New onset refractory status epilepticus: State of the art.

NORSE (new onset refractory status epilepticus) has recently been defined as a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurological disorder, with new onset of refractory status epilepticus without a clear acute or active structural, toxic or metabolic cause. It includes the concept of FIRES described in children with a similar condition but preceded by a 2-14-day febrile illness. NORSE constitutes the acute phase of an entity preceded by a prodromal phase which may be accompanied by numerous manifestations (febrile episode, behavioural changes, headache, …), and followed by a chronic phase marked by long-term neurological sequelae, cognitive impairment, epilepsy and functional disability. There are many causes of NORSE: autoimmune, infectious, genetic, toxic, … but in half of the cases, despite an exhaustive assessment, the cause remains undetermined. Paraneoplastic and non-paraneoplastic autoimmune encephalitis remains by far the leading cause of NORSE. For these reasons, immunotherapy should be considered rapidly in parallel with the treatment of the status epilepticus, including in cryptogenic NORSE. Good communication with the family is important because the management of the acute phase is long and difficult. Although mortality remains high (11-22%), and sequelae can be severe, the majority of survivors can have a good or fair outcome.

COVID-19 Neurologic Complication with CNS Vasculitis-Like Pattern.

Coronavirus disease 2019 (COVID-19) is a viral infection caused by the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), which spreads rapidly from person to person and manifests in most symptomatic patients as a respiratory illness, similar to prior SARS viruses. Neurologic manifestations of COVID-19 are uncommon; those so far reported include encephalopathy, stroke from large-vessel occlusion, and polyneuropathy. We report a unique neurologic complication of COVID-19 in a patient who had extensive cerebral small-vessel ischemic lesions resembling cerebral vasculitis in a characteristic combined imaging pattern of ischemia, hemorrhage, and punctuate postcontrast enhancement. Also, a characteristic lower extremity skin rash was present in our patient. Our observation lends support to the increasingly suspected mechanism of "endotheliitis" associated with this novel coronavirus.

EEG in adults in the laboratory or at the patient's bedside.

Electroencephalogram (EEG) recording in the laboratory lasts at least 20 minutes and uses 19 active electrodes. It includes rest periods, stimulation procedures, a 3-mn hyperventilation period and intermittent photic stimulation (IPS). Recorded at the bedside, the EEG uses at least eight electrodes; the stimulation procedures, duration of the EEG and need to repeat the examination depend on the indication. Simultaneous video recording is recommended. The EEG report describes the basic rhythm, its reactivity and pathological activities, whether epileptic or not, and their organization. The synthetic conclusion interprets the results while taking into account the clinical context and contributes, if possible, diagnostic and/or therapeutic help in patient management. EEG performed as soon as possible after a seizure is essential for the diagnosis and initial management of epilepsy. It is helpful to characterize the epileptic syndrome in order to initiate optimal treatment. EEG is also useful in managing the withdrawal of antiepileptic drugs. EEG is also extremely useful in case of impaired consciousness, confusional state or even acute or subacute cognitive disorders. It is the only available tool able to validate the diagnosis of non-convulsive status epilepticus presenting with confusional state. EEG helps in the diagnosis of toxic or metabolic encephalopathy and can assess its severity, especially in hepatic encephalopathy. Except in rare exceptions, EEG is not routinely indicated for the evaluation of typical vasovagal syncope, headaches, dizziness, typical transient global amnesia and transient ischemic attack. EEG is irreplaceable in the diagnosis and management of certain severe and frequent pathologies involving the cerebral cortex.

Neodymium yttrium-aluminium-garnet laser resection significantly improves quality of life in patients with malignant central airway obstruction due to lung cancer.

Neodymium yttrium-aluminium-garnet (Nd : YAG) laser resection is one of the mostly used interventional pulmonology techniques for urgent desobstruction of malignant central airway obstruction (CAO). The major aim of this trial was to evaluate potential influence of Nd : YAG laser resection on overall quality of life (QoL) in patients with central lung cancer. Patients with malignant CAO scheduled for Nd : YAG laser resection were prospectively recruited in the trial. All patients were given European Organization for Research and Treatment, Quality of Life questionnaire (EORTC QLQ-30 v.3) before the procedure and approximately 2 weeks after the treatment. There were 37 male and 10 female patients, average age 54 ± 10 years. Most common tumour type was adenocarcinoma diagnosed in 51% of patients. Majority of patients were diagnosed in stage IIIB (53.2%) and stage IV (25.5%). Most common Eastern Cooperative Oncology Group performance status was 1 (72.3%). Nd : YAG laser resection significantly improved (P<0.0001) QoL and overall health according to EORTC QLQ-30. However, in some of the questions dealing with nausea, vomiting, diarrhoea, constipation, family life, social activities and financial situation, we did not observe statistically significant improvement. Nd : YAG laser resection of malignant CAO significantly improves QoL and overall health in patients with lung cancer.

[French guidelines on electroencephalogram]. / Recommandations françaises sur l'électroencéphalogramme.

Electroencephalography allows the functional analysis of electrical brain cortical activity and is the gold standard for analyzing electrophysiological processes involved in epilepsy but also in several other dysfunctions of the central nervous system. Morphological imaging yields complementary data, yet it cannot replace the essential functional analysis tool that is EEG. Furthermore, EEG has the great advantage of being non-invasive, easy to perform and allows control tests when follow-up is necessary, even at the patient's bedside. Faced with the advances in knowledge, techniques and indications, the Société de Neurophysiologie Clinique de Langue Française (SNCLF) and the Ligue Française Contre l'Épilepsie (LFCE) found it necessary to provide an update on EEG recommendations. This article will review the methodology applied to this work, refine the various topics detailed in the following chapters. It will go over the summary of recommendations for each of these chapters and underline proposals for writing an EEG report. Some questions could not be answered by the review of the literature; in those cases, an expert advice was given by the working and reading groups in addition to the guidelines.

Clinical prognostic factors and outcome of surgical treatment in patients with early-stage bronchial carcinoid tumors.

PURPOSE: Surgical resection is the treatment of choice for bronchial carcinoids (BC). The primary endpoint of this study was to look at the survival of patients with BC after the surgical treatment and to identify some clinicopathological prognostic factors influencing survival. METHODS: The analysis included 57 patients with early- stage BC submitted to surgical treatment in the period 2000-2008. Major inclusion criteria were: pathologically confirmed BC, ECOG performance status 0-2, and surgical resection of the tumor. RESULTS: No significant difference in survival in relation to gender was registered. N0, N1 and N2 status was registered in 39, 9 and 2 patients, respectively. There were statistically significant differences in survival according to N status (p=0.032). Twenty-two patients had T1N0 stage, 21 T2N0, and 4 T1N1. There was a trend for significant differences in survival according to TN stage (p=0.063). Also, analysis revealed significant differences in survival depending on tumor size (p=0.000), as well as on the type of the tumor (typical vs. atypical) (p=0.010). CONCLUSION: Nodal status and TN stage affect patients' survival. Tumor size and typical/atypical tumor are also significant prognostic factors for survival of surgically treated patients.

Atelectasis: positive or negative prognostic factor on outcome of patients with non-small cell lung cancer?

PURPOSE: the aim of this study was to evaluate the influence of atelectasis (AT) on overall survival of patients with non small cell lung cancer (NSCLC). METHODS: the study included patients of both sexes with unresectable stage III and IV NSCLC with good performance status (PS) (ECOG ≤ 2). Patients were divided into two groups: with AT (AT+) and without AT (AT-): Factors analyzed included sex, age, histologic type, ECOG performance status, stage of disease and treatment modality. Overall survival was estimated according to Kaplan-Meier method, and multivariate analysis was used to identify independent prognostic factors. RESULTS: we evaluated 247 patients (83% males and 17% females); 47/247 (19%) of patients belonged to AT+ group. In this group 21% of patients had stage IIIA, 46% IIIB stage, and 33% IV stage. Overall survival was significantly longer in the AT+ group (15.23 vs. 9.03 months, p=0.001). AT+ patients in stages III and IV had significantly longer overall survival than AT- patients in the same stages (p=0.001, p=0.002, respectively). Multivariate analysis showed that atelectasis (p=0.001), stage of disease (p=0.001), and treatment modality (p=0.005) were independent prognostic factors associated with survival. CONCLUSION: atelectasis is favorable prognostic factor concerning overall survival in patients with NSCLC.

Alertness in young healthy subjects: an fMRI study of brain region interactivity enhanced by a warning signal.

An effective connectivity study was carried out on 16 young, healthy subjects performing an alertness task. The objective of this study was to develop and to evaluate a putative network model of alertness by adapting structural equation modeling to fMRI data. This study was designed to evaluate the directed interactivity of an attentional network during intrinsic and phasic alerting tasks. On the basis of theoretical hypotheses, clinical observations, behavioral data and neuroimaging studies, it was hypothesized that neural circuits in the right hemisphere including the dorsolateral prefrontal cortex (DLPFC), anterior cingulate cortex, inferior parietal cortex and the thalamus were involved. The results of this study support the existence of a common network of activated areas with significant path coefficient differences between intrinsic and phasic alertness. Functional interactivity was significantly reinforced during the phasic alertness task and appeared to preferentially involve activity in the DLPFC region, whereas the path coefficients of the model were well-balanced during intrinsic alertness. This study highlights the predominant role of the DLPFC region in maintenance of a state of alertness and in temporal preparation during an alertness task.

Radiochemotherapy in the elderly with lung cancer.

Lung cancer is the leading cause of cancer mortality with the median age of incidence being 69 years in males and 67 years in females. Radiochemotherapy (RT-CHT) is indicated in locally advanced non-small-cell lung cancer and limited-stage small-cell lung cancer; however, a significant under-representation of the elderly has been observed in patient recruitment in cancer treatment trials. In the last decades of the 20th Century, studies showed that elderly patients achieved the best quality-adjusted survival with radiotherapy alone, but recent trials have found that fit elderly patients benefit from concurrent RT-CHT, although with more short-term toxicity. Age alone should not exclude fit patients and deprive them of the standard treatment. Using tools, such as comprehensive geriatric assessment, a patient's tolerance to therapy can be assessed and monitoring can be performed. This review will focus on RT-CHT treatment in elderly patients with nonoperable stage III non-small-cell lung cancer and limited-stage small-cell lung cancer exclusively.

Radiochemotherapy for lung cancer in developing countries.

Radiochemotherapy has become a standard approach in locally advanced non-small cell lung cancer and limited disease small cell lung cancer. Most of the data supporting this observation come from the developed world and only extremely rarely have good-quality clinical trials been carried out in developing countries. It is therefore of paramount importance to put the experience of the developed world into the context of the limited resources and other health care problems of developing countries. In this overview, the problems with the implementation of such data are discussed. The necessity of carrying out clinical trials specifically designed to address the needs of developing countries is emphasised. The research on cheaper ways of radiochemotherapy combination should be encouraged. The specific national guidelines for local needs should be created and followed. The availability of radiotherapy equipment is of major importance, as radiotherapy has a pivotal role in non-surgical treatment of lung cancer, especially in the developing world.

Anatomy of executive deficit following ruptured anterior communicating artery aneurysm.

BACKGROUND AND PURPOSE: To evaluate behavioral and cognitive deficits following anterior communicating artery aneurysm rupture and determine critical lesion locations. METHODS: We investigated 74 patients with standardized cognitive tests and behavioral inventory. Two examiners rated MRI signal abnormalities in 51 predetermined regions of interest. Classification tree analysis was used to select regions associated with each cognitive deficit. RESULTS: Eleven patients presented behavioral executive deficits and 10 had cognitive executive deficit. Their presence depended on left hemisphere lesions only: (i) ventral striatum lesion was associated with behavioral executive deficit (P = 0.04), reduction of activities (P = 0.01), and hyperactivity (P = 0.02); (ii) superior frontal gyrus lesion, with cognitive executive deficit (P = 0.01), action initiation deficit (P = 0.02), and rule deduction deficit (P = 0.02); (iii) anterior half of centrum semiovale lesion, with Stroop inhibition deficit (P = 0.02); (iv) medial superior and middle frontal gyri lesions, with task coordination deficit (P = 0.01); and (v) middle frontal gyrus lesion, with words generation deficit (P = 0.02). CONCLUSION: This study supports that (i) cognitive executive deficits depend mostly on lateral prefrontal lesions, (ii) with locations varying according to executive process, and (iii) behavioral executive deficits are mainly due to left ventral striatum lesion in post-aneurysmal damage.

[Femoral and humeral head osteonecrosis in a patient with hypofibrinolysis and hyperhomocysteinemia. A case report and a review of the literature]. / Osteonecrosi delle teste femorali ed omerali in un paziente con ipofibrinolisi e iperomocisteinemia. Descrizione del caso e revisione della letteratura.

Osteonecrosis is a disease characterized by the death of marrow and bone tissues. All bones may be affected, most commonly those of the hip, knee, shoulder, ankle as well as the small bones of the hands and feet. When the disease involves a weight-bearing joint there is a significant risk that subarticular fracture may develop leading to disabling arthrosis and requiring, therefore, arthroplasty surgery. Osteonecrosis typically affects patients in their third, fourth and fifth decades of life and is associated with many factors including other diseases and co-morbidities. Multifocal osteonecrosis is defined according to the involvement of at least three separated anatomic sites. We describe the case of a young man with osteonecrosis of the shoulder and hip joints which required total arthroplasty. Among biochemical investigations, an increase in the plasminogen activator inhibitor type 1 (PAI-1) levels associated with mild hyperhomocysteinemia was present. Another finding was the HLA B27, without signs of spondyloarthropathies. In patients with osteonecrosis, especially if multifocal, a careful medical history, a complete physical examination and some biochemical investigations, particularly those related to thrombophilia and hypofibrinolysis, should be performed.

Somatosensory evoked potentials for the diagnosis of proximal sensory median neuropathy with preserved distal sensory action potential.

A 33 year-old-man with paresthesia in first three fingers of the right hand after minor trauma of the arm was examined electrophysiologically. The proximal sensory median neuropathy was isolated which it is unusual in traumatic lesion. Motor and distal sensory conduction studies were normal but sensory evoked potentials (SEPs) were abnormal by right median nerve stimulation at the wrist level with decrease in amplitude of peripheral potential at the Erb's point, the cervical and contralateral parietal levels. This pattern, preserved distal sensory action potential and abnormal peripheral SEPs were suggesting the presence of proximal sensory block conduction without wallerian degeneration. The recovery was complete and fast in correlation with the absence of axonopathy.

[Acute knee block. Assessment with magnetic resonance, correlated with arthroscopy]. / Blocco articolare acuto del ginocchio. Studio con Risonanza Magnetica, correlato con artroscopia.

Posttraumatic acute articular blocks of the knee may be caused by "mechanical" factors, such as the interposition of some osteochondral, meniscal or ligamentous fragments between condyles and tibial plateau or by non-mechanical ("functional") factors, such as the pain associated with capsular-ligamentous structure injuries or with intraosseous bruises involving the synovia. From January, 1994, to January, 1996, we examined 751 patients for posttraumatic knee injuries. The patients were submitted to MRI with a dedicated unit and we selected 86 of them who had an acute articular block as the major symptom. The block had a mechanical cause in 36 patients of the selected group (41.8%), as confirmed at arthroscopy, while the other 50 patients (58.2%) had a functional block. Fifteen of the latter patients had only intraosseous bruising, with no ligament or meniscus damage, while the other 35 had isolated or variously associated menisco-ligamentous injuries, as confirmed at arthroscopy. All the patients also had some intraosseous bruises which were clearly depicted at MRI. This study demonstrates that MRI is an extremely valuable tool in assessing the cause of articular blocks, allowing a prompt appropriate choice to be made between therapeutic arthroscopy and weight-free limb immobilization.

[Ultrasonic assessment of the capsular-ligamentous structures of the ankle. Normal features]. / Valutazione ectomografica delle strutture capsulo-legamentose della caviglia. Aspetti normali.

The study of normal ankles by means of US has enabled the authors to define the articular system so as to obtain a useful reference for the study of pathological ankles. A real-time (Ansaldo AU 530) unit with a 10 MHz sectorial probe was employed together with a Toshiba unit with a 7.5 MHz sectorial probe. In 6 cases, the stretching of the capsuloligamentous system before arthroscopy was examined. The authors' attention focused on 3 major functional anatomic areas: the talofibular ligament area, the calcaneofibular ligament area, and the deltoid ligament area. The comparison of US scans before and after stretching the capsula with a physiological solution allowed the most interesting structures to be recognized and quantified from a US-anatomical point of view. Useful parameters were both the length of the lateral aspect of the ligament (mean difference in length between rest and exercise conditions: 15 mm for the anterior talofibular ligament and 14 mm for calcaneofibular ligament) and the thickness of intra-articular echoes (mean value: 5 mm).

[Sclerosing adenosis and infiltrating epitheliosis of the breast. Radiohistopathologic correlations and differential diagnosis of carcinoma]. / Adenosi sclerosante ed epiteliosi infiltrante della mammella. Correlazioni radioistopatologiche e diagnosi differenziale col carcinoma.

Sclerosing adenosis and infiltrating epitheliosis are both benign diseases which are clinically, radiologically and macroscopically impossible to distinguish from cancer. Over a four years' period, 27 lesions of this kind, which are usually considered as rare, were found in 27 patients. The average age of the patients was 36 years, which confirmed the lesions as diseases typical of fertile women. In all cases, both clinical and instrumental findings (mammography and echotomography) indicated a kind of malignant cancer. The final diagnosis was always made on surgical/bioptic (fine-needle biopsy) specimens. This paper is aimed at stressing the lack of mammographic findings useful for the differential diagnosis of sclerosing adenosis-infiltrating epitheliosis and breast cancer. The utility of fine-needle aspiration biopsy is also stressed.

[Echotomographic evaluation of the anterior urethra]. / Valutazione ecotomografica dell'uretra anteriore.

A simple method of sonographic (US) evaluation of penile and bulbous urethra is reported. Twenty-three dysuric patients were examined. They were divided into 2 groups according to their pathology. The US patterns of normal urethra were evaluated in 10 patients (first group) with no obstructive lesions. Urethral and periurethral structures were examined in 13 patients (second group) with urethral obstructive pathology. All patients underwent conventional cystourethrography. The diagnostic parameters considered were urethral gauge and thickness, echogenicity of the urethral wall, and Cowper's glands. US evaluation of obstructive lesions provided the same findings as conventional radiological techniques. Moreover, US allowed the evaluation of both thickness and echogenicity of the urethral wall, and of normal/injured Cowper's glands.

[Dilatation of benign urethral stenosis using a balloon catheter]. / Dilatazione delle stenosi uretrali benigne con catetere a palloncino.

The authors report their experience of benign urethral stricture dilatation by balloon catheter in 11 male patients. Ten posterior and 2 anterior urethral strictures were treated; in 1 patient several narrowings coexisted at various levels. Etiology was inflammatory in 4 cases, iatrogen in 3, post-traumatic in 2, and equivocal in 2. The patients were studied both before and soon after dilatation by means of retrograde and voiding cystourethrogram and uroflowgraphy; the follow-up (2-14 months) was performed by urodynamics alone. In all cases, dilatation was followed by the restoration of urethral gauge, together with prompt functional improvement of urodynamic parameters. The latter result subsisted in time in 9 patients. In 2 cases recurrences were observed, demonstrated at once by clinics and urodynamics. Both lesions were successfully re-treated. Neither early nor late complications occurred. In spite of the limited material, the valuable results obtained, together with the absence of complications, the peculiar morphology of recurrences, and the chance of repeating it make the procedure advisible as a valid alternative to conventional techniques for these pathologies.