Head down tilt 15° in experimental intracerebral hemorrhage: a randomized noninferiority safety trial.

BACKGROUND AND PURPOSE: Head down tilt 15° (HDT15°), applied before recanalization, increases collateral flow and improves outcome in experimental ischemic stroke. For its simplicity and low cost, HDT15° holds considerable potential to be developed as an emergency treatment of acute stroke in the prehospital setting, where hemorrhagic stroke is the major mimic of ischemic stroke. In this study, we assessed safety of HDT15° in the acute phase of experimental intracerebral hemorrhage. METHODS: Intracerebral hemorrhage was produced by stereotaxic injection of collagenase in Wistar rats. A randomized noninferiority trial design was used to assign rats to HDT15° or flat position (n = 64). HDT15° was applied for 1 h during the time window of hematoma expansion. The primary outcome was hematoma volume at 24 h. Secondary outcomes were mass effect, mortality, and functional deficit in the main study and acute changes of intracranial pressure, hematoma growth, and cardiorespiratory parameters in separate sets of randomized animals (n = 32). RESULTS: HDT15° achieved the specified criteria of noninferiority for hematoma volume at 24 h. Mass effect, mortality, and functional deficit at 24 h showed no difference in the two groups. HDT15° induced a mild increase in intracranial pressure with respect to the pretreatment values (+2.91 ± 1.76 mmHg). HDT15° had a neutral effect on MRI-based analysis of hematoma growth and cardiorespiratory parameters. CONCLUSIONS: Application of HDT15° in the hyperacute phase of experimental intracerebral hemorrhage does not worsen early outcome. Further research is needed to implement HDT15° as an emergency collateral therapeutic for acute stroke.

Adverse Effects and Surgical Complications in Pediatric Patients Undergoing Vagal Nerve Stimulation for Drug-Resistant Epilepsy.

Vagal nerve stimulation (VNS) is an effective treatment for drug-resistant epilepsy that is not suitable for resective surgery, both in adults and in children. Few reports describe the adverse effects and complications of VNS. The aim of our study was to present a series of 33 pediatric patients who underwent VNS for drug-resistant epilepsy and to discuss the adverse effects and complications through a review of the literature.The adverse effects of VNS are usually transient and are dependent on stimulation of the vagus and its efferent fibers; surgical complications of the procedure may be challenging and patients sometimes require further surgery; generally these complications affect VNS efficacy; in addition, hardware complications also have to be taken into account.In our experience and according to the literature, adverse effects and surgical and hardware complications are uncommon and can usually be managed definitely. Careful selection of patients, particularly from a respiratory and cardiac point of view, has to be done before surgery to limit the incidence of some adverse effects.

Intracranial pressure monitoring in pediatric bacterial meningitis: a fancy or useful tool? A case report.

Childhood meningitis is associated with high mortality and morbidity. In selected cases, the prompt institution of invasive intracranial pressure (ICP) monitoring and therapy may improve survival but few studies have evaluated the indications for ICP monitoring in this specific neurological disease. This article examines the case of a five-year-old child who was comatose when admitted to the hospital with unilateral dilated pupil, neck stiffness and fever (T 39 degrees C). The initial brain computed tomography scan was unremarkable. Dexamethasone and empirical antibiotic therapy for suspected meningitis was started and a lumbar puncture (LP) was performed. The LP opening pressure was 45 mmHg. Cerebrospinal fluid microscopy demonstrated Meningococcal meningitis. The likelihood of raised ICP, associated with third nerve palsy, prompted insertion of an intraparenchymal catheter for ICP monitoring. Intracranial hypertension was treated with medical therapy. ICP was controlled within 72 hours. On day nine, the ICP device was removed. On the same day, the child started to obey commands, was rapidly weaned from mechanical ventilation and was extubated. He was discharged from the Department on day 13 and after two weeks went home with residual dysmetria and mild motor impairment. This study indicates that ICP-targeted treatment in children improves the outcome of severe cases of bacterial meningitis. ICP monitoring could particularly be useful to optimize brain perfusion and provide relief from severe neurological impairment, which is associated with the clinical signs of meningitis and increased ICP levels.

Combined transcranial and endoscopic nasal resection for esthesioneuroblastoma. Technical note.

Esthesioneuroblastoma is a rare malignant neoplasm arising in the nasal cavity. Huge esthesioneuroblastomas, extending into the ethmoid roof and the cribriform plate, or invading the anterior cranial fossa, have traditionally been treated by craniofacial resection. Because of the invasiveness and potentially disfiguring results of a transfacial approach, a new technique has been proposed, combining endoscopic nasal and anterior craniotomy resection. We describe the case of a young male presenting with a large esthesioneuroblastoma involving the nasal cavity and the anterior cranial fossa, causing a huge skull base destruction. A combined transcranial and endoscopic nasal resection resulted in a macroscopically total removal of the tumor. The operative technique is reviewed in detail, along with the method used for the reconstruction of the anterior skull base defect.

Hemodynamic instability after extracranial carotid stenting.

OBJECTIVE: Hemodynamic instability (hypertension, hypotension and bradycardia) is a well-known complication of carotid endarterectomy. Carotid angioplasty and stenting (CAS) is becoming a valuable alternative treatment for patients with severe carotid stenosis and increased surgical risk. CAS implies instrumentation of the carotid bulb, so baroceptor dysfunction may provoke hemodynamic instability. The aim of this work was to calculate the incidence of this complication and to detect factors to predict it. METHODS: Medical records and angiograms of 51 consecutive patients submitted to CAS for severe atherosclerotic stenosis (40 cases) or postsurgical restenosis (11 cases) were retrospectively reviewed in order to detect the occurrence of intra- and post-procedural hypertension (systolic blood pressure >160 mmHg), hypotension (systolic blood pressure <90 mmHg) and bradycardia (heart rate <60 beats/min). The relationship between clinical, procedural and angiographic factors and the occurrence of hemodynamic instability was assessed with univariate and multivariate analysis (logistic regression). RESULTS: Transient mild systolic post-procedural hypertension occurred in five cases (10%); preprocedural hypertension, asymptomatic stenosis and ipsilateral post-surgical restenosis predicted this. Hypotension with bradycardia also occurred in five cases (10%), one with neurological sequelae. Transient periprocedural bradycardia occurred in 19 cases (37%). Severe bradycardia without hypotension arose in one case only. Factors predicting post-procedural hypotension included the presence of a fibrous plaque and the ratio between the pre- and post-stenting diameter of the internal carotid artery. Peri-procedural bradycardia predicted post-procedural bradycardia. None of these factors were confirmed by multivariate analysis as a significant prognostic predictor. CONCLUSION: Mild systolic hypertension may occur after CAS, but is resolved by medical treatment. Prolonged hypotension and bradycardia may also arise and this can be dangerous because it may cause neurological deterioration due to hypoperfusion. These complications cannot be predicted by clinical, procedural, and angiographic factors.

[Steroids in acute spinal cord injury. An unproven standard of care]. / Steroidi nel traumatismo midollare. Uno standard di cura non documentto.

Since 1990s, methylprednisolone has become a widely prescribed therapy for improving the outcome of acute spinal cord injured victims and has considered a standard of care based. This have been claimed on the results of two randomized controlled trials (NASCIS II and III), even if the studies failed to demonstrate improvements due to methylprednisolone administration in any of the a priori hypothesis tested. Although, post hoc analyses were carefully constructed for evidencing minimal benefits of the steroid therapy in subgroups of patients and were publicized worldwide, these presumed benefit have been extended to all acute spinal cord injured patients. Further analyses of the papers, devoid of the participation of the authors, performed by external reviewers and evidence-based experts, failed to demonstrate clinically significant treatment effects. For this reason and for the consideration that high dose methylprednisolone could be harmful to the patients, the use of methylprednisolone in acute spinal cord injury cannot be recommended and cannot be considered a standard of care.

Accuracy of stereotactic localisation with magnetic resonance compared to CT scan: experimental findings.

BACKGROUND: Stereotactic localisation of proper targets can be obtained with Magnetic Resonance imaging (MRI), pending correction of the well-known inaccuracy of MRI in reproducing exact geometrical dimension. The aim of the experimental work was to determine the real extent of the MRI distortion and to correct it. METHODS: PVC phantoms and fixed human brains were used as target simulators: stereotactic targeting was obtained with CT and MRI: the results were compared and, finally, the real stereotactic values were measured on a commercial stereotactic device. To optimise MRI targeting it was necessary to abate the "chemical-shift", to modify the head-coil receiver (tuning the "off-resonance" frequencies) and to correct the targeting directly on the images (especially for the Y axis values); careful quality control and environmental tests were also necessary to maintain good performances along the time. RESULTS: 172 measurements were carried out using both CT, plain X-ray and MRI on PVC phantom. The values obtained from CT were considered as reference. Significant geometrical accuracy was found with CT targeting, except for the Z co-ordinate, due to the slice thickness. Mean value differences between the targets on MRI and their real geometric position are about 1 mm on X and Z axises and about 2 mm on Y axis. Similar results were obtained on fixed brains, where absolute values of X and Y co-ordinates of the simulators were measured using a millimetre grid placed over the brain slice. INTERPRETATION: Experimental findings concerning stereotactic targeting with MRI suggest accuracy adequate for clinical practice, even when extreme geometrical precision is required, such as in radiosurgery or functional stereotaxy. Careful quality control and intensive experimental setting of the MRI device are mandatory to obtain satisfactory results.

Dissecting vertebral aneurysm. Report of a case.

Aneurysms of the vertebral artery (VA) are relatively uncommon, accounting for less than 0.5-3.0% of all aneurysms and 20% of aneurysms originating in the posterior fossa. There are three distinct forms of aneurysms: saccular, fusiform and dissecting. The diagnosis of dissecting aneurysm is based on the findings of angiography, surgery and autopsy. Irregular fusiform appearance, intramural retention of contrast medium in the venous phase and alternating irregular stenotic and dilated segment (string and pearl sign) are the basal angiographic findings. Patients with dissection of VA often develop subarachnoid hemorrhages (SAHs), with the typical neck pain or suffer cerebral ischemia. Because of the high risk of rebleeding of dissecting aneurysms, they should be treated as soon as possible, with occlusion of the VA. Nowadays, both surgical and endovascular procedures allow the treatment of dissecting vertebral aneurysms. Anyway, one should be aware that vertebral occlusion performed proximal to PICA origin may be followed by ischemic complications. In this paper, we discuss the diagnostic and therapeutic difficulties associated with dissecting vertebral aneurysms on the basis of personal observation and a review of the literature.

[Cerebral blood flow in subarachnoid hemorrhage]. / Flusso ematico cerebrale dopo emorragia subaracnoidea.

Cerebral blood flow (CBF) following subarachnoid haemorrhage varies according to the time of sampling, with regard to the time of bleeding, to clinical conditions of patients and to any possible occurrence of vasospasm. CBF is proportionally reduced upon clinical conditions, involves the totality of patients and represents a diffuse bilateral phenomenon, not dependent on the location of the aneurysm. Following events, such as vasospasm, may deteriorate haemodynamic conditions, especially when unstable. Thus, CBF monitoring is necessary and useful in these patients. The evaluation of this parameter, according to the metabolic demands, appears rather fundamental. Besides, during the first two weeks, all the available therapeutic strategies have to employed in order to achieve the best optimization of the CBF so as to avoid the occurrence or at least minimising the extent of ischemic cerebral lesions.

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

The high risk of rebleeding of ruptured aneurysms imposes the need of their early exclusion from arterial circulation. The onset of endovascular technique of embolization gives a new chance, making, time by time, necessary the choice for the best treatment. The advantages and limits of surgical option are well known and consolidated. The results of endovascular technique are similar in the acute phase, but it lacks an adequate follow up and a clear definition of some technical knowledges. Clinical and anatomical data and a serious analysis of specific technical difficulties of both methods must condition the choice of treatment. Present experience allows us to give sure indications only for certain cases, whereas final landmarks are indisposable in many other situations. However, the team discussion between the neurosurgeon, the neuroradiologist and the neuroreanimator must be the crucial point of the decisional way in every single case.

Acute pneumocephalus: an unusual complication of thoracotomy.

The authors describe a iatrogenic cerebrospinal fluid fistula into the pleural cavity, a rare and unusual complication of thoracic surgery. The importance of considering this diagnosis in patients who suffer from headache and altered mental status after thoracotomy and the early surgical repair of this potentially fatal complication are stressed.

Primary traumatic benign midbrain haematoma in hyperextension injuries of the head.

Primary traumatic brain stem injury occurring in isolation is not universally recognized as a distinct pathological entity which may follow a head injury. We describe two patients with clinical and radiological evidence of primary posttraumatic midbrain haemorrhage occurring in isolation associated with good recoveries. It is suggested that paramedian midbrain syndromes associated with midbrain haemorrhages should be recognized as a distinct, although unusual, complication of hyperextension injury to the head which may have a benign course.

Primary intracranial rhabdomyosarcoma: report of two cases.

Primary intracranial rhabdomyosarcoma (RMS) is a rare tumor in infancy and childhood that is found in various locations in the central nervous system. The clinical course worsens rapidly, and the final outcome is poor, with a median survival time of 8-10 months. Invasion of the meninges, spontaneous intratumoral bleeding, spinal leptomeningeal CSF spreading of tumor cells, and early recurrence of the mass are the distinctive features of RMS. Diagnosis of RMS may be missed: immunohistochemical staining using specific markers (myoglobin, myosin, desmin, vimentin, enolase), along with ultrastructural studies, provide the basis for making the final diagnosis. Treatment of RMS includes surgical excision, craniospinal radiation therapy, and chemotherapy. We report two cases of primary RMS in the CNS located in the posterior fossa and frontotemporal area. Both children underwent total surgical removal of the mass. Early recurrence of the tumor mass was noticed in both patients 2 months after surgery. Both children died shortly thereafter.

Clinicoradiological and therapeutic considerations in severe diffuse traumatic brain injury in children.

Forty-one children with severe head injuries and diffuse brain lesions were selected from a consecutive series of 62 children in traumatic coma (21 focal mass lesions) and studied. According to the CT pattern, two main types of intracranial lesions were considered: diffuse axonal injury (DAI) and diffuse brain swelling (DBS). High mortality, due to secondary increases of intracranial pressure (ICP), correlated well with the patterns of severe DBS, absence of perimesencephalic cisterns, and obliteration of the ventricles. However, children with normal CTs, and/or obvious shearing injuries indicative of DAI, had favorable outcomes; there was no mortality if increased ICP was not present. We conclude that although there does not seem to be any routine indications for ICP monitoring in children with pure DAI, early ICP monitoring and aggressive management of increasing ICP should be considered in comatose children with DBS, especially when associated with subarachnoid hemorrhage and respiratory or circulatory failure.

[Diffuse traumatic cerebral injuries in children]. / Lesioni cerebrali traumatiche diffuse in età pediatrica.

A consecutive series of 41 patients aged less than 16 and admitted to the Department of Neurosurgery of the University of Milan in the period 1977-1978 following serious cranioencephalic trauma with Glasgow Coma Score (GCS) less than or equal to 7, duration of coma longer than 24 h and CT picture of diffuse lesion has been examined. These patients account for 5% of the paediatric cranial traumas observed in the same period and 66% of those in a state of coma. The CT picture made it possible to split patients into 3 groups: a) those without visible cerebral lesions and with subarachnoid and cisternal spaces present; b) those with small hyperdense lesions due to intraparenchymal or median/paramedian subcortical shearing lesions; c) those with marked constriction or absence of the 3rd ventricle and of the perimesencephalic cisterns. The first two pictures (a, b) were considered to be the expression of diffuse axonal damage, the last (c) of diffuse cerebral swelling. Intracranial pressure was monitored in about 50% of patients. The overall outcome of the series was favourable in more than 68% of cases with total mortality of 26.8%. Analysis of individual tomographic categories, however, showed that whereas the group of patients with diffuse axonal lesion presented nil mortality, those with diffuse cerebral swelling had 52% mortality owing to the onset of refractory intracranial hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cervical vertebral and spinal cord injury in intensive therapy]. / Il trauma vertebro-midollare cervicale in terapia intensiva.

24 of 184 patients with vertebro-medullary trauma admitted to the Neurosurgery Clinic of Milan University in the years 1976-1988 have been examined. A common feature of these was a myelic lesion (transverse, complete or incomplete) at cervical level in which respiratory problems had made a period of intensive care indispensable. The purpose of the research was to assess the reliability of certain parameters in establishing patient prognosis. The following parameters were compared: clinical, objective and instrumental examination for a strictly neurological evaluation and for an evaluation of general condition, quantification of the same clinical examination through two scales, the Sunnybrook Cord Injury Scale (SCIS) for the neurological factor and the APACHE II for general condition, the type of treatment, with the same basic medical-resuscitation treatment. The result of the surgery or non-surgery was considered a posteriori. It is concluded that, in the case of the patients considered (high myelic lesion) the prognosis must be split into two different moments that the patient goes through in succession: the acute phase and the stabilisation phase. In the first phase, in which the vital functions are involved, the SCIS and APACHE II scales (with their sum) have great prognostic value; in the second phase, certain values, already considered on the APACHE II scale, are comparable in all patients and the prognostic problem is based on the other scale (SCIS) and on the adjuvant neurophysiological techniques. The very distinction between the two different phases that the patient traverses appears important also for the purposes of surgical indication.2