Correlazione tra diagnosi clinica, timing chirurgico e outcome nell'idrocefalo cronico dell'adulto.

PARTE PRIMA – IDROCEFALO 1.0. Introduzione . 1 1.1. Cenni storici . 2 1.2. Anatomia del sistema ventricolare . 8 • Ventricoli laterali . 9 • Terzo ventricolo . 15 • Acquedotto Cerebrale di Silvio . 17 • Quarto ventricolo . 18 • Quinto ventricolo di Varolio . 21 • Formazioni circumventricolari . 22 1.3. Fisiologia liquorale 1.3.1. Meccanismi molecolari della produzione del liquido cefalo – rachidiano . 24 1.3.2. Circolazione liquorale . 31 1.3.3. Meccanismi di riassorbimento liquorale . 33 1.3.4 Dinamica liquorale . 37 1.4. Epidemiologia . 42 1.5. Classificazione ed eziopatogenesi . 43 1.6. Clinica, diagnosi e terapia • Clinica . 47 • Diagnosi . 49 • Trattamento . 51 SECONDA PARTE – IDROCEFALO CRONICO DELL’ADULTO 2.1. Definizione . 52 2.2. Epidemiologia . 54 2.3. Eziopatogenesi . 55 2.4. Segni e sintomi . 59 • Disturbo della deambulazione . 59 • Incontinenza urinaria . 69 • Demenza . 61 2.5. Diagnosi clinico – radiologica . 63 • Valutazione clinica . 64 • Radiografia . 66 • Tomografia computerizzata . 66 • Risonanza magnetica nucleare e cine – RM . 67 • Imaging con tensore di diffusione . 69 • Tecniche di medicina nucleare . 70 • Biomarker . 70 2.5. Diagnosi differenziale . 72 2.6. Tipologie di trattamento . 76 • Shunt . 76 • Terzoventricolostomia endoscopica . 78 • Componenti del sistema di shunt . 78 • Tecnica chirurgica . 80 2.7. Complicanze . 87 2.8. Outcome . 90 • Predittori di risposta al trattamento chirurgico . 93 TERZA PARTE – STUDIO CLINICO 3.1. Obiettivi . 97 3.2. Materiali e metodi . 98 • Mini mental state examination . 98 • Deambulazione . 104 • Incontinenza urinaria . 104 3.3. Casistica – tavole prospettiche • Tabella – Dati demografici . 106 • Tabella – Dati clinici alla diagnosi . 107 • Tabella – Dati clinici post tap test e postoperatori . 108 • Tabella – Settaggio della valvola . 109 • Complicanze riscontrate . 109 3.4. Risultati e discussione • Tabella – Risultati cognitivi .112 • Tabella – Risultati nella deambulazione . 114 • Tabella – Risultati nell’incontinenza urinaria . 116 • Tabella – Settaggio della valvola . 118 • Risultati – Complicanze . 118 3.5. Conclusioni . 119 BIBLIOGRAFIA . 12

Cognitive modulation of psychophysical, respiratory and autonomic responses to cold pressor test

In healthy subjects with high hypnotisability (highs) under hypnosis, subjectively effective suggestions for analgesia abolish the increases in blood pressure associated with cold pressor test (cpt) by reducing the peripheral vascular resistance. The aim of the present study was to investigate the effects of the suggestions of analgesia on the responses to cpt in healthy highs (n = 22) and in low hypnotisable participants (lows, n = 22) out of hypnosis. Cpt was administered without (CPT) and with suggestions for analgesia (CPT+AN). Psychophysical (pain intensity, pain threshold, cpt duration (time of immersion) and pain tolerance, defined as the difference between cpt duration and pain threshold), respiratory (amplitude and frequency) and autonomic variables (tonic skin conductance, mean RR interval (RR = 1/heart rate), blood pressure, skin blood flow) were studied. The suggestions for analgesia increased cpt duration and RR in both groups, but decreased pain intensity and enhanced pain threshold only in highs; in both groups they did not modulate systolic blood pressure, tonic skin conductance and skin blood flow; thus, increased parasympathetic activity appears responsible for the heart rate reduction induced by suggestions in both groups. In conclusion, our findings show that suggestions modulate pain experience differentially in highs and lows, and are partially effective also in lows. We hypothesize that the mechanisms responsible for the efficacy of suggestions in healthy lows may be involved also in their efficacy in chronic pain patients with low hypnotisability

Cognitive modulation of psychophysical, respiratory and autonomic responses to cold pressor test.

In healthy subjects with high hypnotisability (highs) under hypnosis, subjectively effective suggestions for analgesia abolish the increases in blood pressure associated with cold pressor test (cpt) by reducing the peripheral vascular resistance. The aim of the present study was to investigate the effects of the suggestions of analgesia on the responses to cpt in healthy highs (n = 22) and in low hypnotisable participants (lows, n = 22) out of hypnosis. Cpt was administered without (CPT) and with suggestions for analgesia (CPT+AN). Psychophysical (pain intensity, pain threshold, cpt duration (time of immersion) and pain tolerance, defined as the difference between cpt duration and pain threshold), respiratory (amplitude and frequency) and autonomic variables (tonic skin conductance, mean RR interval (RR = 1/heart rate), blood pressure, skin blood flow) were studied. The suggestions for analgesia increased cpt duration and RR in both groups, but decreased pain intensity and enhanced pain threshold only in highs; in both groups they did not modulate systolic blood pressure, tonic skin conductance and skin blood flow; thus, increased parasympathetic activity appears responsible for the heart rate reduction induced by suggestions in both groups. In conclusion, our findings show that suggestions modulate pain experience differentially in highs and lows, and are partially effective also in lows. We hypothesize that the mechanisms responsible for the efficacy of suggestions in healthy lows may be involved also in their efficacy in chronic pain patients with low hypnotisability

Cold pressor test duration.

<p>The suggestions for analgesia (CPT+AN) increased the cpt duration with respect to CPT (cpt without suggestions) in both <i>highs</i> (dark bars) and <i>lows</i> (light bars) across 20 sec intervals. Bars represent the percentage of <i>highs</i> and <i>lows</i> keeping left right hand in the icy water for more than 10 sec of each interval.</p

Summary of respiratory and autonomic effects.

<p>intervals: b (basal before CPT and CPT+AN), interval 1 (CPT₁ and CPT+AN₁), interval 2 (CPT₂ and CPT+AN₂); conditions : CPT, CPT+AN.</p

Distribution of pain threshold and tolerance (sec).

<p>CPT: cpt without suggestions; CPT+AN: cpt during suggestions of analgesia; <i>highs</i>: upper panels (black points); <i>lows</i>: lower panels (white points).</p

Endovascular Thrombectomy Versus Best Medical Therapy for Late Presentation Acute Ischemic Stroke With Proximal Large‐Vessel Occlusion Selected on the Basis of Noncontrast Computed Tomography: A Retrospective Analysis of 2 Prospectively Defined Cohorts

Background The efficacy and safety of endovascular thrombectomy (EVT) >6 hours from acute ischemic stroke (AIS) onset for patients selected without computed tomography (CT) perfusion or magnetic resonance imaging is undetermined in routine clinical practice. Methods In this single‐center study, we identified consecutive late‐presenting patients with AIS who were eligible for EVT on the basis of noncontrast CT/CT angiography (without CT perfusion or magnetic resonance imaging) using an Alberta Stroke Program Early CT Score of ≥6, >6 hours from stroke onset, between January 2018 and March 2022. During the study period, EVT capacity limitations meant EVT‐eligible patients presenting out of regular working hours, consistently received best medical management (BMM). Functional outcomes (modified Rankin Scale at 90 days), symptomatic intracranial hemorrhage, and mortality at 90 days were compared between patients receiving EVT or BMM following multivariable adjustment for age, sex, baseline stroke severity, Alberta Stroke Program Early CT Score, onset‐to‐neuroimaging time, intravenous thrombolysis, and clot location. Results Among 4802 patients with AIS, 150 patients (3.1%) presenting beyond 6 hours of onset were eligible for EVT: 74 (49%) treated with EVT and 76 (51%) with BMM. Compared with the BMM group, patients treated with EVT had significantly improved functional outcome (modified Rankin Scale) (adjusted common odds ratio, 2.23 [95% CI, 1.18–4.22]; P=0.013), and higher rates of functional independence (modified Rankin Scale ≤2; 39.2.% versus 9.2%; adjusted odds ratio, =4.73 [95% CI, 1.64–13.63]; P=0.004). No significant difference was observed between the EVT and BMM groups in the symptomatic intracranial hemorrhage (5.4% versus 2.6%; P=0.94) or mortality (20.2% versus 47.3%; P=0.16) rates, respectively. Conclusion In routine clinical practice, of the 3.1% of patients in our AIS population presenting after 6 hours from stroke onset who were deemed eligible for EVT by noncontrast CT/CT angiography alone, those treated with EVT achieved significantly improved functional outcome, compared with patients treated with BMM only. No significant differences were noted between the 2 groups with respect to symptomatic intracranial hemorrhage and mortality. While confirmatory randomized trials are awaited, these findings suggest that EVT is effective and safe when performed in patients with AIS selected without CT perfusion or magnetic resonance imaging >6 hours from stroke onset

Endovascular Thrombectomy vs Best Medical Therapy for Late Presentation Acute Ischaemic Stroke with Proximal Large Vessel Occlusion Selected Based on Non-Contrast CT: A Retrospective Analysis of Two Prospectively Defined Cohorts

Background: The efficacy and safety of endovascular thrombectomy (EVT) beyond 6 hours from acute ischaemic stroke (AIS) onset for patients selected without CT perfusion or MR imaging is undetermined in routine clinical practice. Methods: In this single centre study, we identified consecutive late presenting AIS patients who were eligible for EVT based on non-contrast CT/CT angiography (without CT perfusion or MR imaging) using an Alberta Stroke Program Early CT Score (ASPECTS) of ≥6, beyond 6 hours from stroke onset, between January 2018 and March 2022. During the study period, EVT capacity limitations meant EVT-eligible patients presenting out of regular working hours, consistently received best medical management (BMM). Functional outcomes (modified Rankin Scale (mRS) at 90 days), symptomatic intracranial haemorrhage (sICH) and mortality at 90 days were compared between patients receiving EVT or BMM following multivariable adjustment for age, sex, baseline stroke severity, ASPECTS, onset-to-neuroimaging time, IV thrombolysis, and clot location. Results: Among 4802 AIS patients, 150 patients (3.1%) presenting beyond 6-hours of onset were eligible for EVT: 74 (49%) treated with EVT and 76 (51%) with BMM. Compared to the BMM group, patients treated with EVT had significantly improved functional outcome (mRS) (adjusted common OR=2.23, 95%CI 1.18-4.22, p=0.013), and higher rates of functional independence (mRS≤2; 39.2.% vs 9.2%; aOR=4.73, 95%CI 1.64-13.63, p=0.004). No significant difference was observed between the EVT and BMM groups in the sICH (5.4% vs 2.6%, p=0.94) or mortality (20.2% vs 47.3%, p=0.16) rates, respectively. Conclusion: In routine clinical practice, of the 3.1% of patients in our AIS population presenting after 6 hours from stroke onset who were deemed eligible for EVT by NCCT/CTA alone, those treated with EVT achieved significantly improved functional outcome, compared to patients treated with BMM only. No significant differences were noted between the two groups with respect to sICH and mortality. While confirmatory randomised trials are awaited, these findings suggest that EVT is effective and safe when performed in AIS patients selected without CTP or MRI beyond 6 hours from stroke onset

Abstract Number: LBA1 Endovascular Thrombectomy vs Best Medical Therapy for Late Presentation Ischaemic Stroke Selected using Non‐Contrast CT

Introduction The efficacy and safety of endovascular thrombectomy (EVT) beyond 6 hours from acute ischaemic stroke (AIS) onset for patients with proximal large vessel occlusion (LVO) selected without CT perfusion or MR imaging is undetermined in routine clinical practice. Methods In this single centre study, we identified consecutive AIS patients with an ICA or M1 MCA segment occlusion who were eligible for EVT based on non‐contrast CT/CT angiography (without CT perfusion or MR imaging) using an Alberta Stroke Program Early CT Score (ASPECTS) of ≥ 6, and an NIHSS score of≥ 6, presenting beyond 6 hours from stroke onset, between January 2018 and March 2022. During the study period, EVT capacity limitations meant EVT‐eligible patients presenting out of regular working hours (between 18.00 and 08.00 on weekdays) or on weekends, consistently received best medical management (BMM). This systemic unavailability of EVT, allows a comparison of EVT and BMM in patients who meet the same inclusion criteria, in which selection based on physician‐related bias is significantly reduced. Functional outcomes (modified Rankin Scale (mRS) at 90 days), symptomatic intracranial haemorrhage (sICH) and mortality at 90 days were compared between patients receiving EVT or BMM following multivariable adjustment for age, sex, baseline stroke severity, ASPECTS, onset‐to‐neuroimaging time, IV thrombolysis, and clot location.Pre‐specified subgroup analyses were performed. Results Among 4802 AIS patients, 150 patients (3.1%) presenting beyond 6‐hours of onset were eligible for EVT: 74 (49%) treated with EVT and 76 (51%) with BMM. Compared to the BMM group, patients treated with EVT had significantly improved functional outcome (mRS) (adjusted common OR = 2.23, 95%CI 1.18‐4.22, p = 0.013), and higher rates of functional independence (mRS≤2; 39.2.% vs 9.2%; aOR = 4.73, 95%CI 1.64‐13.63, p = 0.004). No significant difference was observed between the EVT and BMM groups in the sICH (5.4% vs 2.6%, p = 0.94) or mortality (20.2% vs 47.3%, p = 0.16) rates, respectively. EVT remained effective within the 6–12 hour and >12 hour time window subgroups. No significant treatment interaction was observed in all subgroups. Conclusions In routine clinical practice, of the 3.1% of patients in our AIS population presenting after 6 hours from stroke onset who were deemed eligible for EVT by NCCT/CTA alone, those treated with EVT achieved significantly improved functional outcome, compared to patients treated with BMM only. No significant differences were noted between the two groups with respect to sICH and mortality. While confirmatory randomised trials are awaited, these findings suggest that EVT is effective and safe when performed in AIS patients selected without CTP or MRI beyond 6 hours from stroke onset