Negative MRI and a seizure onset zone close to eloquent areas in FCD type II: Application of MRg-LiTT after a SEEG re-evaluation in pediatric patients with a previous failed surgery.

OBJECTIVE: Negative MRI and an epileptogenic zone (EZ) adjacent to eloquent areas are two main issues that can be encountered during pre-surgical evaluation for epilepsy surgery. Focal Cortical Dysplasia type II (FCD type II) is the most common aetiology underlying a negative MRI. The objective of this study is to present three cases of pediatric patients exhibiting negative MRI and a seizure onset zone close to eloquent areas, who previously underwent traditional open surgery or SEEG-guided radiofrequency thermocoagulations (RF-TC). After seizure seizure recrudescence, pre-surgical SEEG was re-evaluated and Magnetic Resonance-guided laser interstitial thermal therapy (MRg-LiTT) was performed. We discuss the SEEG patterns, the planning of laser probes trajectories and the outcomes one year after the procedure. METHODS: Pediatric patients who underwent SEEG followed by MRg-LiTT for drug-resistant epilepsy associated with FCD type II at our Centre were included. Pre-surgical videoEEG (vEEG), stereoEEG (sEEG), and MRI were reviewed. Post-procedure clinical outcome (measured by Engel score) and complications rates were evaluated. RESULTS: Three patients underwent 3 MRg-LiTT procedures from January 2022 to June 2022. Epileptogenic zone was previously studied via SEEG in all the patients. All the three patients pre-surgical MRI was deemed negative. Mean age at seizure onset was 47 months (21-96 months), mean age at MRg-LiTT was 12 years (10 years 10 months - 12 years 9 months). Engel class Ia outcome was achieved in patients #2 and #3, Engel class Ib in patient #1. Mean follow-up length was of 17 months (13 months - 20 months). Complications occurred in one patient (patient #2, extradural hematoma). CONCLUSIONS: The combined use of SEEG and MRg-LiTT in complex cases can lead to good outcomes both as a rescue therapy after failed surgery, but also as an alternative to open surgery after a successful SEEG-guided Radiofrequency Thermocoagulation (RF-TC). Specific SEEG patterns and a previous good outcome from RF-TC can be predictors of a favourable outcome.

Transient meningism in children after non-autologous duraplasty for Chiari Malformation surgery: A case series.

BACKGROUND: Increasing the posterior fossa volume is the mainstay of treatment for Chiari type 1 Malformation (C1M) and type 1.5 (C1.5M). Different options to restore CSF flow have been described but no consensus has been reached yet. Bony decompression of posterior cranial fossa with dural opening provides good results but at the price of complications such as pseudomeningocele and aseptic meningitis. A single center retrospective analysis was conducted to find any relationships between outcome and perioperative factors. As a second goal a specific analysis was conducted on the complications and their hypothetical causes. METHODS: All the pediatric patients who underwent to posterior fossa bony decompression and dural opening for C1M or C1.5M in the period 2008-2020 were included in the study. A minimum period of three-months follow-up was considered among the inclusion criteria. RESULTS: A population of fifty-three consecutive patients was collected. Pseudomeningocele and a mild meningeal irritation resulted the most frequent complications. Considering preoperative and intraoperative factors, the type of dural graft showed a relatively strong correlation (P<.01) with pseudomeningocele appearance and the development of meningism. In the latter case, a short course of steroids was the only treatment required to control symptoms. CONCLUSIONS: Different factors could influence the outcome in Chiari Malformation surgery and eventually the development of complications. An adequate dural graft selection is of paramount importance when a dural opening for posterior fossa augmentation is planned. In case of mild meningeal irritation, a trial with short course steroids could avoid revision surgery.

Noninvasive Assessment of Hemodynamic Stress Distribution after Indirect Revascularization for Pediatric Moyamoya Vasculopathy.

BACKGROUND AND PURPOSE: Indirect revascularization surgery is an effective treatment in children with Moyamoya vasculopathy. In the present study, we hypothesized that DSC-PWI may reliably assess the evolution of CBF-related parameters after revascularization surgery, monitoring the outcome of surgical pediatric patients with Moyamoya vasculopathy. Thus, we aimed to evaluate differences in DSC-PWI parameters, including the hemodynamic stress distribution, in surgical and nonsurgical children with Moyamoya vasculopathy and to correlate them with long-term postoperative outcome. MATERIALS AND METHODS: Pre- and postoperative DSC parameters of 28 patients (16 females; mean age, 5.5 ± 4.8 years) treated with indirect revascularization were compared with those obtained at 2 time points in 10 nonsurgical patients (6 females; mean age, 6.9 ± 4.7 years). We calculated 4 normalized CBF-related parameters and their percentage variance: mean normalized CBF of the MCA territory, mean normalized CBF of the proximal MCA territory, mean normalized CBF of cortical the MCA territory, and hemodynamic stress distribution. The relationship between perfusion parameters and postoperative outcomes (poor, fair, good, excellent) was explored using 1-way analysis of covariance (P < .05). RESULTS: A significant decrease of the mean normalized CBF of the proximal MCA territory and hemodynamic stress distribution and an increase of the mean normalized CBF of the cortical MCA territory were observed after revascularization surgery (P < .001). No variations were observed in nonsurgical children. Postoperative hemodynamic stress distribution and its percentage change were significantly different in outcome groups (P < .001). CONCLUSIONS: DSC-PWI indices show postoperative hemodynamic changes that correlate with clinical outcome after revascularization surgery in children with Moyamoya disease.

A prospective, randomised, cross-over trial comparing two standard polyvinyl chloride tracheal tubes. Are all the tubes the same? / Estudio prospectivo, aleatorizado y cruzado que compara 2 tubos endotraqueales de polivinilo. ¿Son todos los tubos iguales?

BACKGROUND: A randomised study was conducted on the number of attempts made during the conventional endotracheal intubation of a mannequin using two polyvinyl (PVC) tracheal tubes, apparently similar but from different manufactures: INTERSURGICAL (IS; Intersurgical S.L., Madrid, Spain) and Mallinckrodt (ML; Mallinkrodt Medical S.A., Madrid, Spain). METHODS: A total of 26 anaesthesiologists, in randomly established order (generated by Epidat 3.1) intubated a mannequin twice using a different tube each time. The tubes were masked by painting them to prevent recognition. The main outcome of the study was to compare the number of attempts needed to complete the manoeuvre for each tube. Data on intubation time and failed intubations were also collected. RESULTS: The number of attempts with the ML tube was significantly lower than with the IS tube. Intubation was completed on the first attempt with the ML tube in 93.3% of cases, while using the IS tube the percentage fell to 30.8% (Fisher exact test, P<.001). The time required to complete the manoeuvre was greater with the IS tube (median 10.8seconds, interquartile range 6-22) than with the ML tube (median 4.4seconds, interquartile range 3.5 to 6.3). CONCLUSIONS: The PVC tube from the ML manufacturer was superior when compared with the IS, the latter was also associated with a larger number of attempts to complete intubation using a conventional Macintosh blade.

Development and optimization of a method for analyzing biodiesel mixtures with non-aqueous reversed phase liquid chromatography.

Biodiesel (a mixture of fatty acid esters) is normally analyzed using gas chromatography/flame ionization detection, as specified by the ASTM D6584 and EN14105 standards. This paper proposes a binary gradient method for analyzing biodiesel mixtures using non-aqueous reverse phase HPLC with a UV detector capable of overcoming the drawbacks of the gas chromatographic technique normally used. The new analytical method was developed by means of a statistical sensitivity analysis applied to the main parameters influencing the recording, using the full factorial design method combined with the Yates algorithm and the steepest ascent optimization procedure. The present study shows the influence of the main biodiesel mixture separation analysis parameters. The resulting tool proved valid for analyzing not only biodiesel but also any traces of unreacted oil.

A comparative study on ferritin concentration in serum and bilateral bronchoalveolar lavage fluid of patients with peripheral lung cancer versus control subjects.

OBJECTIVES: To assess the diagnostic value of bronchoalveolar lavage fluid (BALF) ferritin as a lung tumor marker by comparing serum and BALF ferritin concentrations in patients with peripheral lung cancer versus control subjects with benign lung disease, and to examine the theory of ferritin compartmentalization around the tumor area by comparing ferritin concentrations in serum and bilateral (affected and unaffected side) BALF in cancer patients. METHODS: Four groups of patients were investigated: 10 control nonsmokers, 10 control smokers, 10 smokers with chronic obstructive pulmonary disease (COPD), and 22 patients with primary bronchogenic carcinoma. A bronchoalveolar lavage (BAL) was performed in all subjects (both sides in 13 oncological patients, one side in the others) and samples of BALF and blood were submitted to biochemical analysis. RESULTS: As a lung tumor marker, BALF ferritin showed 54% sensitivity and 93% specificity and serum ferritin 22% sensitivity and 93% specificity. A significant difference was observed between the two sides in the cancer patients (p = 0.033), and between BALF ferritin from the affected side and COPD patients (p = 0.025). Greater differences were obtained when BALF ferritin in the affected side of cancer patients was compared with values in both control nonsmokers (p < 0.0001) and control smokers (p < 0.001). CONCLUSIONS: These findings seem to confirm the relative diagnostic value of BALF ferritin as a lung tumor marker and the theory of ferritin compartmentalization. However, further studies are required to clarify the relations between iron and ferritin on the one hand and inflammation, tumorigenesis and host response on the other.

Gd-HP-DO3A in clinical MR imaging of the brain.

As part of a phase II clinical trial, 14 patients with presumed intracranial neoplastic disease underwent magnetic resonance (MR) imaging before and after intravenous injection of gadolinium 1,4,7-tris(carboxymethyl)-10-(2'-hydroxypropyl)-1,4,7,10-tetraazacycl ododecane (HP-DO3A). This neutral (nonionic) gadolinium chelate has lower osmolality, when formulated at equimolar concentrations, and superior in vitro stability compared with gadopentetate dimeglumine. The safety profile of Gd-HP-DO3A permitted administration of doses up to 0.3 mmol/kg, three times the dose of gadopentetate dimeglumine approved by the U.S. Food and Drug Administration. In this limited clinical trial, Gd-HP-DO3A proved to be a safe and efficacious agent in MR imaging of the head. The only change documented in patient monitoring was that of slight skin redness at the injection site immediately after administration in two patients. No statistically significant changes due to administration of the agent were noted in laboratory evaluations. These results differ from those obtained with gadopentetate, which induces a transient rise in serum iron and bilirubin levels in up to 26% of patients. Administration of higher doses of Gd-HP-DO3A, either 0.2 or 0.3 mmol/kg, appeared to provide improved enhancement. No decrease in efficacy at these high doses was noted.

The prospective evaluation of Gd-DTPA in 225 consecutive cranial cases: adverse reactions and diagnostic value.

This prospective study evaluates two facets of gadopentetate dimeglumine (Gd-DTPA) enhanced MR imaging in 225 consecutive cranial cases in patients greater than 18 years of age: (i) patient and physician perception of adverse reactions, (ii) diagnostic value of the Gd-DTPA enhanced exam. The 225 cases included 173 head cases, 27 IAC cases, and 25 sella cases. Forty-six percent of the cases were abnormal excluding cases of mild atrophy and ischemic white matter disease judged to be related to aging and not pertinent to the patient's presenting complaint. Concerning adverse reactions, 83% of patients had no complaints. Five percent of the patients had reactions that were judged by the physician to be related to Gd-DTPA. All reactions were minor and required no therapy. In a subset of exams (115) that were blindly and independently interpreted by two board-certified, fellowship-trained radiologists, the Gd-DTPA-enhanced exam resulted in a change in diagnosis in 5%-8% of cases. Additionally, a major benefit of Gd-DTPA administration was the increased diagnostic confidence afforded by the addition of a contrast enhanced exam due to improved lesion characterization and exclusion of additional significant intracranial pathology. In 52%-69% of the abnormal cases, Gd-DTPA provided additional diagnostic information and in 26%-39% the absence of enhancement aided in interpretation. The Gd-DTPA-enhanced exam aids in the diagnosis and characterization of neoplastic disease, acoustic neuroma, subacute infarction, inflammatory disease (meningeal and parenchymal), and certain vascular abnormalities.

Immunodiagnosis of acute leukemia displaying ectopic antigens: proposal for a classification of promiscuous phenotypes.

The nature of the blast cells in 163 cases of acute leukemia was investigated by immunophenotyping, with particular emphasis on the expression of "ectopic" surface membrane structures. Although no antigen included in our panel except CD3 revealed absolute lineage restriction, immunological typing allowed a definite characterization of blast cells in more than 90% of cases. Four groups of patients were identified (A, B, C, D) with different degrees of antigen ectopic expression. We classified as group A leukemias (74%) those expressing conventional antigenic patterns, in absence of cross-lineage markers. Samples classified as group B (18%) showed a single ectopic membrane specificity, apparently discordant with the overall composite phenotype; such a "low-grade deviation" did not prevent a definite immunodiagnosis. Pattern C specimens (5%) revealed a promiscuous coexpression of markers related to different lineages (biphenotypic leukemias), whereas group D included unclassifiable phenotypes, characterized by no antigen or DR-only expression. Our findings suggest the possibility of interpreting complex phenotypic constellations of membrane markers in a consistent and logical manner.

Determination of T lymphocyte subpopulations in patients with lung cancer. A comparison between lung lavage and peripheral blood by monoclonal antibodies and flow cytometry.

In order to determine whether the alterations of immunoregulatory T cells described both in smokers and in patients with lung cancer occur in the deep lung as well as in peripheral blood, we analyzed T lymphocyte subpopulations in bronchoalveolar lavage (BAL) and in the blood of 12 patients with untreated lung cancer and of 8 controls. The immunocompetent cellular population of BAL fluid analyzed by differential cell count of alveolar macrophages, lymphocytes and neutrophils did not show considerable differences in the two groups studied. By contrast, the analysis of BAL T lymphocytes and their subsets showed significant alterations in patients compared with controls: a percentage increase of OKT3+ and OKT8+ lymphocytes and a decrease of the OKT4+/OKT8+ ratio was found in both the involved and uninvolved lung of patients. The immunologic pattern of T lymphocytes in blood did not show significant differences between patients and controls. Our data indicate that alterations in immunoregulatory T cells in lung cancer are more pronounced in BAL fluid obtained from both lungs than in peripheral blood.

Potassium tolerance and bronchial reactivity in asthmatic and nonasthmatic atopic subjects.

Abnormal autonomic nervous system responsiveness may contribute to the pathogenesis of allergic diseases. Therefore, we measured the beta-adrenergic systemic (metabolic) responsiveness by means of acute potassium load in 10 normal healthy subjects and in 19 patients with allergic asthma and/or rhinitis. Ten allergic patients showed a greater potassium increment, as in normal subjects, when potassium was infused in the presence of propranolol. There was no difference between asthmatic and rhinitic patients. We then examined the relation between the response to potassium tolerance and the nonspecific, nonpharmacological bronchial reactivity in response to inhalation of ultrasonically nebulized distilled water. Some allergic patients showed bronchial hyperreactivity, while others did not show a difference compared with the controls; there was no significant difference between asthmatics and rhinitics, and there was no relation between nonspecific bronchial reactivity and potassium load tolerance. These findings suggest that systemic beta-adrenergic hyporesponsiveness may be present only in some allergic patients. There is no demonstrable relation among atopic state, nonspecific, nonpharmacological bronchial reactivity, and systemic beta-adrenergic hyporesponsiveness.

Detection of circulating DNA in plasma of patients with pulmonary embolism by counterimmunoelectrophoresis.

In order to confirm the usefulness of free plasma DNA detection in the diagnosis of pulmonary embolism (PE), we have studied 16 patients with PE, 33 with various diseases, and 13 normal subjects. Free plasma DNA was detectable in 15 of 16 patients with PE (94%) and in 3 control patients, but never in plasma from normal subjects. In most cases, DNA was detectable until the 10th day after PE. In conclusion, counterimmunoelectrophoresis is a rapid, inexpensive and specific test which may be used as an exclusion test in the detection of patients suspected of having PE, who will have to undergo more extensive evaluation.

[Behavior of glutamic-pyruvic transaminase during the clinical course of acute myocardial infarct]. / Comportamento della transaminasi glutammico-piruvica lungo il decorso clinico dell'infarto acuto del miocardio.

The increase in serum Alanine-aminotransferase (SGPT) levels in 104 patients with acute myocardial infarction is studied. The time course of serum enzyme changes shows two peaks of activity: in the first days after infarction and at the end of the second week of the disease. The clinical significance of this finding is discussed.