Ultrasonic dissection system technology in breast cancer: a case-control study in a large cohort of patients requiring axillary dissection.

In the sentinel node era, axillary dissection (ALND) for breast cancer (BC) is required much less frequently than in the past. However, complications, such as prolonged drainage output and seroma formation, are still observed. Harmonic dissection devices (HDDs) are widely used in laparoscopic and minimally invasive surgery to reduce collateral damage during tissue dissection, but its usefulness in breast surgery is unclear. The aim of this study was to evaluate the efficacy of HDDs compared to that of conventional dissection in performing ALND. One hundred thirty-nine women (median age 61 years, range 34-71 years) with confirmed pT1-2 primary infiltrating ductal BC undergoing curative surgery were enrolled in the study. The population was prospectively randomized between two age- and stage-matched arms: group A (cases)-68 (48.9 %) patients (HDD technique), versus group B (controls)-71 (51.1 %) patients (conventional technique). In group B, skin flaps were obtained using a scalpel, scissors, and electrocautery which was never used for ALND. In group A, for each operation time, the HDDs were used exclusively. The mean operative time, intraoperative blood loss, and drainage output were (A vs. B) 95 ± 22 versus 109 ± 25 min, 56 ± 12 versus 86 ± 15 mL, and 412 ± 83 versus 456 ± 69 mL, respectively (p < 0.01). Twenty-nine (20.9 %) patients developed an axillary seroma: 9 (13.2 %) and 20 (28.2 %) for groups A and B, respectively (p = 0.030). Our study confirms that in patients with BC requiring ALND the use of HDDs is more time efficient than conventional surgery, and reduces intraoperative bleeding, the amount of drainage, and the risk of seroma formation. These results may lead to several short- and long-term advantages. Thus, a careful evaluation of the cost-benefits of nontraditional tools, such as HDDs, should be performed in all patients undergoing modified radical or partial mastectomy and ALND for BC.

Glubran 2((r)):a new acrylic glue for neuroradiological endovascular use: a complementary histological study.

SUMMARY: Two Landrace Large White swine underwent angiography by the femoral route. In both cases, the superior left renal artery was embolized by injection of 2 ml of Glubran 2((R)), diluted with Lipiodol 1:1 thereby excluding the superior left kidney poles from blood flow. During the follow-up period, neither pig presented any clinical symptom correlated to the embolization procedure. Case 1 was sacrificed after 30 days and case 2 after 60 days. Macroscopic and microscopic analysis was performed in both animals. Long-term follow-up of the two cases after endovascular injection of Glubran 2((R)) showed that the embolization procedure was well-tolerated by the swine in terms of clinical symptoms and histological findings. Arterial occlusion was stable and a reasonable quantity of scar tissue appeared between 30 and 60 days, surrounding the ischaemic tissue. This follow-up experimental study offers further evidence that Glubran 2((R)) is a safe embolizing material for human use as far as its chemical activity is concerned.

Correlation between MRI findings and long-term outcome in patients with severe brain trauma.

Our aim was to relate MRI findings in patients with severe traumatic brain injury (TBI) to clinical severity and long-term outcome. We studied 37 patients with severe TBI, who were submitted to clinical assessment for disability and cognition and to MRI 60-90 days after trauma. Clinical assessment was also performed 3, 6 and 12 months later. The number and volume of lesions in various cerebral structures were calculated semiautomatically from FLAIR and fast field-echo images. Possible correlations between total and regional lesion volume and clinical deficits were then investigated. The frontal and temporal lobes were most frequently involved. Total lesion volume on FLAIR images correlated significantly with clinical outcome, whereas that on FFE images did not. Regional analysis showed that FLAIR lesion volume in the corpus callosum correlated significantly with scores on disability and cognition scales at the first clinical assessment. FLAIR lesion volume in the frontal lobes correlated significantly with clinical scores 1 year later.

[Usefulness of selective partial inversion recover (SPIR) sequences in optic nerve diseases]. / Utilità delle sequenze "Selective Partial Inversion Recover" (SPIR) nelle malattie del nervo ottico.

PURPOSE: To evaluate the yield of SPIR sequences with fat suppression in the diagnosis of optic nerve lesions. MATERIAL AND METHODS: Ten patients with suspected optic nerve involvement on the basis of clinical data and abnormalities of visual evoked potentials were examined. MRI was performed with a 1.5 T unit (Philips NT 15) using T1 weighted conventional spin-echo and T1- and T2 weighted SPIR sequences with fat suppression. Axial images were obtained along the optic nerve course, while coronal images throughout the optic nerve axis; slices were 3 mm thick. Axial T2 weighted SPIR sequences were also performed with the volumetric technique (1.5 mm thickness); coronal and parasagittal reconstructions along the nerve axis were obtained too. After paramagnetic contrast medium injection, conventional T1 weighted and SPIR sequences were performed on axial and coronal planes. RESULTS: Optic nerve lesions consistent with the diagnosis of neuritis were demonstrated with T2 weighted images in 4 of 10 patients. No abnormalities and/or nerve enlargement were found on T1 weighted images. An enhancement area was seen after contrast medium injection in only one case. MRI showed a pilocytic astrocytoma in one patient and selective atrophy of the right optic nerve in another. MRI showed normal findings in 4 patients. CONCLUSIONS: T1 and T2 weighted fat-suppressed SPIR imaging of the optic nerve improves anatomical definition, lesion detection and characterization in optic nerve conditions.

Pleomorphic xanthoastrocytoma with CT and MRI appearance of meningioma.

We describe a pleomorphic xanthoastrocytoma (PXA) in a young girls whose frontal lobe location, solid structure, dural tail and MRI signal characteristics led to a preoperative diagnosis of meningioma. PXA should be considered in differential diagnosis of tumours affecting young patients with neuroradiological characteristics suggestive of meningioma.

[Assessment with magnetic resonance with Turbo-FLAIR sequences and volumetric analysis of the hippocampal region in drug-resistant temporal epilepsy]. / Valutazione con Risonanza Magnetica con sequenze Turbo-FLAIR e analisi volumetrica della regione ippocampale nell'epilessia temporale farmaco-resistente.

INTRODUCTION: We studied the hippocampal region using Fluid Attenuation Inversion Recovery (Turbo-FLAIR) sequences to detect signal intensity abnormalities, and volumetric sequences to detect cortical thickness changes, in patients with drug-resistant temporal epilepsy. MATERIALS AND METHODS: We examined 30 patients with drug-resistant temporal epilepsy with a 1.5 Tesla unit (NT 15 Philips Gyroscan). Conventional SE, Turbo SE, IR, Turbo-FLAIR, volumetric 3D sequences on coronal plane, PD, T2-weighted SE sequences on axial plane, T1-weighted SE on sagittal plane were performed. Signal intensity and volumetric computerized measurements were obtained using the SUN system. RESULTS: Differences in signal intensity values between the two hippocampal regions were found in 18 patients with Turbo-FLAIR sequences. In 6 of these patients no significant differences in computerized evaluation of signal intensity were detected with either conventional or Turbo-SE sequences. Volumetric analysis showed hippocampal cortex thinning in 9 of 18 patients with hippocampal signal intensity abnormalities. CONCLUSIONS: Turbo-FLAIR were the best sequences for the detection of signal intensity changes in the hippocampal region. Such changes are strongly suggestive of hippocampal sclerosis, especially when associated with cortical atrophy.

Radiological assessment of necrosis in glioblastoma: variability and prognostic value.

In a previous study, we found that the extent of necrosis was the only radiological feature which correlated significantly with survival in patients with glioblastoma. The aim of this paper was to evaluate the variability and prognostic value of the extent of the necrotic area as seen on contrast-enhanced MRI and CT in a larger series. We studied 72 patients who underwent surgical removal of supratentorial glioblastomas and had CT and/or MRI with contrast medium before surgery; 38, all undergoing the same treatment (surgery plus radiotherapy), were followed clinically. Necrosis within the tumour varied greatly, ranging from none (only 1 case) to involvement of 76% of the tumour. Survival data in the subgroup suggested that only patients with a small area of necrosis (less than 35% of the tumour) had a significantly longer survival time. When necrosis involved more than 35% of the mass, patients had a shorter survival time, without any further correlation with the extent of necrosis.

Supratentorial diffuse astrocytic tumours: proposal of an MRI classification.

The aim of this study was to obtain an MRI severity-related classification of diffuse astrocytic tumours able to integrate the histological data in the grading of such tumours. We studied presurgical MR images of 91 patients with a histological diagnosis of astrocytoma, anaplastic astrocytoma and glioblastoma. A score ranging from 1 to 3 was assigned by two independent readers to each of the following MR features: oedema, mass effect, contrast enhancement, borders, signal homogeneity, necrosis, haemorrhage and flow void. Statistical analysis showed significant differences in the mean MRI scores between the three histological grades. Contrast enhancement was found to be the best predictor of the histological grade followed by necrosis, signal homogeneity and border scores. This classification represents a simple and reproducible means of carefully evaluating some macroscopic characteristics of these tumours. It could be used to integrate histological data especially in cases in which tissue sampling defects may affect the validity of this examination.

Supratentorial glioblastoma: neuroradiological findings and survival after surgery and radiotherapy.

Few studies have attempted to correlate neuroimaging with outcome in patients with glioblastoma. Our aim was to evaluate the relationship between neuroradiological findings and survival in these patients. We studied 18 consecutive patients with glioblastoma who had undergone surgery and radiotherapy. We assessed the following features, using preoperative CT and/or MRI: tumour size, extent of necrotic area within the mass, extent of perifocal oedema and contrast enhancement. The mean survival was 14.2 +/- 5 months (range 6-22). The extent of radiological evidence of necrosis within the mass correlated significantly with survival time, whereas tumour size, perifocal oedema and contrast enhancement did not.

Neoplasms of the optic-chiasmatic region.

Diagnosis of neoplasms of the optic-chiasmatic region is facilitated by assessment of onset symptoms. They represent the basis for a specific radiologic study, allowing a differential diagnosis between radiologically similar forms. An easy approach to these neoplasms is to separate malignant lesions from non-neoplastic space-occupying lesions. Diagnostic imaging of neoplasms of the optic-chiasmatic region is based on MRI, occasionally combined with CT. Because of its peculiar embryology, the region is the site of numerous neoformations. However, differential diagnosis is ready in most cases. To plan the most suitable surgical management, the relations of the lesions with adjacent anatomical structures should be carefully assessed. More complex syndromes (gliomas in NF1, infundibulopeduncular histiocytosis in eosinophilic granulomatosis, etc.) should also be considered.

Acetyl-L-carnitine in Alzheimer disease: a short-term study on CSF neurotransmitters and neuropeptides.

Acetyl-L-carnitine (ALCAR) is a drug currently under investigation for Alzheimer disease (AD) therapy. ALCAR seems to exert a number of central nervous system (CNS)-related effects, even though a clear pharmacological action that could explain clinical results in AD has not been identified yet. The aim of this study was to determine cerebrospinal fluid (CSF) and plasma biological correlates of ALCAR effects in AD after a short-term, high-dose, intravenous, open treatment. Results show that ALCAR CSF levels achieved under treatment were significantly higher than the ones at baseline, reflecting a good penetration through the blood-brain barrier and thus a direct CNS challenge. ALCAR treatment produced no apparent change on CSF classic neurotransmitters and their metabolite levels (homovanillic acid, 5-hydroxyindoleacetic acid, MHPG, dopamine, choline). Among CSF peptides, while corticotropin-releasing hormone and adrenocorticotropic hormone remained unchanged, beta-endorphins significantly decreased after treatment; plasma cortisol levels matched this reduction. Since both CSF beta-endorphins and plasma cortisol decreased, one possible explanation is that ALCAR reduced the AD-dependent hypothalamic-pituitary-adrenocortical (HPA) axis hyperactivity. At present, no clear explanation can be proposed for the specific mechanism of this action.

Neurogenic model of migraine.

Activation of peripheral trigeminal fibers induces neurogenic inflammation in rat dura mater, as well as vascular and mat cell changes. These changes parallel an increase of vasodilating and permeability promoting peptides in venous effluent of the cephalic circulation. The experimental model of electrical trigeminal ganglion stimulation or systemic capsaicin administration has proven effective in detecting cellular activation in brainstem trigeminal nuclei. Animal experimental models of trigeminovascular activation and the effects of antimigraine drugs on functional and morphological consequences of such activation provide the background for further models and for developing pharmacological strategies in this field.

[A clinical case of Arnold-Chiari malformation, type I. Neuroradiologic and neurophysiologic study]. / Un caso clinico di malformazione di Arnold-Chiari tipo I. Studio neuroradiologico e neurofisiologico.

The Authors present a case of type I Arnold-Chiari malformation (ACM), with early appearance of clinical symptoms and worsening course of the illness even after surgical treatment. The interest of the case rest both in the rich symptomatology and multiple exams performed which represent the evolution of the neuroradiological techniques of the last thirty years for the study of ACM. Recently, neurophysiologic exams such as somatosensory evoked potentials (SEP) helped to further evaluate these patients. Despite such diagnostic evolution, there is no definite etiopathogenesis. Furthermore, as for therapeutics, the best approach is still the Gardner surgical technique, which, at the moment, is debated for frequent post-operative complications and the absence of significant clinical improvement, especially in the most severe cases.

Comparative evaluation of SPECT, CT and CW Doppler data in patients with ischemic lesions of the brain.

We report the SPECT, CT and CW Doppler findings in a series of 117 patients with cerebral ischemic lesions and correlate them with the clinical findings. SPECT-PAO proved to be more sensitive in localizing focal lesions than CT, which in 50% of the cases was normal or yielded an image of cerebral atrophy. In the latter cases CW Doppler ultrasound on the supraaortic trunks showed changes, circumscribed or diffuse. On the CW Doppler and SPECT evidence we consider that the CT image of cerebral atrophy may denote an alteration of the cerebral blood flow and metabolism and should be assessed in this light in the diagnosis and prognosis of cerebral ischemic lesions.

Neuroradiological, neurophysiological and anatomopathological study of a case of locked-in syndrome.

We report an anatomoclinical case of locked-in syndrome together with the neuroradiological and neurophysiological findings. MRI confirmed its value in the diagnosis of posterior cranial fossa pathology while the neurophysiological work-up (BAEPs, SEPs, MAPs and TEPs) revealed that the lesion may have broader functional implications than may be gauged from the neuroradiological and pathological evidence. Evoked potentials may therefore be of considerable importance in pinpointing brainstem lesions.