G. Stura

The corticotrophin-releasing hormone test is the most reliable noninvasive method to differentiate pituitary from ectopic ACTH secretion in Cushing's syndrome.

objective It has been reported previously that the paired interpretation of the corticotrophin‐releasing hormone (CRH) test and the 8‐mg dexamethasone suppression test (HDDST) could have higher diagnostic power than any single test in the differential diagnosis of ACTH‐dependent Cushings syndrome. This finding has not been confirmed thereafter in large series. The aim of the present study has been to assess the operating characteristics of either the CRH test or the overnight HDDST and also to evaluate the potential utility of combining the interpretation of both tests in the differential diagnosis of ACTH‐dependent Cushings syndrome.

Mechanical Thrombolysis in Ischemic Stroke Attributable to Basilar Artery Occlusion as First-Line Treatment

Background and Purpose— To report results of mechanical disruption or retrieval of thrombus as first-line treatment in patients with stroke attributable to occlusion of the basilar artery, in particular regarding efficiency and safety. Methods— In 12 consecutive patients with acute stroke attributable to basilar occlusion, mechanical disruption or thrombus retrieval using various loop-shaped tools was tried before eventually starting local intra-arterial thrombolysis with recombinant tissue plasminogen activator (r-tPA). Main inclusion criteria were: National Institutes of Health Stroke Scale score >8 or Glasgow Coma Scale score <12; onset or worsening of symptoms <8 hours; no hemorrhages or large hypodensities on computed tomography scan; and occlusion of the basilar artery matching clinical symptoms. Efficiency included recanalization, procedure time, and r-tPA dose; safety was defined as rate of procedure-related complications. Outcome was evaluated at 3 months. Results— Mechanical recanalization was successful in 6 patients. A single brain infarction, possibly attributable to distal embolization, occurred. Three patients had good outcomes. In 5 of 6 remaining patients, the artery was recanalized using r-tPA. A single asymptomatic hemorrhage occurred; 3 patients had good outcomes. Procedure time and r-tPA were significantly less in patients with successful mechanical thrombolysis (43.33 minutes and 13.33 mg versus 112.33 minutes and 55.83 mg, respectively). Conclusion— Mechanical recanalization was effective in half of the patients and at least as safe as local intra-arterial thrombolysis. It allowed to save r-tPA and time. Although the low success rate remains a limit, the excellent and quick anatomical recanalization obtained after successful procedures makes this approach promising.

False-negative angiograms in subarachnoid haemorrhage due to intracranial aneurysms

Abstract Of 440 patients with spontaneous subarachnoid haemorrhage in whom an aneurysm was suspected, 60 had a negative angiogram. A second angiogram performed 1–4 weeks later revealed an aneurysm in 5 of 40 cases. Of these patients, 3 had a second haemorrhage. In all cases, diffuse bleeding, with involvement of the anteroinferior interhemispheric fissure, was present on CT. There were three aneurysms of the anterior communicating artery and two of the carotid siphon. The reasons for the false-negative angiograms and the usefulness of repeated angiography are discussed.

Periprocedural morbidity and mortality by endovascular treatment of cerebral aneurysms with GDC: a retrospective 12-year experience of a single center.

Despite increasing experience and improved material, endovascular treatment of cerebral aneurysms still has risks linked to the technique itself and to the specificity of the pathology treated. The purpose of this report is to examine procedural technical and clinical negative events, even minimal ones, occurring in this type of treatment. We considered 557 procedures carried out from January 1994 to December 2005 in 533 patients harboring 550 aneurysms. Of the patients, 448 presented with SAH and 85 with unruptured aneurysms. All procedures were performed under general anesthesia. The GDC-10 system was routinely used. Additional devices like the balloon remodeling technique, Trispan and stents were also occasionally used. Every procedural complication occurring during or soon after treatment was registered. Endovascular treatment was completed in 539 out of 557 procedures. There were 18 failures (3.3%). Occlusion of the aneurysm was judged complete in 343 (64%), near complete in 184 (34%) and incomplete in 12 (2%). Procedural complications occurred in 72 (13%) of the cases. The most frequent negative events were thromboembolisms (6.6%) and ruptures (3.9%). Other types (coil migration, transient occlusions of the parent vessel, dissections and early rebleeding) were rarer (2.5%). In the majority of cases there were no clinical consequences. Procedural morbidity and mortality were 1.1 and 1.8%, respectively. Considering the 449 procedures performed in ruptured and the 90 in the unruptured aneurysms separately, morbidity and mortality were 1.1 and 2.2% in the former group and 1.1 and 0% in the latter. Many factors influence the risk of complications. Being progressively aware of this and with increasing experience, the frequency can be limited. Negative events linked to the procedure have more significant serious clinical consequences in patients admitted in a critical clinical condition after SAH, because of the already present changes involving the brain parenchyma and cerebral circulation.

Endovascular Treatment of Cerebral Aneurysms Part One

Balloon occlusion of parent vessel and direct coiling are the two endovascular techniques routinely used and commonly accepted as alternatives to surgery for treatment of the cerebral aneurysm in many patients. Based on our experience and what is reported in the literature, the various aspects concerning techniques, difficulties, risks, are described. In comparison to surgery, the endovascular approach is a relatively new technique, which is still in evolution. To date, there is no objective indication regarding the method to be used in a given case. The experience and attitude of the involved team still play an essential role.

Endovascular Treatment: Part Two Results

The aim of this study is to consider the results of the aneurysms treated in our unit in the last years. The results of a given treatment are very difficult to evaluate if a series of prior assumptions have not been made, i.e., the goals of treatment, patient selection, and so on. This is particularly true if alternative treatments are available and if, as in the present work, the cases are recruited over a relatively long time with respect to the time of evolution of the technique. Two techniques were used, occlusion of the parent vessel with secondary thrombosis of the aneurysm and selective occlusion of the aneurysm with coils.

Endovascular Treatment of Brain Arteriovenous Malformations

In spite of major advances in the endovascular tools and a better understanding of the disease, the treatment of brain arteriovenous malformations remains difficult. Many aspects of the disease are still unpredictable, and the therapeutic approach frequently depends on the experience and skill of the teams involved. Different approaches - neuro/radiosurgical or endovascular, are possible. A consensus on the best treatment has not yet been reached and to date a combined treatment is probably the best possible choice for the majority of the patients, avoiding overestimation of a single technique. We report our experience in the endovascular treatment of 44 consecutive cases of brain arteriovenous malformations.

Lacunes and other holes: diagnosis, pathogenesis, therapy.

Lacunar ischemic lesions are related to a pathology involving perforators, due to direct changes in the arteries or to an indirect mechanism, such as cardiac or artery to artery embolism, or to hypoperfusion in cases of cardiac failure, or proximal occlusion of large arteries. Changes involving the large intracranial arteries have progressively been taken into consideration as a cause of the disease. This latter aspect is interesting since possible endovascular treatment can be proposed in selected cases. In patients with lacunar syndrome an extended clinical and neuroradiological approach is indicated to choose the most appropriate therapy. Not all lesions recognizable on CT/MR are the expressions of ischemic lesions, this is another important aspect that should be considered in the differential diagnosis.

Paediatric dissecting aneurysm of the posterior cerebral artery:.case report and review of the literature.

Aneurysms in children are rare. We describe a large spontaneous dissecting aneurysm of the posterior cerebral artery. The clinical presentation was characterized by headache as the sole symptom due to a mass effect leading to hydrocephalus. Acute treatment with a temporary ventricular shunt was followed by occlusion of the aneurysm via an endovascular approach leading to a complete recovery of the patient.

Cerebral vasospasm in subarachnoid haemorrhage

In the second and third weeks after a subarachnoid haemorrhage a series of mechanisms causes a decrease of the diameter of the cerebral vessels. These phenomena are globally included in the term “vasospasm”. A certain degree of vasospasm is found in the majority of the patients after a subarachnoid bleeding. This can be detected by instrumental examinations, in particular trans-cranial doppler and angiography. However, only a minor percentage of these patients will suffer clinical consequences. The vasospasm is currently treated by hypertensive-hypervolemic-haemodilution therapy (the so called “HHH” therapy), or may be treated by selective injection of vasoactive substances (Papaverine, nimodipine) or by mechanical dilatation of the involved vessels with balloons, mainly because of an improved medical management and a better monitoring of critical patients the incidence of clinical vasospasm has decreased in the recent years.