Typical values related to the complexity of interventional treatment of acute ischemic stroke.

BACKGROUND AND PURPOSE: Interventional Neuroradiology (INR) procedures are often complex, requiring prolonged high-dose exposures. This leads to increased radiation exposure to both patient and operating staff. The purpose of this study is to identify parameters related to the complexity of acute ischemic stroke (AIS) procedures that increase patient exposure and derive DRLs according to ICRP 135. METHODS: Data from 145 patients treated for AIS between 2017 and 2019 in a Hub Stroke center were retrospectively analyzed. Dosimetric parameters, demographic and clinical data were collected for each patient. The INR operator and the fluoroscopy system used were included. RESULTS: A multivariable analysis was performed to identify which parameters significantly influence the dosimetric data. Thrombus location and the use of stent retriever were noted as the most likely parameters of complex INR procedures. Male sex is an indicator of complex procedure only with regards to the Kerma area product and the air kerma. Patient age significantly affects the exposure time alone. Senior or more experienced operator's data demonstrated reduced patient's exposure time and therefore the KAP and Kar values. The type of X-ray equipment influenced the outcome of the procedure in terms of number of images acquired. Typical values obtained are 168 Gycm2, 0.68 Gy, 19 min and 181 images. CONCLUSION: Typical values derived in this study promote patient dose optimization, when considering the complexity of INR procedures. The clinical variables related to the complexity of procedure that mainly affect the dosimetric data in our experience are thrombus location and use of stent retrievers.

Endovascular Thrombectomy for Acute Ischemic Stroke Beyond 6 Hours From Onset: A Real-World Experience.

BACKGROUND AND PURPOSE: To evaluate outcome and safety of endovascular treatment beyond 6 hours of onset of ischemic stroke due to large vessel occlusion in the anterior circulation, in routine clinical practice. METHODS: From the Italian Registry of Endovascular Thrombectomy, we extracted clinical and outcome data of patients treated for stroke of known onset beyond 6 hours. Additional inclusion criteria were prestroke modified Rankin Scale score ≤2 and ASPECTS score ≥6. Patients were selected on individual basis by a combination of CT perfusion mismatch (difference between total hypoperfusion and infarct core sizes) and CT collateral score. The primary outcome measure was the score on modified Rankin Scale at 90 days. Safety outcomes were 90-day mortality and the occurrence of symptomatic intracranial hemorrhage. Data were compared with those from patients treated within 6 hours. RESULTS: Out of 3057 patients, 327 were treated beyond 6 hours. Their mean age was 66.8±14.9 years, the median baseline National Institutes of Health Stroke Scale 16, and the median onset to groin puncture time 430 minutes. The most frequent site of occlusion was middle cerebral artery (45.1%). Functional independence (90-day modified Rankin Scale score, 0-2) was achieved by 41.3% of cases. Symptomatic intracranial hemorrhage occurred in 6.7% of patients, and 3-month case fatality rate was 17.1%. The probability of surviving with modified Rankin Scale score, 0-2 (odds ratio, 0.58 [95% CI, 0.43-0.77]) was significantly lower in patients treated beyond 6 hours as compared with patients treated earlier No differences were found regarding recanalization rates and safety outcomes between patients treated within and beyond 6 hours. There were no differences in outcome between people treated 6-12 hours from onset (278 patients) and those treated 12 to 24 hours from onset (49 patients). CONCLUSIONS: This real-world study suggests that in patients with large vessel occlusion selected on the basis of CT perfusion and collateral circulation assessment, endovascular treatment beyond 6 hours is feasible and safe with no increase in symptomatic intracranial hemorrhage.

The Italian Registry of Endovascular Treatment in Acute Stroke: rationale, design and baseline features of patients.

Endovascular treatment (ET) showed to be safe in acute stroke, but its superiority over intravenous thrombolysis is debated. As ET is rapidly evolving, it is not clear which role it may deserve in the future of stoke treatments. Based on an observational design, a treatment registry allows to study a broad range of patients, turning into a powerful tool for patients' selection. We report the methodology and a descriptive analysis of patients from a national registry of ET for stroke. The Italian Registry of Endovascular Treatment in Acute Stroke is a multicenter, observational registry running in Italy from 2010. All patients treated with ET in the participating centers were consecutively recorded. Safety measures were symptomatic intracranial hemorrhage, procedural adverse events and death rate. Efficacy measures were arterial recanalization and 3-month good functional outcome. From 2008 to 2012, 960 patients were treated in 25 centers. Median age was 67 years, male gender 57 %. Median baseline NIHSS was 17. The most frequent occlusion site was Middle cerebral artery (46.9 %). Intra-arterial thrombolytics were used in 165 (17.9 %) patients, in 531 (57.5 %) thrombectomy was employed, and 228 (24.7 %) patients received both treatments. Baseline features of this cohort are in line with data from large clinical series and recent trials. This registry allows to collect data from a real practice scenario and to highlight time trends in treatment modalities. It can address unsolved safety and efficacy issues on ET of stroke, providing a useful tool for the planning of new trials.

Childhood abuse is associated with structural impairment in the ventrolateral prefrontal cortex and aggressiveness in patients with borderline personality disorder.

Volume reduction and functional impairment in areas of the prefrontal cortex (PFC) have been found in borderline personality disorder (BPD), particularly in patients with a history of childhood abuse. These abnormalities may contribute to the expression of emotion dysregulation and aggressiveness. In this study we investigated whether the volume of the PFC is reduced in BPD patients and whether a history of childhood abuse would be associated with greater PFC structural changes. Structural MRI data were obtained from 18 BPD patients and 19 healthy individuals matched for age, sex, handedness, and education and were analyzed using voxel based morphometry. The Child Abuse Scale was used to elicit a past history of abuse; aggression was evaluated using the Buss-Durkee Hostility Inventory (BDHI). The volume of the right ventrolateral PFC (VLPFC) was significantly reduced in BPD subjects with a history of childhood abuse compared to those without this risk factor. Additionally, right VLPFC gray matter volume significantly correlated with the BDHI total score and with BDHI irritability and negativism subscale scores in patients with a history of childhood abuse. Our results suggest that a history of childhood abuse may lead to increased aggression mediated by an impairment of the right VLPFC.

Concurrent intra-arterial carboplatin administration and radiation therapy for the treatment of advanced head and neck squamous cell carcinoma: short term results.

BACKGROUND: The aim of the present study was to evaluate the survival, efficacy and safety of a modified RADPLAT-like protocol using carboplatin instead of cisplatin. METHODS: Fifty-six patients with primary head and neck squamous cell carcinoma received 4 cycles of intra-arterial carboplatin (350 mg/m2 per cycle every 2 weeks), with concurrent three-dimensional conformal radiation therapy. RESULTS: Two major and 4 minor complications were observed. Forty-five of the 56 patients (80%) completed the protocol, while 11 (20%) patients had to discontinue the intra-arterial infusions due to the occurrence of severe haematological toxicity, but were able to complete radiotherapy. Forty-four (98%) of the 45 patients who completed the protocol and 10 (91%) of the 11 who did not, were free of disease at the end of the treatment, for a comprehensive 96% of CR overall. After a median 23.55 months (range: 2 to 58 months) of follow-up, 40 patients (71%) are alive and disease-free, 1 (2%) is alive but affected by disease and 15 (27%) have died of the disease or other causes. CONCLUSION: Intra-arterial carboplatin administration with concurrent three-dimensional conformal radiation therapy seems to be a promising alternative to RADPLAT in the treatment of advanced head and neck tumours. Haematological and non-haematological toxicities are virtually similar, but carboplatin has the advantage in that it is not nephrotoxic and can be used at very high doses without any significant increase in the extent of side effects.

Oxaliplatin-eluting microspheres for the treatment of intrahepatic cholangiocarcinoma: a case report.

Intrahepatic cholangiocarcinoma account for 13% of annual cancer-related deaths worldwide and for 3% in the USA. Patient with unresectable disease can benefit from palliative therapies such as systemic chemotherapy. However, the only curative treatment for intrahepatic cholangiocarcinoma is complete surgical resection with histologically negative resection margins.

Curative and organ-preserving treatment with intra-arterial carboplatin induction followed by surgery and/or radiotherapy for advanced head and neck cancer: single-center five-year results.

BACKGROUND: This study evaluated the feasibility, toxicity, response rate and survival of neoadjuvant superselective intra-arterial infusion of high dose carboplatin in advanced head and neck cancer. METHODS: Forty-six patients with primary head and neck squamous cell carcinoma received 3 cycles of intra-arterial carboplatin (300 to 350 mg/m2 per cycle every 2 weeks), followed by radiotherapy or surgery plus radiotherapy. RESULTS: No complications or severe toxicity occurred. Sixteen patients (35%) were complete responders, 20 (43%) partial responders while 10 (22%) did not respond to treatment. After completion of the multimodality treatment, 38/46 patients (83%) were complete responders. After a 5-year follow-up period, 18/46 patients (39%) are alive and disease-free, 3 (6,5%) have died of a second primary tumor and 25 (54.5%) have died of the disease. CONCLUSION: Intra-arterial carboplatin induction chemotherapy is a safe, well-tolerated technique that discriminates between responders and non-responders and so may have prognostic significance in planning further integrated treatments aimed to organ preservation for advanced head and neck carcinomas.

Endoscopic treatment of ethmoidal hemangioendothelioma: case report and review of the literature.

Hemangioendothelioma (HE) is a rare vascular tumor of endothelial cell origin that usually involves long bone or soft tissue. However, there are cases of head and neck involvement. In the literature, only 19 cases of nasal involvement are described. We report a case of an 18-month-old child who had HE of the ethmoid sinus. Endoscopic resection of the tumor was performed. The patient is well without any recurrence after 4 years of follow-up. Because of its rarity, the literature on HE in the nasal cavity and paranasal sinus is reviewed and its management is discussed.

Parry-Romberg syndrome with migraine and intracranial aneurysm.

Parry-Romberg syndrome or progressive facial hemiatrophy (PFH) is a rare disease of unknown etiology characterized by atrophy of the skin and subcutaneous tissue on one side of the face. The authors present the case of a 32-year-old woman with PFH who had migraine and an intracranial aneurysm. The findings support the hypothesis that the disease could be related to a neural crest migration disorder, from which both fronto-nasal mass and cranial vessels take origin.

Frontal and parieto-temporal cortical ablations and diaschisis-like effects on auditory neurocognitive potentials evocable from apparently intact ipsilateral association areas in humans: five case reports.

The aim of this study was to investigate the effects of disruption on the warning auditory S1-elicited ERP and CNV complexes recordable on the site and on remote ipsilateral apparently normal anatomo-functionally interconnected brain regions. These effects in some cases showed aspects of a probable diaschisis-like phenomenon, due to resections of extensive frontal association cortex or of primary and secondary sensory parieto-temporal areas damaged by differing pathological processes. Using a standard CNV paradigm, 21/19 EEG electrodes connected with three different references, and scalp-topographic bidimensional mapping analysis, the S1 auditory binaural/monaural clicks N1a,b,c, P2, N2, P3 and CNV waves were recorded in 10 normal subjects and 11 patients. Nine of the latter had been submitted to unilateral frontal dorsolateral cortex ablation, one to bihemispheric dorsomedial cortex ablation, and one to unilateral ablation of sensory parieto-temporal cortex and underlying white matter, verified through CT/MRI examinations. No true S1ERP/CNV components were recordable over the ablated cortical areas, whereas normal ERP/CNV complexes were observable on the intact hemispheres. In five patients, four of whom with frontocortical ablations, the S1 ERP/CNV complexes appeared severely diminished or disrupted, in two cases in a slow, partially-reversible manner, also in the neuroradiologically normal ipsilateral functionally-connected post-rolandic sensory and association areas. Similar deactivation of some ERP components was observed in reverse on the unilateral dorsolateral frontocortical region in the fifth patient with parieto-temporal cortex ablation. Even when they are partially reversible, these ipsilateral remote ERP changes in apparently intact brain regions, due to ablations of functionally-interconnected cortical formations, probably reflect cortical deactivation or simply dysfacilitation deriving from functional unilateral diaschisis. If these changes are instead irreversible they may probably be interpreted as transneuronal degeneration phenomena, though they are not at present easy to document either neuroradiologically or electroclinically.