Riccardo Fornaro

Subarachnoid hemorrhage in elderly: Advantages of the endovascular treatment.

Aim:  Subarachnoid hemorrhage (SAH) from aneurysm rupture accounts for approximately 3% of all strokes. A significant improvement in surgery and endovascular procedures has reduced mortality and morbidity. Nowadays, endovascular treatment is a viable alternative to conservative treatment in elderly patients. We designed a retrospective observational study on all endovascular procedures carried out in our department in order to evaluate the outcome in elderly patients compared with a younger cohort.

Interleukin-1 cluster gene polymorphisms and aneurysmal subarachnoid hemorrhage.

BACKGROUNDEmerging data indicate that proinflammatory cytokines may be involved in the pathogenesis of intracranial aneurysms. Interleukin (IL)-1 is a proinflammatory cytokine that plays a pivotal role in both acute and chronic central nervous system injuries. OBJECTIVETo investigate whether select polymorphisms in the IL-1α, IL-1β, and IL-1 receptor antagonist genes are associated with both susceptibility to and clinical characteristics of subarachnoid hemorrhage due to intracranial aneurysm rupture. METHODSAllelic and genotypic frequencies of the IL-1α (−889), IL-1β (-511), and IL-1 receptor antagonist (VNTR) genes were determined in 215 patients and 155 healthy controls. Patient files were reviewed for the clinical characteristics at hospital admission and at 6-month follow-up. RESULTSNo association between aneurysmal subarachnoid hemorrhage susceptibility and the examined cytokine gene polymorphisms was found. Haplotype analysis did not show any significant difference between cases and controls. However, aneurysmal subarachnoid hemorrhage patients carrying the T/T genotype of the IL-1β gene showed a significant (P = .034) increase in the Hunt and Hess scores at hospital admission and a significant (P = .026) reduction in 6-month Glasgow Outcome Scale scores. The remaining polymorphisms showed no effect on the clinical features examined. CONCLUSIONOur results do not support the hypothesis that genetic variation in select polymorphisms of the IL-1 cluster genes is associated with aneurysmal subarachnoid cerebral hemorrhage. However, the IL-1β gene may modify disease severity and may be regarded as disease severity gene.

Does intraoperative microrecording really increase the risk of hemorrhagic complications in deep brain stimulation

Stereotactic surgery represents a highly effective therapy for the treatment of Parkinson’s disease and other movement disorders refractory to medical treatment. Despite its demonstrated safety, some rare adverse events could result in potentially disabling outcomes.Amongthem,hemorrhagic complications (HC)areunarguably themost dangerous and dreaded. In a recent systematic survey of the literature, themost important patient-related factors associatedwith an increased risk of HC were age and hypertension, whereas risk factors related to surgical technique included the use of intraoperative microelectrode recording (MER), the number of MER penetrations, and the sulcal or ventricular involvement by the trajectory [1]. The incidence of HC in studies adopting MER was significantly higher than that reported with exclusively image-guided approaches [1e3]. Furthermore, the coexistence of hypertension and MER has been associated to an additional rise of bleeding incidence [4]. Herewe describe a large consecutive series of 221 patients undergoing surgery for Deep Brain Stimulation (DBS) lead placement at our institution mainly for advanced Parkinson’s disease without the occurrence of HC despite the routinely use of intraoperativeMER. Medical records and postoperative imaging studies of all patients who underwent bilateral DBS lead placement at Torino University Hospital between October 1998 and December 2013 were collected. Awritten informedconsentwasobtained for all participants. Theprocedures consisted of a single-session bilateral stereotactic lead implantation [5], performed under local anesthesia by a single primary surgeon (ML), using the CosmaneRobertseWells stereotactic frame (CRW, IntegraRadionics, Burlington,MA). Cranialmagnetic resonance imaging (MRI)/computed tomography (CT) image fusion (Image Fusion, Integra Radionics and I-Plan Stereotaxy, Brainlab AG, Feldkirchen, Germany) was used for anatomical targeting, adopting the Schaltenbrand-Wahren atlas as a reference [6]. Patients were positioned supine with their head slightly elevated (approximately 15 ). A 14-mmburr holewas located along the planned trajectory and specific lead-anchoring systemsfixed to the skull (burr-hole ring and cap early in the series; Stimloc, Medtronic, Minneapolis, MN, more recently). The dural and pial entry points were coagulatedwith bipolar electrocautery and opened sharply. To minimize the risk of HC, a trajectory avoiding sulci, arteries and ventricles was plotted. Intraoperative electrophysiological recording with a single-track MER was performed starting from 10 mm above the anatomical target (Microtargeting Electrodes BP, FHC Inc., Bowdoin,ME, early in the series, and

Double concentric craniotomy: Safe and effective technique to achieve an en bloc resection of tumor involving both skull and duraa

Highlights • Many tumors can involve the skull. Radical excision is the golden standard of treatment.• Elevate a bone flap when the tumor involves both the skull and the dura present a technical challenges.• Double concentric craniotomy is a safe and effective technique to remove tumor involving both skull and dura structures under direct vision.

Multiple cavernomas of the brain: simultaneous hemorrhage of two lesions in a non-familial form.

BACKGROUND Cavernomas of the brain are congenital lesions clinically divided into hereditary and a sporadic forms. Multiple lesions are usually observed in the familial form, whereas the sporadic variant generally shows a single cavernoma. In this case we describe the simultaneous bleeding of two lesions in a patient with a non-familial cavernomatosis. CASE DESCRIPTION A 46-year-old woman presented with slight hyposthenia involving the left arm and cervical stiffness. Examinations revealed two cavernomas with recent signs of bleeding. The lesions were surgically removed achieving a total excision. The patient was discharged after 10 days with slight left hyposthenia. DISCUSSION Simultaneous hemorrhage of multiple cavernomas is rare. To the best of our knowledge, this is the first case showing a sporadic form presenting with two hemorrhagic lesions. We suggest an aggressive approach in order to avoid the risk of rebleeding, which is particularly high in case of hemorrhagic cavernomatosis.

Rare Case of Dumbbell-Shaped Spinal Cavernous Hemangioma and Literature Review

BACKGROUND Spinal epidural cavernous hemangiomas are rare vascular malformations. Exceptionally, they present with dumbbell-shaped morphology. When they happen, its mandatory to include their pathology in the differential diagnosis because of their similarity to schwannomas. CASE DESCRIPTION We report the case of a 72-year-old woman with a dumbbell-shaped thoracic epidural cavernous hemangioma. A literature review of diagnostic features and current treatment options are also discussed. CONCLUSIONS Surgery is safe and effective in both improving patient condition and preventing acute hemorrhage that can worsen the outcome, causing neurologic and potentially irreversible deficits. The favorable result we obtained in our patient suggests that surgery should be evaluated as the first option, even in patients with large epidural cavernous hemangiomas.

Postoperative Care of Patients with High-grade Glioma: Is There a Real Need for the Neurocritical ICU and Early CT Scan?

Background Pressure on economic resources now requires a careful rationalization of services. For adult patients with supratentorial gliomas, there is no consensus on the real need for care in a postoperative neurocritical intensive care unit (NICU) and on the timing of a postsurgical computed tomography (CT) scan. In this retrospective nonrandomized study, we assessed if and when there is a real need for NICU and if an early CT scan could be justified in the absence of neurologic worsening. Methods Of 264 patients, 21 were admitted to the NICU after the procedure as planned before the surgery for their clinical features (Karnofsky performance status < 70, American Society of Anesthesiologists score > 2, or Charlson Comorbidity Index > 5). Results The mean stay in the NICU was 19.7 hours. One of these patients had developed a postoperative hematoma that was subsequently removed, and died afterward. The other 243 patients were followed clinically after the procedure: 219 underwent a cerebral CT scan 24 hours after the procedure and were discharged in good condition. The other 24 patients had a cerebral CT scan within 24 hours after the procedure. The early CT showed the presence of a local edema in five cases and a hematoma surgically treated with a subsequent admission to the NICU in two cases. Conclusion Considering our data, we suggest that NICU should not always be used after craniotomy for supratentorial gliomas. Clinical observation was sufficient to predict early postoperative complications. A CT scan before 24 hours after surgery is not recommended in the absence of clinical worsening.

P08.10SINGLE BRAIN METASTASIS 9 YEARS AFTER ORTHOTOPIC LIVER TRANSPLANT WITH HISTOLOGICAL NEGATIVE EXPIANTED LIVER: CASE REPORT

We describe the case of a 67 years old man, that underwent orthotopic liver transplant (OLT) in 2004 for cirrhosis. Native liver hystological examination was negative for focal hepatocarcinoma (HCC) areas. In 2008, during regular follow up, pulmonary lesions were found and diagnosed as hepatocarcinoma metastasis.In 2013, patient accused vertigo and dizziness: neuroimaging showed a cerebellar lesion. Hystological diagnosis was HCC metastases. The peculiarity is the onset of lung metastasis after transplant, with negative analysis on native liver, and brain metastasis after stable disease. This case is also relevant due to long survival related to the unavailability of many oncologic therapies in transplanted patients.

Importance of early treatment in case of spontaneous intracranial hypotension.

Spontaneous intracranial hypotension (SIH) is caused by an diopathic leakage of cerebrospinal fluid (CSF). Patients present a ew-onset headache that generally occurs shortly after assuming pright position (orthostatic headache). SIH is not always well recgnized as an independent clinical condition, and patients may e diagnosed with migraine or tension-type headache. Associated ymptoms can be nausea, tinnitus, vertigo, hypoacusia, and neck tiffness.