Gianni Boris Bradac

PCV chemotherapy for recurrent oligodendrogliomas and oligoastrocytomas.

OBJECTIVE The role of chemotherapy in the treatment of low-grade oligodendrogliomas and oligoastrocytomas is still unclear. A Phase II study was conducted to determine the benefits and toxicity of the procarbazine, lomustine, and vincristine (PCV) regimen in patients with low-grade oligodendrogliomas and oligoastrocytomas recurrent after surgery alone or surgery with radiotherapy. METHODS Patients with both enhancing and nonenhancing tumors were treated with up to six cycles of standard PCV, and response was evaluated by conventional criteria based on computed tomography or magnetic resonance imaging. RESULTS Sixteen of 26 patients (62%) responded to PCV: 3 (12%) experienced complete response, 13 (50%) experienced partial response, 8 (31%) had stable disease, and 2 (8%) had progressive disease. All symptomatic patients who responded and three with stable disease improved in seizure frequency, lateralizing signs, and symptoms of intracranial hypertension. The response rate for patients with enhancing lesions revealed by computed tomography or magnetic resonance imaging (74%) was significantly higher than that of patients with nonenhancing lesions (29%) (P < 0.05). Both oligodendrogliomas and oligoastrocytomas responded to PCV, with complete responses occurring in association with pure tumors only. The median time to tumor progression of all 26 patients was 24 months and was significantly longer for those with oligodendrogliomas compared with those with oligoastrocytomas (32 versus 12 mo) (P < 0.001). Chemotherapy was well tolerated, with mild hematological toxicity and rare skin rashes being the most frequent sequelae. CONCLUSION These results suggest that chemotherapy with PCV is effective in the treatment of recurrent low-grade oligodendrogliomas and oligoastrocytomas.

In vivo evidence of global and focal brain alterations in anorexia nervosa.

Brain alterations are known to be associated with anorexia nervosa (AN) and tend to be distributed across brain structures, with only a few reports describing focal damage. Magnetic resonance images of 21 anorexic patients with different disease duration and 27 control subjects were acquired and compared using voxel-based morphometry (VBM). Patients had a significant reduction of total white matter (WM) volume and focal gray matter (GM) atrophy in cerebellum, hypothalamus, caudate nucleus and frontal, parietal and temporal areas. The cerebellum was more affected in patients with longer disease duration, whereas the hypothalamic alterations were more pronounced in patients with shorter food restriction. A correlation with body mass index (BMI) and GM was found in the hypothalamus. Our data demonstrate a diffuse reduction of WM together with focal areas of GM atrophy in AN. The finding of a hypothalamic focal atrophy points to hormonal dysfunction and opens the possibility for a central dysregulation of homeostasis. The involvement of temporoparietal areas could account for body image distortion. Finally, the cerebellar GM atrophy confirms previous findings and seems to be a late consequence of AN that could play a role in the chronic phase of the disease.

Diffusion-weighted images of intracranial cyst-like lesions

Abstract Magnetic resonance sequences may be designed to evaluate the diffusion movements of the protons (diffusion-weighted images, DWI). In these images, a bright signal identifies a region where the diffusion along a spatial axis is restricted. The contents of a cystic lesion frequently have the signal intensities of a generic homogeneous hyperproteinic fluid (hypointensity in T1-, hyperintensity in T2-weighted images). DWI may give further information about the microscopic organisation of these fluids: a hyperintense signal indicates the presence of a restricted diffusion, due to some kind of microscopic organisation, at the cellular or macromolecular level. This may provide additional information useful for clinical purposes. We obtained DWI in 24 consecutive patients with intracranial cystic lesions, (19 intra-axial: five abscesses, five gliomas, six metastases, two demyelinating lesions, one neurocysticercosis; five extra-axial: two arachnoid cysts, two epidermoid cysts, one cholesteatoma). We found a strongly hyperintense signal, indicating restricted diffusion, in brain abscesses, epidermoid cysts and cholesteatoma; all the remaining lesions were hypointense or mildly hyperintense. We found these data useful in critical diagnoses, such as in differentiating abscesses from tumours, and in identifying elusive tumours such as epidermoid cysts.

Progressive multifocal leukoencephalopathy: diffusion-weighted imaging and pathological correlations.

We examined MRI of two patients with progressive multifocal leukoencephalopathy (PML), including diffusion-weighted imaging (DWI), with calculation of apparent diffusion coefficients (ADC). The pathology findings of one patient were compared with those of MRI. The lesions had different ADC and DWI appearances, depending on the stage of the disease. Newer lesions and the advancing edge of large lesions had normal-to-low ADC and gave high signal on DWI. Older lesions and the centre of large lesions had increased ADC and gave low signal. High signal on DWI and low ADC mark the regions of active infection and cell swelling, distinguishing them from areas of reparative gliosis.

Peritumoral edema in meningiomas

SummaryPeritumoral edema associated with 76 supratentorial meningiomas was studied. The results of radiological investigation (CT, NMR, Angiography) and histological studies are described and correlated to each other. Mechanical factors alone are not sufficient to explain edema in the majority of the cases. It may be assumed that a secretory activity of the tumor itself also plays a role. The mechanism of this is described and discussed.

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.

Spinal intramedullary cavernous angiomas: A literature metaanalysis

The present report reviews 57 (out of 65) cases of spinal intramedullary cavernomas collected from the literature, plus one personal patient. Almost 70% of all patients were women. Mean age at diagnosis for women was 36.4 years, with a peak in the third decade. More than three-fourths of all women became symptomatic between the second and fourth decades, with a peak in the fourth decade. Unlike in men, cervical and thoracic lesions are almost equally represented, generally involving 1-2 vertebral levels. Mean size at diagnosis is 1.7 cm; no enlargement over time was seen. Symptoms are more frequently acute; pain and sensorimotor deficits are the usual complaints, but the clinical picture may simulate that of multiple sclerosis. The duration of history was less than 5 years in more than 80% of women. Bleeding was seen in 60% of women, with a risk of 1.6%/person-year of exposure globally. Cervical lesions have both a shorter course and increased frequency of bleeding. If not immediately recognized, repeated cycles of bleeding are the norm, with a mean interval of 39.6 months between the first and second episodes. The preoperative status was the single most important factor bearing on outcome, whereas sex, age, size, location, duration of history and extent of removal were not. Magnetic resonance imaging was diagnostic in all cases, whereas angiography was 100% negative. Surgery should not be a necessary first option, as recovery from the first bleeding is apparently fairly frequent.

Primitive cerebral melanoma: case report and review of the literature

BACKGROUND Central nervous system primary malignant melanoma accounts for approximately 1% of all the cases of melanoma; reports in the literature are relatively rare. CASE DESCRIPTION A 74-year-old man was hospitalized because of an episode of aphasia. The neuroradiologic examinations demonstrated a round homogeneous lesion extending near the left sylvian fissure. He had no extracranial abnormalities. The patient underwent a neurosurgical procedure and the tumor was macroscopically totally excised. Pathological examination of the surgical specimen revealed a histological appearance similar to that of melanoma. A diagnosis of primary CNS melanoma was made after careful dermatologic and ophthalmologic examination, which ruled out presence of cutaneous or choroidal melanoma. The patient did not receive any further treatment and he is free of disease 2 years after diagnosis. CONCLUSIONS We report a case of primary cerebral melanoma of the left temporal lobe; clinical, neuroradiological, and histological findings are discussed with review of the literature. Primary melanoma of the CNS may present either with localized intra/extra-axial mass lesions or with meningeal spread, which carries a worse prognosis. The prognosis of cerebral primitive melanoma is variable, although it is common opinion that primitive cerebral melanoma has a better prognosis than cutaneous melanoma, with two cases in the literature surviving 9 and 12 years.

The effect of gender on planning: An fMRI study using the Tower of London task.

Since the introduction of brain mapping, evidences of functional gender differences have been corroborating previous behavioral and neuropsychological results showing a sex-specific brain organization. We investigated gender differences in brain activation during the performance of the Tower of London (TOL) task which is a standardized test to assess executive functions. Eighteen healthy subjects (9 females and 9 males) underwent fMRI scanning while solving a series of TOL problems with different levels of difficulty. Data were analyzed by modeling both genders and difficulty task load. Task-elicited brain activations comprised a bilateral fronto-parietal network, common to both genders; within this network, females activated more than males in dorsolateral prefrontal cortex (DLPFC) and right parietal cortex, whereas males showed higher activity in precuneus. A prominent parietal activity was found at low level of difficulty while, with heavier task demand, several frontal regions and subcortical structures were recruited. Our results suggest peculiar gender strategies, with males relying more on visuospatial abilities and females on executive processing.

Brain lesions due to cerebral venous thrombosis do not correlate with sinus involvement.

Abstract Cerebral venous thrombosis may be well tolerated or lead to a brain lesion; availability of collateral venous pathways may explain the great variability of the lesions. This collateral circulation involves mainly medullary and cortical veins. These are difficult to assess neuroradiologically, particularly if thrombosed. Cerebral venous thrombosis is diagnosed usually based on thrombosis of dural sinuses and of the deep venous system. We tried to correlate the site and extent of dural sinus thrombosis with the location and the size of brain lesions in 26 consecutive patients with cerebral venous thrombosis, to investigate whether a simple causal relationship exists. No significant correlation between the extent and site of thrombosis in dural sinuses and the extent and location of brain lesions was found. In some cases a clear relationship between thrombosis of cortical and medullary veins and the lesions was evident. These data suggest that sinus thrombosis alone may be well tolerated in many cases, while involvement of cortical and medullary veins leads to a worse clinical situation.