Carmine Mottolese - Academia.edu (original) (raw)
Papers by Carmine Mottolese
Annales francaises d'anesthesie et de reanimation
Neurological Research
Even if clipping is the ideal and only complete treatment of the intracranial aneurysm, wrapping ... more Even if clipping is the ideal and only complete treatment of the intracranial aneurysm, wrapping is a well-known alternative technique when aneurysm clipping is not feasible, or is not completely satisfactory. We present a technique of wrapping using fibres of Teflon material shaped in strings or in pledgets, arranged on or around the area to be treated and fixed by fibrin glue. This Teflon technique was used during the years 1990 to 1992, in 44 treated aneurysms (33% or all aneurysms treated during the same period), and in 3 situations: 1) to reinforce a residual or additional ectasia next to the clipped aneurysm, usually proximal to the clip (25 cases, i.e., 57%), 2) to treat an arterial ectasia, so called preaneurysmal ectasia, which proved not clippable at surgery (10 cases, 23%) and 3) to protect a nervous or vascular neighbouring structure which was compressed by the clip grip (9 cases, 20%). No complication was noted in relation to this technique. Up to now, no other know wrapping material has received worldwide approval for being completely innocuous and effective. The Teflon material has been widely used in neurosurgical microvascular decompression and in cardiovascular surgery. In these fields, its reliability, safety, and lack of harmful effects have been widely recognized and should also apply in aneurysm surgery. A very long follow-up will be necessary to assess the outcome for this new wrapping technique.
Neurological Research
A series of 67 patients treated for cerebral AVM with a multidisciplinary approach is reported. T... more A series of 67 patients treated for cerebral AVM with a multidisciplinary approach is reported. The malformations were classified after the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: surgical resection alone (25% of cases), embolization plus resection (25% of cases), embolization alone (21%) and radiosurgery (30%) either alone (12%), or after incomplete embolization (15%) or after incomplete resection (3%). The clinical outcome was evaluated in terms of deterioration due to treatment. The treatment was responsible for a deterioration in 28% of all patients, either minor deterioration (19%) neurological deficit (4%), or death (4%). All complications of surgical resection (17% of all operated cases) and of radiosurgery (10% of irradiated cases) remained minor. None was haemodynamic-related. After endovascular embolization, a deterioration occurred in 25% of all embolized cases (minor 13%, neurological deficit 5% and death 8%). These complications occurring after embolization were haemodynamic related: ischaemia and haemorrhage (50% for each mechanism). Haemorrhage occurred either during or some days after the embolization procedure. The angiographic eradication rate was: 80% overall, 91% after resection (with or without previous embolization), 87% after radiosurgery (alone or after other techniques), and 10% after embolization alone. The discussion reviews in the literature the general evolution of the management of cerebral AVMs, with successive application of first surgical resection, the embolization and lastly radiosurgery.(ABSTRACT TRUNCATED AT 250 WORDS)
Neurochirurgie
A series of 67 patients treated for cerebral AVMs using a multidisciplinary approach is reported,... more A series of 67 patients treated for cerebral AVMs using a multidisciplinary approach is reported, paying special attention to the complications due to treatment. The malformations were classified according to the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: resection alone (25% of cases), embolization plus resection (24%), embolization alone (21%), and radiosurgery, (30%) either alone or after embolization or surgery. The following eradication rates were obtained: 80% overall, 91% after resection (with or without embolization), 13% after embolization alone, 87% after radiosurgery. The outcome was evaluated in terms of deterioration due to treatment. Treatment-related deterioration occurred in 28% of cases and consisted of a minor deterioration (19%), a neurological deficit (4%), or death (4%). As far as the mode of treatment is concerned, surgical resection was followed by deterioration in 20% of all operated cases (minor 17%, deficit 3%). Radiosurgery was followed by a minor deterioration in 10% of irradiated cases. Embolization resulted in complication in 25% of all embolized cases (minor 12.5%, neurological deficit 5%, or death 7.5%). The mechanism of the complication was: resection on manipulation of a functional area and the haemorrhage for cases treated by surgery, radionecrosis for radiosurgery, ischemia and haemorrhage (50% each) for embolization. In 4 out of the 5 cases of haemorrhage due to embolization, an occlusion of the main venous drainage could be demonstrated. The haemodynamic disturbances relating to AVMs and to their treatment are reviewed in the literature. The main haemodynamic mechanisms at the origin of a complication after treatment of cerebral AVMs are the normal perfusion pressure breakthrough syndrome, venous drainage defects (venous overload or occlusive hyperemia), and retrograde thrombosis of the feeding arteries. Improved treatment of cerebral AVMs has been achieved through the multidisciplinary approach, and especially through the endovascular embolization technique. Such an improvement is especially visible in the field of high-grade malformations, which are the most difficult and the most dangerous to treat. As a consequence, the risk of the treatment has naturally shifted from surgical resection towards endovascular embolization which is the first procedure to be performed in difficult cases. Careful consultation between the various specialists is necessary in this pathology, particularly as some of these AVMs are a good indication for each of the three available methods of treatment.
Neurological Research
ABSTRACT
Neurological Research
73 patients admitted from day 0 to day 3 (D0 to D3) after a subarachnoid haemorrhage and being in... more 73 patients admitted from day 0 to day 3 (D0 to D3) after a subarachnoid haemorrhage and being in Hunt and Hess grades I to IV after aneurysm rupture, were studied. All admitted patients were operated upon. The timing of surgery was neither systematic early nor systematic late surgery, but modulated surgery. Patients in good grades (I and II) and under 50 years of age were operated on early. Patients in poor grade and over 50 years of age were operated late. Other patients were operated on preferably early if they were young, even in poor grade, or late if they were old even in good grade. The overall immediate outcome was: good and fair--85%, poor--4%, and death--11%. For those patients operated on early after SAH (D0-3) the good and fair outcome rate went up to 90%. The long term outcome was evaluated after 1 year (from 1 to 6 years, average 1 year 8 months). 97% of patients were available for follow-up. The long-term neurological outcome was identical to the immediate outcome. The resumption of activity was the criteria chosen to evaluate the long term outcome. The long term ability to work in 63 followed-up surviving patients was: normal activity--57%, reduced level of activity--16%, no resumption of activity--27%. This rate of activity resumption was not improved in patients operated on early. Among patients with a good long term neurological outcome, only 67% resumed their previous activity at the same level.(ABSTRACT TRUNCATED AT 250 WORDS)
Neurochirurgie
Through the findings in the literature on the basis of 9 personal cases, we review the indication... more Through the findings in the literature on the basis of 9 personal cases, we review the indications and value of decompressive hemicraniectomy with plasty of the dura mater in cases of medically uncontrolled and decompensated intracranial hypertension. Seven patients had a pseudo-tumoral brain infarction. Five patients survived and their functional recovery is consistent with an autonomous daily life. Another patient with acute traumatic sub-dural haemorrhage died. The ninth patient had presuppurative encephalitis and recovered with no disability. At the time of surgery, all the patients were comatose with herniation of the mesencephalon (n = 3), uncal transtentorial herniation which was either unilateral (n = 4) or bilateral (n = 2). ICP was between 25 and 60 mmHg before the operation. After flap removal, ICP decreased by 15% and, after opening of the dura, it fell a further 70%. In 6 patients we were able to carry out continued post-operative monitoring of ICP, which stayed below 50% of initial values. Decompressive hemicraniectomy is an effective means of treating ICH caused by carotid cerebrovascular accidents with a high degree of edema, where mortality rises to 70-85% when only medical treatment is administered. No haemorrhagic complications, which can occur during hemispherectomies, were observed during decompression.
Annales Françaises d'Anesthésie et de Réanimation, 2014
Annales Françaises d Anesthésie et de Réanimation
We report the case of a 2-year-old child who sustained a permanent diabetes insipidus following a... more We report the case of a 2-year-old child who sustained a permanent diabetes insipidus following a third ventriculostomy for hydrocephalus from a Dandy-Walker syndrome. Ventriculostomy, used for therapy of non-communicating hydrocephalus, can cause complications such as diabetes insipidus. The latter has rarely been reported and is usually transient. Following ventriculostomy, a close postoperative surveillance is essential, especially in children.
Annales françaises d'anesthèsie et de rèanimation, 2006
Annales françaises d'anesthèsie et de rèanimation, 2000
Annales françaises d'anesthèsie et de rèanimation, 2000
Journal of Neuroradiology, 2008
13 12 à 18 mois en cours permettront d'évaluer l'efficacité à moyen et long terme de l'Hydrocoïl.
Pédiatrie, 1993
The authors report on three cases of staphylococcal cerebrospinal fluid (CSF) infection with norm... more The authors report on three cases of staphylococcal cerebrospinal fluid (CSF) infection with normal white blood cell count and normal CSF glucose level in repeated lumbar CSF examination. All three children (2 months, 17 months and 4 years old) have been operated for neonatal hydrocephalus with setting of a ventriculo-peritoneal shunt one to two months before. Infection was suspected because of fever without evocative clinical signs. In two cases plasma C reactive protein level was increased, and in all three cases a leucocytosis was present. The diagnosis was made by bacteriological examination of the ventricular CSF. Both surgical and medical management were required and the bacteriological outcome was favourable. Since neurological sequellae may occur if the treatment is delayed such atypical infection needs to be promptly assessed.
Neurochirurgie, 2014
Circumventricular organs (CVOs) are a diverse group of specialised structures characterized by pe... more Circumventricular organs (CVOs) are a diverse group of specialised structures characterized by peculiar vascular and position around the third and fourth ventricles of the brain. In humans, these organs are present during the fetal period and some become vestigial after birth. Some, such as the pineal gland (PG), subcommissural organ (SCO) and organum vasculosum of the lamina terminalis (OVLT), which are located around the third ventricle, might be the site of origin of periventricular tumours. In contrast to humans, CVOs are present in the adult rat and can be dissected by laser capture microdissection (LCM). In this study, we used LCM and microarrays to analyse the transcriptomes of three CVOs, the SCO, the subfornical organ (SFO) and the PG and the third ventricle ependyma of the adult rat, in order to better characterise these organs at the molecular level. Furthermore, an immunohistochemical study of Claudin-3 (CLDN3), a membrane protein involved in forming cellular tight junctions, was performed at the level of the SCO. This study highlighted some potentially new or already described specific markers of these structures as Erbb2 and Col11a1 in ependyma, Epcam and CLDN3 in the SCO, Ren1 and Slc22a3 in the SFO and Tph, Anat and Asmt in the PG. Moreover, we found that CLDN3 expression was restricted to the apical pole of ependymocytes in the SCO.
Pédiatrie
The authors studied the reliability and tolerance of a new intra-parenchymatous fiberoptic device... more The authors studied the reliability and tolerance of a new intra-parenchymatous fiberoptic device for intracranial pressure monitoring in 20 neurosurgical children. The system proved to be reliable, and the measures were well correlated with clinical evolution, CT scan lesions, and the abolition of the cerebral perfusion pressure in the case of brain death. There was a minimal shift of the electric 0 after 15 days of monitoring. The tolerance was good and no hemorrhagic, infectious or epileptic complications were observed.
Pédiatrie
Acute neurogenic pulmonary edema (NPE) can dramatically complicate a serious brain injury. From b... more Acute neurogenic pulmonary edema (NPE) can dramatically complicate a serious brain injury. From bibliographic data and four personal cases documented by and haemodynamical study, the authors analyse the pathophysiological mechanisms and the haemodynamical changes resulting from massive sympathic outflow, the main mechanism of NPE being haemodynamical rather than lesional. This rare complication needs to be recognized in order to undergo an intensive care treatment generally leading to a favourable evolution. This treatment lies on circulatory and ventilatory supports with positive and expiratory pressure in order to maintain an optimal oxygenation and an optimal cerebral perfusion pressure. With this treatment the outcome of NPE is usually favourable with complete recovery within 2 to 5 days.
Neurophysiologie Clinique/Clinical Neurophysiology
Annales francaises d'anesthesie et de reanimation
Neurological Research
Even if clipping is the ideal and only complete treatment of the intracranial aneurysm, wrapping ... more Even if clipping is the ideal and only complete treatment of the intracranial aneurysm, wrapping is a well-known alternative technique when aneurysm clipping is not feasible, or is not completely satisfactory. We present a technique of wrapping using fibres of Teflon material shaped in strings or in pledgets, arranged on or around the area to be treated and fixed by fibrin glue. This Teflon technique was used during the years 1990 to 1992, in 44 treated aneurysms (33% or all aneurysms treated during the same period), and in 3 situations: 1) to reinforce a residual or additional ectasia next to the clipped aneurysm, usually proximal to the clip (25 cases, i.e., 57%), 2) to treat an arterial ectasia, so called preaneurysmal ectasia, which proved not clippable at surgery (10 cases, 23%) and 3) to protect a nervous or vascular neighbouring structure which was compressed by the clip grip (9 cases, 20%). No complication was noted in relation to this technique. Up to now, no other know wrapping material has received worldwide approval for being completely innocuous and effective. The Teflon material has been widely used in neurosurgical microvascular decompression and in cardiovascular surgery. In these fields, its reliability, safety, and lack of harmful effects have been widely recognized and should also apply in aneurysm surgery. A very long follow-up will be necessary to assess the outcome for this new wrapping technique.
Neurological Research
A series of 67 patients treated for cerebral AVM with a multidisciplinary approach is reported. T... more A series of 67 patients treated for cerebral AVM with a multidisciplinary approach is reported. The malformations were classified after the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: surgical resection alone (25% of cases), embolization plus resection (25% of cases), embolization alone (21%) and radiosurgery (30%) either alone (12%), or after incomplete embolization (15%) or after incomplete resection (3%). The clinical outcome was evaluated in terms of deterioration due to treatment. The treatment was responsible for a deterioration in 28% of all patients, either minor deterioration (19%) neurological deficit (4%), or death (4%). All complications of surgical resection (17% of all operated cases) and of radiosurgery (10% of irradiated cases) remained minor. None was haemodynamic-related. After endovascular embolization, a deterioration occurred in 25% of all embolized cases (minor 13%, neurological deficit 5% and death 8%). These complications occurring after embolization were haemodynamic related: ischaemia and haemorrhage (50% for each mechanism). Haemorrhage occurred either during or some days after the embolization procedure. The angiographic eradication rate was: 80% overall, 91% after resection (with or without previous embolization), 87% after radiosurgery (alone or after other techniques), and 10% after embolization alone. The discussion reviews in the literature the general evolution of the management of cerebral AVMs, with successive application of first surgical resection, the embolization and lastly radiosurgery.(ABSTRACT TRUNCATED AT 250 WORDS)
Neurochirurgie
A series of 67 patients treated for cerebral AVMs using a multidisciplinary approach is reported,... more A series of 67 patients treated for cerebral AVMs using a multidisciplinary approach is reported, paying special attention to the complications due to treatment. The malformations were classified according to the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: resection alone (25% of cases), embolization plus resection (24%), embolization alone (21%), and radiosurgery, (30%) either alone or after embolization or surgery. The following eradication rates were obtained: 80% overall, 91% after resection (with or without embolization), 13% after embolization alone, 87% after radiosurgery. The outcome was evaluated in terms of deterioration due to treatment. Treatment-related deterioration occurred in 28% of cases and consisted of a minor deterioration (19%), a neurological deficit (4%), or death (4%). As far as the mode of treatment is concerned, surgical resection was followed by deterioration in 20% of all operated cases (minor 17%, deficit 3%). Radiosurgery was followed by a minor deterioration in 10% of irradiated cases. Embolization resulted in complication in 25% of all embolized cases (minor 12.5%, neurological deficit 5%, or death 7.5%). The mechanism of the complication was: resection on manipulation of a functional area and the haemorrhage for cases treated by surgery, radionecrosis for radiosurgery, ischemia and haemorrhage (50% each) for embolization. In 4 out of the 5 cases of haemorrhage due to embolization, an occlusion of the main venous drainage could be demonstrated. The haemodynamic disturbances relating to AVMs and to their treatment are reviewed in the literature. The main haemodynamic mechanisms at the origin of a complication after treatment of cerebral AVMs are the normal perfusion pressure breakthrough syndrome, venous drainage defects (venous overload or occlusive hyperemia), and retrograde thrombosis of the feeding arteries. Improved treatment of cerebral AVMs has been achieved through the multidisciplinary approach, and especially through the endovascular embolization technique. Such an improvement is especially visible in the field of high-grade malformations, which are the most difficult and the most dangerous to treat. As a consequence, the risk of the treatment has naturally shifted from surgical resection towards endovascular embolization which is the first procedure to be performed in difficult cases. Careful consultation between the various specialists is necessary in this pathology, particularly as some of these AVMs are a good indication for each of the three available methods of treatment.
Neurological Research
ABSTRACT
Neurological Research
73 patients admitted from day 0 to day 3 (D0 to D3) after a subarachnoid haemorrhage and being in... more 73 patients admitted from day 0 to day 3 (D0 to D3) after a subarachnoid haemorrhage and being in Hunt and Hess grades I to IV after aneurysm rupture, were studied. All admitted patients were operated upon. The timing of surgery was neither systematic early nor systematic late surgery, but modulated surgery. Patients in good grades (I and II) and under 50 years of age were operated on early. Patients in poor grade and over 50 years of age were operated late. Other patients were operated on preferably early if they were young, even in poor grade, or late if they were old even in good grade. The overall immediate outcome was: good and fair--85%, poor--4%, and death--11%. For those patients operated on early after SAH (D0-3) the good and fair outcome rate went up to 90%. The long term outcome was evaluated after 1 year (from 1 to 6 years, average 1 year 8 months). 97% of patients were available for follow-up. The long-term neurological outcome was identical to the immediate outcome. The resumption of activity was the criteria chosen to evaluate the long term outcome. The long term ability to work in 63 followed-up surviving patients was: normal activity--57%, reduced level of activity--16%, no resumption of activity--27%. This rate of activity resumption was not improved in patients operated on early. Among patients with a good long term neurological outcome, only 67% resumed their previous activity at the same level.(ABSTRACT TRUNCATED AT 250 WORDS)
Neurochirurgie
Through the findings in the literature on the basis of 9 personal cases, we review the indication... more Through the findings in the literature on the basis of 9 personal cases, we review the indications and value of decompressive hemicraniectomy with plasty of the dura mater in cases of medically uncontrolled and decompensated intracranial hypertension. Seven patients had a pseudo-tumoral brain infarction. Five patients survived and their functional recovery is consistent with an autonomous daily life. Another patient with acute traumatic sub-dural haemorrhage died. The ninth patient had presuppurative encephalitis and recovered with no disability. At the time of surgery, all the patients were comatose with herniation of the mesencephalon (n = 3), uncal transtentorial herniation which was either unilateral (n = 4) or bilateral (n = 2). ICP was between 25 and 60 mmHg before the operation. After flap removal, ICP decreased by 15% and, after opening of the dura, it fell a further 70%. In 6 patients we were able to carry out continued post-operative monitoring of ICP, which stayed below 50% of initial values. Decompressive hemicraniectomy is an effective means of treating ICH caused by carotid cerebrovascular accidents with a high degree of edema, where mortality rises to 70-85% when only medical treatment is administered. No haemorrhagic complications, which can occur during hemispherectomies, were observed during decompression.
Annales Françaises d'Anesthésie et de Réanimation, 2014
Annales Françaises d Anesthésie et de Réanimation
We report the case of a 2-year-old child who sustained a permanent diabetes insipidus following a... more We report the case of a 2-year-old child who sustained a permanent diabetes insipidus following a third ventriculostomy for hydrocephalus from a Dandy-Walker syndrome. Ventriculostomy, used for therapy of non-communicating hydrocephalus, can cause complications such as diabetes insipidus. The latter has rarely been reported and is usually transient. Following ventriculostomy, a close postoperative surveillance is essential, especially in children.
Annales françaises d'anesthèsie et de rèanimation, 2006
Annales françaises d'anesthèsie et de rèanimation, 2000
Annales françaises d'anesthèsie et de rèanimation, 2000
Journal of Neuroradiology, 2008
13 12 à 18 mois en cours permettront d'évaluer l'efficacité à moyen et long terme de l'Hydrocoïl.
Pédiatrie, 1993
The authors report on three cases of staphylococcal cerebrospinal fluid (CSF) infection with norm... more The authors report on three cases of staphylococcal cerebrospinal fluid (CSF) infection with normal white blood cell count and normal CSF glucose level in repeated lumbar CSF examination. All three children (2 months, 17 months and 4 years old) have been operated for neonatal hydrocephalus with setting of a ventriculo-peritoneal shunt one to two months before. Infection was suspected because of fever without evocative clinical signs. In two cases plasma C reactive protein level was increased, and in all three cases a leucocytosis was present. The diagnosis was made by bacteriological examination of the ventricular CSF. Both surgical and medical management were required and the bacteriological outcome was favourable. Since neurological sequellae may occur if the treatment is delayed such atypical infection needs to be promptly assessed.
Neurochirurgie, 2014
Circumventricular organs (CVOs) are a diverse group of specialised structures characterized by pe... more Circumventricular organs (CVOs) are a diverse group of specialised structures characterized by peculiar vascular and position around the third and fourth ventricles of the brain. In humans, these organs are present during the fetal period and some become vestigial after birth. Some, such as the pineal gland (PG), subcommissural organ (SCO) and organum vasculosum of the lamina terminalis (OVLT), which are located around the third ventricle, might be the site of origin of periventricular tumours. In contrast to humans, CVOs are present in the adult rat and can be dissected by laser capture microdissection (LCM). In this study, we used LCM and microarrays to analyse the transcriptomes of three CVOs, the SCO, the subfornical organ (SFO) and the PG and the third ventricle ependyma of the adult rat, in order to better characterise these organs at the molecular level. Furthermore, an immunohistochemical study of Claudin-3 (CLDN3), a membrane protein involved in forming cellular tight junctions, was performed at the level of the SCO. This study highlighted some potentially new or already described specific markers of these structures as Erbb2 and Col11a1 in ependyma, Epcam and CLDN3 in the SCO, Ren1 and Slc22a3 in the SFO and Tph, Anat and Asmt in the PG. Moreover, we found that CLDN3 expression was restricted to the apical pole of ependymocytes in the SCO.
Pédiatrie
The authors studied the reliability and tolerance of a new intra-parenchymatous fiberoptic device... more The authors studied the reliability and tolerance of a new intra-parenchymatous fiberoptic device for intracranial pressure monitoring in 20 neurosurgical children. The system proved to be reliable, and the measures were well correlated with clinical evolution, CT scan lesions, and the abolition of the cerebral perfusion pressure in the case of brain death. There was a minimal shift of the electric 0 after 15 days of monitoring. The tolerance was good and no hemorrhagic, infectious or epileptic complications were observed.
Pédiatrie
Acute neurogenic pulmonary edema (NPE) can dramatically complicate a serious brain injury. From b... more Acute neurogenic pulmonary edema (NPE) can dramatically complicate a serious brain injury. From bibliographic data and four personal cases documented by and haemodynamical study, the authors analyse the pathophysiological mechanisms and the haemodynamical changes resulting from massive sympathic outflow, the main mechanism of NPE being haemodynamical rather than lesional. This rare complication needs to be recognized in order to undergo an intensive care treatment generally leading to a favourable evolution. This treatment lies on circulatory and ventilatory supports with positive and expiratory pressure in order to maintain an optimal oxygenation and an optimal cerebral perfusion pressure. With this treatment the outcome of NPE is usually favourable with complete recovery within 2 to 5 days.
Neurophysiologie Clinique/Clinical Neurophysiology