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Acromegaly is a rare and severe disease caused by an increased and autonomous secretion of growth hormone (GH), thus resulting in high circulating levels of insulin-like growth factor 1 (IGF-1). Comorbidities and mortality rate are closely related to the disease duration. However, in most cases achieving biochemical control means reducing or even normalizing mortality and restoring normal life expectancy. Current treatment for acromegaly includes neurosurgery, radiotherapy and medical therapy. Transsphenoidal surgery often represents the recommended first-line treatment. First-generation somatostatin receptor ligands (SRLs) are the drug of choice in patients with persistent disease after surgery and are suggested as first-line treatment for those ineligible for surgery. However, only about half of patients treated with octreotide (or lanreotide) achieve biochemical control. Other available drugs approved for clinical use are the second-generation SRL pasireotide, the dopamine agonist cabergoline, and the GH-receptor antagonist pegvisomant. In the present paper, we revised the current literature about the management of acromegaly, aiming to highlight the most relevant and recent therapeutic strategies proposed for patients resistant to first-line medical therapy. Furthermore, we discussed the potential molecular mechanisms involved in the variable response to first-generation SRLs. Due to the availability of different medical therapies, the choice for the most appropriate drug can be currently based also on the peculiar clinical characteristics of each patient.

We present a case of ophthalmic artery (OA) traumatic avulsion, leading to a post-traumatic subarachnoid hemorrhage (SAH) with ventricular blood invasion and hydrocephalus, mimicking an internal carotid aneurysm rupture. This is the third case of such an event reported in literature and the first without orbital fractures and optic nerve avulsion. Conservative treatment was sufficient for the avulsion, but surgery was needed for the coexisting eye luxation. Traumatic OA avulsion is a rare but possible event and should be suspected in case of basal cisterns SAH, evidence of orbital trauma and CT angiogram or angiographic absence of opacification of the OA.

IntroductionSpontaneous posterior interosseous nerve palsy is a rare condition. Entrapment is mostly at level of the arcade of Frohse, and a few cases of distal entrapment have been described.MethodsA case of entrapment distal to the arcade of Frohse is described here. Cases of distal entrapment have been reviewed from the published literature in order to evaluate the frequency of atraumatic mechanical palsy.ResultsSeven cases of distal entrapment have been identified. Lesion is the cause of palsy in 58.7% of the cases and entrapment in 20.65%. The pathology is at the elbow in 33.7% of the cases, at the arcade of Frohse in 28.26%, and at the supinator canal in 10.33%. Entrapment is at the arcade of Frohse in 64.45%, proximal in 20%, and distal in 15.55%.ConclusionPosterior interosseous nerve distal entrapment is a rare condition; therefore, further investigation is needed when radiological images at the arcade of Frohse do not show any entrapment.

Sinus pericranii (SP) is a rare, benign, extradural venous anomaly whose extracranial connection consists in an enlarged subgaleal drainage composed of a network of thin-walled veins that form a varix on the external table of the skull. In the present series of three patients we present three variantesof SP which have never been described, characterized by an extensive diploic erosion causing a “karstic” effect. A systematic review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. A comprehensive search for relevant articles was performed on PubMed from 1992 to 2022 using the following search words: “sinus pericranii”. The search produced 77 articles with 137 patients. In all the cases analysed, there were not reported any patients with extensive diploic erosion, namely “karstic” variants. So, the authors present clinical history, neuroimages, treatment strategies and outcome of 3 patients with a “karstic” SP with the aim to describe this clinicradiological entity. In this study, our group identified a peculiar variant of SP characterized by bony involvement with extensive diploic “karstic” erosion of diploe, with possible tendency to enlarge during time. •Sinus Pericranii (SP) is a rare, benign, extradural venous anomaly consisting in an abnormal emissary intradiploic vein originating from an intracranial sinus and connecting with the extracranial venous system.•SP may be classified according to their drainage patterns into three subtypes (A, B, C).•A peculiar variant of SP characterized by calvarial defect with extensive erosion of diploe and tendency to enlarge during time has been identified.•If the varicosities of SP continue to enlarge, surgical treatment is recommended.

PurposeAcromegaly is a severe chronic endocrine disease. Achieving biochemical control often needs a multimodal treatment approach, including prolonged medical treatment. Aim of the study is to evaluate the burden of treatment direct costs with respect to the different therapeutic strategies, disease control, and follow-up length.MethodsSingle center retrospective study on 73 acromegaly patients. Costs of acromegaly treatments were computed based on a detailed revision of patients’ clinical charts.ResultsMedian total treatment cost/patient was €47,343 during the entire follow-up (8 years), while median treatment cost/patient/year was €6811. The majority of patients received medical therapy (71/73, 97.3%). Median cost for first-line medical treatment (first-generation somatostatin receptor ligands) was lower compared to second-line treatments (pegvisomant monotherapy or combination therapies), considering both total (€22,824 vs €76,140; p < 0.001), and yearly cost/patient (€4927 vs €9161; p < 0.001). Sixty patients (82.2%) reached biochemical control at last follow-up (IGF-1 ≤ 1 xULN). The percentage of patients treated with first- or second-line medical therapies was comparable between controlled and uncontrolled patients (p = 1.000), and the yearly cost/patient did not significantly differ between the two groups (€6936 vs €6680; p = 0.829). Follow-up duration was significantly longer in controlled patients compared to the uncontrolled ones (8.7 vs 3.5 years; p = 0.019).ConclusionsDirect costs for the management of acromegaly have a significant burden on the healthcare systems. However, more than 80% of our patients reached biochemical control using multimodal approaches. Treatment modalities and yearly costs did not significantly differ between controlled and uncontrolled patients, while follow-up length represented a major determinant of biochemical outcome.

PurposeSpinal aneurysms are rare vascular malformations, commonly associated with spinal AVMs. AVM-associated spinal aneurysms are burdened by significant morbidity. The purpose of our study is to evaluate the best treatment strategy for these uncommon vascular lesions and to report an illustrative case.MethodsWe reviewed clinical and radiological data of a patient surgically treated at our institution for a spinal AVM with an associated prenidal aneurysm. According to PRISMA guidelines, a systematic literature review has been performed in order to discuss the best management AVM-associated prenidal aneurysms.ResultsIn the reported case, the aneurysm showed spontaneous regression at follow-up after surgical removal of the AVM. Only 6 articles reported management of spinal prenidal AVM-associated aneurysms. Basing on our experience and data from literature, surgical treatment of the aneurysm may be indicated along with the resection of the AVM if the aneurysm is close to the nidus. Conversely, if the aneurysm is far away from the nidus or in an unfavorable position, resection of the nidus only may lead to aneurysm regression as in the reported case.ConclusionsThe treatment strategy for AVM-associated spinal aneurysms should be tailored on the single patient. In presence of large aneurysms that cause mass-effect symptoms, when rupture of the aneurysm is suspected or when treatment of the AVM is not proposable, direct treatment of the aneurysm should be considered. Otherwise, when complete resection of the nidus is performed, the eventually associated unruptured aneurysms located in challenging positions can be safely managed conservatively.

Abstract Context The COVID-19 pandemic and its lockdown restrictions changed people's lifestyles with potential negative impact on health. Objective This longitudinal study aimed to assess the COVID-19 lockdown influence on the adherence to the Mediterranean diet (MD) pattern and its effects on the metabolic inflammatory profile in a cohort of healthy adolescents. Methods We analyzed anthropometric measurements, body composition, and MD adherence along with serum metabolic and inflammatory profile in 77 healthy adolescents from southern Italy before and after the COVID-19 pandemic lockdown. Additionally, we evaluated the biological properties of prelockdown and postlockdown serum on human HepG2 and HuH-7 hepatic cells. Results We did not observe any significant differences in anthropometric and body composition parameters as well as MD adherence score in adolescents between prelockdown and postlockdown COVID-19. Intriguingly, although the metabolic profile of adolescents postlockdown was within the normal range, we evidenced increased levels of fasting glucose, triglycerides, total cholesterol, and low-density lipoprotein (LDL) along with a reduction in high-density lipoprotein (HDL) in postlockdown compared with prelockdown adolescent serum. In addition, elevated levels of tumor necrosis factor (TNF)-α, interleukin-1β, and ferritin were found in postlockdown adolescents compared with their prelockdown counterparts. Consistent with the biochemical parameters, we observed enhanced lipid accumulation with altered mitochondrial functions and increased reactive oxygen species production in HepG2 and HuH-7 cells treated with pooled serum from postlockdown with respect to prelockdown period. Receiver operator characteristic curve analysis identified total cholesterol, LDL, HDL, TNF-α, and ferritin to be predictive serum markers for metabolic and inflammatory profiling after the lockdown period. Conclusion Our findings highlight that the COVID-19 lockdown, forcing sedentary behavior, had a negative impact on adolescents’ metabolic and inflammatory profile which may result in long-term poor health outcomes.