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In adult human brain, neurogenesis seems to persist throughout life and ischemic stroke was proved to stimulate this process. Using magnetic resonance spectroscopy (MRS), a 1.28-ppm peak, putative biomarker of neural progenitor cells (NPCs), was identified both in vitro and in vivo, i.e., in normal rat and healthy human brain. The aim of our study was to identify a 1.28-ppm peak in adult human ischemic brain by using 3.0 T multivoxel MRS.We studied 10 patients, six males, and four females, with a mean (± SD) age of 59.3 (± 17.3), at three different time points from ischemic stroke onset (T0: 5 days; T14: 14 ± 2 days; T30: 30 ± 2 days).In all patients except one, a 1.28-ppm peak at T14 was detected at the ischemic boundary (all p values 0.05). MRS performed on six voluntary age-matched healthy subjects did not detect any 1.28-ppm peak.The nature of this 1.28-pm peak is uncertain; however, our data support the hypothesis that it might represent a marker of NPCs in post-stroke human brain.

Aneurysms with a major diameter > 25 mm are defined as giant intracranial aneurysms (GIAs). Different clinical, pathological, and radiological factors were revealed as playing a role in choosing the best strategy between surgical and endovascular approaches. Despite the improvement of both techniques, the efficacy and safety of these different management are still debated. We evaluated the differences in clinical and radiological outcomes of GIAs treated with surgical and endovascular techniques in a large retrospective mono-centric study. We compared aneurysm location, clinical, morphological features, treatment outcome, and complications on the ground of treatment technique. The final cohort consisted of 162 patients. All the patients were assigned on the ground of the type of eligible treatment: surgical (118 patients) and endovascular procedure (44 patients). The different treatment strategies were made through a multidisciplinary selection whereas clinical parameters, location, and morphologic features of the aneurysm were considered. The surgical group manifested a greater reduction in performance levels and neurological status in the post-operative phases than the endovascular group (p p = 0.012) in contrast to a lower recurrence rate (p > 0.01). There is no significant difference in post-operative mortality and survival between surgical and endovascular groups. The surgical group manifested a higher incidence of complications after treatment. The endovascular group has a better post-operative outcome, but a higher risk of recurrence and the necessity of further treatment.

The risk of stroke and cerebrovascular disease complicating infection with SARS-CoV-2 has been extensively reported since the onset of the pandemic. The striking efforts of many scientists in cooperation with regulators and governments worldwide have rapidly brought the development of a large landscape of vaccines against SARS-CoV-2. The novel DNA and mRNA vaccines have offered great flexibility in terms of antigen production and led to an unprecedented rapidity in effective and safe vaccine production. However, as mass vaccination has progressed, rare but catastrophic cases of thrombosis have occurred in association with thrombocytopenia and antibodies against PF4 (platelet factor 4). This catastrophic syndrome has been named vaccine-induced immune thrombotic thrombocytopenia. Rarely, ischemic stroke can be the symptom onset of vaccine-induced immune thrombotic thrombocytopenia or can complicate the course of the disease. In this review, we provide an overview of stroke and cerebrovascular disease as a complication of the SARS-CoV-2 infection and outline the main clinical and radiological characteristics of cerebrovascular complications of vaccinations, with a focus on vaccine-induced immune thrombotic thrombocytopenia. Based on the available data from the literature and from our experience, we propose a therapeutic protocol to manage this challenging condition. Finally, we highlight the overlapping pathophysiologic mechanisms of SARS-CoV-2 infection and vaccination leading to thrombosis.

Background and purpose The PHASES score was formulated to predict the 5-year risk of rupture for intracranial aneurysms. We retrospectively analyzed all patients treated in our institution for aneurysmal SAH and applied the PHASES score to estimate the probable predicted risk of bleeding in this group of patients. Methods Between February 2015 and August 2018, all patients with aneurysmal SAH were retrospectively analyzed and the PHASES score was applied. A total of 155 patients were included with a mean age of 53.8 years, including 60 males and 95 females. Results Of our patients 110 (70.9%) had a PHASES score of below or equal to 5, with a hemorrhagic risk of up to 1.3% over 5 years. If we analyze the patients with a risk of below 2% this figure increases to 122 patients (78.7%). Of these 99.3% were European and 0.6% were Japanese (1 patient). In 86 patients (55.4%), the aneurysm was smaller than 5 mm and in 10 patients (6.4%) the aneurysm was located in the posterior circulation. Conclusion Of our patients 78.7% had less than a 2% 5-year rupture risk based on their PHASES score, highlighting the discrepancy of the rupture risk calculated with the PHASES score when hypothetically applied to this group of patients. In the hypothetical scenario that our patients had unruptured aneurysms, our retrospective analysis shows that the PHASES score may only provide a weak tool for clinicians to use in the decision-making process as to whether or not to treat these aneurysms.

There is an ongoing debate regarding the benefits of using transradial access (TRA) over transfemoral access (TFA) in endovascular therapies including endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) patients. This study sought to investigate the association of TRA and TFA with procedural success, access-site complications, first-pass reperfusion (FPR), puncture-to-recanalisation (PTR) time and hemorrhagic transformation (HT) by performing a meta-analysis.PubMed, EMBASE and Scopus were searched. Studies with patients aged ≥ 18 years and head-to-head TRA vs TFA comparisons were included. Random-effects modeling was performed to obtain summary effects and forest plots were plotted to study the association of TFA with access site complications, FPR, HT, PTR time and procedural success.Six studies encompassing 945 patients (347 TRA and 598 TFA) were included in the meta-analysis. Meta-analysis revealed that in AIS patients receiving EVT, TRA was significantly associated with a decreased risk of access-site complications (RR 0.17, 95% CI 0.05 0.54; p = 0.003, z = -2.957) and HT (RR 0.07, 95% CI 0.02 0.27; p 0.0001, z = -3.8841). However, TRA was not significantly associated with procedural success (RR 0.96, 95% CI 0.90 1.01; p = 0.141, z = -1.473), FPR (RR 0.91, 95% CI 0.79 1.05; p = 0.194, z = -1.299) and PTR time (SMD -0.14, 95% CI -0.42 -0.14; p = 0.323, z = -0.989).Our meta-analysis demonstrated that TRA is a safe alternative to TFA, in AIS patients receiving EVT, with significantly decreased access-site complications and HT with TRA, albeit with comparable procedural success, FPR and PTR time to TFA.The original contributions presented in the study are included in the article/Supplementary information, further inquiries can be directed to the corresponding author.

Background and purposeAcute ischemic stroke (AIS) is a fearful complication of Coronavirus Disease-2019 (COVID-19). Aims of this study were to compare clinical/radiological characteristics, endothelial and coagulation dysfunction between acute ischemic stroke (AIS) patients with and without COVID-19 and to investigate if and how the SARS-CoV-2 spike protein (SP) was implicated in triggering platelet activation.MethodsWe enrolled AIS patients with COVID-19 within 12 h from onset and compared them with an age- and sex-matched cohort of AIS controls without COVID-19. Neuroimaging studies were performed within 24 h. Blood samples were collected in a subset of 10 patients.ResultsOf 39 AIS patients, 22 had COVID-19 and 17 did not. Admission levels of Factor VIII and von Willebrand factor antigen were significantly higher in COVID-19 patients and positively correlated with the infarct volume. In multivariate linear regression analyses, COVID-19 was an independent predictor of infarct volume (B 20.318, Beta 0.576, 95%CI 6.077–34.559; p = 0.011). SP was found in serum of 2 of the 10 examined COVID-19 patients. Platelets from healthy donors showed a similar degree of procoagulant activation induced by COVID-19 and non-COVID-19 patients' sera. The anti-SP and anti-FcγRIIA blocking antibodies had no effect in modulating platelet activity in both groups.ConclusionsSARS-CoV-2 infection seems to play a major role in endothelium activation and infarct volume extension during AIS.

Background. Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare syndrome of unclear aetiology occurring after DNA-based vaccinations against COVID-19. The aim of this study was to investigate the DNA vaccine-encoded Sars-cov-2 soluble spike protein (SP). as a potential trigger of platelet activation in VITT. Methods. We studied three VITT patients and seven healthy controls (HCs) within 3 weeks from the first dose of ChAdOx1 nCoV-19, and one non vaccinated HC. Serum levels of SP and soluble angiotensin-converting enzyme 2 (sACE2), ACE2 expression in platelets and platelet response to VITT serum stimulation were studied. A thrombus retrieved during mechanical thrombectomy from one VITT patients, was analysed by immunohistochemistry for SP and ACE2. Neutrophil extracellular traps (NETs) markers and coagulation parameters were also measured. Results. We detected serum SP (up to 35 days post-vaccination) and sACE2 in all VITT patients, and respectively in two and three out of 7 vaccinated HCs. Only platelets from one non-vaccinated HC expressed ACE2. VITT sera markedly activated platelets and this activation was inhibited by both anti-SP and anti-FcγRIIA blocking antibodies. The thrombus showed positive immunohistochemical labelling of platelets using an anti-SP antibody with reduced ACE2 expression, compared to a thrombus from a pre-pandemic stroke patient. Markers of endothelial dysfunction, NETs and hypercoagulability state were present in all VITT sera. Conclusions. The present data provides first evidence that DNA vaccine-encoded Sars-cov-2 SP is detectable in VITT sera (several weeks post-vaccination) and in a platelet-rich thrombus, and that may contribute to the initial platelet stimulation in VITT patients.

Vaccine induced thrombotic thrombocytopenia is a new syndrome recently described in young adults within two weeks from the first dose of the ChAdOx1 nCoV-19 vaccine and characterized by cerebral venous thrombosis. We report two cases of malignant middle cerebral artery (MCA) infarct and thrombocytopenia within 10 days after vaccination with ChAdOx1 nCoV-19. Patient 1 was a 57-year-old woman who underwent decompressive craniectomy despite two successful mechanical thrombectomies. Patient 2 was a 55-year-old woman who developed a fatal bilateral malignant MCA infarct. Both the patients had pulmonary and portal vein thrombosis and high level of antibodies to platelet factor 4-polyanion complexes.

Vaccine-induced thrombotic thrombocytopenia with cerebral venous thrombosis is a syndrome recently described in young adults within two weeks from the first dose of the ChAdOx1 nCoV-19 vaccine. Here we report two cases of malignant middle cerebral artery (MCA) infarct and thrombocytopenia 9-10 days following ChAdOx1 nCoV-19 vaccination. The two cases arrived in our facility around the same time but from different geographical areas, potentially excluding epidemiological links; meanwhile, no abnormality was found in the respective vaccine batches. Patient 1 was a 57-year-old woman who underwent decompressive craniectomy despite two prior, successful mechanical thrombectomies. Patient 2 was a 55-year-old woman who developed a fatal bilateral malignant MCA infarct. Both patients manifested pulmonary and portal vein thrombosis and high level of antibodies to platelet factor 4-polyanion complexes. None of the patients had ever received heparin in the past before stroke onset. Our observations of rare arterial thrombosis may contribute to assessment of possible adverse effects associated with COVID-19 vaccination., Vaccination is an effective strategy in suppressing COVID-19 pandemic, but rare adverse effects have been reported, including cerebral venous thrombosis. Here the authors report two cases of middle cerebral artery infarct within 9-10 days following ChAdOx1 nCov-19 vaccination that also manifest pulmonary and portal vein thrombosis.

This case report describes a combined neurosurgical and endovascular approach for the treatment of a conus medullaris arteriovenous malformation resulting in considerable improvement in the patient’s neurological condition (modified Rankin Scale score 2).

This case report describes a combined neurosurgical and endovascular approach for the treatment of a conus medullaris arteriovenous malformation resulting in considerable improvement in the patient’s neurological condition (modified Rankin Scale score 2).

Purpose: Intracranial carotid artery occlusion represents an underinvestigated cause of acute ischemic stroke as well as an indication for mechanical thrombectomy. We investigated baseline and procedural characteristics, outcomes and predictors of outcome in patients with acute ischemic stroke secondary to intracranial carotid artery occlusion. Methods: A retrospective analysis of the Italian Registry of Endovascular Treatment in Acute Stroke was performed. Patients with intracranial carotid artery occlusion (infraclinoid and supraclinoid) with or without cervical artery occlusion but with patent intracranial arteries were included. The 3‑month functional independence, mortality, successful reperfusion and symptomatic intracranial hemorrhage were evaluated. Results: Intracranial carotid artery occlusion with patent intracranial arteries was diagnosed in 387 out of 4940 (7.8%) patients. The median age was 74 years and median baseline National Institute of Health Stroke Scale (NIHSS) was 18. Functional independence was achieved in 130 (34%) patients, successful reperfusion in 289 (75%) and symptomatic intracranial hemorrhage in 33 (9%), whereas mortality occurred in 111 (29%) patients. In univariate analysis functional independence was associated with lower age, lower NIHSS at presentation, higher rate of successful reperfusion and lower rate of symptomatic intracranial hemorrhage. Multivariable regression analysis found age (odds ratio, OR:1.03; P = 0.006), NIHSS at presentation (OR: 1.07; P < 0.001), diabetes (OR: 2.60; P = 0.002), successful reperfusion (OR:0.20; P < 0.001) and symptomatic intracranial hemorrhage (OR: 4.17; P < 0.001) as the best independent predictors of outcome. Conclusion: Our study showed a not negligible rate of intracranial carotid artery occlusion with patent intracranial arteries, presenting mostly as severe stroke, with an acceptable rate of 3‑month functional independence. Age, NIHSS at presentation and successful reperfusion were the best independent predictors of outcome. © 2020, Springer-Verlag GmbH Germany, part of Springer Nature.

BackgroundNeo-intimal hyperplasia (NIH) is frequently observed after flow-diverter stent (FDS) implantation. Although mostly asymptomatic, this vascular response can sometimes lead to delayed ischemic strokes. This study intended to evaluate the factors potentially influencing the rates of NIH following FDS treatment.Material and MethodsAll aneurysm treatments performed with a Pipeline embolization device (PED) or a SILK stent from May 2011 to May 2015 were collected in a prospectively maintained database. Patient demographics, clinical, and angiographic outcomes including both digital subtraction angiography and C-arm cone-beam CT were registered. Two blind reviewers rated the presence of NIH on a binary scale (present/absent).ResultsFrom 148 patients, 63 datasets were available for analysis. Inter-reader agreement was excellent (Kappa=0.88). NIH was positively correlated with smoking, dyslipidemia, and high blood pressure, but not with aneurysm characteristics. At early follow-up (ConclusionNIH is a dual-vessel reaction after FDS implant. When planning a treatment in locations at risk of ischemic complications if severe NIH would occur, then the stent design should be considered. However, minimal NIH might also be needed as it is involved in aneurysm healing. Before treatment patients should be recommended best medical management of their cardiovascular risks factors to prevent an excessive NIH reaction.

OBJECTIVE To assess the spectrum of genetic anomalies in a cohort of children presenting at least one cerebral or spinal pial arteriovenous fistula (AVF), and to describe their clinical characteristics. METHODS From 1988 to 2016, all consecutive patients with at least one cerebral or spinal pial AVF were screened for genetic disease. All patients aged

Background Recent reports have revealed a worsening of aneurysm occlusion between WEB treatment baseline and angiographic follow-up due to “compression” of the device. Objective We utilized computational fluid dynamics (CFD) in order to determine whether the underlying mechanism of this worsening is flow related. Methods We included data from all consecutive patients treated in our institution with a WEB for unruptured aneurysms located either at the middle cerebral artery or basilar tip. The CFD study was performed using pre-operative 3D rotational angiography. From digital subtraction follow-up angiographies patients were dichotomized into two groups: one with WEB “compression” and one without. We performed statistical analyses to determine a potential correlation between WEB compression and CFD inflow ratio. Results Between July 2012 and June 2015, a total of 22 unruptured middle cerebral artery or basilar tip aneurysms were treated with a WEB device in our department. Three patients were excluded from the analysis and the mean follow-up period was 17 months. Eleven WEBs presented “compression” during follow-up. Interestingly, device “compression” was statistically correlated to the CFD inflow ratio ( P = 0.018), although not to aneurysm volume, aspect ratio or neck size. Conclusion The mechanisms underlying the worsening of aneurysm occlusion in WEB-treated patients due to device compression are most likely complex as well as multifactorial. However, it is apparent from our pilot study that a high arterial inflow is, at least, partially involved. Further theoretical and animal research studies are needed to increase our understanding of this phenomenon.

BackgroundAneurysms of the anterior communicating artery (ACoA) are difficult to treat with coiling or clipping because of the anatomical variation in this region. Flow diversion represents a feasible treatment, but no consensus exists as to which stent deployment technique is more suitable.MethodsAll patients with ACoA aneurysms treated with flow diverters between April 2014 and November 2018 were retrospectively analyzed. Aneurysm characteristics, follow-up results, and clinical outcome data were recorded, and a new classification comparing the diameters of both A1 segments is proposed: H1=same diameters; H2=ResultsWe analyzed 30 procedures in 30 patients with ACoA aneurysms, including 16 ruptured aneurysms treated with coiling embolization and 4 previously unruptured aneurysms (two Medina and two Woven EndoBridge devices). Adequate aneurysm occlusion occurred in 86.9%; one patient (3.3%) experienced symptomatic ischemic stroke. The global thromboembolic complications for each group were 17.6% (H1), 25% (H2), and 60% (H3).ConclusionFlow diversion treatment in this region is safe, feasible, and effective. The most suitable anatomical configuration for flow diverter treatment seems to be the H1 configuration where the ‘I technique’ is suitable (from an A1 segment to the ipsilateral A2). There is a tendency that the H3 configuration is not a good indication for flow diverter treatment. However, further studies are needed to evaluate the feasibility of this anatomical classification and the reproducibility of our findings.

Background: Randomized controlled trials for calcium antagonists therapy in patients with acute ischemic stroke have failed to show a benefit as a stand-alone therapy, due largely to the reduction of blood pressure, especially in the absence of early recanalization. Since mechanical thrombectomy (MT) has led to high successful recanalization rates, the effect of nimodipin as an adjuvant therapy during MT has not been evaluated. Materials and Methods: We retrospectively reviewed all consecutive cases of MT for which Nimodipin was used as an adjuvant therapy after at least one pass of any device. Clinical and angiographic characteristics, as well as immediate vessel caliber modifications, reperfusion status and early neurological improvement were collected between January 2016 and December 2017. Results: Procedural intra-arterial nimodipin infusion was administered in 10.3 % (58/559; 95%CI 7.8-12.8 %) of patients, after at least one pass of MT device. In 52/58 patients, < 3 manoeuvers of MT were performed. Angiographic vasospasm was identified on the carotid artery in 17/58 (29.3%) cases, on the middle cerebral artery in 35/58 (60.4%) cases and in vertebro-basilar artery in 6/58 (10.3%) cases. The vasospasm was responsible for an immediate reocclusion in 12% of the patients. Angiographic effect of nimodipin with the restauration of a normal vessel caliber and the improvement of the reperfusion without supplementary maneuver was observed in 77.5% % of the cases. Successful recanalization TICI 2b/3 was reached in 81% patients. Significant drop of blood pressure (BP) with need for additional vasopressive drugs was observed in 6 cases. Symptomatic hemorrhage occurred in 3 patients (5%). Concomitant fibrinolytic therapy did not influence the rate of intracranial hemorrhage rate after procedural nimodipin infusion (p=0.912). Early neurological improvement was reached in 46% and was not associated with a high initial systolic and diastolic BP at the admission (p=0.89) or with the modality of anesthesia (p =0.76). Conclusion: Nimodipin can be an efficient and safe adjuvant therapy in the setting of vasospasm due to MT, by normalizing the caliber of the recanalized artery and then, improving the reperfusion status without supplementary maneuver of MT.

Background The authors sought to assess the safety and early efficacy of the pCONUS Bifurcation Aneurysm Implants in a meaningful number of patients; we performed a systematic review and meta-analysis for the treatment of 203 intracranial aneurysms. Methods A literature search was performed by a reference librarian, and after screening nine case series were included in this analysis. We estimated from each study the cumulative incidence (event rate) and 95% confidence interval (CI) for each outcome. Event rates were pooled in a meta-analysis across studies using the random-effects model; descriptive statistics were reported when relevant. Results The pCONUS devices can be used with a technical success rate of 100% (95% CI: 0.98-1.00) and a technical complication rate of 0% (95% CI: 0.00-0.02). Perioperative morbidity and mortality rates were 7% (95% CI: 0.03-0.11) and 0% (95% CI: 0.00-0.01), respectively. Perioperative hemorrhage rate was 0% (95% CI: 0.00-0.02); rate of treatment-related long-term neurological deficit was 2% (95% CI: 0.00-0.06). The long-term complete occlusion rate was 60% (95% CI: 0.52-0.69) and retreatment rate was 14% (95% CI: 0.06-0.22). Conclusions The pCONUS devices are an additional tool for the treatment of wide-necked intracranial aneurysms with high rates of technical success and sufficiently low rates of morbidity and mortality. Comparative studies with longer-term follow-up are needed to clarify the role of this device in the management of challenging aneurysms.

OBJECTIVEEndovascular treatment in children, especially neonates, can be more challenging than analogous procedures in adults. This study aimed to describe the clinical and radiological findings, type and timing of endovascular treatment, and early outcomes in children who present with neurovascular malformations, who are treated with embolization, and who weigh less than 5 kg.METHODSThe authors carried out a retrospective review of all consecutively treated children weighing less than 5 kg with neurovascular arteriovenous malformations (AVMs) at a single institution over a 10-year period.RESULTSFifty-two patients were included in the study. Thirty-eight had a vein of Galen aneurysmal malformation, 3 a pial AVM, 6 a pial arteriovenous fistula, and 5 a dural sinus malformation. The endovascular treatment goals were control of cardiac failure or hydrocephalus in cases of nonhemorrhagic malformations or to prevent new bleeding in cases of previous hemorrhage. A hemorrhagic complication occurred in 12 procedures and an ischemic complication in 2. Both complication types were correlated with the age of the infant (age cutoff at 3 months) (p = of 0.015 and 0.049, respectively). No correlation was found with the weight of the infant or the duration of the procedure.CONCLUSIONSThe embolization of AVMs in these patients prevented adverse cardiac effects, hydrovenous disorders, and rebleeding. The risk of major cerebral complications seems mainly correlated with age, with a threshold at 3 months. A multidisciplinary team involved in the treatment of these children may help to improve treatment success and management.

Introduction The treatment of wide-neck bifurcation aneurysms is still challenging despite the use of new techniques, such as Y-stenting, the waffle-cone technique and intrasaccular flow disrupters, in recent years. Moreover, the use of flow diverter stents in bifurcation aneurysms has been proposed by several teams, although the results remain controversial. This study aims to evaluate the feasibility and efficacy of Y-stent assisted coiling of bifurcation aneurysms with braided stents. Methods We retrospectively reviewed all patients in whom Y-stenting with braided stents had been performed in our center. Six patients were identified and analyzed. Technical success, complications, angiographic outcomes, procedural data, and follow-up controls are reported here. This study was approved by our local ethical committee. Results Technical success was achieved in all procedures. Overall procedure-related morbidity and mortality was 0%. In the immediate post-treatment angiography, adequate occlusion (neck remnant or total occlusion) was observed in all patients. Short- and long-term follow-up angiography showed adequate occlusion of the aneurysms. Conclusions In this small, retrospective single-center analysis we showed that Y-stent assisted coiling with braided stents is a safe and feasible technique. Moreover, it has a high immediate occlusion rate and very good long-term stability.

BackroundThe treatment of wide neck bifurcation aneurysms remains challenging despite the introduction of new techniques (Y stenting, waffle cone technique, or flow diverter stents). The Woven EndoBridge (WEB) device is an innovative solution for this type of cerebral aneurysm. A new WEB 17 is now available and has been designed to offer smaller sized devices to optimize navigability and delivery.MethodsBetween February 2017 and April 2018 all patients treated with the WEB 17 device in our center were retrospectively reviewed. 25 patients with 28 non-ruptured aneurysms were identified and analyzed. Three patients with two aneurysms both treated with the WEB device were identified.ResultsThe device was successfully deployed in all cases. Procedure related morbidity was 4% and mortality was 0%. In one case, a delayed postprocedural thromboembolic event occurred owing to device protrusion. Technical success, complications, angiographic outcomes, procedural data, and follow-ups are reported. The modified Rankin Scale score at discharge was 0 for 24 patients (96%). At the 3, 6, or 9 month follow-up, angiograms were taken of 21 of the 25 patients (84%) (24 of 28 aneurysms had been controlled); 3 patients (3 aneurysms) did not receive angiographic follow-up at the time of submission of this work. Complete occlusion was achieved in 22 of 24 aneurysms (91.66%), and 2 of 24 aneurysm (8.33%) showed a neck remnant.ConclusionsThe WEB 17 is safe and technically feasible, according to this retrospective single center analysis. For very small bifurcation aneurysms, the WEB 17 seems to have lower complication rates than stent assisted techniques. However, further studies are needed to evaluate the complication rate and long term efficiency.

BACKGROUND AND PURPOSE: The treatment of microcystic lymphatic malformations remains challenging. Our aim was to describe the lymphographic-like technique, a new technique of slow bleomycin infusion for the treatment of microcyst components of 30%) clinical improvement, respectively. Patients were reviewed 3 months after each sclerotherapy session. Lymphographic-like technique safety and efficacy were assessed. RESULTS: Between January 2012 and July 2016, sixteen patients (5 males, 11 females; mean age, 15 years; range, 1–47 years) underwent the bleomycin lymphographic-like technique for microcystic lymphatic malformations. Sixty sclerotherapy sessions were performed, with a mean of 4 sessions per patient (range, 1–8 sessions) and a mean follow-up of 26 months (range, 5–58 months). We observed no major and 3 minor complications: 1 eyelid infection, 1 case of severe postprocedural nausea and vomiting, and 1 case of skin discoloration. One patient was lost to follow-up. Overall MR imaging objective improvement was observed in 5/16 (31%) patients; overall improvement of clinical symptoms was obtained in 93% of treated patients. CONCLUSIONS: The bleomycin lymphographic-like technique for microcystic lymphatic malformations is safe and feasible with objective improvement in about one-third of patients. MR signal intensity changes after the lymphographic-like technique are associated with subjective improvement of the patient's symptoms.

BackgroundDirect punctures of intracranial tumors have rarely been described in the literature.ObjectiveTo assess the feasibility, safety, efficacy, and advantages of using 3D DSA-guided direct puncture rather than the traditional transarterial route to preoperatively devascularize intracranial lesions in particular clinical situations, paying special attention to any correlation with surgical observations; we present the largest series to date.MethodsBetween July 2015 and July 2016, data from all presurgical embolizations performed in our institution were prospectively collected. Information on tumor type, location, size, eventual bone erosion, complications, devascularization percentage, and estimated blood loss was analyzed.ResultsTumors of four patients (two meningioma, two endolymphatic sac tumor) were embolized using direct puncture. 3D XperGuide planning software was used in all procedures. Embolization was feasible in all cases. In one case, a small craniotomy was specifically performed to allow needle positioning. In all cases n-butyl cyanoacrylate was used. No ischemic or hemorrhagic complications related to embolization occurred. Complete or near complete devascularization was obtained in all cases. In one case, surgery was not performed and the patient was monitored. Resection was complete without significant blood loss in two cases, and resection was incomplete but satisfactory in one case.ConclusionsIn selected cases, 3D-guided direct puncture of intracranial tumors appears safe, feasible, and efficient for preoperative embolization.

Background Intracranial pial arteriovenous fistulas (PAVFs) are direct communications between the arterial and venous system of the brain, with the characteristic absence of a plexiform nidus, as seen in the classic cerebral arteriovenous malformations. These vascular malformations, usually occurring in the pediatric population, very rarely are diagnosed in utero, because of a lack of understanding of the condition and because they may be hard to visualize. Case Description We report a rare case of a mass-effect PAVF diagnosed with fetal magnetic resonance imaging, involving the right cerebral hemisphere, fed by a pericallosal artery and associated with a giant venous dilatation. The PAVF initially was managed by the endovascular embolization. The recruitment of a middle cerebral artery feeder and the rapidly enlarging size of the venous pouch with mass effect required subsequent surgery. Conclusions The 2-stage multimodal treatment resulted in complete disappearance of the PAVF without complications.

Purpose The purpose of this study was to define the feasibility, the efficacy and the safety of preoperative embolization (POE) of meningiomas using polyvinyl alcohol (PVA) particles. Materials and methods Between January 2006 and June 2014, 191 consecutive patients were referred to our institution for the treatment of meningiomas; of these 57 patients were excluded from the study. A total of 64 patients (22 men and 42 women) with a mean age of 58.4 ± 10.8 [SD] years (range: 14–82 years) who underwent POE with PVA particles, achieving extensive (> 90%) devascularization were ultimately included and compared to 70 patients who had surgery without POE. Surgical time and intraoperative blood loss were compared between the two groups. The duration of procedures and complications related to POE were analyzed. Results No differences were found between the two groups with respect to intraoperative blood loss. A significant reduction in surgical time was observed for the group who had POE (207.4 ± 79.5 [SD] min vs. 226.9 ± 117.6 [SD] min; P = 0.028). In a subgroup analysis, the size and location of meningiomas did not influence these results. The duration of procedures was 41.4 ± 10.5 [SD] min. Minor complications related to POE occurred in 3 out of 64 patients (4.7%). Conclusion POE of meningiomas using PVA particles is effective in reducing surgical time, when extensive tumor devascularization is achieved. However, radiation exposure, the duration of procedures and complications related to POE with PVA particles do not justify this technique in most patients.

Deep infiltrating endometriosis is an important gynecologic disease that may develop during the reproductive years and is responsible for severe pelvic pain. Deep pelvic endometriosis can affect the retrocervical region, uterosacral ligament, rectum, rectovaginal septum, vagina, urinary tract, and other extraperitoneal pelvic sites. Surgery remains the best therapeutic treatment for affected patients and an accurate preoperative evaluation of the extension of endometriotic lesions is essential for a successful outcome. However, many atypical locations for deep pelvic endometriosis exist although still lesser known to both gynecologists and radiologists such as endometriosis of the round ligaments of the uterus (RLUs). In this article, we review embryology and anatomy of the RLUs as well clinical characteristics associated with these endometriotic locations. In addition, we describe magnetic resonance (MR) imaging protocol, normal MR imaging appearances of the RLUs and the most common abnormal findings of endometriotic involvement of these ligaments at MR imaging. Radiologists should always keep in mind the RLUs as a possible site of deep pelvic endometriosis localization and should not forget to carefully look for them on MR images.

none 5 no This research was supported by funds from the University of Bologna (RFO2014) to S.B.and from the University of Urbino (RFO 2014) to V.S.. Quinoa (Chenopodium quinoa Willd), an ancient Andean seed crop, exhibits exceptional nutritional properties and resistance to abiotic stress. The species' tolerance to heavy metals has, however, not yet been investigated nor its ability to take up and translocate chromium (Cr). This study aimed to investigate the metabolic adjustments occurring upon exposure of quinoa to several concentrations (0.01–5mM) of CrCl3. Young hydroponically grown plants were used to evaluate Cr uptake, growth, oxidative stress, and other biochemical parameters three and/or seven days after treatment. Leaves accumulated the lowest amounts of Cr, while roots and stems accumulated the most at low and at high metal concentrations, respectively. Fresh weight and photosynthetic pigments were reduced only by the higher Cr(III) doses. Substantially increased lipid peroxidation, hydrogen peroxide, and proline levels were observed only with 5mM Cr(III). Except for a significant decrease at day 7 with 5mM Cr(III), total polyphenols and flavonoids maintained control levels in Cr(III)-treated plants, whereas antioxidant activity increased in a dose-dependent manner. Maximum polyamine accumulation was observed in 1mM CrCl3-treated plants. Even though α- and γ-tocopherols also showed enhanced levels only with the 1mM concentration, tyrosine aminotransferase (TAT, EC 2.6.1.5) activity increased under Cr(III) treatment in a dose- and time-dependent manner. Taken together, results suggest that polyamines, tocopherols, and TAT activity could contribute to tolerance to 1mM Cr(III), but not to the highest concentration that, instead, generated oxidative stress. open Scoccianti, Valeria; Bucchini, Anahi E.; Iacobucci, Marta; Ruiz, Karina B.; Biondi, Stefania Scoccianti, Valeria; Bucchini, Anahi E.; Iacobucci, Marta; Ruiz, Karina B.; Biondi, Stefania

This paper highlights an updated anatomy of parametrial extension with emphasis on magnetic resonance imaging (MRI) assessment of disease spread in the parametrium in patients with locally advanced cervical cancer. Pelvic landmarks were identified to assess the anterior and posterior extensions of the parametria, besides the lateral extension, as defined in a previous anatomical study. A series of schematic drawings and MRI images are shown to document the anatomical delineation of disease on MRI, which is crucial not only for correct image-based three-dimensional radiotherapy but also for the surgical oncologist, since neoadjuvant chemoradiotherapy followed by radical surgery is emerging in Europe as a valid alternative to standard chemoradiation.

The vast use of silver nanoparticles (AgNPs) mandates thorough investigation of their impact on biosystems at various levels. The cytotoxicity of PVP coated-AgNPs to pollen, the aploid male gametophyte of higher plants, has been assessed here for the first time. The negative effects of AgNPs include substantial decreases in pollen viability and performance, specific ultrastructural alterations, early changes in calcium content, and unbalance of redox status. Ag+ released from AgNPs damaged pollen membranes and inhibited germination to a greater extent than the AgNPs themselves. By contrast, the AgNPs were more potent at disrupting the tube elongation process. ROS deficiency and overproduction were registered in the Ag+- and AgNP-treatment, respectively. The peculiar features of AgNP toxicity reflected their specific modes of interaction with pollen surface and membranes, and the dynamic exchange between coating (PVP) and culture medium. In contrast, the effects of Ag+ were most likely induced through chemical/physicochemical interactions.

Both trivalent and hexavalent chromium, i.e., Cr(III) and Cr(VI), respectively, were previously demonstrated to affect in vitro germination and ultrastructure of kiwifruit (Actinidia deliciosa) pollen. In the present work, the response to chromium in germinating pollen was evaluated in terms of changes in the polyamine profile. Slight, though significant, increases in free spermidine and spermine occurred after exposure to Cr(III), while the levels remained almost unchanged after Cr(VI) treatment. The spermidine synthase inhibitor cyclohexylamine (CHA) caused a dramatic increase in free putrescine in both chromium-treated and untreated samples, while spermidine content was not affected. Interestingly, CHA positively affected the performance of chromium-treated pollen by partially, though significantly, restoring pollen tube growth. The major growth recovery was registered with 1 mM CHA in the presence of Cr(VI), concomitant with a considerable reduction in uptake of the metal. Conversely, endogenous calcium levels were more heavily affected in Cr(III)-treated pollen. The effect of CHA on production of reactive oxygen species also varied depending on the chromium species. The response of pollen to the CHA-induced putrescine excess was compared with that exerted by an exogenous supply of the same diamine. Results show that in Cr(III)-treated pollen, putrescine over-accumulation induced by CHA exerted similar effects as exogenous putrescine, while this was not true in the Cr(VI) treatment. It appears that the diamine was able to improve pollen tolerance to metal stress through different mechanisms, mostly depending upon the chromium species, namely via reduced metal uptake or by substituting for calcium.

BackgroundCorrect alignment of prosthetic components is the most important factor for the success of total knee arthroplasty (TKA). Dual-energy computed tomography (DECT) may be a reliable method in determining implant position after TKA.PurposeTo evaluate the accuracy and reproducibility of DECT in determining implant position after TKA.Material and MethodsInstitutional review board approval was obtained. Forty-five patients (age 75.2 ± 6.4 years) prospectively underwent TKA at our institution between May and December 2012. DECT was performed 1 year after surgery, using an alignment similar to a standing position and generating images at an extrapolated energy of 120 kVp, in order to reduce metal artifacts. Implant position was evaluated by two independent readers. Intra- and inter-observer agreements were calculated. DECT measurements on implant position were compared with the preoperative planning based on radiographs. Additional clinical and DECT findings were taken into account.ResultsMetal artifact reduction was judged satisfactory in all cases. Regarding implant position assessed with DECT, good to excellent intra-observer (k: 0.74–0.87 and k: 0.75–0.88, respectively), and inter-observer agreement (k: 0.72–0.82) were found. In the comparison with preoperative planning, the widest limits of agreement were within 3.9° for the sagittal orientation of tibial component. A single patient with postoperative knee pain and stiffness had periprosthetic osteopenia, quadriceps femoris tendon calcifications, articular effusion, and excessive intrarotation of the femoral component.ConclusionDECT is an accurate and reproducible tool for determining implant position after TKA.

Trace elements were analyzed in organisms collected at five sampling stations along coastal areas of Linosa Island, Sicily (southern Tyrrhenian Sea, Italy). Concentrations of Cd, Cr, Cu, Pb, and Zn were measured in Posidonia oceanica L. Delile tissues, the two brown algae Padina pavonica (L.) Thivy and Cystoseira sp., and the two gastropod mollusks Monodonta turbinata Born and Patella caerulea L. Seawater samples were also collected at each site to assess soluble metal concentrations and to gain relevant information on their bioaccumulation ability. Data were processed by multivariate techniques, such as principal component analysis (PCA) and linear discriminant analysis on PCA factors. The scoreplots obtained showed that the pollutant distribution is more significantly correlated with species than with sites. For seaweeds, P. oceanica was associated with higher Cd, Cu, and Zn levels; Padina species had higher Cr concentrations, and Cystoseira had higher Pb levels. For mollusks, Monodonta species had high concentrations of Cu and Cr and Patella species were associated with Cd. Some general metal bioaccumulation patterns are described but no one sampling site was more contaminated than the others. The hypothesis of Linosa island serving as a reference ecosystem for baseline trace metal levels in southern Tyrrhenian areas is indeed supported by the statistical comparison among other southern Tyrrhenian ecosystems performed with Kruskall Wallis and Mann-Whitney tests. For P. oceanica leaves, P. pavonica, M. turbinata, and P. caerulea, this study confirms their usefulness as possible cosmopolitan biomonitors of trace metals in marine Mediterranean areas.

The accumulation of chromium by germinating kiwifruit pollen appears to be significantly affected by Cr species, Cr concentration and calcium vailability. Cr(III) accumulation always occurred in a linear manner while Cr(VI) uptake followed a logarithmic model. In the absence of exogenous calcium, Cr(III) accumulation was much higher than that of Cr(VI). It was observed that, as the Cr(III) concentration increased, there was a significant decrease in the endogenous calcium content of pollen, ultimately leading to complete calcium depletion after 90 min of incubation at 150 lM Cr(III). This loss of calcium could be responsible for the strong inhibition of tube emergence and growth following exposure of pollen to Cr(III). Indeed, when exogenous calcium was added to the kiwifruit pollen culture medium, significant growth recovery and reduced Cr(III) uptake occurred; the opposite was true in Cr (VI)-treatments. A significant rise in lipid peroxide production occurs in the presence of both Cr species; the effect was more pronounced following Cr(VI) exposure. Finally, glutathione pool dynamics appears to be differentially affected by chromium species and concentrations. In conclusion, results of the present study have provided important information regarding the different activity profi les of Cr(III) and Cr(VI) in relation to kiwifruit pollen performance, and have also demonstrated differences in some biochemical esponses of pollen to metal stress. © 2008 Elsevier Ltd. All rights reserved doi:10.1016/j.chemosphere.2008.07.083

Fifty seven samples of Mytilus galloprovincialis (Lamarck, 1819) collected along the breakwater barriers of Fano (station 1) and Pesaro (station 2), Adriatic Sea, Marche Region, central Italy, were analyzed by atomic absorption spectrometry and Cd, Cu, Pb and Zn concentrations in the soft tissues were measured. The aims of this work were the statistical analysis of Cd-weight, Cu-weight, Pb-weight, Zn-weight relationships, and the building of a tendency function that allows assessing with a good approximation the concentrations of a metal in different weight organisms. In Mytilus galloprovincialis the content of Cd proportionally grew with the weight and therefore its concentration was independent from this factor; while the concentration of Pb decreased as the weight increased. In both cases the accuracy of multiple regression models improved considering the variable 'site', while the same approach appeared not reliable for Cu and Zn, that were two essential metals. Our results showed that a tendency function was reliable, solid and able to predict to a very satisfying extent the concentration of non-physiological metals, like Cd and Pb; while it did not show a good approximation with real Cu and Zn contents.

Marine organisms were tested as possible biomonitors of heavy metal contamination in Ustica (island of the Southern Tyrrhenian Sea). The concentrations of Cd, Cr, Cu, Pb and Zn were measured in the phanerogam Posidonia oceanica L. Delile, the two brown algae Padina pavonica (L.) Thivy and Cystoseira sp., and the two gastropod molluscs Monodonta turbinata Born and Patella caerulea L. collected at five coastal stations on the island of Ustica. The biomonitors examined showed a high ability to accumulate metals, with concentration factors higher than 10³, with respect to the concentration (soluble fraction) in marine waters. The data from this study were also compared with those previously obtained from uncontaminated sites in the Sicilian sea (Favignana island, Italy) and those obtained from the area of the Gulf of Gaeta (Tyrrhenian Sea, central Italy). Results clearly show the diversity between these three marine ecosystems.

Individuals of Mytilus chiloensis (Hupe, 1854) and Nacella magellanica metalica (Rochebrune and Mabille, 1885) were evaluated as possible biomonitors of trace metal baseline contamination in the Beagle Channel, Tierra de Fuego (Argentina). The selected species have the necessary prerequisites for use as biomonitors. They are well distributed in all coastal areas of the Beagle Channel and other regional seas, they are easy to identify and available all year round. The first aim of this preliminary survey is to evaluate the concentrations of Cr, Cu, Pb and Zn present in soft tissues of the selected species in order to have more information on the use of these selected species as possible cosmopolitan biomonitors. Samples were collected in seven stations situated along 170 km of the coast in the tidal zone. The validity of these two species as bioaccumulators was tested. Significant differences between metal concentrations in molluscs from different stations were tested by ANCOVA on log10 transformed data with body weight as covariate. Multiple comparison tests (MCT) were conducted when significant differences were detected among the stations. In M. chiloensis metal concentrations decreased in the order: Zn > Cu > Pb ≥ Cr while for Nacella metal concentrations decreased in the order: Zn > Cu > Cr > Pb showing good bioaccumulation ability. At present, they can be considered as good candidates as trace metals biomonitors for the studied area. From all the obtained data and statistical analysis (ANCOVA, MCT) the results showed clearly that there is no one site univocally more contaminated (with clearly high levels of metals accumulation in biomonitors) than any other. Thus the possible hypothesis of the Ushuaia Harbour as being the most contaminated site must be reconsidered. Metal concentrations recorded may be used for background levels for intraspecific comparison within the Patagonian seas. www.witpress.com, ISSN 1743-3541 (on-line) © 2006 WIT Press WIT Transactions on Ecology and the Environment, Vol 99, doi:10.2495/RAV060471 Management of Natural Resources, Sustainable Development and Ecological Hazards 473

This work describes the use of some multivariate statistical methods for retrieving the information present in a typical dataset coming from a biomonitoring study applied to trace metals measured on Patella caerulea and Monodonta turbinata samples. These samples were collected at five stations in Linosa Island in the Sicilian Channel (Mediterranean Sea) and the multivariate statistical methods applied were Principal Component Analysis (PCA), Hotelling T² test and Discriminant Analysis by means of Mahalanobis Distance (DAMD). Using PCA it is possible to have in a single and fast step, a direct insight into the structure of data, and thus obtain peculiar information that allows the different accumulation characteristics of the two types of mollusc to be seen. PCA also gives information about the metals that cause the peculiar accumulation characteristics of each mollusc. Hotelling's T² and DAMD are other important multivariate methods that confirm the results of PCA and also give complementary information for the interpretation of experimental data.

Monodonta turbinata B. and Patella caerulea L. were evaluated as possible biomonitors of trace metal contamination in marine coastal areas. These species are marine gastropod molluscs; they are distributed in all coastal areas of the Mediterranean sea and are easy to identify and available all year round. They have the necessary prerequisites for use as biomonitors. The first aim of this preliminary survey is to evaluate the concentrations of Cd, Cr, Cu, Pb and Zn present in soft tissues of the selected species. Samples were collected in the tidal zone (1-2 meters depth) in a possible reference ecosystem (Linosa island, Sicily, Italy). Five coastal stations were selected according to the species availability. The second purpose was to establish the validity of these two gastropod species as bioaccumulators. The station number 4 (Pozzolana di Ponente) is the only site in Italy where the sea turtle Caretta caretta, annually deposes her eggs; thus this station is of a particular ecological relevance. In order to test the bioaccumulation capabilities of these biomonitors seawater samples were collected in each site to assess soluble metal concentrations and then CFs. Seawater samples were collected appropriately in a 6-month period of sampling in the selected stations. Statistical multivariate analyses, PCA, were applied to test the differences between metal concentrations in different sites and species. Results showed high results (CFs) with respect to the concentrations in marine waters (soluble fraction). This confirmed the suitability of these species for biomonitoring purposes. PCA analysis showed clearly two separated patterns of bioaccumulation (i.e. Patella and Monodonta) and no significant differences (p = 0.05) for trace metal accumulation were obtained between the studied sites. This finding agrees with the hypothesis of this island as reference ecosystem for intraspecific comparison within Tyrrhenian areas. www.witpress.com, ISSN 1743-3541 (on-line) © 2006 WIT Press WIT Transactions on Ecology and the Environment, Vol 88, doi:10.2495/CENV060011 Environmental Problems in Coastal Regions VI 3

This work underlines the importance of the statistical procedures necessary for the significant assessment of analytical data of heavy metals derived from marine organisms (biomonitors) collected at five stations in Ustica at the Southern Tyrrhenian Sea. The statistical method described indicates that, where the differences among the averages of Pb, Cu and Zn concentrations in the molluscs of the sites analysed tested with ANOVA are significant, it is necessary to conduct multiple comparison tests in order to determine which average is significantly different from the other. Using the method described, it is possible to indicate which site or sites is/are more contaminated in comparison with the other sites. This way it is possible to make a preliminary evaluation of the basal levels of trace metals present in the reference marine ecosystem under study.