Luigi Cirillo

Ophthalmoplegic migraine: From questions to answers

Introduction The International Classification of Headache Disorders classifies ophthalmoplegic migraine (OM) under “cranial neuralgias and central causes of facial pain.” OM is diagnosed when all the following criteria are satisfied: At least two attacks fulfilling criterion B. Migraine-like headache accompanied or followed within four days of its onset by paresis of one or more of the III, IV and/or VI cranial nerves. Parasellar orbital fissure and posterior fossa lesions ruled out by appropriate investigations. In children the syndrome is rare and magnetic resonance (MR) shows strongly enhancing thickened nerve at the root entry zone (REZ). Method The authors review the literature focusing on pathogenesis theories. Results The authors suggest that ischemic reversible breakdown of the blood-nerve barrier is the most probable cause of OM and to include MR findings in the hallmarks of the disease. Conclusion OM is the same disease in adulthood and childhood, even if in adults the MR imaging findings are negative. In the authors’ opinion, OM should be classified as migraine.

Staged Treatment of a Blood Blister-Like Aneurysm with Stent-Assisted Coiling Followed by Flow Diverter in-Stent Insertion: A Case Report

Blood blister-like aneurysms (BBLA) are rare lesions sometimes difficult to recognize and in most cases associated with diffuse subarachnoid haemorrhage and severe clinical conditions. BBLA are life-threatening because they tend to enlarge rapidly and to rebleed, and no consensus has so far been reached on the best management strategy. We describe a patient with a BBLA in the right ICA treated successful by a two-stage embolization procedure first with coils and an open cell stent (Neuroform 3) and later by further coil placement and insertion of a flow-diverting stent (Silk).

Postprocedural, midterm, and long-term results of cerebral aneurysms treated with flow-diverter devices: 7-year experience at a single center

OBJECTIVE Flow diversion has emerged as a viable treatment option for selected intracranial aneurysms and recently has been gaining traction. The aim of this study was to evaluate the safety and effectiveness of flow-diverter devices (FDDs) over a long-term follow-up period. METHODS The authors retrospectively reviewed all cerebral aneurysm cases that had been admitted to the Division of Neurosurgery of the Università degli Studi di Napoli between November 2008 and November 2015 and treated with an FDD. The records of 60 patients (48 females and 12 males) harboring 69 cerebral aneurysms were analyzed. The study end points were angiographic evidence of complete aneurysm occlusion, recanalization rate, occlusion of the parent artery, and clinical and radiological evidence of brain ischemia. The occlusion rate was evaluated according to the OKelly-Marotta (OKM) Scale for flow diversion, based on the degree of filling (A, total filling; B, subtotal filling; C, entry remnant; D, no filling). Postprocedural, midterm, and long-term results were strictly analyzed. RESULTS Complete occlusion (OKM D) was achieved in 63 (91%) of 69 aneurysms, partial occlusion (OKM C) in 4 (6%), occlusion of the parent artery in 2 (3%). Intraprocedural technical complications occurred in 3 patients (5%). Postprocedural complications occurred in 6 patients (10%), without neurological deficits. At the 12-month follow-up, 3 patients (5%) experienced asymptomatic cerebral infarction. No further complications were observed at later follow-up evaluations (> 24 months). There were no reports of any delayed aneurysm rupture, subarachnoid or intraparenchymal hemorrhage, ischemic complications, or procedure- or device-related deaths. CONCLUSIONS Endovascular treatment with an FDD is a safe treatment for unruptured cerebral aneurysms, resulting in a high rate of occlusion. In the present study, the authors observed effective and stable aneurysm occlusion, even at the long-term follow-up. Data in this study also suggest that ischemic complications can occur at a later stage, particularly at 12-18 months. On the other hand, no other ischemic or hemorrhagic complications occurred beyond 24 months.

Oxygen-Ozone Therapy for Herniated Lumbar Disc in Patients with Subacute Partial Motor Weakness Due to Nerve Root Compression

Intradiscal oxygen-ozone (O2-O3) chemonucleolysis is a well-known effective treatment for pain caused by protruding disc disease and nerve root compression due to bulging or herniated disc. The most widely used therapeutic combination is intradiscal injection of an O2-O3 mixture (chemonucleolysis), followed by periradicular injection of O2-O3, steroid and local anaesthetic to enhance the anti-inflammatory and analgesic effect. The treatment is designed to resolve pain and is administered to patients without motor weakness, whereas patients with acute paralysis caused by nerve root compression undergo surgery 24–48h after the onset of neurological deficit. This paper reports on the efficacy of O2-O3 chemonucleolysis associated with anti-inflammatory foraminal injection in 13 patients with low back pain and cruralgia, low back pain and sciatica and subacute partial motor weakness caused by nerve root compression unresponsive to medical treatment. All patients were managed in conjunction with our colleagues in the Neurosurgery Unit of Bellaria Hospital and the IRCCS Institute of Neurological Sciences, Bologna. The outcomes obtained are promising: 100% patients had a resolution of motor weakness, while 84.6% had complete pain relief. Our results demonstrate that O2-O3 therapy can be considered a valid treatment option for this category of patients.

Early tumour shrinkage as a survival predictor in patients with recurrent glioblastoma treated with bevacizumab in the AVAREG randomized phase II study

BACKGROUNDnDisease assessment for recurrent glioblastoma (GBM) represents a challenge, especially with the use of antiangiogenic agents. Moreover, validated neuroradiological predictors of outcome are lacking. Recently, the concept of early tumor shrinkage (ETS) has been developed to better assess the ability of treatments in determining a rapid and remarkable tumor response.The aim of the study was to evaluate the role of ETS in predicting survival of GBM patients treated with BEVMETHODS: We examined the radiological data of patients with recurrent GBM treated with bevacizumab (BEV) or fotemustine (FTM) in the randomized phase II AVAREG trial (EudraCT: 2011-001363-46).Radiologic assessments at first disease assessment (day 46) were used to calculate the relative change in the sum of the products of perpendicular diameters of all measurable lesions determined by either T1 contrast and T2/FLAIR.nnnRESULTSnIn patients treated with BEV, the best ETS cut-off was reduction of 15% with T1 contrast and of 40% with T2/FLAIR. Adopting this cut-off for T1 contrast radiological changes, ETS was a significant predictor of OS for patients treated with BEV (HR = 0.511, 95%CI:0.269-0.971, p = 0.040). The cut-off obtained for T2/FLAIR was not significantly correlated with OS (p = 0.102), but we found a trend for correlation with survival when considering the variable as continuous (p = 0.058).nnnCONCLUSIONSnETS evaluating T1 contrast reduction is a helpful predictor of survival in patients with recurrent GBM treated with BEV, and if validated in a larger prospective trial could be a helpful surrogate endpoint.BACKGROUND Disease assessment for recurrent glioblastoma (GBM) represents a challenge, especially with the use of antiangiogenic agents. Moreover, validated neuroradiological predictors of outcome are lacking. Recently, the concept of early tumor shrinkage (ETS) has been developed to better assess the ability of treatments in determining a rapid and remarkable tumor response. The aim of the study was to evaluate the role of ETS in predicting survival of GBM patients treated with BEV METHODS We examined the radiological data of patients with recurrent GBM treated with bevacizumab (BEV) or fotemustine (FTM) in the randomized phase II AVAREG trial (EudraCT: 2011-001363-46). Radiologic assessments at first disease assessment (day 46) were used to calculate the relative change in the sum of the products of perpendicular diameters of all measurable lesions determined by either T1 contrast and T2/FLAIR. RESULTS In patients treated with BEV, the best ETS cut-off was reduction of 15% with T1 contrast and of 40% with T2/FLAIR. Adopting this cut-off for T1 contrast radiological changes, ETS was a significant predictor of OS for patients treated with BEV (HR = 0.511, 95%CI:0.269-0.971, p = 0.040). The cut-off obtained for T2/FLAIR was not significantly correlated with OS (p = 0.102), but we found a trend for correlation with survival when considering the variable as continuous (p = 0.058). CONCLUSIONS ETS evaluating T1 contrast reduction is a helpful predictor of survival in patients with recurrent GBM treated with BEV, and if validated in a larger prospective trial could be a helpful surrogate endpoint.

Evaluation of CTA, time-resolved 4D CE-MRA and DSA in the follow-up of an intracranial aneurysm treated with a flow diverter stent: Experience from a single case.

Endovascular treatment of giant, fusiform and dissecting aneurysms with flow diverter stents is becoming more and more popular. However, very few studies on the follow-up have been published. We describe a patient with a dissecting aneurysm of the right vertebral artery treated with flow diverter stent placement. The patient was followed up with CT angiography (CTA), time-resolved contrast-enhanced MR angiography (CE-MRA) and digital subtraction angiography (DSA). CTA had false negative results in two instances, whereas time-resolved CE-MRA and DSA were the most accurate in depicting the residual flow in the aneurysmal sac. However, in the case of DSA the demonstration of residual flow proved quite difficult and required a very thorough examination with oblique projections. Our 2.5-year experience with this patient led us to believe that time-resolved CE-MRA is a valuable tool in the follow-up of flow diverter-treated stents.

Flat Panel Angiography Images in the Post-Operative Follow-Up of Surgically Clipped Intracranial Aneurysms

Cerebral aneurysms must be monitored for varying periods after surgical and/or endovascular treatment and the duration of follow-up will depend on the type of therapy and the immediate post-operative outcome. Surgical clipping for intracranial aneurysms is a valid treatment but the metal clips generate artefacts so that follow-up monitoring still relies on catheter angiography. This study reports our preliminary experience with volumetric angiography using a Philips Allura Xper FD biplane system in the post-operative monitoring of aneurysm residues or major vascular changes following the surgical clipping of intracranial aneurysms. Volumetric angiography yields not only volume-rendered (VR) images, but a volume CT can also be reconstructed at high spatial and contrast resolution from a single acquisition, significantly enhancing the techniques diagnostic power. Between August 2012 and April 2013, we studied 19 patients with a total of 26 aneurysms treated by surgical clipping alone or in combination with endovascular treatment. All patients underwent standard post-operative angiographic follow-up including a rotational volumetric acquisition. Follow-up monitoring disclosed eight aneurysm residues whose assessment was optimal after surgical clipping both in patients with one metal clip and in those with two or more clips. In addition, small residues (1.3 mm) could be monitored together with any change in the calibre or course of vessels located adjacent to the clips. In conclusion, flat panel volume CT is much more reliable than the old 3D acquisitions that yielded only VR images. This is particularly true in patients with small aneurysm residues or lesions with multiple metal clips.

Superficial siderosis associated with peripheral autonomic failure and tetraventricular hydrocephalus: a case report

We describe the case of a man whose initial clinical presentation included sensorineural hearing loss and orthostatic hypotension. The patient was diagnosed with superficial siderosis associated with peripheral autonomic failure and tetraventricular hydrocephalus.

Application of intravoxel incoherent motion (IVIM) magnetic resonance imaging in the evaluation of primitive brain tumours

Intravoxel incoherent motion is a potential non-invasive diagnostic tool in brain tumours, without any clear guidelines for its evaluation yet. In our study, we compare intravoxel incoherent motion with dynamic susceptibility contrast magnetic resonance imaging in the quantification of tumour tissue blood perfusion in 28 patients affected by brain tumours, highlighting the issues encountered during the acquisition set-up and post-processing steps. Intravoxel incoherent motion is a new imaging tool and an alternative technique to dynamic susceptibility contrast-magnetic resonance imaging which is of considerable interest at present. This is partly because it does not require the use of a contrast agent and relies on the intrinsic properties of motion in the capillaries of the spins. Compared to dynamic susceptibility contrast-magnetic resonance imaging, the intravoxel incoherent motion technique is also characterised by better resolution because the gadolinium-based contrast agent bolus used in the standard technique results in a variation by more than 50% of the signal coming from the brain. Finally, intravoxel incoherent motion is more sensitive to the incoherent motion that originates from small capillary vessels, while the dynamic susceptibility contrast signal is also contaminated by the input from larger arteries and veins, which may result in an overestimation of the blood volume. Although there are limitations due to the heterogeneity of the sample considered in our study, intravoxel incoherent motion has been shown to be an accurate noninvasive radiological biomarker, useful to distinguish between low and high grade glial tumours.

Percutaneous ozone nucleolysis for lumbar disc herniation

PurposeAll percutaneous minimally invasive disc treatments are typically indicated to contained disc herniations. Our study’s aim is to evaluate prospectively the efficacy of ozone nucleolysis in the treatment of either contained or uncontained lumbar disc herniations.MethodsFifty-two patients, aged 27–87xa0years, with symptomatic herniated lumbar discs, without migration, sequestration, or severe degenerative disc changes, who failed conservative treatment, were included in our study. The patients underwent fluoroscopic-guided intradiscal oxygen-ozone mixture injection (5xa0ml) at a concentration of 27–30xa0μg/ml and periradicular injection of the same O2-O3 mixture (10xa0ml), steroid (1xa0ml), and local anesthetic (1xa0ml). Clinical outcomes were evaluated, based on the Oswestry Disability Index (ODI) and pain intensity (0–5) scale results, obtained initially and at 2- and 6-month controls. Our results were analyzed by ANOVA and chi-squared (χ2) tests.ResultsOur initial results obtained at 2-month control were promising, indicating a significant decrease in pain disability and intensity in 74% (37) and 76% (38) of the patients respectively, and minimally increased to 76% (38) and 78% (39) at 6-month control (Pu2009<u20090.001 and CI 99.9%). The mean preprocedure ODI and pain intensity scores were 35u2009±u200914.36 and 2.38u2009±u20090.90, respectively, which were reduced to 19.36u2009±u200913.12 and 1.04u2009±u20090.92 at 6-month control. Our failure had been mostly related to long symptoms duration of more than 1xa0year. No complications were recorded.ConclusionOzone nucleolysis is a safe cost-effective minimally invasive technique for treatment of contained and uncontained lumbar disc herniations.