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1.
Neurosurg Rev ; 41(2): 391-398, 2018 Apr.
Article in English | MEDLINE | ID: mdl-27426100

ABSTRACT

Ethmoidal dural arteriovenous fistulae are rare vascular malformations associated with a high risk of bleeding. We present a multicenter contemporary series of patients treated with microsurgical and endovascular techniques. Sixteen consecutive patients were evaluated and/or treated between 2008 and 2015 at four centers with large experience in the endovascular and surgical treatment of cerebrovascular diseases. We analyzed demographic and clinical data, risk factors for dural fistulas, treatment type, peri- and post-operative morbidity, clinical and radiological outcomes, rates of occlusion, and long-term neurological outcome. Sixteen patients (81 % men, mean age of 58 years) with ethmoidal dural fistulas were included in the analysis. Seven patients had suffered an intracranial hemorrhage; the remaining presenting with neurological signs and symptoms or the fistula was an incidental finding. Three patients were managed conservatively. Among patients who underwent intervention (n = 13), 46.1 % were treated with endovascular therapy and 53.9 % were treated surgically. Complete angiographic obliteration was achieved in 100 % immediately after treatment and at last follow-up evaluation. All patients experienced a favorable neurological recovery (mRS 0-2) at the last follow-up visit (12 months). Ethmoidal dural AVFs are found mostly in male patients. Nowadays, due to wider use of non-invasive imaging, AVFs are discovered with increasing frequency in patients with minimal or no symptoms. Traditionally, these fistulas were considered "surgical." However, in the modern endovascular era, selected patients can be effectively and safely treated with embolization although surgical ligation continues to have an important role in their management.


Subject(s)
Central Nervous System Vascular Malformations/surgery , Cranial Fossa, Anterior/blood supply , Embolization, Therapeutic/methods , Microsurgery , Adult , Aged , Aged, 80 and over , Central Nervous System Vascular Malformations/diagnostic imaging , Cerebral Angiography , Cranial Fossa, Anterior/diagnostic imaging , Female , Humans , Intracranial Hemorrhages/diagnostic imaging , Intracranial Hemorrhages/surgery , Male , Middle Aged , Tomography, X-Ray Computed , Treatment Outcome , Young Adult
2.
Neurosurg Rev ; 38(1): 197-202; discussion 202-3, 2015 Jan.
Article in English | MEDLINE | ID: mdl-25323097

ABSTRACT

Blood blister-like aneurysms (BBA) were described for the first time in the 1990s, as small hemispherical bulges arising from a very fragile arterial wall. Until 2008, it was thought that this type of aneurysm almost exclusively affected the internal carotid artery, in particular, its dorsal portion. Subsequently, it was discovered that a BBA may also be present on the anterior communicating artery and on the vessels of the posterior cranial fossa. However, we found no reports in English-language literature of BBA arising from the middle cerebral artery (MCA). In this article, we present three cases of MCA BBA and discuss the unique diagnostic and therapeutic aspects of this vascular lesion. In our retrospective, multicenter review of 1330 patients with non-traumatic subarachnoid hemorrhage admitted to our services from 2000 to 2013, we found three cases (all in men) of MCA BBA. The patients' outcome was assessed using the modified Rankin scale. All three patients underwent angio-computed tomography, which did not reveal any aneurysms. Digital subtraction angiography performed within 24-48 h after admission, in all cases, demonstrated a very small aneurysm (<2 mm), with a triangular shape and abroad base, at non-branching sites of MCA. All the aneurysms were treated: one by wrapping + clipping, one by wrapping + flow-diverter stent, and one with coils. At the time of surgery, the aneurysms appeared on the surface of the parent artery without any involvement of the branches. All presented as blister-like aneurysms that were thin-walled and lacked a surgical neck. At the time of discharge, the outcome was good in one patient and poor in the other two. Our cases demonstrate that BBA can also arise from the MCA, despite the lack of previous reports of this occurrence; a BBA should be suspected, particularly in cases of non-perimesencephalic subarachnoid hemorrhage in which the presence of a MCA aneurysm is suspected but not revealed by digital subtraction angiography or angio-computed tomography.


Subject(s)
Aneurysm, Ruptured/surgery , Anterior Cerebral Artery/surgery , Intracranial Aneurysm/diagnosis , Intracranial Aneurysm/surgery , Adult , Aged , Aneurysm, Ruptured/diagnosis , Cerebral Angiography/methods , Humans , Male , Retrospective Studies , Treatment Outcome
3.
Eur J Trauma Emerg Surg ; 40(3): 343-50, 2014 Jun.
Article in English | MEDLINE | ID: mdl-26816070

ABSTRACT

PURPOSE: Traumatic fractures to the craniovertebral junction (CVJ) are rare events requiring complex clinical management. Several classification systems are currently in use; however, recent improvements of junctional knowledge has focused attention on the role of ligaments and membranes in vertebral biomechanical stability. The aim of this study was to present our preliminary experience with the "MILD" score scale, which should allow fast and effective classification of all CVJ traumatic fractures based on vertebral instability in the acute setting. METHODS: A prospective study was conducted on 38 consecutive patients with 43 traumatic junctional fractures identified by computed tomography (CT) scan in the acute trauma phase. The MILD scale was applied to all fractures, and a score was obtained for each patient. All cases underwent magnetic resonance imaging (MRI) to assess the anatomical integrity of ligaments and membranes. RESULTS: Twenty-seven patients (71 %) were classified as MILD type 1 (0-1 points), showed a negative MRI, and healed with conservative treatment. Eight patients (21 %) were classified as MILD type 2 (2 points) and showed modest indirect signs of ligamentous injuries. Four of these patients healed with conservative treatment, while three patients underwent surgery due to wide bone fracture fragment displacement. Three patients (8 %) were classified as MILD type 3 (3 points), all of whom showed extensive ligamentous damage and underwent surgery. CONCLUSIONS: The close association between the MILD scale and spinal instability is promising, although further studies are warranted in order to confirm our preliminary data.

4.
Acta Neurochir (Wien) ; 150(9): 879-86; discussion 887, 2008 Sep.
Article in English | MEDLINE | ID: mdl-18754072

ABSTRACT

INTRODUCTION: The risk of leaving a remnant after surgery for a cavernous malformation in the brainstem is generally not stressed enough, even though such remnants appear to have a high risk of re-bleeding. At least 40% of known cavernoma remnants after surgery have further bleeding episodes. A retrospective analysis of 30 patients with brainstem cavernoma who underwent surgery is presented, focusing on incidence, risk factors and management of post-surgical residuals. The sites were, medulla in three patients, pons-medulla in four, pons in 16, pons-midbrain in four and midbrain in three. All 30 patients came to our clinical observation with at least one episode of acute-onset neurological deficit and all were operated in the sub-acute phase. Only one patient had a worse stable outcome than the pre-surgical state, and 29 did better or were stable. All patients had a brain MRI scan within 72 h after surgery to confirm that complete removal had been achieved. In three, although the surgical cavity and its border appeared clean at the end of surgery, with no lesion remaining, post-operative MRI detected a residuum. These three patients were re-operated, but one had a further bleed prior to excision. MATERIALS AND METHODS: In our series, the surgical finding of a multi-lobular cavernoma (as opposed to the more frequent finding of a discrete lesion with a thick capsule), with a thin wall and satellite nodules separated by a thin layer of apparently intact white matter, was common (seven patients). This group included the three patients with evidence of residuum on post-operative MRI. In our experience, the surgical finding of a multi-lobular cavernoma carries a higher risk of residuum and post-surgical re-bleeding. CONCLUSION: Immediate post-operative brain MRI scans are therefore strongly recommended for their detection, especially in this group of patients, and if a residual is detected early re-intervention is less risky than the natural history.


Subject(s)
Brain Stem Neoplasms/surgery , Hemangioma, Cavernous, Central Nervous System/surgery , Neurosurgical Procedures , Adolescent , Adult , Brain Stem Neoplasms/pathology , Child , Child, Preschool , Hemangioma, Cavernous, Central Nervous System/pathology , Humans , Incidence , Magnetic Resonance Imaging , Middle Aged , Neoplasm, Residual/diagnosis , Neoplasm, Residual/epidemiology , Neoplasm, Residual/surgery , Postoperative Period , Reoperation , Risk Factors , Time Factors , Treatment Outcome , Young Adult
5.
Acta Neurochir (Wien) ; 149(12): 1255-7; discussion 1257, 2007 Dec.
Article in English | MEDLINE | ID: mdl-17987255

ABSTRACT

A 45-year-old man presented with a history of dysaesthesiae, sensory impairment of the legs and sphincter disturbances. Selective angiography showed a mid-thoracic dural arterio-venous fistula with five shunt points. The venous plexuses were demonstrated by injections at T5 on the right side and T6 on the left, but the venous pattern on the two sides did not overlap. Angiography did not unquestionably point to any single location of a fistula, as would normally be expected. During surgery five dorsal locations of shunt were identified. We have not found any publication describing a spinal dural arterio-venous fistula with multiple venous drainage channels at the same level.


Subject(s)
Angiography , Central Nervous System Vascular Malformations/diagnostic imaging , Myelography , Spinal Cord Compression/diagnostic imaging , Central Nervous System Vascular Malformations/surgery , Electrocoagulation , Follow-Up Studies , Humans , Laminectomy , Male , Middle Aged , Neurologic Examination , Phlebography , Postoperative Complications/diagnostic imaging , Spinal Cord Compression/surgery , Thoracic Vertebrae/blood supply , Thoracic Vertebrae/surgery
6.
Acta Neurochir (Wien) ; 142(6): 677-83; discussion 683-4, 2000.
Article in English | MEDLINE | ID: mdl-10949443

ABSTRACT

The GDC endovascular approach represent an effective alternative to surgery for treatment of intracranial aneurysms. Anyway no data are available about the impact of endovascular embolization with GDC on overall outcome of patients with subarachnoid hemorrhage. We analyse retrospectively a series of 234 patients admitted for ruptured intracranial aneurysm. Results were then compared with results of three surgical series from the literature. The 95.7% of patients underwent aneurysm treatment; 56.4% of patients were classified as good recovery, 12.8% presented moderate disability, 10.3% were severely disabled, 3% were in persistent vegetative state and 17.5% were dead. Patients older than 60 years accounted for 37% of all cases and good outcome in this group accounted for 54.7%. Good results were obtained in 90.1%, 61.7% and 22.8% of patients with Hunt-Hess grade I-II, III and IV-V respectively. Finally good outcome was observed in 82.8% of patients with aneurysms of the posterior circulation. Introduction of GDC embolization in clinical practice contributed to the extension of indication for aneurysm treatment leading to a reduction of overall mortality. GDC utilisation does not affect the overall percentage of patients with good outcome reflecting an increase of severely disabled patients. Endovascular treatment seems an effective theraputic choice in selected grade I-II patients. Results in grade III patients suggest that surgery may be advantageous because of washing and decompression of the basal cisterns while results in grade IV and V patients are unsatisfactory. GDC embolization clearly improves the prognosis of patients with posterior circulation aneurysms and probably is an advantageous theraputic choice in elderly patients.


Subject(s)
Aneurysm, Ruptured/complications , Embolization, Therapeutic/methods , Intracranial Aneurysm/complications , Subarachnoid Hemorrhage/etiology , Subarachnoid Hemorrhage/therapy , Adolescent , Adult , Aged , Aged, 80 and over , Embolization, Therapeutic/instrumentation , Female , Humans , Male , Middle Aged , Prognosis , Retrospective Studies , Subarachnoid Hemorrhage/mortality , Subarachnoid Hemorrhage/surgery , Treatment Outcome
7.
J Neurosurg Anesthesiol ; 8(2): 137-41, 1996 Apr.
Article in English | MEDLINE | ID: mdl-8829561

ABSTRACT

Intravenous hypertonic fluid therapy has been proposed to improve secondary ischemic injury after cerebrospinal trauma. We report the case of a 14-year-old boy with vasospasm of the intracranial vertebral arteries and ischemic brain stem damage following head trauma. The patient presented with severe tetraparesis and somatosensory (SSEPs) and brain stem auditory evoked potentials (BAEPs) impairment. The patient was treated with two subsequent hypertonic saline (HS) infusions, 2.7% and 5.4%, respectively, for a period of 48 sp, followed by standard hypervolemic therapy. After the first treatment with 2.7% HS, improvement of SSEPs without neurological improvement was apparent. Relative hypervolemia was subsequently maintained by administration of crystalloids and 20% albumin for 48 h. During standard hypervolemic therapy, no clinical and/or electrophysiological change occurred. The second infusion of 5.4% HS was concomitant with further amelioration of SSEPs and improvement of motor performance. Twelve hours after the second HS infusion, the neurological status returned to preinfusion levels, while SSEPs showed no further changes. BAEPs never changed during fluid therapy. No complication occurred secondary to the infusion of HS. This case report suggests that local improvement of brain stem perfusion following hypertonic fluid therapy accounts for or relevantly contributes to the neurological and SSEPs improvement of the patient.


Subject(s)
Brain Ischemia/therapy , Brain Stem/injuries , Saline Solution, Hypertonic/therapeutic use , Accidents, Traffic , Adolescent , Brain Ischemia/etiology , Brain Stem/blood supply , Cerebrovascular Circulation/physiology , Evoked Potentials, Auditory, Brain Stem/physiology , Evoked Potentials, Somatosensory/physiology , Glasgow Coma Scale , Humans , Magnetic Resonance Imaging , Male
8.
Interv Neuroradiol ; 1(1): 65-70, 1995 Nov 30.
Article in English | MEDLINE | ID: mdl-20684809

ABSTRACT

SUMMARY: Intensive care of patients with SAH is targeted to recognize and treat the leading cause of death and disability. Hemorrhage, vasospasm, rebleeding, intracranial hypertension can produce ischaemia because the ratio between metabolism (CMR0 (2) ) and cerebral blood flow (CBP) is not coupled. Neuro-ICU bedside monitoring provides information on the intracranial dynamics. Aggressive treatment attempts to avoid ischaemia but needs a clipped or thrombosed (via endovascular approach) aneurysm. The authors propose treatment to improve CBP and reduce CMRO (2) : hypervolaemia, hemodilution, hypertension, ICP reduction, normocapnia, mannitol infusion, normothermia or mild hypothermia and sedation with intravenous anaesthetics. Medical complications such as hypovolemia, infections, pulmonary oedema, gastrointestinal bleeding need to be recognized early and treated.

9.
Riv Ital Odontoiatr Infant ; 1(2): 21-8, 1990.
Article in Italian | MEDLINE | ID: mdl-2126960

ABSTRACT

The coronal fractures of the upper incisors for traumatic injuries represent the 8% of the total dental trauma. The use of new dentinal adhesive have permitted to obtain new interesting development in dental traumatology and dental esthetic, like the possibility of the utilisation of the dental fragment, of the incisor broken for a trauma. The new dentinal adhesive is the Gluma (Bayer). The Authors describe the technique, the times, some particulars and step by step all the method to obtain good final results. Finally are presented all the advantages compared to the traditional methods with the composites materials.


Subject(s)
Dental Bonding , Dental Cements , Glutaral , Incisor/injuries , Polymethacrylic Acids , Tooth Fractures/therapy , Adhesives , Calcium Hydroxide , Child , Dentin , Humans
10.
Article in English | MEDLINE | ID: mdl-3189021

ABSTRACT

Deliberate arterial hypotension is currently used to operate upon cerebral aneurysms. However, it is not ascertained whether this practice is really safe for all patients, especially those presenting with preoperative vasospasm. 50 patients, requiring surgical treatment for cerebral aneurysm, have been submitted, during surgery, to the recording of Somatosensory Evoked Potentials (SEPs) on median nerve stimulation. This technique allows the functional evaluation of neural pathways mediating the somatosensory stimuli and of primary somatosensory cortex; it is known that a decrease of cerebral perfusion may affect the SEP waveforms in terms of reduced subcortical conduction velocity (i.e., increased central conduction time, CCT) and of reduced cortical response amplitude. These changes may be apparent before a permanent neurological damage is produced. Preoperative SEP recording demonstrated a prolonged CCT, possibly related to vasospasm, in 9 patients, a normal clinical evaluation notwithstanding (grade I and II). During intraoperative deliberate hypotension, a SEP change has always been produced. No postoperative damage has been observed, however, as long as the CCT did not exceed 9 msec for 10 minutes (maximum normal CCT value is 6.7 msec) and as the cortical response had been visible throughout the whole surgical procedure. The critical value of CCT has been reached at a mean arterial pressure (MAP) lower than 60 Torr in patients with a normal preoperative SEP recording; at the opposite, in patients presenting with a prolonged preoperative CCT, the value of 9 msec was arrived at with a MAP value that is generally accepted as safe for all patients (75 Torr).(ABSTRACT TRUNCATED AT 250 WORDS)


Subject(s)
Brain/physiopathology , Evoked Potentials, Somatosensory , Intracranial Aneurysm/surgery , Monitoring, Physiologic , Anesthesia , Brain/surgery , Evoked Potentials, Auditory , Humans , Intracranial Aneurysm/physiopathology , Neural Conduction
12.
J Neurosurg Sci ; 30(1-2): 61-6, 1986.
Article in English | MEDLINE | ID: mdl-3772498

ABSTRACT

26 patients harbouring a CSF shunt for non-tumoral aqueductal stenosis hydrocephalus underwent Brainstem Acoustic Evoked Potentials (BAEPs) recording, to evaluate brainstem function. Only 6 patients presented with normal responses both at standard and at sensitized tests. In the remaining 19 patients, BAEPs were abnormal, bilaterally in 10 cases, monolaterally in 9. Four out of the 6 normal responses belonged to the group recognized of congenital origin. As refers to ventricular size BAEPs were abnormal in 62% of patients with normal ventricle and in 92% of patients with enlarged ventricles. The most significant BAEPs abnormalities were found in patients with maximal ventricular dilation. It appears that BAEPs abnormalities are to the ascribed to both primary and secondary brainstem dysfunction: no reliable criterion to differentiate between these two possibilities is evident. In the individual patient, serial BAEPs recording may contribute to recognize the early phase of supratentorial hypertension due to shunt dysfunction.


Subject(s)
Brain Stem/physiopathology , Cerebral Aqueduct , Cerebrospinal Fluid Shunts , Evoked Potentials, Auditory , Hydrocephalus/physiopathology , Adolescent , Adult , Brain Diseases/complications , Brain Diseases/physiopathology , Brain Diseases/surgery , Child , Child, Preschool , Humans , Hydrocephalus/complications , Hydrocephalus/surgery , Nervous System Diseases/complications , Nervous System Diseases/physiopathology
13.
J Exp Psychol Hum Percept Perform ; 11(6): 828-45, 1985 Dec.
Article in English | MEDLINE | ID: mdl-2934511

ABSTRACT

In two experiments we explore the structure of complex sequences of drawing movements. We find that in these movements a single parameter--the velocity gain factor--relates the geometrical and kinematic aspects of the movement trajectory via a two-thirds power law. In Experiment 1 we investigate the relation between the velocity gain factor and the linear extent of the trajectory. In Experiment 2 we demonstrate that the gain factor provides a criterion for segmenting the movement into distinct units of motor action, and we investigate the effects of the speed of execution on this segmentation. A theoretical analysis shows that the results of both Experiments 1 and 2 can be given a unitary interpretation by assuming a coupling function of variable strength between segments. The general problem of representing motor programs is discussed within this theoretical framework.


Subject(s)
Psychomotor Performance , Adult , Female , Humans , Male , Mathematics , Motor Skills
15.
Childs Nerv Syst ; 1(5): 282-7, 1985.
Article in English | MEDLINE | ID: mdl-4084912

ABSTRACT

Visual evoked potentials (VEP) were recorded in 20 children undergoing dialysis for chronic renal failure. VEP before treatment (72 h after last dialysis) were pathological in 17 patients (85%); responses obtained 3 h after treatment were abnormal in only 6 cases (30%). Furthermore, all patients improved after treatment, except two who were unchanged. However, VEP recorded immediately after dialysis were worse in 4 of 7 patients than before treatment, probably as an effect of the dysequilibrium syndrome; they improved spontaneously afterwards. The acute changes caused by dialysis seem to be more evident in children than in adults. No correlations have been found between blood chemistry indexes and VEP modifications. Finally, VEP have proved to be more sensitive than EEG in identifying a central nervous system (CNS) dysfunction in these uremic patients.


Subject(s)
Evoked Potentials, Visual , Renal Dialysis/adverse effects , Adolescent , Child , Child, Preschool , Electroencephalography , Female , Humans , Male , Time Factors
16.
Electroencephalogr Clin Neurophysiol ; 53(3): 338-42, 1982 Mar.
Article in English | MEDLINE | ID: mdl-6174311

ABSTRACT

The influence of the brain stem reticular formation (RF) on transfer of somatosensory information has been studied in intact cats and in cats with a chronic hemisection of the brain stem at the pretrigeminal level. An air-jet applied to the hairy skin receptive field evoked the discharge of thalamocortical relay cells in nucleus ventralis postero-lateralis, extracellularly recorded. Conditioning stimuli were brief trains of electrical pulses to mesencephalic (MRF) and bulbar (BRF) reticular formation. In intact cats both MRF and BRF induced in a small percentage of cells slight facilitation or inhibition of evoked discharge. In pretrigeminal cats MRF stimulation increased the probability of discharge in response to peripheral stimuli, whereas BRF stimulation induced a striking decrease in evoked firing in a great percentage of neurones. It is suggested that RF activation can decrease the incoming peripheral volley by means of its caudalmost part, while it is able to enhance thalamic response by way of the more rostral structures.


Subject(s)
Brain Stem/physiology , Mechanoreceptors/physiology , Mesencephalon/physiology , Reticular Formation/physiology , Somatosensory Cortex/physiology , Synaptic Transmission , Thalamus/physiology , Afferent Pathways/physiology , Animals , Cats , Electric Stimulation , Electroencephalography , Evoked Potentials, Somatosensory , Neural Inhibition , Neurons/physiology
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