Rosa Morabito

Necrosis Score, Surgical Time, and Transfused Blood Volume in Patients Treated with Preoperative Embolization of Intracranial Meningiomas. Analysis of a Single-Centre Experience and a Review of Literature

PurposeSeveral authors have demonstrated that preoperative embolization of meningiomas reduces blood loss during surgery. However, preoperative embolization is still under debate. Aim of this study is the retrospective evaluation of necrosis score, surgical time, and transfused blood volume, on patients affected by intracranial meningiomas treated with preoperative embolization before surgery, compared with a control group treated only with surgery.MethodTwenty-eight patients with meningiomas were subjected to a preoperative embolization with polyvinyl alcohol (PVA). These patients were divided into two groups: group 1, patients with preoperative embolization performed at least 7 days before surgery; and group 2, patients with preoperative embolization performed less than 7 days before surgery. A statistical evaluation was made by comparing necrosis score, surgical time, and transfused blood volume of these groups. Then, we compared these parameters also with group 3, which included patients with surgically treated meningioma who did not undergo preoperative embolization.ResultsSurgery time and transfused blood volume were significantly lower in patients who had been embolized at least 7 days before definitive surgery. Furthermore, large confluent areas of necrosis were significantly more frequent in patients with a larger time span between embolization and surgery.ConclusionPreoperative embolization with PVA in patients with intracranial meningiomas is safe and effective, as it reduces the volume of transfused blood during surgical operation. However, patients should undergo surgery at least 7 days after embolization, as a shorter time interval has been correlated with a longer surgical time and a higher transfused blood volume.

A rare case of cerebellar agenesis: a probabilistic Constrained Spherical Deconvolution tractographic study

Aim of this study is to show the potential of probabilistic tractographic techniques, based on the Constrained Spherical Deconvolution (CSD) algorithms, in recognizing white matter fiber bundle anomalies in patients with complex cerebral malformations, such as cerebellar agenesis. The morphological and tractographic study of a 17-year-old male patient affected by cerebellar agenesis was performed by using a 3Tesla MRI scanner. Genetic and neuropsychological tests were carried out. An MRI morphological study showed the absence of both cerebellar hemispheres and the flattening of the anterior side of the pons. Moreover, it showed a severe vermian hypoplasia with a minimal vermian residual. The study recognized two thin cerebellar remnants, medially in contact with the small vermian residual, at the pontine level. The third ventricle, morphologically normal, communicated with a permagna cerebello-medullary cistern. Probabilistic CSD tractography identified some abnormal and aberrant infratentorial tracts, symmetrical on both sides. In particular, the transverse pontine fibers were absent and the following tracts with aberrant trajectories have been identified: “cerebello-thalamic” tracts; “fronto-cerebellar” tracts; and ipsilateral and contralateral “spino-cerebellar” tracts. Abnormal tracts connecting the two thin cerebellar remnants have also been detected. There were no visible alterations in the main supratentorial tracts in either side. Neuropsychiatric evaluation showed moderate cognitive-motor impairment with discrete adaptive compensation. Probabilistic CSD tractography is a promising technique that overcome reconstruction biases of other diffusion tensor-based approaches and allowed us to recognize, in a patient with cerebellar agenesis, abnormal tracts and aberrant trajectories of normally existing tracts.

Benign External Hydrocephalus in Infants A Single Centre Experience and Literature Review

We report our experience in treatment of traumatic direct carotid cavernous fistula (CCF) via endovascular intervention. We hereof recommend an additional classification system for type A CCF and suggest respective treatment strategies. Only type A CCF patients (Barrows classification) would be recruited for the study. Based on the angiographic characteristics of the CCF, we classified type A CCF into three subtypes including small size, medium size and large size fistula depending on whether there was presence of the anterior carotid artery (ACA) and/or middle carotid artery (MCA). Angiograms with opacification of both ACA and MCA were categorized as small size fistula. Angiograms with opacification of either ACA or MCA were categorized as medium size fistula and those without opacification of neither ACA nor MCA were classified as large size fiatula. After the confirm angiogram, endovascular embolization would be performed impromptu using detachable balloon, coils or both. All cases were followed up for complication and effect after the embolization. A total of 172 direct traumatic CCF patients were enrolled. The small size fistula was accountant for 12.8% (22 cases), medium size 35.5% (61 cases) and large size fistula accountant for 51.7% (89 cases). The successful rate of fistula occlusion under endovascular embolization was 94% with preservation of the carotid artery in 70%. For the treatment of each subtype, a total of 21/22 cases of the small size fistulas were successfully treated using coils alone. The other single case of small fistula was defaulted. Most of the medium and large size fistulas were cured using detachable balloons. When the fistula sealing could not be obtained using detachable balloon, coils were added to affirm the embolization of the cavernous sinus via venous access. There were about 2.9% of patient experienced direct carotid artery puncture and 0.6% puncture after carotid artery cut-down exposure. About 30% of cases experienced sacrifice of the parent vessels and it was associated with sizes of the fistula. Total severe complication was about 2.4% which included 1 death (0.6%) due to vagal shock; 1 transient hemiparesis post-sacrifice occlusion of the carotid artery but the patient had recovered after 3 months; 1 acute thrombus embolism and the patient was completely saved with recombinant tissue plaminogen activator (rTPA); 1 balloon dislodgement then got stuck at the anterior communicating artery but the patient was asymptomatic. Endovascular intervention as the treatment of direct traumatic CCF had high cure rate and low complication with its ability to preserve the carotid artery. It also can supply flexible accesses to the fistulous site with various alternative embolic materials. The new classification of type A CCF based on angiographic features was helpful for planning for the embolization. Coil should be considered as the first embolic material for small size fistula meanwhile detachable balloons was suggested as the first-choice embolic agent for the medium and large size fistula.External hydrocephalus (EH) is a benign clinical entity in which macrocephaly is associated with an increase in volume of the subarachnoid space, especially overlying both frontal lobes, and a normal or only slight increase in volume of the lateral ventricles. Several pathogenic hypotheses have been proposed but the most accredited theory seems to be delayed maturation of the arachnoid villi. There is a consensus that this is a benign entity, correlated to a familial predisposition and, in some cases, inheritance. CT and MRI are very important to make a diagnosis but also to establish the prognosis in patients who encounter the rare complications such as subdural haematomas. In conclusion, CT and MRI can provide a highly accurate diagnosis in these patients, allowing a preliminary assessment of the prognosis, particularly regarding the enlarged subarachnoid space limits and the “cortical vein” sign which can predict a further complication. These results are obtained with the same examination performed in a standard CT or MRI study of the brain and no injection of contrast medium is needed.

Proton magnetic resonance spectroscopy (H-MRS) in chronic schizophrenia. A single-voxel study in three regions involved in a pathogenetic theory.

The cognitive dysmetria theory suggests a disconnectivity between the dorsolateral prefrontal cortex, thalami and vermis to explain the pathophysiology of schizophrenia. This study investigated the metabolic integrity of this neurologic circuit in patients with schizophrenia using proton magnetic resonance spectroscopy (H-MRS). Twenty-two patients with schizophrenia and twelve control subjects were studied. Metabolites concentrations were evaluated by a single-voxel technique in the prefrontal cortex, thalami and vermis. To our knowledge, this is the first H-MRS experience with concomitant evaluation of these regions in schizophrenic patients. We found no significant statistical difference in N-AA, Cho and Cr absolute concentrations and N-AA/Cho, N-AA/Cr and Cho/Cr ratios between the schizophrenic patients and control group. At the vermis, we found a constant spectrum with low levels of N-AA and higher levels of Cho and Cr. Our experience does not clearly support or refute the cognitive dysmetria theory. The consistency of metabolic findings in the cerebellar vermis could represent an important datum, highlighting the specificity of metabolic and functional activity in this region.

Advanced virtual magnetic resonance imaging (MRI) techniques in neurovascular conflict: bidimensional image fusion and virtual cisternography

PurposeThe aim of this study was to evaluate the advantages and limits of virtual magnetic resonance techniques in planning surgery for microvascular decompression in patients with neurovascular conflict.Materials and methodsBetween December 2010 and December 2011, we prospectively observed 32 patients (30 with trigeminal neuralgia and two with hemifacial spasm), with a suspected clinical diagnosis of neurovascular conflict. To assess the contact between nerve and vessel, magnetic resonance imaging (MRI) by three-dimensional (3D) constructive interference in steady state (CISS) and high-resolution MR angiography (MRA) were performed in all cases. Moreover, we performed presurgical simulation of microvascular decompression using MR two-dimensional image fusion and virtual cisternography. The neuroradiological findings were compared with the surgical findings.ResultsIn all cases, we demonstrated the anatomical relations between cranial nerves and offending vessels with an optimal correlation between radiological and surgical patterns.ConclusionsAdvanced virtual MRI techniques, such as image fusion and virtual cisternography, are able to depict the complex anatomical relationships between neural and vascular structures within the cisternal spaces of the skull base. These techniques can be considered an optimal presurgical tool to support traditional MRI evaluation of this region.RiassuntoObiettivoScopo del presente lavoro è stato valutare le possibilità e i limiti di tecniche virtuali avanzate di risonanza magnetica nella pianificazione pre-chirurgica dell’intervento di decompressione microvascolare in pazienti con conflitto neuro-vascolare.Materiali e metodiTra dicembre 2010 e dicembre 2011, sono stati prospetticamente arruolati 32 pazienti (30 con nevralgia trigeminale e 2 con emispasmo faciale), con diagnosi clinica di conflitto neuro-vascolare. Allo scopo di definire il contatto anomalo tra una struttura vascolare e il nervo cranico, i pazienti sono stati sottoposti a risonanza magnetica (RM) con tecnica 3D-constructive interference in steady-state (CISS), e a studio angio-RM ad alta risoluzione. In tutti i pazienti, inoltre, abbiamo realizzato una simulazione pre-chirurgica dell’intervento di decompressione microvascolare utilizzando la tecnica di fusione di immagine bidimensionale e la cisternografia virtuale. I rilievi radiologici sono stati, quindi, comparati con i rilievi chirurgici.RisultatiIn tutti i casi, è stato dimostrato lo stretto rapporto di contiguità anatomica tra nervo cranico e struttura vascolare a decorso anomalo, con un’ottima correlazione tra rilievo radiologico e chirurgico.ConclusioniLe tecniche di fusione di immagine bidimensionale e la cisternografia virtuale si sono dimostrate adeguate nella valutazione dei complessi rapporti anatomici tra strutture nervose e strutture vascolari nel contesto degli spazi cisternali della base cranica. Esse costituiscono un ottimo strumento pre-chirurgico in grado di migliorare la tradizionale valutazione RM di questa regione.

Perfusion computed tomography of intracranial meningiomas: In vivo correlation of cerebral blood volume and vascular permeability

Background A noninvasive method to predict the grade of a meningioma would be desirable since it would anticipate information about tumour nature, recurrence and improve tumour management and outcomes. The aim of the present study was to assess the ability of perfusion computed tomography (PCT) technique in predicting the meningioma grade before surgery. Data from PCT, such as cerebral blood volume (CBV) and permeability surface (PS), were correlated with immunohistolopathological information. Methods Twenty-three patients with a diagnosis of intracranial meningioma underwent PCT for pre-surgical evaluation of CBV and PS. During surgery, samples from the centre and periphery of the tumour were obtained. Two correspondent regions of interest (ROIs) were drawn on CBV and PS maps. Central and peripheral CBV and PS mean values were calculated. PCT parameters were correlated to CD-34 and endoglin. Results There was a positive correlation between PS and CD-34. No correlation was found between PS values and endoglin, CBV values and CD-34 and endoglin values. Conclusion Our findings suggest that PCT may support conventional morphological imaging in predicting meningioma grading before surgery.

Functional Evaluation of Awareness in Vegetative and Minimally Conscious State

Objective: The aim of this study was to assess differences in brain activation in a large sample of Vegetative State (VS) and Minimally Conscious State (MCS) patients, using functional magnetic resonance imaging (fMRI). Methods: We studied 50 patients four to seven months after brain injury. By using international clinical criteria and validated behavioural scales such as the Glasgow Coma Scale and the Clinical Unawareness Assessment Scale, the patients were grouped into VS (n=23) and MCS (n=27). All patients underwent to fMRI examination. After 6 months, the patients were reassessed using Glasgow Outcome Scale and Revised Coma Recovery Scale. Results: fMRI showed significant (p<0.01, cluster-corrected) brain activation in the primary auditory cortex bilaterally during the acoustic stimuli in patients with both VS and MCS. However, ten patients clinically classified as VS, showed a pattern of brain activation very similar to that of MCS patients. Six months later, these ten VS patients had significant clinical improvement, evolving into MCS, whereas the other VS patients and patients with MCS remained clinically stable. Conclusion: Brain activity could help in discerning whether the status of wakefulness in VS is also accompanied by partial awareness, as occurs in MCS. This may have very important prognostic implications.

Cortical reorganization in multiple sclerosis after intrathecal baclofen therapy

Our objective was to assess the role of Intrathecal Baclofen Therapy (ITB) in the cortical reorganization in a patient affected by multiple sclerosis (MS) undergoing physical therapy. We reported a case of a woman affected by MS and severe spasticity, who performed an fMRI examination, before and after the ITB implantation. The subject showed controlateral motor cortex activation after motor task. After a month of ITB implantation, patient showed ipsilateral and controlateral motor cortex activation although with a broader extension. fMRI examination supported the hypothesis of a central influence in patients who undergo physiotherapy and therapy with ITB.

Pharyngeal enterogenous cyst associated with canalis basilaris medianus in a newborn

We report the CT and MR characteristics of a newborn with a rare, complex malformation characterised by a large rhinopharyngeal and oropharyngeal enterogenous cyst, associated with an osseous defect of the basiocciput, called canalis basilaris medianus (CBM). A partial herniation of the bulb was demonstrated through the bony defect on the midline. The enterogenous cyst occupied the rhinopharynx and oropharynx, narrowing the pharyngeal lumen and making it difficult for the introduction of an orotracheal tube.

Acute onset of bulbar amyotrophic lateral sclerosis after flu – look at the differential diagnosis: A case report:

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder affecting upper and lower motor neurones. It can be either familial (fALS) or sporadic (sALS). ALS is characterized by muscle weakness and atrophy that can involve the limbs and trunk (i.e. the spinal form of the disease) or speech and swallowing (i.e. the bulbar form). The aetiology of sALS remains unclear although a gene–environment interaction has been proposed as a concomitant trigger for the neurodegenerative process together with viral infections, smoking, heavy metals and pesticide exposure. Herein, we report the case of a 67-year-old woman who experienced an acute onset of bulbar ALS with an atypical clinical course that was probably triggered by a bout of influenza.