Autoregulation of cortical blood flow during surgery for ruptured intracranial aneurysms.

BACKGROUND: Little information is available about the extent and the time course of possible impairment of cerebral circulation occurring after aneurysmal subarachnoid haemorrhage (SAH). The aim of this study was to correlate cerebral autoregulation, neurological impairment at surgery and timing of surgery in patients with ruptured intracerebral aneurysms. METHODS: Cortical blood flow (CoBF) was measured intraoperatively by a thermal diffusion probe in 77 patients during surgery for ruptured supratentorial aneurysms, who were operated on at different time intervals after bleeding. An autoregulation index (AI), expressed as the ratio between the change in CoBF and the change of mean arterial blood pressure at the time of rising the systemic blood pressure after occlusion of the aneurysm(s), was determined in each case. RESULTS: Among good-grade patients (WFNS grade I-II), those operated on days 0-2 after SAH had a significantly better autoregulatory response, compared either with patients who underwent surgery on days 3-7 after bleeding (p<0.01), or with those whose aneurysm was occluded more than 7 days after rupture (p<0.03). The mean AI of poor-grade patients (WFNS grade IV-V), who received surgery on days 0-2 after SAH, was significantly higher (p<0.01) compared with the corresponding value of good-grade patients. No significant difference was found between the mean AIs of patients who subsequently did, or did not, develop symptomatic vasospasm. CONCLUSIONS: It is concluded that good-grade patients operated on within 48 hours after bleeding take advantage of a preserved autoregulatory function during controlled hypotension.

[Subarachnoid hemorrhage and pregnancy]. / ESA e gravidanza.

Intracranial haemorrhage from ruptured aneurysm or bleeding in arteriovenous malformation is rare, but may result in significant maternal and fetal mortality and serious neurological morbidity in survivors. Surgical intervention creates risks for the mother and her fetus, but is the best form of management. The anaesthetic procedure can present many clinical dilemmas, one of which is the role of induced hypotension. This review will focus on the diagnosis and management of this dramatic event.

Megestrol acetate plus alpha 2a interferon as second line therapy for postmenopausal patients with advanced breast cancer: results of a multicentric phase II trial.

This phase II study was aimed to evaluate the activity of a combination of megestrol acetate (MA) and alpha 2a interferon (IFN) in a group of tamoxifen-responsive breast cancer patients. Thirty patients with metastatic breast cancer either previously treated with adjuvant tamoxifen for at least 24 months or treated with tamoxifen for metastatic disease and showing an objective response or stability of disease, were given MA (single daily dose of 160 mg per os) and alpha 2a IFN (3 million units-MU-three times per week intramuscularly-i.m.-). Of the 29 evaluable patients, 2 (6.8%) achieved a complete response and 4 (13.8%) a partial response for an overall response rate of 20.6% (95% confidence limits = 5.9%-35.4%). Treatment toxicity was mild and no patient had to discontinue or delay the treatment due to IFN side effects. Our results seem to rule out that alpha 2a IFN is able to improve the activity of MA as second-line therapy in tamoxifen-responsive patients.

Ovarian ablation versus goserelin with or without tamoxifen in pre-perimenopausal patients with advanced breast cancer: results of a multicentric Italian study.

BACKGROUND: Oophorectomy is one of the treatments of choice for premenopausal women with advanced breast cancer. However, in recent years LH-RH analogs have replaced surgical castration (or ovarian irradiation) on the basis of the comparable therapeutic activity shown by these drugs in phase II studies. Moreover, the combination of tamoxifen and LH-RH analogs has gained popularity among clinicians attempting to obtain a 'total estrogen blockade' according to the same rationale previously proposed for advanced prostatic cancer. However, it has thus far not been proven that medical castration is as effective as oophorectomy or ovarian irradiation, nor is there enough evidence that tamoxifen could improve the efficacy of ovarian ablation. PATIENTS AND METHODS: Eighty-five perimenopausal patients with estrogen receptor or unknown positive metastatic breast cancer were randomly allocated to receive one of the following treatments: surgical castration (or ovarian irradiation); goserelin; surgical castration (or ovarian irradiation) plus tamoxifen; goserelin plus tamoxifen. The study was performed according to a 2 x 2 factorial randomised design. RESULTS: While overall there was no significant difference in the response rates observed after two by two grouping, a trend did favour oophorectomy (or ovarian ablation) with respect to treatment activity. In fact, the best response rate was observed in patients allocated to this treatment (46.6% OR -95% CL: 21.2-72.9) while the lowest rate was observed in patients treated with oophorectomy plus tamoxifen (11.1% OR: CL: -3.4-25.6). Response to goserelin and goserelin plus tamoxifen was 27.2% (+/- 18.6) and 45% (+/- 21.8), respectively. Logistical regression analysis suggested that there might be a different interaction between tamoxifen and goserelin or oophorectomy (ovarian irradiation), respectively. Nevertheless, patient survivals were comparable, irrespective of allocated treatment. This indicates that two by two grouping has some value with respect to treatment efficacy and shows that oophorectomy (or ovarian irradiation) and goserelin have comparable efficacies. Tamoxifen did not improve the efficacy of gonadal ablation, although it did enhance the activity of goserelin treatment. CONCLUSIONS: The results of the present study confirm prospectively that the efficacy of chemical castration is comparable to that of oophorectomy (or ovarian irradiation). The concurrent use of tamoxifen can probably enhance the activity of goserelin, but it also induces more side effects. However, it doesn't appear that 'total estrogen blockade' is more effective than gonadal ablation alone. Indeed, the question of whether chemical and surgical castration have the same effect in breast cancer is still open as is the one concerning the interaction between tamoxifen and gonadal ablation. Both questions should be addressed by prospective studies.

Cortical blood flow recorded during early or delayed surgery for ruptured intracranial aneurysms.

Forty-three patients were operated on for ruptured intracranial aneurysms during a 12-month-period. Intraoperative evaluation of cortical blood flow by means of a thermal diffusion probe was performed in 23 out of the 41 patients who were operated on for aneurysms of the anterior circulation. The autoregulation index was determined at the time of raising the systemic blood pressure after clipping of the aneurysm(s). No statistically significant difference was found between the averages of the autoregulation indexes calculated in the subgroups of patients submitted respectively to early or delayed surgery. There was no correlation of both cortical blood flow and autoregulation with either age of the patients, or preoperative neurological grade. On the contrary, the autoregulation index showed a statistically significant correlation with outcome.

[Intra- and postoperative cerebral blood flow in patients with subarachnoid hemorrhage from a ruptured aneurysm]. / Flusso ematico cerebrale intra- e postoperatorio in pazienti con emorragia subaracnoidea da fissurazione di aneurisma.

The CBF of eight patients, who underwent surgery for ruptured aneurysm, was monitored using the termodiffusion technique (TDF). The device employed in this investigation allowed a continuous monitoring in "real time" of the cortical flow. The purpose of the study was to detect disorders of autoregulation, which were evaluated with the autoregulation index (AI). Autoregulation was correlated with the neurological preoperative grading, the postoperative changes of CBF (Xe133 clearance) and the outcome. The results of this preliminary study showed a correlation between these parameters and stressed the value of CBF monitoring during surgery.