[Show abstract][Hide abstract] ABSTRACT: Glioblastoma Multiforme, the most common and aggressive primary brain tumor, remains incurable despite of the advent of modern surgical and medical treatments. This poor prognosis depends by the recurrence after surgery and intrinsic or acquired resistance to chemotherapy and radiotherapy. Nitric oxide is a small molecule that plays a key roles in glioma pathophysiology. Many researches showing that NO is involved in induction of apoptosis, radiosensitization and chemosensitization. Therefore, NO role, if clarified, may improve the knowledge about this unsolved puzzle called GBM.
[Show abstract][Hide abstract] ABSTRACT: OBJECT Vasopressor-induced hypertension (VIH) is an established treatment for patients with aneurysmal subarachnoid hemorrhage (SAH) who develop vasospasm and delayed cerebral ischemia (DCI). However, the safety of VIH in patients with coincident, unruptured, unprotected intracranial aneurysms is uncertain. METHODS This retrospective multiinstitutional study identified 1) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who required VIH therapy (VIH group), and 2) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who did not require VIH therapy (non-VIH group). All patients had previously undergone surgical or endovascular treatment for the presumed ruptured aneurysm. Comparisons between the VIH and non-VIH patients were made in terms of the patient characteristics, clinical and radiographic severity of SAH, total number of aneurysms, number of ruptured/unruptured aneurysms, aneurysm location/size, number of unruptured and unprotected aneurysms during VIH, severity of vasospasm, degree of hypervolemia, and degree and duration of VIH therapy. RESULTS For the VIH group (n = 176), 484 aneurysms were diagnosed, 231 aneurysms were treated, and 253 unruptured aneurysms were left unprotected during 1293 total days of VIH therapy (5.12 total years of VIH therapy for unruptured, unprotected aneurysms). For the non-VIH group (n = 73), 207 aneurysms were diagnosed, 93 aneurysms were treated, and 114 unruptured aneurysms were left unprotected. For the VIH and non-VIH groups, the mean sizes of the ruptured (7.2 ± 0.3 vs 7.8 ± 0.6 mm, respectively; p = 0.27) and unruptured (3.4 ± 0.2 vs 3.2 ± 0.2 mm, respectively; p = 0.40) aneurysms did not differ. The authors observed 1 new SAH from a previously unruptured, unprotected aneurysm in each group (1 of 176 vs 1 of 73 patients; p = 0.50). Baseline patient characteristics and comorbidities were similar between groups. While the degree of hypervolemia was similar between the VIH and non-VIH patients (fluid balance over the first 10 days of therapy: 3146.2 ± 296.4 vs 2910.5 ± 450.7 ml, respectively; p = 0.67), VIH resulted in a significant increase in mean arterial pressure (mean increase over the first 10 days of therapy relative to baseline: 125.1% ± 1.0% vs 98.2% ± 1.2%, respectively; p < 0.01) and systolic blood pressure (125.6% ± 1.1% vs. 104.1% ± 5.2%, respectively; p < 0.01). CONCLUSIONS For small, unruptured, unprotected intracranial aneurysms in SAH patients, the frequency of aneurysm rupture during VIH therapy is rare. The authors do not recommend withholding VIH therapy from these patients.
Full-text · Article · Jul 2015 · Journal of Neurosurgery
[Show abstract][Hide abstract] ABSTRACT: I gliomi di alto grado continuano a rimanere un problema irrisolto a causa dell’inesorabile e precoce comparsa della loro recidiva. Malgrado le numerose scoperte in merito alla genetica di questi tumori, non vi sono, allo stato, nuovi trattamenti che stravolgano la prognosi di questi pazienti. Nelle scorse decadi, quindi, vi é stato un atteggiamento chirurgico molto conservativo, volto soprattutto a garantire una diagnosi. Su queste basi non si procedeva pertanto, se non in rari casi, al trattamento chirurgico delle recidive. Negli ultimi anni é stata dimostrata una correlazione tra l’estensione della resezione chirurgica e la sopravvivenza dei pazienti con Glioblastoma di nuova diagnosi. Sono nati quindi nuovi studi che suggeriscono una maggiore aggressività chirurgica anche nelle recidive. Per garantire un’adeguata resezione sono disponibili diverse tecnologie tra cui la neuronavigazione, l’ecografia intraoperatoria ed il 5ALA. La neuronavigazione standard si basa su immagini preoperatorie e pertanto non può essere ritenuta affidabile dopo la craniotomia, l’apertura durale, la deliquorazione e l’inizio della resezione a causa del “brain shift”. Una metodica che, invece, garantisce immagini in tempo reale é l’ecografia. Un’ulteriore metodica di comprovata efficacia per una visualizzazione “diretta” del residuo tumorale, è l’impiego del 5ALA.
In letteratura vi sono scarse evidenze sull’impiego dell’Eco e del 5ALA in associazione, soprattutto nei pazienti con recidiva di malattia.
Descriviamo, quindi, la nostra esperienza sull'utilizzo dell’associazione Eco/5ALA, in pazienti con recidiva di glioma di alto grado.
Dal 2013 ad oggi, sono stati selezionati pazienti con recidiva di malattia, indipendentemente dai marker molecolari, includendo anche pazienti con lesioni in area eloquente, con KPS > 80 ed età inferiore a 65 anni, sottoposti a cicli di CT ed RT adiuvanti secondo schema STUPP, in progressione radiologica e clinica di malattia.
Il protocollo prevede la somministrazione di 5-ALA 3 ore prima della procedura (20 mg/kg), con fotoprotezione e l'utilizzo del sistema Sonowand, utilizzato sia come Neuronavigatore che come ecografo intraoperatorio. In seguito all’intervento, i pazienti eseguono un controllo RM encefalo con mdc entro le 48 h post-operatorie in modo da poter valutare l’estensione della resezione in assenza dei falsi positivi determinati dall’alterazione di barriera.
Il vantaggio ricavato da questo protocollo ha portato ad una resezione completa del nodulo enhancing. Alle valutazioni neurologiche seriate eseguite durante la degenza, abbiamo osservato un iniziale peggioramento del quadro clinico con progressivo recupero.
Riteniamo che in casi selezionati sia giustificata una maggiore aggressività chirurgica anche nei casi di recidiva di Gliomi di alto grado. E’ ormai dimostrato che un ottimo controllo locale della patologia ne migliori la prognosi e a tal fine sono attualmente disponibili varie tecnologie che possono venire in soccorso al Neurochirurgo per l’ottenimento di un’ampia e sicura resezione, anche in aree eloquenti.
[Show abstract][Hide abstract] ABSTRACT: OBIETTIVO Uno dei maggiori fa-ori che contribuiscono ad un " poor " outcome dopo emorragia subaracnoidea (ESA) è l ' ischemia cerebrale ad insorgenza precoce (da ro-ura dell ' aneurisma o alla procedura scelta per il tra-amento) o tardiva. Al fine di valutare la relazione tra queste due Dpologie di ischemia e l ' outcome del paziente abbiamo analizzato la frequenza relaDva dell ' infarto precoce vs tardivo dopo ESA nei pazienD tra-aD con clipping o coiling. METODI E ' stata effe-uata un ' analisi retrospeFva dei pazienD con ESA afferiD dal 2003 al 2015. Sono staD raccolD i daD demografici , WFNS score al ricovero , Fisher grade , sede dell ' aneurisma , metodo di tra-amento (clipping o coiling) , vasospasmo ed outcome (GOS score) alla dimissione. TC encefalo a 24-‐48 ore post-‐tra-amento o TC encefalo eseguita alla comparsa di disturbi neurologici sono state confrontate con indagini strumentali finali al fine di definire la condizione di ischemia precoce o tardiva. In ulDmo , sono state confrontate le cara-erisDche cliniche dei pazienD all ' ingresso e alla dimissione per valutare possibili associazioni significaDve con queste due Dpologie di infarto. CONCLUSIONI L ' infarto precoce è associato a clipping dell ' aneurisma , non a vasospasmo , e ad un outcome clinico buono nel maggior parte dei casi. L ' infarto cerebrale tardivo è associato a vasospasmo , più che alla Dpologia di tra-amento scelto , e ad un ' evoluzione sfavorevole dell ' outcome clinico. 288 pazien7 71 ischemie (5 casi precoce + tardiva)
[Show abstract][Hide abstract] ABSTRACT: Cerebral vasospasm represents the most critical event that could occur after subarachnoid hemorrhage (SAH). Therapy is only partially effective because cerebral arterial constriction is not fully understood yet. One of the most important biological messenger associated to SAH is nitric oxide (NO), that is considered local regulator of cerebral blood flow. Different nitric oxide synthase (NOS) forms play a role in different biological processes, one of which is to link neuronal activity to blood flow in cerebral cortex. We performed a reassessment of the literature to summarize the role of NO as the main inflammatory pathway activated after SAH to clarify its importance for treatment of vasospasm.
No preview · Article · Jan 2015 · Journal of neurosurgical sciences
[Show abstract][Hide abstract] ABSTRACT: Purpose:
a literature review was made to investigate the role of nitric oxide (NO) in spinal cord injury, a pathological condition that leads to motor, sensory, and autonomic deficit. Besides, we were interested in potential therapeutic strategies interfering with NO mechanism of secondary damage.
A literature search using PubMed Medline database has been performed.
excessive NO production after spinal cord injury promotes oxidative damage perpetuating the injury causing neuronal loss at the injured site and in the surrounding area.
different therapeutic approaches for contrasting or avoiding NO secondary damage have been studied, these include nitric oxide synthase inhibitors, compounds that interfere with inducible NO synthase expression, and molecules working as antioxidant. Further studies are needed to explain the neuroprotective or cytotoxic role of the different isoforms of NO synthase and the other mediators that take part or influence the NO cascade. In this way, it would be possible to find new therapeutic targets and furthermore to extend the experimentation to humans.
Full-text · Article · Apr 2014 · The International journal of neuroscience
[Show abstract][Hide abstract] ABSTRACT: Objective:
The worldwide population aging and the nowadays medical advances impose to consider new management guidelines for elderly. Aim of this study was to assess the best treatment in elderly with multiple intracranial aneurysms (MIA).
From 1994 to 2011, we admitted 1462 patients with ruptured cerebral aneurysm. Among those aged ≥65 years, 43 had MIA (15% of elderly). Size and aneurysm location, timing and type of treatment were analyzed. Patients were thus stratified according to Hunt-Hess grade on admission and evaluated at 6 months using the Glasgow Outcome Scale (GOS).
We had 87 aneurysms in the final series. Three patients died because of the impossibility to treat the ruptured aneurysm. No new bleeding from untreated aneurysms was observed; no retreatment after previous coiling was performed.
MIA lead to significantly poorer outcomes, especially in elderly, because of their general clinical condition, presence of risk factors and lower capacity of reaction to stressful events. In patients without large hematomas, coiling of the ruptured aneurysm represents the procedure with high effectiveness. The clinical conditions on admission represent the most important factor for the treatment results. To reduce the treatment-related risks we do recommend a conservative approach for the unruptured aneurysms.
No preview · Article · Dec 2013 · The International journal of neuroscience
[Show abstract][Hide abstract] ABSTRACT: There is little information about clinical characteristics, management, and outcome of patients with intracranial aneurysms and internal carotid artery occlusion. We will describe clinical characteristics, treatment and outcome of patients with coexistent internal carotid artery occlusion and intracranial aneurysms.
We conducted a retrospective chart review of 22 patients (eight males and 14 females) with coexistent internal carotid artery (ICA) occlusion and intracranial aneurysms.
This series includes 14 females and eight males with a mean age of 63 years (range, 49 to 80). These patients harbored a total of 35 aneurysms, which were located on the same side of the ICA occlusion in five cases, on the contralateral side in 20 cases, while in ten cases the aneurysm had a midline location (AcomA 9, Basilar tip 1). Treatment consisted of surgery for eight aneurysms and endovascular embolization for 13 aneurysms. No invasive treatment was recommended for 14 aneurysms (eight patients with single aneurysm). No permanent perioperative or periprocedural complications occurred in the selected group of patients undergoing invasive treatment. At a mean follow-up of 57 months (range, 3-203), no patient had a subarachnoid hemorrhage and three patients had died of causes not related to the aneurysm.
Surgical and endovascular treatment can be accomplished safely in selected patients with coexistent ICA occlusion and intracranial aneurysms. Conservative treatment is a valid alternative, especially in elderly patients or in patients with very small aneurysms, especially if not located along the collateral pathway.
No preview · Article · Sep 2013 · Acta Neurochirurgica
[Show abstract][Hide abstract] ABSTRACT: Flow-diverters are used in the treatment of large and complex intracranial aneurysms. One major concern with this concept is the potential for compromise of side branches and perforators covered by the device. We describe three patients treated with the Pipeline embolization device (PED; ev3 Endovascular, Plymouth, MN, USA) who developed immediate compromise of flow into an eloquent side branch covered by the device. Three patients, two with giant posterior circulation aneurysms and one with recurrence of a previously clipped and subsequently coiled middle cerebral artery aneurysm, were each treated by placement of a single PED. Shortly after placement of the devices, despite adequate antiplatelet and anticoagulation regimens, partial or complete occlusion of a major side branch occurred. In all three patients, the occlusion was promptly reversed with intra-arterial administration of abciximab with no clinical sequelae. These cases are concerning because branch occlusion occurred even in the setting of patients appropriately premedicated with dual antiplatelet therapy and in whom genetic testing suggested clopidogrel responsiveness. Close monitoring of patients treated with these devices is critical to establish the frequency of this and other unanticipated complications.
No preview · Article · Aug 2013 · Journal of Clinical Neuroscience
[Show abstract][Hide abstract] ABSTRACT: Background and purpose:
Flow diversion is a new strategy for the treatment of complex paraclinoid aneurysms. However, flow diverters have, to date, not been tested in direct comparison with other available treatments. We present a matched-pair comparison of paraclinoid aneurysms treated with the PED versus other endovascular techniques.
Materials and methods:
Twenty-one eligible patients with 22 paraclinoid aneurysms treated with the PED at our institution were matched with historic controls with aneurysms of similar size and location.
There were no statistically significant differences between the 2 groups in terms of aneurysm size, location, risk factors, or comorbidities. Mean dome size was 13.9 ± 6.7 mm in the control group and 14.9 ± 6.3 mm in the PED group (P = .52). Balloon and stent assistance were used in 31.8% and 9.1% of controls, respectively, while carotid sacrifice was used in 36.4% of the controls. There was a significant difference in the rate of complete occlusion favoring PED at radiologic follow-up (P = .03).
Flow diverters achieve a much higher rate of complete angiographic obliteration compared with other standard endovascular techniques in the treatment of internal carotid artery aneurysms. In this series, this higher angiographic obliteration rate did not occur at the expense of an increased rate of complications. Careful long-term follow-up is of the utmost importance to definitively validate flow diversion as a superior therapeutic strategy for proximal internal carotid artery aneurysms.
Preview · Article · Jul 2012 · American Journal of Neuroradiology
[Show abstract][Hide abstract] ABSTRACT: Background Flow diversion represents a major paradigm shift in the treatment of unruptured intracranial aneurysms. The potential impact of this technique on coil utilization and adjunctive techniques such as balloon-assisted and stent-assisted coiling is unknown. In this study, the effect of introduction of flow diversion devices on the utilization of coil and adjunctive techniques was assessed.
Methods A retrospective review was conducted of consecutive patients with unruptured aneurysms treated at our institution comparing two groups: Group 1 (patients treated in the 2-year interval preceding the introduction of the Pipeline Embolization Device (PED) and Group 2 (patients treated during the 2-year interval following introduction in our practice of the PED).
Results Mean aneurysm diameter was 8.7±6.3 mm in Group 1 and 8.5±6.1 mm in Group 2 (p=0.79). PED therapy was employed in 38 (21.7%) of 175 aneurysms in Group 2. The proportion of stent-assisted procedures was significantly less in Group 2 than in Group 1 (6.9% vs 14.7%, p=0.04), as was the proportion of patients undergoing parent artery sacrifice (0.6% vs 3.9%, p=0.046). The mean and median number of coils used per aneurysm were 5.4±3.6 and 5 (range 1–18) for Group 1 and 3.2±3.2 and 3 (range 0–19) for Group 2 (p≤0.0001).
Conclusions Flow diversion represents a disruptive technology. More than one-fifth of unruptured aneurysms at our institution were treated with PED after introduction of this technology, resulting in marked decreases in coil and stent utilization.
No preview · Article · Apr 2012 · Journal of Neurointerventional Surgery
[Show abstract][Hide abstract] ABSTRACT: Proximal aneurysms of the medullary postero-inferior cerebellar artery (PICA) tract are peculiar due to critical anatomical location, small size and tortuosity of the parent vessel, close origin to brainstem perforators, and fragility of the sac wall. Moreover, most patients present after bleeding, increasing the challenges. Aim of this study is to evaluate the treatment modality and outcome of these patients during the last decade at the University Clinic of Torino. Databases of the Neurosurgical and Neuroradiological Department of the University of Torino were analyzed to retrieve patients treated for aneurysms of the medullary PICA tract. Charts and neuroradiological documentation were revised to complete the database. Of 621 patients treated for an intracranial aneurysm, 23 had PICA aneurysm, 18 located at the medullary tract. Only two were unruptured and 16 were ruptured aneurysms. Sixteen underwent endovascular treatment and two underwent surgery. In six cases the aneurysm was cured by parent vessel occlusion. At 6 months follow-up, the Glasgow outcome scale was high (5 and 4) in 16 patients; two patients had died in the acute phase, for reasons unrelated to the procedure. If not adequately compensated, parent vessel occlusion associates with high risks of ischemia and related brain swelling. In the present series sufficient collateral flow contributed to a good tolerance toward occlusion in all cases. Despite the small size of the present series, most treated cases presented a good outcome. Nevertheless, distal revascularization of the occluded artery would be indicated where collateral flow is insufficient.
[Show abstract][Hide abstract] ABSTRACT: SUMMARY:Angiographic recurrence following endovascular therapy is an indirect measure of the potential for hemorrhage. Because patients and physicians consider recurrence to be a suboptimal outcome with some chance of future hemorrhage, much effort has been expended to reduce the incidence of recurrence. The literature regarding aneurysm recurrence following endovascular therapy, spanning 2 decades, is extensive. We will review and summarize the effort to reduce recurrence following endovascular treatment of cerebral aneurysms.
Preview · Article · Mar 2012 · American Journal of Neuroradiology
[Show abstract][Hide abstract] ABSTRACT: SUMMARY:Cerebral aneurysms are treated to prevent hemorrhage or rehemorrhage. Angiographic recurrences following endovascular therapy have been a problem since the advent of this treatment technique, even though posttreatment hemorrhage remains rare. Notwithstanding its unclear clinical significance, angiographic recurrence remains not only a prime focus in the literature but also frequently leads to potentially risky retreatments. The literature regarding aneurysm recurrence following endovascular therapy, spanning 2 decades, is immense and immensely confusing. We review the topic of recurrence following endovascular treatment of cerebral aneurysms in an effort to distill it down to fundamental material relevant to clinical practice.
Preview · Article · Mar 2012 · American Journal of Neuroradiology
[Show abstract][Hide abstract] ABSTRACT: Patients with aneurysmal subarachnoid hemorrhage are typically kept in the intensive care unit to be monitored for signs of delayed cerebral ischemia (DCI). Identifying patients at lower risk for DCI could have a positive financial impact by allowing earlier transfer from the intensive care unit.
We analyzed 307 consecutive patients admitted to the intensive care unit. Demographic, clinical, and neuroimaging data were recorded. The relationship with absent DCI was analyzed using univariate and multivariate logistic regression models.
DCI did not develop in 169 patients (57.9%). Among factors at admission, age 68 years or older (P=0.0003; OR, 3.16; 95% CI, 1.66-6.39), World Federation of Neurological Surgeons (WFNS) I to III at presentation (P=0.0003; OR, 2.73; 95% CI, 1.57-4.79), WFNS I to III at worst (P=0.0003; OR, 2.39; 95% CI, 1.48-3.87), WFNS I to III after resuscitation (P=0.0006; OR, 2.85; 95% CI, 1.56-5.32), modified Fisher grade 1 to 2 (P=0.0021; OR, 2.43; 95% CI, 1.37-4.47), absence of intracranial hematoma (P=0.0042; OR, 2.26; 95% CI, 1.29-4.01), and aneurysm in the posterior circulation (P=0.025; OR, 1.74; 95% CI, 1.07-2.87) were associated with absence of DCI. On multivariate analysis, a model including age 68 years or older, WFNS I to III at presentation and a modified Fisher grade 1 to 2 were independently predictive of the absence of DCI, with a specificity of 100% and a positive predictive value of 100%.
We propose a new model that can reliably identify patients with aneurysmal subarachnoid hemorrhage who are at very low risk for DCI. These patients could be candidates for early transfer to the general ward.