Antonio Scollato

Changes in Aqueductal CSF Stroke Volume and Progression of Symptoms in Patients With Unshunted Idiopathic Normal Pressure Hydrocephalus

BACKGROUND AND PURPOSE: Idiopathic normal pressure hydrocephalus (iNPH) represents a diagnostic challenge, given its variable presentation and progression. Stroke volume (SV), defined as the mean volume of CSF passing through the aqueduct during both systole and diastole, greater than or equal to 42 μL, serves as a selection criterion for patients with good probabilities of improvement after ventriculoperitoneal shunt surgery (VPS). In this study, we evaluated the changes in SV during the progression of clinical symptoms in patients with suspected NPH. MATERIALS AND METHODS: Nine patients who presented with clinical and radiologic evidence of NPH, but refused treatment with VPS, were evaluated every 6 months for up to 2 years for progression in their clinical symptoms and changes in their SV, as measured by phase-contrast cine MR imaging (PCCMR). RESULTS: SV seems to increase between the onset of the symptoms and the following 18 to 20 months, then seems to plateau, followed in the next 18 to 20 months by a slight decline, and finally to a more precipitous drop in the next 12 months. During this time, however, the patients clinical symptoms progressively worsen. CONCLUSION: Patients with a low SV have not necessarily had brain atrophy and can show, in the following months, a progressive increase in SV, which qualifies them as good candidates for VPS. The progressive reduction of the SV in untreated patients with worsening clinical symptoms may be a sign of a progressive cerebral ischemic injury, which renders the NPH irreversible.

Radiation leukoencephalopathy associated with moderate hydrocephalus: intracranial pressure monitoring and results of ventriculoperitoneal shunting

Abstract. Delayed neurological sequelae of radiotherapy have several manifestations; leukoencephalopathy is one of the most common. Pathogenetic relationships between radiation leukoencephalopathy and other findings of diffuse radiation injury (brain atrophy and progressive ventriculomegaly) are not well defined. Moreover, no guidelines have been established for the treatment of hydrocephalus when associated with radiation leukoencephalopathy. Our study reportsintracranial pressure (ICP) monitoring in two patients with radiation leukoencephalopathy with moderate hydrocephalus. High intraventricular mean pressure and high peaks were found, and marked improvement of clinical status after shunting was achieved. This study, although restricted to only two patients, shows that ventriculoperitoneal shunting insertion is useful in radiation-induced hydrocephalus, when ICP monitoring detects high mean pressure. A hypothesis is advanced concerning radiation-induced hydrocephalus with high ICP, emphasizing periventricular astrocytosis and its connections with cerebral compliance.

Changes in Aqueductal CSF Stroke Volume in Shunted Patients with Idiopathic Normal-Pressure Hydrocephalus

BACKGROUND AND PURPOSE: Aqueductal CSF stroke volume (ACSV) measured by phase-contrast MR imaging is a tool for selection of surgical patients with idiopathic normal-pressure hydrocephalus (iNPH). The aim of the present study was to investigate whether there is a relationship between clinical outcome and changes in ACSV in patients with iNPH who have been shunted. MATERIALS AND METHODS: Sixty-five shunted patients with iNPH underwent clinical evaluation and ACSV measurements 7–30 days before and 1, 3, 6, and 12 months after surgery. RESULTS: Two patients were excluded from the study for the occurrence of a perioperative complication. In a group of 35 clinically improved patients, the mean preoperative ACSV (157.01 μL) decreased to 18% one month after ventriculoperitoneal shunt (VPS) and ≤49% at 12 months post-VPS. In a group of 15 unimproved patients, the lower mean preoperative ACSV (84.2 μL) decreased to 14.3% one month post-VPS and ≤34% at 12 months post-VPS. In the other 8 improved patients who developed a subdural fluid collection (SDFC), ACSV values decreased by 43%–75% in the 3 months post-VPS. A postoperative ACSV increase was noted in 6 patients with a shunt system malfunction. One patient experienced both SDCF and shunt malfunction. CONCLUSIONS: ACSV decreases in all patients in whom the VPS system works properly, with the rate of ACSV decrease being higher in the patients who show clinical improvement. Postoperative ACSV increase suggests shunt malfunction. A precipitous drop of ACSV values after VPS may be the consequence of increased drainage and herald the occurrence of SDFC.

Intracranial meningioma containing metastatic colon carcinoma

SummaryTumour-to-tumour metastasis is a rare pathological entity. Meningioma is the most common intracranial tumour to host metastases, the majority of which arise from breast and lung cancers. We present the first report of a colonic cancer metastasis within an intracranial meningioma.A 76-year-old woman presented with a one month history of partial seizures. Her medical history included resection of an adenocarcinoma of the descending colon followed by adjuvant chemotherapy 1 year before our evaluation. Magnetic resonance imaging revealed a homogeneously enhancing lesion in the right frontal convexity.A well capsulated tumour attached to the frontal dura was surgically removed. The pathological examination demonstrated a mixture of fibrous meningioma and colloid adenocarcinoma. Possible explanations for the development of a cohesive chimeric mass of composite pathology are investigated.

Intramedullary spinal cord metastasis from synovial sarcoma : Case illustration

Intramedullary spinal cord metastases originating from mesenchymal tumors are rare. We report on a case of intramedullary metastasis from synovial sarcoma (SS). This 59-year-old man presented with rapidly progressive quadriparesis and exacerbating cordonal pain. Six years earlier he had undergone surgical removal of an SS of the right forearm, followed by chemotherapy and radiation therapy. Magnetic resonance (MR) imaging demonstrated an intramedullary lesion at C3‐5. On computed tomography scanning, a right pulmonary mass was also revealed. The patient refused chemotherapy, but agreed to surgical treatment of the spinal lesion to relieve pain and prevent further neurological deterioration. At surgery, a discrete red smooth mass was removed via a longitudinal myelotomy (Fig. 1). Histological examination of a sample of the lesion revealed proliferation of spindle cells with scanty cytoplasm and oval-shaped, dark-staining nuclei. Against a myxoid and microcystic background, hemorrhagic foci, micronecrosis, and small areas with less cellularity were present. Epithelial cells were inconspicuous. The morphological appearance was compatible with the diagnosis of metastatic monophasic SS (Fig. 2). Postoperatively, the patient experienced pain

Results of surgical and endovascular treatment of intracranial micro-arteriovenous malformations with emphasis on superselective angiography

SummaryBackground. The authors retrospectively reviewed the results of two different treatment modalities (surgery and endovascular approach) in patients with intracranial micro-arteriovenous malformations (micro-AVMs). The goal of this study is to evaluate the respective role of surgical treatment and superselective acrylic embolization in the management of micro-AVMs.Method. Fourteen patients with micro-AVMs who had been treated by surgical resection or endovascular acrylic embolization during a 6-year period were analyzed. The average age at presentation was 44.6 years (range, 24–65 yr) with no sex dominance. All patients presented with an intracranial haemorrhage, which was superficial in twelve patients and in eloquent brain areas in seven patients. Severe neurological deficits were observed in eleven patients.Findings. Digital subtraction angiography (DSA) demonstrated micro-AVMs in eleven patients (78.5%) while in three patients (21.5%) the micro-AVM was detected only by superselective angiography (SA). Eight patients underwent surgical intervention which led to definitive resection in seven with no peri-operative morbidity. SA was performed in nine patients and followed by successful acrylic embolization of the micro-AVM in seven with haemorrhagic complications in two patients. All fourteen lesions were completely obliterated as demonstrated angiographically. Outcomes were classified according to the Modified Rankin Scale. With a mean long term clinical follow-up of 33 months (range, 8–75 mo), seven patients were Grade 0, six patients were Grade I and one patient was Grade IV.Conclusions. SA is deemed necessary to visualize micro-AVMs in case of questionable or negative findings also at delayed DSA in young healthy patients with otherwise unexplained intracranial haemorrhage. Obliteration of micro-AVM can be accomplished either surgically or endovascularly; however, the endovascular approach is associated with a defined procedural risk for haemorrhagic complications and long term angiographic follow-up is necessary.

Aβ Clearance, “hub” of Multiple Deficiencies Leading to Alzheimer Disease

The role of the amyloid cascade in the pathogenesis of Alzheimer’s disease (AD) is still the subject of passionate debates (Herrup, 2015; Musiek and Holtzman, 2015). According to quite a radical viewpoint (Herrup, 2015), the tendency to try to find a unifying etiopathogenetic pathway has so far hampered the understanding of such a complex disease. Thus, it would be better to reject the amyloid cascade hypothesis since it is neither necessary nor sufficient to drive the development and progression of AD. Herrup (2015) proposes, as food for thought, to relocate the amyloid cascade in a multifactorial context where it represents only one of a number of deficiencies contributing to degenerative escalation in the age-weakened brain (Herrup, 2015). From a more conservative perspective, the amyloid cascade is the necessary key initiator of a complex sequence of pathological changes, especially tau protein hyperphosphorylation, which mediates neurodegeneration (Musiek and Holtzman, 2015). However, owing to the lapse in time between the appearance of amyloid plaques and that of tau protein tangles, neuronal loss and dementia, as well as the absence of an obvious anatomical colocalization between the amyloidogenic process and neurodegeneration areas, the amyloid cascade hypothesis is not sufficient to explain AD pathology unless supported by a series of “wingmen” (Musiek and Holtzman, 2015).

CSF proteomic analysis in patients with normal pressure hydrocephalus selected for the shunt: CSF biomarkers of response to surgical treatment

The aim of our pilot study was to investigate, by a proteomic approach, the expressed differences in cerebrospinal fluid (CSF) protein patterns in order to aid in the diagnosis and treatment of normal pressure hydrocephalus (NPH). Seventeen patients with NPH, selected by Intracranial-Pressure monitoring (ICPmo), underwent implantation of a shunt and after 6 months were clinically re-evaluated. Thirteen patients improved, whereas four did not. During ICPmo CSF was collected and its proteoma was analyzed by 2D gel electrophoresis and mass spectrometry. The over-expression of α2HS glycoprotein, α1 antichimotrypsin and α1beta glycoprotein and the under-expression of glial fibrillary acidic protein, apolipoproteins (AIV, J and E), complement C3c, anti-thrombin, α2 antiplasmin and albumin seem to be associated with a positive response to surgery. Most of these proteins have been reported to be altered in Alzheimer disease, supporting the hypothesis of a possible link between these two nosological entities.

Cerebrospinal fluid diversion in patients with enlarged Virchow-Robin spaces without ventriculomegaly

Enlarged Virchow‐Robin spaces (eVRS) are an MRI biomarker in several neurological diseases of inflammatory, neurodegenerative, vascular, metabolic, or genetic origin. We report on a further condition in which eVRS were observed in patients with an ongoing chronic hydrocephalus‐like clinical picture without ventriculomegaly who improved after CSF diversion, and we discuss the possible mechanisms underlying this finding.

Decompressive craniectomy arrests pulsatile aqueductal CSF flux: An in vivo demonstration using phase-contrast MRI. Case report.

Abstract We give a case study demonstration, using aqueductal cerebrospinal fluid (CSF) stroke volume quantification with phase-contrast magnetic resonance imaging, of a large opening in the rigid cranium by a decompressive craniectomy and its subsequent closure by bone flap repositioning resulted in the arrest and subsequent restoration of aqueductal CSF flow.