Spinal subarachnoid hematomas: our experience and literature review

STUDY DESIGN

Spinal subarachnoid hematomas are unusual and difficult to diagnose and the outcome of treatment is influenced by the lesions that frequently accompany them.

OBJECTIVES

To clarify the neuroradiological diagnostic aspects of spinal subarachnoid hematoma as well as the results of treatment.

BACKGROUND

Only recently has subarachnoid hematoma been clearly distinguished from more common subarachnoid hemorrhage and its characteristics have still not been dealt with in detail.

METHODS

A total of 69 cases (3 personal case, 66 published cases) were revised in terms of etiology, diagnostic imaging and the results of both surgical and conservative treatment.

RESULTS

The most common causes of spinal subarachnoid hematoma are coagulopathies (either pharmacologically-induced or resulting from systemic diseases) (40.5%), lumbar puncture for diagnostic or anesthesiological purposes (44.9%) and traumatic injuries (15.9%): these factors may be present singly or variously combined. They may be spontaneous (17.3%) or, in rare cases, associated with aortic coarctation or degenerative vascular diseases. Overall mortality is 25.7%. In the 50 cases in whom long-term follow-up was possible, the outcome of treatment, which is almost exclusively always surgical, was good in 93.5% of 31 patients in whom neurological status on admission was satisfactory and in 15.8% of 19 cases with severe neurological deficits.

CONCLUSIONS

MRI and CT are not usually diagnostic because they are not able to differentiate between a subarachnoid lesion and a subdural one. However, diagnosis may be possible when these investigations detect the CSF or the contrast medium surrounding the hematoma. Although the risks of producing spinal subarachnoid hematoma as a result of LP are remote, this is, in fact, the primary cause in patients with coagulopathies. The results of treatment depend on the patient's initial neurological condition, the severity of any concomitant pathologies, the position of the hematoma and the eventual association of a subdural hematoma.

Porcine odorant-binding protein: structural stability and ligand affinities measured by fourier-transform infrared spectroscopy and fluorescence spectroscopy

Infrared spectra show that the binding of the odorants 2-isobuthyl-3-methoxypyrazine (PYR) and 3,7-dimethyl-1-octanol (DMO) stabilises the tertiary structure of porcine OBP-I against thermal denaturation. The fluorescence emission spectrum of the single tryptophan shows a lambdamax at 337 nm, indicating that the residue is not directly exposed to the solvent. Tryptophan does not appear to be involved in the odorant binding process and it is not accessible to the fluorescence quenchers NaI, CsCl and acrylamide. The binding of the fluorescent dye 1-aminoanthracene (1-AMA), a strong ligand, does not modify the tryptophan fluorescence spectrum. In contrast, the lambdamax of 1-AMA bound to OBP-I is shifted from 537 to 481 nm, with a lambdamax intensity increase by a factor of 80. Bound 1-AMA is displaced by odorant molecules in competitive binding assays and can be employed in simple and rapid binding assay, avoiding the use of radioactive ligands. The Scatchard plot shows that 1-AMA binds to OBP-I with a dissociation constant of 1.3 microM and an equimolar stoichiometry.

Spinous process marking: a reliable method for preoperative surface localization of intradural lesions of the high thoracic spine

Surgical exposure of intradural lesions in the thoracic spine requires intraoperative landmarks to identify the vertebral level. If spinal neuronavigation is not available, the surgeon must rely on alternative localizing methods. Intraoperative fluoroscopy is traditionally used to count the vertebrae throughout the whole spine. In the high thoracic spine, counting the vertebrae is often hampered by the scapular shadows. In these cases, a preoperative marking procedure seems preferable. Magnetic resonance imaging (MRI) based techniques have been increasingly reported, but they share an intrinsic risk of error due to the skin shift occurring at the time of surgery. We describe here a simple technique for unequivocal identification of the vertebral target. In six patients undergoing surgery for intradural lesions of the high thoracic spine, the spinous process of the vertebra corresponding to the lesion was preoperatively identified on an anteroposterior radiograph view and marked infiltrating its tip with a blue dye. At surgery, the vertebral target was identified easily and immediately. No errors occurred. No complications related to the technique were observed. Preoperative marking of the vertebral spinous process with a coloured dye is a simple and unequivocal guide to expose intradural lesions in the high thoracic spine.

Amino acid sequence, post-translational modifications, binding and labelling of porcine odorant-binding protein

An odorant-binding protein, migrating in SDS-PAGE with an apparent molecular weight of 22 kDa and an isoelectric point of 4.2, has been purified from pig nasal mucosa. Its complete amino acid sequence was determined by a combination of mass spectrometry and Edman degradation procedures. The protein consists of a single polypeptide chain of 157 amino acids, presenting at the N-terminus a pyroglutamic acid residue. The two cysteine residues, occurring in the primary structure at positions 63 and 155, are involved in an intramolecular disulphide bridge. Sequence comparison with other lipocalins revealed a good similarity with bovine odorant-binding protein, the only member of this class which does not contain disulphide bonds and of which the three-dimensional structure recently has been resolved. Nine out of the 1 6 residues lining the binding pocket in bovine OBP are conserved in the porcine protein, suggesting structural similarities in this region of the molecule. The synthesis of a fluorescent photoaffinity labelling agent and of two tin-containing thymol analogues is also described. These compounds together with other ligands were able to bind the protein as revealed by competitive binding experiments.

Synergistic induction of PI-PLCβ1 signaling by azacitidine and valproic acid in high-risk myelodysplastic syndromes

The association between azacitidine (AZA) and valproic acid (VPA) has shown high response rates in high-risk myelodysplastic syndromes (MDS) cases with unfavorable prognosis. However, little is known about the molecular mechanisms underlying this therapy, and molecular markers useful to monitor the disease and the effect of the treatment are needed. Phosphoinositide-phospholipase C (PI-PLC) β1 is involved in both genetic and epigenetic mechanisms of MDS progression to acute myeloid leukemia. Indeed, AZA as a single agent was able to induce PI-PLCβ1 expression, therefore providing a promising new tool in the evaluation of response to demethylating therapies. In this study, we assessed the efficacy of the combination of AZA and VPA on inducing PI-PLCβ1 expression in high-risk MDS patients. Furthermore, we observed an increase in Cyclin D3 expression, a downstream target of PI-PLCβ1 signaling, therefore suggesting a potential combined activity of AZA and VPA in high-risk MDS in activating PI-PLCβ1 signaling, thus affecting cell proliferation and differentiation. Taken together, our findings might open up new lines of investigations aiming at evaluating the role of the activation of PI-PLCβ1 signaling in the epigenetic therapy, which may also lead to the identification of innovative targets for the epigenetic therapy of high-risk MDS.

Purification, cloning and characterisation of odorant- and pheromone-binding proteins from pig nasal epithelium

Two distinct classes of lipocalin isoforms (OBP-IIs and OBP-IIIs) were purified and identified from porcine nasal mucosa of male and female individuals. Using primers designed on their N-terminal sequence, the complete primary structures of the mature polypeptides were determined. Mass spectrometry analysis confirmed the identity of the cDNA-derived sequences and provided information regarding their post-translational modifications. These species strongly resemble a lipocalin expressed by von Ebner's gland and salivary lipocalins carrying sex-specific pheromones secreted only by the boar's submaxillary glands. Both OBP-IIs and OBP-IIIs present two cysteines paired in a disulphide bond; the remaining residues occur in a reduced form. In addition, OBP-IIIs are heavily glycosylated and markedly different in their glycan moiety from the salivary lipocalins. A three-dimensional model is proposed based on protein species with known structure. Like salivary lipocalins, OBP-IIIs bind a number of odorant molecules, with highest affinity for the specific pheromone 5alpha-androst-16-en-3-one. The high similarity between OBPs from the nasal area and lipocalins from secretory glands suggests a common function in binding the same pheromonal ligands, the latter carrying chemical messages into the environment the former delivering them to specific receptors.

Solitary cerebral metastases from intestinal carcinoma

The authors report 34 cases of solitary cerebral metastases from intestinal cancer. In 24 cases the tumour was localized in the colonrectum and in 10 in the small intestine. In 8 patients (23%) neurological symptoms were the first clinical sign of systemic spread of the tumour; in 26 cases (77%) there was a long interval between treatment of the primary and appearance of the cerebral metastasis (average 24 months). Average survival was 10 months and was influenced solely by staging of the primary. Interestingly, the prognostic value of radiotherapy was minimal and none of the patients operated by the "no touch technique" presented with a recurrence.

Cerebral vasospasm in patients with unruptured intracranial aneurysms

Intracranial arterial vasospasm is a typical sequela of subarachnoid haemorrhage. The association between symptomatic vasospasm and unruptured aneurysms has been sporadically presented in the literature. The pathogenesis of this unusual entity is unclear. The published cases were collected in this review and analysed with regard to timing, clinical presentation and possible relationship with surgical factors. We also added an illustrative case which was recently observed in our department.

Mass spectrometry study of ecto-5'-nucleotidase from bull seminal plasma

The structure of ecto-5'-nucleotidase from bull seminal plasma, containing a glycosyl-phosphatidylinositol anchor, was studied using mass spectrometry. MALDI-MS analysis of intact protein indicated a mass of 65 568.2 Da for the monomeric form, and it also showed a heterogeneous population of glycoforms with the glycosidic moiety accounting for approximately 6000 Da. MALDI-MS analysis showed that Asn53, Asn311, Asn333 and Asn403 were four sites of N-glycosylation. GC-MS analysis provided information on the glycosidic structures linked to the four asparagines. Asn53, Asn311 and Asn333 were linked to high-mannose saccharide chains, whereas the glycan chains linked to Asn403 contained a heterogeneous mixture of oligosaccharides, the high-mannose type structure being the most abundant and hybrid or complex type glycans being minor components. By combining enzymatic and/or chemical hydrolysis with GC-MS analysis, detailed characterization of the glycosyl-phpsphatidylinositol anchor was obtained. MALDI spectral analysis indicated that the glycosyl-phosphatidylinositol core contained EtN(P)Man3GlcNH2-myo-inositol(P)-glycerol, principally modified by stearoyl and palmitoyl residues or by stearoyl and myristoyl residues to a minor extent. Moreover, 1-palmitoylglycerol and 1-stearoylglycerol outweighed 2-palmitoylglycerol and 2-stearoylglycerol. The combination of chemical and enzymatic digestions of the protein with the mass spectral analysis yielded a complete pattern of S-S bridges. The protein does not contain free thiols and its eight cysteines are linked by intramolecular disulfide bonds, the pairs being: Cys51-Cys57, Cys353-Cys358, Cys365-Cys387 and Cys476-Cys479. This work resolves details of the structure of ecto-5'-nucleotidase, with particular regard to the localization and composition of the glycidic moiety, number and localization of the disulfide bridges and characterization of the glycosyl-phosphatidylinositol anchor.

Tetraplegia following parathyroidectomy in two long-term haemodialysis patients

We report two cases of postoperative iatrogenic tetraparesis, which occurred in different hospitals after surgery for parathyroidectomy. Both patients were on long-term haemodialysis. The prolonged neck extension usually required by this procedure was probably the main factor involved in the genesis of the spinal cord injury. Spinal abnormalities associated with chronic renal failure may have made these patients more vulnerable. In our opinion, it is advisable to investigate thoroughly any sign of spinal stenosis in patients who undergo any procedure requiring significant neck extension, particularly if on long-term haemodialysis.

Imatinib mesylate in the treatment of newly diagnosed or refractory/resistant c-KIT positive acute myeloid leukemia. Results of an italian multicentric phase II study

We evaluated safety and efficacy of imatinib (600 mg) in 36 c-KIT+ acute myeloid leukemia patients not amenable to receive conventional chemotherapy. No patient achieved complete remission. One patient obtained a hematologic improvement (platelet increase with transfusion independence). Median overall survival was 3 months (0.5-44+). Non-hematologic toxicity was overall mild.

Ethylene oxide sterilization of autologous bone flaps following decompressive craniectomy

INTRODUCTION

In patients undergoing decompressive craniectomy, the bone flap is temporarily preserved either in the subcutaneous tissue of the patient or frozen. However, there are some drawbacks related to these methods.

MATERIAL AND METHODS

In 16 patients in whom the bone flap was removed for decompressive craniectomy, the bone was firstly washed in hydrogen peroxide and then placed in hermetically-sealed bags and sterilized using ethylene oxide. The bone was repositioned after an average period of 4.3 months.

RESULTS

One patient sustained an infection of the surgical wound which required permanent exclusion of the bone flap. In all the others, esthetic and functional results were good after an average follow-up of 20 months. Control CT-scan of the bone flap demonstrated preservation of its structural features with fusion of the bone margins and revitalization of the flap. On MRI a subdural space was again visible.

CONCLUSIONS

Sterilization of the bone flap with ethylene oxide in patients undergoing decompressive craniectomy avoids some of the drawbacks related to the techniques currently used. The easiness, low cost, good aesthetic and functional results of this procedure make it a valid alternative to other techniques for preservation of autologous bone in decompressive craniectomies.

Cerebral Whipple's disease as a cause of reversible dementia

We describe a case of reversible dementia caused by Tropheryma whippelii (TW). Diagnosis was confirmed by a positive polymerase chain reaction for this pathogen both on serum and cerebrospinal fluid. Specific antibiotic therapy resulted in distinct clinical and neuroradiological improvement. Control polymerase chain reaction for T. whippelii on serum and cerebrospinal fluid was negative.

Atypical tentorial meningioma 30 years after radiotherapy for a pituitary adenoma

Although the human central nervous system used to be considered relatively resistant to the carcinogenic action of ionizing radiation, several lines of evidence now document a high incidence of secondary tumors in irradiated patients. The numerous reports of radiation-induced cerebral meningiomas generally distinguish those induced by high-dose radiation from those induced by low-dose radiation. We describe the case of patient who underwent subtotal resection of a chromophobe pituitary adenoma at the age of 18 years, who was successively treated by conventional fractionated radiotherapy with gamma rays emitted by a source of 60Co until a total dose of 41 Gy. Over the next 30 years the patient experienced all the known late effects of radiation, including panhypopituitarism, cranial-nerve deficits (II, III and VI), massive radiation necrosis involving the left cerebral hemisphere and causing right hemiparesis and aphasia and, ultimately, an atypical tentorial meningioma with early recurrence after total resection.

Surgical exposure of lateral orbital lesions using a coronal scalp flap and lateral orbitozygomatic approach: clinical experience

BACKGROUND

The lateral extraconal compartment is a typical localization of intra-orbital tumours. With the exception of anterior lesions, which can be reached by a transconjuntival route, most of these tumours are currently approached through the classic lateral orbitotomy originally described by Kronlein. We present here our experience in the management of lateral orbital lesions, using a coronal skin flap, followed by subfascial dissection of the temporalis muscle. The procedure was intended to overcome the potential drawbacks associated with the classic transtemporal approach.

METHODS

The approach was used in eleven patients harbouring bone lesions of the lateral orbital wall or intra-orbital lesion of the lateral extra-ocular compartment. The postoperative results were assessed using a simple cosmetic outcome scale, which evalutated the temporalis muscle trophism and the function of the frontotemporal branch of the facial nerve.

RESULTS

All lesions were satisfactorily exposed. The subfascial dissection of the temporalis muscle is a key manoeuvre which, at the same time, abolishes the risk of injury to the frontotemporal branch of the facial nerve and provides a wide exposure of the lateral orbital wall. The cosmetic outcome was excellent in 9 patients and good in 2 patients.

CONCLUSIONS

The reported technique is a convenient surgical option to approach lateral intra-orbital lesions, with a minimal cosmetic impact.

Discontinuous myelotomy: an alternative to standard myelotomy in the surgical treatment of intramedullary spinal cord tumours

BACKGROUND

Myelotomy is an essential step for the removal of intramedullary tumours. Often, this manoeuvre requires division of large vessels surfacing the midline, contributing to the development of postoperative sensory deficits. We developed a technique of discontinuous myelotomy to preserve the integrity of these large spinal cord vessels.

METHODS

Over a three-year period, we approached 20 intramedullary astrocytomas through a posterior myelotomy consisting of two separate incisions one above and the other below the midline vessel. The tumour was removed using the Cavitron ultrasound aspirator (CUSA), through either incision. Tumour underlying the bridging area between the two incisions was successfully removed through an oblique view.

FINDINGS

We retrospectively analysed the clinical outcome in terms of sensory function. Follow-up examinations showed that up to 70% of the patients had their sensory function unchaged. 5 (20%) patients experienced a permanent worsening of their deficits, involving superficial and deep sensation in cases 1 and 4, respectively. Two (10%) patients showed significant improvement.

INTERPRETATION

Discontinuous myelotomy is a viable technical option whenever the presence of large vessels on the median raphe would make the standard midline myelotomy unsafe.

Paramedian diencephalic syndrome

The clinical characteristics of paramedian diencephalic syndrome (PDS) are described on the basis of two recently observed cases: one with paramedian thalamic infarct, the other with paramedian thalamopeduncular infarct. Analysis of the clinical symptoms and the results of CBF study show that PDS is a complex neurological syndrome characterized by symptoms due to both anatomical lesions and functional disconnections.

Innovative phase I study of concomitant and consecutive treatment with dasatinib and MK-0457 in refractory Ph+ CML and ALL patients

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Background: MK-0457 is a pan-aurora kinase inhibitor with activity against wild-type and mutated BCR-ABL, including the T315I form, FLT3, and JAK-2. Methods: We conducted an innovative Phase I clinical study of sequential and concomitant treatment with dasatinib, previously administered for 3 months, and MK-0457. This combined activity suggests that MK-0457, in association with dasatinib, would suppress the emergence of T315I and other resistant clone, improving upon the response rate for dasatinib and the durability of response. The trial investigated two schedules of therapy: patients who achieved and maintained a major hematologic response (MHR) after 3 months of therapy with dasatinib (70 mg twice daily) received a 6-hour biweekly infusion of MK-0457 at 64 mg/m2/hr, whereas patients who failed to achieve a MHR received a 5-days continuous infusion of MK-0457 at 10 mg/m2/hr, every 4 weeks. Results: Two patients with Ph+ ALL and one patient with CML in myeloid blast crisis, previously unsuccessfully treated with imatinib, were enrolled. The first two patients, both in hematologic response after three months of treatment with dasatinib, subsequently received the 6-hour biweekly schedule, maintaining the hematological response. No hematological toxicity was described. The third patient, in progression disease, received the 5 days MK-0457 schedule. His peripheral blood count showed a severe pancytopenia, and his bad clinical conditions were compromised by a severe hemorrhagic pleural effusion. After one cycle of MK-0457, a complete recovery of the pulmonary disease and a complete hematologic response were obtained. Conclusions: The sequential and concomitant administration of dasatinib and MK-0457 represents a promising therapeutic strategy for refractory Ph+ CML and ALL. Supported by: European LeukemiaNet, AIL, AIRC, FIRB 2006, Fondazione del Monte di Bologna e Ravenna, Merck Sharp & Dohme.

No significant financial relationships to disclose.