An angio-tomographic approach to the study of the variation of the middle meningeal artery in humans

Introduction. The middle meningeal artery usually enters the endocranial cavity through the foramen spinosum, running within the dura mater and developing a vascular network on the frontal, parietal, and occipital surfaces of the brain. Little information is available on its morphogenesis and variation in human populations or within primates (Falk 1993). Its imprints on the endocranial walls can be recognised on fossil specimens, allowing inferences on the evolution of this vascular system. While extinct human species display a limited reticulation of this vessels, Homo sapiens shows a definite increase of its complexity (Bruner et al., 2005). Current hypotheses on the evolution of a complex meningeal vascularisation in our species include biomechanical protection and thermoregulation of the brain surface (Bruner et al., 2011). Taking into account the limited knowledge on the variation of this arterial network, this study is aimed at quantifying individual differences in the branching patterns, as well as at investigating the spatial relationships between middle meningeal arteries, cerebral arteries, and neurocranial bones. Methods. Angio-tomography and digital anatomy are used to reconstruct in vivo the meningeal vascular system in 37 individuals with age spanning from 20 to 85 years. Three-dimensional reconstructions of the cerebral and meningeal vascular systems have been computed by using Mimics 11.1 (Materialise Software). Variations in basic branching patterns have been described by standard anatomical approaches, as well as by using standard morphometrics. Complexity of the branching pattern has been quantified also by using fractal approaches (Zamir 1999). Results. Anatomical descriptions and metrics are reported for different age classes, sexes, and hemispheres, providing mean values and ranges of distribution accounting for the vascular patterns. Conclusions. Although the middle meningeal network shows a variable and complex geometry, its spatial organization can be quantified in terms of branching patterns and topological relationships with the neurocranial elements. This information allows to test evolutionary hypothesis by quantifying individual or between-groups differences. At the same time this information is helpful in biomedical and neurosurgical context, providing statistical values for the position and distribution of the vessels

Second hematopoietic SCT in patients with thalassemia recurrence following rejection of the first graft

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The use of alteplase, although safe, does not offer clear clinical advantages when mild stroke is non-disabling

IntroductionIt is unknown whether alteplase is effective and safe in patients with mild acute ischemic stroke (AIS). Determining whether symptoms are “disabling” or not is a crucial factor in the management of these patients. This study aimed to investigate the efficacy and safety of alteplase in patients with mild, non-disabling AIS.MethodsWe included all consecutive patients admitted for AIS at our institution from January 2015 to May 2022 who presented a baseline NIHSS score of 0–5 and fit the criteria to receive intravenous thrombolysis. In order to select only subjects with non-disabling AIS, we excluded patients who scored more than 1 point in the following NIHSS single items: vision, language, neglect, and single limb. Patients who scored at least 1 point in the NIHSS consciousness item were excluded as well. This study is a retrospective analysis of a prospectively collected database.ResultsAfter the application of the exclusion criteria, we included 319 patients, stratified into patients receiving and not receiving alteplase based on non-disabling symptoms. The two groups were comparable regarding demographic and clinical data. Rates of a 3-month favorable outcome, defined as a 3-month mRS score of 0–1, were similar, being 82.3% and 86.1% in the treated and untreated patients, respectively. Hemorrhagic complications and mortality occurred infrequently and were not affected by alteplase treatment.DiscussionThis observational study suggests that the use of alteplase, although safe, is not associated with a better outcome in highly selected patients with non-disabling AIS

Three-row versus two-row circular staplers for left-sided colorectal anastomosis: a propensity score-matched analysis of the iCral 2 and 3 prospective cohorts

Background: Since most anastomoses after left-sided colorectal resections are performed with a circular stapler, any technological change in stapling devices may influence the incidence of anastomotic adverse events. The aim of the present study was to analyze the effect of a three-row circular stapler on anastomotic leakage and related morbidity after left-sided colorectal resections. Materials and methods: A circular stapled anastomosis was performed in 4255 (50.9%) out of 8359 patients enrolled in two prospective multicenter studies in Italy, and, after exclusion criteria to reduce heterogeneity, 2799 (65.8%) cases were retrospectively analyzed through a 1:1 propensity score-matching model including 20 covariates relative to patient characteristics, to surgery and to perioperative management. Two well-balanced groups of 425 patients each were obtained: group (A) – true population of interest, anastomosis performed with a three-row circular stapler; group (B) – control population, anastomosis performed with a two-row circular stapler. The target of inferences was the average treatment effect in the treated (ATT). The primary endpoints were overall and major anastomotic leakage and overall anastomotic bleeding; the secondary endpoints were overall and major morbidity and mortality rates. The results of multiple logistic regression analyses for the outcomes, including the 20 covariates selected for matching, were presented as odds ratios (OR) and 95% confidence intervals (95% CI). Results: Group A versus group B showed a significantly lower risk of overall anastomotic leakage (2.1 vs. 6.1%; OR 0.33; 95% CI 0.15–0.73; P = 0.006), major anastomotic leakage (2.1 vs. 5.2%; OR 0.39; 95% CI 0.17–0.87; P = 0.022), and major morbidity (3.5 vs. 6.6% events; OR 0.47; 95% CI 0.24–0.91; P = 0.026). Conclusion: The use of three-row circular staplers independently reduced the risk of anastomotic leakage and related morbidity after left-sided colorectal resection. Twenty-five patients were required to avoid one leakage

Valutazione dell'efficacia della terapia trombolitica con rt-PA endovena in pazienti con ictus ischemico acuto entro 4.5 ore dall'esordio clinico mediante rm 3t con sequenze pesate in diffusione e perfusione

Scopo: L'efficacia della terapia trombolitica con rt-PA ev somministrata entro 3 ore dall'esordio clinico nei pazienti con ictus ischemico acuto è stata già studiata; tuttavia il trail europeo ECASS III ha recentemente riportato dei vantaggi significativi indotti da questa terapia anche oltre tale limite temporale. L'obiettivo di questo studio è una valutazione retrospettiva della efficacia della terapia trombolitica con rt-PA ev somministrato entro 4.5 ore dall'esordio clinico mediante RM 3 T con l'utilizzo di sequenze pesate in Diffusione e Perfusione. Materiali e Metodi: Pazienti con il sospetto di ictus ischemico acuto, giunti alla nostra osservazione a non più di 3 ore dall'esordio clinico e che presentavano esame di Tomografia Computerizzata (TC) basale negativo per emorragie intracraniche, sono stati sottoposti ad un primo esame di Risonanza Magnetica (RM) entro 4.5 ore dall'esordio sintomatologico e ad un successivo esame RM di controllo a circa 6-7 giorni. Il protocollo di studio RM prevedeva l'acquisizione di sequenze pesate ad alto coefficiente di diffusione (DWI) e sequenze di perfusione (PWI) con somministrazione a bolo ev di mezzo di contrasto paramagnetico. Risultati: Da una serie consecutiva di 350 pazienti con ictus ischemico acuto, ne sono stati selezionati 98 potenzialmente suscettibili di trattamento trombolitico e che presentavano "mismatch" DWI/PWI. 29 pazienti sono stati trattati con rt-PA ev entro 4.5 ore dall'esordio clinico. I pazienti trattati con rt-PA ev entro 3 ore hanno presentato una più bassa percentuale di incremento volumetrico della lesione ischemica rispetto ai pazienti non trattati e una più elevata percentuale di penombra ischemica preservata. Abbiamo inoltre osservato un outcome simile anche nel sottogruppo di pazienti trattati tra 3 e 4.5 ore. Conclusioni: La terapia trombolitica con rt-PA ev è sicura ed efficace se utilizzata nella finestra temporale delle 3 ore e può essere efficacemente estesa anche sino a 4.5 ore dall'esordio clinico, come recentemente dimostrato dal trial ECASS III, anche con l'ausilio delle tecniche di RM in diffusione e perfusione, nella caratterizzazione della lesione ischemica acuta e della penombra valutata in termini di mismatch DWI/PWI, e nella entità finale della lesione ischemica stessa. A tutt'oggi non vi è tuttavia consenso unanime su quale sia il parametro RM più idoneo alla caratterizzazione del mismatch

Decompressive craniectomy and hydrocephalus: proposal of a therapeutic flow-chart

The decompressive craniectomy (DC), procedure that may be necessary to save lives of patients suffering from intracranial hypertension, is not complication-free. The two main complications are hydrocephalus and the sinking skin flap syndrome (SSFS). The radiological findings and the clinical evaluation may be not enough to decide when and/or how to treat hydrocephalus in a decompressed patient. SSFS and hydrocephalus may be not unrelated. In fact, a patient affected by hydrocephalus, after the ventriculoperitoneal shunt, can develop SSFS; on the other hand, SSFS per se can cause hydrocephalus.Treating hydrocephalus in decompressed patients can be challenging. Radiological findings and clinical evaluation may not be enough to define the most appropriate therapeutic strategy. CSF dynamics and metabolic evaluations can represent important diagnostic tools for assessing the need of a CSF shunt in patients with a poor baseline neurologic status. Based on our experience, we propose a flow-chart for treating decompressed patients affected by ventriculomegaly

The Number of Pills, Rather Than the Type of Renin-Angiotensin System Inhibitor, Predicts Ambulatory Blood Pressure Control in Essential Hypertensives on Triple Therapy: A Real-Life Cross-Sectional Study

none10noIntroduction We evaluated the prevalence and predictors of ambulatory blood pressure (BP) control in patients taking a triple antihypertensive therapy (renin-angiotensin system inhibitor + calcium channel blocker + thiazide/thiazide-like diuretic, in either free or fixed-dose combinations) containing an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB). Methods We performed an observational cross-sectional study on 520 consecutive patients with essential hypertension taking a stable triple therapy in whom 24-h ambulatory BP was evaluated. Both number of pills and antihypertensive treatment intensity (ATI), as possible pharmacological predictors of ambulatory BP control, were taken into account. Results A total of 189 (36.3%) patients were taking triple therapy with ACEi and 331 (63.7%) patients were taking triple therapy with ARB. Mean age was 62.7 +/- 12.2 years. Patients on triple therapy with ACEi had a significantly lower ATI and took fewer antihypertensive pills than patients on triple therapy with ARB (22.2% of patients took a single-pill triple fixed-dose combination). Patients taking triple therapy with ACEi had higher prevalence of both 24-h (54.8% vs 44.0%; p = 0.019) and daytime BP control (61.8% vs 49.2%; p = 0.006) than patients taking triple therapy with ARB, even after adjusting for age, sex, body mass index, smoking habit, type 2 diabetes mellitus, estimated glomerular filtration rate, and ATI [OR 1.5 (95% CI 1.1-2.2) and OR 1.6 (95% CI 1.1-2.4), respectively]. However, these independent associations with ambulatory BP control were lost when the number of antihypertensive pills was included in the model. Conclusion The higher prevalence of ambulatory BP control found in patients taking a triple therapy with ACEi was affected by the lower number of antihypertensive pills taken, which was also the key predictor of ambulatory BP control in our study. This confirms the importance of fixed-dose combinations in the management of essential hypertension.openSarzani, Riccardo; Giulietti, Federico; Filipponi, Andrea; Marziali, Sonia; Ristori, Letizia; Buscarini, Silvia; Garbuglia, Caterina; Biondini, Simone; Allevi, Massimiliano; Spannella, FrancescoSarzani, Riccardo; Giulietti, Federico; Filipponi, Andrea; Marziali, Sonia; Ristori, Letizia; Buscarini, Silvia; Garbuglia, Caterina; Biondini, Simone; Allevi, Massimiliano; Spannella, Francesc

Late-onset hemorrhagic cystitis in children after hematopoietic stem cell transplantation for thalassemia and sickle cell anemia: a prospective evaluation of polyoma (BK) virus infection and treatment with cidofovir

Little is known about late-onset hemorrhagic cystitis (HC) in children, its relationship to BK virus, and treatment with cidofovir (CDV) following hematopoietic stem cell transplantation (HSCT). We prospectively investigated BK virus reactivation in children who underwent HSCT from a matched related donor for thalassemia or sickle cell anemia following busulfan-cyclophosphamide-based conditioning regimens and analyzed risk factors for development of HC and its treatment with CDV. Grade 2-4 HC occurred in 30 patients with a cumulative incidence of 26% (95% confidence interval [CI] = 18%-34%). The cumulative incidences of BK viruria and viremia were 81% (95% CI = 69%-89%) and 28% (95% CI = 18%-40%), respectively. Multivariate analysis revealed that use of antithymocyte globulin (ATG) (hazard ratio [HR] = 10.5; P = .001), peak BK viruria >100,000 copies/mL (HR = 6.2; P = .004), and grade II-IV acute graft-versus-host disease (HR = 5.3; P = .007) were predictive factors for HC. Nineteen patients with HC were given CDV at 1.5 mg/kg/day 3 times a week, or 5 mg/kg/week. The median duration of therapy was 27 days (range, 21-180 days), and a median of 9 doses were given (range, 6-22). All patients had a complete clinical response (CCR), and 69% had a microbiological response at 4 weeks. Eleven patients with BK virus-related HC receiving supportive care also had CCR. The median duration of HC in these patients was similar to that in patients treated with CDV. None of the patients with HC cleared BK viruria when CCR was achieved. We conclude that late-onset HC is more prevalent in children with sustained high BK viruria who are treated with ATG or who develop graft-versus-host disease. Randomized clinical trials are urgently needed to better define the role of CDV in treating BK virus-related HC