Sodium fluorescein application in brain tumor biopsy.

BACKGROUND: Needle biopsy is a routinely, relatively safe, and effective tool for patients with brain tumors not suitable for surgical resection. Despite technical advancements, missed diagnosis is still reported in up to 24% of cases. The aim of this study is to investigate the role of sodium fluorescein (NaFL), a cheap and safe fluorophore, in the biopsy setting mainly with the perspective of an enhancement of the sampling accuracy. METHODS: Between January 2018 and March 2020, we prospectively enrolled 48 consecutive patients with suspicion of high-grade glioma to receive NaFL-guided brain tumor biopsy. We compared results between NaFL-group and our historical cohort of patients that underwent biopsy without any dye administration (N.=58). RESULTS: In the NaFL-guided biopsy group, there was a statistically significant increase in diagnostic accuracy compared to the historical cohort (100% vs. 86.2%, P<0.05). The mean number of samples was significantly reduced, (3.3 instead of 4.4 of the control group, P<0.05). Differences in terms of complications related to the procedure, hospital stay, and surgical time were not significant (P=0.49). CONCLUSIONS: To the authors' knowledge, this is the largest published series supporting the usefulness of NaFL during biopsy procedure, with improved diagnostic accuracy. This also allows a reduction in the number of samples needed for diagnosis, and subsequent risks of procedure-related complications, without adding risks related to the drug itself.

Infundibulum of Accessory Anterior Cerebral Artery: Rare, Likely Benign Malformation of Anterior Communicating Artery Complex to Keep in Mind.

BACKGROUND: Infundibular dilations (IDs) are funnel-shaped enlargements located at the origin of cerebral arteries. Neuroradiologists and neurosurgeons are familiar with IDs of the posterior communicating artery, which are relatively common. Other locations, being unexpected sites of IDs, can pose diagnostic and therapeutic challenges. CASE DESCRIPTION: In this paper, we describe a case of infundibulum of the accessory anterior cerebral artery, diagnosed with 3-dimensional reconstructions of computed tomography angiography, which is to our knowledge the first report of an ID of this anatomic variant. CONCLUSIONS: Anterior communicating artery represents a rare location for infundibular dilations. Differential diagnosis between them and true aneurysms can be sometimes challenging, especially when associated with anatomic variants; thus neurosurgeons and radiologists must be aware of these pathologic entities.

A cause of atypical intracranial subarachnoid hemorrhage: posterior spinal artery aneurysms.

BACKGROUND: Approximately 1 % of cases of intracranial subarachnoid hemorrhage (SAH) are caused by spinal vascular pathologies. Among them, isolated spinal artery aneurysms are uncommon and a limited number of cases have been reported in the literature. METHODS: This is a report of two cases and review of the literature. RESULTS: Both patients presented with an atypical intracranial SAH and were also found to have spinal SAH caused by a ruptured posterior spinal aneurysm. CONCLUSION: Isolated spinal artery aneurysms represent a rare cause of intracranial SAH. Symptoms such as back pain and lower-extremity weakness can be clues to the adequate diagnosis. Surgical or endovascular treatment should be pursued in all patients, as the risk of rebleeding is non-negligible.

Surgery in cerebral metastases: are numbers so important?

BACKGROUND: The prognosis of cerebral metastases (MTS) is linked to progression of both systemic and local disease. The importance of MTS resection has been already pointed out. The observation of a high mortality for not-neurological causes confirms that the modern treatments allow a significant control of the disease within the nervous system. Nevertheless, management difficulties increase with multiple lesions and in these cases the role of surgery has still to be defined. MATERIALS AND METHODS: We collected the clinical data of patients operated in two centers for cerebral MTS from lung carcinoma during 8 years. Patient selection for surgery followed definite criteria; the limit for multiple MTS was three. We analyzed the functional and survival outcomes of the cohort. RESULTS AND CONCLUSIONS: Our series included 242 patients: 105 had multiple MTS. Statistical analysis did not show significant differences in mean survival and outcomes between patients with single and multiple lesions. The decease occurred for neurological causes in 15.7% of cases. The selection of candidates for surgery requires several considerations and entails the success rate of this treatment. In patients with the multiple lesions who fulfilled the selection criteria we observed a nevertheless satisfying success after the operation. Our results imply that surgery may be applied also in selected patients with more diffuse intracranial disease. A pre-operative accurate patient selection is related to acceptable quality-of-life following the operation even in cases of multiple MTS.

Acute supratentorial ischemic stroke: when surgery is mandatory.

Acute occlusion of middle cerebral artery (MCA) leads to severe brain swelling and to a malignant, often fatal syndrome. The authors summarize the current knowledge about such a condition and review the main surgical issues involved. Decompressive hemicraniectomy keeps being a valid option in accurately selected patients.

Cerebrovascular diseases in the elderly: the challenge of multiple aneurysms.

OBJECTIVE: The worldwide population aging and the nowadays medical advances impose to consider new management guidelines for elderly. Aim of this study was to assess the best treatment in elderly with multiple intracranial aneurysms (MIA). METHODS: From 1994 to 2011, we admitted 1462 patients with ruptured cerebral aneurysm. Among those aged ≥65 years, 43 had MIA (15% of elderly). Size and aneurysm location, timing and type of treatment were analyzed. Patients were thus stratified according to Hunt-Hess grade on admission and evaluated at 6 months using the Glasgow Outcome Scale (GOS). RESULTS: We had 87 aneurysms in the final series. Three patients died because of the impossibility to treat the ruptured aneurysm. No new bleeding from untreated aneurysms was observed; no retreatment after previous coiling was performed. CONCLUSIONS: MIA lead to significantly poorer outcomes, especially in elderly, because of their general clinical condition, presence of risk factors and lower capacity of reaction to stressful events. In patients without large hematomas, coiling of the ruptured aneurysm represents the procedure with high effectiveness. The clinical conditions on admission represent the most important factor for the treatment results. To reduce the treatment-related risks we do recommend a conservative approach for the unruptured aneurysms.

Automated end-to-side anastomosis to the middle cerebral artery with C-Port xA: A feasibility study on human cadavers.

BACKGROUND: Anastomosis to the superficial temporal artery is suitable in patients with functional and structural impairment of the middle cerebral artery (i.e., complex aneurysms and skull base tumors), as either definitive treatment or an additional safety measure. A shorter occlusion time or a non-occlusive technique is expected to reduce the risk of cerebral ischemia following the procedure. In this cadaver study, we assessed the fitness of C-Port xA(®) device for use in superficial temporal artery (STA)-middle cerebral artery (MCA) bypass. MATERIALS AND METHODS: Seven fixed human head specimens were prepared through eight pterional craniotomies. The superficial temporal artery was dissected and the sylvian fissure was opened to access the MCA. The C-Port xA was tested on each of the eight exposures. We recorded the lengths of both donor and recipient vessel, the durations of the procedure and the craniotomy, and sylvian scissure opening sizes. The bypass was then assessed by pressure injection of methylene blue in the donor vessel. RESULTS: C-Port xA-assisted STA-MCA anastomosis was successfully accomplished in seven dissections. A minimum STA length of 7 cm, a sylvian scissure opening larger than 5 cm, and a craniotomy size of at least 6 × 6 cm appeared to be the requisites for a safe maneuverability of the device. The MCA occlusion time lasted in all cases less than 4.5 min, and we observed a clear improvement in time performance with growing experience. CONCLUSIONS: The results suggest that the C-Port xA device is suitable for STA-MCA bypass. We experienced a shorter occlusion time and a shorter learning curve compared to conventional techniques. Further miniaturization and special adaptation of this device may allow a future application even to deeper intracranial vessels. Clinical trials will have to assess the long-term results and benefits of this minimal occlusive technique.

Ruptured aneurysm in sphenoid sinus: which is the best treatment?

Internal carotid artery (ICA) aneurysms involving the sphenoid sinus are uncommon, and their optimal treatment remains debated. We report the case of a patient presenting with recurrent epistaxis due to a bleeding cavernous ICA aneurysm. We suggest a combined endovascular and endoscopic approach when ICA occlusion may not be performed.

Antipsychotic-induced metabolic and cardiovascular side effects in schizophrenia: a novel mechanistic hypothesis.

The use of antipsychotics is hindered by the frequent occurrence of metabolic and cardiovascular side effects, resulting in worsened quality of life and greater mortality as a result of cardiovascular and cerebrovascular disorders in schizophrenia patients than the comparable general population. The various antipsychotics induce extrapyramidal symptoms, impaired glucose and lipid metabolism, weight gain, hypertension and arrhythmias, with variable frequency. Second-generation antipsychotics appear to have several advantages over first-generation antipsychotics, including a claimed better action on cognitive function and the negative symptoms of schizophrenia, and lower frequency of extrapyramidal side effects; however, their use is associated with a greater frequency of metabolic and cardiovascular disturbances. The mechanisms of these important side effects are not well understood, and generic approaches (psychoeducational programmes and symptomatic therapies) have been proposed to limit their severity. Extensive data from the literature indicate that autonomic nervous system dysfunction--intrinsic to schizophrenia and strongly exacerbated by antipsychotic treatment--is the cause of the pervasive metabolic and vascular dysfunctions associated with schizophrenia. In this article, we marshal further literature data to argue that the metabolic and cardiovascular side effects of antipsychotics are primarily mediated by their ability to block peripheral dopamine receptors, which physiologically modulate sympathetic activity. We also propose that these effects might be overcome by providing peripheral dopaminergic stimulation.

Recovery after delayed surgery in a case of spinal subdural hematoma.

Spinal chronic subdural hematoma (SCSH) is a rare pathology usually associated with trauma or hematological alterations or is due to iatrogenic causes; rarely SCSH can be spontaneous. We report a case of a 79-year-old female who underwent a surgical evacuation of a spontaneous SCSH one year after diagnosis. She presented with a severe paraparesis and showed a considerable improvement in sensory-motor performances after surgery. The treatment of spontaneous SCSH is not well defined and universally accepted. Early surgery is mandatory in cases presenting with severe deficits. To the best of our knowledge, this is the first case showing a good outcome in a case of SCSH following a delayed surgery. In our opinion, an aggressive approach should be considered as a viable option in cases of spontaneous SCSH even after a lasting spinal cord compression.

Dorsal paddle leads implant for spinal cord stimulation through laminotomy with midline structures preservation.

BACKGROUND: Pain relief obtained with spinal cord stimulation (SCS) in failed back surgery syndrome (FBSS) has been shown to be more effective with paddle leads than with percutaneous catheters. A laminectomy is generally required to implant the paddles, but the surgical approach may lead to iatrogenic spinal instability in flexion. In contrast, clinical and experimental data showed that a laminotomy performed through flavectomy and minimal resection of inferior and superior lamina with preservation of the midline ligamentous structures allowed to prevent iatrogenic instability. Aim of the study was to assess degree of instability and pain level in patients operated for SCS through laminectomy or laminotomy with midline structures integrity. The surgical technique is described and our preliminary results are discussed. METHODS: Nineteen patients with FBSS underwent SCS, 12 through laminectomy and 7 through uni- or bilateral interlaminotomy with supraspinous ligament preservation. Postoperative local pain was evaluated at 15, 30, and 60 days. Static and dynamic X-rays were performed after 2 months. RESULTS: The techniques allowed implanting the paddle leads in all cases. No intraoperative complications occurred. Local pain was higher and recovery time was longer in patients with laminectomy. We did not observe radiological signs of postoperative iatrogenic vertebral instability. Nevertheless, two patients who underwent laminectomy showed persistence of local pain after 2 months probably due to pathologic compensatory stability provided by the paraspinal musculature. CONCLUSIONS: The laminotomy is a minimally invasive approach that ensures rapid recovery after surgery, spinal functional integrity, and complete reversibility. Further studies are needed to confirm our preliminary results.

La medicación dopaminérgica podría ser útil para mejorar el síndrome metabólico en la enfermedad de Parkinson / Dopaminergic medication could be of use in improving metabolic syndrome in Parkinson’s disease

Realizamos un estudio de casos y controles con 483 pacientes consecutivos con enfermedad de Parkinson idiopática (EP) y 533 controles apareados por edad y sexo con el fin de investigar la relación entre la EP y los factores de riesgo de enfermedades cardiovasculares. Mediante análisis multivariado, la diabetes, la hipertensión, los antecedentes de tabaquismo, colesterol elevado y altos niveles de triglicéridos fueron significativamente menos frecuentes en la EP que en los controles. Además, estas asociaciones resultaban más evidentes para los pacientes tratados con levodopa. Interpretamos esta asociación entre EP y reducción de los factores de riesgo vascular como debidos a insuficiencia en el eje hipotálamo-hipófisosuprarrenal, desnervación simpática generalizada en la EP y estimulación central o periférica de los receptores dopamínicos D1 y D2 por la levodopa. Estos efectos cardiovasculares y metabólicos favorables sugieren que la medicación dopaminérgica puede resultar útil en el tratamiento de los trastornos cardiovasculares.

La medicación dopaminérgica podría ser útil para mejorar el síndrome metabólico en la enfermedad de Parkinson / Dopaminergic medication could be of use in improving metabolic syndrome in Parkinsons disease

Realizamos un estudio de casos y controles con 483 pacientes consecutivos con enfermedad de Parkinson idiopática (EP) y 533 controles apareados por edad y sexo con el fin de investigar la relación entre la EP y los factores de riesgo de enfermedades cardiovasculares. Mediante análisis multivariado, la diabetes, la hipertensión, los antecedentes de tabaquismo, colesterol elevado y altos niveles de triglicéridos fueron significativamente menos frecuentes en la EP que en los controles. Además, estas asociaciones resultaban más evidentes para los pacientes tratados con levodopa. Interpretamos esta asociación entre EP y reducción de los factores de riesgo vascular como debidos a insuficiencia en el eje hipotálamo-hipófisosuprarrenal, desnervación simpática generalizada en la EP y estimulación central o periférica de los receptores dopamínicos D1 y D2 por la levodopa. Estos efectos cardiovasculares y metabólicos favorables sugieren que la medicación dopaminérgica puede resultar útil en el tratamiento de los trastornos cardiovasculares.(AU)

Sympathetic modulation by levodopa reduces vascular risk factors in Parkinson disease.

BACKGROUND: Sympathetic nervous system hyperactivity promotes vascular disorders by its catabolic effects and by increasing arterial blood pressure. Levodopa-derived dopamine modulates sympathetic overactivity and is known to reduce blood pressure, but its effects on glucose and lipid metabolism have not been studied in large series of patients. METHODS: We retrospectively examined 483 consecutive parkinsonian patients, admitted to a single institute between 1970 and 1987, before statins were available. We compared risk factors for vascular disease in the 305 who were on levodopa with the 178 who had never received the drug. RESULTS: On admission levodopa-treated patients had significantly lower plasma levels of triglycerides, total cholesterol and lipids, and lower frequency of diabetes and hypertension than untreated patients. Mean body mass index, resting blood pressure, fasting plasma glucose, and smoking did not differ between the groups. A year after enrollment 160 patients were re-hospitalized; of these 63 had started levodopa during first hospitalization. In these new levodopa users total cholesterol, triglycerides and lipids had reduced to levels comparable with those of longer-term levodopa users. CONCLUSION: Levodopa use in parkinsonian patients is associated with reduced vascular risk factors. In causal terms this finding might be attributed to the inhibitory action of levodopa-derived dopamine on the sympathetic nervous system.

Autonomic nervous system and risk factors for vascular disease. Effects of autonomic unbalance in schizophrenia and Parkinson's disease.

Alterations of the cardiovascular system and of the glucose and lipid metabolism can represent important factors of vascular risk. The autonomic nervous system, through its two efferent branches, the parasympatheticcholinergic and the sympathetic-adrenergic, plays an important role in the control of the cardiovascular activity and of the glucose and lipid metabolism, and its impaired working can interfere with these functions. An increased sympathetic activity and an increased frequency of diabetes, dyslipidemia, hypertension and obesity have been reported in untreated schizophrenic patients, and a further worsening of these vascular risk factors has been signalled as a side effect of treatment with neuroleptic drugs. The opposite is observed in Parkinson's disease, where the reduced autonomic activity induced by the illness is associated with a decreased frequency of vascular risk factors, and their occurrence is further reduced by the treatment with dopaminergic drugs.

Reduced risk factors for vascular disorders in Parkinson disease patients: a case-control study.

BACKGROUND AND PURPOSE: Sympathetic hyperactivity is a contributing cause of vascular disorders because it increases blood pressure, blood sugar, and blood lipids. Pervasive compromise of the central and peripheral autonomic nervous systems is common in idiopathic Parkinson disease (IPD) resulting in reduced sympathetic and parasympathetic function. We hypothesized that IPD was associated with reduced prevalence of cardiovascular disease risk factors as a result of reduced sympathetic activity. METHODS: We performed a retrospective case-control study on 178 newly diagnosed consecutive IPD patients, and 533 age- (+/-3 years) and sex-matched controls with other neurological diseases seen over the same period at the same hospital. For each case and control the following were noted on admission: smoking, diabetes, hypertension, body mass index, serum glucose, plasma cholesterol, triglycerides and total lipid levels, and blood pressure. RESULTS: Diabetes, history of smoking, high blood pressure, high blood glucose, high blood cholesterol, and triglycerides were significantly less frequent in IPD than controls. CONCLUSIONS: IDP is a natural model of impaired hypothalamic-pituitary-adrenal axis activity and generalized sympathetic denervation. We interpret the association of untreated IPD with reduced vascular diseases risk factors as attributable to reduced autonomic activity, suggesting that autonomic hyperactivity may be involved in the pathogenesis of vascular disorders.