Biomedical subjects
Publications and source records attributed to A Franzini.
The potential proliferative activity of glial tumors has been investigate by serial stereotactic biopsies and by "in vitro" 3H-thymidine incorporation procedure (labeling index, LI). The methodology of this combined approach and the preliminary results in 33 patients are reported. Cell kinetic data have been matched with the histological classification (W.H.O.).
Complete recovery from deep brain abscesses was achieved in four patients treated by a specialized stereotactic method. In one patient the lesion was in the right thalamus, in two patients within the brain stem and in one case in the right rolandic cortex. The technique consists in the stereotactic implantation of a chronic intracavitary catheter connected to a subcutaneous reservoir to allow postoperative multiple evacuations and local antibiotic irrigations. Serial CT scan examinations guided the timing of intracavitary treatment and the removal of the catheter. No recurrence developed. The diagnostic and therapeutic advantages of this stereotactic technique are emphasized.
Microsurgery for supratentorial aneurysm was performed in 19 patients over the age of 65 with good results in 74%. Mortality and complications are discussed in the light of the preoperative neurological status and general condition. The indications for surgery are outlined.
33 consecutive patients with brain glial tumors underwent serial stereotactic biopsies and (3H)-thymidine in vitro investigation. The labeling index has been determined in each case and matched with the WHO histological classification. The feasibility and the accuracy of cell kinetics study applied to stereotactic biopsies are discussed in view of future application for prognostic purposes. Particular attention is given to the description of the method.
In order to utilize computed tomography (CT) for functional neurosurgical procedures, a number of problems must be resolved. One such problem is the development of an appropriate technique for digital processing of neuroanatomical images. Our previous work concerned a numerical reproduction of a well-known stereotactic atlas and its three-dimensional manipulation. In order to efficiently utilize this information with CT images we propose a technique for data reduction that allows the reconstruction of anatomical structures from the atlas. The logic of implementing these data in CT-assisted stereotactic surgery is described.
In 17 patients, 2-16 years old, the clinical and neuroradiological data were unable to give clear-cut information regarding the histology of deep brain neoplasms. The lesions were located within the brain stem in two cases, in the pineal region in two cases, within the third ventricle in two cases, in the sellar and parasellar area in three cases, in the basal ganglia and thalamic region in seven cases, and in the fronto-callosal region in one case. In these patients, serial stereotactic biopsies were performed with the guidance of CT scan in order to assess the nature and the real boundaries of the growths. The choice between conservative or surgical treatment was made after the established histological findings became available. The operative technique of stereotactic biopsy is briefly described and the value of this method is stressed in the treatment of brain tumors in children.
A group of 33 patients (between 10 and 30 years old and with average intelligence) underwent stereotactic surgery for abnormal movements due to cerebral palsy. Neurological, neurofunctional, and neuropsychological examinations were performed pre- and postoperatively. The length of follow-up ranged between 1 and 4 years. The clinical results are reported and discussed in relation to the targets, the side of the lesion, and the clinical picture. Our data show that better results are obtained in patients with tremor and hyperkinesias; dystonia is improved to a lesser extent, whereas spasticity tends to recur. Operation is more effective for patients with unilateral signs than for patients with bilateral symptoms. The clinical results are stable in time, and the side effects fade away after a few months.
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Twenty patients suffering from non-neoplastic symptomatic facial pain underwent percutaneous radiofrequency trigeminal thermo-rhizotomy. Fourteen patients had long-standing severe multiple sclerosis, two patients had intracranial aneurysms, three patients had basilar impression secondary to Paget's disease and developmental malformations of the skull, and one patient was suffering from chronic ocular pain that developed after retinal hemorrhage. Pain paroxysms similar to tic douloureux were present in patients with multiple sclerosis and in those with basilar impression, while continuous aching pain was present in the others. After thermo-rhizotomy, pain disappeared in all patients; however, at 1 to 4 years follow-up examination, a high recurrence rate (40%) was present in the multiple sclerosis group, and the percutaneous procedure was successfully repeated. In the patients with intracranial aneurysm not amenable to direct surgery, and in the other non-neoplastic diseases, complete pain relief was found at 4 years follow-up review.
Surgical and pharmacological management of cancer pain is described and discussed according to the physiopathological mechanisms underlying this complex syndrome. The therapeutic approach is planned in three mayor phases which may be employed alone or in combination, following an accurate evaluation of the pathophysiology and the clinical pattern in every single patient. The first phase includes multifocal pharmacological therapy by nonnarcotic drugs in order to affect at different levels the physiopathological mechanisms of cancer pain. The second phase is indicated when nonnarcotic drugs cannot achieve complete pain relief; neurosurgical procedures (nerve blocks, rhizotomies, cordotomies, ecc...) are employed in this phase. The pharmacological treatment must be continued and associated to surgery. The third phase includes hypophysectomy, deep brain stimulation, psychosurgery and/or narcotic drug therapy, which are the last step in management of terminal cancer pain when all treatments have been ineffective. The results of this therapeutic program in 188 patients affected by pain of malignant origin are reported and discussed.
Thirty-five patients with deep brain tumours have been submitted to transtumoral stereotactic impedance monitoring and serial biopsy. The direct examination of the biopsy samples confirmed the presumptive clinical and neuroradiological diagnosis in 25 patients, but in 10 patients the histological diagnosis differed from the presumptive one. In this second group the treatment was changed as a result of the histological findings. Stereotactic biopsy avoided the risks of "blind" management. The technique, the indications and the diagnostic advantages of stereotactic biopsy are reported with two illustrative cases.
Thirty-five patients with partial complex seizures and two patients with generalized epilepsy were treated by stereotactic radiofrequency lesions. Follow-up from 2 to 13 years was available in 30 patients. The stereotactic targets in patients with partial complex seizures were: a) Amygdala; b) Ammon's horns; c) parahippocampal gyrus; d) Fornix. Depending on scalp EEG and depth electrode studies, each patient had one or more target coagulated, unilaterally or bilaterally. In the 2 cases of generalized epilepsy, bilateral Forel field lesions were performed. Late surgical results are discussed in relation to the depth EEG studies and the number and site of stereotactic lesions.
Phrenic nerve pacing was performed in a patient with tetraplegia and complete respiratory insufficiency soon after cervical decompressive laminectomy for spondylotic myelopathy. The electrophrenic stimulation, in spite of being performed only unilaterally, gave respiratory autonomy to the patient, who was then no longer dependent on mechanical ventilation. This allowed him to move freely out of bed and have intensive motor rehabilitation, which in the end resulted in a satisfactory recovery. The stimulator was removed when no longer needed. The technique, the physiological parameters, and the indications for diaphragm pacing are discussed.
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Acute interictal psychotic attacks during withdrawal of medication are described in two patients with temporal lobe epilepsy submitted to depth EEG study with a view to surgical treatment. The patients were on chronic treatment with clonazepam associated in one with phenobarbitone and in the other with phenobarbitone plus carbamazepine. Our observations suggest that the acute withdrawal of clonazepam, the plasma levels of which were monitored may play a part in producing psychotic attacks characterised by dysphoric manifestations, irritability, aggressiveness, anxiety, and hallucinations. These symptoms could be interpreted as a withdrawal syndrome.
The authors describe a seventeen-years-old girl suffering from partial seizures with complex symptomatology. The neuroradiological studies demonstrated a slow-growing glial tumour seated deeply in the right temporo-occipital region. Scalp EEG demonstrated a bilateral asynchronous temporal focus without definite lateralization. Chronic depth electrodes recording allowed identification of a primary epileptogenic area in the right rhinencephalic structures. Radiofrequency lesions performed in the right amygdala and anterior third of right Ammon's horn abolished the seizures at ten months follow up.
There are limited data in the literature concerning chemotherapy trials for the treatment of anaplastic astrocytomas. Forty-one anaplastic astrocytoma patients, operated on during the period 1988 to 1993 at the Neurological institute of Milan, received 4-5 cycles of chemotherapy (BCNU + cisplatin), subsequently radiotherapy (median dose 56.5 Gy), and finally a second-line chemotherapy protocol at recurrence (procarbazine, vincristine, lomustine). The aim of the study was to evaluate the effectiveness of the planned protocol, considering the time to tumor progression and the survival time. The group of anaplastic astrocytoma patients was compared with a homogeneous group of 39 anaplastic astrocytoma patients treated only with radiotherapy after surgery. The median time to tumor progression of patients on the protocol was 24.5 months. The median survival time for anaplastic astrocytoma patients treated with our scheduled protocol or only with radiotherapy was 38.8 and 21 months, respectively. However, our data need to be confirmed by large randomized clinical studies.
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