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.

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.

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.

Treatment of non-neoplastic stenosis of the aqueduct of Sylvius with extrathecal CSF shunts.

A series of 185 patients operated on with extrathecal shunts for non-neoplastic aqueductal stenosis has been reviewed. The longterm results of 84 of them, followed-up for 2 to 20 years after primary surgery, are illustrated and critically analyzed. This study indicates that a normal mental development or normalization of mental and neurological conditions can be expected in a high percentage of patients after the CSF diversional procedure which nonetheless is still associated with a high percentage of even serious complications.

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.

Intraventricular hemorrhage: role of early ventricular drainage.

Intraventricular hemorrhage (IVH) is usually the result of life-threatening intracranial bleedings eventually leading to death. Early ventricular drainage is suggested as a possible means of reducing fatalities. The retrospective analysis of 80 patients with CT diagnosed IVHs has indeed shown that early drainage prolongs significantly survival before death but does not influence mortality. Clinical and CT grading still remain fundamental prognostic indexes accounting for the irreversible hemorrhagic lesion. Thus ICP monitoring and ventricular drainage may be useful only in selected patients with alterations of consciousness of intermediate severity and sluggish evolution.

Cervical vertebral erosion due to tortuous vertebral artery.

A case of cervical vertebral erosion due to tortuous vertebral artery is presented. This entity is rare and only 11 cases have been reported in the literature. The present case is the first to be demonstrated by magnetic resonance imaging. The importance of considering this vascular anomaly in the differential diagnosis of cervical spinal tumors is discussed.

[Use of psychotropic substances with antidepressive action in pain control]. / Considerazioni sull'uso di sostanze psicotrope ad azione antidepressiva in terapia antalgica.

Starting with the conviction that chronic oncological pain needs an interdisciplinary approach, the use of antidepressant tricyclic compounds in association with other techiques in antalgic therapy is commented on. In spite of the possible side effects, it is concluded that the drugs are definitely effective, and that in addition to combating the depressive component, when present, their analgesic action potentiates the effect of other drugs.

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.

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.

Ganglioside content and composition in human gliomas.

Many alterations of ganglioside content and distribution have been described in human and experimental tumours. Our previous data showed the presence of lipid alterations in meningiomas, in particular an increased monosialylganglioside content. Therefore we analyzed the distribution and content of gangliosides in various gliomas. The data show that ganglioside content is inversely proportional to tissue malignancy and that the ganglioside pattern can be described as lacking of polysialylgangliosides with increased GD3 content. The amount of GD3 (as percent of total gangliosides sialic acid) increases from 15% in astrocytomas grade I to 60% in grade IV. The GD3 increase seems to be almost specific of glioma. Because anti-GD3 antibodies could be used to localize immunohistochemically the ganglioside and to help the tumour grading, we used a purified preparation of GD3 to produce monoclonal antibodies in balb/c mice. But because some clones did produce anti-GD3 antibodies the low yield requires further experiments to obtain an antibody useful for this purpose.

[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.

[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)

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.

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.