Somatosensory evoked potentials and transcranial color Doppler monitoring in subarachnoid hemorrhage.

OBJECTIVES: The outcome of patients with subarachnoid hemorrhage (SAH) is broadly influenced by the complications that may result from the hemorrhage. We describe a series of subjects, in which neurophysiological monitoring executed by simultaneous recording of somatosensory evoked potentials (SEPs) and transcranial color Doppler (TCD) was performed to reveal possible, early complications following acute SAH. MATERIALS AND METHODS: We described the absolute and interhemispheric values of SEPs from the upper limb and TCD examinations of the cerebral arteries in 13 subjects with acute SAH. RESULTS: In cases with middle cerebral artery (MCA) vasospasm, N20 SEP amplitude absolute values for the hemisphere involved in the vasospasm were much lower than the contralateral ones. The N20 amplitude ratio reduction correlated with reciprocal of MCA mean flow velocity values detected within each patient. In the subjects with early ischemic damage following SAH, the affected hemisphere showed N20 amplitude drop; in addition, the relationship between SEPs and TCD findings was missing. CONCLUSION: Our findings emphasize the utility of simultaneous evaluation of SEPs and TCD in SAH follow-up, since the two methods reflect different pathomechanisms of possible secondary brain damage in aneurysmal SAH.

Superselective ophthalmic artery infusion of melphalan for intraocular retinoblastoma: preliminary results from 140 treatments.

PURPOSE: To report our experience in superselective ophthalmic artery infusion of melphalan (SOAIM) for intraocular retinoblastoma. METHODS: From June 2008 to October 2010, 38 patients (18 women, 20 men; age range at first treatment, 7 months to 22 years) with 41 eyes with retinoblastoma were scheduled for SOAIM, for 17 newly diagnosed retinoblastomas Tumour, Node and Metastasis (TNM) 7th Edition 1a (n = 1), 1b (n = 1), 2a (n = 7), 2b (n = 4) and 3a (n = 4) and 24 retinoblastomas with partial remission/relapse TNM 7th Edition 1b (n = 13), 2a (n = 1) and 2b (n = 10). Eight patients (ten eyes) have been treated by SOAIM alone. Follow-up was 6-27 months in 28 patients (30 eyes). RESULTS: Ophthalmic artery cannulation failed in two patients. Thirty-six patients underwent 140 treatments by internal (n = 112) or external (n = 28) carotid arteries. No major procedural complications occurred. Two patients have been lost to follow-up. Remaining 34 patients (37 eyes) had no metastatic disease. Four patients suffered permanent ocular complications: chorioretinal dystrophy (n = 2), ptosis (n = 1) and strabismus/exotropia (n = 1). Eight (22%) eyes in eight (24%) patients underwent enucleation: 7/16 (43%) newly diagnosed retinoblastomas and 1/22 (4.5%) retinoblastomas undergoing partial remission/relapse. For all treated eyes, Kaplan-Meier eye enucleation-free rates (K-M) were 85.4% (95% CI, 73.3-97.5%), 74.4% (95% CI, 57-91.8%) and still stable at 6, 12 months and 2 years, respectively. For eyes with partial remission/relapse, and eyes at presentation, K-M at 2 years were 95.5% (95% CI, 86.9-100%) and 45.6% (95% CI, 16.6-74.6%), respectively. CONCLUSION: Superselective ophthalmic artery infusion of melphalan was safe and powerful, especially following other therapies. Superselective ophthalmic artery infusion of melphalan should be added to focal therapies spectrum. In selected cases, melphalan should be combined with other chemotherapeutic agents.

Reversible post-traumatic bilateral extensive restricted diffusion of the brain. A case study and review of the literature.

PRIMARY OBJECTIVE: To increase the knowledge about diffuse traumatic brain injury (TBI) by reporting the magnetic resonance imaging (MRI) findings observed in a patient with reversible extensive restricted diffusion of the brain at diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) maps. CASE STUDY: An 18-year-old patient was admitted after high-energy closed TBI. Glasgow Coma Scale score was 4. Head computed tomography showed small left frontal and temporal haemorrhagic contusions and a small haemorrhage in the left thalamus. Ten days later, brain MRI showed diffuse high-signal intensity on T2-weighted images and DWI and restricted diffusion in the subcortical white matter of both centri semiovali, genu and splenium of corpus callosum and parietal cortex bilaterally (mean ADC value = 0.434-0.811 x 10(-3) mm(2) s(-1)). Eleven days later, follow-up brain MRI showed gliotic changes in the left splenium of corpus callosum, a clearcut decrease of T2-weighted high-signal intensity and resolution of abnormalities at DWI and ADC maps in all other involved sites. This was confirmed 36 days later. Three months later, the patient did not show neurological, cognitive or neuropsychiatric deficits. CONCLUSIONS: In the patient reported herein, closed TBI most likely induced diffuse excitotoxic injury of the brain which resulted in mainly reversible cytotoxic or intramyelinic oedema.

Acute metabolic brain changes following traumatic brain injury and their relevance to clinical severity and outcome.

BACKGROUND: Conventional MRI can provide critical information for care of patients with traumatic brain injury (TBI), but MRI abnormalities rarely correlate to clinical severity and outcome. Previous magnetic resonance spectroscopy studies have reported clinically relevant brain metabolic changes in patients with TBI. However, these changes were often assessed a few to several days after the trauma, with a consequent variation of the metabolic pattern due to temporal changes. METHODS: Proton magnetic resonance spectroscopic imaging (1H-MRSI) examinations were performed in 10 patients with TBI 48-72 h after the trauma, to obtain early measurements of central brain levels of N-acetylaspartate (NAA), choline (Cho), creatine (Cr) and lactate (La). Metabolite values were expressed as ratios to (1) a metabolic pattern, given by the sum of the resonance intensities of all metabolites detected in the same voxel and (2) intravoxel Cr. RESULTS: NAA ratios were found to be significantly lower in patients with TBI than in normal controls. In contrast, Cho ratios were significantly higher in patients with TBI than in normal controls. Increased La levels were found in 5 of 10 patients with TBI. Both NAA and La values correlated closely with those of the Glasgow Coma Scale at presentation (r = 0.73 and -0.62, respectively; p<0.01 for both) and the Glasgow Outcome Scale at 3 months (r = -0.79 and 0.79, respectively; p<0.01 for both). CONCLUSION: Spectroscopic measures of neuro-axonal damage occurring soon after a brain trauma are clinically relevant. Significant increases in cerebral La level also may be detected when 1H-MRSI is performed early after the trauma and, at this stage, can represent a reliable index of injury severity and disease outcome in patients with TBI.