The diffusion-weighted imaging and 11-C-methionine positron emission tomography depiction of an endodermal cyst at the cervico-medullary junction.

A case of a 52-year-old male with left-sided neck pain, vertigo and gait instability is reported. A MRI scan revealed an intra-dural mass at the cervico-medullary junction, further characterised by diffusion-weighted imaging and 11-C-methionine positron emission tomography. Pathological diagnosis was endodermal cyst. The clinico-surgical relevance of the imaging findings is discussed.

Percutaneous vertebral augmentation in metastatic disease: state of the art.

Improvements in diagnosis and treatment have prolonged cancer survival, with a consequent increase in the incidence of spinal metastases and vertebral compression fractures with associated axial pain, progressive radiculomyelopathy, and mechanical instability. Pain relief in malignant vertebral compression fractures is key to achieving a better quality of life in patients under palliative care. The gold standard for pain relief is nonsteroidal anti-inflammatory drugs and opioids. Nonresponsive cases are then treated with radiotherapy, which may require 2-4 weeks to take effect and in most cases does not provide complete pain relief. Percutaneous vertebroplasty and percutaneous kyphoplasty can in particular give relief in patients with vertebral body compression fractures that do not cause neurological deficits but severely compromise quality of life because of intractable pain.

Human glioblastoma tumours and neural cancer stem cells express the chemokine CX3CL1 and its receptor CX3CR1.

Human gliomas represent an unmet clinical challenge as nearly two-thirds of them are highly malignant lesions with fast progression, resistance to treatment and poor prognosis. The most severe form, the glioblastoma multiforme, is characterised by a marked and diffuse infiltration through the normal brain parenchyma. Given the multiple effects of chemokines on tumour progression, aim of this study was to analyse the expression of the chemokine CX3CL1 and of its specific receptor CX3CR1 in 36 human surgical glioma samples, with different degrees of histological malignancy and in glioblastoma-derived neurospheres. Herein we show that both ligand and receptor are expressed at the mRNA and protein levels in most specimens (31/36). While receptor expression was similarly detected in low or high grade tumours, the uppermost scores of CX3CL1 were found in grades III-IV tumours: oligodendrogliomas, anaplastic astrocytomas and glioblastomas. Accordingly, the expression of CX3CL1 was inversely correlated with patient overall survival (p = 0.01). Glioblastoma-derived neurospheres, containing a mixed population of stem and progenitor cells, were positive for both CX3CR1 and for the membrane-bound chemokine, which was further up-regulated and secreted after TNF-IFNγ stimulation. Confocal microscopy of 3D neurospheres showed that the ligand was primarily expressed in the outer layer cells, with points of co-localisation with CX3CR1, indicating that this ligand-receptor pair may have important intercellular adhesive functions. The high expression of CXC3L1 in the most severe forms of gliomas suggests the involvement of this chemokine and its receptor in the malignant behaviour of these tumours.

Correlation of microvascular fractal dimension with positron emission tomography [(11)C]-methionine uptake in glioblastoma multiforme: preliminary findings.

Neuroradiological and metabolic imaging is a fundamental diagnostic procedure in the assessment of patients with primary and metastatic brain tumors. The correlation between objective parameters capable of quantifying the neoplastic angioarchitecture and imaging data may improve our understanding of the underlying physiopathology and make it possible to evaluate treatment efficacy in brain tumors. Only a few studies have so far correlated the quantitative parameters measuring the neovascularity of brain tumors with the metabolic profiles measured by means of amino acid uptake in positron emission tomography (PET) scans. Fractal geometry offers new mathematical tools for the description and quantification of complex anatomical systems, including microvascularity. In this study, we evaluated the microvascular network complexity of six cases of human glioblastoma multiforme quantifying the surface fractal dimension on CD34 immunostained specimens. The microvascular fractal dimension was estimated by applying the box-counting algorithm. As the fractal dimension depends on the density, size and shape of the vessels, and their distribution pattern, we defined it as an index of the whole complexity of microvascular architecture and compared it with the uptake of (11)C-methionine (MET) assessed by PET. The different fractal dimension values observed showed that the same histological category of brain tumor had different microvascular network architectures. Fractal dimension ranged between 1.19 and 1.77 (mean: 1.415+/-0.225), and the uptake of (11)C-methionine ranged between 1.30 and 5.30. A statistically significant direct correlation between the microvascular fractal dimension and the uptake of (11)C-methionine (p=0.02) was found. Our preliminary findings indicate that that vascularity (estimated on the histologic specimens by means of the fractal dimension) and (11)C-methionine uptake (assessed by PET) closely correlate in glioblastoma multiforme and that microvascular fractal dimension can be a useful parameter to objectively describe and quantify the geometrical complexity of the microangioarchitecture in glioblastoma multiforme.

Magnetic resonance elastography: a general overview of its current and future applications in brain imaging.

Magnetic resonance elastography (MRE) has been developed over the last few years as a non-invasive means of evaluating the elasticity of biological tissues. The presence of the skull has always prevented semeiotic palpation of the brain, but MRE now offers the possibility of "palpating by imaging" in order to detect brain consistency under physiological and pathological conditions. The aim of this article is to review the current state-of-the-art of MRE imaging and discuss its possible future diagnostic applications in neuroscience.

Multimodal approach to the management of metastatic epidural spinal cord compression (MESCC) due to solid tumors.

PURPOSE: To assess the impact of a multidisciplinary approach for treatment of patients with metastatic epidural spinal cord compression in terms of feasibility, local control, and survival. METHODS AND MATERIALS: Eighty-nine consecutive patients treated between January 2004 and December 2007 were included. The most common primary cancers were lung, breast, and kidney cancers. Ninety-eight surgical procedures were performed. Radiotherapy was performed within the first month postoperatively. Clinical outcome was evaluated by modified visual analog scale for pain, Frankel scale for neurologic deficit, and magnetic resonance imaging or computed tomography scan. Nearly all patients (93%) had back pain before treatment, whereas major or minor preoperative neurologic deficit was present in 62 cases (63%). RESULTS: Clinical remission of pain was obtained in the vast majority of patients (91%). Improvement of neurologic deficit was observed in 45 cases (72.5%). Local relapse occurred in 10%. Median survival was 11 months (range, 0-46 months). Overall survival at 1 year was 43.6%. Type of primary tumor significantly affected survival. CONCLUSIONS: In patients with metastatic epidural spinal cord compression, the combination of surgery plus radiotherapy is feasible and provides clinical benefit in most patients. The discussion of each single case within a multidisciplinary team has been of pivotal importance in implementing the most appropriate therapeutic approach.

Vertebroplasty for pain relief and spinal stabilization in multiple myeloma.

Mechanical stabilization of oncological vertebral fractures with cement augmentation is the first mechanism of pain relief, with or without restoration of vertebral body height. The aim of this study was to assess the safety and efficacy of vertebroplasty for painful vertebral body fractures in patients with multiple myeloma, in each phase of the disease. The authors reviewed a consecutive group of patients with multiple myeloma who underwent vertebroplasty at our Institute between November 2003 and December 2005. Twenty-eight levels were performed on 11 patients during 14 treatment sessions. All patients suffered from intractable back pain, and presented various lesion types (with and without fractures of posterior wall, and with and without epidural disease). The preoperative median visual analog scale (VAS) score was 7. The median duration of symptoms was 1.1 months. Eight patients were ambulating with orthopaedic devices (57%) in the pre-treatment period. Improvement or complete pain relief was observed in all patients (immediately in 8 cases, and after 2 days in 6 cases). The median VAS pain score decreased to 2. There was no symptomatic procedure-related complication. There were three cases (21%) of PMMA leakage: in the disc space in one case (7%), and in the anterior spinal canal in two cases (14%). Complete removal of orthopaedic devices was obtained in five patients (36%). No new deformation or collapse of the treated vertebrae was observed during the follow-up (range 1 day-25 months). In conclusion, vertebroplasty is a safe and efficient procedure in the treatment of painful vertebral body fractures in patients with multiple myeloma, without potential contraindications, such as fractures of the posterior wall or epidural disease. We also treated three and more levels in 28% of cases in a single session without complications. Due to the early pain relief and the low complication rate, it is possible to expand the indication to vertebroplasty for the prophylactic augmentation of those vertebral bodies at risk of fracture in which significant neoplastic substitution of the body is present.

Adipose-derived stem cell therapy for intervertebral disc regeneration: an in vitro reconstructed tissue in alginate capsules.

The degenerative pathologies of the intervertebral disc have a remarkable social impact in the industrialized countries and can provide serious disabilities in the population. The current treatment consists of conservative treatments (such as symptomatic pharmacological therapies and physiokinetic therapy) and surgical treatments (intervertebral fusion, total disc replacement, nucleus pulposus (NP) replacement, or surgical exeresis). Recent advances in cell therapy foresee the possibility of regenerating the damaged disc; the autologous disc tissue can be withdrawn, in vitro regenerated, and re-implanted. The aim of this work was to verify whether autologous adipose-derived adult stem cells can improve the quality of an in vitro reconstructed nucleus pulposus tissue. A three-dimensional (3D) co-culture of NP cells and adipose tissue non-adipocyte fraction cells (nAFs) was assessed in a previously developed alginate 3D culture system following the good manufacturing practice guidelines to ensure patient safety for clinical studies. Morphological investigation of cultured and co-cultured cells was performed using transmission electron microscopy and immunofluorescence for collagen type I, aggrecan, CD90, CD34, and vimentin. Results indicate that co-culture of NP and nAFs improves the quality of the in vitro reconstructed tissue in term of extracellular matrix production and 3D cell organization. Technological resources are available for NP cell encapsulation intended for regenerating the intervertebral disc.

Euclidean and fractal geometry of microvascular networks in normal and neoplastic pituitary tissue.

In geometrical terms, tumour vascularity is an exemplary anatomical system that irregularly fills a three-dimensional Euclidean space. This physical characteristic and the highly variable shapes of the vessels lead to considerable spatial and temporal heterogeneity in the delivery of oxygen, nutrients and drugs, and the removal of metabolites. Although these biological characteristics are well known, quantitative analyses of newly formed vessels in two-dimensional histological sections still fail to view their architecture as a non-Euclidean geometrical entity, thus leading to errors in visual interpretation and discordant results from different laboratories concerning the same tumour. We here review the literature concerning microvessel density estimates (a Euclidean-based approach quantifying vascularity in normal and neoplastic pituitary tissues) and compare the results. We also discuss the limitations of Euclidean quantitative analyses of vascularity and the helpfulness of a fractal geometry-based approach as a better means of quantifying normal and neoplastic pituitary microvasculature.

The neuroanatomical plates of Guido da Vigevano.

Guido da Vigevano was an Italian physician and engineer who lived in the 13th and 14th centuries. He was the first scientist who used pictures to illustrate his anatomical descriptions, developing for the first time a close relationship between anatomical studies and artistic drawings. This was further developed in the Renaissance. In his textbook Anathomia are displayed six plates showing for the first time neuroanatomical structures and techniques: dissection of the head by means of trephination, and depictions of the meninges, cerebrum, and spinal cord. On the surface of the brain painting it is possible to recognize a vague patterning of cortical convolutions. Ventricles are also described and shown. This book constituted the first attempt in the history of neuroscience to illustrate an anatomical description with schematic pictures to achieve a better understanding of such complex structures.

Lancisi's nerves and the seat of the soul.

The striae longitudinales mediales corporis callosi, or medial longitudinal striae of the corpus callosum, are two slender bands of myelinated fibers that form longitudinal ridges in the indusium griseum on the superior aspect of each half of the corpus callosum. They were first described by the Italian physician Giovanni Maria Lancisi, who served as the personal physician of three successive Popes. This essay offers an account of this eminent physician, his era, and his philosophical background, as well as a description of the anatomic structures that bear his name.

Spinal decompression and vertebroplasty in Paget's disease of the spine.

Paget's disease is an osteometabolic disorder affecting in particular long bones. The spine is the second most commonly involved site in Paget's disease. This pathology can cause low back pain, spinal stenosis, myeloradiculopathy, and vertebral collapse. Medical therapy is the first choice for the treatment of Paget's disease of the spine; in case of failure, surgery remains a valid option. In the present article, we report a case of a patient with leg disability due to myelopathy caused by spinal Paget's disease treated with spinal decompression and vertebroplasty. To our knowledge, this is the first case report in which these procedures have been performed together in the same operation to treat spinal pathologies due to Paget's disease.

Functional disability after instrumented stabilization in lumbar degenerative spondylolisthesis: a follow-up study.

Low back pain (LBP) is a widespread health problem and a major contributor to increasing health costs and lost work days. Different pathologies cause LBP and one of these is lumbar degenerative spondylolisthesis (SPL). There are no generally accepted and standardized methods for assessing the outcome of patients treated for degenerative lumbar SPL. This study aims to assess quality of life after surgery for lumbar degenerative SPL through the adoption of outcome measures. We studied 76 patients treated, for degenerative lumbar SPL, with spinal stabilization, decompression and bilateral dorsolateral fusion, followed up for at least two years. We used the Roland-Morris (RM) scale and the Oswestry Disability Index (ODI) to assess the quality of life of the patients before surgery and at follow up. Each patient was pre-operatively studied through standard and dynamic x-rays, CT scan and MRI of lumbar column. Relationships between clinical, radiological and disability scores, grouped by categories, were tested. The sample comprised 25 males and 51 females. Mean age was 59.6 years (SD 12.2). The mean duration of symptoms (from clinical onset to surgery) was 23.42 months (median 13, range 4-100 months). In about half of the cases, duration of symptoms before surgery was >12 months. At follow up, the fusion rate was 85.5%, and the ODI score was significantly reduced: an improvement of <20 points in 35.7% of patients, and of >20 points in 55.7%. On the RM scale, 59.4% of patients had a reduction >5 points, 13.1% a reduction of 2-4 points, and 27.5% an unchanged or worse score. There was no significant reduction in RM scale and ODI scores in patients with fusion versus pseudoarthrosis. Instrumental pedicle screw fixation and arthorodesis seem to be very effective in improving quality of life, as shown by the reduced disability scores at follow up.

Sperm protein 17 is expressed in human nervous system tumours.

BACKGROUND: Human sperm protein 17 (Sp17) is a highly conserved protein that was originally isolated from a rabbit epididymal sperm membrane and testis membrane pellet. It has recently been included in the cancer/testis (CT) antigen family, and shown to be expressed in multiple myeloma and ovarian cancer. We investigated its immunolocalisation in specimens of nervous system (NS) malignancies, in order to establish its usefulness as a target for tumour-vaccine strategies. METHODS: The expression of Sp17 was assessed by means of a standardised immunohistochemical procedure [(mAb/antigen) MF1/Sp17] in formalin-fixed and paraffin embedded surgical specimens of NS malignancies, including 28 neuroectodermal primary tumours (6 astrocytomas, 16 glioblastoma multiforme, 5 oligodendrogliomas, and 1 ependymoma), 25 meningeal tumours, and five peripheral nerve sheath tumours (4 schwannomas, and 1 neurofibroma). RESULTS: A number of neuroectodermal (21%) and meningeal tumours (4%) were found heterogeneously immunopositive for Sp17. None of the peripheral nerve sheath tumours was immunopositive for Sp17. The expression pattern was heterogeneous in all of the positive samples, and did not correlate with the degree of malignancy. CONCLUSION: The frequency of expression and non-uniform cell distribution of Sp17 suggest that it cannot be used as a unique immunotherapeutic target in NS cancer. However, our results do show the immunolocalisation of Sp17 in a proportion of NS tumour cells, but not in their non-pathological counterparts. The emerging complex function of Sp17 makes further studies necessary to clarify the link between it and immunopositive cells.

Surgery for herniated lumbar disc disease: factors influencing outcome measures. An analysis of 403 cases.

The records of 403 patients treated for herniated lumbar disc disease were analysed in a retrospective observational study in order to verify how three outcome measures, i.e., satisfaction with the outcome of surgery, the degree of return to activities of daily living including work (ADL), and duration of interruption of ADL, may be influenced by clinical variables. Age, type of disc herniation, radiological evidence of recurrence (radiological recurrence), and need for a second surgical operation for disc herniation (surgical recurrence) were found to be significantly related to the patient's satisfaction with the outcome of surgery at follow up. Satisfaction with the outcome of surgery was not found to depend on the interval between clinical onset and radiological diagnosis, or on the timing of surgery. The degree of return to ADL was found to be significantly related to age, surgical recurrence, type of disc herniation, and timing of surgery. The results of the present study suggest that age and type of disc herniation are among the most important factors to consider when deciding whether or not to operate on a patient for herniated lumbar disc and that return to ADL after surgery is closely correlated with disc disease recurrence.

Oxidative damage after severe head injury and its relationship to neurological outcome.

OBJECTIVE: We sought to establish the time course of reactive oxygen species after severe head injuries in humans and to investigate their relationship with clinical outcomes. METHODS: Both the markers of oxidative damage-malonylaldehyde (MDA) and the enzymatic and nonenzymatic antioxidant defenses (i.e., superoxide dismutase [SOD] and vitamin E [VE], respectively)-were studied. To assess the time course of MDA, SOD, and VE, jugular bulb (JB) and peripheral venous blood samples were obtained from 30 patients within 8 hours of severe head trauma onset (T(0)) and 6 (T(1)), 12 (T(2)), 24 (T(3)), and 48 hours (T(4)) after trauma onset. Patients were divided into good and poor outcome groups according to their 6-month neurological outcome as determined on the basis of their Glasgow Outcome Scale scores and biochemical profiles. RESULTS: In JB samples, MDA levels increased significantly at T(1), T(2), T(3), and T(4) as compared with T(0); SOD activity increased significantly at T(2) and T(3) as compared with T(0); and VE levels decreased significantly at T(1), T(2), and T(3) as compared with T(0). The same variables did not change significantly over time in peripheral venous blood samples. Moreover, the MDA levels and SOD activity detected in JB samples were significantly higher in the poor outcome group at T(1) and T(2). No significant difference in VE levels was observed between the two outcome groups. CONCLUSION: Reactive oxygen species-mediated oxidative damage can play an important role in determining the prognosis of severe brain injury in humans.