Pituitary apoplexy during pregnancy: a rare, but dangerous headache.

Pituitary apoplexy is a rare endocrine emergency that occurs in a small number of patients with a pituitary tumor. It is a clinical syndrome characterized by the sudden onset of headache, nausea, vomiting, visual impairment, and decreased consciousness, caused by hemorrhage and/or infarction of the pituitary gland. Pituitary apoplexy has very rarely been described during pregnancy, when it is potentially life-threatening to both the mother and the fetus, if unrecognized. Only a few cases have been published to date. The review of the existing literature underlines that pituitary apoplexy, although rare, should be borne in mind when a pregnant woman presents with severe headache and visual defects of sudden onset. After initial management, which includes intravenous glucocorticoid therapy, fluid and electrolyte replacement, the final selection of medical or surgical treatment should result from a multidisciplinary approach involving expert specialists, keeping into account both severity of clinical presentation and gestational week.

Intracranial metastasis of testicular seminoma in an HIV-positive. Case report and review.

We present what appears to be the first case of an intracranial metastasis from testicular seminoma in an HIV-positive patient. The computed tomography and magnetic resonance imaging appearance of the lesion mimicked meningioma or lymphoma. A significant increase in the risk of testicular seminoma has been reported in AIDS patients. Whenever there is lymph-node involvement upon diagnosis of testicular seminoma, intracranial metastases may appear. After surgical removal of an intracranial metastasis from testicular seminoma, radiotherapy should be considered. Chemotherapy is to be included in the treatment of intracranial metastases from testicular seminoma with systemic involvement.

Multiple intracranial lesions in head injury: clinical considerations, prognostic factors, management, and results in 95 patients.

BACKGROUND: The goal of this study was to identify clinical and radiological predictors of prognosis in patients with multiple post-traumatic intracranial lesions. METHODS: We reviewed 95 patients (75 male and 20 female) between the ages of 18 and 70 (average 38) admitted between 1993 and 2000 with multiple post-traumatic intracranial lesions. Intracranial pressure (ICP) monitoring was carried out in 67 patients (70%); 77 received intensive care unit (ICU) treatment. Since in all cases it was possible to identify a clearly predominant lesion, 3 groups of patients emerged from the data: the first with extradural hematoma (EDH), the second with a combination of homolateral subdural (SDH) and intracerebral hematoma (ICH), and the third with pure focal intracerebral hematoma (ICH). RESULTS: Twenty-seven patients were treated conservatively, 2 of whom died (7.4%); both had bilateral ICH and compression of the basal cisterns. Sixty-eight patients underwent one or more surgeries; 8 died (11.7%). In the group with EDH-predominant lesions (27 cases) all patients were operated (16 for multiple lesions); no one died. In the group with SDH+ICH-predominant lesions, 26 of 32 patients were operated (10 had multiple procedures); 6 died (18.7%), 3 were vegetative. In the group with ICH-predominant lesion, 15 of 36 patients were operated (7 bilaterally); 4 died (11%). Decompressive craniectomy proved to be a useful means to control ICP. Bilateral lobectomy is not recommended because of poor results. Immediate postoperative computed tomography (CT) scan proved to be mandatory to detect additional surgically treatable lesions (16 cases). Statistical analysis was performed by means of chi(2) analysis and multiple linear regression model. The multiple linear regression model was used to ascertain risk factors independently associated with the outcome. The type of lesion (presence of SDH+ICH predominant lesion), the worst recorded Glasgow Coma Scale (GCS) score, the presence of prolonged increased ICP, and the absence of pupillary reflexes were all statistically significant predictors of a bad outcome (dead or vegetative state). CONCLUSIONS: Multiple lesions have the same prognosis as the corresponding single lesions; therefore, their management should be guided by the predominant pathology.

[Giant aneurysms]. / Aneurismi giganti.

Giant aneurysms (> 2.5 cm) represent only 5-7% of all aneurysms. Nevertheless, their management is rather difficult due to their atypical natural history and peculiar treatment. Clinical history of giant aneurysms does not differ from that of the smaller ones regarding the incidence of subarachnoid hemorrhage, but it is complicated by much more neurologic deficits and by the occurrence of chronic intracranial hypertension syndrome. Diagnosis is essentially based upon CT scan and MR imaging in order to detect the morphological mass features and anatomical relationships, and upon angiography to appreciate characteristics regarding arterial flow and vascular relationships. The goal of treatment lies in the exclusion of the aneurysmal sac from the blood-stream and in the reduction of the mass effect. The treatment may be either surgical, endovascular or both. The most common surgical techniques consist in the direct occlusion of the neck of the aneurysm by means of metallic clips, or by fastening or trapping the carrier vessel or by removing the aneurysmal sac with the reconstruction of the arterial aspect when severe mass effect is detectable. The use of endovascular techniques goes for occlusion of the carrier vessel with balloons or for dynamic study of the collateral vascular districts with temporary occlusions.

Management of head-injured patients in the emergency department: a practical protocol.

BACKGROUND: The management of head-injured patients admitted to emergency departments is not standardized. METHODS: The authors performed a retrospective analysis of 10,000 head-injured patients admitted to the Emergency Department of our hospital in a 21-month period and, on the basis of a statistical correlation between each clinical parameter (symptoms and signs upon arrival at the hospital or risk factors) and the presence of intracranial lesions, they propose a practical protocol in an attempt to avoid the overuse or radiologic examinations and yet identify patients with possible life-threatening complications. RESULTS: On the basis of this correlation the patients have been divided into four groups. In the first group (called group alpha) are patients with: no history of loss of consciousness, no vomiting or amnesia, a normal neurologic examination, and minimal if any subgaleal swelling. They can be released into the care of relatives who are given a special instruction sheet (X rays unnecessary). No patient in group alpha had complications of any kind. The second group (group beta) is made up of patients with at least one of the following features: transient loss of consciousness, post-traumatic amnesia, a single episode of vomiting or significant subgaleal swelling. They undergo a computed tomography (CT) scan and if this is normal, only a short period of observation is needed. If CT scan is not available, the skull is X rayed and, if this X ray is negative, the patient is sent home with the warning sheet after an observation period. If a fracture is found, CT scan should be performed promptly. No patient in group beta with normal skull X rays developed intracranial lesions. The third group (group gamma) contains patients with at least one of the following symptoms: impaired consciousness, repeated episodes of vomiting, neurologic deficits, otorrhagia, otorrhea, rhinorrea, signs of basal skull fracture, seizures, penetrating or perforating wounds, lack of cooperation for varying reasons, patients who have undergone previous intracranial operations or been affected by coagulopathy or submitted to anticoagulant therapy, and finally, epileptic or alcoholic patients. They receive a CT scan immediately and, if necessary, again prior to discharge. Six patients in group gamma with GCS = 15 upon admission were operated on for intracranial hematoma. The fourth group (group delta) is composed of comatose patients. Immediately following resuscitation maneuvers and prior to any surgical intervention, they undergo a CT scan. A linear association between the severity groups and the presence of intracranial lesions has been demonstrated. CONCLUSIONS: The present protocol stresses the importance of the patient's clinical and anamnestic evaluation upon arrival in the Emergency Department, especially in minor head injuries.

Recurrence of brain abscess associated with asymptomatic arteriovenous malformation of the lung.

On the basis of the data provided by literature the majority of patients with an arteriovenous malformation of the lung who develop a brain abscess suffer from hereditary hemorrhagic telangiectasia, or Rendu-Osler-Weber disease. Only nine cases of brain abscesses in which the arteriovenous malformation of the lung was isolated have been described and in all of these, clinical signs and/or alterations in the laboratory data were detected which can be attributed to the arteriovenous malformation itself. The case taken in this article would seem to be the first case of a recurrent brain abscess in a patient not suffering from Rendu-Osler-Weber with a completely asymptomatic arteriovenous malformation of the lung, both from the clinical point of view and from laboratory data. The authors stress the appropriacy of an angiographic pulmonary study in cases of recurrent brain abscesses, even where the chest X-ray has been negative.

Intracranial meningiomas in patients over 70 years old. Follow-up in operated and unoperated cases.

Forty-six cases of intracranial meningioma in patients above 70 years of age form the basis of this study; 34 underwent surgery while 12 did not. The decision to operate was based on the general condition of the patient, evaluated according to the Karnofsky index, neurological conditions, the site and dimensions of the tumor, and the presence of peritumoral edema. The post-surgical mortality rate was 11.5% at 30 days, and 20% at 3 months. Long-term follow-up in both patient groups ranged from 1 to 5 years, and quality of life was evaluated by the Karnofsky index. Five operated patients died during follow-up (only 1 from intracranial pathology); the 22 survivors showed further improvement in their grading level compared to scores immediately following surgery. Among the unoperated patients, 6 died within two years of diagnosis, all from causes related to intracranial pathology; among the survivors, the Karnofsky index was unchanged in 2, and diminished in the other 4 cases.

Depletion of calcitonin gene-related peptide in perivascular nerves during acute phase of posthemorrhagic vasospasm in the rabbit.

The behaviour of various neuropeptides during early and late vasospasm following experimental subarachnoid hemorrhage has been investigated by several authors. Recently, a reduction of the content of vasodilatory neuropeptides (vasodilatory intestinal peptide, substance P and calcitonin gene-related peptide) has been demonstrated in the perivascular nerves of cerebral arteries after few days from induction of experimental subarachnoid hemorrhage. In the present immunohistochemical study, the authors investigated secretion and expression of CGRP a few minutes after injection of autologous blood into the cisterna magna of the rabbit. The authors propose that the marked decrease of calcitonin gene-related peptide immunoreactivity in the perivascular nerves, observed after experimental subarachnoid hemorrhage, is due to compensatory secretion of the peptide.

Regulation of turnover and number of acetylcholine receptors at neuromuscular junctions.

The number and metabolic stability of acetylcholine receptors (AChRs) at neuromuscular junctions of rat tibialis anterior (TA) and soleus (SOL) muscles were examined after denervation, paralysis by continuous application of tetrodotoxin to the nerve, or denervation and direct stimulation of the muscle through implanted electrodes. After 18 days of denervation AChR half-life declined from about 10 days to 2.3 days (TA) or 3.6 days (SOL) and after 18 days of nerve conduction block to 3.1 days (TA). In contrast, the total number of AChRs per endplate was unaffected by these treatments. Denervation for 33 days had no further effect on AChR half-life but reduced the total number of AChRs to about 54% (SOL) or 38% (TA) of normal. Direct stimulation of the 33-day denervated SOL from day 18 restored normal AChR stability and counteracted muscle atrophy but had no effect on the decline in AChR number. The results indicate that motoneurons control the stability of junctional AChRs through evoked muscle activity and the number of junctional AChRs through trophic factors.

Clinical evaluation and long-term follow-up in 16 patients with pseudotumour cerebri.

Medical treatment must be promptly established in patients with pseudotumour cerebri. In fact, even though a spontaneous remission of the symptoms is recognized in the literature, we have not any predictive criteria of future visual impairment.

Developmentally regulated expression of calcitonin gene-related peptide at mammalian neuromuscular junction.

Using indirect immunofluorescence techniques, we have found that calcitonin gene-related peptide-like immunoreactivity is present in the neuromuscular junctions of somatic muscles as well as in almost all motor neurons of the lumbar enlargement of 1-week-old rats. It gradually decreases in both motor neurons and motor nerve endings as the animal grows up and completely disappears from the neuromuscular junctions in adult rats, persisting only in the motor nerve endings on the intrafusal fibers. In situ hybridization experiments have shown that the down-regulation of calcitonin gene-related peptide-like immunoreactivity is strictly related to a reduction in CGRP mRNA levels in the spinal motor neurons. These results indicate that the expression of CGRP is developmentally regulated in spinal cord alpha motor neurons. They also suggest that the peptide may play an important role at the immature neuromuscular junction.