Microbial, chemical, and isotopic monitoring integrated approach to assess potential leachate contamination of groundwater in a karstic aquifer (Apulia, Italy).

Landfill sites are subjected to long-term risks of accidental spill of leachate through the soil and consequential contamination of the groundwater. Wide areas surrounding the landfill can seriously be threatened with possible consequences to human health and the environment. Given the potential impact of different coexisting anthropic pollution sources (i.e., agriculture and cattle farming) on the same site, the perturbation of the groundwater quality may be due to multiple factors. Therefore, it is a challenging issue to correctly establish the pollution source of an aquifer where the landfill is not isolated from other anthropic land uses, especially in the case of a karstic coastal aquifer. The present study is aimed at setting in place an integrated environmental monitoring system that included microbiological, chemical, and isotope methods to evaluate potential groundwater pollution in a landfill district in the south of Italy located in Murgia karstic aquifer. Conventional (microbial plate count and physical-chemical analyses) and advanced methods (PCR-ARISA, isotope analysis of δ18O, δ2H, 3H, δ 13C, δ 15N-NO3-, and δ 18O-NO3-) were included in the study. Through data integration, it was possible to reconstruct a scenario in which agriculture and other human activities along with seawater intrusion in the karst aquifer were the main drivers of groundwater pollution at the monitored site. The microbiological, chemical, and isotope results confirmed the absence of leachate effects on groundwater quality, showing the decisive role of fertilizers as potential nitrate sources. The next goal will be to extend long-term integrated monitoring to other landfill districts, with different geological and hydrogeological characteristics and including different sources of pollution, to support the ecological restoration of landfills.

Coastal hydrogeological system of Mar Piccolo (Taranto, Italy).

The Mar Piccolo basin is an internal sea basin located along the Ionian coast (Southern Italy), and it is surrounded primarily by fractured carbonate karstic environment. Because of the karstic features, the main continental water inflow is from groundwater discharge. The Mar Piccolo basin represents a peculiar and sensitive environment and a social emergency because of sea water and sediment pollution. This pollution appears to be caused by the overlapping effects of dangerous anthropogenic activities, including heavy industries and commercial and navy dockyards. The paper aims to define the contribution of subaerial and submarine coastal springs to the hydrological dynamic equilibrium of this internal sea basin. A general approach was defined, including a hydrogeological basin border assessment to detect inflowing springs, detailed geological and hydrogeological conceptualisation, in situ submarine and subaerial spring measurements, and flow numerical modelling. Multiple sources of data were obtained to define a relevant geodatabase, and it contained information on approximately 2000 wells, located in the study area (1600 km(2)). The conceptualisation of the hydrogeological basin, which is 978 km(2) wide, was supported by a 3D geological model that interpolated 716 stratigraphic logs. The variability in hydraulic conductivity was determined using hundreds of pumping tests. Five surveys were performed to acquire hydro-geochemical data and spring flow-yield measurements; the isotope groundwater age was assessed and used for model validation. The mean annual volume exchanged by the hydrogeological basin was assessed equal to 106.93 10(6) m(3). The numerical modelling permitted an assessment of the mean monthly yield of each spring outflow (surveyed or not), travel time, and main path flow.

Predictors of carotid clamping intolerance during endarterectomy that would be wise to apply to stenting procedures.

BACKGROUND AND PURPOSE: Carotid artery stenting procedures are increasingly being performed with devices such as the MO.MA or the Parodi system that involve endovascular clamping of the common carotid artery, thus exposing the ipsilateral hemisphere to the risk of hypoperfusion. The aim of the present study was to look for predictors of carotid clamping intolerance by means of transcranial Doppler. PATIENTS AND METHODS: We analysed the findings of an earlier Italian multicentre prospective study (SCITEA, Italian Cooperative Study of Transcranial Doppler in Carotid Endarterectomy) in which 513 consecutive patients (males/females 397/116, mean age 67 +/- 7 years, mean carotid stenosis 81 +/- 11%, NASCET method) scheduled to undergo carotid endarterectomy had been investigated non-invasively with transcranial Doppler, and we correlated the data obtained preoperatively with the need to insert a shunt during surgery as an index of intolerance to carotid clamping. RESULTS: Four hundred and thirty-nine patients (85.6%) underwent surgery without and 74 (14.4%) with the insertion of a shunt. Patients who needed a shunt (intolerant) had a significantly higher decrement in mean flow velocity in the ipsilateral middle cerebral artery (MCA) after compression of the ipsilateral common carotid artery (71.8 +/- 22 vs. 30.6 +/- 24%) and were significantly more likely to have non-recruitable collateral pathways (75 vs. 18%). Logistic regression analysis confirmed that an MCA decrement of >85% (p = 0.005) and no potential collateralization (p = 0.011) were independent predictors of clamping intolerance. Combining the results of both compression tests (MCA decrement and collateral recruitment) yielded a sensitivity of 64%, a specificity of 99%, a positive predicted value of 88%, a negative predicted value of 95% and an overall accuracy of 95% in predicting shunt insertion. CONCLUSIONS: The preoperative assessment of recruitable collaterals and of maximal decrement in MCA mean flow velocity after carotid compression are useful predictors of carotid clamping intolerance. The criteria derived from carotid endarterectomy need to be applied and validated in a prospective series of patients undergoing carotid artery stenting procedures.

[Transcranial ultrasonography in neurosurgery]. / L'ultrasonografia transcranica in neurochirurgia.

Transcranial doppler sonography is a diagnostic tool that allows the noninvasive study of intracranial circulation. In patients with aneurysmal subarachnoid hemorrhage, cerebral vasospasm is promptly diagnosed, even before clinical related symptoms. Feeding arteries of an arteriovenous cerebral malformation can be detected and their variations can be correlated to the treatment (neurosurgical and/or neuroradiological). When raised intracranial pressure (namely in head trauma), transcranial doppler sonography depicts vasospasm and/or typical variations of the waveforms, suggesting intracranial circulatory arrest.

Dissecting aneurysms of the vertebrobasilar system: study of 16 cases.

In the last 14 years we have encountered 16 patients with spontaneous intracranial dissections of the vertebrobasilar (VB) system (mean age was 46 years and male/female ratio was 10/6). VB dissections presented in eight cases with subarachnoid bleeding and in eight with brainstem, cerebellar, or cerebral ischemia. Three patients had multiple dissections. Ten dissections occurred in the vertebral artery (two extended to the basilar artery), three in the posterior cerebral artery (one bilateral), two in the basilar artery, and one in the posterior inferior cerebellar artery. The angiographic configuration included "string" sign, "pearl and string" sign, fusiform dilation, and double lumen. The following angiographic evolution (available in 11 cases) was that of complete healing (three cases), partial resolution (five cases), progression (one case), and unimproving (two cases). Three patients died (two due to recurrent subarachnoid hemorrhage): two patients were explored surgically (one had further intravascular therapeutic embolization), and the rest were treated conservatively. Not all dissecting aneurysms fared in the same manner, depending either on the location in the VB circulation or on the variable vascular configuration: treatment should be fitted to the timing of diagnosis.

Vertebro-basilar aneurysms: does delayed surgery represent the best surgical strategy?

The appropriate time to perform surgery for posterior circulation aneurysms is debated. Controversy exists secondary to the lack of information regarding the overall management and outcome, as well as difficulties with their surgical treatment and infrequent occurrence. The present study examines the results of 46 patients with ruptured vertebro-basilar aneurysms treated with a delayed surgical protocol. Twenty-four were Hunt-Hess grade I/II on admission, 13 were grade III, and 9 grade IV/V. Nineteen patients (40%) (4 grade I/II, 6 grade III, and the 9 grade IV/V on admission) died before meeting the required conditions for surgery. Causes of death were vasospasm (8 cases), direct effect of the initial bleeding (7 cases), and rebleeding (4 cases). Surgical results were excellent/good in 87% of the patients. Surgical mortality was 8% (2 out of 24). In this study, despite encouraging surgical results, overall mortality was disappointingly high. We suggest that as more experience is gained in treating vertebrobasilar aneurysms, early surgery should be performed in selected cases. Early surgery is prophylactic for rebleeding and allows for more aggressive treatment of cerebral vasospasm.

Orbital pain and unruptured carotid-posterior communicating artery aneurysms: the role of sensory fibers of the third cranial nerve.

Intact aneurysms of the carotid siphon at the point of take-off of the posterior communicating artery may exhibit orbital pain, whether associated with oculomotor palsy or not as a warning symptom prior to rupture. In order to explain this symptom the hypothesis of a sensory pathway within the third cranial nerve, which is liable to compression by the enlarging aneurysm sac, has been investigated. Data from human autopsy material show evidence of sensory ganglion cells within the rootlets of the oculomotor nerve; furthermore, studies in animals prove that the third nerve contains sensory fibers which run proximally along the nerve bundles, enter the brainstem and reach the spinal trigeminal nucleus. These fibers come from the ophthalmic division of the fifth nerve and join the third nerve at the level of the lateral wall of the cavernous sinus. Although a number of questions remain to be solved, the presence of a sensory pattern within the third nerve could account for fronto-orbital pain from enlarging aneurysms impinging on the third nerve itself.

Etiopathogenesis and prognosis of cerebral ischemia in young adults. A survey of 155 treated patients.

Etiology and long-term prognosis were prospectively investigated in 155 consecutive patients (96 men and 59 women), aged 16 to 45 years, referred to our Neurosurgical Unit with cerebral transient ischemic attacks or infarction during the period 1978-1988. All patients underwent neurological and medical-cardiological evaluation, cerebral computerized tomography scanning, electrocardiogram, and laboratory tests. Two-dimensional echocardiography was performed in 123 cases (79%), cerebral angiography in 147 (95%). Atherosclerosis was the leading etiology occurring in 48 patients (31%). A cardioembolic disorder was considered the probable cause of ischemia in 8 cases (5.1%). Further possible etiologies were contraceptive pill assumption (5.8% of the total, but 15.3% within the female group), spontaneous arterial dissection (4.5%), migraine (4%), puerperium (2.6%), cervical trauma (2.6%), and other, more uncommon conditions. Despite extensive evaluation, the cause of cerebral ischemia remained unknown in 40% of cases. All patients received antiplatelet medication and 16 underwent surgery. The long-term outcome at a mean follow-up of 5.8 years was favorable: 91% of subjects resumed their work on a full or part-time basis.

PIP: Etiology and longterm prognosis were prospectively investigated in 155 consecutive patients (96 men, 50 women) ages 16-45 years who were referred to the Neurosurgical Unit with cerebral transient ischemic attacks or infarction during the period 1978-88. All patients underwent neurological and medical-cardiological evaluation, cerebral computerized tomography scanning, electrocardiogram, and laboratory tests. 2-dimensional echocardiography was performed in 123 cases (79%), cerebral angiography in 147 (95%). Atherosclerosis was the leading etiology, occurring in 48 patients (31%). A cardioembolic disorder was considered the probable cause of ischemia in 8 cases (5.1%). Further possible etiologies were though to be: oral contraceptives (5.8% of the total, but 15.3% within the females), spontaneous arterial dissection (4.5%), migraine (4%), puerperium (2.6%), cervical trauma (2.6%), and other, more uncommon conditions. Despite extensive evaluation, the cause of cerebral ischemia remained unknown in 40% of the cases. All patients received antiplatelet medication and 16 underwent surgery. The longterm outcome at a mean followup of 5.8 years was favorable in that 91% of the subjects resumed their workload on a full or parttime basis.

Overall results in 304 consecutive patients with acute spontaneous subarachnoid hemorrhage.

The results obtained in 304 consecutive patients with spontaneous subarachnoid hemorrhage are described, the majority of whom (86%) were admitted while in acute condition. Only 46% of the patients in this series were in good condition at admission. The initial management was standardized for all patients, but the protocol of "delayed surgery" was applied to patients with subarachnoid hemorrhage from aneurysmal rupture. Two hundred and twenty-two patients (73%) had intracranial aneurysms. Of these, 20 (9%) were moribund and died shortly after admission; nine (4%) underwent emergency surgery due to the coexistence of a life-threatening cerebral hematoma; seven (3%) were operated upon within 3 days of admission; 78 (35%) died after rebleeding or after steady deterioration of the patient's condition due to vasospasm while awaiting surgery. Of the remaining 108 patients ready for delayed surgery, 12 (11%) (operation refused, elderly patients in poor general condition, spontaneous thrombosis of the aneurysm) were treated conservatively, and 96 (89%), who were in various clinical conditions, were actually operated on. Of these 96 patients, 79 (82%) exhibited excellent or good results, 5 (5%) were disabled, and 12 (12%) died. In the authors' experience, the overall management of intracranial aneurysms in unselected patients according to the protocol of delayed surgery results in significant loss of patients awaiting surgery, and good surgical results in the survivors.

[Cardiopathy and acute cerebrovascular insufficiency. Prospective study with two-dimensional echocardiography]. / Cardiopatie ed insufficienza cerebrovascolare acuta. Studio prospettico con ecocardiografia bidimensionale.

Many cardiac disorders can cause acute cerebrovascular insufficiency. The spectrum of potentially embolic cardiac conditions is wide; early recognition may determine a definite change in the management and prognosis of patients. In recent years the relevance of echocardiography in the screening of patients with cerebral ischemia has been emphasized. In order to identify potentially embolic cardiac conditions, 180 consecutive non selected patients with cerebrovascular insufficiency, underwent a clinical cardiological evaluation and an echocardiogram. The study population included 132 men and 48 women; the mean age was 51.7 years (range 19 to 72 years). A technically adequate echocardiogram was obtained in 153 patients. In 131 patients echocardiography was negative; cardiac lesions were detected in 22 patients (14.4%): mitral stenosis in 2, calcified aortic stenosis in 1, valvular endocarditis vegetations in 3, dilatative cardiomyopathy in 2, hypertrophic cardiomyopathy in 4, mitral valve prolapse in 4, regional left ventricular diskynesia in 5, mitral anulus calcification in 1. Patients were divided into 3 groups according to the results of cerebral angiography: 68 patients with normal angiography (Group I), 54 patients with atheromasic lesions on cerebral angiography (Group II), 31 patients in whom cerebral angiography was not performed (Group III). A higher incidence of cardiac diseases was found in the patients of Group I. The lack of lesions on cerebral angiography and the presence of embolic high-risk cardiac conditions strengthened a causal relationship of the cardiac disorder with cerebrovascular insufficiency in 10 of the 23 patients. In the mean follow-up period of 18 months of these 10 patients who underwent cardiac surgery or anticoagulation, no further attacks of cerebrovascular insufficiency were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemorheologic changes in patients with a history of stroke or cerebral remittent ischemic attacks.

Hemorheologic parameters were measured in cerebrovascular patients with a history of stroke or recurrent ischemic attacks in a quiescent phase of the disease. All patients were submitted to aortic arch angiography and then classified according to the presence or absence of detectable arterial lesions. In comparison with a group of control subjects, cerebrovascular patients had significantly elevated levels of blood and plasma viscosity, fibrinogen, factors VIII:C and VIIIR:Ag and lowered values of erythrocyte filtration. Blood viscosity was increased and erythrocyte filtration reduced only in male patients. Elderly patients had higher blood viscosity and fibrinogen levels, and those with a history of stroke also showed the highest hematocrit and plasma viscosity values. Patients with a stroke history compared with those affected by remittent ischemic attacks, and patients with positive in comparison with those with negative angiograms were characterized only by higher fibrinogen (and sometimes factor VIII) levels, but not by other differences in hemorheologic values. It is concluded that changes in hemorheologic values consistent with hyperviscosity are a feature of cerebrovascular patients also in the quiescent phase of the disease and not only as a result of acute ischemic attacks. These changes are however most frequent in males and in elderly subjects, while they seem to be almost evenly distributed in patients with or without evidence of arterial disease.

Long-term follow-up in 257 ICA occlusion: comparison between EIAB-treated and untreated patients.

The purpose of this paper is to estimate the real value of the Extra-Intracranial Arterial Bypass (EIAB) in preventing or reducing further and more catastrophic ischaemic events in patients suffering from an Internal Carotid Artery (ICA) occlusion. 257 patients, suffering from ICA occlusion, are considered retrospectively: 122 of them submitted to EIAB and 135 medically treated or untreated. In both groups, homogeneous by sex, age, neurological grading distribution and length of follow-up, the following parameters were considered: the incidence of ischaemic recurrences during the follow-up period; the characters of the recurrences with particular reference to the fatal stroke; the rate of ischaemic events per year. The comparison between the outcome in surgically treated patients and in "untreated" ones indicates that the EIAB can be effective in preventing or reducing the ischaemic recurrences and the frequency of fatal stroke in TIA-, RIND, or stroke-patients suffering from ICA occlusion.

Delayed angiographic appearance of a large basilar aneurysm.

A technically adequate four-vessel cerebral angiogram was normal on the first day after a typical episode of subarachnoid hemorrhage. The study was repeated 40 days later showing a large aneurysm of the basilar bifurcation. Hypothetically, the first attempt to visualize the aneurysm was negative due to early transitory thrombosis of the aneurysmal sac. In some cases of subarachnoid hemorrhage it is beneficial to repeat previously normal angiographic studies.

Extra-intracranial arterial bypass in typical carotid reversible ischaemic deficits: long-term follow-up in 100 patients.

The long-term follow-up of 100 consecutive patients who suffered from a reversible ischaemic attack (RIA) in the carotid territory and were submitted to extra-intracranial arterial bypass (EIAB) surgery in seven Italian Neurosurgical Centres is reported. The preoperative angiographic and clinical features, and the surgical complications are reported. The follow-up ranged from two to seven years with a mean of thirty-five months. In this period in the territory served by the bypass only two completed strokes and six RIAs occurred. Four patients died, only one for cerebral ischaemic problems. The results of the present series have been compared with those of the literature: they appeared consistent with other surgical series and clearly better than those of medical treated patients. The EIAB can then be considered a good therapeutic choice for the treatment of RIAs in carotid territory.

Long term prognosis after occlusion of middle cerebral artery.

Seventy patients who had developed occlusion of the middle cerebral artery confirmed by angiography between 1970 and 1980 were followed up after an average of six years. Fourteen patients had died in the acute stage of the initial stroke. In the remaining 56 patients actuarial analysis showed that the observed incidence of survival for five years was 81.8% compared with an incidence of 94.1% in a matched normal population. Six patients sustained new strokes, four of which were ipsilateral to the middle cerebral artery occlusion. The observed cumulative incidence of subsequent strokes was 2% a year for the first five years of follow up. Twelve patients developed epileptic seizures.

[Cardiac arrhythmias associated with subarachnoid hemorrhage. Prospective study with dynamic electrocardiography]. / Aritmie cardiache associate ad emorragia subaracnoidea. Studio prospettico con elettrocardiografia dinamica.

Electrocardiographic abnormalities associated with intracranial diseases, especially subarachnoid hemorrhage, are well known, while there is hardly mention of cardiac arrhythmias in the neurological and cardiological literature. In order to assess the incidence of arrhythmias 52 consecutive patients with subarachnoid hemorrhage secondary to ruptured aneurysm were investigated with 24-hour Holter recordings. Bradyarrhythmias and tachyarrhythmias were found in 46 patients (88%); premature ventricular beats in 25 pts (12 of these in 3rd-5th Lown classes), ventricular tachycardia in 2, premature supraventricular beats in 14, paroxysmal atrial fibrillation in 1, sinoatrial blocks and arrests in 18, atrioventricular dissociation in 2 and idioventricular rythm in 2. Moreover in 5 pts ST segment changes were found, suggestive of transitory acute myocardial ischemia. The presence and severity of arrhythmias were correlated with the time elapsed from the episode of bleeding, with the QT interval, and with the hemorrhage extent. Our results indicate an high incidence of arrhythmias in subarachnoid hemorrhage, sometimes serious mainly in early stage. Continuous electrocardiographic monitoring is therefore extremely useful and provides data for therapeutic consideration.

Aneurysm growth and hemodynamic stress.

Two cases of intracranial saccular aneurysm related to an arteriovenous malformation (AVM) are illustrated, in which a remarkable growth of the sac over the years was demonstrated angiographically. According to the relevant literature, aneurysm enlargement is correlated to the flow toward the AVM, increasing the intrasaccular turbulence and stress on the wall to which "solitary" aneurysms are usually subjected. The presence of bilateral infundibular widening at the origin of the posterior communicating artery is noted in one of the cases. This finding possibly confirms further the effects of hemodynamic stress.

The clinical course and prognosis of carotid artery occlusion.

The clinical course of 100 consecutive patients with angiographically proven carotid occlusion was reviewed. Ninety-three patients had been hospitalised for early stroke appropriate to the occlusion, and seven for transient ischaemic attacks. 68 patients were followed up from 1.5 to 5.9 years. The observed five year survival rate on an actuarial basis was 62.3%, compared to the expected rate of 90% in a matched normal population. The observed rate of recurrent stroke was 4.8% at 1 year. 12.2% at 3 years, 17.1% at 5 years. Among survivors, six patients (11.3%) developed seizures.