Frequency of brain ventricular enlargement among patients with diabetes mellitus.

AIMS: To determine the prevalence of dilated ventricles and concomitant high blood glucose measures. METHODS: We retrieved blood glucose measures from the emergency department database and selected a subgroup of individuals having both the radiological marker Evans' index (EI) values and blood glucose measures. RESULTS: Out of 1221 consecutive patients submitted to axial Computed Tomography scans, a blood glucose measure was detected in 841 individuals. 176 scans (21 %) showed an EI > 0.30. According to the blood glucose categorization, diabetic patients were 104 (12 %), 25 of them (24 %) were dilated (mean EI 0.33). The age difference between dilated and not-dilated ventricles is about ten years in not-diabetic participants, whereas it is five years in diabetic participants. The age difference between dilated and not-dilated ventricles is about 10 years in diabetic men, whereas it zero in diabetic women. CONCLUSIONS: Pathological ventricular enlargement is more frequent in men and in the elderly. In diabetic patients (especially women), the cerebral ventricles enlarge faster than in non-diabetic individuals. Age, sex, and diabetes may interact in determining how cerebral ventricle size changes over time, especially in diabetic women, making routine brain imaging advisable in these patients after the age of 70 years.

Cerebellum's Contribution to Attention, Executive Functions and Timing: Psychophysiological Evidence from Event-Related Potentials.

Since 1998, when Schmahmann first proposed the concept of the "cognitive affective syndrome" that linked cerebellar damage to cognitive and emotional impairments, a substantial body of literature has emerged. Anatomical, neurophysiological, and functional neuroimaging data suggest that the cerebellum contributes to cognitive functions through specific cerebral-cerebellar connections organized in a series of parallel loops. The aim of this paper is to review the current findings on the involvement of the cerebellum in selective cognitive functions, using a psychophysiological perspective with event-related potentials (ERPs), alone or in combination with non-invasive brain stimulation techniques. ERPs represent a very informative method of monitoring cognitive functioning online and have the potential to serve as valuable biomarkers of brain dysfunction that is undetected by other traditional clinical tools. This review will focus on the data on attention, executive functions, and time processing obtained in healthy subjects and patients with varying clinical conditions, thus confirming the role of ERPs in understanding the role of the cerebellum in cognition and exploring the potential diagnostic and therapeutic implications of ERP-based assessments in patients.

Balloon-Assisted Corpus Callosotomy. Reducing the Impact of Transcallosal Approaches.

BACKGROUND: The interhemispheric transcallosal approach is widely used to remove intraventricular lesions. Corpus callosotomy gives immediate access to the ventricular chambers but is invasive in nature. Loss of callosal fibers, although normally tolerate, may cause disturbances ranging from a classical disconnection syndrome up to minor neuropsychological changes. OBJECTIVE: To open an operative window in the corpus callosum through separation rather than disconnection of the white matter fibers. METHODS: In 7 patients undergoing the interhemispheric transcallosal approach for intraventricular lesions, lying around or below the foramen of Monro, a stoma was created within the corpus callosum by using a 4F Fogarty catheter. The series included 3 colloid of the third ventricle, 2 thalamic cavernomas, 1 subependymoma, and 1 ependymoma of the foramen of Monro. We illustrate the technique and the clinico-radiological outcome, focusing on the size of callosotomy as seen on postoperative MRI. RESULTS: The balloon-assisted corpus callosotomy provided a circular, smooth-walled access to the ventricular chambers, which allowed uncomplicated removal of the lesions. On postoperative MRI, the size of the callosotomy shrinked compared with surgery (2.8-6.4 mm at follow-up vs 6-9 mm as measured intraoperatively). No signs of disconnection syndrome or new permanent deficits were observed in this series. CONCLUSION: The balloon-assisted technique produces a small callosotomy, without clinical consequences, showing a self-closing trend on postoperative MRI. This technique is a rewarding tool to reduce the impact of callosotomy while keeping the advantages of microsurgical interhemispheric approaches.

Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis.

BACKGROUND: Emergent carotid artery stenting (eCAS) is performed during mechanical thrombectomy for acute ischemic stroke due to tandem occlusion. However, the optimal management strategy in this setting is still unclear. OBJECTIVE: To carry out a systematic review and meta-analysis to investigate the safety and efficacy of eCAS in patients with tandem occlusion. METHODS: Systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from January 1, 2004 to March 7, 2022 for studies evaluating eCAS and no-stenting approach in patients with stroke with tandem occlusion. Primary endpoint was the 90-day modified Rankin Scale score 0-2; secondary outcomes were (1) symptomatic intracerebral hemorrhage (sICH), (2) recurrent stroke, (3) successful recanalization (Thrombolysis in Cerebral Infarction score 2b-3), (4) embolization in new territories, and (5) restenosis rate. Meta-analysis was performed using the Mantel-Haenszel method and random-effects modeling. RESULTS: Forty-six studies reached synthesis. eCAS was associated with higher good functional outcome compared with the no-stenting approach (OR=1.52, 95% CI 1.19 to 1.95), despite a significantly increased risk of sICH (OR=1.97, 95% CI 1.23 to 3.15), and higher successful recanalization rate (OR=1.91, 95% CI 1.29 to 2.85). Restenosis rate was lower in the eCAS group than in the no-stenting group (2% vs 9%, p=0.001). Recanalization rate was higher in retrograde than antegrade eCAS (OR=0.51, 95% CI 0.28 to 0.93). Intraprocedural antiplatelets during eCAS were associated with higher rate of good functional outcome (60% vs 46%, p=0.016) and lower rate of sICH (7% vs 11%; p=0.08) compared with glycoprotein IIb/IIIa inhibitors. CONCLUSIONS: In observational studies, eCAS seems to be associated with higher good functional outcome than no-stenting in patients with acute ischemic stroke due to tandem occlusion, despite the higher risk of sICH. Dedicated trials are needed to confirm these results.

The Central Cord Syndrome in Patients with Cervical Spinal Cord Tumors: A 19th-Century Vignette from (Karl) Julius Vogel (1814-1880).

Between 1830 and 1850, (Karl) Julius Vogel was one of the most important German pathologists. He received his doctorate in medicine in 1838 from the University of Munich and habilitation in pathology in 1840. In 1846, he moved to the University of Giessen as a full professor of pathology. From 1855, he taught special pathology and therapy at the University of Halle and became director of the internal clinic. Vogel and Heinrich Adolph Karl Dittmar were the first clinicians to describe the symptoms and pathologic findings of the central cord syndrome in a cervical spine tumor.

Interhemispheric contralateral approach: the falx as a retractor.

The contralateral transfalcine approach is a valuable option to access lesions around the mesial surface of the brain hemispheres. Despite a favourable perspective, surgical manoeuvres within the interhemispheric fissure carry a risk of inadvertent injury to the healthy cortex on the craniotomy side. To overcome this drawback, a new method of brain retraction was developed. After dissecting the interhemispheric fissure, the falx was incised in an upside-down U-shaped manner and hinged inferiorly, taking care not to violate the inferior sagittal sinus. The falcine flap was reflected laterally and fixed to the lateral edge of the craniotomy, providing homogeneous retraction of the ipsilateral mesial cortex. Surgery proceeded with the brain surface hidden from the surgeon's view and protected by the flap. The absence of retractor devices hindering the surgeon's movements further simplified the procedure.

Cotinine levels influence the risk of rupture of brain aneurysms.

Cotinine, the primary metabolite of nicotine, is currently regarded as the best biomarker of tobacco smoke exposure. We aim to assess whether cotinine levels are associated with (1) intracranial aneurysm and (2) intracranial aneurysm rupture. METHODS: We performed a single-center case-control study. Cases were consecutive patients admitted with diagnosis of brain aneurysm (ruptured or unruptured). We randomly selected controls without intracranial aneurysm from the same source population that produced the cases. Smoking data were collected by questionnaire, and serum levels of cotinine were used as an objective measure of nicotine exposure. Logistic regression models were used to assess the relationship between cotinine levels and aneurysm rupture. RESULTS: We included 86 patients with intracranial aneurysm and 96 controls. Smoking status (p < .001), cotinine levels (p = .009), and female sex (p = .006) were associated with diagnosis of intracranial aneurysm. In the multivariate analysis, controlling for sex, smoker status and age, levels of cotinine were independently associated with aneurysm rupture (OR 1.53, 95% CI 1.10-2.13, p = .012). CONCLUSIONS: Our results suggest that high cotinine levels in smokers with brain aneurysm are significantly associated with high rupture risk, independently of smoker status, age, and sex.

Retrospective multicenter study on the management of asymptomatic carotid artery stenosis with coexistent unruptured intracerebral aneurysm.

OBJECTIVE: To evaluate the results of carotid endarterectomy (CEA) in patients with a concomitant asymptomatic intracranial aneurysm discovered at preoperative diagnostic imaging. METHODS: From January 2000 to December 2020, 75 consecutive patients admitted for surgical treatment of asymptomatic more than 70% (North American Symptomatic Carotid Endarterectomy Trial) carotid artery stenosis presented at preoperative computed tomography angiography (CTA) with a concomitant, unruptured intracranial aneurysm (UIA). Aneurysm diameter was 5 mm or less in 25 patients (group A), from 6 to 9 mm in 38 patients (group B), and 10 or more mm in 12 patients (group C). Sixty UIAs (80%) were treated before performing CEA, 10 in group A (40%), 38 (100%) in group B, and 12 (100%) in group C. Twenty-five UIAs (42%) were subjected to surgical clipping and 35 (58%) to coiling. The mean time intervals were 48 days (range, 20-55 days) between clipping and CEA, and 8 days (range, 4 -13 days) between coiling and CEA. CEA was standard and performed through eversion of the internal carotid artery in 36 patients (48%) and through longitudinal arteriotomy with systematic patch closure in 39 patients (52%). The primary end points of the study were mortality and morbidity related to each of the two treatments, including any complication occurring during the time interval between the two procedures or within 30 days after the last procedure. Secondary end points were mid-term survival and freedom from ischemic or hemorrhagic stroke and carotid restenosis. RESULTS: One patient died during the 30 days after the clipping of a 11-mm diameter UIA of the basilar artery. No other death or complication was observed after CEA and treatment of the UIA, or during the time interval between the two procedures. During a median follow-up of 26 months (interquartile range, 18-30 months), no late stroke and no carotid restenosis were observed. At 22, 27, 29 and 31 months after CEA, four patients in group A underwent surgical clipping of an enlarging intracranial aneurysm that had not been treated initially owing to its small diameter. The cumulative survival rate at 30 months by Kaplan-Meier plots was 83 ± 5%. CONCLUSIONS: Concomitant asymptomatic carotid artery stenosis and UIA is a rare entity. Our study suggests that in this setting, prior treatment of the UIA followed by CEA is safe.

Temporal Horn Enlargements Predict Secondary Hydrocephalus Diagnosis Earlier than Evans' Index.

The aim of this study was to identify early radiological signs of secondary hydrocephalus. We retrieved neuroradiological data from scans performed at various times in patients who underwent surgery for secondary hydrocephalus due to severe traumatic brain injury (TBI), subarachnoid haemorrhage (SAH), or brain tumour (BT). Baseline measurements, performed on the earliest images acquired after the neurological event (T0), included Evans' index, the distance between frontal horns, and the widths of both temporal horns. The next neuroimage that showed an increase in at least one of these four parameters­and that lead the surgeon to act­was selected as an indication of ventricular enlargement (T1). Comparisons of T0 and T1 neuroimages showed increases in Evans' index, in the mean frontal horn distance, and in the mean right and left temporal horn widths. Interestingly, in T1 scans, mean Evans' index scores > 0.30 were only observed in patients with BT. However, the temporal horn widths increased up to ten-fold in most patients, independent of Evans' index scores. In conclusion temporal horn enlargements were the earliest, most sensitive findings in predicting ventricular enlargement secondary to TBI, SAH, or BT. To anticipate a secondary hydrocephalus radiological diagnosis, clinicians should measure both Evans' index and the temporal horn widths, to avoid severe disability and poor outcome related to temporal lobe damage.

Surgical Treatment of Single Pontomedullary Junction Metastasis from Lung Cancer.

Background: When lung cancer develops a solitary metastasis at the pontomedullary junction, due to surgical risk, the current oncologic treatment is radiosurgery and chemotherapy. Case Description. We describe a patient with a single intrinsic metastasis at the pons and medulla. Removal was successful, without complication. Conclusion: Surgery can provide excellent results, and in selected patients, it should be considered a first-line treatment in experienced hands.

Third Cranial Nerve Palsy after Monoclonal Antibody Therapy for Lung Cancer: A Case Report.

Immune checkpoint inhibitors (ICIs) have shown promise in treating cancer patients, and pembrolizumab is a monoclonal IgG4 antibody that targets a human cell surface protein (receptor) called PD-1. Among the side effects, a rare cranial nerve palsy unrelated to the surgical treatment may occur. We report a case of a woman, which after neurosurgical treatment for cerebellar metastasis presented painless third cranial nerve palsy. The benefits of ICIs have been ascertained, but side effects also take place. Neurological symptoms should be recognized early to avoid substantial morbidity, and if necessary, the oncologic treatment should be changed.

Near-Infrared Transflectance Spectroscopy Discriminates Solutions Containing Two Commercial Formulations of Botulinum Toxin Type A Diluted at Recommended Volumes for Clinical Reconstitution.

Botulinum neurotoxin type A (BoNT-A) is the active substance in pharmaceutical preparations widely used worldwide for the highly effective treatment of various disorders. Among the three commercial formulations of BoNT-A currently available in Italy for neurological indications, abobotulinum A toxin (Dysport®, Ipsen SpA, Milano, Italy) and incobotulinum A toxin (Xeomin®, Merz Pharma Italia srl, Milano, Italy) differ in the content of neurotoxin, non-toxic protein, and excipients. Clinical applications of BoNT-A adopt extremely diluted solutions (10-6 mg/mL) for injection in the target body district. Near-infrared spectroscopy (NIRS) and chemometrics allow rapid, non-invasive, and non-destructive methods for qualitative and quantitative analysis. No data are available to date on the chemometric analysis of the spectral fingerprints acquired from the diluted commercial formulations of BoNT-A. In this proof-of-concept study, we tested whether NIRS can categorize solutions of incobotulinum A toxin (lacking non-toxic proteins) and abobotulinum A toxin (containing non-toxic proteins). Distinct excipients in the two formulations were also analyzed. We acquired transmittance spectra in the visible and short-wave infrared regions (350-2500 nm) by an ASD FieldSpec 4™ Standard-Res Spectrophotoradiometer, using a submerged dip probe designed to read spectra in transflectance mode from liquid samples. After preliminary spectra pre-processing, principal component analysis was applied to characterize the spectral features of the two BoNT-A solutions and those of the various excipients diluted according to clinical standards. Partial least squares-discriminant analysis was used to implement a classification model able to discriminate the BoNT-A solutions and excipients. NIRS distinguished solutions containing distinct BoNT-A commercial formulations (abobotulinum A toxin vs. incobotulinum A toxin) diluted at recommended volumes for clinical reconstitution, distinct proteins (HSA vs. incobotulinum A toxin), very diluted solutions of simple sugars (lactose vs. sucrose), and saline or water. Predictive models of botulinum toxin formulations were also performed with the highest precision and accuracy.

Preoperative brain shift is a prognostic factor for survival in certain neurosurgical diseases other than severe head injury: a case series and literature review.

Preoperative brain shift after severe brain injury is a prognostic factor for survival. The aim of this study was to determine whether preoperative brain shift in conditions other than severe head injury has significant prognostic value. We analyzed a radiological database of 800 consecutive patients, who underwent neurosurgical treatment. Brain shift was measured at two anatomical landmarks: Monro's foramina (MF) and the corpus callosum (CC). Four hundred seventy-three patients were included. The disease exerting the highest mean brain shift was acute subdural hematoma (MF 11.6 mm, CC 12.4 mm), followed by intraparenchymal hematoma (MF 10.2 mm, CC 10.3 mm) and malignant ischemia (MF 10.4 mm, CC 10.5 mm). On univariate analysis, brain shift was a significant negative factor for survival in all diseases (p < 0.001). Analyzed individually by group, brain shift at both anatomical landmarks had a statistically significant effect on survival in malignant ischemia and at one anatomical landmark in chronic subdural and intraparenchymal hematomas. Multivariate analysis demonstrated that the only independent factor negatively impacting survival was brain shift at MF (OR = 0.89; 95% CI: 0.84-0.95) and CC (OR = 0.90; 95% CI: 0.85-0.96). Brain shift is a prognostic factor for survival in patients with expansive intracranial lesions in certain neurosurgical diseases. MF and CC are reliable anatomical landmarks and should be quoted routinely in radiological reports as well as in neurosurgical practice.

Habituation of Somatosensory Evoked Potentials in Patients with Alzheimer's Disease and Those with Vascular Dementia.

Background and Objectives: The most prevalent dementia are Alzheimer's disease and vascular dementia. There is evidence that cortical synaptic function may differ in these two conditions. Habituation of cortical responses to repeated stimuli is a well-preserved phenomenon in a normal brain cortex, related to an underlying mechanism of synaptic efficacy regulation. Lack of habituation represents a marker of synaptic dysfunction. The purpose of this study was to assess the habituation of somatosensory evoked potentials (SEPs) in 29 patients affected by mild-to-moderate Alzheimer's disease (AD-type) or vascular (VD-type) dementia. Materials and Methods: All patients underwent a clinical history interview, neuropsychological evaluation, and neuroimaging examination. SEPs were elicited by electrical stimulation of the right median nerve at the wrist. Six-hundred stimuli were delivered, and cortical responses divided in three blocks of 200. Habituation was calculated by measuring changes of N20 amplitude from block 1 to block 3. SEP variables recorded in patients were compared with those recorded in 15 age- and gender-matched healthy volunteers. Results: SEP recordings showed similar N20 amplitudes in AD-type and VD-type patients in block 1, that were higher than those recorded in controls. N20 amplitude decreased from block 1 to block 3 (habituation) in normal subjects and in VD-type patients, whereas in AD-type patients it remained unchanged (lack of habituation). Conclusions: The findings suggest that neurophysiologic mechanisms of synaptic efficacy that underneath habituation are impaired in patients with AD-type dementia but not in patients with VD-type dementia. SEPs habituation may contribute to early distinction of Alzheimer's disease vs. vascular dementia.

In vivo non-invasive near-infrared spectroscopy distinguishes normal, post-stroke, and botulinum toxin treated human muscles.

In post-stroke hemiparesis, neural impairment alters muscle control, causing abnormal movement and posture in the affected limbs. A decrease in voluntary use of the paretic arm and flexed posture during rest also induce secondary tissue transformation in the upper limb muscles. To obtain a specific, accurate, and reproducible marker of the current biological status of muscles, we collected visible (VIS) and short-wave Infrared (SWIR) reflectance spectra in vivo using a portable spectroradiometer (350-2500 nm), which provided the spectral fingerprints of the elbow flexors and extensors. We compared the spectra for the affected and unaffected sides in 23 patients with post-stroke hemiparesis (25-87 years, 8 women) and eight healthy controls (33-87 years, 5 women). In eight patients, spectra were collected before and after botulinum toxin injection. Spectra underwent off-line preprocessing, principal component analysis, and partial least-squares discriminant analysis. Spectral fingerprints discriminated the muscle (biceps vs. triceps), neurological condition (normal vs. affected vs. unaffected), and effect of botulinum toxin treatment (before vs. 30 to 40 days vs. 110 to 120 days after injection). VIS-SWIR spectroscopy proved valuable for non-invasive assessment of optical properties in muscles, enabled more comprehensive evaluation of hemiparetic muscles, and provided optimal monitoring of the effectiveness of medication.