Claudio Cornali

Emergent decompressive craniectomy in patients with fixed dilated pupils due to cerebral venous and dural sinus thrombosis: report of three cases.

OBJECTIVE AND IMPORTANCE Cerebral venous and dural sinus thrombosis is a rare cause of stroke. Although morbidity and mortality have greatly decreased in recent years as a result of early diagnosis and timely medical treatment, when coma occurs the prognosis remains poor. We evaluated whether emergent decompressive craniectomy has a role in the treatment of patients with brain herniation from dural sinus thrombosis and hemorrhagic infarct. CLINICAL PRESENTATION Three patients developed large hemorrhagic infarct with coma and bilaterally fixed and dilated pupils resulting from aseptic dural sinus thrombosis. INTERVENTION Two patients underwent emergent surgical decompression as soon as brain herniation developed, and these patients had complete functional recovery. One underwent delayed surgical decompression and remained severely disabled. CONCLUSION Our results provide preliminary evidence that emergent decompressive craniectomy is effective in patients with brain herniation from dural sinus thrombosis, provided that the clinical onset is recent. We therefore recommend consideration of this aggressive surgical technique for such patients, who may survive with good outcomes.

Altered structure of small cerebral arteries in patients with essential hypertension.

Objective Structural alterations in the microcirculation may be considered an important mechanism of organ damage. An increased media-to-lumen ratio of subcutaneous small resistance arteries has been demonstrated to predict the development of cardiocerebrovascular events in hypertensive patients. Alterations in the structure of small cerebral arteries have been demonstrated in animal models of experimental or genetic hypertension. However, no evaluation with reliable techniques has ever been performed in humans. Design and methods Twenty-eight participants were included in the present study: they were 13 hypertensive patients and 15 normotensive individuals. All participants underwent a neurosurgical intervention for benign or malign tumors. A small portion of morphologically normal cerebral tissue was excised from surgical samples and examined. Cerebral small resistance arteries (relaxed diameter around 200 μm) were dissected and mounted on an isometric and isobaric myograph, and the tunica media to internal lumen ratio was measured. In addition, cerebral cortical microvessel density (MVD) was also evaluated. The tissue was sectioned and stained for CD31, and MVD was measured with an automated image analyzer (percentage of area stained). Blood pressure values were evaluated, before surgical intervention, by standard sphygmomanometry. Results M/L was significantly greater and MVD significantly lower in hypertensive patients than that in normotensive individuals. No difference between groups in collagen content or mechanical properties of cerebral small arteries was observed. Conclusion Our results indicate that structural alterations of small cerebral vessels are present in hypertensive patients compared with normotensive individuals, similar to those previously observed in subcutaneous small arteries.

Ruptured Aneurysm in Sphenoid Sinus: Which Is the Best Treatment?

Internal carotid artery (ICA) aneurysms involving the sphenoid sinus are uncommon, and their optimal treatment remains debated. We report the case of a patient presenting with recurrent epistaxis due to a bleeding cavernous ICA aneurysm. We suggest a combined endovascular and endoscopic approach when ICA occlusion may not be performed.

Recovery after Delayed Surgery in a Case of Spinal Subdural Hematoma

Spinal chronic subdural hematoma (SCSH) is a rare pathology usually associated with trauma or hematological alterations or is due to iatrogenic causes; rarely SCSH can be spontaneous. We report a case of a 79-year-old female who underwent a surgical evacuation of a spontaneous SCSH one year after diagnosis. She presented with a severe paraparesis and showed a considerable improvement in sensory-motor performances after surgery. The treatment of spontaneous SCSH is not well defined and universally accepted. Early surgery is mandatory in cases presenting with severe deficits. To the best of our knowledge, this is the first case showing a good outcome in a case of SCSH following a delayed surgery. In our opinion, an aggressive approach should be considered as a viable option in cases of spontaneous SCSH even after a lasting spinal cord compression.

Resistance-Sized Arteries Structure and Capillary Density Changes in Glioblastoma and Meningioma Peritumoral Brain Tissue

Background: Brain vessels play a relevant role in the development of malignant primary tumors. Previous studies performed in preclinical models of brain tumors demonstrated the irregular morphology of vessels in glioblastoma, characterized by multiple abnormalities in shape, permeability and relationship with the contacting structures, such as the basement membrane; however no data about microvascular structural alterations in the brain of patients affected by brain tumors have been previously reported. Methods: We studied small vessels structural alterations, microvascular rarefaction and vascular collagen content in the peritumoral brain tissue of two groups of patients, respectively affected by glioblastoma and by meningioma, who underwent a surgical operation in order to remove the tumor. The two groups of patients were matched for clinical, laboratory variables and risk factors, with the exception of sex. Results: Media to lumen ratio was significantly higher in patients with meningioma compared to patients affected by glioblastoma. Vessels in the brain surrounding glioblastomas show a less organized structure, as demonstrated by the thinner media, by the lower content in collagen and by the lower capillary density. Conclusions: For the first time, we used an in vitro ex vivo technique to analyze structural alterations of resistance sized arteries of peritumoral brain tissue at the radiological tumor-brain interface in patients affected by glioblastoma and meningioma. This approach, together with immunohistochemical evaluation of microvessel density, has supplied new data about the brain microcirculation. These findings can be the result of the aberrant angiogenic process that characterizes glioblastomas and can finally play a role in tumor growth. Further studies are needed to confirm our data, to identify the pathways that lead to this microvascular pattern and to identify possible clinical applications

CEREBRAL SMALL RESISTANCE ARTERY STRUCTURE AND CEREBRAL BLOOD FLOW IN NORMOTENSIVE SUBJECTS AND IN HYPERTENSIVE PATIENTS: 3D.01

We have previously demonstrated that, in essential hypertensive patients, subcutaneous small resistance artery structural alterations, as indicated by an increased media to lumen ratio (M/L), may predict coronary (J Hypertens 2003;21:625–631) and forearm (J Hypertens 1995;13:341–347) flow reserve. In essential hypertension also human cerebral small arteries present a clear increase in M/L (Rizzoni D et al, J Hypertens 2009; 27:838–845). However, there is no available demonstration about the presence of a direct relationship between cerebral blood flow and cerebral small resistance artery structure. Patients and Methods: Ten subjects were included in the present study. They were 5 hypertensive patients (HP) and 5 normotensive control subjects (NS). All subjects underwent a neurosurgical intervention (trauma, meningioma, etc.). A small portion of morphologically normal cerebral tissue was excised and rapidly put in chilled physiological saline solution. Cerebral small resistance arteries (relaxed diameter around 200 μm) were dissected and mounted on an isometric myograph, and the tunica media to internal lumen ratio was measured (M/L). Before surgical intervention we have also investigated cerebral blood flow (CBF) in different areas (cortex, lenticular nucleus, thalamus and subcortical white matter) by means of dynamic susceptibility contrast (DSC) MR imaging with bolus injection of gadolinium, focusing on specific regions of interest. Results: Are summarized in the Table (*=p < 0.05; ***p < 0.001 vs. NS). Figure 1. No caption available. A statistically significant inverse correlation was observed between M/L of cerebral arteries and CBF in the lenticular nucleus (r=−0.80, p < 0.01) and with CBF in the thalamus (r = −0.75, p < 0.01), while correlation with CBF in the cortex and in the subcortical white matter were not statistically significant (r = −0.21 and −0.21, respectively). Conclusions: Our results indicate that cerebral small artery structure might play a major role in controlling CBF, and this might help to explain the relevant role of structural alterations of small resistance arteries in predicting cerebrovascular events (Circulation 2003;108:2230–2235).

Association between concussion history and knowledge among italian youth soccer athletes

Objective To compare concussion-based knowledge between Italian youth soccer athletes who reported a previously diagnosed concussion or concussion-like symptoms and those without prior concussion history. Design Cross sectional. Setting Self-reported survey. Subjects Male soccer athletes (n=766, age=16.9 ± 1.3 years, experience=6.6 ± 3.9 years) from 25 club teams across three professional leagues in Italy. Intervention The independent variables studied were diagnosed concussion group (prior diagnosed concussion vs. no diagnosed concussion) and self-reported concussion symptom group (experienced concussion-like symptoms vs. no concussion-like symptoms). Outcome measures The dependent variables were total knowledge scores, measured through accurate endorsement of symptoms and responses to true and false prompts. Independent t-tests were used to determine group differences. Results 45 (6%) respondents indicated they sustained a physician-diagnosed concussion. The mean number of diagnosed concussions was 0.065±0.3 (range 0–3). 198 (26.2%) respondents indicated they had experienced concussion-like symptoms. The mean frequency of self-reported concussion-like symptoms was 0.54±1.3 (range: 0–15). There were no significant differences in concussion symptom knowledge (P=0.616, 13.9±2.0 vs. 14.1±2.2) or true and false knowledge (P=0.390, 10.7±1.8 vs. 10.4±1.7) between the group with a previously diagnosed concussion compared to the one without. There were also no significant differences in concussion symptom knowledge (P=0.499, 14.2±2.1 vs 14.1±2.2) or true and false knowledge (P=0.256, 10.5±1.6 vs. 10.4±1.8) between the group that had experienced concussion-like symptoms compared to the group that had not. Conclusions These results suggest the necessity for targeted knowledge-based interventions for youth athletes, especially for those who sustain and report concussions. Competing interests None.