Complications in the treatment of intracranial aneurysms with silk stents: an analysis of 30 consecutive patients

Flow-diverting stents (Silk and PED) have radically changed the approach to intracranial aneurysm treatment from the use of endosaccular materials to use of an extraaneurysmal endoluminal device. However, much debate surrounds the most appropriate indications for the use of FD stents and the problems raised by several possible complications.We analysed our technical difficulties and the early (less than ten days after treatment) and late complications encountered in 30 aneurysms treated comprising 13 giant lesions, 12 large, five with maximum diameters <10 mm and one blister-like aneurysm. In our experience the primary indications for the use of FD stents can be the symptomatic intracavernous giant aneurysms. Although the extracavernous carotid siphon aneurysms have major risk of bleeding, FD stents are indicated clearly explaining the risks to the patient in case of severe mass effect. There is a very complex assessment for aneurysms of the vertebrobasilar circulation.

FMRI activation with an "affective speech" paradigm in vegetative and minimally conscious States: applicability and prognostic value

Vegetative state (VS) and minimally conscious state (MCS) are considered different clinical entities but their differential diagnosis remains challenging. Some VS patients can show an MCS-like activation in functional magnetic resonance imaging (fMRI) studies that seems to predict recovery from VS. We studied fMRI activation with an affective speech paradigm in a cohort of non-communicative brain-injured individuals consecutively admitted to a post-acute neurorehabilitation facility in five years. Among 93 eligible subjects, 65 met the clinical criteria for VS and 28 for MCS. Because of exclusion criteria, activation studies were performed in only 30 cases out of 93 and analysed in only 24 (about ¼ of the eligible cases): 19 VS and five MCS patients. The passive acoustic stimulus consisted in a familiar voice narrating a significant episode in the patient's life, administered by nonmagnetic earphones. All the MCS patients showed an activation spread to secondary associative cortices but also 52.7% of the VS patients displayed an "atypical" large-scale activation pattern. Regarding the clinical outcome, 80% of the patients with large-scale network activation (LSNA) had some recovery of consciousness. Our results confirm that the VS patients with LSNA at fMRI study have potential for further recovery of consciousness, whereas no patient without activation or only typical activation improved. fMRI study with an affective speech paradigm, when applicable, seems to have a valuable prognostic value in VS patients, even if there are major limitations in terms of applicability.

In vitro and in vivo antifungal activity of some essential oils against feline isolates of Microsporum canis

The treatment of dermatophytoses due to Microsporum canis is cumbersome and relapses can occur. Volatile essential oils (EOs) obtained from plants would seem to represent suitable tools to contrast mycoses both in human and animals. The anti-M. canis activity of some EOs chemically characterized was evaluated both in vitro and in vivo. Eleven feline isolates of M. canis were tested by microdilution against EOs extracted from Thymus serpillum, Origanum vulgare, Rosmarinus officinalis, Illicium verum and Citrus limon. A mixture composed by 5% O. vulgare, 5% R. officinalis and 2% T. serpillum, in sweet almond oil was administered to seven infected, symptomatic cats. T. serpillum and O. vulgare showed the lowest MICs, followed by I. verum, R. officinalis and C. limon. The assay performed on mixture showed that antimycotic activity of each component was enhanced. Four out of seven treated cats recovered both clinically and culturally. T. serpillum and O. vulgare EOs showed a strong antifungal activity. Preliminary data suggest a possible application in managing feline microsporiasis. Considering the potential zoonotic impact of this infection, the use of alternative antimycotic compounds would be of aid to limit the risk of environmental spreading of arthrospores.

A minimally invasive treatment for lumbar disc herniation: DiscoGel® chemonucleolysis in patients unresponsive to chemonucleolysis with oxygen-ozone

A multitude of therapies is available to treat disc herniation, ranging from conservative methods (medication and physical therapy) to minimally invasive (percutaneous) treatments and surgery. O₂-O₃ chemonucleolysis (O₂-O₃ therapy) is one of the minimally invasive treatments with the best cost/benefit ratio and lowest complication rate. Another substance recently made available exploiting the chemical properties of pure ethanol is DiscoGel®, a radiopaque gelified ethanol more viscous than absolute alcohol 8,9. The present study aimed to assess the therapeutic outcome of DiscoGel® chemonucleolysis in patients with lumbar disc herniation unresponsive to O₂-O₃ therapy. Thirty-two patients aged between 20 and 79 years were treated by DiscoGel® chemonucleolysis between December 2008 and January 2010. The treatment was successful (improvement in pain) in 24 out of 32 patients. DiscoGel® is safe and easy to handle and there were no complications related to product diffusivity outside the treatment site. The therapeutic success rate of DiscoGel® chemonucleolysis in patients unresponsive to O₂-O₃ therapy was satisfactory. Among other methods used to treat lumbar disc herniation, DiscoGel® chemonucleolysis can be deemed an intermediate procedure bridging conservative medical treatments and surgery.

Children in vegetative state and minimally conscious state: patients' condition and caregivers' burden

Caring for children in vegetative state (VS) or minimally conscious state (MCS) challenges parents and impacts on their well-being. This study aims to evaluate caregivers' health condition, coping, anxiety and depression levels, and how these issues relate to children's disability. 35 children with VS and MCS were administered the disability rating scale (DRS) and 35 caregivers completed the Coping Orientations to Problem Experiences, Short Form-12, Beck Depression Inventory, and the Spielberger State-Trait Anxiety Inventory-Y. Children were mainly males (68.6%), hosted at domicile (77.1%), and diagnosed with VS (60%), with anoxic aetiology (45.7%). Caregivers were mainly mothers (85.7%), married (82.9%), and housewives (51.4%); 60% declared financial difficulties, and 82.9% provided full-time assistance. 57.2% reported depressive symptoms, poor mental health, and high level of state and trait anxiety. “Problem-oriented” (P < 0.001) and “emotional-oriented” (P < 0.001), were more adopted than “potentially dysfunctional” ones. DRS scores (mean = 22.0; SD = 1.9) did not significantly correlate to any psychological measure. Rehabilitative programs for children with SV and SMC should also provide interventions on surrounding systems: improving the network of psychological support and social assistance may decrease the burden of caregivers and, in turn, improve caring abilities and children quality of life.

Awareness of, usage of and willingness to use HIV pre-exposure prophylaxis among men in downtown Toronto, Canada

Pre-exposure prophylaxis (PrEP) is a promising strategy whereby HIV-uninfected people could take antiretroviral (ARV) medications to reduce their risk of HIV acquisition. Reports suggest that unsupervised PrEP use has been occurring in gay communities of USA cities before human safety and efficacy data became available. We administered a 20-item questionnaire to men undergoing HIV testing at Hassle Free Clinic, a sexual health clinic in the gay village of Toronto. Questionnaire items enquired about demographics, sexual partners, substance use and awareness of, usage of and willingness to use PrEP. Logistic regression was used to identify characteristics associated with PrEP-related outcomes. Of 256 participants, 11.7% were aware of PrEP, with more men who have sex with men (MSM) aware (14.1%) than non-MSM (4.9%). No participants reported PrEP usage. Willingness to consider PrEP use was high and associated with high-risk activities, suggesting opportunities for PrEP use in the future.

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).

Treatment of intracranial aneurysms using flow-diverting silk stents (BALT): a single centre experience

The Silk stent (Balt, Montmorency, France) is a retractable device designed to achieve curative reconstruction of the parent artery associated with an intracranial aneurysm. We present our initial experience with the Silk flow-diverting stent in the management and follow-up of 25 patients presenting with intracranial aneurysms.Twenty-five patients (age range, 34-81 years; 24 female) were treated with the Silk flow-diverting device. Aneurysms ranged in size from small (5), large (10) and giant (10) and included wide-necked aneurysms, multiple, nonsaccular, and recurrent intracranial aneurysms. Nine aneurysms were treated for headache, 14 for mass effect. None presented with haemorrhage. All patients were pretreated with dual antiplatelet medications for at least 72 hours before surgery and continued taking both agents for at least three months after treatment. A total of 25 Silk stents were used. Control MR angiography and/or CT angiography was typically performed prior to discharge and at one, three, six and 12 months post treatment. A follow-up digital subtraction angiogram was performed between six and 19 months post treatment.Complete angiographic occlusion or subtotal occlusion was achieved in 15 patients in a time frame from three days to 12 months. Three deaths and one major complication were encountered during the study period. Two patients, all with cavernous giant aneurysms, experienced transient exacerbations of preexisting cranial neuropathies and headache after the Silk treatment. Both were treated with corticosteroids, and symptoms resolved completely within a month.In our experience the Silk stent has proven to be a valuable tool in the endovascular treatment of intracranial giant partially thrombosed aneurysms and aneurysms of the internal carotid artery cavernous segment presenting with mass effect. The time of complete occlusion of the aneurysms and the risk of the bleeding is currently not predictable.

Metabolic abnormalities in pain-processing regions of patients with fibromyalgia: a 3T MR spectroscopy study

BACKGROUND AND PURPOSE

A growing body of evidence suggests the involvement of the brain in FM. The purpose of this proton MRS study was to test the hypothesis that there are metabolic alterations in some brain regions processing pain (VLPFC and thalamus) in patients with FM compared with HC.

MATERIALS AND METHODS

Twelve patients with FM (30-54 years of age; mean age, 43.2 years), and 12 HC, matched for age and sex, underwent 1 session of single-voxel MRS performed on a 3T MR imaging scanner. MRS spectra were acquired with a PRESS for localization. The raw data from each spectrum was evaluated with an LCModel. T tests were used to evaluate differences of brain metabolites between groups. The Pearson correlation tested the relationship of metabolite ratios and clinical symptoms.

RESULTS

Glx/Cr and Glu/Cr ratios within the VLPFC of both sides were significantly higher in patients than in HC (P < .01). No significant differences of metabolites between groups were found in the thalami. Positive correlations were found between Glu/Cr in the left thalamus and the VAS for pain (r = 0.730, P = .007) and between mIns/Cr in the right VLPFC and the VAS for pain (r = 0.607, P = .037) and the FIQ (r = 0.719, P = .008).

CONCLUSIONS

The presence of elevated Glu/Cr levels in VLPFC strengthens the opinion that a complex neurophysiologic imbalance of different brain areas involved in pain processing underlies FM. These data may be useful in the diagnosis and development of more effective pharmacologic treatments.

Assessment of the ecological status of transitional waters in Sicily (Italy): first characterisation and classification according to a multiparametric approach

A 1-year cycle of observations was performed in four Sicilian transitional water systems (Oliveri-Tindari, Cape Peloro, Vendicari and Marsala) to characterise their ecological status. A panel of variables among which trophic and microbial (enzyme activities, abundance of hetetrophic bacteria and of bacterial pollution indicators) parameters, were selected. Particulate organic carbon (POC) and nitrogen (PON) and chlorophyll-a (Chl-a) contents defined the trophic state, while microbial hydrolysis rates and abundance gave insights on microbial community efficiency in organic matter transformation and on allochthonous inputs. To classify the trophic state of examined waters, the synthetic trophic state index (TRIX) was calculated. Microbial hydrolysis rates correlated positively with POC and Chl-a, which increased along the eutrophication gradient. The significant relationships among TRIX, trophic and microbial parameters suggested the use of leucine aminopeptidase, alkaline phosphatase and POC as suitable parameters to implement the Water Framework Directive when assessing the ecological status of transitional water systems.

The use of flow-diverting stents in the treatment of giant cerebral aneurysms: preliminary results

The treatment of giant cerebral aneurysms has always been a challenge for neurosurgeons and neuroradiologists. Flow-diverting stents (Silk; Pipeline Embolization Device) are new endovascular devices introduced for the treatment of intracranial aneurysms without release of intrasaccular coils. They are tubular bimetallic endoluminal devices with low porosity. We have employed these stents in the Neuroradiology Unit of Bellaria Hospital (Bologna, Italy) since the end of 2008, treating nine patients with giant carotid cerebral aneurysms using nine Silk stents as soon as the device obtained the CE mark. All patients were pretreated with dual antiplatelet medications before surgery. The Silk stents were deployed through a 4F Balt introducer, which ensured an uneventful and very quick procedure. Control CT angiography or MR angiography was typically performed at discharge and one, three, six and 12 months after treatment. Post-treatment results were: four complete occlusions, three near complete occlusions (residual neck flow) with reduced volume of the aneurysm and two more than 50% reduction of intra-aneurysmal flow. A fatal hemorrhagic complication occurred in one patient, probably due to the antiplatelet treatment. The Silk stent seems a very interesting curative device to treat giant aneurysms with preservation of the parent artery and small adjacent branches. Technical improvements will certainly reduce the thrombogenic effect with the related risks.

A Little Talk on Adamkiewicz's Artery. Some Practical Considerations on the Pre-Operative Identification of this Artery Starting from a Single Team Experience in Pre-Surgical Selective Embolization of Vascularized Spinal Lesions

The major radicular artery eponymically named "Adamkiewicz's artery" (AKA) is an important vessel supplying the spinal cord, especially the lumbar enlargement. This report emphasizes the importance of anatomical knowledge of this artery and highlights the concept of the potential risk of neurological complications during different procedures: spine orthopedic/neurosurgery, aortic repair (vascular surgery) and endovascular selective embolizations performed by interventional neuro/radiologists. Anatomical considerations are made on the spinal cord arterial circulation with a special focus on the AKA. Our review of the literature considered this anatomical element essential to compare the potential risk of spinal cord ischemic damage during orthopedic/neurosurgical spine procedures, aortic vascular surgery repair procedures and endovascular selective arterial embolizations. Evaluation of the endovascular selective arterial spine embolization risk was based on our series of 410 embolization procedures. Spinal cord infarction and transient or permanent paraplegia may result from inadvertent interruption of the AKA. The presence of intersegmental collaterals may decrease the risk of spinal cord ischemia: this is an important element to bear in mind that may help in spine surgery or aortic repair procedures performed by vascular surgeons. Nevertheless, during aortic repair (open surgery or stent-graft procedures) interruption of bilateral segmental arteries at multiple consecutive levels including that of the AKA may occur thereby increasing the ischemic spinal cord risk, annulling the benefit of intersegmental collaterals. Accidental embolizations of the AKA during endovascular spine procedures (i.e. selective arterial embolizations) performed by interventional neuro/radiologists will cause an almost certain spinal cord infarction due to the consequent embolizations of the anterior spinal artery (ASA).

Role of contrast-enhanced magnetic resonance angiography in spinal dural arteriovenous fistula

Spinal dural arteriovenous fistulae (SDAVF) are the most common vascular malformations of the spine. Although digital subtraction angiography (DSA) remains the standard of reference to diagnose and classify vascular spinal lesions, we investigated the clinical value of contrast-enhanced MR angiography (CE-MRA), equipped with TRICKS sequences, in localizing SDAVF before selective catheter angiography and possible subsequent treatment. We studied 16 consecutive patients suspected of harbouring vascular spinal cord malformations and we tried to determine the level and the side of the arterial feeder to the arteriovenous abnormality. In 12 cases the results were compared with DSA and/or possible post-operative findings. In nine cases CE-MRA correctly depicted the origin of the fistula: in particular one patient was treated surgically only on the basis of MRA results. Thanks to its elevated spatial and temporal resolution, spinal contrast-enhanced MRA using TRICKS sequences proved reliable in detecting and localizing the SDAVF arterial feeders and can be used as a guide to subsequent selective DSA examination.

[Earthquake in Abruzzo, public health interventions. Preliminary report]

On 6th April 2009, at 3.32 AM, there was in L'Aquila and in some neighbouring villages, after an earthquake swarm last some months, an earthquake of M(L) = 5.8 (Richter magnitude scale) on depth of 8.8 km. The event was sensed in a very broad area, till in Rome and Ancon. The operative committee of the Civil Protection Department immediately gathered and a first operating group was despatched in the epicentre; the voluntary association of civil protection were in a pre-alarm situation and then were activated. This work want describe all the activities from 6th April 2009 till 31th August 2009, giving too a synthesis of the normative lines in case of catastrophic events typology C, otherwise all that events impossible to manage without national intervention.

Quantitative cervical spinal cord 3T proton MR spectroscopy in multiple sclerosis

BACKGROUND AND PURPOSE

Brain proton MR spectroscopy ((1)H-MR spectroscopy) is a useful technique for evaluating neuronal/axonal damage and demyelization in multiple sclerosis (MS). Because MS disability is frequently related to spinal cord lesions, potential markers for MS stage differentiation and severity would require in vivo quantification of spinal integrity. However, few spectroscopy studies have investigated cervical disease due to technical difficulties. The present study used 3T (1)H-MR spectroscopy to measure the main metabolites in cervical spinal cord plaques of a group in patients with relapsing-remitting MS (RRMS) and compared them with metabolite measurements in healthy volunteers.

MATERIALS AND METHODS

A (1)H-MR point-resolved spectroscopy sequence volume of interest was prescribed along the main axis of the cord between C2 and C3 levels on a plaque in a group of 15 patients with RRMS for a total acquisition time of approximately 14 minutes. MR spectroscopy data were analyzed by the user-independent fitting routine LCModel, and relative metabolite concentrations were expressed by the absolute concentration ratios. A Student t test was used to evaluate the difference compared with the healthy metabolite content previously published.

RESULTS

We found a significant decrease of total N-acetylaspartate/choline and an increase in choline/creatine and myo-inositol/creatine content on MS plaques in comparison with healthy cervical spine tissue.

CONCLUSIONS

In vivo (1)H-MR spectroscopy, if confirmed by other similar studies, should be as reliable for clinical studies as it is in brain imaging. Moreover, (1)H-MR spectroscopy allows examination of spinal cord integrity at a biochemical level and may be sensitive to subtle changes occurring during the course of MS disease.

3T MRI in the Evaluation of Brain Aneurysms Treated with Flow-Diverting Stents: Preliminary Experience

Deployment of stents across the neck of intracranial aneurysms to isolate the lesion from the circulation is a recently introduced endovascular treatment. These devices are known as flow-diverting stents because the stent mesh design drastically slows the blood flow within the aneurysm sac, thereby stimulating thrombus formation. Treated aneurysms require close follow-up monitoring using an effective minimally invasive method. We devised a dedicated follow-up protocol using a high field strength magnetic resonance system (MR) with gadolinium administration to monitor 11 patients treated by insertion of flow-diverting stents. Findings were compared with the results of a reference imaging procedure (CT angiography). MR accurately demonstrated patency of the stent lumen and monitored the evolution of the aneurysmal sac in all patients. Gadolinium administration proved essential in two patients to depict the complete exclusion of the flow within the aneurysmal sac.

Potential of high field functional MRI in the neuroradiological diagnosis of brain tumours

Functional 3 tesla magnetic resonance imaging (MRI) techniques such as diffusion and perfusion imaging and MR spectroscopy (MRS) allow a more accurate diagnosis of central nervous system tumours. This retrospective study analysed the MRI scans of 121 consecutive patients with a diagnosis of glial brain tumours who underwent surgery and/or biopsy and whose histological reports were available. Our aim was to establish if and how functional MRI techniques had enhanced the diagnostic accuracy with respect to morphological examination. To quantify the diagnostic contribution of these techniques and their predictive value, a questionnaire was compiled by an observer blinded to the neuroradiological diagnosis and to the histological results after surgery/biopsy. Patients were divided into two groups based on the time of 3T MRI examination performed: before or after surgery/biopsy. In the group of non-operated patients low grade gliomas could be distinguished from high grade malignant tumours, whereas in the group of operated patients signs of tumour persistence or recurrence could be distinguished from the effects of previous treatments. Functional MRI techniques improved the accuracy of diagnosis with respect to morphological examination alone in both groups of patients: areas of increased cellularity, neoangiogenesis or metabolic changes were identified confirming diagnosis, whereas methodological errors were disclosed in cases of incorrect diagnosis.