N-terminal pro B-Type natriuretic peptide is inversely correlated with low density lipoprotein cholesterol in the very elderly

BACKGROUND AND AIMS

Laboratory studies on human adipose tissue and differentiated adipocytes indicate that natriuretic peptides (NPs) affect lipid metabolism and plasma cholesterol. Few previous clinical studies in non-elderly populations found associations between NPs in the physiological range and cholesterol.

AIM

evaluate the association between NT-proBNP and lipid profile in very elderly hospitalized patients characterized by a wide range of NT-proBNP levels.

METHODS AND RESULTS

Cross-sectional study on 288 very elderly patients hospitalized for medical conditions, in which increased NT-proBNP levels are very common. NT-proBNP, total cholesterol (TC), HDL cholesterol (HDLc) and triglycerides were collected just few days before discharge. Patients taking lipid-lowering drugs and patients with an admission diagnosis of acute heart failure were excluded. Calculated LDL-cholesterol (LDLc) was used for the analyses. Mean age: 87.7 ± 6.2 years; female prevalence (57.3%). Median NT-proBNP: 2949 (1005-7335) pg/ml; mean TC: 145.1 ± 40.3 mg/dl; mean HDLc: 38.4 ± 18.6 mg/dl; median triglycerides: 100 (75-129) mg/dl; mean LDLc: 84.0 ± 29.5 mg/dl. We found negative correlations between NT-proBNP and both TC and LDLc (Rho = -0.157; p = 0.008 and Rho = -0.166; p = 0.005, respectively), while no correlations emerged between NT-proBNP and HDLc (Rho = -0.065; p = 0.275) or triglycerides (Rho = -0.009; p = 0.874). These associations were confirmed considering NT-proBNP tertiles. The inverse association between NT-proBNP and LDLc was maintained even after adjusting for confounding factors.

CONCLUSION

Our real-life clinical study supports the hypothesis that NPs play a role on cholesterol metabolism, given the association found between LDLc and NT-proBNP even in very elderly patients where NT-proBNP values are often in the pathological range.

Cefaloceli

I cefaloceli sono difetti congeniti o acquisiti del cranio e della dura attraverso i quail possono erniare diverse strutture intracraniche. Un semplice difetto osseo della teca cranica in sede mediana o paramediana non attraversato da un prolasso delle strutture intracraniche prende il nome di cranio bifido occulto. I cefaloceli congeniti possono essere suddivisi in quattro gruppi a seconda del contenuto del tessuto erniato attraverso il difetto osseo:

– Meningoceli, le strutture erniate consistono in meningi e liquor. – Meningoencefaloceli, oltre a meningi e liquor ernia pure parte dell'encefalo. Se l'encefalo erniato comprende anche parte del sistema ventricolare il cefalocele prende il nome di idroencefalomeningocele. – Glioceli, il tessuto erniato è formato da una raccolta di liquor delimitata da tessuto neurogliale. – Cefaloceli atresici, forme fruste di cefaloceli localizzate in sede parietale o occipitale.

I disrafismi cranici congeniti sono piu rari dei disrafismi spinali: l'incidenza dei cefaloceli varia da 0.3 a 4 per 10.000 nati. La sede più frequente dei cefaloceli è la regione occipitale anche se nelle popolazioni orientali predomina le sede fronto-etmoidale. Vi è una prevalenza femminile per le localizzazioni occipitali e maschile per quelle parietali e sincipitali.

A seconda della loro sede i cefaloceli sono classificati in quattro gruppi: occipitali, della volta cranica, fronto-etmoidali (sincipitali) e del basicranio.

Da un punto di vista diagnostico: l'ecografia è di fondamentale importanza per la diagnosi prenatale delle anomalie più grossolane; lo studio del difetto osseo va condotto sia con i radiogrammi convenzionali che con studi di Tomografia Computerizzata (TC) con successive ricostruzioni tridimensionali; mentre la valutazione della componente erniata parenchimale e vascolare deve essere effettuata mediante la Risonanza Magnetica (RM) e la angiografia RM.

Systemic granulomatosis after surgical injection of silicone oil for retinal detachment in a child affected by Fisher-Evans syndrome

Silicone oil is used for complicated retinal detachment, but it can be associated with relevant side effects. We report a 6-year-old South American female admitted to our hospital with steroid-resistant Fisher-Evans syndrome. She also had developed a retinal detachment, managed with intravitreal oil injection. During treatment for Fisher-Evans syndrome, she progressively developed recurrent and refractory bronchospasm, peaks of hypereosinophilia and orbital soft-tissue swelling. Despite the persistent negativity of all microbiologic tests, she was treated empirically with antibiotics. Failure of the treatment led to the execution of a biopsy of the periocular tissue that revealed an intense polymorphous infiltrate constituted by numerous monoclonal population (FR2 monoclonality) of plasma-cells. A diagnosis of lymphoma with plasmacytoid differentiation was suspected and cytotoxic treatment was started without response. For the appearance of swelling in left parotid and laterocervical region, an excisional biopsy was performed and a diagnosis of granulomatous reaction to ocular implant of silicone oil was made. In consideration of the clinical evolution, enucleation was considered, but parents did not consent to the procedure until the child developed cerebral lesions suspected to be silicone localizations. After enucleation, eosinophilic count normalized and the child no longer presented any new episode of fever or swelling.

CONCLUSIONS

In this patient a granulomatous reaction is present at distance from the site of oil injection. This case suggests caution in using this substance even in ocular diseases, especially in immunocompromised patients.

MRI Findings in Patients with Clinical Onset Consistent with Infantile Neuroaxonal Dystrophy (INAD), Literature Review, Clinical and MRI Follow-up

Infantile neuroaxonal dystrophy (INAD) is a rare autosomal recessive neurodegenerative disorder characterized by infantile onset and rapid progression of psychomotor regression and hypotonia evolving into spasticity. The neuroradiologic hallmark of the disease is represented by progressive cerebellar atrophy. Prior to the discovery of mutations in the PLA2G6 gene in family with INAD, the clinical diagnosis of the disease had been confirmed by the presence of spheroid bodies (SB) in a peripheral nerve biopsy. Various studies have found that some patients with mutations lacked SB and some without mutations had SB, indicating incomplete detection using either pathologic or molecular methods 7. This, together with the observation that the spectrum of clinical features associated with mutations in PLA2G6 is broader than previously described, has increased the usefulness of Magnetic Resonance (MR) in INAD diagnosis, particularly in the frequent occurrence of atypical cases, especially in the early stages of the disease. We retrospectively reviewed the MR studies of eight patients in whom clinical and imaging onset met the typical criteria for INAD. Their clinical and MR imaging (MRI) onset and follow-up were evaluated together with the neuroradiological findings reported in the literature in order to identify MRI features useful in differentiating INAD from other diseases with similar clinical onset and to discuss which of them are the most important, thus suggesting INAD diagnosis. Our contribution included the use of Proton Spectroscopy (1H-MR), diffusion weighted MR imaging (DWI) and diffusion tensor imaging (DTI) in the follow-up of seven of the eight patients. The literature reviewed included attempts to correlate clinical and MR data with the genotype in the group of patients carrying PLA2G6 mutations. From the limited and inhomogeneous cohort of patients included in our study, a correlation between the MR features, phenotype and genotype was not exhaustive.

Integrin alpha2beta1 induces phosphorylation-dependent and phosphorylation-independent activation of phospholipase Cgamma2 in platelets: role of Src kinase and Rac GTPase

BACKGROUND

Platelet adhesion promoted by integrin alpha2beta1 induces integrin alpha(IIb)beta3 activation through the phospholipase C (PLC)-dependent stimulation of the small GTPase Rap1b.

OBJECTIVE

To analyze the mechanism of PLC activation downstream of alpha2beta1 that is required for regulation of Rap1b and alpha(IIb)beta3.

METHODS

Human and murine platelets were allowed to adhere to immobilized type I monomeric collagen through alpha2beta1. Tyrosine phosphorylation of PLCgamma2, PLC activation, accumulation of GTP-bound Rap1b and fibrinogen binding were measured and compared.

RESULTS

Integrin alpha2beta1 recruitment induced an evident PLC activation that was concomitant with robust tyrosine phosphorylation of PLCgamma2, and was suppressed in platelets from PLCgamma2-knockout mice. Moreover, PLCgamma2(-/-) platelets were unable to accumulate active Rap1b and to activate alpha(IIb)beta3 upon adhesion through alpha2beta1. Inhibition of Src kinases completely prevented tyrosine phosphorylation of PLCgamma2 in adherent platelets, but did not affect its activation, and both Rap1b and alpha(IIb)beta3 stimulation occurred normally. Importantly, alpha(IIb)beta3-induced phosphorylation and activation of PLCgamma2, as well as accumulation of active Rap1b, were totally suppressed by Src inhibition. Integrin alpha2beta1 recruitment triggered the Src kinase-independent activation of the small GTPase Rac1, and activation of Rac1 was not required for PLCgamma2 phosphorylation. However, when phosphorylation of PLCgamma2 was blocked by the Src kinase inhibitor PP2, prevention of Rac1 activation significantly reduced PLCgamma2 activation, GTP-Rap1b accumulation, and alpha(IIb)beta3 stimulation.

CONCLUSIONS

Src kinases and the Rac GTPases mediate independent pathways for PLCgamma2 activation downstream of alpha2beta1.

Accurate neurosonographic prediction of brain injury in the surviving fetus after the death of a monochorionic cotwin

OBJECTIVE

To assess the feasibility of the prenatal diagnosis using fetal neurosonography of brain injuries in the surviving fetus after the demise of a monochorionic cotwin.

METHODS

This was a retrospective observational study in the period 1990-2004 of monochorionic twin pregnancies with a single fetal demise. A detailed sonographic evaluation of the intracranial anatomy of the surviving twin had been performed whenever possible using a multiplanar approach and from 1999, fetal magnetic resonance imaging was offered as well. Postnatal follow-up was obtained in all cases.

RESULTS

In six of nine cases, abnormal neurosonographic findings were identified including intracranial hemorrhage, brain atrophy, porencephaly and periventricular echogenicities evolving into polymicrogyria. Prenatal diagnosis of brain lesions was confirmed postnatally and all affected infants who survived had severe neurological sequelae. Two fetuses had normal cerebral structures both on the prenatal neurosonogram and on postnatal imaging and were following normal developmental milestones, one at 1 and the other at 5 years of age. In one case the neurosonographic examination was suboptimal and the infant was found at birth to have a porencephalic cyst. Fetal magnetic resonance imaging was performed in two cases and confirmed the ultrasound diagnosis.

CONCLUSIONS

Prenatal neurosonography is a valuable tool for the prediction of neurological outcome in fetuses surviving after the intrauterine death of a monochorionic cotwin. Although our experience is limited, we suggest that magnetic resonance imaging should also be offered.

Clinical features and long term outcome of epilepsy in periventricular nodular heterotopia. Simple compared with plus forms

OBJECTIVES

Little is known about the long term outcome of patients with periventricular nodular heterotopia (PNH) and epilepsy, particularly the course of seizures. This study investigated the electroclinical and prognostic features of 16 patients with PNH.

METHODS

Of 120 patients with epilepsy and malformations of cortical development, 16 had PNH. Of these, eight patients had periventricular nodules only (simple PNH) and eight also presented with other cortical or cerebral malformations (subcortical heterotopia; polymicrogyria; focal dysplasia; schizencephaly; cortical infolding; agenesis of the corpus callosum; mega cisterna magna and cerebellar atrophy) (PNH plus). All patients underwent clinical, neurophysiological, and MRI investigation. The mean follow up was 17.3 years (2-40 years).

RESULTS

Two electroclinical patterns emerged: (1) The first pattern, associated with simple PNH, was characterised by normal intelligence and seizures, usually partial, which began during the second decade of life. The seizures never became frequent and tended to disappear or become very rare. The EEG showed focal abnormalities. (2) The second pattern, associated with PNH plus, was characterised by mental retardation and seizures that began during the first decade of life. The seizures were very frequent in most cases and sudden drops were observed in six patients. Seizures were medically refractory in four patients. The EEG showed focal and bisynchronous abnormalities.

CONCLUSIONS

Two groups of PNH patients with different electroclinical and neuroradiological features can be identified after a long term follow up. The presence of other types of cortical or cerebral malformations, in addition to periventricular nodules, determines a poor prognosis.

Outcome of antenatally diagnosed intracranial hemorrhage: case series and review of the literature

OBJECTIVES

Prenatal diagnosis of intracranial hemorrhage (ICH) has been widely reported. Hemorrhages may occur either within the cerebral ventricles, subdural space or infratentorial fossa. The aim of this study was to determine the sonographic criteria for the diagnosis of fetal ICH, the role of in utero magnetic resonance imaging (MRI) and the outcome of this condition.

METHODS

The archives of our ultrasound laboratory and the literature were searched for all cases of antenatally diagnosed ICH. A grading system was used to classify the intraventricular lesions as suggested in postnatal sonographic studies.

RESULTS

Adding our series of 16 fetuses to the 93 cases identified in the literature, a group of 109 fetal ICHs was obtained: 89 were intracerebral (79 intraventricular and 10 infratentorial) and 20 were subdural hemorrhages. Intraventricular lesions were mostly classified as severe (32 each for Grades III and IV). In 27 cases antenatal MRI was performed additionally to ultrasound and confirmed the sonographic findings. Of the entire group, 65 infants (59%) were reported to be alive 1 month after birth (51 intraventricular hemorrhages, three infratentorial hemorrhages, 11 subdural hematomas). At 12 months, of the 48 infants whose follow-up was available, 25 or 52% were judged neurologically normal (17/36 or 47% among the intraventricular hemorrhages, 6/9 or 66% among the hematomas, and 2/3 or 66% among the infratentorial hemorrhages).

CONCLUSIONS

Fetal ICH may be accurately identified and categorized by antenatal sonography. The outcome is usually poor, especially for those fetuses affected by higher-grade intraventricular hemorrhages.

Localized unresectable neuroblastoma: results of treatment based on clinical prognostic factors

BACKGROUND

We previously reported that stage 3 neuroblastoma comprises (i) a low-risk group including all infants (age 0-11 months) as well as older children with non-abdominal primaries, and (ii) a high-risk group made up of children >1 year of age with abdominal primaries. Aggressive chemotherapy was effective only in the latter group.

PATIENTS AND TREATMENT

On this basis, in 1990 we designed a new protocol by which all low-risk patients received standard-dose chemotherapy, while the high-risk ones received very aggressive chemotherapy.

RESULTS

Between November 1990 and December 1997 a total of 95 eligible and evaluable children were enrolled: 47 were low-risk (35 infants and 12>1 year of age at diagnosis and having non-abdominal primaries), and 48 were high-risk (being >1 year of age and having abdominal primaries). Of the 47 low-risk patients, five relapsed and four subsequently died. The 5-year overall survival (OS) was 91%. Of the 48 patients in the high-risk group, 22 relapsed or progressed, 18 of whom died from their disease and two from toxicity, and one was lost to follow-up. The 5-year OS was 60%. Univariate analysis showed that age, site of primary, risk-group, urine vanillylmandelic excretion, plasma levels of lactate dehydrogenase, ferritin and neurone-specific enolase, and MYCN status correlated with outcome. However, multivariate analysis showed that only MYCN status retained prognostic value.

CONCLUSIONS

In low-risk stage 3 neuroblastoma, standard-dose chemotherapy is associated with an excellent chance of being cured. Aggressive chemotherapy is effective for high-risk patients, but results are still unsatisfactory. MYCN gene amplification is a prognostic indicator for most, but not all, treatment failures.

Occipital aneurysmal bone cyst secondary to eosinophilic granuloma

We describe the case of a 2-year-old male patient with an aneurysmal bone cyst (ABC) of the occiput secondary to unifocal eosinophilic granuloma (EG). The lesion presented as a painless mass of the scalp which had grown rapidly over the 2 weeks prior to admission. Radiologically, the lesion was osteolytic and multicystic with fluid-fluid levels. On histology, the cyst wall contained hemosiderin-laden histiocytes, spindle cells, multinucleated giant cells, Langerhans' cells and eosinophils. Surgical treatment consisted of en bloc resection. Fourteen months after surgery, the patient was well with no local recurrence. Association between EG and ABC is rare. To our knowledge, this is the first case involving the skull.

Gaze-evoked amaurosis heralding orbital angiomyoma. Case report

The unusual case of a patient presenting with gaze-evoked amaurosis as an early and isolated sign of orbital angiomyoma is reported. Computed tomography or magnetic resonance of the orbits need to be expeditiously performed in patients with gaze-evoked amaurosis in order to identify or rule out the possible presence of an underlying tumor.

Band brain heterotopia. Case report and literature review

The authors describe the case of an 11-year-old boy with a neuroradiologic pattern of band gray matter heterotopia, clinically characterized by epileptic seizures as well as normal psychomotor development. The clinical history and neurophysiological and neuroradiological investigations are reported. The diagnosis is based on brain magnetic resonance (MR) imaging, which has proved to be the most specific and sensitive test to describe neuronal migration disorders. Possible treatments are discussed.

MRI and CT in Krabbe's disease: case report

A case of infantile Krabbe's disease was first recognised as areas of relatively increased density on CT in the thalamus lateral geniculate body and dentate nucleus. These sites were subsequently shown on MRI to have a paramagnetic effect, being characterised by short T2 and T1. Subsequent examinations showed development of atrophy and high signal in white matter.

Magnetic resonance tomographic angiography in the investigation of hemifacial spasm

Magnetic resonance angiography (MRA), combined with submillimeter magnetic resonance tomographic angiographic sections (MRTA) showed vascular compression of the 7th cranial nerve or its root exit zone (REZ) in the brain stem in 24 of 37 patients (64.86%) with hemifacial spasm. MRA alone was positive for REZ compression in only 19 (51.4%) cases, while conventional MRI was even less revealing, only 10 (27%) cases being positive.

Neuroradiologic evaluation of pediatric craniocerebral trauma

Although cranial computed tomography (CT) remains the initial diagnostic test in the evaluation and triage of the pediatric head-injury patient, magnetic resonance imagining (MRI) has become the next step in the diagnostic evaluation of those with focal or diffuse neurologic deficits. MRI is better able to demonstrate the extent and location of both hemorrhagic and nonhemorrhagic injury, thereby providing prognostic information. In nonaccidental head injury, MRI has proved valuable in detecting subtle subacute contusions and even not so subtle chronic subdural hematomas that may be difficult to see on CT or that can mimic enlargement of the subarachnoid space on CT.

Hemifacial spasm: evaluation by magnetic resonance imaging and magnetic resonance tomographic angiography

We evaluated 37 patients with hemifacial spasm and 16 age-matched control patients with other neurological disorders using magnetic resonance (MR) imaging, MR angiography, and MR tomographic angiography. MR tomographic angiography is a new technique using computer reconstruction of MR angiographic images to create coronal angiotomes that display tissue and arterial structures on the same image. Twenty-four of 37 (64.9%) patients with hemifacial spasm had ipsilateral vascular compression of cranial nerve VII or the pons noted by this technique, whereas only 1 of 16 (6.3%) control patients had compression. MR imaging and MR angiography were less sensitive and less specific in evaluating for vascular compression. This study supports vascular compression of cranial nerve VII or the pons as a cause of hemifacial spasm, and demonstrates MR tomographic angiography's value as an excellent, noninvasive technique to demonstrate the compression.

Spinal cord compression by extramedullary hematopoietic tissue in a thalassemic patient: prompt effect of radiotherapy

As described in the literature, spinal cord compression by extramedullary hematopoietic tissue rarely occurs in thalassemic patients. Laminectomy and/or radiotherapy are the main approaches. We report on a patient with thalassemia intermedia who developed paralysis of both lower extremities due to the compression of the spinal cord by extramedullary hematopoietic tissue.

Arteriovenous malformations of the spinal cord in the pediatric age group. Case report and review of the literature

Arteriovenous malformations (AVMs) of the spinal cord are a rare occurrence in the pediatric age group. This report describes the successful, complete removal of such a lesion in a boy age 12. The clinico-radiological findings and different treatment modalities of these entities are reviewed.

Further experiences on experimental cerebral "no-reflow phenomenon"

The authors evaluate the effectiveness of combination groups of antiedema pharmacological agents on experimental transient bilateral cerebral ischemia. The results show that dexamethasone and furosemide appear to be the most useful combination group. However, the improvement of post-ischemic vascular re-perfusion is not different when these antiedema agents are employed simultaneously or when they are administrated alone. The experimental model allows the authors to evaluate various modalities of the injection of the dye and drugs. Better filling of the cerebral hemisphere in which the antiedema agents were injected through the common carotid artery is always recorded. Therefore, the authors conclude that the best way to obtain homogeneous post-ischemic vascular re-perfusion is to inject half of drugs through the left common carotid artery and half through the right common carotid artery.

Experimental cerebral "no-reflow phenomenon"

The authors describe an experimental model of transient (15 min). unilateral, cerebral ischemia followed by 60 min of reperfusion in anesthetized rats. Zones of non perfusion are recorded and referred to as the "no-reflow phenomenon". The authors believe that vascular changes which interfere with postischemic reperfusion are due to ischemia-induced swelling of perivascular glia. The effects of the intracarotid injection of dexamethasone, furosemide and escina are evaluated in the attempt to show the importance of brain edema in ischemic cerebral damage.

[Cerebral and spinal cord glioma in the same individual multiple or multicentric?]

The problem of multiple primary gliomas is discussed starting from a personal report concerning with a case of coexisting cerebral and intramedullary gliomas. Pathological examination allows the Authors to differentiate the cerebral from the medullary tumor by means of the principles of the new WHO classification of brain tumors. In this way it is possible to support the hypothesis of multicentricity. In diagnosing multiple or multifocal tumors the clinical criteria are preferred to the pathological observations. It is felt that in this way a more correct diagnostic and therapeutic approach to the multicentric tumors may yield good results. The theoretical basis for multicentric growth conclude the work.