The role of radiation therapy in the management of non-functioning pituitary adenomas.

Surgical removal of non-functioning pituitary adenoma (NFPA) is the first-choice therapeutic option, but radical removal of the tumor cannot be accomplished in all patients. The best strategy to prevent regrowth of NFPA is still a matter of debate. Adjuvant radiotherapy is very effective in reducing recurrence rate after incomplete removal of NFPA, but concerns still exist about long-term toxicity of radiation. Different modalities have been developed to irradiate the pituitary region. One major distinction is between radiation techniques that deliver the total dose in multiple sessions using 3 fixed radiation beams and radiosurgical equipment that delivers the total dose to the target volume in a single treatment session. Progression-free survival of patients with NFPA treated by adjuvant radiotherapy is well above 90% at 5 yr in most studies and diminishes only slightly at 10 yr. Very few studies have a more prolonged follow-up. In comparison, the 5- and 10-yr estimated recurrence rate without adjuvant radiotherapy ranged from 15% to 51% and from 44% to 78%, respectively. Complications of radiation include rare but severe side-effects, such as secondary brain neoplasm, optic neuropathy, cerebrovascular accidents, and more frequent but less severe complications, such as pituitary deficiency. Optimal management of patients with residual or recurring NFPA after surgical debulking can be achieved through the judicious use of different treatment options, necessitating close cooperation between neurosurgeons, endocrinologists, and radiation oncologists.

Reversible inhibition of the pollen germination and the stigma penetration in Crocus vernus ssp. vernus (Iridaceae) following fumigations with NO2, CO, and O3 Gases.

We assessed the pollen hydration, the pollen germination, and the stigma papilla penetration of CROCUS VERNUS subsp. VERNUS (Iridaceae) after 2 h fumigations with O (3), NO (2), and CO gases within humidified (90 - 100 % RH) box experiments. When the pollen and the pistil were separately fumigated, the pollen retained the capacity to emit a tube which penetrated papilla, and the stigma papillae retained the receptivity; when the pistils were first pollinated and then fumigated, the capacity of pollen to hydrate was not affected, but the germination was significantly reduced. The vulnerability to gases became evident at 0.3 ppm O (3), 0.2 ppm NO (2), and 0.5 ppm CO. The inhibition curves as a function of the gas concentrations were of an exponential type, and they saturated at 2 ppm NO (2), 25 ppm CO, and 0.5 ppm O (3), with germination percentages of 17 %, 27 %, and 60 %, respectively. Both the pollen germination and the papilla penetration were fully restored by prolonging for 60 - 90 min the incubation at 90 - 100 % RH, after the cessation of fumigations. The vulnerability of the pollen-papilla system is discussed.

Regional blood-brain barrier permeability changes after restoration of blood flow in postischemic gerbil brains: a quantitative study.

A quantitative technique utilising [14C]alpha-aminoisobutyric acid as a tracer was used to study cerebrovascular permeability in 22 Mongolian gerbils. Seven other animals were used to measure cerebral blood volumes. Global cerebral ischaemia was produced by temporary bilateral carotid artery occlusion (60 min) in 16 gerbils that were sacrificed at 1, 2, and 3 h following reperfusion. The blood-to-brain transfer constant was significantly increased after 2 h of reperfusion in the ischaemic zones and also in structures, like the cerebellum, not supplied by the carotid artery and not ischaemic during the vessel occlusion. The blood-brain barrier (BBB) alterations were coincident with the onset of ischaemia--induced seizures that were accompanied by sudden "spikes" of systemic blood pressure. Epilepsy may play an important role in the development of BBB damage in this ischaemic model, and this factor must be considered in the interpretation of BBB damage data in gerbils.

Quantitative measurement of cerebral blood flow and cerebral blood volume after cerebral ischaemia.

CBF obtained by the hydrogen clearance technique and cerebral blood volume (CBV) calculated from the [14C]dextran space were measured in three groups of rats subjected to temporary four-vessel occlusion to produce 15 min of ischaemia, followed by 60 min of reperfusion. In the control animals, mean CBF was 93 +/- 6 ml 100 g-1 min-1, which fell to 5.5 +/- 0.5 ml 100 g-1 min-1 during ischaemia. There was a marked early postischaemic hyperaemia (262 +/- 18 ml 100 g-1 min-1), but 1 h after the onset of ischaemia, there was a significant hypoperfusion (51 +/- 3 ml 100 g-1 min-1). Mean cortical dextran space was 1.58 +/- 0.09 ml 100 g-1 prior to ischaemia. Early in reperfusion there was a significant increase in CBV (1.85 +/- 0.24 ml 100 g-1) with a decrease during the period of hypoperfusion (1.33 +/- 0.03 ml 100 g-1). Therefore, following a period of temporary ischaemia, there are commensurate changes in CBF and CBV, and alterations in the permeability-surface area product at this time may be due to variations in surface area and not necessarily permeability.

Genomic organization and transcription of the human retinol dehydrogenase 10 (RDH10) gene.

A cDNA clone up-regulated in hydraulic lung edema in rabbit showed high similarity with human RDH10 mRNA, which encodes a protein involved in retinoic acid metabolism. We defined the organization of the human gene, which includes a unique transcriptional start site, a coding region with six translated exons and a 3' untranslated region containing at least two used polyadenylation sites. The two poly(A) signals are responsible for the production of the 3 and 4 kb RDH10 mRNA isoforms detected in several human tissues and cell lines.

The role of cerebral blood volume changes in brain specific-gravity measurements.

Cerebral blood volume (CBV) was calculated in gerbils from specific-gravity (SG) changes between normal and saline-perfused brains. Furthermore, changes in CBV were investigated during ischemia using carbon-14-labeled dextran (MW 70,000) as an intravascular marker. Both data were used to evaluate the possible error due to a change in CBV on the measurement of ischemic brain edema by the SG method. The methodological error found was 0.0004 for a 100% CBV change. This error is insignificant, being less than the standard deviation in the SG measured for the gerbil cortex (SG 1.0494 +/- 0.0006). Thus, CBV changes are not responsible for the SG variations observed during the first phase of ischemia. These variations are better explained as an increase of brain water content during ischemia.

Physiopathological criteria of vasospasm treatment.

Cerebral vasospasm following aneurysmal subarachnoid hemorrhage is one of the most important causes of cerebral ischemia, and is the leading cause of death and disability after aneurysmal rupture. The optimal treatment of vasospasm awaits development of agents for blocking or inactivating spasmogenic substances, or blocking arterial smooth muscle contraction. Rheological and/or hemodynamic manipulation using triple-H (hypertensive-hypervolemic-hemodilution) therapy to prevent or reverse ischemic consequences are relatively effective, but complicated and hazardous, and should be viewed principally as interim measures awaiting development of more specific therapies for arterial narrowing.

Mild hypothermia.

Recent evidence indicates that the relationship between "brain protection" and the degree of hypothermia is not linear, and even mild reduction of body temperature (i.e. 2-5 degrees C) may provide protection against cerebral ischemia. The protective effects of mild hypothermia have been demonstrated in various animal models of cerebral ischemia, and are encouraging in human studies. At the present time, although there is no randomized clinical trial assessing the benefits of mild hypothermia for intracranial aneurysm clipping, some neurosurgical centers are routinely instituting mild hypothermia before vascular occlusion.

Choroid plexus papilloma of the third ventricle.

Choroid plexus papillomas are rarely located in the third ventricle. The case of a 49-year-old man who had a total microsurgical excision of such a lesion is reported. The neuroradiological features and the surgical results are discussed, with a review of 25 other cases reported in the literature. Microsurgical technique made possible a good exposure and successful complete removal of the tumor.

Paramedian hourglass epidermoid extending above and below the tentorium.

The case of a 22-year-old woman with a large hourglass epidermoid tumor extending both below and above the tentorium is presented. The tumor was located in the suprasellar region, left middle cranial fossa, and posterior fossa on the left side. Conventional computerized tomographic (CT) scanning was inconclusive as to the actual extension of the tumor, whereas air encephalography was more helpful. The subtemporal transtentorial approach made it possible to achieve a seemingly radical excision of the tumor. Nevertheless, the CT scan one year later showed the presence of a small tumor mass. The diagnostic and surgical implications are discussed in light of few similar cases reported in the literature.

[What happened to Zollinger-Ellison syndrome?]. / Dove sono finite le sindromi di Zollinger-Ellison?

Three Zollinger-Ellison syndrome patients were treated during the period January 1977 to June 1978. The first patient is in good health 11 years 3 months after a total gastrectomy as is the second patient, 11 year after the enucleation of a cephalo-pancreatic gastrinoma. However the third patient died from malignancy 5 years after a total gastrectomy and enucleation of a cephalo-pancreatic gastrinoma followed by therapeutic cycles with streptozotocin and 5-fluorouracil. The decline in the Zollinger-Ellison syndrome over the last ten years is examined and the type of surgical treatment is discussed. Total gastrectomy once advocated as the preferred treatment, is now reappraised because of the effectiveness of medical therapy in controlling ulcers and because of the frequent malignancy of pancreatic gastrinomas.

[VIPoma: surgical treatment]. / VIPoma: trattamento chirurgico.

This paper reports a case of pancreatic VIPoma with widespread hepatic metastasis which was treated for approximately 2 years with a synthetic somatostatin analog (SMS 201/995). The treatment of choice in cases in which the tumour was fully removable is surgical resection. This occurred rarely since approximately 80% of VIPomas are malignant and are operated late when local infiltration is already widespread; in addition, 50% of cases are already metastasised at diagnosis. In this case, due to the infiltration of the superior mesenteric artery by the primary tumour it was necessary to carry out a left pancreasectomy which included two-thirds of the neoplastic mass. This was justified by slow tumour growth and also facilitated control of diarrhea and ensured a greater efficacy of possible postoperative chemotherapy. The use of synthetic somatostatin analog (SMS 201/995) enabled diarrhea to be satisfactorily controlled and is therefore specifically indicated for this type of tumour. NSE serum assay (neuron specific enolase) allowed the evolution of disease to be monitored during follow-up.

[Diagnostic problems and results of laparoscopic cholecystectomy in chronic acalculous cholecystitis]. / Problemi diagnostici e risultati della colecistectomia laparoscopica nella colecistite cronica alitiasica.

We report on our experience with laparoscopic cholecystectomy in 15 patients, 12 females and 3 males (mean age: 44 years), with chronic acalculous cholecystitis. These patients presented with recurrent episodes of biliary colic together with a dysmorphic or dysfunctioning gallbladder as confirmed by ultrasound and/or cholescintiscan with 99m-Tc HIDA performed in fasting conditions and after meals. First of all, we considered the possible presence of concomitant digestive disease (peptic ulcer disease, recurrent pancreatitis, irritable bowel syndrome, chronic hepatitis) potentially responsible for the pain. Ultrasound investigations revealed a pathological gallbladder in 10 patients. Cholecystectomy was curative in 8/10. Cholescintiscan revealed a pathological gallbladder in 8 patients and cholecystectomy was curative in only 5 of these. No postoperative deaths or significant complications occurred. The mean duration of the operation (35 vs 48 min) and hospital stay (2.1 vs 2.8 days) were reduced in comparison to 346 cholecystectomies performed for gallstones. After 6-36 months' follow-up, resolution of symptoms was successful in 10/15 cases (66.6%); in 3 cases, only dyspepsia was reduced, whilst in the other 2 cases, who also presented concomitant irritable bowel syndrome and gastroduodenitis, there was no improvement in pain. In all but the latter two cases (86.6%), histological examination revealed chronic gallbladder inflammation. In conclusion, laparoscopic cholecystectomy was curative (66.6%) or led to an improvement in symptoms (20%) in patients with chronic acalculous cholcystitis. Cholescintiscans were not always diagnostic for the disease, whereas ultrasound findings were more useful as an indication for surgery.

[Multicenter prospective study of informed consent in general surgery]. / Studio prospettico multicentrico sul consenso informato in chirurgia generale.

To understand the level of acceptance, awareness and usefulness of informed consent, a group of 119 patients (59 men and 60 women) from different types of hospitals were given a questionnaire which required only 'YES or NO' answers, both before and after surgery. The questionnaire concerned the patient's knowledge about pathology, operative risks, approval, anxiety caused, understanding of information received and consent given, and also if he would inform a relative in the same condition. From the analysis of the results it was established that: the more information a patient has about his illness and operation risks, the more he will want to have; the less he knows the less he will want to know, and he will also have more faith in the doctors. Some patients would not inform a relative with a similar pathology. To conclude, informed consent, instead of being a right of the patient is progressively becoming more a right of the doctor. It does not have any real effect on the patient's choice but is useful, as it represents a moment of personalised attention from medical personnel, though the patient may not completely understand the information received. There are few advantages in strictly medical terms but informed consent has increased malpractice litigation.

[An assessment of neuronal regeneration in neural anastomoses by synthetic guide and biological systems and insulin administration: an experimental study in the rat]. / Valutazione della rigenerazione neuronale nelle anastomosi nervose mediante sistemi tutoriali sintetici, biologici e somministrazione di insulina: studio sperimentale sul ratto.

The synthetic and biological nerve guide regeneration gives interesting perspective of use in making artificial conduits for peripheral nerve reconstruction. In sixty Wistar rats, under general anesthesia and with microsurgical technique, the ischiatic nerve was isolated. On the right side a segment of the nerve was removed in order to create a 10 mm gap. The defect then repaired using the conduit. Control were performed at 20, 90, 180 days and consisted in histological microscopy and electromyography investigation. The regeneration of the nerve fibers in the lumen of the conduit was not significantly different on the contralateral nerve limb.

Vestibular assessment in patients with vestibular schwannomas: what really matters?

Vestibular function is often underdiagnosed in vestibular schwannomas (VS). To evaluate it in a selected group of patients harbouring vestibular schwannomas, 64 patients were included in this study, recruited between March 2008 and June 2011 at our institution. All patients underwent Gd-enhanced MRI and complete neurotological evaluation before gamma knife surgery. Morphological measurements included Koos Classification and quantification of internal acoustic canal filling in length and diameter. Cochlear and vestibular functions were assessed considering pure tone and speech audiometry, bedside examination and caloric test by videonystagmography. A statistical analysis was performed to find possible correlations between morphological and cochleovestibular data. Patients with a higher intracanalicular length (ICL, mean value 8.59 and median 8.8 mm) of the tumour presented a higher value of UW than the subgroup with a lower length (51.9 ± 24.3% and 38.8 ± 18.1% respectively, p = 0.04), while no difference was detected for pure tone audiometry (PTA) values (50.9 ± 22.3 db and 51.1 ± 28.9 db respectively). Patients with a higher ICL also presented a higher rate of positive HIT (88% and 60% respectively, p = 0.006). Patients with a higher value of intracanalicular diameter (ICD, mean value 5.22 and median 5.15 mm) demonstrated higher values of UW (50.2 ± 29.1% and 39.3 ± 21% respectively, p = 0.03), but not different PTA (50.2 ± 29.1 db and 51.9 ± 29.9 db respectively). Finally, patients with a positive head impulse test (HIT) demonstrated significantly higher values of unilateral weakness (UW) (p = 0.001). Vestibular disorders are probably underdiagnosed in patients with VS. ICL and ICD seem to be the main parameters that correlate with vestibular function. Also, in case of small intracanalar T1 VS a slight increase of these variables can result in significant vestibular impairment. The data reported in the present study are not inconsistent with the possibility of proactive treatment of patients with VS.

Painful cervical dystonia triggered by the extension wire of a deep brain stimulator.

Deep brain stimulation (DBS) can be complicated by adverse events, which are generally classified as surgical-hardware or stimulation-related. Here we report the onset of a painful cervical dystonia probably triggered by the extension wire of a subthalamic nucleus (STN)-DBS device in a woman suffering from advanced Parkinson's disease (PD). Two months after implantation of the STN-DBS device, our patient developed a painful cervical dystonia, which was not responsive to neurostimulation or to medication. No sign of infections or fibrosis was detected. A patch test with the components of the device was performed, revealing no hypersensibility. The patient was referred back to surgery to reposition the pulse generator in the contralateral subclavian region. A deeper channeling of the wire extensions produced a complete remission of the painful dystonia.

Treatment with daptomycin for Corynebacterium Jeikeium left-sided prosthetic valve endocarditis.

Prosthetic valve endocarditis (PVE) is a serious complication with potential fatal consequences, classified as early or late PVE, depending on whether typical symptoms occur within or later than 12 months from surgery. The incidence of early PVE is under 1%, but it carries high morbidity and mortality rates. There are few reported cases in literature of PVE due to Corynebacterium Jeikeium even though it is present in normal skin flora particularly in hospitalized patients. Corynebacterium species are, in fact, recognized as uncommon agents of endocarditis and little is known regarding species-specific risk factors and the outcome in this kind of endocarditis. Described is an unusual case report of a 57-year-old man who had early aortic PVE due to Corynebacterium Jeikeium infection complicated by dehiscence of the prosthesis, complete atrio-ventricular block, perforation of the interventricular septum and septic shock. Prompt diagnosis, choice of daptomycin as antibiotic therapy although it has only been approved by the European Medicine Agency (EMEA) for right-sided endocarditis and timely open heart surgery, resulted in a successful outcome.

MR imaging of neoplastic central nervous system lesions: review and recommendations for current practice.

MR imaging is the preferred technique for the diagnosis, treatment planning, and monitoring of patients with neoplastic CNS lesions. Conventional MR imaging, with gadolinium-based contrast enhancement, is increasingly combined with advanced, functional MR imaging techniques to offer morphologic, metabolic, and physiologic information. This article provides updated recommendations to neuroradiologists, neuro-oncologists, neurosurgeons, and radiation oncologists on the practical applications of MR imaging of neoplastic CNS lesions in adults, with particular focus on gliomas, based on a review of the clinical trial evidence and personal experiences shared at a recent international meeting of experts in neuroradiology, neuro-oncology, neurosurgery, and radio-oncology.

Changes in brain glucose metabolism in subthalamic nucleus deep brain stimulation for advanced Parkinson's disease.

BACKGROUND: Despite its large clinical application, our understanding about the mechanisms of action of deep brain stimulation of the subthalamic nucleus is still limited. Aim of the present study was to explore cortical and subcortical metabolic modulations measured by Positron Emission Tomography associated with improved motor manifestations after deep brain stimulation in Parkinson disease, comparing the ON and OFF conditions. PATIENTS AND METHODS: Investigations were performed in the stimulator off- and on-conditions in 14 parkinsonian patients and results were compared with a group of matched healthy controls. The results were also used to correlate metabolic changes with the clinical effectiveness of the procedure. RESULTS: The comparisons using Statistical parametric mapping revealed a brain metabolic pattern typical of advanced Parkinson disease. The direct comparison in ON vs OFF condition showed mainly an increased metabolism in subthalamic regions, corresponding to the deep brain stimulation site. A positive correlation exists between neurostimulation clinical effectiveness and metabolic differences in ON and OFF state, including the primary sensorimotor, premotor and parietal cortices, anterior cingulate cortex. CONCLUSION: Deep brain stimulation seems to operate modulating the neuronal network rather than merely exciting or inhibiting basal ganglia nuclei. Correlations with Parkinson Disease cardinal features suggest that the improvement of specific motor signs associated with deep brain stimulation might be explained by the functional modulation, not only in the target region, but also in surrounding and remote connecting areas, resulting in clinically beneficial effects.