Gianni De Berti

Evidence-Based Diagnosis of Nontraumatic Headache in the Emergency Department: A Consensus Statement on Four Clinical Scenarios

Objective.—To provide to emergency department (ED) physicians with guidelines for diagnosis of patients with nontraumatic headaches.

Administration of conscious sedation by a neuroradiology team during percutaneous vertebroplasty and spinal biopsy procedures

IntroductionPercutaneous vertebroplasty, i.e. the consolidation of a vertebral body with polymethylmethacrylate, is a safe and effective image-guided technique increasingly used as a treatment option for different pathologic conditions, mainly vertebral body fractures secondary to osteoporosis, hemangiomas and metastasis. The procedure, although minimally invasive, could be painful and is better tolerated if a conscious sedation regimen is added to local anesthesia. An anesthesiologist usually performs the sedo/analgesia, but frequently, he is not available in our angiography unit, so we have begun to perform the sedo/analgesia ourselves following an analogous situation that physicians of the Digestive Endoscopic Unit of our institution experienced some years ago.MethodsUsing the guidelines developed by Italian Society of Digestive Endoscopy, Italian Society of Anesthesia, Analgesia, Reanimation and Intensive Therapy and National Association of Endoscopy Operators and Technicians as a starting point, we then adapted their protocol to our vertebroplasty requirements, after an adequate training period carried out by our anesthesiologist staff.ResultsThe results have been very satisfactory, greatly appreciated by patients for good pain control; we have never registered any adverse effects nor have we had any particular problems in controlling sedation or monitoring procedures.ConclusionIn our experience, we have observed that conscious sedation can be safely administered by neuroradiologists during spinal procedures, provided that some basic rules are respected regarding patient selection and monitoring, personnel training and angiography equipment.

An unexpected evolution of symptomatic mild middle cerebral artery (MCA) stenosis: asymptomatic occlusion

BackgroundThe intracranial localization of large artery disease is recognized as the main cause of ischemic stroke in the world, considering all countries, although its global burden is widely underestimated. Indeed it has been reported more frequently in Asians and African-American people, but the finding of intracranial stenosis as a cause of ischemic stroke is relatively common also in Caucasians. The prognosis of patients with stroke due to intracranial steno-occlusion is strictly dependent on the time of recanalization. Moreover, the course of the vessel involvement is highly dynamic in both directions, improvement or worsening, although several data are derived from the atherosclerotic subtype, compared to other causes.Case descriptionWe report the clinical, neurosonological and neuroradiological findings of a young woman, who came to our Stroke Unit because of the abrupt onset of aphasia during her work. An urgent neurosonological examination showed a left M1 MCA stenosis, congruent with the presenting symptoms; magnetic resonance imaging confirmed this finding and identified an acute ischemic lesion on the left MCA territory. The past history of the patient was significant only for a hyperinsulinemic condition, treated with metformine, and a mild overweight. At this time a selective cerebral angiography was not performed because of the patient refusal and she was discharged on antiplatelet and lipid-lowering therapy, having failed to identify autoimmune or inflammatory diseases. Within 1 month, she went back to our attention because of the recurrence of aphasia, lasting about ten minutes. Neuroimaging findings were unchanged, but the patient accepted to undergo a selective cerebral angiography, which showed a mild left distal M1 MCA stenosis.During the follow-up the patient did not experienced any recurrence, but a routine neurosonological examination found an unexpected evolution of the known MCA stenosis, i.e. left M1 MCA occlusion. Neuroradiological imaging did not identify new lesions of the brain parenchyma and a repeated selective cerebral angiography confirmed the left M1 MCA occlusion.ConclusionsRegardless of the role of metabolic and/or inflammatory factors on the aetiology of the intracranial stenosis in this case, the course of the vessel disease was unexpected and previously unreported in the literature at our knowledge.

Hypertension-induced posterior reversible encephalopathy syndrome as the presentation of progressive bilateral renal artery stenosis

Posterior reversible encephalopathy syndrome (PRES) is characterized clinically by headache, altered mental status, visual loss, and seizures. PRES is associated with neuroradiological findings characterized by white matter abnormalities, predominantly in the parieto-occipital regions of the brain. PRES is most often described in cases of hypertensive encephalopathy, eclampsia, renal failure, and immunosuppressive or anticancer therapy. We report a case of PRES associated with severe hypertension in the setting of a progressive renovascular hypertension from bilateral atherosclerotic renal artery stenosis. The pathogenesis of PRES is discussed and the importance of a prompt diagnosis and treatment is emphasized.