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Intrasphenoid rupture of a non-traumatic aneurysm of the cavernous carotid artery is rare. We describe a patient in whom this condition manifested with epistaxis and led to the formation of a pseudoaneurysm occupying the right sphenoid sinus. The lesion recurred after repeated attempts at conservative endovascular therapy. Eventually the patient was treated with endovascular occlusion of the right internal carotid artery. Our report emphasizes the relapsing behaviour of a non-traumatic aneurysm of the cavernous portion of the internal carotid artery ruptured into the sphenoid sinus.

The clinical findings of intracranial vascular malformations are strictly related to their morphologic, angioarchitectural and hemodynamic characteristics. An overall study of these features is the first step to understand the different classifications for arteriovenous malformations, dural arteriovenous fistulas and carotid-cavernous fistulas. This evaluation will also suggest the correct timing of endovascular treatment and which part of the lesion should be the target of the therapy. Conventional cerebral angiography is mandatory when a correct classification of intracranial arteriovenous malformative shunts must be achieved. The angioarchitectural classification of brain arteriovenous malformations considers all angiographic features of each component of the malformation, both morphologically and hemodynamically, and relates them to the clinical course of the disease. The correlation between clinical findings, angiographic features and classifications is even stronger for cranial dural arteriovenous fistulas, in which cortical venous drainage is typical of “aggressive” fistulas and is usually absent in the “benign” type. Similarly, carotid-cavernous fistulas can be differentiated at angiography into high or low flow lesions according to the flow rate of the shunt, and into direct or indirect fistulas, according to the origin of arterial feeders. This paper focuses on the existing relation between the hemodynamics of brain arteriovenous malformations, cranial dural arteriovenous fistulas, carotid-cavernous fistulas, and their most frequent clinical findings, through an analysis of the most widely used different classification systems.

We describe a 22-year-old woman admitted to hospital in emergency with nuchal headache and vomiting. CT scan disclosed subarachnoid hemorrhage. Digital subtraction angiography with three-dimensional rotational acquisitions showed a ruptured aneurysm of a right persistent primitive hypoglossal artery as the cause of symptoms and hemorrhage. The patient was successfully treated with endovascular coiling of the aneurysm. This is the second literature report describing endovascular treatment in this unusual condition.

We investigated the levels of auto-PEEP and dynamic hyperinflation during high frequency jet ventilation (HFJV) and controlled mechanical ventilation (CMV) in six patients with chronic obstructive pulmonary disease within the first 36h of acute exacerbation. The comparative evaluation was performed at similar conditions of gas exchange in HFJV and CMV: PaO277.6±11 mmHg vs 80.8±12 mmHg; PaCO246.8±2.5 mmHg vs 47±2.8 mmHg; pH 7.38 vs 7.38. In this situation, the values of auto-PEEP and dynamic hyperinflation, expressed as Δ over the apneic functional residual capacity (FRC) did not differ: (auto-PEEPHFJV8.9±3.8 cmH2O; auto-PEEPCMV8.8±4.7 cmH2O; ΔFRCHFJV0.56±0.191; ΔFRCCMV0.54±0.2l). This result suggests that, with a suitable machine setting and similar gas exchanges, HFJV produces the same level of auto-PEEP and dynamic hyperinflation as CMV in patients with chronic obstructive pulmonary disease.

Objective: To evaluate the efficiency of a new device developed to remove obstructions from endotracheal tubes (ETT) in mechanically ventilated patients. Design: Open study in mechanically ventilated sedated and paralyzed ICU patients. Setting: General ICU and Laboratory of Respiratory Mechanics of the University of Rome “La Sapienza”. Patients: 8 consecutive unselected mechanically ventilated, critically ill patients in which a partial obstruction of ETT was suspected on the basis of an increase of the peak inspiratory pressure (>20%) plus the difficult introduction of a standard suction catheter. Interventions: Obstructions to ETT were removed with an experimental “obstruction remover” (OR) Measurements: “In vivo” ETT airflow resistance (0.25; 0.5; 0.75; 1l/s) was evaluated before and after use of the OR; the work of breathing necessary to overcome ETT resistance (WOBett) was also evaluated before and after OR use. Results: The use of OR significantly reduced in all patients the ETT “in vivo” resistance (From 5.5±2.3 to 2.9±0.5 cmH2O/l/s at 0.25l/s,p<0.05; from 9±2.4 to 3.8±0.8 cmH2O/l/s at 0.51l/s; from 12.2±3.5 to 5.7±1.2 cmH2O/l/s at 0.75l/s; from 16.9±6 to 9.3±3.8 cmH2O/l/s at 1l/s,p<0.01 respectively). Also the WOBettwas significantly reduced after use of the OR (from 0.66±0.19 to 0.34±0.08 J/l;p<0.05) Conclusion: This experimental device can be safely and successfully used to remove obstructions from the ETT lumen, without suspending mechanical ventilation, reducing the need for rapid ETT substitution in emergency and life-threatening situations.

A 12-year-old boy with recessive polycystic kidney disease and congenital hepatic failure, presented intracranial subarachnoid haemorrhage, due to the rupture of a laterobasilar tip aneurysm. In addition, he presented a left-sided middle cerebral unruptured aneurysm demonstrated during the screening procedure.Our patient is a boy, like most children with intracranial aneurysms, but differs from children with intracranial aneurysms in polycystic kidney disease. The age of bleeding was low (actually the second youngest case reported), with a good Hunt and Hess grade at admission.The localization of the aneurysm is exceptionally posterior (laterobasilar tip); in our case as intracranial aneurysms can be multifocal at that age. Renal function and blood pressure were normal. The endovascular GDC approach achieved a good result and excellent clinical outcome. Although most of what is known in this disease belongs to the autosomal dominant form, it is unclear whether the risk of a demonstrated unruptured intracranial aneurysm is the same as the risk of SAH from a non demonstrated one. It even seems that bleeding during follow-up in patients with polycystic kidney disease mostly occurs from non previously demonstrated intracranial aneurysms9.

This paper highlights the fundamental role of MRI in the diagnosis of Neuro-Behçet disease. We present 4 cases examined between 1990 and 1991. Treatment in all the cases seems to have improved the patients' prognoses.

Objective: The present study was intended to evaluate the “in vivo” endotracheal (ET) tube resistance and respiratory mechanics in mechanically ventilated patients with respiratory failure by using fiber optic catheters.Design: Two fiber optic catheters, consisting of a thin probe with a pressure transducer on the tip, were used. The first was placed at the proximal side of the ET tube and the second was positioned distally beyond the end. A low compliant air-filled catheter connected to a traditional pressure transducer was placed close to the proximal fiber optic device to compare the pressure values obtained with both systems.Setting: The study was performed in the General Intensive Care Unit of Rome “La Sapienza”, University Hospital.Patients and participants: Seven patients admitted for the management of acute respiratory failure of different etiologies were included in the protocol. All the patients were intubated and mechanically ventilated for a least 48h prior to the investigation.Measurements and results: The endotracheal tube resistance was obtained both by the end-inspiratory occlusion method and measuring pressure proximally and distally to the ET tube. The measurement of respiratory mechanics was obtained proximally and distally to the ET tube. Different flows and tidal volume changes were performed. The results showed that the fiber optic device gives an adequate evaluation of airway pressure and the possibility for an easy detection of obstructions and/or deformations of the ET tube. The area described by inspiratory and expiratory pressure recorded at both sides of the ET tube showed a positive relationship between the surface and flows while no surface changes were shown when the tidal volumes were modified. Thoraco-pulmonary compliance measured proximally and distally to the ET tube gave rise to a small and statistically insignificant differenceConclusion: This study confirms that 48h after the positioning of ET tubes the airflow resistance is significantly higher than might be expected from the “in vitro” data. The presence of the endotracheal tube can interfere with the evaluation of thoraco-pulmonary mechanics, particularly in dynamic conditions. The fiber optic system represents an interesting and simple tool for the evaluation of ET tube resistance and pulmonary mechanics in patients undergoing mechanical ventilation.

We investigated the levels of auto-PEEP and dynamic hyperinflation during high frequency jet ventilation (HFJV) and controlled mechanical ventilation (CMV) in six patients with chronic obstructive pulmonary disease within the first 36 h of acute exacerbation. The comparative evaluation was performed at similar conditions of gas exchange in HFJV and CMV: PaO277.6±11 mmHg vs 80.8±12 mmHg; PaCO246.8±2.5 mmHg vs 47±2.8 mmHg; pH 7.38 vs 7.38. In this situation, the values of auto-PEEP and dynamic hyperinflation, expressed as Δ over the apneic functional residual capacity (FRC) did not differ: (auto-PEEPHFJV8.9±3.8 cmH2O; auto-PEEPCMV8.8±4.7 cmH2O; ΔFRCHFJV0.56±0.19 l; ΔFRCCMV0.54±0.2 l). This result suggests that, with a suitable machine setting and similar gas exchanges, HFJV produces the same level of auto-PEEP and dynamic hyperinflation as CMV in patients with chronic obstructive pulmonary disease.

Six patients with acute myocardial infarction (AMI) complicated by cardiogenic shock were studied in order to compare the haemodynamic tolerance of controlled mechanical ventilation (CMV) and high frequency jet ventilation (HFJV). The comparative analysis of the two techniques was performed with the same levels of PaO2(CMV: 101±13 mmHg; HFJV: 104.2±14 p=ns); and PaCO2(CMV: 37±1.7; HFJV: 35.7±1.4p=ns). In this situation the values of mean airway pressure (Paw) did not differ significantly (CMV: 13±3 cm H2O; HFJV: 12.6±3.8 cm H2O) and no statistically significant difference in haemodynamic values was observed. These results demonstrate that in patients with cardiogenic shock, there is no difference between HFJV and CMV in terms of haemodynamic tolerance. Because of the more difficult clinical management of HFJV, this technique does not seem indicated as ventilatory support in patients with cardiogenic shock states.

La frequente associazione tra anomalie del rachide e malformazioni dell'orecchio interno che riconosce probabilmente un unico momento etiologico durante la vita fetale, è da tempo conosciuta.Gli autori descrivono un caso di malformazione complessa dell'orecchio interno coinvolgente la coclea, il vestibolo ed i canali semicircolari, associata ad anomalia di Klippel-Feil e stimmate malformative varie (polidattilia, destrocardia).L'associazione tra malformazione di Mondini e sindrome di Klippel-Feil probabilmente deriva da un comune disordine che si manifesta nella vita embrionaria nella fase contemporanea di chiusura del tubo neurale e di sviluppo dell'otocisti.Lo studio routinario MR dell'angolo ponto-cerebellare e delle strutture dell'orecchio interno è stato completato dall'applicazione di una sequenza PSIF-3DFT che permette minimo spessore di strato, forte contrasto tra le strutture labirintiche e l'osso, ed una visione multiplanare dovuta alla ricostruzione 3DFT effettuata attraverso l'applicazione del MIP.Gli autori propongono questa nuova tecnica di acquisizione nello studio della patologia dell'orecchio interno, anche al fine di un inquadramento diagnostico nell'ambito di sindromi malformative pluridistrettuali.

In this paper an artificial modular system applied to object classification in brain MR images is presented. It consists of two modules based on neural architectures joined in sequence to perform first an image segmentation and then an object classification. For these two steps a Self Organizing Map and a Multilayer Perceptron trained with the Back-Propagation learning rule have been used. The objective of the system is the automatic recognition of the anatomic structures in MR images of the cerebral section passing through the orbits and the visual pathways. To reach this goal we have submitted the two networks to a training phase realized by an unsupervised process for the image segmentation and by a supervised process for regions labelling. This last step has been based on topographic relations supplied by a medical expert. The system has been useful to discriminate 20 different classes of anatomic objects over the considered section. Preliminary results are presented.

Scopo di questo studio doppio cieco, randomizzato, comparativo a tre gruppi paralleli, è stato il confronto della sicurezza tollerabilità ed efficacia della concentrazione più bassa (270 mgI/ml: 39 pazienti) e più alta (320 mgI/ml: 39 pazienti) di iodixanolo (Visipaque ®), un nuovo mezzo di contrasto iodato non-ionico dimero, con iopamidolo (300 mgI/ml: 40 pazienti) nell'esame di tomografia computerizzata della testa. Le caratteristiche generali dei pazienti risultarono simili nei 3 gruppi di trattamento. Nessuna differenza significativa (p > 0,05) fu riscontrata tra i 3 gruppi di trattamento nella informazione diagnostica, il principale parametro di efficacia (ottimale in 37, 36 e 39 pazienti del gruppo iodixanolo 270, iodixanolo 320 e iopamidolo 300 rispettivamente). I risultati riguardanti la sicurezza non mostrarono nessuna differenza significativa tra i 3 mezzi di contrasto considerati. Su 118 pazienti, 9 accusarono discomfort(7%, 5%, e 10% nel gruppo iodixanolo 270, iodixanolo 320 e iopamidolo 300 rispettivamente) e solo 1 pz. del gruppo iodixanolo 320 mgI/ml presentò un evento avverso diverso dal discomfort(transitoria e lieve nausea, tosse, e dispnea). Il test esatto di Fisher dette p = 0,50 nel confronto tra gruppo iodixanolo 320 e gruppo iopamidolo 300.In conclusione, iodixanolo 270 mgI/ml e 320 mgI/ml risultarono mezzi di contrasto sicuri ed efficaci nell'esame di tomografia computerizzata della testa, e non fu riscontrata nessuna differenza significativa nella sicurezza ed efficacia rispetto a iopamidolo 300 mgI/ml.

La sarcoidosi è una malattia infiammatoria granulomatosa poco comune, ad eziologia sconosciuta, caratterizzata da abnorme incremento dell'immunità cellulo mediata nei siti di lesione, sotto forma di noduli sarcoidei.Il sesso più colpito è quello femminile con età di insorgenza compresa fra i 20 e i 40 anni.Sono state formulate diverse ipotesi eziopatogenetiche nel tentativo di identificare l'agente capace di coinvolgere i meccanismi responsabili dell'accumulo di linfociti e di macrofagi nella sede di lesione. Oltre alla teoria similtumorale alcuni autori propongono che alla base del processo vi sia un'anomala risposta immunitaria ereditaria e/o acquisita ad uno stimolo virale. Il maggior numero degli studiosi propende per una terza ipotesi che prevederebbe un antigene specifico, la cui eliminazione risulterebbe difficoltosa, innescando una cronica reazione di risposta immunitaria.La diagnosi di sarcoidosi si basa attualmente sulla positività scintigrafica di Gallio 67 con accumulo in sedi polmonari e delle ghiandole salivari accoppiata alla ricerca del SACE (enzima sierico di conversione dell'angiotensina).Il coinvolgimento del Sistema Nervoso Centrale in corso di Sarcoidosi avviene in una percentuale variabile dal 10 al 20% dei casi, talvolta di solo riscontro autoptico.Una sintomatologia d'esordio di tipo neurologico avviene nel 2,5% dei casi. La neurosarcoidosi isolata è rara e costituisce il 5% dei casi.La diagnosi di neurosarcoidosi isolata è spesso difficile per l'impossibilità di giungere ad una diagnosi di certezza non ricorrendo al dato bioptico.Nel SNC le sedi di localizzazione possono essere molteplici, interessando strutture in rapporto alla presenza del sistema reticolo istiocitario, quali il peduncolo vascolare ipofisario, l'ependima, i plessi corioidei, le leptomeningi.Il nostro studio si basa sull'esperienza personale di 7 casi, esaminati mediante RM prima e dopo somministrazione di Gadolinio DTPA.In 5 casi su 7 è stata rilevata la localizzazione del processo a livello dell'asse ipotalamo ipofisario e di tali pazienti 3 presentavano sintomi riferibili alla sede di lesione (diabete insipido, amenorrea, riduzione della libido, obesità).In 3 pazienti sono state rinvenute lesioni meningee a livello del seno cavernoso e della meninge corticale.In 1 paziente infine erano presenti localizzazioni multiple rilevate in successione temporale: peduncolo ipofisario, meninge corticale, epifisi, VII° e VIII° nervo cranico di sinistra e quindi del II° e VIIP° di destra. I rilievi neuroradiologici non sono patognomonici ma mimano lesioni di diversa eziologia nelle sedi succitate.Nella localizzazione al SNC di malattia sarcoidosica sistemica la RM conferma il dubbio clinico di lesioni in sedi tipiche. D'altro canto in assenza di altre localizzazioni la RM ha infatti solo il ruolo di diagnosi di esistenza di lesione.Solo nei casi di scomparsa o riduzione di lesioni meningee e dell'asse ipotalamo ipofisario dopo terapia steroidea mediante un accurato studio longitudinale di immagini, la RM puo' supportare l'ipotesi diagnostica di neurosarcoidosi isolata.

Esponiamo i risultati della nostra esperienza nello studio dei linfomi secondari del SNC con la risonanza magnetica, in confronto con i dati disponibili in letteratura.In particolare, abbiamo analizzato i dati epidemiologici e l'eventuale ricaduta delle risultanze della RM sul protocollo diagnostico-terapeutico dei linfomi secondari.Inoltre, abbiamo tentato di identificare delle ipotesi di correlazione tra quadro anatomo-patologico e segnale RM.Nei 10 pazienti sono state individuate 20 lesioni, in 7 casi singole, in 3 multiple, queste ultime da un minimo di 2 a un massimo di 6.Complessivamente le lesioni sono risultate così distribuite:— 15 lesioni intrassiali, 5 delle quali singole, 3 multiple; 1 lesione intra-assiale aveva localizzazione midollare;— 5 lesioni extrassiali, di cui 3 meningo-durali e 2 leptomeningee, tutte singole.Nelle lesioni intrassiali in T1 la zona 1 è apparsa sostanzialmente isointensa (80%) e raramente ipero iso-iperintensa (20%). In T2 si è evidenziata una prevalente iperintensità (70%), raramente una isointensità (20%) o una ipointensità (10%). La zona 2 è risultata evidente nel 30% dei casi. L '80% delle lesioni ha mostrato un potenziamento dopo contrasto, in tutti i casi da moderato a marcato e di aspetto omogeneo. In nessun caso è stata evidenziata una diffusione subependimale.Nelle immagini tardive solo nel 10% dei casi si è osservato un aumento del grado di impregnazione e senza estensione alla zona 2.Le lesioni meningodurali, così come le leptomeningee, si presentano isointense in T1, male apprezzabili in T2, ma vengono rivelate dopo mdc dalla netta impregnazione.All'esame istologico, tali forme secondarie si sono rivelate eterogenee: 5 casi a grandi cellule, 1 a piccole cellule, 1 linfoblastico, 1 tipo Burkitt, 2 linfomi di Hodgkin. In un caso a presentazione contemporanea nel SNC ed in sede periferica, il riscontro istologico cerebrale (a grandi cellule), si è mostrato differente da quello bioptico linfonodale (a piccole cellule).È stata valutata infine la risposta al trattamento, in massima parte chemioterapico; in 2 pazienti questo è stato associato a radioterapia.Si è osservata una regressione o una riduzione volumetrica lesionale nel 50% dei casi, una progressione nel 30%, ed un reperto sostanzialmente invariato nel 20%. La durata minima di tali regressioni è stata di circa 2 mesi. Solo un paziente è attualmente in remissione completa dopo circa 12 mesi dalla regressione delle lesioni.L'esame RM ha confermato di possedere una elevatissima sensibilità alle ripetizioni secondarie dei linfomi a livello del SNC: il rilievo di una elevata frequenza di tali localizzazioni, comunque in misura inferiore a quanto segnalato nei lavori anatomopatologici, è da mettere in rapporto alla selezione delle forme linfomatose a più elevata malignità, forme nelle quali il contributo dell'esame di risonanza ci appare irrinunciabile, al punto di caldeggiarne l'introduzione nei protocolli diagnostici standard.

Objective: To investigate the role played by the endotracheal tube (ETT) in the correct evaluation of respiratory system mechanics with the end inflation occlusion method during constant flow controlled mechanical ventilation. Setting: General ICU, university of Rome “La Sapienza”. Patients: 12 consecutive patients undergoing controlled mechanical ventilation. Methods: We compared the values of minimal resistance of the respiratory system (i.e. airway resistance) (RRS min) obtained: i) subtracting the theoretical value of ETT resistance from the difference between P max and P1, measured on airway pressure tracings obtained from the distal end of the ETT; ii) directly measuring airway pressure 2 cm below the ETT, thus automatically excluding ETT resistance from the data. Results: The values of RRS min obtained by measuring airway pressure below the ETT were significantly lower than those obtained by measuring airway pressure at the distal end of the ETT and subtracting the theoretical ETT resistance (4.5±2.8 versus 2.5±1.6 cm H2O/l/s,p<0.01). Conclusion: When precise measurements of ohmic resistances are required in mechanically ventilated patients, the measurements must be obtained from airways pressure data obtained at tracheal level. The “in vivo” positioning of ETT significantly increases the airflow resistance of the ETT.

I disturbi di migrazione neuronale sono classificati tra i disturbi dell'organogenesi.Sono compresi in questo gruppo di anomalie il complesso agiria-pachigiria (lissencefalia), la pachigiria, la schizencefalia, l'eterotopia di sostanza grigia.Qualunque insulto di natura vascolare, infettiva, e/o teratogena può interrompere il complesso processo della migrazione neuronale in un'epoca che va dalla 6aalla 15asettimana di età gestazionale.Le anomalie sono state classificate seguendo il criterio cronologico, dalle più precoci alle più tardive, e saranno riportati i dati della nostra personale esperienza, basata sullo studio di 28 casi: 16 complessi agiria-pachigiria, 6 schizencefalie, 3 micropoligirie, 3 eterotopie di sostanza grigia.

Abstract: The Klippel-Trenaunay syndrome (KTS) is a congenital disorder resulting from a mesodermal abnormality, characterised by cutaneous capillary haemangiomas, hypertrophy of bone and soft tissues and varicose veins. The presence of intracranial aneurysms has rarely been described, while oesophageal duplication has not been reported previously. We describe a patient with the KTS with both there additional abnormalities, which could be explained by a postulated mosaic gene abnormality.

Abstract: Tissue oxygen saturation quantification was obtained using a frequency-domain multi-source method based on two wavelength light-emitting diodes. Brain saturation was 60311% (n=12). Brachioradial muscle saturation declined during forearm ischaemia and maximal voluntary contraction from 73718 and 74718% at rest to 44233 and 61429%, respectively.

In recent years the use of devices called Heat and Moisture Exchangers (HME) has become widespread as gas conditioners for ICU patients requiring mechanical ventilation. As an important variation of the resistive properties of the HME, related to flow and duration of use, has recently been pointed out during “in vitro” studies, the use of these devices in COPD patients could increase the levels of auto PEEP and dynamic hyperinflation. In this study we have compared the levels of auto PEEP and difference in functional residual capacity (Δ FRC) in a group of COPD patients, requiring controlled mechanical ventilation (CMV), at basal conditions and after the insertion into the circuit of three HMEs (Dar Hygrobac, Pall Ultipor, Engstrom Edith) at random: the results obtained excluded a significant increase of auto PEEP and Δ (FRC) both with “new” HMEs and after 12 h of continuous use.

At the beginning of 1997, the new rules for payment of services supplied by public and private health institutions started. This new system creates a common base among all public and private subjects, with an authority (the Region), having the financial responsability, and the role to plan the entire organization, to control the services' quality, and to determinate the tariff charges.This system is completely different from the previous one, and creates a direct competition between public health service and private operators.In this work the rules and the problems linked with their progressive application will be analyzed.