Posterior reversible encephalopathy syndrome and COVID-19: A series of 6 cases from Lombardy, Italy.

Posterior reversible encephalopathy cases are increasingly being reported in patients affected by COVID-19, but the largest series so far only includes 4 patients. We present a series of 6 patients diagnosed with PRES during COVID-19 hospitalized in 5 Centers in Lombardia, Italy. 5 out of the 6 patients required intensive care assistence and seizures developed at weaning from assisted ventilation. 3 out of 6 patients underwent cerebrospinal fluid analysis which was normal in all cases, with negative PCR for Sars-CoV-2 genome search. PRES occurrence may be less rare than supposed in COVID-19 patients and a high suspicion index is warranted for prompt diagnosis and treatment.

Repeated Cerebrospinal Fluid Removal Procedure in Older Patients With Idiopathic Normal Pressure Hydrocephalus Ineligible for Surgical Treatment.

OBJECTIVES: To evaluate the effects of repeated cerebrospinal fluid (CSF) tap procedures in idiopathic normal pressure hydrocephalus (iNPH) patients ineligible for surgical treatment. DESIGN: Prospective, monocentric, pilot study. SETTING: University hospital. PARTICIPANTS: Thirty-nine patients aged 75 years and older, ineligible for shunting surgical intervention. INTERVENTION: Repeated CSF taps. MEASUREMENTS: All patients underwent a comprehensive geriatric assessment before and after each CSF tap. Adverse events were recorded. RESULTS: No major side effect was reported. Eleven patients showed no response to the first CSF tap test and were excluded. In the remaining 28 patients, all physical and cognitive functions improved after the drainage procedures, except for continence (which seemed poorly influenced). According to clinical judgment, the mean time frame of benefit between CSF taps was 7 months. Patients withdrawing from the protocol during the clinical follow-up showed a worsening of functional and cognitive performances after the interruption. CONCLUSIONS/IMPLICATIONS: Periodic CSF therapeutic taps are safe, allow a better control of iNPH symptoms, and prevent functional decline in geriatric patients.

Intercostal Neurolysis for The Treatment of Postsurgical Thoracic Pain: a Case Series.

INTRODUCTION: We investigated the possible role of intercostal surgical neurolysis in relieving chronic neuropathic pain refractory to other nonsurgical treatments in patients with postsurgical thoracic pain. METHODS: We retrospectively collected clinical data on patients referred to the Neurosurgery Unit of Policlinic Hospital of Milan. Ten patients (age range, 20-68 years) suffering from neuropathic pain for at least 2 months after thoracic surgery underwent intercostal neurolysis. RESULTS: Compared with preneurolysis, pain intensity decreased 1 month postneurolysis and remained stable 2 months postneurolysis (median score [interquartile range]: 8 [6-9] preneurolysis, 4 [3-5] 1 month after, and 3 [2-5] 2 months after, P < 0.001). Antiepileptic drugs for pain control decreased after neurolysis. DISCUSSION: Surgical intercostal neurolysis may be a promising therapeutic option in patients with chronic neuropathic pain associated with neurological deficits. Muscle Nerve 58: 671-675, 2018.

Supplementary Tests in Idiopathic Normal Pressure Hydrocephalus: A Single-Center Experience with a Combined Lumbar Infusion Test and Tap Test.

BACKGROUND: The lumbar infusion test (LIT) and tap test (TT) have previously been described for the diagnosis and selection of appropriate surgical candidates in idiopathic normal pressure hydrocephalus (iNPH). METHODS: We retrospectively reviewed 81 consecutive patients with a clinical diagnosis of iNPH selected for supplementary testing. Clinical evaluation was scored with the Japanese Grading Scale for Normal Pressure Hydrocephalus, the Global Deterioration Score, and the modified Rankin Scale (mRS). The test protocol included a cerebrospinal fluid pressure monitoring (PMi), an LIT, and a TT. Patients were selected for surgery if outflow resistance was ≥14 mm Hg/mL/minute or if a clinical improvement was recorded after TT. RESULTS: Sixty-eight patients were selected for ventriculoperitoneal shunting; 72.8% had a positive PMi or LIT, 74.1% had a positive TT, and 63.0% were positive to both tests. Complications were all transient. Clinical evaluation at 12 months after shunting showed a global improvement in 60 patients (88.2%). Overall, 75.0% of patients had no significant disability (mRS score, 1 and 2), 20.6% had an mRS score of 3 or 4, and 4.4% had severe disability after surgery. The positive predictive value of PMi/LIT, TT, or both combined was similar (89.8, 90.0, and 88.2%); however, 21.7% of patients who improved after surgery were selected with either a positive LIT or TT alone. CONCLUSIONS: LIT and TT are complementary and they can easily be combined in sequence with a low complication rate and high probability of selecting patients with iNPH who may benefit from ventriculoperitoneal shunt surgery.

Stem cell salvage of injured peripheral nerve.

We previously developed a collagen tube filled with autologous skin-derived stem cells (SDSCs) for bridging long rat sciatic nerve gaps. Here we present a case report describing a compassionate use of this graft for repairing the polyinjured motor and sensory nerves of the upper arms of a patient. Preclinical assessment was performed with collagen/SDSC implantation in rats after sectioning the sciatic nerve. For the patient, during the 3-year follow-up period, functional recovery of injured median and ulnar nerves was assessed by pinch gauge test and static two-point discrimination and touch test with monofilaments, along with electrophysiological and MRI examinations. Preclinical experiments in rats revealed rescue of sciatic nerve and no side effects of patient-derived SDSC transplantation (30 and 180 days of treatment). In the patient treatment, motor and sensory functions of the median nerve demonstrated ongoing recovery postimplantation during the follow-up period. The results indicate that the collagen/SDSC artificial nerve graft could be used for surgical repair of larger defects in major lesions of peripheral nerves, increasing patient quality of life by saving the upper arms from amputation.

Third Ventriculostomy in Late-onset Idiopathic Aqueductal Stenosis Treatment: A Focus on Clinical Presentation and Radiological Diagnosis.

Endoscopic third ventriculostomy (ETV) is considered the gold standard treatment for obstructive hydrocephalus due to partial or complete obstruction of cerebrospinal fluid (CSF) ventricular pathways caused by mass lesions. However long-term efficacy of this procedure remains controversial as treatment of chronic adult hydrocephalus due to stenosis of Sylvian acqueduct [late-onset idiopathic aqueductal stenosis (LIAS)]. The authors describe clinical presentation, diagnostic investigations in patients affected by LIAS, and define their clinical and radiological outcome after ETV. From January 2003 to December 2008, 13 consecutive LIAS patients treated by ETV were retrospectively reviewed. Pre- and post-operative clinical and radiological findings, including conventional and phase-contrast (PC) cine magnetic resonance imaging (MRI) were investigated. ETV was successfully performed in all patients. Patient's neurological condition improved. No one required a second ETV procedure or shunt implantation. Clinical and radiological results reveal a satisfactory outcome of LIAS patients treated by ETV. At follow-up a clinical improvement could be demonstrated in all cases. Selection criteria of LIAS patients seem to be crucial to obtain satisfactory and long-lasting results. Even in elderly patients with chronic hydrocephalus, ETV can be considered the treatment of choice.

Endoscopic endonasal removal of a cavernous hemangioma of the orbital apex.

BACKGROUND: Cavernous hemangioma are the most common benign lesions of the orbit. Their surgical resection is still challenging and several surgical approaches have been proposed. CASE DESCRIPTION: We present the case of a 59-year-old woman with a cavernous hemangioma of the orbital apex, which was diagnosed incidentally. The hemangioma was extraconal and involved mainly the medial orbital apex; it also extended to the pterygoid fossa, to the middle fossa, to the maxillary and sphenoid sinuses. The surgical resection was performed by a pure endoscopic transphenoidal, transmaxillary, transethmoidal approach, achieving a total removal. The patient had a transient and incomplete paresis of the VI cranial nerve on the left side and did not experience other postoperative complications. CONCLUSION: The endoscopic endonasal approach proved successful in the management of this case and it should be considered in the surgical management of extraconal orbital apex lesions with medial or inferior extension.

Metastatic Spreading of Community Acquired Staphylococcus aureus Bacteraemia.

A 29-year-old woman presented to the Fondazione IRCCS "Cà Granda" Ospedale Maggiore, a tertiary care university hospital in Milan (Italy), with skin lesions, fever, myalgia, joint pain and swelling, and a one-week history of low back pain. The diagnosis was Staphylococcus aureus (S. aureus) bacteraemia spreading to skin, bones, and joints and a lumbosacral epidural abscess L5-S2. Neither initial focus nor predisposing conditions were apparent. The antibiotic therapy was prolonged for six-weeks with the resolution of fever, skin lesions, articular inflammation, and the epidural abscess. Community-acquired S. aureus infections can affect patients without traditional healthcare-associated risk factors, and community acquisition is a risk-factor for the development of complications. Raised awareness of S. aureus bacteraemia, also in patients without healthcare-associated risk factors, is important in the diagnosis, management, and control of this infection, because failure to recognise patients with serious infection and lack of understanding of empirical antimicrobial selection are associated with a high mortality rate in otherwise healthy people.

Anterior cranial base reconstruction following a complicated nasal septoplasty.

We present a 29 year old man who had unilateral visual loss and 3rd cranial nerve palsy after a nasal septoplasty. Nasal packing was extending from the right nasal cavity into the right frontal lobe passing through the right orbit. A combined trans-cranial and endoscopic endonasal approach was performed to safely remove the nasal packing and to achieve a leak-proof sealing of the anterior cranial base. This surgical technique proved successful in the management of this unique complication and should be considered in the surgical management of foreign body removal from the anterior cranial base.

[Analysis of quality in a first level trauma center in Milan, Italy]. / Analisi di qualità di un trauma center di I livello nella città di Milano.

BACKGROUND: In Italy there isn't a State Trauma System. Many attempts have been done to increase the quality of trauma care in prehospital and hospital phases, but only by local resources. In Mila (Italy)o Emergency Medical System is organized by Regional rules and five Hospitals warrant high level of care for trauma patients. There isn't an official registry for trauma. Creating a Trauma Registry is the prerogative to analyse the quality of assistance and to propose new solutions. OBJECTIVES: To analyse major trauma patients admitted to Ospedale Maggiore Policlinico IRCCS; to evaluate diagnostic and therapeutic protocols in order to identify preventable deaths. PATIENTS: We have observed trauma patients admitted to Ospedale Maggiore from January to December 2004. We collected demographic data, informations about the traumatic event and prehospital rescue, emergency room examination, diagnostic exams, surgical operations and results of treatment. We selected patients admitted among 6917 trauma patients observed in this period. We have calculated RTS, ISS and TRISS. Patients were followed during their staying at the hospital to record length of staying, lenght of ICU and mortality rate. We collected the autopsy of the all death patients. RESULTS: We selected 299 patients, 207 males and 92 females. Mean age was 42.4 +/- 19.5 for males (range 15 - 99) and 57.7 +/- 22.5 for female (range 7 - 101). Motorvehicle and road incident were the main cause of trauma (55.5%). A penetrating injury was observed only in 5% of cases. Mean RTS was 7.5 +/- 1. ISS and TRISS were (mean +/- SD) 13 +/- 9 and 94.9% +/- 11.5, respectively. Patients with ISS = 16 were 109 (36.4%). Forty five patients (15%) required a surgical treatment during the first 48 hours. Total length of staying was 8.9 +/- 11.2 (mean +/- SD) days (median of 5.5 days) and the length of ICU was (mean +/- SD) 11.7 +/- 10.3 days (median 9 days). 12 patients died (mortality rate 4.08%), 11 at Policlinico (2 in the emergency room, 3 in the operative room, 5 in ICU. One patient died in surgical ward), 1 at Ospedale Niguarda. Autopsy was available for 8 patients. In 2 cases the cause of death was established by clinical examination and in 1 case police are still investigating for poisons or other letal drugs. The main cause of death was the cerebral injury. Only for 1 patient it was impossibile to determine the cause of death so he was considered a potentially preventable death. His clinical RTS in the emergency room was 12 (7,4808 in the statistical analysis) and no severe lesions were observed during primary and secondary survey. CONCLUSIONS: Our data are typical of an urban area of a western country. Penetrating injury are very rare, 5% of incidence. Diagnostic and therapeutic protocols are similar to countries where a Trauma Center is active. The 4% of overall mortality rate is similar to Trauma Centers in USA. This result is better than other hospitals in Milan. The high number of ATLS providers in the trauma team could be one of causes of good results. Quality audit can't consider only RTS, ISS and TRISS. Scores are very practical and useful but they aren't enough. We must analyse every single case of death and Trauma Registry is the first tool to evaluate trauma care in a modern EMS.

Impact of cerebrovascular disease on the surgical treatment of idiopathic normal pressure hydrocephalus.

OBJECTIVE: The influence of cerebrovascular disease (CVD) on the short- and long-term results of surgery was evaluated in a series of consecutive patients with idiopathic normal-pressure hydrocephalus (iNPH). METHODS: Patients with suspected iNPH admitted to our department between June 1996 and June 2003 were evaluated with four clinical and handicap scales. CVD and risk factors for vascular disease were rated. All patients underwent intracranial pressure monitoring via a spinal catheter. Sixty-six patients received a ventriculoperitoneal shunt with a programmable valve. Prospective assessments were programmed at 2 weeks and 3 months after surgery (short-term follow-up). Long-term follow-up evaluations were arranged in June 2004 with patients and/or relatives and health/home care assistants. RESULTS: At the short-term follow-up examination, a significant clinical improvement was globally present in 89% of the patients (P < 0.05). CVD, such as leucoaraiosis or previous strokes, were present in 71% of the patients. Patients both with and without CVD and/or risk factors for vascular disease presented a significant improvement (P < 0.05) after shunting; 85 and 100% of the patients with and without CVD, respectively. At the long-term follow-up examination (mean, 52 +/- 24.8 mo), 24% of the patients were dead and 8% had experienced stroke. Globally, 60% of the patients were still improved (P < 0.05); 52 and 79% of the patients with and without CVD, respectively. CONCLUSION: A high success rate in treatment of iNPH is possible in patients with and without CVD. Despite poorer short- and long-term treatment outcome of iNPH patients with CVD, a long-lasting improvement in their quality of life favors surgery.

Gelastic seizures and low-grade hypothalamic astrocytoma: a case report.

The typical, well recognized childhood epilepsy syndrome caused by hypothalamic hamartoma is characterized by early-onset, stereotyped attacks of uncontrollable laughter, frequent refractory seizures with progressive cognitive deterioration and severe behavioral problems. Here, we report a 17-year-old patient with gelastic phenomenon started in the neonatal period, later on associated with drug resistant polymorphic seizures, intellectual deficit and behavioral disorders, who improved by partial resection of an expected hypothalamic hamartoma that, in turn, resulted to be a hypothalamic low-grade astrocytoma.