In vivo visualization of pituitary dopaminergic receptors by iodine-123 methoxybenzamide (IBZM) correlates with sensitivity to dopamine agonists in two patients with macroprolactinomas

We performed in two patients with macroprolactinoma, pituitary scintigraphy with 123 iodine-methoxybenzamide (IBZM), a dopaminergic antagonist that specifically binds to the D2 dopaminergic receptors. In a 34-yr-old woman with basal PRL levels of about 2000 ng/mL, 7.5 mg/day of Bromocriptine (Br) for a month neither reduced PRL levels nor affected tumor size; in this patient single photon emission tomography SPECT failed to show any pituitary accumulation of the tracer. In the other patient, a 27-yr-old man presenting with cerebrospinal fluid rhinorrhea, basal PRL levels were at 5000 ng/mL; magnetic resonance imaging (MRI) demonstrated a huge pituitary tumor, and SPECT showed a very intense concentration of IBZM at the level of the adenoma. PRL levels fell dramatically to 530 ng/mL with only 2.5 mg/day of Br after 4 days; after 6 days with 7.5 mg/day Br, PRL levels were 63 ng/mL, and the patient underwent surgery to correct cerebrospinal fluid leakage. We conclude that, in these two patients, the pituitary scintigraphy with IBZM has given information on the density of dopamine receptors on the adenoma and has correlated with the inhibitory effect of Br on PRL secretion. Whether this tool might be of value in identifying patients with pituitary tumors potentially responsive to Br treatment is still to be investigated.

[Cerebral amyloid angiopathy (congophilic angiopathy): a rare cause of massive cerebral hemorrhage. Report of an "age-related" sporadic case]

Cerebral amyloidosis is a form of organ-limited amyloidosis, which doesn't involve any organ other than brain and which comprises several subtypes, including "congophilic angiopathy" (CA), "senile plaques" (SP), "neurofibrillary degeneration" (ND), "stellate amyloid cores" of spongiform encephalopathies. It is found in 5 to around 20% of human population in people aged 60 to 90 years, the increasing being strictly related to ageing. Usually it is associated to SP and occasionally to ND, being distinguished into familial and non-familial (age-related) variants. It affects intracortical and leptomeningeal variously sized vessels of the brain and is a leading pathogenetic factor in determining a rare but possibly even recurrent form of a massive intraparenchymal cerebral hemorrhage, constituting a 0.2 per cent of brain vascular accidents of any origin and a 5-10 per cent if only primary non traumatic brain hemorrhages are considered. A case of non-familial CA in a previously non-demented nor hypertensive female patient aged 65 years is reported on, who was admitted due to an almost abrupt onset of neurologic symptoms mainly dominated by a sudden loss of consciousness together with a left sensory-motor deficiency syndrome. The patient who had been operated on of unilateral mastectomy eight years earlier due to an invasive ductal carcinoma of the breast was found affected by a devastating brain hemorrhage in the right temporo-occipital lobes with subsequent deflection of the brainstem axis toward the opposite side detected by means of CT/MRI and angiographic investigations.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transluminal therapy of stenosing lesions of the supra-aortic vessels. Personal experience]

Percutaneous transluminal angioplasty (PTA) is commonly used to treat peripheral vascular diseases, but its use has recently spread to the treatment of stenotic lesions involving the supra-aortic vessels. The authors report their initial experience in 10 patients with left subclavian artery stenoses--8 of them treated with PTA and 2 with PTA and vascular stenting--and two more patients with fibromuscular stenosis of the internal carotid artery (ICA), which was treated by means of PTA. In the authors' opinion, PTA can be considered the procedure of choice to treat the stenotic lesions of the supra-aortic vessels. Intravascular stents can be extremely useful to prevent post-PTA restenosis, but further experience and probably further technological refinements are needed. To conclude, PTA of ICA is an effective method in selected cases--e.g., in the patients with symptomatic hemodynamic lesions and low risk of embolism, in the patients with difficult surgical access or in the event of high anesthesiological and/or surgical morbidity.

[Risk of postoperative epilepsy in acute surgery of cerebral aneurysms]

Forty-nine patients operated during an early clipping phase of cerebral aneurysm were reviewed; none had an associated ventricular flooding and/or intraparenchymal hematoma. Starting from the day of operation 37 patients were treated with anticonvulsant drugs using methods and dosages where were unlikely to guarantee efficacious cover. Forty-two patients made a satisfactory recovery, 5 patients died and 2 had severe neurological sequelae; 2 patients (4.4%) had early seizures during the first week after operation. In view of the inadequate cover of the anticonvulsant drugs and the homogeneous clinical characteristics of patients included in the study, the low number of attacks suggests an overall re-evaluation of anticonvulsant treatment and the need to select patients with a higher risk of an epileptic attack.

[Early epilepsy in surgery of extra-axial supratentorial neoplasms]

A retrospective study was performed to evaluate the incidence of seizure and anticonvulsant prophylaxis in 138 patients operated from september 1987 to august 1989 for extra-axial supratentorial tumors. 15 patients (10.9%) developed seizures in the early post-operative period. We have considered the importance of histological type and side of lesions, a previous history of epilepsy and the pre and intraoperative prophylaxis. We can say that there is a statistical significance between sellar and middle cranial fossa tumors and the frequency of post-operative epilepsy and that anticonvulsant prophylaxis can reduce post-operative seizure. There is no statistical significance between the previous history of epilepsy the type of anesthesia and post-operative seizure.

N omega-nitro-L-arginine-methyl ester inhibits electrocortical recovery subsequent to transient global brain ischemia in Mongolian gerbil

Electrocorticographic (ECoG) activity remains isoelectric for about 15 min after transient (10 min) bilateral carotid arteries occlusion in mongolian gerbils. In this model of global forebrain ischemia N omega-Nitro-L-arginine methyl ester (L-NAME), a nitric oxide (NO) synthase inhibitor, significantly delays the recovery of ECoG amplitude. Thus, the present experiments suggest that NO is involved in the cerebrovascular physiological response to brain ischemia.

Spontaneous haematoma as unusual complication of silastic dural substitute. Report of 2 cases

Two cases of an unusual complication of synthetic duraplasty are reported. In both cases, patients had been operated on because of meningiomas and dural defects had been repaired with Silastic. Some years later they developed severe graft-related haematomas and were ultimately successfully treated only by the removal of the synthetic grafts. On the basis of this and other clinical experiences, biological dural grafts seem to be preferable to synthetic ones.

Cerebral metastasis from an epithelioid malignant schwannoma: case report

The authors present a case of brain metastasis from an epithelioid malignant schwannoma. The patient previously had undergone a surgical resection of the primary tumor in the right forearm. The neoplasm was composed of nests of cells with an entirely epithelioid appearance without spindle cell areas. Immunohistochemically, the tumor cells stained positive for S100 protein and negative for cytokeratin, neuron-specific enolase, and anti-melanoma antiserum. To our knowledge, this is the first reported case of cerebral metastasis from an epithelioid malignant tumor of the peripheral nerve sheath.

[Focus. An expert system for the clinical diagnosis of the location of acute neurologic events]

Focus is an expert system developed to diagnose, by the findings on neurological examination, the anatomic location of an acute neurologic event. The inference engine uses a forward tracking algorithm and a rule based data base that includes associations of neurological signs with specific anatomic areas. Focus is linked to a data base in which all personal cases and final diagnoses confirmed by laboratory studies are stored. This makes it possible to assess the validity of the system's diagnoses and use personal cases as additional example to the revision of the rules. The program is easy to use and runs on MS-DOS microcomputer. Furthermore the diagnostic rules are accessible so Focus may furnish an interactive teaching device.

CBF side-to-side asymmetries in stenosis-occlusion of internal carotid artery. Relevance of CT findings and collateral supply

Cerebral blood flow (CBF) was studied at rest by 133-Xenon inhalation method in 15 normal subjects, in 10 patients with cerebral infarction and normal angiograms of major cerebral arteries and in 28 patients with unilateral stenosis-occlusion of the internal carotid artery (ICA), with or without cerebral infarction. All the normals and 20 patients with ICA stenosis-occlusion were tested again after cerebral vasodilatation induced by an intravenous bolus of acetazolamide. At rest the patients with cerebral infarction, irrespective of whether ICa stenosis-occlusion was present or not, showed abnormal side-to-side CBF asymmetry. After cerebral vasodilation variations in side-to-side asymmetry were shown to depend on the inefficiency of the collaterals and not on the degree of ICA obstruction or on the presence of cerebral infarction. These data indicate that at rest side-to-side CBF distribution is influenced more by the presence of an ischemic zone than by a ICA stenosis-occlusion and that under these circumstances the hemodynamic effect of the vascular stenosis cannot be assessed. After cerebral vasodilatation a subset of patients--irrespective of the degree of ICA obstruction and of whether or not cerebral infarction is present--with true cerebrovascular insufficiency can be isolated.

Bilateral carotid occlusion in normotensive rats: olds facts and new observations

This work describes that prolonged mild cerebral ischemia may lead to either general or regional derangement of brain morphofunctional integrity. Normotensive adult Wistar rats were used. Under anesthesia with volatile agents or thiopental, the common carotid arteries were ligated permanently. In one group of animals local cerebral blood flow (1CBF) was measured two hours after carotid occlusion using the [14C]iodoantipyrine method. The other carotid-occluded animals were used for clinical rating and histological evaluation, which was performed two days to 4 weeks after surgical operation. The [14C]iodoantipyrine method showed widespread reduction in the cerebral circulation of carotid-occluded animals. Several hours after carotid occlusion, 40% of the animals showed dramatic neurological signs and died on the day of operation. In 35% of surviving animals, brain infarctions were observed in one and exceptionally two areas of the sensorimotor cortex, thalamus, hippocampus or cerebellum. The evolutionary sequence of the histopathological changes seems to date the induction of the infarcts to the early period of carotid occlusion. In conclusion, reduction of cerebral blood flow causes, in a high percentage of animals, various degrees of acute brain damage after an apparent symptom-free interval.

Increase of dopamine beta-hydroxylase immunoreactivity in non-noradrenergic nerves of rat cerebral arteries following long-term sympathectomy

The expression of dopamine beta-hydroxylase (DBH) and tyrosine hydroxylase (TH) immunoreactivity (IR) after short-term (2 days) and long-term (3 weeks) sympathectomy was investigated in rat cerebral vessels, dura mater and pterygopalatine ganglion neurones (which are known to project to cerebral arteries) by immunohistochemistry at both the light and electron microscopical levels. TH-IR, like glyoxylic acid-induced fluorescence, was completely abolished by sympathectomy. By contrast, DBH-IR was localized in nerve fibres, lacking 5-hydroxydopamine (5-OHDA)-labelled vesicles, along cerebral vessels of long-term sympathectomized rats, but not in the dura mater, and in pterygopalatine ganglia, where the number of DBH-IR neurons increased from 27.87% to 54.11%. Since virtually all the pterygopalatine neurons displayed choline acetyltransferase (ChAT)-IR, both in control and sympathectomized rats, it is concluded that long-term sympathectomy caused an increase of the expression of DBH-IR in cholinergic neurones of the pterygopalatine ganglion, without these neurons producing or storing noradrenaline.

Clinical efficacy and safety of cisapride and clebopride in the management of chronic functional dyspepsia: a double-blind, randomized study

The clinical efficacy and the safety of chronic oral administration of cisapride, a new gastrointestinal prokinetic agent, (10 mg tid) and clebopride (0.5 mg tid) was assayed in 48 outpatients affected with functional dyspepsia, in a randomized double-blind study. Each of the drugs induced a significant reduction in dyspeptic symptoms after 2 and 4 weeks (p less than 0.001). Two patients, given clebopride, dropped out of the study because of severe side effects during the first week of treatment. Mild adverse reactions were reported in 6 out of 23 cisapride-treated patients and in 10 out of 20 clebopride-treated patients who completed the study. The most common side effect of cisapride was diarrhoea and that of clebopride was drowsiness. Cisapride appears to be as effective as clebopride in reducing dyspeptic symptoms and seems to induce less severe side effects.

A simple method for localisation and removal of small subcortical brain tumours

Images

Late malignant recurrence of childhood cerebellar astrocytoma

Juvenile pilocytic astrocytoma of the cerebellum has a benign course and a good prognosis. We report a case of juvenile cerebellar astrocytoma in a 6-year-old girl that underwent surgical resection of the tumor and had two recurrences, 13 and 35 years after first removal. After surgery the patient did not receive any radiation therapy. The last relapse showed histological features of an anaplastic astrocytoma. Six months later the patient died with a diffuse leptomeningeal dissemination. Late malignant transformation of a benign cerebellar astrocytoma is very rare and it is thought to be favored by postsurgical irradiation. The possible pathogenetic mechanisms of this evolution are discussed. This case and the few others reported in the literature emphasize the risk of an unpredictable outcome with the low-grade cerebellar astrocytomas of childhood.

Value of magnetic resonance imaging in spontaneous extradural spinal hematoma due to vascular malformation: case report

A case of spinal cord compression due to spontaneous extradural spinal hematoma is reported. A spinal arteriovenous malformation was suspected on the basis of magnetic resonance imaging. Early surgical exploration allowed a complete neurological recovery. The vascular malformation was histopathologically confirmed. The role of magnetic resonance imaging in the evaluation of acute spinal cord compression syndromes is stressed.

Chronic encapsulated intracerebral haematoma: pathogenetic and diagnostic considerations

Two cases of chronic encapsulated intracerebral haematoma are reported. The patients presented with progressive neurological deficits. Computed tomography scan showed a roundish, intracerebral lesion, that revealed ring blush after contrast infusion, with mass effect. At operation a thick, fibrous, brownish capsule, containing clots in different states of formation, was removed. The hypothesis of capsule formation due to an exuberant proliferation of arachnoidal fibroblasts, is discussed. Differentiation between encapsulated intracerebral haematoma and other chronic intracerebral blood collections is considered mandatory for appropriate treatment.

Intraventricular craniopharyngioma. Clinical and surgical considerations

The authors present two cases of craniopharyngioma wholly located within the cavity of the third ventricle. The rarity of this condition is outlined. In these cases the computed tomography is not always sufficient to determine the correct surgical approach; therefore the Authors stress the importance of the clinical findings.

"Primary" leptomeningeal dissemination of medulloblastoma. Report of an unusual case

The Authors report the case of a 5-year-old boy medulloblastoma presenting with "primary" widespread diffusion in the subarachnoid spaces of the posterior fossa without true mass lesion. The diagnosis, suspected first on the basis of the computed tomography (CT) findings, was confirmed by cytological examination of the cerebrospinal fluid (CSF) and by surgery. The Authors analyse the peculiar clinical features (rapid and severe deterioration of general conditions, hyperacute course of the illness and fatal issue) and the morphological aspects of the tumor (CT and surgical findings). To our knowledge no case of "primary" dissemination of medulloblastoma was previously reported.

Intracerebral hemorrhage and angiographic beading following amphetamine abuse

We report a case of severe and rare complications of amphetamine abuse: intracerebral hemorrhage and spasm-induced changes in the cerebral vessels. The pathogenesis and treatment are discussed in the light of published data.

Surgical treatment of common carotid artery occlusion

Complete occlusion of the common carotid artery (CCA) has been found in 4 to 5% of patients suffering from cerebral ischemia due to atherosclerotic lesions. The classical surgical treatment of the lesion consists of retrograde thromboendar-terectomy or bypass grafting between the subclavian artery and the carotid bifurcation with the aim of restoring flow into the internal carotid artery (ICA) or revascularizing the external carotid artery (ECA) when the ICA is definitively occluded. Recent reconstructive microneurosurgical techniques offer these patients alternative or additional possibilities of cerebral revascularization. During the last 5 years, we have treated nine patients with CCA occlusion, using different techniques mainly according to the site and extent of obstruction and the anatomical conditions of the arteries. In only one patient was the ICA found to be patent: a subclavian-ICA bypass was performed. In four other patients with occlusion of the full length of the CCA (proximal lesion) and ICA occlusion, attempts at retrograde thromboendarterectomy were made and then subclavian-ECA bypass and superficial temporal-middle cerebral artery (STA-MCA) bypass were performed in two steps. In four patients with CCA obstruction limited to the carotid bifurcation area (distal lesion) and with ICA occlusion, the following techniques were used: (a) endarterectomy of the CCA and ECA and STA-MCA bypass in two steps (one case), (b) CCA-ECA bypass and STA-MCA bypass in two steps (one case), and (c) subclavian-MCA bypass (two cases). Four of nine patients were treated by contralateral ICA endarterectomy after repair of the CCA obstruction. Angiography was performed 7 to 10 days after every surgical procedure, and all arteries and grafts, originally opened, were found to be patent. No operative death occurred in the series, but one patient suffered a transient neurological deficit. During the follow-up period (average, 14 months), no ischemic episode occurred. These data suggest that a versatile surgical approach is rational for the treatment of CCA occlusion.