180 research outputs found
Brainstem cavernous angioma in an octagenarian cardiopathic patient: anesthesiologic and neurosurgical challanges
No full textLearning Track: 6. Neuroanaesthesiology
Title: Brainstem cavernous angioma in an octogenarian cardiopathic patient: anesthesiologic and neurosurgical challenges
Author(s): Urli T.1, Nicolini F.2, Giulioni M.2, Sturiale C.2, Zanello M.1
Institute(s): 1IRCCS Istituto delle Scienze Neurologiche, Bellaria Hospital, Anesthesia and Intensive Care, Bologna, Italy, 2IRCCS Istituto delle Scienze Neurologiche, Bellaria Hospital, Neurosurgery, Bologna, Italy
Text: Background: Cerebral cavernous angiomas are uncommon diseases mostly affecting young and middle-aged people. Brainstem location can be related to severe complications both in cases of conservative or surgical management. Anesthesiologic concern is the hemodynamic instability due to manipulation of brainstem (dysrhythmias, hypertension, hypotension), and the risk of cranial nerves dysfunction.
Case report: A 81-year-old male presented painful dysesthesias and gait instability. The Magnetic Resonance Imaging revealed a large hemorrhagic multicystic lesion in the medulla oblongata. The patient had a cardiac disease with previous heart surgery (biological prosthesis, Bentall procedure); the artificial aortic valve was degenerating with moderate regurgitation. According to patient will, surgical intervention was scheduled for reducing the brainstem compression and the risk of rebleeding. Preoperative anesthesiologic evaluation pointed out the high risk of the procedure. The anesthetic plan included: prone position, balanced anesthesia with midazolam, sevoflurane and remifentanil, endocarditis prophylaxis, and a hemodynamic management fit for a patient with aortic regurgitation. External pacemaker-defibrillator pads were applied in advance. Surgical resection was carried out until occurrence of sudden bradycardia with hypotension, managed with atropine. After a short stay in ICU, the patient was transferred to the ward and then to the rehabilitation unit. Postoperatively he presented hemiparesis, slowly improving after physical therapy. The histopathological analysis confirmed the diagnosis of cavernoma.
Discussion: We found no previous report of brainstem cavernoma surgery in octogenarian cardiopathic patients, but advanced age is not a sufficient reason to deny surgical treatment if the patient may benefit. In this case the usual concern about intraoperative hemodynamic instability was increased by the type of cardiac valvulopathy: intraoperative dysrhythmias, especially bradycardia, can worsen the degree of aortic regurgitation and can precipitate left ventricular failure. The medical team weighted carefully risk benefit ratio as well as the patient wish.
Learning points: Neurosurgery of brainstem cavernomas can be performed in selected elderly patients in Hospitals with specific neurosurgical and anesthesiologic experience. The presence of serious comorbidities should not rule out the possibility of anesthesiologic and surgical treatment.
Preferred Presentation Type: Case report
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Conference: Euroanaesthesia 2017 · Abstract: A-805-0061-00727 · Status: Draf
Economic Evaluation Framework of Resource Allocation Methods in Service-Oriented Architectures
No full text
[Increasing the pressure of cerebral perfusion to control intracranial pressure]
No full textICP control can be achieved removing the surgical masses and manipulating the intracranial compartments; in the intensive care setting that can be attempted using CSF withdrawal or changing the cerebrovascular resistances, the intracranial blood content and the cerebral water content. The reduction of the ICP and the maintenance of a good cerebral perfusion pressure are the main aims of the therapy; when any standard treatment fails to control ICP a further attempt to preserve cerebral perfusion should be done by increasing the mean arterial pressure. In 10 patients with severe brain damage (GCS on admission ranging from 3 to 7, mean 5) from subarachnoid hemorrhage (3 cases) or trauma an infusion of dopamine (25-150 mg/h) and noradrenaline (0.4-2.4 mg/h) was started in case of intractable ICP. The ICP was defined intractable when the pressure was more than 40 mmHg for more than 5 m' after maximum therapy, as evaluated using the Therapy Intensity Level score. The infusion obtained a raise of the MAP of approximately 25% and a variable response on ICP. In 9 cases ICP dropped, in one case, instead, the ICP increased together with the arterial pressure. The reduction of ICP was 20-30%, with a good improvement of the CPP. The patients with a good response survived, the only patient without control of the ICP died. The physiopathologic mechanisms of this treatment are discussed; the most suitable explanation is indicated in an autoregulatory process. The infusion of cathecolamines can be harmful, and the patients eligible for this treatment must be carefully chosen. Notwithstanding this approach deserves further studies for the cases of intractable ICP
MRI findings in low grade tumours associated with focal cortical dysplasia
No full textMagnetic resonance imaging (MRI) is mandatory to identify the epileptogenic zone in refractory temporal lobe epilepsy (TLE). The correct identification of lesions is essential to obtain good post-surgery seizure control. Low grade tumors (LGT) and focal cortical dysplasia (FCD) ore common findings in symptomatic TLE, and frequently coexist. The aim of thid study was to identify the MRI characteristics in the diagnosis of FDC associated with LGT. We analyzed 24 subjects with TLE who underwent tailored surgery. They all had LGTs. Two expert neuroradiologists analyzed the imaging data and compared them with histological results, hypothesizing the cases of diagnostic errors in the identification of FCD. We selected three exemplary cases to report the most important causes of errors. An incomplete MRI protocol, the large dimensions of the tumour, infiltration and related oedema were the most important factors limiting MRI accuracy. MRI can be limited by an incomplete protocol. In addition, the presence of an LGT may limit the neuroradiological diagnosis of FCD in the temporal lobe. Advanced MRI techniques could help reveal subtle lesion that eluded a previous imaging inspection
Neurogenesis in temporal lobe epilepsy: relationship between histological findings and changes in dentate gyrus proliferative properties
No full textOBJECTIVE:
The relationship between hippocampal histopathological abnormalities, epileptogenesis and neurogenesis remains rather unclear.
METHODS:
Tissue samples including the subgranular zone of dentate gyrus (DG) were freshly collected for tissue culture for neurospheres generation in 16 patients who underwent surgery for drug-resistant temporal lobe epilepsy. Remaining tissues were histologically examined to assess the presence of mesial temporal sclerosis (MTS) and focal cortical dysplasia.
RESULTS:
MTS was detected in 8 cases. Neurospheres were formed in 10/16 cases. Only three out of these 10 cases exhibited MTS; on the contrary 5/6 cases lacking neurosphere proliferation presented MTS. There was a significant correlation between presence of MTS and absence of proliferation (p = 0.0389). We also observed a correlation between history of febrile seizures (FS) and presence of MTS (p = 0.0004) and among the 6 cases lacking neurosphere proliferation, 4 cases (66.6%) had experienced prolonged FS. Among "proliferating" cases the percentage of granular cells pathology (GCP) was lower (20% vs 50%) compared to "non proliferating" cases.
CONCLUSION:
A decreased potential to generate neurosphere from the SGZ is related to MTS and to alterations of dentate gyrus granule cells, especially in MTS type 1b and GCP type 1. These histological findings may have different prognostic implications, regarding seizure and neuropsychological outcome, compared to patients with other epileptogenic lesions (such as FCD, glioneuronal tumours, vascular lesions)
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