Heart-fatty acid-binding and tau proteins relate to brain injury severity and long-term outcome in subarachnoid haemorrhage patients.

BACKGROUND: Vasospasm and other secondary neurological insults may follow subarachnoid haemorrhage (SAH). Biomarkers have the potential to stratify patient risk and perhaps serve as an early warning sign of delayed ischaemic injury. METHODS: Serial cerebrospinal fluid (CSF) samples were collected from 38 consecutive patients with aneurysmal SAH admitted to the neurosurgical intensive care unit. We measured heart-fatty acid-binding protein (H-FABP) and tau protein (τ) levels in the CSF to evaluate their association with brain damage, and their potential as predictors of the long-term outcome. H-FABP and τ were analysed in relation to acute clinical status, assessed by the World Federation of Neurological Surgeons (WFNS) scale, radiological findings, clinical vasospasm, and 6-month outcome. RESULTS: H-FABP and τ increased after SAH. H-FABP and τ were higher in patients in poor clinical status on admission (WFNS 4-5) compared with milder patients (WFNS 1-3). Elevated H-FABP and τ levels were also observed in patients with early cerebral ischaemia, defined as a CT scan hypodense lesion visible within the first 3 days after SAH. After the acute phase, H-FABP, and τ showed a delayed increase with the occurrence of clinical vasospasm. Finally, patients with the unfavourable outcome (death, vegetative state, or severe disability) had higher peak levels of both proteins compared with patients with good recovery or moderate disability. CONCLUSIONS: H-FABP and τ show promise as biomarkers of brain injury after SAH. They may help to identify the occurrence of vasospasm and predict the long-term outcome.

Acromegaly secondary to an incidentally discovered growth-hormone-releasing hormone secreting bronchial carcinoid tumour associated to a pituitary incidentaloma.

In this report we emphasize the opportunity of considering the uncommon causes of chronic GH-excess in the initial diagnostic process, such as GHRH hypersecretion, especially in the presence of ambiguous pituitary neuroimaging. This topic may have an important clinical significance in order to plan the most cost-effective diagnostic procedures and management and to avoid unnecessary pituitary neurosurgery.

Safety of carotid stenting for stroke prevention: need of an independent outcome assessor.

Safety and efficacy of carotid artery stenting have still to be fully established. We propose a standardized registry of carotid artery stenting in use at our hospital to evaluate whether the presence of an independent neurologist performing basal, procedural and post-procedural observation increases the accuracy of outcome assessment. We collected a cohort of patients receiving carotid stenting. An external neurologist supervised the endovascular intervention and monitored the patient's clinical conditions during procedure and follow-up time (12 months). The procedure was carried out successfully in all cases. We registered two intra-procedural strokes and two strokes within 24 h. The risk of major complications in our study was 9.1% at 30 days. Our complication rate is higher than in previous studies. These findings could be partly explained by the unemployment of distal protection devices, but also by the presence of an independent observer that might have increased the accuracy of neurological evaluation.

A potential catastrophic trap: an unusually presenting sellar lesion.

A 63-year-old man was admitted to our emergency unit complaining headache, vomit and vertigo. A MR of the brain showed an expanding lesion within the sellar region. A subsequent angio-MR excluded any intracranial vascular malformations. Surprisingly, a cerebral angiography performed later on the basis of worsening of neurological signs and symptoms, demonstrated an aneurysm of the internal carotid artery. At the best of our knowledge, this is the first case of a thrombosis of an intracavernous carotid aneurysm mimicking a pituitary apoplexy documented by MR and angio-MR. The treatment of a milder syndrome of pituitary apoplexy is still controversial. This case would favour conservative treatment opposed to surgery at least when an intracavernous extension or invasion of the adenoma would limit the opportunity of a complete tumour removal.

Increased levels of CSF heart-type fatty acid-binding protein and tau protein after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Heart-type Fatty Acid-Binding Protein (H-FABP) and tau protein (tau) have been shown to be novel biomarkers associated with brain injury and, therefore, they could represent a useful diagnostic tool in patients with subarachnoid hemorrhage (SAH). The goal of this study was to measure H-FABP and tau in cerebrospinal fluid (CSF) following SAH to test the hypothesis that a relationship exists between SAH severity and H-FABP/tau values. METHODS: Twenty-seven consecutive SAH patients admitted to our ICU were studied. Serial CSF samples were obtained in every patient starting on the day of SAH and daily for up to 2 weeks post-SAH. H-FABP/tau levels were measured by enzyme-linked immunosorbent assay. RESULTS: Patients with severe SAH showed significantly higher peak levels of H-FABP and tau compared to mild-SAH patients (FABP: p = 0.02; tay: p = 0.002). In addition the peak concentrations of H-FABP and tau in CSF from SAH patients correlated significantly with Glasgow Coma Scale motor score (H-FABP: Spearman r = -0.52, p = 0.006; tau: Spearman r = -0.63, p = 0.0004). Based on outcome at discharge from the hospital, patients were categorized into survivors and non-survivors. Peak concentrations of both proteins in the non-survivors group were significantly higher than in the survivors. CONCLUSIONS: H-FABP and tau CSF levels are proportional to SAH severity and may be novel biomarkers that can be used to predict the severity of outcome following clinical SAH.

Cortical and subcortical motor mapping in rolandic and perirolandic glioma surgery: impact on postoperative morbidity and extent of resection.

AIM: Surgery for gliomas located inside or in proximity of motor cortex or tracts requires cortical and subcortical mapping to locate motor function; direct electrical stimulation of brain cortex or subcortical pathways allows identification and preservation of motor function. In this study we evaluated the effect which subcortical motor mapping had on postoperative morbidity and extent of resection in a series of patients with gliomas involving motor areas or pathways. METHODS: One hundred and forty-six patients were included in the study. Intraoperative findings of primary motor cortex or subcortical tracts were reported, together with incidence of new postoperative deficits at short (1 week) and long term (1 month) examination. The relationship between intraoperative identification of subcortical motor tracts and extent of resection was reported. RESULTS: The motor strip was found in 133 patients (91%) and subcortical motor tracts in 91 patients (62.3%). New immediate postoperative motor deficits were documented in 59.3% of patients in whom a subcortical motor tract was identified intra-operatively and in 10.9% of those in whom subcortical tracts were not observed; permanent deficits were observed in 6.5% and 3.5%, respectively. A total resection was achieved in 94.4% of patients with high-grade gliomas and in 46.1% of those with low-grade gliomas.

Cabergoline in acromegaly: a renewed role for dopamine agonist treatment?

OBJECTIVE AND DESIGN: Eighteen active acromegalics entered a prospective open study with cabergoline (CAB), a dopaminergic drug much more potent than bromocriptine (Br). METHODS: CAB was administered for 6 months at doses ranging between 0.5 mg twice weekly and 0.5 mg/day. Clinical-anamnestic characteristics of the patients were: (i) sensitivity to dopamine agonist drugs (10 patients); (ii) resistance to somatostatin analogs (SAs) (8 patients): (iii) intolerance to SA (3 patients). In 2 patients marked hyperprolactinemia was present. RESULTS: Basal GH was 6.6 microg/l (2.2-50) (median (range)), and on treatment it was 3.5 microg/l (1.2-34) (P=0.013). The corresponding IGF-I values were 720 microg/l (410-1438) and 375 microg/l (167-1260) respectively (P=0.00001). Individual GH levels decreased below 2 microg/l in 5 patients, and between 2 and 5 microg/l in another 5 patients. IGF-I levels were suppressed below 50% of baseline in 8 patients and normal age-adjusted IGF-I values were reached in 5 patients (27% of the series). The retrospective comparison with previous chronic treatment with Br in the 10 suitable patients showed a greater effectiveness of CAB (IGF-I decrease on CAB treatment, 46.8%, on Br treatment, 31%, P=0.02). Adenoma shrank in the 3 patients whose pituitary imaging was repeated during CAB. CONCLUSIONS: These results envisage that CAB may represent a worthy therapeutic tool in acromegalic patients, inducing a degree of IGF-I and GH suppression comparable to SAs, administered by the oral route and much less expensive.

Progressive myelopathy caused by intracranial dural arteriovenous fistula: report of two cases and review of the literature.

We report two rare cases of progressive myelopathy caused by intracranial dural arteriovenous fistulae with venous drainage into the spinal medullary veins. Both patients were referred to us with a history of progressively worsening quadriparesis. A posterior fossa dural arteriovenous fistula with spinal venous drainage was discovered by angiography in both cases. Treatment consisted of direct clipping of the venous drainage in one patient and of transarterial embolization and excision of the involved dural sinus in the other patient. Such procedures provided a radioanatomical cure and marked neurological recovery in both patients. Only 10 cases of progressive myelopathy caused by an intracranial dural arteriovenous fistula have been previously reported. Dysfunction of the cervical cord by venous engorgement is thought to be the most probable cause of the neurological symptoms in such cases.

Surgical interruption of leptomeningeal drainage as treatment for intracranial dural arteriovenous fistulas without dural sinus drainage.

Intracranial dural arteriovenous fistulas (AVFs) have been recognized as acquired lesions that can behave aggressively depending on the pattern of venous drainage. Based on the type of venous drainage, they can be classified as fistulas drained only by venous sinuses, those drained by venous sinuses with retrograde flow in arterialized leptomeningeal veins, and fistulas drained solely by arterialized leptomeningeal veins. Serious symptoms, including hemorrhage and focal deficit, are related to the presence of arterialized leptomeningeal veins. In this paper, the authors report a consecutive series treated between 1988 and 1993 of 20 cases of intracranial dural AVFs with "pure leptomeningeal drainage." All patients underwent surgical interruption of the leptomeningeal draining veins. Based on the arterial supply, nine patients were managed by direct surgery, whereas 11 patients were prepared for surgery by means of preoperative arterial embolization. Radioanatomical cure of the fistula and good neurological recovery were achieved in 18 cases. Complete obliteration of the fistula was documented angiographically in two cases, but fatal hemorrhage occurred, probably due to partial thrombosis of the venous drainage. Based on this experience, the authors believe that surgical interruption of the draining veins is the best treatment option for intracranial dural AVFs. However, surgical results may be affected by the extension of postoperative thrombosis, which in turn may be related to the degree of preoperative venous engorgement.

Endovascular treatment with GDCs: results in 100 patients.

BACKGROUND: In this paper we review the clinical and morphological results of intracranial aneurysms treated with Guglielmi Detachable Coils. METHODS: We report our experience in 100 patients with intracranial aneurysms treated with GDC. Since February 1993 we have treated 70 females and 30 males, with a mean age of 57 years old, for a total of 118 intracranial aneurysms. Sixty-five patients had a recent history of ruptured aneurysm, 10 suffered from a previous subarachnoid hemorrhage and 25 patients had never bled. In the choice of treatment for subarachnoid aneurysm, in accordance with our neurosurgeons, we have not applied a protocol, rather we have followed guidelines in relation to: age, neurological clinical conditions, systemic disease and location of aneurysm. Morphological aspect of immediate aneurysm occlusion was: 60% more or less complete occlusion, 30% loose packing with 10% failures. RESULTS AND CONCLUSIONS: The clinical outcome at follow-up (1 month-3 years) was: 72 patients without neurological deficits, 19 patients improved pre-existing neurological deficits, 3 patients worsened for procedural complications; 6 patients died (1 patient unrelated).

Inflammatory meningioma of the fourth ventricle. Case report.

A case of meningioma with inflammatory reaction within the fourth ventricle in a 37 year-old man is described. The differential diagnosis between inflammatory meningioma, plasma cell granuloma and a possible collision of a meningioma with a plasmacytoma is discussed. The immunohistochemical examination of plasma cell population is emphasized. This is the first case reported of inflammatory meningioma located in the fourth ventricle.

Multidisciplinary (surgical and endovascular) approach to intracranial aneurysms.

In spite of the availability of the new endovascular technique (GDC) to manage cerebral aneurysms, to date, the crucial question "which is the proper treatment in a given patient?" still remains unsettled. In order to check whether an answer is possible, we retrospectively reviewed a personal series of 192 consecutive patients with cerebral aneurysms (1993-1995). We found 164 patients who had been considered eligible for active aneurysm treatment. Treatment modality has been chosen case by case on the basis of patient conditions, and aneurysm size and location. Four groups of patients were identified: Group 1: 104 patients (63.4%) with subarachnoid hemorrhage (SAH) in whom the treatment of choice was surgery; Group 2: 27 SAH patients (16.4%) in whom the first choice was GDC; Group 3: 7 SAH patients (4.2%) who died before the scheduled treatment; Group 4: 26 patients (15%) with not ruptured aneurysm who had either surgery or GDC. Based on the results of this series (improvement of the overall results through the multidisciplinary approach), we have developed the guidelines to prospectively manage future cases of cerebral aneurysms with the purpose to rationalize the management, thus further improving the overall results.

[Temporal lobe epilepsy: stereotaxic methods]. / Epilessie temporali: metodologia stereotassica.

We give a description of stereotaxic methodology as originally elaborated by the S.te Anne Hospital School in Paris, and successively modified and utilised in Niguarda Hospital in Milan. Performing a stereotactic arteriography and ventriculography should allow the appreciation of minimal modification of vascular anatomy, identification of sulci and gyri by utilising stereoscopic technique and the proportional grid, based on bicommissural line, evaluation of the morphological abnormalities and their precise reconstruction in the intracranial space. Anatomical information obtained by this kind of examinations are essential for intracerebral stereo-EEG investigation and for planning surgical procedure.

The endovascular treatment of a spinal perimedullary arteriovenous fistula with coils: a case report.

We report a case of direct spinal intradural ventral arteriovenous fistula of the thoraco-lumbar region. Angiography demonstrated a single feeder from the anterior spinal artery that drained directly into a markedly dilated vein without an intervening nidus. The endovascular treatment was performed by a transarterial approach and the occlusion of the fistula, after a failed treatment by a detachable balloon, was obtained by coils released in the initial fistulous site inside a venous dilatation with complete clinical cure. This case indicates that endovascular treatment is possible using coils as a valid and safe alternative to a balloon, glue or surgical approach.

Stenting for the treatment of high-grade intracranial stenoses.

To date, evidence to recommend endovascular treatment in patients with intracranial stenoses is lacking. Recently, the introduction of self-expanding stents (Wingspan Stent System) aroused considerable expectations in their employ for stroke prevention. We report a single-center experience of percutaneous transluminal angioplasty and stenting in a series of consecutive patients with intracranial stenoses and compare the safety and performance of balloon-mounted stents versus self-expanding stent systems (Wingspan). Thirty-four patients with 39 severe (>70%) intracranial stenoses were treated during a 6-year period. An independent stroke neurologist collected data about intra and periprocedural complications and short-term outcome. We considered as endpoint measures (1) any 30-day stroke or death (2) any major 30-day complication and (3) procedure technical success. Technical success was achieved in all patients. No vessel dissection or ruptures were observed. The 30-day stroke/death rate was 17.9%. Five ischemic strokes in the territory of treated vessels and two intracranial hemorrhages occurred respectively within 24 h and 5 days after endovascular treatment. Three (17.6%) patients of Wingspan treated group and four (18.2%) of the patients treated with different stent systems had unfavorable outcome. Our study confirms that endovascular treatment can be performed with a high technical success rate, even though the safety of these devices has still to be demonstrated.

The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism.

BACKGROUND AND PURPOSE: Data from recent reports have indicated that mechanical thrombectomy may have potential as a treatment for acute ischemic stroke. The purpose of this study was to assess the safety and performance of the Penumbra System (PS): a novel mechanical device designed to reduce clot burden in acute stroke due to large-vessel occlusive disease. MATERIALS AND METHODS: A prospective, single arm, independently monitored and core laboratory adjudicated trial enrolled subjects with an acute neurologic deficit consistent with acute stroke, presenting within 8 hours of symptom onset and an angiographically verified occlusion (Thrombolysis in Myocardial Infarction [TIMI] grade 0 or 1) of a treatable intracranial vessel. The primary end point was revascularization of the target vessel to TIMI grade 2 or 3. Secondary end points were the proportion of subjects who achieved a modified Rankin Scale (mRS) score of 2 or less or a 4-point improvement on the National Institutes of Health Stroke Scale (NIHSS) score at 30-day follow-up, as well as all-cause mortality. RESULTS: Twenty-three subjects were enrolled, and 21 target vessels were treated in 20 subjects by the PS. At baseline, mean age was 60 years, mean mRS score was 4.6, and mean NIHSS score was 21. Postprocedure, all 21 of the treated vessels (100%) were successfully revascularized by the PS to TIMI 2 or 3. At 30-day follow-up, 9 subjects (45%) had a 4-point or more NIHSS improvement or an mRS of 2 or less. The all-cause mortality rate was 45% (9 of 20), which is lower than expected in this severe stroke cohort, where 70% of the subjects at baseline had either an NIHSS score of more than 20 or a basilar occlusion. CONCLUSION: Thus, early clinical experience suggests that the PS allows revascularization in certain subjects experiencing acute ischemic stroke.

[Surgical versus endovascular treatment in cerebral aneurysm. The opinion of a neuroradiologist]. / Trattamento chirurgico o endovascolare dell'aneurisma cerebrale. Il parere del neuroradiologo.

Surgery is currently the treatment of choice for acutely ruptured aneurysms, representing an efficient option both in the short and long term. We believe that the endovascular option may be of help in high surgical-risk cases.

Stimulatory effect of oCRH on alpha-subunit secretion during petrosal sinus sampling in patients with Cushing's disease.

During bilateral and simultaneous venous sampling of the inferior petrosal sinuses for preoperative localization of ACTH secreting microadenomas, alpha-subunit levels, in addition to ACTH, were determined in 9 patients with Cushing's disease. The aim of the study was to evaluate the possible occurrence of unilateral increases of alpha-subunit in basal conditions and the alpha-subunit responsiveness to oCRH. All the patients examined showed a central to peripheral and an intersinus gradient of ACTH concentrations before and/or after oCRH stimulation. Seven patients showed a central to peripheral alpha-subunit gradient in basal conditions. Lateralization of alpha-subunit concentrations was recorded in 4 patients in basal conditions (intersinus gradient > or = 1.55) and paralleled the side with the highest ACTH concentrations. After oCRH stimulation all but one patient showed a unilateral alpha-subunit increase in blood from the inferior petrosal sinus with the highest oCRH stimulated ACTH increase. The present data confirm the occurrence of an increase of alpha-subunit concentration in response to nonspecific stimulation with exogenously administered oCRH, concurrent with an ipsilateral increase of ACTH levels. The mechanism underlying this finding is still unclear, although a paracrine effect from the corticotroph tumour on adjacent pituitary tissue seems so far the most likely explanation.

Inferior petrosal sinus sampling: evidence of a stimulatory effect of oCRH on GH secretion in Cushing's disease.

Preoperative localization of ACTH-secreting microadenomas has been performed in 9 patients with Cushing's disease by using bilateral and simultaneous venous sampling of the inferior petrosal sinuses. In addition to ACTH and PRL we determined GH levels after oCRH stimulation in order to confirm the possible occurrence of unilateral GH increases, as recently observed by us in one patient. A central-to-peripheral and an intersinus gradient of ACTH concentration was observed in all patients examined before and/or after oCRH stimulation. In 7 patients central-to-peripheral and side-to-side PRL gradients were recorded in basal conditions: in 5 of these patients a unilateral oCRH-induced PRL increase was observed. Six out of the 7 patients with unilateral PRL increases also showed an intersinus GH gradient in basal conditions (ratio greater than or equal to 1.5); in 5 of them a clearcut oCRH-induced GH increase was observed. A peripheral oCRH-induced GH and PRL increase was not observed in any of the patients. The observation of a paradoxical oCRH-induced GH increase in the inferior petrosal sinus with the higher ACTH concentration is of speculative and clinical interest; whether it reflects co-secretion of hormones by the tumour or hormone release by non-tumourous cells via paracrine mechanism is still to be clarified. The unilateral GH increase could represent an additional signal of the presence and localization of an ACTH-secreting tumour.