The effect of indomethacin, a cyclooxygenase inhibitor, was studied in the treatment of 10 patients with head injury and one patient with spontaneous subarachnoid hemorrhage, each of whom presented with high intracranial pressure (ICP) (34.4 +/- 13.1 mm Hg) and cerebral perfusion pressure (CPP) impairment (67.0 +/- 15.4 mm Hg), which did not improve with standard therapy using mannitol, hyperventilation, and barbiturates. The patient had Glasgow Coma Scale scores of 8 or less. Recordings were made of the patients' ICP and mean arterial blood pressure from the nurse's end-hour recording at the bedside, as well as of their CPP, rectal temperature, and standard therapy regimens. The authors assessed the effects of an indomethacin bolus (50 mg in 20 minutes) on ICP and CPP; an indomethacin infusion (21.5 +/- 11 mg/hour over 30 +/- 9 hours) on ICP, CPP, rectal temperature, and standard therapy regimens (matching the values before and during infusion in a similar time interval); and discontinuation of indomethacin treatment on ICP, CPP, and rectal temperature. The indomethacin bolus was very effective in lowering ICP (p < 0.0005) and improving CPP (p < 0.006). The indomethacin infusion decreased ICP (p < 0.02), but did not improve CPP and rectal temperature. The effects of standard therapy regimens before and during indomethacin infusion showed no significant changes, except in three patients in whom mannitol reestablished its action on ICP and CPP. Sudden discontinuation of indomethacin treatment was followed by significant ICP rebound. The authors suggest that indomethacin may be considered one of the frontline agents for raised ICP and CPP impairment.

Osmotic agents are still the most common treatment for controlling intracranial hypertension (ICH). Mannitol, glycerol, sorbitol, and hypertonic serum saline are the agents currently available. This work was designed to compare mannitol and glycerol in a similar population of brain injured patients, randomly divided into two groups of eight. The following mean day parameters were obtained: number of infusions, hydric balance, mean arterial pressure (MAP), and intracranial pressure (ICP). Cerebral perfusion pressure (CPP) was calculated. Brain computed tomographies (CT) were obtained on arrival, at follow-up whenever justified and at discharge. For comparison of both groups a modified therapeutic intensity level (mTIL) was used. Both agents induced a statistically equally effective decrease on ICP and increase on CPP evaluated at one and two hours post infusion but the mean day mTIL showed a statistically significant difference in favour of glycerol. The possible explanations of this difference are discussed. According to our results mannitol would be most indicated as a bolus to control sudden rises in ICP whereas glycerol would be most indicated as a basal treatment.

The purpose of this paper is to describe the risks of ventriculopleural shunt in patients with spina bifida and end-stage-renal-diseases (ESRD), and to describe endoscopic third ventriculostomy as an alternative for the combination of cerebrospinal shunt and dialysis modality. We report a 16-year-old boy with spina bifida on chronic dialysis with a massive unilateral hydrothorax and respiratory distress complicating a ventriculopleural (VPL) shunt. Two thoracocenteses were performed, draining 3200 ml of a clear fluid. The VPL shunt was removed and revised successfully to a third ventriculostomy (TVE). Peritoneal dialysis (PD) was the initial dialysis modality. After 12 months on PD, the patient was transferred to hemodialysis (HD) because of refractory peritonitis. Hydrothorax developed while the patient was on PD, reaching its maximum 2 months after the transference to HD. To our knowledge there has been no other report of ventriculopleural (VPL) shunt failure, and endoscopic TVE, as a cerebrospinal fluid (CSF) diversion alternative in patients on chronic dialysis.

The Chiaravalle Cross, a masterpiece of Mediaeval goldsmithery, went under restoration in 2016. This was a unique opportunity to undertake an in-depth multidisciplinary study. Several issues were addressed, as for example the chronology of the Cross, lacking any official document about it. The scientific investigations included in situ and laboratory measurements, and the analyses, part of a multidisciplinary protocol, completely characterized the gemstones adorning the Cross, the cameos, the gold, silver, jasper and glass parts, to derive indications on their provenance, authenticity and dating issues. All the results were shared with the whole collaboration of experts, which included art historians, a restorer, a conservator, a scholar in ancient glyptic, gemologists, archaeometallurgists, physicists and scientists in a very fruitful exchange of knowledge. This work is an example of a real multidisciplinary research, gathering good practices in the study of a complex piece of art.

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