Abnormalities of the executive control network in multiple sclerosis phenotypes: An fMRI effective connectivity study

The Stroop interference task is a cognitively demanding task of executive control, a cognitive ability that is often impaired in patients with multiple sclerosis (MS). The aim of this study was to compare effective connectivity patterns within a network of brain regions involved in the Stroop task performance between MS patients with three disease clinical phenotypes [relapsing‐remitting (RRMS), benign (BMS), and secondary progressive (SPMS)] and healthy subjects. Effective connectivity analysis was performed on Stroop task data using a novel method based on causal Bayes networks. Compared with controls, MS phenotypes were slower at performing the task and had reduced performance accuracy during incongruent trials that required increased cognitive control. MS phenotypes also exhibited connectivity abnormalities reflected as weaker shared connections, presence of extra connections (i.e., connections absent in the HC connectivity pattern), connection reversal, and loss. In SPMS and the BMS groups but not in the RRMS group, extra connections were associated with deficits in the Stroop task performance. In the BMS group, the response time associated with correct responses during the congruent condition showed a positive correlation with the left posterior parietal → dorsal anterior cingulate connection. In the SPMS group, performance accuracy during the congruent condition showed a negative correlation with the right insula → left insula connection. No associations between extra connections and behavioral performance measures were observed in the RRMS group. These results suggest that, depending on the phenotype, patients with MS use different strategies when cognitive control demands are high and rely on different network connections. Hum Brain Mapp, 37:2293–2304, 2016. © 2016 Wiley Periodicals, Inc.     

Intraoperative DTI and brain mapping for surgery of neoplasm of the motor cortex and the corticospinal tract: our protocol and series in BrainSUITE

We report our preliminary series of patients treated for lesions involving the motor cortex and the corticospinal tract in BrainSuite, with intraoperative MRI, tractography and "neuronavigated" electrophysiological cortical and subcortical mapping. An exact localization of the cortical and subcortical functional areas is mandatory for executing surgery of intra-parenchymal neoplasm involving the motor cortex and the corticospinal tract. Nowadays modern technology offers a variety of tools to reduce as much as possible postoperative deficits during surgery of cerebral eloquent areas. From December 2008 and June 2010, 18 patients underwent functional surgery, for neoplasm involving the motor cortex and/or the subcortical pathway, in BrainSuite. Our preliminary series include 14 gliomas and 4 metastases; Table 1 summarizes all of the data. We included in this series patients with complete removal of lesions of eloquent areas with an average distance from the corticospinal tract of 4 mm. Six neoplasms were considered in contact and/or involving the motor cortex, while in 18 cases (100%) the tumour involved eloquent areas concerning the corticospinal tract. All of the patients underwent complete removal of the lesion as subsequently demonstrated by intraoperative postsurgical MRI. Our series highlights the good integration and the high compatibility between BrainSUITE with 1.5 T intraoperative magnetic field and neurophysiological monitoring. We strongly believe that intraoperative MRI with DTI allows us to treat complex surgery tumours that without its auxilium we would not be able to deal with.     

Surgery after intracranial investigation with subdural electrodes in patients with drug-resistant focal epilepsy: outcome and complications

Video-EEG monitoring with intracranial subdural electrodes is a useful assessment tool for the localization of the epileptogenic zone in patients with drug-resistant focal epilepsy. We aimed at assessing the morbidity related to electrode implantation and the surgical outcome in patients who underwent epilepsy surgery after intracranial EEG monitoring. All patients (N?=?58) admitted to our Epilepsy Surgery Centre for drug-resistant focal epilepsy who underwent resective surgery after intracranial monitoring with subdural electrodes and were followed up for at least 2?years were included in the study. Their mean age was 30.4?years (range 8-60?years), 25 (43?%) were female, and 44 (76?%) had a preoperatively detected structural lesion. The mean duration of invasive recording was 2.3?days (range 1-14?days). Extraoperative ECoG allowed the identification of the epileptogenic focus in all cases. The temporal lobe was involved in 21 (36?%) patients, whereas extratemporal foci were identified in 24 (41?%) patients. Thirteen patients (23?%) had multilobar involvement. Functional brain mapping was performed in 15 (26?%) patients. Transient complications related to electrode implantation occurred in three patients. Among patients with evidence of lesion on preoperative MRI, lesionectomy alone was performed in 12 cases (27?%), while it was combined with tailored cortical resection in the remaining cases. Tailored cortical resection was also performed in patients without evidence of lesion on MRI. After resective surgery, transient neurological deficits occurred in five cases, while another patient experienced permanent lateral homonymous hemianopia. At the last follow-up observation, 34 (57?%) patients were seizure-free (Engel class I). This study suggests that invasive EEG recording with subdural electrodes may be useful and fairly safe for many candidates for epilepsy surgery.     

A prospective controlled trial on effect of percutaneous transluminal angioplasty on functioning arteriovenous fistulae survival

Balloon angioplasty (PTA) is an established treatment modality for stenosis in dysfunctional arteriovenous fistulae (AVF), although most studies showing efficacy have been retrospective, uncontrolled, and nonrandomized. In addition, it is unknown whether correction of stenosis not associated with significant hemodynamic, functional, and clinical abnormality may improve survival in AVF. This study was a prospective controlled open trial to evaluate whether prophylactic PTA of stenosis not associated with access dysfunction improves survival in native, virgin, radiocephalic forearm AVF. Sixty-two stenotic, functioning AVF, i.e., able to provide adequate dialysis, were enrolled in the study: 30 were allocated to control and 32 to PTA. End points of the study were either AVF thrombosis or surgical revision due to reduction in delivered dialysis dose. Kaplan-Meier analysis showed that PTA improved AVF functional failure-free survival rates (P = 0.012) with a fourfold increase in median survival and a 2.87-fold decrease in risk of failure. Cox proportional hazard model identified PTA as the only variable associated with outcome (P = 0.012). PTA induced an increase in access blood flow rate (Qa) by 323 (236 to 445) ml/min (P < 0.001), suggesting that improved AVF survival is the result of increased Qa. PTA was also associated with a significant decrease in access-related morbidity by approximately halving the risk of hospitalization, central venous catheterization, and thrombectomy (P < 0.05). This study shows that prophylactic PTA of stenosis in functioning forearm AVF improves access survival and decreases access-related morbidity, supporting the usefulness of preventive correction of stenosis before the development of access dysfunction. It also strongly supports surveillance program for early detection of stenosis.     

Pathologic Features and Long-term Results in Early Gastric Cancer: Report of 116 Cases 8–13 Years after Surgery

One hundred sixteen patients who underwent surgery for early gastric cancer (EGC) at Careggi General Hospital in Florence between 1987 and 1992 were studied with regard to clinicopathologic features, incidence, and recurrence of the disease. The overall 5-year cumulative survival rate was 87.5%, and the disease-specific 5-year survival rate was 88.2%. EGC was limited to the mucosa in 43 patients (37%), while it infiltrated the submucosa in 73 others (63%). At the time of surgery, 9.5% of patients were found to have lymph node metastasis, always concomitant with submucosal invasion. There was 1 postoperative death (0.8%); 16 patients (13.7%) died of tumor recurrence, and 20 (17.2%) died of unrelated causes. Analysis of recurrence showed an intestinal histotype in 13 patients (81.2%), submucosal infiltration in 14 patients (87.5%), a Pen-A growth pattern in 8 patients (50%), and lymph node involvement in 3 patients (18.7%). The Cox proportional hazard model indicated that age and depth of wall invasion were statistically significant. The best predictor of survival appears to be the depth of invasion within the gastric wall. The claim by several investigators that prognosis for EGC is also associated with the presence of lymph node involvement is not supported by the present study. The postoperative 5-year survival rate in node-negative patients was 88.8% compared to 81.8% in node-positive patients (p = 0.296).     

Bicalutamide monotherapy versus flutamide plus goserelin in prostate cancer: updated results of a multicentric trial

OBJECTIVES: To compare the efficacy of bicalutamide monotherapy to maximal androgen blockade in advanced prostatic cancer. PATIENTS AND METHODS: Previously untreated patients with histologically proven stage C or D (American Urological Association Staging System) disease were randomly allocated to either bicalutamide (B) or goserelin plus flutamide (G+F). After disease progression, patients treated with B were assigned to castration. The primary endpoint for this trial was overall survival. Prostate cancer-specific survival and progression were included among secondary endpoints. RESULTS: In total 108 patients received B and 112 received G+F. At a median follow-up time of 54 months (range 1-89), 151 patients progressed and 113 died. There was no significant difference in the duration of either progression-free or overall survival. Hazards of progression, death and cancer-specific death, corrected by disease stage, tumor grade and baseline PSA level, showed that patients initially assigned to B had a higher risk of progression but a comparable risk of death and cancer-specific death with the exception of patients with G3 tumors who had an increased risk of death). CONCLUSIONS: In patients with well or moderately well differentiated tumors, B monotherapy followed by castration may offer the same survival chance as maximal androgen deprivation. In those patients it thus represents a reasonable choice that can avoid the side effects of androgen deprivation for considerable periods of time.     

Late vertebral body fracture after lumbar transpedicular fixation. Report of three cases

Late-onset vertebral body (VB) fracture after lumbar transpedicular fixation has not been previously described in the literature. The authors present three cases in which VB fracture occurred several months after posterolateral fixation in patients with degenerative disease or traumatic injury. The authors suggest that postoperative osteopenia, modified load-sharing function, and intravertebral clefts were responsible for the fractures. Two women and one man were evaluated at a mean follow-up interval of 3 months. Two patients suffered recurrent lumbar pain. Radiography and magnetic resonance imaging revealed fracture of some of the instrumentation-treated VBs. These two patients underwent surgical superior or inferior extension of instrumentation. The third, an asymptomatic patient, received conservative management. The two patients who underwent reoperation made complete recoveries, and there was no evidence of further bone collapse in any case. The authors speculate that alterations in the VBs may occur following application of spinal instrumentation. In rare cases, the device can fracture and consequently lead to recurrent lumbar back pain. Recovery can be achieved by extending the instrumentation in the appropriate direction.     

Treatment of type B aortic dissection: endoluminal repair or conventional medical therapy?

OBJECTIVE: To evaluate the mid-term results of endovascular stent-grafting for type B aortic dissection, in comparison with those of standard medical therapy in uncomplicated cases. METHODS: Between January 1999 and 2004, among 56 patients (mean age 59.5+/-11.5 years) with type B aortic dissection, hypotensive medical therapy was the only treatment in 28 uncomplicated cases, (group A), while stent-graft implantation was performed in 28 patients with uncontrolled hypertension, persistent pain or evidence of dissection progression or complication (group B). In 14 cases (50%) the procedure was performed in an acute setting. Stent-grafting procedures were monitored with intraoperative trans-esophageal echocardiography and cine-angiography. CT scan and trans-esophageal echocardiography were performed before hospital discharge, at 6 and 12 months and then yearly. RESULTS: Follow-up (range 1-61 months, average 18.1+/-16.9 months) was 100% complete. In-hospital mortality was 10.7% (three patients, all belonging to Group B; P=0.24). No spinal cord injuries were observed. Early endoleak occurred in one patient (3.5%). Mid-term mortality was lower in Group B, although the difference was not significant (10.7 versus 14.3% in Group A, P=0.71). Follow-up CT scans evidenced complete thrombosis of the false lumen in 75% cases in Group B, 10.7% in Group A (P=0.0001), and an aneurismal dilatation of the descending aorta in 3.5% cases in Group B, 28.5% in Group A (P=0.02). CONCLUSIONS: Although with still considerable early mortality, endovascular stent-graft implantation is an effective option for the treatment of complicated type B aortic dissection. Endovascular treatment achieved a better mid-term fate of the descending thoracic aorta than medical therapy alone, even in patients with worse preoperative conditions.