Meningiomas of the rolandic region: risk factors for motor deficit and role of intra-operative monitoring.

Objective Meningiomas of the rolandic region are associated to high risk of postoperative motor defcits. This study discusses the factors afecting motor outcome and recurrences from the analysis of a monoinstitutional case series and eight studies from a literature review. Methods Data of 75 patients who underwent surgery for meningioma of the rolandic region were retrospectively reviewed. The analyzed factors included tumor location and size, clinical presentation, magnetic resonance imaging (MRI) and surgical fndings, brain-tumor interface, extent of resection, postoperative outcome and recurrence. Eight studies from literature on rolandic meningiomas treated with or without intraoperative monitoring (IOM) were reviewed with the aim to defne the impact of IOM on the extent of resection and motor outcome. Results Among the 75 patients of the personal series, the meningioma was on the brain convexity in 34 (46%), at the parasagittal region in 28 (37%) and at the falx in 13 (17%). The brain-tumor interface was preserved in 53 cases (71%) at MRI and in 56 (75%) at surgical exploration. Simpson grade I resection was obtained in 43% of patients, grade II in 33%, grade III in 15% and grade IV in 9%. The motor function worsened postoperatively in 9 among 32 cases with preoperative defcit (28%) and in 5 among 43 with no preoperative defcit (11.5%); defnitive motor defcit was evidenced in overall series at follow-up in 7 (9.3%). Patients with meningioma with lost arachnoid interface had signifcant higher rates of worsened postoperative motor defcit (p=0.01) and seizures (p=0.033). Recurrence occurred in 8 patients (11%). The analysis of the 8 reviewed studies (4 with and 4 without IOM) shows in the group without IOM higher rates of Simpson grades I and II resection (p=0.02) and lower rates of grades IV resection (p=0.002); no signifcant diferences in postoperative immediate and long-term motor defcits were evidenced between the two groups. Conclusions Data from literature review show that the use of IOM does not afect the postoperative motor defcit Therefore, its role in rolandic meningiomas resection remains to be determined and will be defned in further studies

Synchronous tumours detected during cancer patient staging : prevalence and patterns of occurrence in multidetector computed tomography

Purpose: The incidental detection of one or more additional primary tumours during computed tomography (CT) staging of a patient with known malignancy is rare but possible. This occurrence should be considered by the radiologist when a new lesion is detected, especially if the lesion location is atypical for metastases. The purpose of this report was to document the usefulness of total body CT scan to detect synchronous primary malignancies in cancer patients undergoing a staging workup. Material and methods: This was done by reviewing the staging CT studies of the adult patients with a newly diagnosed cancer evaluated during a five-year period in a single cancer institute in order to identify any possible correlation, establishing which tumours are more frequently combined with a second tumour and which second tumours are more commonly present. Results: Among the patients with a second tumour, the most frequent first primary tumours were melanoma (eight patients, 17.8%), lymphoma (seven patients, 15.6%), and prostate carcinoma (seven patients, 15.6%). The most frequent incidentally detected second tumours were hepatocellular carcinoma (nine patients, 20% of 45 incidental tumours), renal carcinoma (eight patients, 17.8%), lung carcinoma (seven patients, 15.6%), and bladder carcinoma (four patients, 8.9%). One patient had three primary tumours synchronously. Conclusions: We believe that the radiologist's knowledge of the prevalence and pattern of occurrence of these multiple primary malignancies represents added diagnostic value

A new geometric invariant on initial data for Einstein equations

For a given asymptotically flat initial data set for Einstein equations a new geometric invariant is constructed. This invariant measure the departure of the data set from the stationary regime, it vanishes if and only if the data is stationary. In vacuum, it can be interpreted as a measure of the total amount of radiation contained in the data.Comment: 5 pages. Important corrections regarding the generalization to the non-time symmetric cas

Can Post-Operative Posterior Reversible Encephalopathy Syndrome (PRES) Be Considered an Insidious Rare Surgical Complication?

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterized by neurological symptoms and distinctive neuroimaging findings. There are a few cases reported in the literature in which PRES can occur after surgery, and there is no clear direct relationship between a procedure and its debut. Methods: We performed a review of the literature by analyzing all reported cases of PRES syndrome which debuted after a surgical procedure with the aim of identifying the clinical features, the timing of the symptoms’ onset and the therapy of patients suffering from this unusual surgical complication. Results: The total number of patients collected was 47, with a mean age of 40.9 years. Postoperative PRES can occur in either pediatric or adult patients (ages 4–82 years). The most frequent form of comorbidity reported was cardiovascular disease (fourteen patients, 29.78%). Sixteen patients (36%) had no relevant risk factors or comorbidities at the time of the surgical procedure. The types of surgery most correlated were cranial neuro and maxillofacial surgery (twenty-one patients, 44.68%) followed by transplant surgery (eight patients, 17%). The time of onset of PRES after surgery occurred within the first 3 weeks (mean time of onset 4.7 days), and when rapidly treated with antihypertensive and antiepileptic drugs appeared to have a reversible and benign course. Conclusion: PRES syndrome can be considered a rare complication of procedures and can occur following a wide range of surgeries, especially cranial and transplant surgery. Being able to recognize it in time and treat it ensures a full reversibility of symptoms in most case

Topographic Distribution of Intracranial Meningioma’s Recurrences: Localized Versus Diffuse-Multicentric

Meningiomas recur with a rate of 10–32% at ten years. Several features influence the risk of recurrence. Our aim is to define the pathological and surgical features at risk of diffuse-multicentric versus local-peripheral recurrence. Thirty-three cases of multicentric-diffuse recurrence of intracranial meningiomas were retrospectively analyzed and compared with 50 cases who experienced local-peripheral recurrence. The analyzed factors included age and sex, tumor location and shape, brain-tumor interface, entity of resection, WHO grade, Ki67 MIB1, progesterone receptor (PR) expression, number of reoperations, progression of WHO grade, and outcome. The multicentric-diffuse recurrences were mainly related to flat-shaped and Ki67 Li greater than 4% features at first surgery. Among patients with multicentric-diffuse recurrences, 25 underwent one to three reoperations; among them, 17 are alive with local tumor control or slow progression 2 to 25 years after the initial surgery versus only 2 out of 8 who did not undergo surgery. We conclude that flat-shaped meningiomas and those with Ki67 Li greater than 4% are at higher risk to recur in multicentric-diffuse pattern. Even multiple reoperations over a period of several years may obtain rather long survivals in selected patients with prevalent intradural not anaplastic tumors and not too extensive dural infiltration

Brain Gliomas and Ollier Disease: Molecular Findings as Predictive Risk Factors?

: Background: Ollier disease (OD) is a rare nonhereditary type of dyschondroplasia characterized by multiple enchondromas, with typical onset in the first decade of life. Surgery is the only curative treatment for primary disease and its complications. Patients with OD are at risk of malignant transformation of enchondromas and of occurrence of other neoplasms. Methods: A wide literature review disclosed thirty cases of glioma associated with OD, most of them belonging to the pre-molecular era. Our own case was also included. Demographic, clinical, pathologic, molecular, management, and outcome data were analyzed and compared to those of sporadic gliomas. Results: Gliomas associated with OD more frequently occur at younger age, present higher rates of multicentric lesions (49%), brainstem localizations (29%), and significantly lower rates of glioblastomas (7%) histotype. The IDH1 R132H mutation was detected in 80% of gliomas of OD patients and simultaneously in enchondromas and gliomas in 100% of cases. Conclusions: The molecular data suggest a higher risk of occurrence of glioma in patients with enchondromas harboring the IDH1 R132H mutation than those with the IDH1 R132C mutation. Thus, we suggest considering the IDH1 R132H mutation in enchondromas of patients with OD as a predictive risk factor of occurrence of glioma

COVID-19 : high-resolution computed tomography findings in the first 64 patients admitted to the Hospital of Cremona, the epicentre of the pandemic in Europe

Purpose: In December 2019, a new coronavirus (SARS-CoV-2) was identified as being responsible for the pulmonary infection called COVID-19. On 21 February 2020, the first autochthonous case of COVID-19 was detected in Italy. Our goal is to report the most common chest computed tomography (CT) findings identified in 64 patients, in the initial phase of COVID-19. Methods: Sixty-four chest high-resolution computed tomography (HRCT) examinations performed at the Radiology Unit of the Hospital of Cremona, from 22 to 29 February 2020, of 64 patients during first week of hospitalization for COVID-19 were retrospectively evaluated. All cases were confirmed by real-time RT-PCR for SARS-CoV-2. Image analysis was independently conducted by 2 radiologists with 10 years and 1 year of experience in chest imaging. The inter-observer agreement was obtained by applying a Cohen’s κ test. Results: The average age of patients was 67.1 years (± 12.2); men 42 (66%). HRCT was performed on the 5th (± 1.5) day of hospitalization. More frequently, the initial CT changes of the lung show more or less extensive areas of ground-glass, as single pattern or with parenchymal consolidations. Coronavirus lung involvement appears very frequently multi-lobar, bilateral, and it concerns both subpleural and central regions. An excellent agreement (κ: 0.88-1, CI: 0.79-1.01, p < 0.05) concerning CT findings between the 2 operators was reached. Conclusions: Our data suggest that detection of the most frequent pulmonary CT-scan changes, in the early stages of COVID-19, can be performed, with excellent agreement, among readers with different experience, and consequently attribute their exact diagnostic value, in an appropriate clinical and environmental exposure setting

The feasibility of three port endonasal, transorbital, and sublabial approach to the petroclival region: neurosurgical audit and multiportal anatomic quantitative investigation

Purpose: The petroclival region represents the "Achille's heel" for the neurosurgeons. Many ventral endoscopic routes to this region, mainly performed as isolated, have been described. The aim of the present study is to verify the feasibility of a modular, combined, multiportal approach to the petroclival region to overcome the limits of a single approach, in terms of exposure and working areas, brain retraction and manipulation of neurovascular structures. Methods: Four cadaver heads (8 sides) underwent endoscopic endonasal transclival, transorbital superior eyelid and contralateral sublabial transmaxillary-Caldwell-Luc approaches, to the petroclival region. CT scans were obtained before and after each approach to rigorously separate the contribution of each osteotomy and subsequentially to build a comprehensive 3D model of the progressively enlarged working area after each step. Results: The addition of the contralateral transmaxillary and transorbital corridors to the extended endoscopic endonasal transclival in a combined multiportal approach provides complementary paramedian trajectories to overcome the natural barrier represented by the parasellar and paraclival segments of the internal carotid artery, resulting in significantly greater area of exposure than a pure endonasal midline route (8,77 cm2 and 11,14 cm2 vs 4,68 cm2 and 5,83cm2, extradural and intradural, respectively). Conclusion: The use of different endoscopic "head-on" trajectories can be combined in a wider multiportal extended approach to improve the ventral route to the most inaccessible petroclival regions. Finally, by combining these approaches and reiterating the importance of multiportal strategy, we quantitatively demonstrate the possibility to reach "far away" paramedian petroclival targets while preserving the neurovascular structures

Measurement of the very rare K+→π+ννˉK^+ \to \pi^+ \nu \bar\nu decay

The decay K+→π+νν¯ , with a very precisely predicted branching ratio of less than 10−10 , is among the best processes to reveal indirect effects of new physics. The NA62 experiment at CERN SPS is designed to study the K+→π+νν¯ decay and to measure its branching ratio using a decay-in-flight technique. NA62 took data in 2016, 2017 and 2018, reaching the sensitivity of the Standard Model for the K+→π+νν¯ decay by the analysis of the 2016 and 2017 data, and providing the most precise measurement of the branching ratio to date by the analysis of the 2018 data. This measurement is also used to set limits on BR(K+→π+X ), where X is a scalar or pseudo-scalar particle. The final result of the BR(K+→π+νν¯ ) measurement and its interpretation in terms of the K+→π+X decay from the analysis of the full 2016-2018 data set is presented, and future plans and prospects are reviewed

Management delle assicurazioni: business model, prodotti, regolamentazione e performance

Nel volume si analizzano i principi caratteristici dell’economia delle imprese di assicurazione e si evidenziano le più rilevanti scelte gestionali che influenzano l’equilibrio economico, finanziario e patrimoniale delle compagnie. L’analisi è riferita all’attuale contesto ambientale caratterizzato dall’affermazione della disciplina di mercato che ha portato a nuove regole di vigilanza (Solvency II) e all’adozione dei principi contabili internazionali (IAS/IFRS, in particolare il principio IFRS 17 sui contratti assicurativi) in vigore dal primo gennaio 2023. Si analizzano le funzioni svolte, i criteri di calcolo del premio e le correlate cautele contrattuali, la logica delle scelte del desiderato livello di prudenza e di armonica gestione del portafoglio dei rischi. Si approfondiscono le caratteristiche delle passività assicurative e delle attività a copertura. Largo spazio è riservato alla adozione dei nuovi principi contabili internazionali. Il testo è destinato agli studenti di corsi universitari di economia assicurativa, ma anche a un pubblico di professional, che può trovare utile una sintesi delle complesse regole che le imprese di assicurazione devono rispettare. L’analisi è frutto di una consolidata attività didattica maturata in vari corsi universitari e dell’esperienza pluriennale professionale dei due autori