Headache attributed to intracranial tumours: a prospective cohort study.

Between January 2007 and March 2008, we prospectively studied all patients operated on for intracranial tumours in our Department of Neurosurgery. Preoperatively, all patients were interviewed by a neurologist to collect headache characteristics. Measurements of tumour and oedema volume were made using dedicated software for magnetic resonance imaging studies. Tumour histopathology was established by histological examination postoperatively. If headache improved postoperatively, a diagnosis of 'headache attributed to intracranial neoplasm' was made, according to the 2004 International Classification of Headache Disorders (ICHD-II). A multivariate logistic regression model was used to evaluate the association of headache with potential risk factors. We studied 206 subjects. The prevalence of tumour headache was 47.6%. Intracranial tumour headache was non-specific and in most cases could not be classified by current ICHD-II diagnostic criteria for primary headache syndromes. Its prevalence varied depending on volume, location and type of tumour, as well as on the patient's previous headache history.

Rhabdomyolysis caused by tocolytic therapy with ritodrine hydrochloride.

We report a case of rhabdomyolysis with severe generalized weakness and muscle pain after administration of ritodrine hydrochloride, in a pregnant patient without history of neuromuscular disease. Laboratory tests showed an increase of blood CK value and myoglobinuria. An electromyography was performed, revealing a typical myogenic pattern and diffuse denervation activity. Muscular biopsy allowed to rule out inflammatory and metabolic myopathy. After delivery, the patient underwent intensive rehabilitation with progressive improvement of her clinical situation, until complete recovery. Three months later, both neurological assessment and CK levels were normal. This case highlights that rhabdomyolysis has to be considered even in patient treated with ritodrine alone and without history of neuromuscular disease. Therefore, muscular symptoms and CK levels should be monitored in women treated with ritodrine for premature labour.

Activities of a medical emergency team twenty years after its introduction.

INTRODUCTION: We describe and quantify the wide range of activities that a mature Medical Emergency Team can progressively perform. METHODS: The activities performed by a Medical Emergency Team 20 years after its introduction were prospectively collected during 105 consecutive days. RESULTS: The main activity was focused on the follow-up visits to previously treated critically ill patients (mean 7.5 visits/die in working days, 5.1 in the others). A large amount of other scheduled or unscheduled activities (like sedation or analgesia for diagnostic procedures, central venous line placement, phone consultation regarding critical care aspects of treatments) were performed: on average, 7.3 side-activities/die in working days and 5.2 in the others. First consultations in patients not previously seen were on average 3.1/die on working days, 2.4 in the others. Cardiac arrest accounted for 27 (9%) of first time visits. CONCLUSIONS: A Medical Emergency Team can progressively perform many kinds of activities. An evaluation limited to the reduction of in-hospital cardiac arrests or a too early assessment may underestimate its beneficial effects on the Hospital complexity.

Dilatative percutaneous tracheostomy during double antiplatelet therapy: two consecutive cases.

This article reports two cases of dilatative percutaneous tracheostomy performed on patients treated with double antiplatelet therapy. Both patients had cardiac arrest following myocardial infarction. After primary angioplasty with stent placement, a double antiplatelet therapy was started. Due to poor neurological outcome, dilatative percutaneous tracheostomy was performed on both patients. Antiplatelet therapy was not discontinued because of the unacceptable risk of stent thrombosis. No immediate or late hemorrhagic complications occurred. In our experience, dilatative percutaneous tracheostomy during double antiplatelet therapy can be safely performed in selected patients without other risk factors.

Adult aqueductal stenosis presenting as a thunderclap headache: a case report.

Thunderclap headache is well known to be a presenting feature of a variety of causal events. Indeed, a primary form is considered in the International Classification of Headache Disorders-II, but such diagnosis must be made only after exclusion of a possible secondary cause. We report a case of late-onset idiopathic aqueductal stenosis presenting with thunderclap headache, in the absence of abnormal neurological findings or indirect signs of raised intracranial pressure. The patient recovered completely after endoscopic third ventriculostomy. This case indicates primary aqueduct stenosis as a possible, never previously reported, cause of thunderclap headache.

Effect of morbid obesity on kinetic of desflurane: wash-in wash-out curves and recovery times.

AIM: The aim of this paper was to compare wash-in and wash-out curves of desflurane in morbidly obese and nonobese patients. METHODS: Fourteen patients (7 obese and 7 nonobese) were studied. In the nonobese patients, anaesthesia was started by administering 2 mg/kg propofol bolus and a target controlled effect site concentration of remifentanil set at 2.5 ng/mL. Obese patients were intubated using a flexible fiberoptic bronchoscopic technique facilitated by a target controlled effect site concentration of remifentanil set at 2.5 ng/mL. After endotracheal intubation, general anaesthesia was started by administering a 1.5 mg/kg propofol bolus dose. Ten minutes after induction of anaesthesia, 4% desflurane was administered for 30 min. Desflurane kinetics was determined by collecting end-tidal samples from first breaths at 1, 5, 10, 15, 20, 25 and 30 min. At last skin suture, the end-tidal concentration of desflurane was recorded from 5 consecutive breaths before their discontinuation, then the end-tidal samples of the inhalational agent were collected at 0.5, 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5 and 5 min after terminating its administration. The period of time from discontinuation of desflurane to opening eyes, squeezing the observer's hand, extubation, stating the patients' name and providing date of birth was also recorded. RESULTS: The FA/FI ratio was higher in the nonobese group from the 10th to the 15th min. Wash-out curves of desflurane and recovery times were similar. CONCLUSION: Our results show that desflurane provides similar kinetic and recovery profiles in obese and nonobese patients.

Predictive performance of 'Servin's formula' during BIS-guided propofol-remifentanil target-controlled infusion in morbidly obese patients.

BACKGROUND: The aim of this study was to assess the predictive performance of 'Servin's formula' for bispectral index (BIS)-guided propofol-remifentanil target-controlled infusion (TCI) in morbidly obese patients. METHODS: Twenty patients (ASA physical status II-III, age 32-64 yr) undergoing bilio-intestinal bypass surgery, were recruited. Anaesthesia was induced by using a TCI of propofol with an initial target plasma concentration of 6 microg ml(-1), then adapted to maintain stable BIS values ranging between 40 and 50. A TCI of remifentanil was added to achieve pain control and haemodynamic stability. For propofol, weight was corrected as suggested by Servin and colleagues. With ideal body weight (IBW) corrected according to formula suggested by Lemmens and colleagues. For remifentanil, weight was corrected according to IBW. Arterial blood samples for the determination of blood propofol concentrations were collected at different surgical times. The predictive performance of propofol TCI was evaluated by examining performance accuracy. RESULTS: Median prediction error and median absolute prediction error were -32.6% (range -53.4%; -2.5%) and 33.1% (10.8%; 53.4%), respectively. Wobble median value was 5.9% (2.5%; 25.2%) while divergence median value was -1.5% h(-1) (-7.7; 33.8% h(-1)). CONCLUSION: Significant bias between predicted and measured plasma propofol concentrations was found while the low wobble values suggest that propofol TCI system is able to maintain stable drug concentrations over time. As already suggested before, a computer simulation confirmed that the TCI system performance could be significantly improved when total body weight is used.

Effect site concentrations of remifentanil maintaining cardiovascular homeostasis in response to surgical stimuli during bispectral index guided propofol anestesia in seriously obese patients.

AIM: The aim of this prospective study was to determine the effect site concentrations of remifentanil maintaining cardiovascular homeostasis in response to surgical stimuli during bispectral index (BIS) guided propofol anesthesia in seriously obese patients. METHODS: Twenty-two patients, female/male 15/7, ASA physical status II - III, aged 29-69 years, body mass index (BMI) 54.5+/-12, undergoing major open bariatric surgery, were enrolled to receive a propofol-remifentanil total intravenous anesthesia. All patients were intubated by using a flexible fiberoptic bronchoscopic technique facilitated by a target controlled effect site concentration of remifentanil set at 2.5 ng/mL. After endotracheal intubation, anesthesia was started with a target controlled infusion of propofol initially set at 6 microg/mL, then adjusted to maintain a BIS value between 40 and 50. The mean effect site concentration of remifentanil was recorded at different intervals time during surgery: skin incision-opening of peritoneum (T1), bowel resection (T2), cholecystojejunal anastomosis (T3), ileojejunal anastomosis (T4), closing of peritoneum (T5). RESULTS: The mean plasma concentrations of propofol required to maintain a BIS value between 40 and 50 were 4+/-0.55, 3.8+/-0.64, 3.8+/- 0.63, 3.8+/-0.65 and 3.8+/-0.63 microg/mL at T1, T2, T3, T4 and T5 interval time, respectively. The mean values of remifentanil target effect site concentration were 5.2+/-1.3, 7.7+/-1.7, 9.1+/-1.8, 9.7+/- 2.2 and 9.9+/-2.5 ng/mL at T1, T2, T3, T4 and T5 interval time. CONCLUSIONS: This study suggests that tolerance to remifentanil infusion is profound and develops very rapidly in morbidly obese patients submitted to open bariatric surgery during BIS guided propofol anesthesia. The administration of opiates during anesthesia based on target-controlled infusion should include corrections for the development of tolerance.

The effect of adding two target-controlled concentrations (1-3 ng mL -1 ) of remifentanil on MAC BAR of desflurane.

BACKGROUND AND OBJECTIVES: The aim of this prospective, randomized, double-blind study was to determine the effects of adding two different target-controlled concentrations of remifentanil (1 and 3 ng mL(-1)) on the desflurane requirement for blunting sympathetic responses after surgical incision (minimum anaesthetic concentration (MAC(BAR)). METHODS: 67 patients, aged 20-50 yr, ASA I, undergoing general anaesthesia for elective abdominal surgery were enrolled and randomly allocated to receive no remifentanil infusion (n = 21) or a target-controlled effect-site concentration of 1 ng mL(-1) (n = 24) or 3 ng mL(-1) remifentanil (n = 22). All patients were anaesthetized with propofol, cisatracurium and desflurane with a mixture of 60% nitrous oxide in oxygen. Sympathetic responses to surgical incision were determined after a 20-min period of stable end-tidal desflurane and target-controlled remifentanil concentrations. Predetermined end-tidal desflurane concentrations and the MAC(BAR) for each group were determined using an up-and-down sequential-allocation technique. RESULTS: The MAC(BAR) of desflurane was higher in the group receiving no remifentanil (6.25% [95% confidence interval: 5.9-6.5%]) as compared with patients of the groups receiving 1 ng mL(-1) (2.7% [2.6-2.8%]; P < 0.001) and 3 ng mL(-1) remifentanil (2% [1.9-2.2%]; P < 0.01). When considering a MAC value in this age population and the contribution of 60% nitrous oxide (0.55 MAC), the combined MAC(BAR) values, expressed as multiples of the MAC, were 1.9, 0.8 and 0.6 MAC, in the three groups, respectively. CONCLUSION: A target-controlled concentration of 1 ng mL(-1) remifentanil results in a 57% decrease in the MAC(BAR) of desflurane combined with 60% nitrous oxide. Increasing the target concentration of remifentanil to 3 ng mL(-1) produces a further 26% decrease in the MAC(BAR) values of desflurane.

Oxcarbazepine reduces seizure frequency in a high proportion of patients with both newly diagnosed and refractory partial seizures in clinical practice.

The antiepileptic efficacy and tolerability of oxcarbazepine, used both as monotherapy and adjunctive therapy, were observed for 1 year in 202 adult patients, aged 17-83 years, with newly diagnosed or refractory partial epilepsy in clinical practice in Italy. At first observation, the seizure free rate was 72.2% in newly diagnosed patients given monotherapy, 40% in patients in whom oxcarbazepine replaced another monotherapy and 10.3% in patients given oxcarbazepine as adjunctive therapy. At least 50% reduction in seizure frequency was achieved in 90.7, 72 and 57%, respectively. Efficacy increased with the duration of treatment (p < 0.0001). In the 160 completers the seizure free rate was 61.3% with monotherapy and 28% with adjunctive therapy. 16.3% of patients reported adverse effects, mainly sedation and sleepiness; 5% discontinued oxcarbazepine because of adverse events. OXC is an effective and well-tolerated antiepileptic agent for the long-term treatment of partial epilepsy in adults.

Redo coronary artery bypass grafting on the beating heart and transfusion needs.

AIM: Reoperative coronary artery bypass grafting is associated with significant morbidity and a difficult perioperative management; in particular, important bleeding is observed. Off pump technique may give specific advantages in redo coronary operations since it is associated to decreased interactions of blood with foreign surfaces. We investigated our 5-year database to evaluate the role of off pump technique in reducing transfusion needs. METHODS: The present single centre case control study was carried out in a university tertiary care hospital on 132 consecutive patients undergoing reoperative coronary artery bypass grafting off pump (OP group, 41 patients) or with cardiopulmonary bypass (CPB group, 91 patients). Univariate and multivariate analysis were performed. RESULTS: There was no preoperative difference between the 2 groups; mean number of grafts per patient differed between groups (OP: 1.4+/-0.7, CPB: 2.5+/-1.0). The frequency of patients transfused with blood products was significantly (P=0.004) higher in the CPB group (47.3%) than in the OP group (19.5%). The only independent predictors of transfusions, determined by stepwise multivariate logistic regression analysis, was the use of cardiopulmonary bypass (OR: 4.1, CI: 1.6 - 10.1), and female gender (OR: 7.0, CI: 2.1 - 16.1). CONCLUSION: In our centre, off pump coronary surgery is associated with reduced transfusion of blood products.

Cardioventilatory responses during real or imagined walking at low speed.

There is increasing evidence that motor imagery involves at least in part central processes used in motor control. In order to deepen our understanding on the neural mechanisms underlying vegetative responses to real and imagined exercise, we determined cardioventilatory variables during actual or imagined treadmill walking on flat terrain at speeds of 2, 3.5 or 5 km/h, in a group of 14 healthy volunteers. During actual walking, as expected, a comparable intensity-dependent increase was found in ventilation, oxygen consumption, tidal volume and respiratory rate. Imagined walking led to a significant, albeit small (less than 10%), increase in ventilation and oxygen consumption, and to larger increases (up to 40%) in respiratory rate, which was paralleled by a non significant trend towards a decline of tidal volume. These results confirm and extend previous observations showing that motor imagery is accompanied by centrally induced changes in vegetative responses, and provide evidence for a differential control on respiratory rate and tidal volume.

The effect of adding nitrous oxide on MAC of sevoflurane combined with two target-controlled concentrations of remifentanil in women.

BACKGROUND AND OBJECTIVE: The aim of this prospective, randomized, double-blind study was to determine the effects of adding nitrous oxide on sevoflurane requirement for blunting sympathetic responses after surgical incision combined with two different target-controlled concentrations of remifentanil (1 and 3 ng mL(-1)) in female. METHODS: 102 female patients, aged 20-50 yr, ASA I, undergoing general anaesthesia for elective abdominal surgery were enrolled and randomly allocated to receive sevoflurane anaesthesia alone (Group A, n=53), or with the addition of 60% nitrous oxide (Group N, n=49). Patients of both groups were further assigned to receive a target-controlled remifentanil infusion with an effect-site concentration of either 1 ng mL(-1) (Group N1, n=27; Group A1, n=30), or 3 ng mL(-1) (Group N3, n=22; Group A3, n=23). Sympathetic responses to surgical incision were determined after a 20-min period of stable end-tidal sevoflurane and target-controlled remifentanil concentrations. Predetermined end-tidal sevoflurane concentrations and minimum alveolar concentration (MAC) for each group were determined using an up-and-down sequential allocation technique. RESULTS: The MAC of sevoflurane was 3.96% (95% confidence interval, CI95: 3.69-4.23%) in Group A1 and 1.2% (CI95: 0.9-1.3%) in Group N1 (P < 0.01), while in Groups A3 and N3 the MAC of sevoflurane was 0.36% (CI95: 0.24-0.47%) and 0.18% (CI95: 0.1-0.3%), respectively (P < 0.05). CONCLUSION: Adding 60% nitrous oxide reduces the MAC of sevoflurane by 70% when using a remifentanil concentration of 1 ng mL(-1) and 50% when using a remifentanil concentration of 3 ng mL(-1).

Hemifacial spasm due to a tentorial paramedian meningioma: a case report.

Hemifacial spasm (HFS) is a movement disorder characterised by involuntary paroxysmal facial movements that usually involve the orbicularis oculi and then spread to the other facial muscles. A microvascular compression and demyelination of the seventh nerve at its exit from the brain stem is considered to be the main aetiology of HFS. In addition to rare idiopathic (cryptogenetic) cases, others causes of HFS exist: tumours or vascular malformations have been described, of both the ipsilateral and contralateral cerebellopontine angle (CPA). However, space-occupying lesions in locations other than CPA are usually not thought to be responsible for HFS. Here we describe the case of a 45-year-old woman suffering from HFS, who dramatically improved after surgical removal of a tentorial paramedian meningioma.

Sleep disorders and extrapyramidal diseases: an historical review.

BACKGROUND AND PURPOSE: Sleep disorders have been mentioned since the first descriptions of extrapyramidal diseases in James Parkinson's Essay on the Shaking Palsy, but only recently they have become the subject of attention, thanks to new acquisitions in clinical knowledge and electroencephalographic technology. In the late 1960s, the introduction of L-dopa permitted comparison of sleep patterns in drug-naive patients before and after therapy in conditions very similar to experimental ones. Historically, we can recognise two major lines of study, one dealing with descriptions of sleep behaviours modified by drugs and the other with polysomnographic sleep research carried out before and after treatment. PATIENTS AND METHODS: The data obtained from the first polysomnographic studies led to the definition of sleep macro- and microstructure in patients suffering from Parkinson's disease, but the interpretation of drug-induced changes was not unequivocal. RESULTS: According to some authors, the improvement in sleep architecture was due mainly to improvement of nocturnal motor impairment. Other researchers suggested a primary sleep dysfunction caused by specific neurodegenerative processes in the brain structures regulating the sleep-wake cycle. CONCLUSIONS: The latter hypothesis has recently been supported by the observation that distinct sleep disorders, such as REM behaviour disorder or restless legs syndrome, often herald extrapyramidal diseases or are a frequent adjunctive complaint for these patients.

Relationship between Delta, Sigma, Beta, and Gamma EEG bands at REM sleep onset and REM sleep end.

OBJECTIVE: The aim of the present study was to analyze in detail the relationship of two newly introduced measures, related to the Beta and Gamma EEG bands during REM sleep, with Delta and Sigma activity at REM sleep onset and REM sleep end, in order to understand their eventual role in the sleep modulation mechanism. METHODS: For this purpose, power spectra of 1 EEG channel (C4, referred to A1) were obtained by means of the fast Fourier transform and the power of the bands ranging 0.75-4.50 Hz (Delta), 4.75-7.75 (Theta), 8.00-12.25 (Alpha), 12.50-15.00 (Sigma), 15.25-24.75 (Beta), 25.00-34.75 (Gamma 1), and 35.00-44.75 (Gamma 2) was calculated for the whole period of analysis (7 h), in 10 healthy subjects. Additionally, two other time series were calculated: the ratio between Beta and Gamma2, and between Gamma1 and Gamma2 (Beta and Gamma ratios). For each subject, we extracted 3 epochs of 30 min corresponding to the 15 min preceding and the 15 min following the onset of the first 3 REM episodes. Data were then averaged in order to obtain group mean values and standard deviation. The same process was applied to the 30-min epochs around REM sleep end. RESULTS: The course of the Delta band around REM sleep onset was found to be characterized by a first phase of slow decline lasting from the beginning of our window up to a few seconds before REM onset; this phase was followed by a sudden, short decrease centered around REM onset, lasting for approximately 1.5-2 min. At the end of this phase, the Delta band reached its lowest values and remained stable up to the end of the time window. The Sigma band showed a similar course with stable values before and after REM sleep onset. The Beta and Gamma ratios also showed a 3-phase course; the first phase, in this case, was characterized by stable low values, from the beginning of our window up to approximately 5 min before REM onset. The following second phase was characterized by an increase which reached its maximum shortly after REM sleep onset (approximately 1 min). In the last phase, both Beta and Gamma ratios showed stable high values, up to the end of our time window. At REM sleep end, the Delta band only showed a very small gradual increase, the Sigma band presented a more evident gradual increase; on the contrary, both Beta and Gamma ratios showed a small gradual decrease. CONCLUSIONS: The results of the present study show a different time synchronization of the changes in the Delta band and in Beta and Gamma ratios, at around REM sleep onset, and seem to suggest that the oscillations of these parameters might be modulated by mechanisms more complex than a simple reciprocity. All these considerations point to the fact that REM sleep can be considered as a complex phenomenon and the analysis of high-frequency EEG bands and of our Beta and Gamma ratios represent an additional important element to include in the study of this sleep stage.

Sleep and sleep deprivation as EEG activating methods.

OBJECTIVES: We examined retrospectively 19 patients with a history of clinical seizures, but normal activity or unclear epileptiform abnormalities in wake EEG recordings and obtained preliminary data for a controlled cohort study to evaluate the effects of sleep deprivation (SD) on interictal epileptic activity. METHODS: Nineteen patients referred to our EEG department for diagnostic or follow-up purposes were divided in two groups on the basis of the different EEG protocols applied. The first group (n=5) underwent two laboratory polysomnographies during afternoon naps, after SD, but the patients failed to fall asleep in one of the two occasions. The second group (n=14) was submitted to two polysomnographies, the first without SD and the second after SD. RESULTS: The first group of patients demonstrated focal epileptic discharges in 4 patients in which wake after SD appeared to be less activated that sleep after SD. In the second group the results obtained from the waking part of the recordings suggest a lack of activating effect due to SD. CONCLUSIONS: SD does not seem to offer greater activation than sleep alone. However, a mild SD may be a convenient activating method for inducing sleep and drowsiness without using any drug.

Correlations between individual clinical manifestations and CTG repeat amplification in myotonic dystrophy.

Myotonic dystrophy (DM) is a multisystemic disease caused by the expansion of a CTG repeat, located in the 3'-untranslated region of the DMPK gene. The number of CTG repeats broadly correlates with the overall severity of the disease. However, correlations between CTG repeat number and presence/absence or severity of individual clinical manifestations in the same patients are yet scarce. In this study the number of CTG repeats detected in blood cells of 24 DM subjects was correlated with the severity of single clinical manifestations. The presence/absence of muscular atrophy, respiratory insufficiency, cardiac abnormalities, diabetes, cataract, sleep disorders, sterility or hypogonadism is not related to the number of CTG repeats. Muscular atrophy and respiratory insufficiency are present with the highest frequency, occurring in 96 and 92% of the cases, respectively. A significant correlation was found with age of onset (r = -0.57, p<0.01), muscular disability (r = 0.46, p<0.05), intellective quotient (r = -0.58, p<0.01) and short-term memory (r= -0.59, p<0.01). Therefore, the CTG repeat number has a predictive value only in the case of some clinical manifestations, this suggesting that pathogenetic mechanisms of DM may differ depending on the tissue.