Angelo Lavano

A hypofibrinolytic state in overweight patients with cerebral venous thrombosis and isolated intracranial hypertension

Abstract Evidence suggests that isolated intracranial hypertension (iIH) is often associated with cerebral venous thrombosis (CVT). In eight patients referred to our Institution for iIH who were later shown to harbor CVT we have performed a comprehensive coagulation work-up, including genetic tests for inherited predisposition to thrombophilia, to clarify the etiology of sinus venous thrombosis. All subjects were women. All but one were overweight. There were high plasma concentrations of D dimer, thrombin-antithrombin complexes or prothrombin fragments 1 and 2, further supporting the neuroimaging diagnosis of CVT. Importantly, seven of eight cases had a raised level of plasminogen activator inhibitor 1, a well known inhibitor of fibrinolysis related to obesity. Tissue plasminogen activator levels were elevated accordingly. Factor V gene mutation was present in one subject, and the 20210 prothrombin gene mutation was found in another individual. Three patients had elevated plasmatic levels of homocysteine. In conclusion, the present study provides solid evidence that impaired fibrinolysis probably related to overweight, acting in concert with other prothrombotic abnormalities, is involved in the pathogenesis of CVT presenting as iIH.

Cost-Effectiveness and Cost-Utility Analysis of Spinal Cord Stimulation in Patients With Failed Back Surgery Syndrome: Results From the PRECISE Study

To assess the cost‐effectiveness and cost‐utility of Spinal Cord Stimulation (SCS) in patients with failed back surgery syndrome (FBSS) refractory to conventional medical management (CMM).

Symptomatic tension pneumocephalus after evacuation of chronic subdural haematoma: report of seven cases.

We present seven cases of tension pneumocephalus developing after burr hole evacuation of chronic subdural haematoma. After a careful review of the literature we discuss the physiopathology, the diagnosis and the treatment of this complication of chronic subdural haematoma surgery.

Analysis of UbcH10 expression represents a useful tool for the diagnosis and therapy of astrocytic tumors.

Previous studies suggest the expression of UbcH10 gene, that codes for a protein belonging to the ubiquitin-conjugating enzyme family, as a valid indicator of the proliferative and aggressive status of tumors of different origin. Therefore, to look for possible tools to be used as diagnostic markers in astrocytic neoplasias, we investigated UbcH10 expression in normal brain, gliosis and low-grade and high-grade astrocytic tumors by immunohistochemistry. UbcH10 expression was observed in low-grade astrocytoma and in glioblastoma. Our data indicate a clear correlation between UbcH10 expression and the histological grade of the astrocytic tumors. Moreover, the analysis of UbcH10 expression allows the differentiation between gliotic and malignant tissues. Finally, since proteasome inhibitors have recently been considered as possible drugs in the chemotherapy of various tumors, our results would suggest new perspectives for the treatment of brain malignancies based on the suppression of the UbcH10 function.

Metalloproteinase-9 and neutrophil gelatinase-associated lipocalin plasma and tissue levels evaluation in middle cerebral artery aneurysms

Background. Cerebral aneurysms are relatively common in adults, with a prevalence ranging between 1% and 5%. Subarachnoid hemorrhage, following aneurismal rupture, is a major cause of death and disability in these patients. Matrix Metalloproteinases (MMPs) and Neutrophil Gelatinase-Associated Lipocalin (NGAL) seem to be involved in the pathogenesis and in the clinical course of aneurysms. In this study, we evaluated the relationship between tissue and plasma levels of MMP-9 and NGAL in patient with ruptured and unruptured middle cerebral artery aneurysms. Methods. An open label study was conducted on 7 patients with middle cerebral aneurysms. Three patients had ruptured aneurysms (Group I) and four patients had unruptured aneurysms (Group II). All patients underwent aneurysm clipping. Plasma levels of MMP-9 and NGAL were evaluated through ELISA Test. During the surgery, biopsies of the aneurysmatic arteries were taken and frozen (- 80°C) for Western blot evaluation of MMPs and NGAL expression. Four healthy volunteers (Group III) represented the control group for ELISA testing. Results. Both plasma MMP-9 and NGAL levels were significantly high in aneurysmatic patients respect to those of control patients, and these levels were higher (P < 0.01) in patients with ruptured aneurysms respect to patients with unruptured aneurysms (P < 0.01). The latest findings were similarly evident in tissue evaluation of MMP-9 and NGAL between ruptured and unruptured aneurysms. Conclusion. This study suggests that MMP-9 and NGAL plasma levels may be useful to predict the clinical course of a cerebral aneurysms in order to evaluate the progression of the disease and the tendency of an aneurysm to rupture.

Sacral nerve stimulation with percutaneous dorsal transforamenal approach in treatment of isolated pelvic pain syndromes.

Objectives.  The aim of the study was to test the effectiveness of sacral nerve stimulation (SNS) performed by a transforamenal approach in patients with isolated chronic intractable pelvic pain.

Motor Cortex Stimulation in Parkinson's Disease

Motor Cortex Stimulation (MCS) is less efficacious than Deep Brain Stimulation (DBS) in Parkinsons disease. However, it might be proposed to patients excluded from DBS or unresponsive to DBS. Ten patients with advanced PD underwent unilateral MCS contralaterally to the worst clinical side. A plate electrode was positioned over the motor cortex in the epidural space through single burr hole after identification of the area with neuronavigation and neurophysiological tests. Clinical assessment was performed by total UPDRS, UPDRS III total, UPDRS III-items 27–31, UPDRS IV, and UPDRS II before implantation in off-medication and on-medication states and after surgery at 1, 3, 6, 12, 18, 24, and 36 months in on-medication/on-stimulation and off-medication/on-stimulation states. We assessed changes of quality of life, throughout the Parkinsons disease quality of life scale (PDQoL-39), and the dose of anti-Parkinsons disease medications, throughout the Ldopa equivalent daily dose (LEDD). During off-medication state, we observed moderate and transitory reduction of total UPDRS and UPDRS total scores and significant and long-lasting improvement in UPDRS III items 27–31 score for axial symptoms. There was marked reduction of UPDRS IV score and LEDD. PDQL-39 improvement was also significant. No important complications and adverse events occurred.

Posture-related cough headache and orthostatic drop in lumbar CSF pressure

Sirs: Primary cough headache (PCH) is an uncommon headache disorder marked by a sudden bilateral short-lasting pain precipitated by coughing in the absence of any intracranial disorder [1, 2]. In some patients with PCH, Symonds reported that vertical posture precipitated pain brought on by coughing [3]. We have seen two such patients (a 48-year-old man and a 31-yearold woman) with headaches lasting 1–10 min that were only triggered by coughing when the patients assumed a vertical posture, in whom we have also observed orthostatic drops in their CSF pressures. Neurological examination did not show any deficits. Contrast-enhanced head and spine MRI, and CSF examination findings were all normal. In these patients and in 25 controls (average age: 40.2 ± 7.7 years; 15 women and 10 men) none of whom had a history of headache or structural brain lesion, we recorded the lumbar cerebrospinal fluid (CSF) opening pressure at rest and during three to five coughs, in lateral decubitus, sitting and upright positions. In our patients lumbar CSF opening pressure recorded in lateral decubitus was within normal values (pressure of 153 and 164 mm H2O, respectively). In the sitting position lumbar CSF pressure was higher (330 and 310 mm H2O, respectively) than in lateral decubitus. In both positions a bout of coughing did not induce headache. Surprisingly, when the patients assumed the upright posture their lumbar CSF pressures dropped (160 and 165 mm H2O, respectively) compared with the values recorded in the sitting position, and a bout of coughing induced severe pain at the vertex. In the control group, postural changes (sitting and upright positions) always increased CSF lumbar pressure with more elevated value recorded in the upright posture (Figure). Coughing always increased CSF pressure regardless of positions, both in controls and in patients. The present findings demonstrate that our patients had posture-related cough headaches. Consistent with this observation, in the landmark paper entitled “Cough headache” Symonds [3] described four patients with PCH that was induced by the patients being in upright positions, whereas the patients could cough without pain when they were lying down. The Symonds’ study and the present cases suggest the possibility that in the minority of patients with cough headaches, the pain brought on by coughing can occur only in association with the vertical posture. In addition, our patients had orthostatic drops in their CSF pressures. This finding was never observed in controls in whom vertical posture always elevated their CSF pressures. As our patients had orthostatic headaches precipitated rather than aggravated by coughing, and they did not have imaging abnormalities of intracranial hypotension or low supine CSF pressures, spontaneous intracranial hypotension and abnormally low volume of CSF may be excluded [4–7]. Of note, some authors have recently demonstrated that patients with orthostatic headaches without LETTER TO THE EDITORS

Administration of palmitoylethanolamide in combination with topiramate in the preventive treatment of nummular headache

Nummular headache has been recently described as a primary disorder characterized by head pain exclusively felt in a small rounded area typically 2–6 cm in diameter, not attributed to another disorder. Both size and shape of the painful area remain constant since the onset of symptoms. A 57-year-old woman presented with a history of focal episodic pain in a circumscribed area on the right parietal region. The administration of standard oral doses of palmitoylethanolamide and topiramate in combination showed an improvement in pain symptoms and on pain measuring scales.

Minimally invasive motor cortex stimulation for Parkinson's disease.

Extra/intradural strip electrode implantation on motor cortex may be possible minimally invasive neurosurgical method for therapeutic neuromodulation in Parkinsons disease (PD). The aim of this review is to assess motor cortex stimulation (MCS) efficacy and safety in advanced PD. Sixteen published articles were included with a total of 130 PD patients treated. In almost all results are from prospective observational open labeled study, only in two studies blinded assessment was carried out. Negative results are reported in three studies. Significant improvement in motor symptoms with remarkable effect on axial symptoms, L-dopa-induced dyskinesia and quality of life are outlined in thirteen studies. Surgical technique involved implant of four-contact strip electrode over M1 in epidural space with exception of few cases in which implant was carried out in subdural space. Surgical procedure was performed contralateral to most affected side with exception of five patients in which it was carried at dominant hemisphere; in four patients electrode implant was bilateral but stimulation was carried out simultaneously on both sides only in two cases. Complications and adverse events occurred very rarely for extradural MCS whereas with higher rate for subdural MCS. Based on review of current literature extra/intradural MCS represents an alternative to deep brain stimulation (DBS) to surgically treat PD patients who are not candidate for DBS. MCS is a minimally invasive neuromodulation procedure with low morbidity-mortality that can relieve all three major symptoms of PD on both sides simultaneously and bilaterally; it has significant effectiveness on axial symptoms, gait disturbances and therapy complications.