Changing Clinical and Therapeutic Trends in Tentorial Dural Arteriovenous Fistulas: A Systematic Review

BACKGROUND AND PURPOSE:Tentorial dural arteriovenous fistulas are characterized by a high hemorrhagic risk. We evaluated trends in outcomes and management of tentorial dural arteriovenous fistulas and performed a meta-analysis evaluating clinical and angiographic outcomes by treatment technique.MATERIALS AND METHODS:We performed a comprehensive literature search for studies on surgical and endovascular treatment of tentorial dural arteriovenous fistulas. We compared the proportion of patients undergoing endovascular, surgical, and combined endovascular/surgical management; the proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas; and proportion of patients with good neurologic outcome across 3 time periods: 1980–1995, 1996–2005, and 2006–2014. We performed a random-effects meta-analysis, evaluating the rates of occlusion, long-term good neurologic outcome, perioperative morbidity, and resolution of symptoms for the 3 treatment modalities.RESULTS:Twenty-nine studies with 274 patients were included. The proportion of patients treated with surgical treatment alone decreased from 38.7% to 20.4% between 1980–1995 and 2006–2014. The proportion of patients treated with endovascular therapy alone increased from 16.1% to 48.0%. The proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas decreased from 64.4% to 43.6%. The rate of good neurologic outcome increased from 80.7% to 92.9%. Complete occlusion rates were highest for patients receiving multimodality treatment (84.0%; 95% CI, 72.0%–91.0%) and lowest for endovascular treatment (71.0%; 95% CI, 56.0%–83.0%; P < .01). Long-term good neurologic outcome was highest in the endovascular group (89.0%; 95% CI, 80.0%–95.0%) and lowest for the surgical group (73.0%; 95% CI, 51.0%–87.0%; P = .03).CONCLUSIONS:Patients with tentorial dural arteriovenous fistulas are increasingly presenting with unruptured lesions, being treated endovascularly, and experiencing higher rates of good neurologic outcomes. Endovascular treatment was associated with superior neurologic outcomes but lower occlusion rates.

Intracranial dural arteriovenous fistulas (DAVFs) are abnormal direct shunts between the dural arteries and dural veins.¹ The shunt is located in the intracranial dura mater with venous drainage directed to the dural venous sinuses or cortical veins. Dural arteriovenous fistulas account for 10%–15% of all intracranial vascular shunts.^1,2 Tentorial dural arteriovenous fistulas (TDAVFs) constitute only 4% of DAVFs and are characterized by a high hemorrhagic risk. Because of this, these lesions are treated aggressively on diagnosis.^3–5Traditionally, surgical resection was the only treatment available for these lesions. However, endovascular embolization, either alone or in combination with surgery, is increasingly used.⁶ Stereotactic radiosurgery is also increasingly used as an adjunct to surgical and endovascular treatment.⁷ We performed a systematic review of the literature on surgical and endovascular treatment of TDAVFs from 1980 to 2014. The purpose of our study was the following: 1) to determine whether there was a shift from primarily surgical treatments to endovascular and multimodality treatment during this time period, 2) to determine whether the proportion of patients presenting with ruptured TDAVFs during this time period has changed, 3) to determine whether the rate of good neurologic outcome has changed, and 4) to evaluate clinical and angiographic outcomes in endovascular, surgical, and combined treatments by performing a random-effects meta-analysis.     

Utility of combined use of plasma levels of chromogranin A and pancreatic polypeptide in the diagnosis of gastrointestinal and pancreatic endocrine tumors

BACKGROUND: Chromogranin A (CgA) is considered the most accurate marker in the diagnosis of gastro-entero-pancreatic (GEP) endocrine tumors. Pancreatic polypeptide (PP) has also been proposed to play this role, but then not used due to its low sensitivity. The aim of the present study was to determine whether the assessment of PP would improve the diagnostic reliability of CgA in patients with GEP tumors. PATIENTS AND METHODS: Both markers were assessed in 68 patients [28 functioning (F), 40 non functioning (NF)]. Twenty-seven patients disease-free (DF) after surgery, and 24 with non-endocrine tumors (non-ETs) were used as control groups. RESULTS: CgA sensitivity was: 96% in F, 75% in NF, 74% in pancreatic, and 91% in gastrointestinal (GI) tumors. Specificity was 89% vs DF, and 63% vs non-ETs. PP sensitivity was: 54% in F, 57% in NF, 63% in pancreatic, and 53% in GI tumors. Specificity was 81% vs DF, and 67% vs non-ETs. By combining the two markers a significant gain in sensitivity vs CgA alone was obtained: overall in GEP tumors (96% vs 84%, p = 0.04), in NF (95% vs 75%, p = 0.02), and in pancreatic (94% vs 74%, p = 0.04). More specifically, a 25% gain of sensitivity was obtained in the subgroup of NF pancreatic tumors (93% vs 68%, p = 0.04). CONCLUSION: The combined assessment of PP and CgA leads to a significant increase in sensitivity in the diagnosis of GEP tumors, particularly in pancreatic NF.     

Six-day therapy with ranitidine bismuth citrate plus low-dose clarithromycin and tinidazole to cure Helicobacter pylori infection

BACKGROUND/AIMS: Short-term ranitidine bismuth citrate-based triple regimens have been shown to be effective for the eradication of H. pylori. We investigated the efficacy of an eradicating therapy including ranitidine bismuth citrate, low-dose clarithromycin and tinidazole, administered for only 6 days. METHODOLOGY: Forty-five consecutive patients, who underwent gastroscopy for symptoms and were found to be H. pylori-positive, were recruited. They received ranitidine bismuth citrate 400 mg b.i.d. plus clarithromycin 250 mg b.i.d. plus tinidazole 500 mg b.i.d., given for 6 days. The medications given in twice daily doses were taken after meals with an interval of 12 h. The H. pylori status was evaluated by means of histology and rapid urease test on admission, and by 13C-urea breath test alone 8 weeks after treatment. RESULTS: All 45 enrolled patients completed the study. Thirty-nine of 45 patients returned H. pylori-negative (both per protocol and intention-to-treat analysis = 87%; 95% confidence interval = from 73-95%), while 6 of 45 were still H. pylori-positive (13%). Slight or mild side effects occurred in 5/45 patients (11%). CONCLUSIONS: Ranitidine bismuth citrate-based triple therapy, containing low-dose clarithromycin and tinidazole, given for only 6 days, yielded high eradication rates with modest side effects. Regimens based on ranitidine bismuth citrate plus two antibiotics at low dosages, administered for less than 7 days, constitute highly promising strategies for eradication of H. pylori.     

Decrease of serum carnitine levels in patients with or without gastrointestinal cancer cachexia

AIM: To evaluate the levels of serum carnitine in patients with cancer in digestive organs and to compare them with other cancers in order to provide new insights into the mechanisms of cachexia. METHODS: Fifthy-flve cachectic patients with or without gastrointestinal cancer were enrolled in the present study. They underwent routine laboratory investigations, including examination of the levels of various forms of carnitine present in serum (i.e., long-chain acylcarnitine, short-chain acylcarnitine, free carnitine, and total carnitine). These values were compared with those found in 60 cancer patients in good nutritional status as well as with those of 30 healthy control subjects. RESULTS: When the cachectic patients with gastrointestinal cancer were compared with the cachectic patients without gastrointestinal cancer, the difference was -6.8μmol/L in free carnitine (P < 0.005), 0.04μmol/ L in long chain acylcarnitine (P < 0.05), 8.7μmol/L in total carnitine (P < 0.001). In the cachectic patients with or without gastrointestinal cancer, the difference was 12.2μmol/L in free carnitine (P < 0.001), 4.60μmol/L in short chain acylcarnitine (P < 0.001), and 0.60μmol/L in long-chain acylcarnitine (P < 0.005) and 17.4μmol/L in total carnitine (P < 0.001). In the cachectic patients with gastrointestinal cancer and the healthy control subjects, the difference was 15.5μmol/L in free carnitine (P < 0.001), 5.2μmol/L in short-chain acylcarnitine (P < 0.001), 1.0 umol/L in long chain acylcarnitine (P < 0.001), and 21.8 umol/L in total carnitine (P < 0.001). CONCLUSION: Low serum levels of carnitine in terminal neoplastic patients are decreased greatly due to the decreased dietary intake and impaired endogenous synthesis of this substance. These low serum carnitine levels also contribute to the progression of cachexia in cancer patients.     

Restless legs syndrome in a patient with multifocal motor neuropathy

Restless legs syndrome (RLS) has been frequently reported in association with peripheral neuropathy, and it is especially frequent in some forms of polyneuropathy with preferential involvement of small sensory fibers. Here, we describe a patient with multifocal motor neuropathy, who developed RLS during the course of the disease. Our findings support the notion that RLS may develop in the context of immune-mediated neuropathies and it should be specifically investigated even in those patients with preferentially or exclusive motor involvement.