Assisted sedation: a safe and easy method for pain-free percutaneous vertebroplasty.

BACKGROUND: This study was performed to describe a method of assisted sedation for percutaneous vertebroplasty (PVP). METHODS: A non-randomized observational study was carried out on 20 patients ASA classes 2 and 3, who were undergoing PVP for vertebral body disruption. Patients, spontaneously breathing in prone position, were sedated using fentanyl and propofol. Sedation during PVP was maintained by continuous propofol infusion and was titrated to the patient's need. In addition to sedation, 2% mepivacaine was used as a local anesthetic. Electrocardiogram (ECG) and oxygen saturation (SpO(2)) were continuously monitored. Blood pressure was checked every 5 min. The length of the procedure was recorded and the patient's recovery from sedation was assessed according to a five-level scale, every 5 min from the end of the procedure. Time of discharge to the general ward was recorded. A four point (0-3) operator satisfaction score (OSS) was also used to evaluate surgeon's satisfaction. This score was based on patient movements and procedure interruptions. RESULTS: Sedation allowed a pain free procedure, with high surgeon satisfaction and rapid recovery of the patient. Sedation decreased blood pressure and heart rate, but not SpO(2); however, hypotension and bradycardia were not observed. Age was inversely correlated with propofol total dose. The mean total propofol dose was 4.5+/-1.4 mg/kg. The mean maintenance propofol dose rate was 5.7+/-1.4 mg/kg/h. CONCLUSION: Assisted sedation is a safe and easy method for pain free PVP procedures. Age is an important factor to titrate propofol dose. However, it is noteworthy that no adverse effects were observed independent of age and physical status.

Percutaneous vertebroplasty: indications, contraindications, technique, and complications.

Percutaneous vertebroplasty is emerging as one of the most promising new interventional procedures for relieving (or reducing) painful vertebra, with the injection of surgical polymethylmethacrylate or cement into vertebral bodies. This imaged-guided technique, originally used to treat vertebral hemangioma, has recently been extended to the treatment of metastases, osteoporotic compression fractures, and vertebral myeloma. It is increasingly being accepted as a main treatment of choice in the management of resistant back pain due to vertebral compression fractures, especially in the elderly individual who is not a candidate for surgery. In this article, we review indications, contraindications, technique, and complications of percutaneous vertebroplasty.

Treatment of herniated lumbar disc by intradiscal and intraforaminal oxygen-ozone (O2-O3) injection.

MATERIAL: We report our experience between May 1996 and May 2003 with 2200 patients affected by low back pain or sciatica due to herniated disk treated by intradiscal and intraforaminal oxygen-ozone injection. The patients received medical and physical therapy before treatment for at least 2 months; the patients with conus-cauda syndrome and hyperalgesic sciatica were excluded. We never performed discography before the treatment that was performed under CT guidance or fluoroscopy. CT provided monitoring of gas distribution in the disk and epidural space. RESULTS: No side effects were recorded at short and long-term follow-up. Clinical results were evaluated with the modified McNab method showing an 80% success rate and 20% failure rate in 1750 patients followed up to 6 months while the success rate dropped down at 75% and failure increased at 25% in 1400 followed up to 18 months. CT showed reduction in the size of the herniated disk in only 63% of the followed patients (420 patients). The failure has been mostly related to: calcified herniated disk; spinal canal stenosis; recurrent herniated disk with epidural fibrosis; small descending herniated disk at the level of the lateral recess.

Localised 1H-MR spectroscopy for metabolic characterisation of diffuse and focal brain lesions in patients infected with HIV.

OBJECTIVES: To evaluate the role of proton MR spectroscopy (1H-MRS) in detecting metabolic changes in diffuse or focal lesions in the brain of patients infected with HIV. METHODS: Sixty HIV seropositive patients (25 with HIV related encephalopathies, 20 with toxoplasmosis, eight with progressive multifocal leukoencephalopathies (PMLs), and seven with lymphomas) and 22 HIV seronegative neurological controls were examined with a combined MRI and 1H-MRS technique using a Siemens 1.5 Tesla Magnetom. Spectra (Spin Echo sequence, TE 135 ms) were acquired by single voxel, localised on focal lesions in toxoplasmosis, PML, lymphomas, and HIV encephalopathies and on the centrum semiovale of neurological controls. Choline (Cho), creatine (Cr), N-acetyl aspartate (NAA), lactate, and lipids were evaluated in each spectrum and NAA/Cr, NAA/Cho, and Cho/Cr ratios were calculated. RESULTS: A significant decrease in NAA/Cr and NAA/Cho ratios were found in all HIV diagnostic groups in comparison with neurological controls (p<0.003), suggesting neuronal or axonal damage independent of brain lesion aetiology. However, the NAA/Cr ratio was significantly lower in PML and lymphomas than in HIV encephalopathies (p<0.02) and toxoplasmosis (p<0.05). HIV encephalopathies, lymphomas, and toxoplasmosis showed a significant increase in the Cho/Cr ratio in comparison with neurological controls (p<0.03) without between group differences. The presence of a lipid signal was more frequent in lymphomas (71%) than in other HIV groups (Fisher's test, p=0.00003). The presence of mobile lipid resonance together with a high Cho/Cr ratio in lymphomas may be related to an increased membrane synthesis and turnover in tumour cells. A lactate signal (marker of inflammatory reaction), was found in all but one patient with PML lesions (75%), but had a lower incidence in the other HIV diagnostic groups (Fisher's test, p=0.00024). CONCLUSION: 1H-MRS shows a high sensitivity in detecting brain involvement in HIV related diseases, but a poor specificity in differential diagnosis of HIV brain lesions. Nevertheless, the homogeneous metabolic pattern that characterises PML suggests the usefulness of 1H-MRS as an adjunct to MRI in differentiating CNS white matter lesions, such as HIV encephalopathies, from PML.

Measurement of viral sequences in cerebrospinal fluid of AIDS patients with cerebral white-matter lesions using polymerase chain reaction.

OBJECTIVES: To optimize the use of polymerase chain reaction (PCR) on cerebrospinal fluid (CSF) for the evaluation of central nervous system (CNS) white-matter lesions that along with clinical findings and magnetic resonance imaging (MRI) can allow a definite diagnosis to be made; also to evaluate treatment with zidovudine plus foscarnet. DESIGN AND METHODS: Fifteen AIDS patients with uncertain CNS white-matter lesions were identified. HIV-1 RNA, cytomegalovirus (CMV) and JC virus (JCV) DNA were measured in a total of 29 CSF samples. The results were correlated with clinical and MRI findings and treatment with zidovudine plus foscarnet was evaluated. RESULTS: Four and five out of 15 patients with CMV DNA > or = 1 : 625 and JCV DNA > or = 10(3) copies/microl detected in the CSF were diagnosed with CMV and progressive multifocal leukoencephalopathy (PML), respectively. Six patients who were CMV/JCV-negative with the highest levels of HIV RNA (median, 6.87 log10 copies/ml) in CSF were considered as having HIV-1 encephalitis. Neurological symptoms were non-supportive for diagnosis as was MRI in 11 out of 15 patients. Nine patients completed a 21-day course of zidovudine plus foscarnet. HIV RNA decreased irrespective of neurological diagnosis. All three HIV-1 encephalitis patients and two out of three patients with CMV leukoencephalopathy improved. In these two latter patients, relief of clinical symptoms coincided with decreased CMV DNA. JCV DNA remained unchanged and all three PML patients deteriorated. CONCLUSIONS: Measurement of CSF viral sequences supports the diagnosis of CNS white-matter lesions in AIDS patients. While effective therapy for PML remains elusive, treatment including zidovudine plus foscarnet may be a promising option for HIV-1 and CMV-related manifestations.

Combined protein C deficiency and protein C activated resistance as a cause of caval, peripheral, and cerebral venous thrombosis--a case report.

A 26-year-old woman suffered concomitant inferior vena cava, iliac, and femoral vein thrombosis and cerebral venous thrombosis. Ten days before symptom onset she had started using an oral contraceptive that contained low-dose ethynilestradiol and gestodene. Both protein C deficiency and protein C activated resistance were detected. To our knowledge, the association of cerebral, caval, and ilio-femoral-popliteal venous thrombosis has not been described previously. The severity of the clinical features could be a consequence of the two combined thrombophilic mechanisms and of the continuation of the oral contraceptive. A thrombophilic disorder should be considered in young patients with thromboembolic disease. Because of the high prevalence of the genetic deficiency causing protein C activated resistance, it is probably worthwhile to perform general screening before prescription of oral contraceptives.

Rationale for the use of contrast media in MR imaging.

Understanding the rationale of contrast media use in MR imaging is based on knowledge of the blood brain barrier (BBB) and the pathophysiology of infectious agents attacking the central nervous system. This article focuses on the relationship between BBB structures and functions in healthy and unhealthy conditions and contrast media in patients with acquired immunodeficiency syndrome.

Choreoathetosis in acquired immune deficiency syndrome patients with cerebral toxoplasmosis.

The aim of our study was to evaluate both the incidence and the pathologic and clinical features of extrapyramidal disorders in a population of acquired immune deficiency syndrome (AIDS) patients with cerebral toxoplasmosis. Of 240 AIDS patients evaluated in the 1985-1994 period, 50 of them were diagnosed to have cerebral toxoplasmosis on the basis of the following criteria: occurrence of specific antibodies, computed tomography and/or magnetic resonance imaging (MRI), and regression of the symptoms after specific therapy. Three of 50 (6%) had hemichoreoathetosis. In the first case, the disorder began as a dyskinesia of the left hand that subsequently spread to the whole ipsilateral arm and assumed the features of choreic athetotic movements. The other two cases were characterized by left hemisomatic distal choreic movements. Therapy with pyrimethamine and sulfadiazine led to a complete recovery of the extrapyramidal signs in two cases and to improvement in the third. According to our observations, the onset of these movement disorders could not be related to the dimension of the lesion or to the edema, but to a specific localization in subthalamic nucleus, in subthalamic/pallidal, and pallidal/thalamic pathways. MRI seems the elective tool to perform a more accurate study of the anatomic areas involved in this pathway and to verify their integrity. Cerebral toxoplasmosis in AIDS can be considered as a new etiopathogenic cause of choreoathetosis.

A controlled trial of mitoxantrone in multiple sclerosis: serial MRI evaluation at one year.

We present the results of a randomized double-blinded placebo controlled, multicenter trial, of low-dose mitoxantrone (MX), after one year, in 25 patients with relapsing-remitting multiple sclerosis, who had serial enhanced magnetic resonance imaging (MRI). Treatment groups were balanced for age, gender, duration of illness and neurological disability. Five of the 13 MX patients and 10 of the 12 placebo patients had exacerbations during treatment (p < 0.02). The mean change in the extended disability status scale was not significantly different between the MX and placebo treatment groups. Serial Gadolinium-DTPA enhanced MRI detected no significant difference between the MX treated and placebo groups in the mean total number of new, enlarging, or Gadolinium-DTPA enhancing lesions; there was a trend toward a reduction of new, enlarging and Gadolinium-DTPA enhancing lesions in MX patients. Despite this ameliorating effect, the results indicate that serial Gadolinium-DTPA enhanced MRI, performed over one year in a limited number of patients, could not provide conclusive evidence for a role of MX therapy in relapsing-remitting multiple sclerosis.

CNS cryptococcosis in AIDS: spectrum of MR findings.

Cryptococcus is a ubiquitous saprophytic fungus that may become pathogenic, particularly in immunosuppressed patients. In the CNS of AIDS patients, the incidence of this fungal infection is 5% of all the opportunistic infections. In this study, we review the MR findings in nine AIDS patients affected by CNS cryptococcosis. All MR studies were performed before and after intravenous administration of a single dose of gadopentetate dimeglumine and again after an additional dose. Autopsy was performed in one case. Magnetic resonance imaging revealed evidence of meningitis or meningoencephalitis, dilated Virchow-Robin spaces, cyst-like structures (gelatinous pseudocysts), and granulomas (cryptococcomas) of the choroid plexuses. The last two findings (pseudocysts and choroidal ependymal granulomas) are relatively specific for cryptococcosis.

A case of Landau-Kleffner syndrome secondary to inflammatory demyelinating disease.

A 6-year old girl developed acquired aphasia with epilepsy and a paroxysmal EEG (Landau-Kleffner syndrome). Isoelectric CSF focusing showed oligoclonal IgG bands. Small lesions were visualized in periventricular left frontal white matter and right parietal lobe centrum semiovale with magnetic resonance imaging (MRI). After a week of ACTH therapy, the EEG paroxysmal activity disappeared; during the next few months, the language disorder improved. Further MRI examination showed a decrease in size and signal of the left frontal lesions, with localized white matter atrophy, dilatation of the subarachnoidal spaces, and disappearance of the right parietal lesion. The clinical and neuroradiologic features and the laboratory data suggest an acute disseminated encephalomyelitis.

[Lymph nodes of the neck. Diagnosis using magnetic resonance with gradient-echo technique]. / I linfonodi del collo. Diagnosi mediante risonanza magnetica con tecniche a eco di gradiente.

As for the pathologic conditions of neck lymph nodes, the clinician needs to know if the involved node is reactive, phlogistic, or neoplastic in nature. If accurate tumor staging is required, imaging techniques play a fundamental role. Our study was aimed at assessing the actual role of MR imaging in the evaluation of neck lymph node involvement. The study was performed using an MR Max Plus by General Electrics operating with an 0.5 T superconductive magnet. We employed gradient-echo (GE) pulse sequences with TR 500, TE 15 ms and 90 degrees flip angle for T1-weighted images, and with TR 500, TE 30 ms and 25-30 degrees flip angles for T2-weighted images; for Pd-T2-weighted images, TR was 520, TE 30 ms, and flip angles were 40-45 degrees. The results were correlated with histopathologic findings obtained at biopsy. The advantages of GE sequences were: 1) whole neck imaging--thus saving time, and reducing radiation dose and contrast media; 2) optimal anatomical and topographic evaluation of the lesion; 3) imaging of the longitudinal diameter of the node; 4) higher sensitivity for lymph node tissue modifications; 5) imaging of necrosis, hemorrhage, and/or fibrosis. GE sequences were especially useful for accurate tumor staging, in the follow-up, and to verify response to therapy. However, even though MR imaging has proven to have high sensitivity, its specificity was similar to that of contrast-enhanced CT. Further studies with the use of paramagnetic contrast media are needed to solve these problems.

[Neuro-AIDS: a multicenter neuroradiological study]. / Neuro-AIDS: studio neuroradiologico multicentrico.

The results are described of a retrospective multicentric CT/MR study of 141 neuro-AIDS patients (IV group CDC classification); 114 patients were drug addicted, 13 homosexual, 8 polytransfused, and 6 had other risk factors. The mean age was 29.6 years. The pathologic agent was identified in 47 cases by c.s. fluid examination, biopsy, autopsy or specific treatment response: it was HIV in 20 cases, toxoplasmosis in 11, cryptococcosis in 9, leishmaniasis, salmonella and papovavirus in single cases. In the follow up of 2 cases, a Kaposi's sarcoma and a primitive CNS lymphoma occurred. The main clinical features were AIDS-dementia complex (45% of cases) and focal neurologic manifestations (36%). The neuroradiological protocol consisted of 238 CT exams (97 controls), most of them with DDD (delayed double dose) technique, 7 MR exams (0.15 T) and 2 angiographies. CT findings were divided into 3 groups: negative (16%), atrophic (47%) and focal lesions (37%). In the first and second group, HIV and cryptococcal infections were the main pathologic agents. In the third group toxoplasma infections were discovered, and TB granulomas and other pathologic conditions, with ring-like or nodular enhancement, in cortical/cortico-medullary location. In follow-up patients a high tendency of evolution towards focal lesions was observed, even in negative cases. The DDD enhancement technique allowed in most cases both the demonstration of very small lesions and their grading. According to the literature CT, though a highly sensitive method, is inferior to MR imaging; however our experience in this field is currently insufficient. The specific diagnosis of pathologic agents of neuro-AIDS is difficult, due to the high number of opportunistic AIDS-related infections and neoplasms, with overlapping features: differential diagnostic criteria can be assessed only by comparing the clinical, microbiological, topographic, CT and MR findings. CT and MR exams are necessary to guide and monitor therapy and to plan stereotaxis biopsy.

[Ambulatory radicular myelography with iopamidol]. / Radicolomielografia ambulatoriale con Iopamidolo.

The appearance of side effects was monitored in 70 selected patients who underwent radiculography and myelography. After the examination, a rapid return to normal activity was recommended. In accordance with literature, no greater incidence of side effects was found in patients who were allowed to get up soon after myelography or radiculography, than in patients confined to bed for some hours. These results are essentially attributable to the low toxicity of the contrast medium used in this study (Iopamidol), and to an adequate hydratation of the patients after examination.

Clinical and CT parameters in degenerative cerebellar atrophy in aged patients.

Fifteen cases of degenerative cerebellar atrophy are presented together with the criteria used to assess the diagnosis of cerebellar atrophy by computed tomography.