of papillary squamous cell carcinoma of the palatine tonsil is reported. The lesion (T2N0M0) was located into the left palatine tonsil that hung towards the oral cavity. Both HPV 16 DNA and E6/E7 mRNA were detected in the lesion. The clinicopathological profile of the neoplasm is presented and a comprehensive review of recent literature was made by analysing all aspects of interest of this neoplasm.

Childhood neurofibromatosis type 2 (NF2) and related disorders: from bench to bedside and biologically targeted therapies.

Neurofibromatosis type 2 [NF2; MIM # 101000] is an autosomal dominant disorder characterised by the occurrence of vestibular schwannomas (VSs), schwannomas of other cranial, spinal and cutaneous nerves, cranial and spinal meningiomas and/or other central nervous system (CNS) tumours (e.g., ependymomas, astrocytomas). Additional features include early onset cataracts, optic nerve sheath meningiomas, retinal hamartomas, dermal schwannomas (i.e., NF2-plaques), and (few) café-au-lait spots. Clinically, NF2 children fall into two main groups: (1) congenital NF2 - with bilateral VSs detected as early as the first days to months of life, which can be stable/asymptomatic for one-two decades and suddenly progress; and (2) severe pre-pubertal (Wishart type) NF2- with multiple (and rapidly progressive) CNS tumours other-than-VS, which usually present first, years before VSs [vs. the classical adult (Gardner type) NF2, with bilateral VSs presenting in young adulthood, sometimes as the only disease feature]. Some individuals can develop unilateral VS associated with ipsilateral meningiomas or multiple schwannomas localised to one part of the peripheral nervous system [i.e., mosaic NF2] or multiple non-VS, non-intradermal cranial, spinal and peripheral schwannomas (histologically proven) [schwannomatosis]. NF2 is caused by mutations in the NF2 gene at chromosome 22q12.1, which encodes for a protein called merlin or schwannomin, most similar to the exrin-readixin-moesin (ERM) proteins; mosaicNF2 is due to mosaic phenomena for the NF2 gene, whilst schwannomatosis is caused by coupled germ-line and mosaic mutations either in the SMARCB1 gene [SWNTS1; MIM # 162091] or the LZTR1 gene [SWNTS2; MIM # 615670] both falling within the 22q region and the NF2 gene. Data driven from in vitro and animal studies on the merlin pathway [e.g., post-translational and upstream/downstream regulation] allowed biologically targeted treatment strategies [e.g., Lapatinib, Erlotinib, Bevacizumab] aimed to multiple tumour shrinkage and/or regression and tumour arrest of progression with functional improvement.

Efficacy and safety of omalizumab in paediatric age: an update of literature data.

Immunoglobulin E (IgE) was discovered in 1966 and was found responsible for immune defense against helminths, type I hypersensitivity and allergic diseases. IgE mediates allergic responses by binding to Fc receptors (the high affinity Fc-epsilon receptor I and the low affinity Fc-epsilon receptor II or CD23) expressed on tissue mast cells and blood basophils. This binding leads to degranulation and release of pro-inflammatory mediators. Considering the pivotal role of IgE in allergic diseases, antibodies against IgE potentiate an array of new therapeutic strategies and in this regard omalizumab (rhuMAb-E25, Xolair) has been developed as a monoclonal biologic drug to block serum IgEs. Although the use of omalizumab has been studied vigorously in many adult populations with allergic diseases, there are few heterogenous studies on children. There are very few ongoing clinical trials with omalizumab exclusively on children, although some adult studies have concluded pediatric patients as a part of their studies. Nevertheless, in pediatric clinical trials omalizumab has been demonstrated to be effective and safe also in this age group. Herein, the authors present a systematic review of extensive literature data on the use of omalizumab in children and adolescents.

Parasympathetic nervous system involvement in food allergy: description of a paediatric case.

The latest research data emphasize the interaction between the nervous and the immune systems. It has been demonstrated that the central nervous system (CNS) can be involved secondarily due to blood brain barrier (BBB) disruption via pro-inflammatory cytokines released in allergy. More recently it was demonstrated that the parasympathetic nervous system (PNS) could also be equally involved in models of peripheral inflammation such as food allergy; although this last clinical presentation has rarely been described. Herein, the authors report the case of a five-year-old Caucasian female who was admitted to our Pediatric Acute and Emergency Operative Unit for cyclic vomiting. Her vomiting, which was preceded by objective torque vertigo, headache and weakness, had been recurring with constant frequency every two months since she was 3 years old. After a complex diagnostic flow-chart, it was found that this spectrum of neurologic symptoms was due to a food allergy syndrome, which postulates some etiopathogenic hypotheses to explain the relationship between the two mentioned diseases.

Audiological findings in a case of cerebellar angioreticuloma.

The aetiology of neurosensorial damage with unilateral hearing loss and/or tinnitus and dizziness can often be difficult to determine because they may be caused wide variety of pathologic processes and a variety of diagnostic tests are needed in initial evaluation. In this paper, the authors describe, the techniques and indications of neuroimaging for evaluation of auditory symptoms. Auditory brainstem response (ABR) testing is still the choice when condition is suspected. We present a study of one patient with unilateral tinnitus, with no significant hearing loss and normal ABR: the patient underwent MRI of the district brain and the internal auditory channel (AIC) that showed the presence of a rare intracranial neoplasm, namely cerebellar angioreticuloma.

Post-laryngectomy voice rehabilitation with voice prosthesis: 15 years experience of the ENT Clinic of University of Catania. Retrospective data analysis and literature review.

This study reports our 15-year experience, in Sicily, with the use of voice prostheses, analysing the different variables that have influenced the success or failure of speech rehabilitation. The retrospective clinical analysis was carried out by reviewing the clinical histories of 95 patients with laryngeal cancer, in whom a voice prosthesis had been placed by trachea-oesophageal puncture between 1998 and 2013. Age, type of tumour, type of surgery, use of prior radiation therapy, type of puncture, prosthesis used and its duration, number of replacements, complications and causes for prosthetic success or failure were analysed. The results showed a mean of Harrison-Robillard-Schultz (HRS) TEP rating scale of 11.8 in primary TEP and 12.6 in secondary TEP (P =0.613). PORT did not affect overall rehabilitation success. In these patients, the mean HRS rating scale was 11.2, with long-term success of 85% (P =0.582). In patients over 70 years old, long-term success was 82.5%, with 78% in primary and 86% in secondary TEP, the mean HRS was 11.2 in primary and 12 in secondary TEP (P =0.648). In total, long-term success was 87.5%, with 84% in primary and 91% in secondary TEP. The results obtained by retrospective analysis of 15 years of prosthetic rehabilitation in the Sicilian territory highlighted standard rehabilitation, in terms of intra and postoperative complications, fistula related pathology and overall success.

Pediatric autoimmune neuropsychiatric disorder associated with group a streptococcal infection: the role of surgical treatment.

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus (PANDAS) is a well-defined syndrome in which tics (motor and/or vocal) and/or obsessive compulsive disorders (OCD) consistently exacerbate in temporal correlation to a Group A beta-haemolytic streptococcal infection. In children with PANDAS, there is speculation about whether tonsillectomy or adenotonsillectomy might improve the neuropsychiatric course. Our objective was to examine whether such surgery impacted remission or, in patients without remission, modified clinical course of the disease, streptococcal antibody titers, neuronal antibodies or clinical severity of Obsessive-Compulsive Disorder (OCD) and/or tics. Study participants (n = 120) with positive PANDAS criteria were recruited, examined, and divided into surgical or non-surgery groups. The surgical group consisted of children with tonsillectomy or adenotonsillectomy (n=56). The remaining children were categorized as non-surgery (n=64). Clinical follow-up was made every 2 months for more than 2 years. Surgery did not affect symptomatology progression, streptococcal and neuronal antibodies, or the clinical severity of neuropsychiatric symptoms in these children. In conclusion, in our series clinical progression, antibody production, and neuropsychiatric symptom severity did not differ on the basis of surgical status. We cannot uphold surgical management as likely to impact positive remission rates, course of OCD/tics, or antibody concentrations in children with PANDAS.

Intensive care of patients requiring open abdomen treatment: a case-series analysis.

BACKGROUND: This retrospective overview examines the management of patients with temporary open abdomen (OA). METHODS: The clinical characteristics and intensive care treatment of 34 consecutive patients with OA (1996-2012) were reviewed. RESULTS: Average age was 61 years, SAPS II score 43, SOFA 8. Two patients had non-contaminated abdomen; 12 had intact gut (only 8 later during stay); 7 repaired gut (only later 4); 13 cutaneous stoma (later 14), and 2 entero-atmospheric fistula (later 8+1 entero-enteral). The median ICU stay was 48 [36-94] days. One quarter of the 2376 ICU-days were classified as severe sepsis/septic shock (antibiotics were given for two thirds of the stay); three quarters were with ventilation; in 95% of days sedatives were given (mainly enterally). Continuous cavity lavage was done in three quarters of days; in 3% of days patients were fasted whereas >20 kcal/kg was given for 74% of days; we fed the gut in 95% of fed-days, in half of them combined with parenteral nutrition. Complications are discussed; mortality was 32.4%, limited to the ICU stay. CONCLUSION: The intensive care of patients with OA is challenging but can achieve better outcomes than expected. Continuous abdominal lavage improves the evacuation of contaminated fluid or debris and, coupled with antiseptics and low antibiotic pressure, reinforces the control of infection. The gut can be used for nutrition (even without gastrointestinal continuity), and long-term light sedation (mainly enteral) with minimal impact on perfusion, ventilation and gut motility.

Evaluating daily nursing use and needs in the intensive care unit: a method to assess the rate and appropriateness of ICU resource use.

BACKGROUND: We designed a tool to measure the rate and appropriateness of intensive care unit (ICU) nursing coverage as a proxy for the use of resources. METHODS: We tested the tool in 32 Italian ICUs during a cross-sectional study (4 days/week, October 2001 and April 2002). The level of care was classified as high or low. The appropriate patient-to-nurse ratio for both levels (2/1 and 3/1 in this ICU mix) was defined. The provided and theoretical nurse assistance was computed, the difference between the two quantifying the ICU use of personnel: a positive difference means over-utilization, a negative one under-utilization. We calculated the maximum number of high-level and low-level care days available for ICU and the relative utilization rates. These two rates quantify the appropriateness of resource use in relation to the planned use. RESULTS: Analysing 5783 treatment-days, the tool identified units using almost all available resources (five), overcrowded (14: too small units) or empty (16: too big). Units were overcrowded on account of the high-level of care required (five: utilization rate >100%) or reallocated too much of their residual high-care nursing capacity to low-level care (six). In empty units both utilization rates were lower than expected. CONCLUSIONS: The method quantifies the rate and appropriateness of resource usage and suggests the best management in units with fixed human resources or a fixed number of beds.

Use of sedative and analgesic drugs in the first week of ICU stay in high-level-of-care.

AIM: The aim of this study was to update the current practice of pharmacological sedation and analgesia in Italian intensive care units. DESIGN: observational, prospective, cohort study involving consecutive patients admitted during 5 months in 1999. PATIENTS were evaluated for the first 7 days of high-level-of care. SETTING: 45 adult general intensive care units. PATIENTS: 388 fulfilling enrollment criteria: admission diagnosis out of non-traumatic cerebral hemorrage, stroke, respiratory failure in chronic obstructive pulmonary disease (COPD), acute lung injury/distress syndrome (ALI/ARDS), polytrauma, head trauma, cardiac failure and major abdominal surgery; unit stay longer than 47 hours and high-level-of care treatment. RESULTS: Sedation pattern was different among diagnosis-groups. No therapy was registered in 18.8% of overall days in polytrauma vs 67.6% of cardiac patients. Opioids supply ranged from 10.1% of overall days of acute on COPD patients vs 51.4% of polytrauma patients. Propofol was the more prescribed drug, followed by opioids and benzodiazepines. Propofol was at the top in cerebrovascular disease, ALI/ARDS and COPD; opioids in abdominal surgery and trauma, benzodiazepines in cardiac failure. The average number of prescribed drugs per day was 1.5 ranging from 1.2 on COPD to 1.7 in head trauma. CONCLUSION: Diagnosis influences the pattern of sedation-analgesia during high-level-of-care period. Sedation prevalence is reasonably prescribed in trauma groups while it remains low in ALI/ARDS, post-operative, cerebrovascular, COPD and hearth failure. Particularly opioid use remains limited in post-operative patients. This surveys shows a poorly standardised sedation approach to the different phases of the therapy: induction, short and long-term sedation phase.

Endovascular treatment of iliocaval occlusion caused by retroperitoneal fibrosis: late results in two cases.

We report two cases of iliocaval occlusion caused by retroperitoneal fibrosis; one presented acute symptoms and one chronic. Both were treated by use of transluminal angioplasty and stenting with excellent clinical, hemodynamic, and imaging results at 36 and 51 months. These cases confirm the benefit of endovascular techniques in the treatment of nonmalignant obstructive disease of large veins, and specifically in the case of retroperitoneal fibrosis.

Day surgery for mucosal-hemorrhoidal prolapse using a circular stapler and modified regional anesthesia.

PURPOSE: In 1993, prolapse reduction using the circular stapler for the treatment of hemorrhoidal disease was proposed. The procedure is characterized by minimal postoperative pain. In this study we evaluated the above technique using regional anesthesia to identify the advantages and feasibility of stapled hemorrhoidectomy, with special focus on the efficacy of same-day discharge. METHODS: From December 1997 to November 1999, we performed 70 consecutive reduction corrections of mucosal hemorrhoidal prolapse using the circular stapler with regional anesthesia (a technical modification of Marti's posterior perineal block). Our series included 41 males and 29 females with a mean age of 43.4 (range, 25-74) years. Three patients were affected by second-degree hemorrhoids and 67 by third-degree hemorrhoids. RESULTS: Sixty-two patients were discharged three hours after the operation in good general condition and without pain, whereas eight patients were discharged the day after for early complications, consisting of two cases of early bleeding, three cases of urinary retention, and three cases of persistent severe pain requiring prolonged medical treatment. CONCLUSION: Our study shows that, in selected cases, it is possible to perform day surgery for patients with hemorrhoidal disease using a circular stapler device when combined with regional anesthesia.

Leptin levels in diabetic and nondiabetic subjects.

The role of leptin in human pathophysiology elicits considerable interest in view of its potential role as a treatment tool for obesity and other insulin resistant states, like type 2 diabetes mellitus (T2DM). Leptin has been extensively studied in obese humans, and much less so in other pathologic conditions. Leptin level has been reported to correlate with percent body fat mass (%FM), fasting serum insulin (FPI), insulin sensitivity and blood pressure. The aim of this study was to compare the leptin concentration, and its relationship with some anthropometric and biochemical parameters related to insulin resistance in 140 moderately obese type 2 diabetics (T2DM) and 160 age and weight matched non-diabetic controls in order to get a better insight into the possible role of leptin in the metabolic abnormalities of diabetes. The leptin levels were lower in the diabetic population only when both sexes were combined (p < 0.05) and were higher in the females of both groups. Among the nondiabetics, the leptin levels appeared to be related to BMI, %FM, HDL and FPI, while this was not the case in the diabetics. After correction for BMI, leptin appeared to be correlated with the FPI levels only in the non-diabetic females. When plasma leptin was included in a multiple linear regression model with plasma leptin as a dependent variable, BMI, W:Hr and FPI levels were significantly related to leptin in the non diabetic population, while no relationship reached the level of statistical significance among the diabetics, with the exception of the borderline value for the FPI (p = .052). In conclusion, leptin levels were independent of any of the parameters examined in our diabetic population, possibly due to the progressive loss of the normal mechanisms of leptin regulation with advancing disease. Conclusive data can only be obtained from the longitudinal study of a cohort of newly diagnosed diabetic subjects.

Surgical venous thrombectomy.

Rehabilitation of the technique of venous thrombectomy is justified, but, in order for this technique to be effective, it must only be performed in selected cases. In the authors' view it is of the utmost value in young patients when the venous thrombosis occurs accidentally, after traumatism or surgery and when a diagnostic is made without delay.

Bilateral dissection of the internal carotid artery at the base of the skull due to blunt trauma: incidence and severity.

Between January 1, 1992 and December 31, 1996, a total of 1095 head trauma vicims were admitted in our intensive care unit. If CT scans demonstrated ischemic brain lesions, arteriography to visualize supraaortic vessels was performed. Carotid artery dissection was observed in ten patients (0.91%) and was bilateral in eight patients (0.73%). In the bilateral carotid artery dissection (BCAD) group, there were five women and three men, with a mean age of 35.2 years (range: 17 to 54 years). Injuries resulted from traffic accidents in seven patients and a fall in one patient. Upon admission, six patients presented with alteration of consciousness and three with hemiplegia or hemiparesia, associated with aphasia in two cases. In two other cases, hemiplegia occurred 24 hr and 13 days after the accident. All patients had brain infarction, which was unilateral in five cases and bilateral in three cases. The severity of lesions was graded on the basis of arteriographic findings as follows: Type I, wall involvement without significant stenosis or dilation; Type II, arterial dissection with stenosis >70% (Type IIA) or dilatation >50% (Type IIB) and the normal diameter of the proximal or distal internal carotid artery; and Type III, thrombosis of the internal carotid artery. Lesions were asymmetrical in six patients, including two with Type II and III lesions and four with Type I and II lesions, and symmetrical in two patients, including one with bilateral Type III lesions and one with bilateral Type II lesions. Surgery was performed in two patients with Type II lesions, including one case associated with contralateral carotid thrombosis. The intrapetrous carotid artery was exposed by an ear-nose-throat (ENT) surgeon and repaired by interposition grafting. Follow-up in these two surgical cases was 28 and 31 months. In the remaining six cases, medical treatment was performed. Outcome in nonsurgical cases was variable: death in two cases at 31 and 43 days after the accident, severe permanent hemiplegia in two cases, and minimal or no sequels in two cases. Following blunt trauma, arteriography of supraaortic vessels should be performed to detect BCAD in any patient with immediate or delayed neurologic symptoms that cannot be explained by CT-scan findings. To better understand the natural course of these lesions and define the indications for surgery, we propose a three-grade classification according to arteriographic findings. If surgery is undertaken, vein grafting should be performed following resection of the carotid artery lesions.