Lung Transplantation From Donors After Previous Cardiac Surgery: Ideal Graft in Marginal Donor?

Lung transplantation is a limited by donor pool shortage. Despite the efforts to extend the graft acceptability with recurrent donor criteria reformulations, previous cardiothoracic surgery is still considered a contraindication. A donor who underwent cardiac surgery could potentially provide an ideal lung but high intraoperative risks and intrinsic technical challenges are expected during the graft harvesting. The purpose of this study is to present our dedicated protocol and four clinical cases of successful lung procurements from donors who had a previous major cardiac surgery. One donor had ascending aortic root (AAR) substitution, another had mitral valve substitution, and two had coronary artery bypass surgery. The others' eligibility criteria for organ allocation, such as ABO compatibility, PaO2/FiO2 ratio, absence of aspiration, or sepsis were respected. In one of the cases with previous coronary bypass grafting, the donor had a veno-arterial extracorporeal membrane oxygenation support. Consequently, the grafts required an ex vivo lung perfusion evaluation. We report the technical details of procurement and postoperative courses of recipients. All procurements were uneventful, without lung damage or waste of abdominal organs related to catastrophic intraoperative events. All recipients had a successful clinical outcome. We believe that successful transplantation is achievable even in a complicated setting, such as cases involving donors with previous cardiac surgery frequently are. Facing lung donor shortage, we strongly support any effort to avoid the loss of possible acceptable lungs. In particular, previous major cardiac surgery does not strictly imply a poor quality of lungs as well as unsustainable graft procurement.

Imaging of post-surgical treatment and of related complications in spinal trauma.

Spinal trauma is a devastating event with a high morbidity and mortality. The rationale of imaging is to diagnose the traumatic abnormalities and characterize the type of injury, to estimate the severity of the lesions, to evaluate the potential spinal instability. In case of spinal instability, the goals of operative treatment are decompression of the spinal cord canal and stabilization of the disrupted vertebral column. Particularly, diagnostic imaging, mainly by CT and MR, has a main role in the post-treatment evaluation. The neuroradiological evaluation of the postoperative spine requires a general knowledge of the surgical approach to each spinal region and of the normal temporal evolution of expected postoperative changes. The neuroradiologist should evaluate the devices implanted, their related complications and promptly alert the surgeon of acute complications, mainly vascular and infective. During the follow-up, it is mandatory to know and search chronic complications as pseudomeningocele, accelerated degenerative disease, arachnoiditis, peridural fibrosis. Knowledge of specific complications relating to each surgical approach will assist the neuroradiologist in interpretation of postoperative images.

The lack of the Celf2a splicing factor converts a Duchenne genotype into a Becker phenotype.

Substitutions, deletions and duplications in the dystrophin gene lead to either the severe Duchenne muscular dystrophy (DMD) or mild Becker muscular dystrophy depending on whether out-of-frame or in-frame transcripts are produced. We identified a DMD case (GSΔ44) where the correlation between genotype and phenotype is not respected, even if carrying a typical Duchenne mutation (exon 44 deletion) a Becker-like phenotype was observed. Here we report that in this patient, partial restoration of an in-frame transcript occurs by natural skipping of exon 45 and that this is due to the lack of Celf2a, a splicing factor that interacts with exon 45 in the dystrophin pre-mRNA. Several experiments are presented that demonstrate the central role of Celf2a in controlling exon 45 splicing; our data point to this factor as a potential target for the improvement of those DMD therapeutic treatments, which requires exon 45 skipping.

Endovascular treatment of cerebral aneurysms using the hydrocoil embolic system.

HydroCoils are platinum helical coils coated with a layer of hydrophilic acrylic polymer (hydrogel), which on contact with blood causes disentanglement of polymer chains and expansion. We retrospectively reviewed a series of 29 patients harboring 29 cerebral aneurysms treated with the Hydrocoil Embolic System in the period 2004-2005, discussing the results of endovascular procedures in terms of safety and efficacy. The immediate post-procedure angiographic control demonstrated complete aneurysm occlusion in 21 cases (72.4%), near-complete occlusion in seven cases (24.1%), whereas in one case (3.4%) there was a procedure failure with major perfusion of the sac. Five patients (17.2%) experienced thromboembolic complications, including an asymptomatic lacunar stroke of the head of the caudate nucleus, a thalamic infarct following hypotension secondary to pulmonary edema, temporal ischemia secondary to vasospasm and a small right occipital ischemic lesion. Only one patient (3.4%) suffered a major ischemic accident. No other procedure-related complication occurred. Three-month follow-up control with MR angiography and 12-month follow-up angiography demonstrated no recurrence of aneurysms. Overall, after a mean follow-up of 12 months, the clinical outcome was good recovery in 26 patients (89.6%), moderate disability in three patients (10.3%) and no vegetative status or death. Our HydroCoil series supports the safety and midterm durability of hydrogel-coated aneurysm coils in the treatment of cerebral aneurysms.

Atraumatic vertebral compression fractures: differential diagnosis between benign osteoporotic and malignant fractures by MRI.

Atraumatic vertebral compression fractures are a common clinical problem, especially in elderly population. Metastases are the most frequent source of bone tumors, and the spine is a common site of metastatic disease; in case of cortical involvement or osteolysis, they may result in pathological compression fractures. Atraumatic compression fractures may result from other primary neoplasms of vertebrae and also from osteomyelitis, Paget's disease, hyperparathyroidism and other metabolic processes. Osteoporosis is a common source of vertebral compression fractures in elderly population, which may be indistinguishable from those of metastatic origin. The differentiation between osteoporotic compression fractures and malignant fracture is necessary to establish an appropriate staging and a therapeutic planning, especially in the acute and subacute stages. Anamnestic data about preexisting disease can be useful to individuate the potential cause of vertebral collapse. Plain radiography shows some difficulties in distinguishing whether the fracture represents a consequence of osteoporosis, a metastatic lesion or some other primary bone neoplasm. Computed tomography is one of the most suitable imaging techniques for the evaluation of bone structure and fragments and to establish the degree of cortical bone destruction; MR imaging (MRI) is the most helpful radiological investigation in order to provide the basis for the distinction between metastatic and acute osteoporotic compression fractures. The most relevant MRI findings to establish a differential diagnosis are described.

Magnetic resonance imaging in brachial plexus injury.

Brachial plexus injury represents the most severe nerve injury of the extremities. While obstetric brachial plexus injury has showed a reduction in the number of cases due to the improvements in obstetric care, brachial plexus injury in the adult is an increasingly common clinical problem. The therapeutic measures depend on the pathologic condition and the location of the injury: Preganglionic avulsions are usually not amenable to surgical repair; function of some denervated muscles can be restored with nerve transfers from intercostals or accessory nerves and contralateral C7 transfer. Postganglionic avulsions are repaired with excision of the damaged segment and nerve autograft between nerve ends or followed up conservatively. Magnetic resonance imaging is the modality of choice for depicting the anatomy and pathology of the brachial plexus: It demonstrates the location of the nerve damage (crucial for optimal treatment planning), depicts the nerve continuity (with or without neuroma formation), or may show a completely disrupted/avulsed nerve, thereby aiding in nerve-injury grading for preoperative planning. Computed tomography myelography has the advantage of a higher spatial resolution in demonstration of nerve roots compared with MR myelography; however, it is invasive and shows some difficulties in the depiction of some pseudomeningoceles with little or no communication with the dural sac.

Spontaneous resolution of Chiari type 1 malformation. A case report and literature review.

We describe a 62-year-old woman who presented with a history of ataxia, dizziness and urinary urgency. Neurological examination disclosed a positive Romberg sign, ataxia and postural instability. A magnetic resonance imaging (MRI) scan showed Chiari type 1 malformation (CM1). Forty-eight months later, the patient was clinically improved and underwent a second MRI examination, which showed complete resolution of the Chiari 1 malformation. Spontaneous resolution of CM1 is exceptionally rare and has to be considered in the radiological and clinical management.

Endovascular treatment of a small aneurysm of the superior cerebellar artery with a flow-diverter device. A case report.

We describe the case of a 62-year-old woman who presented with a small fusiform left superior cerebellar artery (SCA) aneurysm. Aneurysms located on the SCA are uncommon and their presentation, natural history and clinical management are poorly understood. Reports on the endovascular or surgical management of SCA aneurysms are rare and usually incorporated in clinical series of basilar artery or posterior circulation aneurysms. The patient was treated by delivery of a flow-diverter Pipeline Embolization Device (PED - Chestnut Medical/ev3) at the origin of vessel. She had no procedural complications and the aneurysm volume was reduced. This paper presents additional evidence to literature reports suggesting that the new endovascular flow-diverter devices are an effective and well-tolerated treatment for complex aneurysms. Our review contributes data on the incidence of recurrence as a measure of long-term efficacy of this therapeutic approach.

Endovascular treatment of vertebro-vertebral arteriovenous fistula. A report of three cases and literature review.

This report describes endovascular approaches for occlusion of vertebro-vertebral arteriovenous fistula (VV-AVF) in a series of three cases and a review of the literature. Complete neuroimaging assessment, including CT, MR and DSA was performed in three patients (two female, one male) with VV-AVF. Based on DSA findings, the VV-AVF were occluded by endovascular positioning of detachable balloons (case 1), coils (case 2), or a combination of both (case 3) with parent artery patency in two out of three cases. In this small series, endovascular techniques for occlusion of VV-AVF were safe and effective methods of treatment. To date, there are no guidelines on the best treatment for VV-AVF. Detachable balloons, endovascular coiling, combined embolization procedures could all be considered well-tolerated treatments.

Epidemiology and genetics of intracranial aneurysms.

Intracranial aneurysms are acquired lesions (5-10% of the population), a fraction of which rupture leading to subarachnoid hemorrhage with devastating consequences. Until now, the exact etiology of intracranial aneurysms formation remains unclear. The low incidence of subarachnoid hemorrhage in comparison with the prevalence of unruptured IAs suggests that the vast majority of intracranial aneurysms do not rupture and that identifying those at highest risk is important in defining the optimal management. The most important factors predicting rupture are aneurysm size and site. In addition to ambiental factors (smoking, excessive alcohol consumption and hypertension), epidemiological studies have demonstrated a familiar influence contributing to the pathogenesis of intracranial aneurysms, with increased frequency in first- and second-degree relatives of people with subarachnoid hemorrhage. In comparison to sporadic aneurysms, familial aneurysms tend to be larger, more often located at the middle cerebral artery, and more likely to be multiple. Other than familiar occurrence, there are several heritable conditions associated with intracranial aneurysm formation, including autosomal dominant polycystic kidney disease, neurofibromatosis type I, Marfan syndrome, multiple endocrine neoplasia type I, pseudoxanthoma elasticum, hereditary hemorrhagic telangiectasia, and Ehlers-Danlos syndrome type II and IV. The familial occurrence and the association with heritable conditions indicate that genetic factors may play a role in the development of intracranial aneurysms. Genome-wide linkage studies in families and sib pairs with intracranial aneurysms have identified several loci on chromosomes showing suggestive evidence of linkage, particularly on chromosomes 1p34.3-p36.13, 7q11, 19q13.3, and Xp22. For the loci on 1p34.3-p36.13 and 7q11, a moderate positive association with positional candidate genes has been demonstrated (perlecan gene, elastin gene, collagen type 1 A2 gene). Moreover, 3 of the polymorphisms analyzed in 2 genes (endothelial nitric oxide synthase T786C, interleukin-6 G572C, and interleukin-6 G174C) were found to be significantly associated with ruptured/unruptured aneurysms: the endothelial nitric oxide synthase gene single-nucleotide polymorphisms increased the risk, while IL-6 G174C seemed protective. More recently, two genomic loci (endothelin receptor A and cyclin-dependent kinase inhibitor 2BAS) have been found to be significantly associated with intracranial aneurysms in the Japanese population; endothelin-1 is a potent vasoconstrictor produced by the endothelial cells. Until now, there are no diagnostic tests for specific genetic risk factors to identify patients who are at a high risk of developing intracranial aneurysms. Knowledge of the genetic determinants may be useful in order to allow clues on stopping aneurysm formation and obtain diagnostic tools for identifying individuals at increased risk. Further multicenter studies have to be carried out.

Spontaneous regression of syringomyelia in a young patient with Chiari type I malformation.

Syringomyelia is a disorder in which a cyst or cavity forms within the spinal cord. This cyst, called syrinx, can expand and elongate over time, destroying the spinal cord. We describe the case of a young patient with partial spontaneous regression of syringomyelia in Chiari I malformation, confirmed by magnetic resonance imaging three years after the diagnosis. During this period the patient did not experience any clinical symptoms. Although described in literature, spontaneous regression is an unusual event and very few cases have been reported. This case report supports the belief that conservative management together with both clinical and imaging periodic controls should be preferred in stable mild-symptomatic patients.

MRI features of spinal solitary fibrous tumors. A report of two cases and literature review.

Spinal solitary fibrous tumors (SFT) are very rare neoplasms occurring in the spinal canal, with only 38 cases reported in ten years since the first description. We describe two cases of SFT of the spine and review 33 well-documented cases in the literature to define distinctive radiological and surgical features raising the suspicion of a spinal SFT before histological verification. A 67-year-old man with cervical myeloradiculopathy had a large extramedullary tumor of the cervical spinal canal extending from C4 to C7. On MRI the tumor was isointense on T1-sequences and hypointense on T2-sequences, and had marked contrast enhancement. At surgery, the tumor was intradural extramedullary, with no dural or root attachment, but it was adherent to the cord. Complete tumor removal was achieved with good outcome. A 75-year-old man with progressive thoracic myelopathy had an intramedullary tumor at C6 and C7 level, which was hypointense on T1- and T2-weighted images of MRI. At surgery, the tumor was intramedullary and strongly adherent to the cord; it was successfully removed. Both tumors were composed of elongated cells with a collagen-matrix background. Immunohistochemical staining was positive for vimentin, CD34, and bcl-2, and negative for EMA and S-100 protein. A careful analysis of our own and the other reported cases of spinal SFTs may disclose some peculiar features of this rare tumor. A spinal intramedullary or extramedullary tumor, hypointense on T2-weighted images of MRI, which intraoperatively shows hard consistency, scarce vascularization, no nerve root involvement, no or weak dural attachment, absence of arachnoidal interface, and adherence to the spinal cord may suggest the diagnosis of SFT.

A rare case of intraosseous lipoma involving the sphenoclival region.

We describe the case of a 23-year-old man whose CT scan revealed a hypodense lesion reshaping the superior and middle third of the clivus and partially invading the sphenoidal sinus. MRI showed an irregular-shaped lesion occupying the body of the sphenoid bone, involving the superior and middle third of the clivus and sprouting into the sphenoid sinus. The lesion was hyperintense on T1- and T2-weighted sequences with a thin peripheral rim of hypointensity, without enhancement after i.v. gadolinium injection. The pathology report confirmed an intraosseus lipoma. Intraosseous lipomas involving the spheno-clival region are extremely rare. CT and MRI scan interpretation can be troublesome but this rare pathology has to be considered in the differential diagnosis.

Endovascular treatment of a giant dissecting aneurysm of the posterior cerebral artery. A case report and literature review.

We describe the case of a 60-year-old man who presented with a giant dissecting aneurysm of the left P2 segment. Intracranial dissecting aneurysms often occur in the vertebrobasilar system, but rarely involve the posterior cerebral artery (PCA). PCA aneurysms tend to have some peculiar features and therefore may be considered a separate entity, even from the vertebrobasilar aneurysms. The patient was treated by endovascular occlusion of both parent vessel and the aneurysm, and he tolerated the procedure well with a complete resolution of clinical deficit, following volume reduction of the aneurysm. This paper presents additional evidence to literature reports suggesting that endovascular parent artery occlusion with coils is an effective and well-tolerated treatment for distal PCA aneurysms. Our review contributes to collect data regarding the incidence of recurrence as a measure of long-term efficacy of this therapeutic approach.

Basilar artery hypoplasia.

A rare case of segmental hypoplasia of the basilar artery is described in a 49-year-old man with transient vertebrobasilar ischemia, explored by magnetic resonance imaging (MRI) and digital angiography (DA). The embryology, clinical relevance and magnetic resonance findings of this arterial anomaly are discussed, with a review of six previously reported cases. Segmental aplasia was suggested in our case by magnetic resonance, and subsequently confirmed not only by time-of-flight magnetic resonance, but also by DA. Only ultrathin-slice T2-weighted images revealed the real finding of basilar artery hypoplasia. This sequence, not employed in previously reported cases, is mandatory to allow a clear differential diagnosis between basilar artery aplasia and hypoplasia.

Anatomical variant of origin of ophthalmic artery: case report.

We report on one case of variant origin of right ophthalmic artery (OA) from C4 choroidal segment of the right supraclinoid internal carotid artery. A 41-year-old woman affected by bitemporal hemianopsia performed Magnetic Resonance Imaging with gadolinium showing tuberculum sellae meningioma. During angiography we observed this variant of origin of OA. At surgical dissection, we observed this variant in carotid cistern.

Fusiform aneurysm of the proximal anterior cerebral artery (A1).

OBJECTIVE: Fusiform aneurysms of the A1 segment of the anterior cerebral artery (ACA) are exceptional, with only 15 reported cases. This article presents an additional case treated by microsurgical trapping. The aim is to discuss the treatment of these aneurysms based on the aneurysm morphology and the anatomy of the ACA complex. CASE REPORT: A 52-year-old woman with subarachnoid hemorrhage (Hunt-Hess grade II) showed an aneurysm of the proximal part of the A1 segment of the left ACA involving the whole circumference of the arterial wall on computerized tomography angiography and digital angiography. There was good collateral blood flow from the right ACA to the distal left ACA. A left pterional craniotomy allowed us to expose a large aneurysm of the proximal part of the A1 segment; the artery entered into the aneurysm sac and could not be identified at the level of the aneurysm. Trapping of the aneurysm was performed with a distal clip placed just before the origin of the artery of Heubner. No neurological deficits were observed postoperatively. CONCLUSION: Clipping of fusiform aneurysms of the A1 segment using an encircling clip is the treatment of choice but, more often, this is impossible. Trapping of the aneurysm with preservation of the perforating branches (mainly the Heubner artery) may be easily performed when collateral blood flow from the contralateral ACA is sufficient.

DWI Reversibility after Intra-Arterial Thrombolysis. A Case Report and Literature Review.

We report our case and review the literature on reversal DWI lesions, ADC thresholds and correlation between DWI lesion and outcome measured with clinical scales. A 30-years old woman was admitted to our hospital 18 hours after stroke onset. Considering the absence of alterations on CT and the worsening of symptomatology, the patient underwent MRI, which showed a slightly hyperintense signal in FLAIR images in the left portion of the pons and midbrain and a more evident bilateral DWI hyperintensity of the pons. The patient was treated with mechanical and pharmacological intra-arterial thrombolysis. The patient showed a rapid improvement of symptoms. Two weeks after the treatment her clinical conditions were characterized by a residual right hemiparesis and complete recovery of right motility, respiratory and swallowing difficulties. MR examination demonstrated a slight signal alteration of the pons left hemiportion and a disappearance of the mesencephalic signal alteration and of the right portion of the pons. DWI lesions represent irreversibly damaged tissue but new evidence suggests that DWI lesions may be reversible, especially with reperfusion, by now well demonstrated in animal models. Therefore acute DWI lesions probably contain not only irreversibly injured tissue but also parts of the penumbra. The debate on the capability of ADC maps to discriminate irreversibly from reversibly damaged tissue is a matter of controversy. ADC values in human stoke are not an independent indicator of tissue viability. The use of thresholds may improve reproducibility but not validity.

Prenatal screening for congenital toxoplasmosis in Campania: preliminary report on activities and results.

By 1997, an open cohort of 1,652 live newborn of 1,637 mothers with gestational toxoplasmosis had been recruited in the Campania region to monitor the burden of congenital toxoplasmosis (CT). Of the 1,556 mother-child pairs that completed the follow up, 92 definite cases were detected, yielding a 5.9% (4.8-7.1 95% CI) transmission rate. The onset was patent for 43% of patients and sensorineural complications were shown for a further 15% of subclinical onset patients later than two years of age. The overall prevalence of toxoplasmosis during gestation was 2.46 of 1,000 deliveries, while the prevalence of definite CT was 1.38 of 10,000 live newborns. However, there is still room for intervention, as only 23% of the maternal diagnoses were proven through seroconversion, 63 of the late-gestation seroconverters remained untreated, and six probable CT diagnoses were made following referrals due to patent sequelae and born during the study period. There was a positive secular trend on the rates of infant referral and definite CT diagnosis, according to the live birth rate (Chi2 for trend < 0.001). Extension of this surveillance system across the country could help to define a future strategy for prevention.