Background Pneumonia with severe respiratory failure represents the principal cause of death in COVID-19, where hyper-inflammation plays an important role in lung damage. An effective treatment aiming at reducing the inflammation without preventing virus clearance is thus urgently needed. Tocilizumab, an anti-soluble IL-6 receptor monoclonal antibody, has been proposed for treatment of patients with COVID-19. Methods A retrospective cohort study at the Montichiari Hospital, Brescia, Italy, was conducted. We included consecutive patients with COVID-19 related pneumonia at the early stage of respiratory failure, all treated with a standard protocol (hydroxychloroquine 400 mg daily, lopinavir 800 mg plus ritonavir 200 mg per day). We compared survival rate and clinical status in a cohort of patients who received additional treatment with tocilizumab once (either 400 mg intravenous or 324 mg subcutaneous) with a retrospective cohort of patients who did not receive tocilizumab (referred to as the standard treatment group). All outcomes were assessed at the end of the follow-up, that correspond to death or complete recovery and discharge from the hospital. Findings 158 patients were included, 90 of which received tocilizumab. 34 out of 68 (50%) patients in the standard treatment group and 7 out of 90 (7.7%) in the tocilizumab group died. Tocilizumab significantly improved survival compared to standard care (multivariate HR: 0.057; 95% C.I = 0.017- 0.187, p < 0.001). No differences between the two administration routes of tocilizumab were observed. No tocilizumab-related infections and/or side effects were observed. Interpretation Early treatment with tocilizumab could be helpful to prevent excessive hyper-inflammation and death in COVID-19 related pneumonia. Low dose administration of tocilizumab is not associated with adverse events. Funding none
We report two cases of lower cranial nerve palsies (XII in case 1, IX-X-XII in case 2) associated with abnormalities of the internal carotid artery at the base of the skull. In case 1 a limited dissection of the carotid wall produced both paresis of the hypoglossal nerve and Horners syndrome by compression of the nerve trunk against the base of the skull and stretching of the periarterial sympathetic fibres respectively. In case 2 we speculate that a narrow angled kinking of the internal carotid artery may have damaged cranial nerves IX, X and XII by interfering with the blood supply to the nerve trunks. In both cases the outcome was favorable with almost complete regression of the initial symptoms. We conclude that the association between lower cranial nerve disturbances and internal carotid artery abnormalities is probably more common than was thought. We suggest that the pathogenesis of the damage to the cranial nerves may differ from one case to the next.
We report the case of a 23 year old male patient who presented for an isolated left accessory nerve palsy which had appeared one year before. Neuroradiological investigations showed that the causative pathology was a giant saccular aneurysm of the intracranial left vertebral artery. Three months after diagnosis, signs of bulbar palsy rapidly developed. An emergency intra-arterial embolization was then attempted, which led to complete recovery except for the accessory nerve palsy which remained unchanged. We conclude that, in cases of apparently isolated accessory nerve palsy, neuroradiological investigations should include the posterior fossa.
Parole chiave: aneurismi cerebrali, angiografia, angio-RM RIASSUNTO -Le recenti acquisizioni tecniche hanno rapidamente reso l'angiografia RM una delle piu importanti indagini vascolari non invasive. Scopo della nostra ricerca e verificare l'applicabilita clinica dell'angiografia RM e valutare la sua accuratezza diagnostica nei confronti dell'angiografia per via arteriosa (angiografia invasiva) nello studio degli aneurismi del circolo cerebrale.Sono stati esaminati con «Angiografia Tridimensionale a Risonanza Magnetica», basata sui fenomeno del «tempo di volo», 23 pazienti, con un numero complessivo di 25 aneurismi, di cui 4 con dimensioni superiori ad 1,5 cm (macroaneurismi). In tutti i casi sono state utilizzate sequenze ad «Eco di Gradiente» 3D con compensazione peril flusso, mentre nei 4 casi di macroaneurisma sono state impiegate anche sequenze ad «Eco di Gradiente» 2D «single slice». In tutti i pazienti l'angiografia RM e stata associata ad una va1utazione con sequenze Spin-Echo del parenchima cerebrale allo scopo di documentare l'eventuale presenza di aree di sofferenza parenchimale. L'angiografia invasiva per via arteriosa era disponibile peril confronto in tutti i casi. 18 pazienti sono stati sottoposti ad intervento chirurgico di «legatura» dell'aneunsma.Nei confonti dell'angiografia invasiva la sensibilita dell'angiografia RM e risultata complessivamente dell' 88% e la specificita del 90%, con un'accuratezza diagnostica dell'89%.Lo studio dimostra come l'angiografia RM, basata sul fenomeno del «tempo di volo», sia in grado di identificare aneurismi di dimensioni fino a 3mm e possa essere utilmente impiegata nella valutazione clinica dell'encefalo come fonte di informazioni supplementari sui circolo cerebrale. SUMMARY -Magnetic resonance angiography, due to recent technical improvement, is becoming a new potential tool for a noninvasive examination of the cerebral vasculature.The aim of our study was to verify the clinical feasibility of magnetic resonance angiography and to compare its diagnostic accuracy with that of intraarterial angiography in the evaluation of intracranial aneurysms. The study population consisted of 23 patients in whom a total of 25 intracranial aneurysms were found by means of either conventional angiography or intraarterial digital subtraction angiography ( DSA ) , with 20 healthy subjects representing the control group. 4 out of the 25 aneurysms were macroaneurysms ranging in size from 15 to 50 mm. M R angiography was performed at 1.5 T with a flo w-compensated volume gradient-echo sequence ( FISP 3D, Flip Angle: 20°) and MRA projections were evaluated either on a hard copy or in video format. A contemporary evaluation of the brain parenchyma was carried out with Spin-Echo sequences. The study of macroaneurysms was completed with a 2D single slice flow-compensated gradient-echo sequence ( FLASH 2D, TR: 30 msec, TE: 10 msec, FA: 30°) in order to avoid saturation of rapidly flo wing blood and to better depict slow flow over a longer distance.MR angiography allowed the identific...
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