Predictors of the Effects of Flow Diversion in Very Large and Giant Aneurysms

BACKGROUND AND PURPOSE

The treatment paradigm for very large and giant aneurysms has recently changed to flow diversion, in light of the results of the Pipeline for Uncoilable or Failed Aneurysms trial. However, the effects of flow diversion were definitely unknown. We explored this topic and identified the predictors of such effects.

MATERIALS AND METHODS

We retrospectively reviewed 51 patients with unruptured aneurysms admitted to our institution for flow diversion between February 2014 and August 2019. Patients were categorized into an effect group (no filling or remnant entry) and a no-effect group (subtotal or total filling). We evaluated the aneurysm size and shape, incorporation vessel, parent artery stenosis and curvature, stagnation of contrast medium within the aneurysm, use of balloon angioplasty, and intra-aneurysm thrombus as potential predictors of the effects of flow diversion.

RESULTS

The effect group comprised 34 patients (66.7%, 34/51; no filling, 35.3%, 18/51; and remnant entry, 31.4%, 16/51). The no-effect group comprised 17 patients (33.3%, 17/51; subtotal filling, 29.4%, 15/51; and total filling, 3.9%, 2/51). An incorporation vessel and balloon angioplasty were independent risk factors for the no-effect group in multivariate logistic regression analyses (OR = 0.13 and 0.05; 95% confidence intervals, 0.02-0.62 and 0.00-0.32; P values, .021 and .004, respectively).

CONCLUSIONS

Flow diversion is effective for very large and giant aneurysms, but the outcomes require further improvement. The results of this study show that an incorporated vessel and excessive balloon angioplasty might compromise flow diversion. This finding can help improve the outcomes of flow diversion.

Intraprocedural Flat Panel Detector Rotational Angiography and an Image Fusion Technique for Delivery of a Microcatheter into the Targeted Shunt Pouch of a Dural Arteriovenous Fistula

The accurate and safe delivery of a microcatheter to a targeted shunt pouch is essential for successful transvenous embolization of intracranial dural arteriovenous fistulas. However, complex anatomy and variations in head and neck veins and occluded sinuses can hinder intraprocedural microcatheter delivery. In this study, we introduce an intraprocedural flat panel detector rotational angiography and image fusion technique to aid precise navigation inside the veins and proper placement of the microcatheter in the targeted shunt pouch.

The Fate of Unruptured Intracranial Vertebrobasilar Dissecting Aneurysm with Brain Stem Compression According to Different Treatment Modalities

BACKGROUND AND PURPOSE

Unruptured intracranial vertebrobasilar dissecting aneurysms with brain stem compression are difficult to treat. In the present study, the clinical and radiologic outcomes of unruptured intracranial vertebrobasilar dissecting aneurysms with brain stem compression based on different treatment modalities were evaluated.

MATERIALS AND METHODS

This study included 28 patients with unruptured intracranial vertebrobasilar dissecting aneurysms with brain stem compression treated from January 2009 to December 2017. Treatment methods were observation (n = 6), stent-assisted coil embolization (n = 9), parent artery occlusion (n = 6), and flow diversion (n = 7). The data of baseline characteristics, change of aneurysm size, retreatment rate, stroke occurrence, and alteration of the mRS score were obtained from retrospective chart review.

RESULTS

The initial size of dissecting aneurysms was largest in the flow diversion group (22.5 ± 7.7 mm), followed by parent artery occlusion (20.3 ± 8.4 mm), stent-assisted coil embolization (11.7 ± 2.2 mm), and observation (17.8 ± 5.5 mm; P = .01) groups. The reduction rate of aneurysm size was highest in the parent artery occlusion group (26.7 ± 32.1%), followed by flow diversion (14.1% ± 28.7%), stent-assisted coil embolization (-17.9 ± 30.3%), and observation (-31.5 ± 30.8%; P = .007) groups. Additional treatment was needed in the observation (4/6, 66.7%) and stent-assisted coil embolization (3/9, 33.3%; P = .017) groups. Improvement of the mRS score on follow-up was observed in the flow diversion (6/7, 85.7%) and parent artery occlusion (4/6, 66.7%) groups but not in the stent-assisted coil embolization and observation groups. A worsened mRS score was most common in the observation group (4/6, 66.7%), followed by stent-assisted coil embolization (3/9, 33.3%), parent artery occlusion (2/6, 33.3%), and flow diversion (0/7, 0%) groups.

CONCLUSIONS

When treating intracranial vertebrobasilar dissecting aneurysms with brain stem compression, parent artery occlusion and flow diversion should be considered to reduce aneurysm size and improve the mRS score.

Intracerebral implantation of autologous peripheral blood stem cells in stroke patients: a randomized phase II study

In our previous study, intracerebral implantation of peripheral blood stem cells (PBSCs) improved functional outcome in rats with chronic cerebral infarction. Based on this finding, a randomized, single blind controlled study was conducted in 30 patients [PBSC group (n = 15) and control group (n = 15)] with middle cerebral artery infarction confirmed on a T2-weighted MRI 6 months to 5 years after a stroke. Only subjects with neurological deficits of intermediate severity based on the National Institute of Health Stroke Scale (NIHSS; range: 9-20) that had been stable for at least 3 months were enrolled. Those in the PBSC group received subcutaneous G-CSF injections (15 µg/kg/day) for 5 consecutive days, and then stereotaxic implantation of 3-8 × 10(6) CD34(+) immunosorted PBSCs. All 30 patients completed the 12-month follow-up. No serious adverse events were noted during study period. Improvements in stroke scales (NIHSS, ESS, and EMS) and functional outcomes (mRS) from baseline to the end of the 12-month follow-up period were significantly greater in the PBSC than the control group. The fiber numbers asymmetry (FNA) scores based on diffusion tensor image (DTI) tractography were reduced in every PBSC-treated subject, but not in the control group. Reduction in the FNA scores correlated well with the improvement in NIHSS. Furthermore, a positive motor-evoked potential (MEP) response by transcranial magnetic stimulation (TMS) appeared in 9 of the 15 subjects in the PBSC group. This phase II study demonstrated that implantation of autologous CD34(+) PBSC was safe, feasible, and effective in improving functional outcome.

The effects of intravesical chemoimmunotherapy with gemcitabine and Bacillus Calmette-Guérin in superficial bladder cancer: a preliminary study

This prospective study investigated the long-term effects of intravesical chemoimmunotherapy with gemcitabine (GEM) and bacillus Calmette-Guérin (BCG; n = 36) versus BCG alone (n = 51) for the treatment of superficial bladder cancer. For the chemoimmunotherapy (GEM + BCG) group, GEM (1000 mg) was instilled immediately after transurethral resection of bladder tumour (TURBT) and again (2000 mg) 1 week later. From 2 to 7 weeks after TURBT, BCG was instilled into the bladder of all patients once weekly. The recurrence-free period of the GEM + BCG group (24.13 months) was significantly longer than that of the BCG monotherapy group (19.81 months). The overall recurrence rate was similar between the groups, although at 6 and 9 months post-TURBT, GEM + BCG produced a significantly lower rate of recurrence compared with BCG alone. This study suggests that intravesical chemoimmunotherapy with GEM + BCG is effective in reducing early tumour recurrence and in prolonging the recurrence-free period of superficial bladder cancer.

Thiopurine S-methyltransferase polymorphisms and the relationship between the mutant alleles and the adverse effects in systemic lupus erythematosus patients taking azathioprine

OBJECTIVE

The present study sought to elucidate the genetic basis of thiopurine methyltransferase (TPMT) polymorphism and subsequently to investigate the relationship between mutant TPMT and an adverse response observed in Korean patients with systemic lupus erythematosus (SLE) taking azathioprine (AZA).

METHODS

The TPMT genotype of 342 patients with SLE was determined by MALDI-TOF mass spectrometry and correlated with the effects of clinical exposure to AZA.

RESULTS

TPMT polymorphism was detected in 17 of the 342 study subjects (5.0%), 12 heterozygous for the TPMT*3C allele and 5 heterozygous for the TPMT*6 allele. Numerous patients taking AZA demonstrated adverse drug responses. Severe nausea occurred in 4 patients with the TPMT*3C allele, while 1 patient with the TPMT*6 allele suffered severe bone marrow toxicity. Leucopenia (n = 17), nausea (n = 4), and abnormal liver function (n = 1) were suspected in 23 of the 94 lupus patients taking AZA. AZA was relatively well tolerated by the remainder of the patients. The heterozygous genotype for the TPMT*3C and *6 alleles was frequently detected in Korean SLE patients.

CONCLUSION

Contrary to previous hypotheses, this study identified no statistical correlation between TPMT genotype and AZA toxicity. We thus conclude that TMPT genotyping cannot replace regular blood monitoring in SLE patients receiving AZA treatment.

Genetic polymorphisms of OPG, RANK, and ESR1 and bone mineral density in Korean postmenopausal women

To evaluate the effects of genetic polymorphisms of OPG, RANK, and ESR1, which regulate osteoclastogenesis, on bone mineral density (BMD), a cross-sectional study was conducted in 650 Korean postmenopausal women. BMDs of the distal radius and the calcaneus were measured by dual energy X-ray absorptiometry (DXA). Genetic polymorphisms of OPG 163 A > G, 1181 G > C; RANK 421 C > T, 575 T > C; and ESR1 1335 C > T, 2142 G > A were determined by matrix-assisted laser desorption/ionization-time of flight (MALDI-ToF) mass spectrometry. The differences between the BMDs of the genotypes of OPG, RANK, and ESR1 were analyzed by multiple linear regression model adjusted for age and body mass index. Women with the OPG 1181 CC genotype had higher BMDs at the distal radius (7%) and calcaneus (10%) than those with the GG genotype; and these differences were statistically significant (P = 0.001 and P = 0.007, respectively). A significant association was also observed between RANK 575 T > C and calcaneus BMD (P for trend = 0.017). No significant association was observed between BMDs and the polymorphisms of ESR1. The association between OPG 1181 G > C and BMD was profound in subjects with the RANK 575 TT or ESR1 2142 GG genotypes; women with OPG 1181 CC had higher BMDs at the distal radius (11%) and calcaneus (11%) than those with OPG 1181 GG only in women with RANK 575 TT genotype (P = 0.002 and P = 0.021, respectively). These results suggest that OPG genetic polymorphisms, especially with the RANK 575 TT or ESR1 2142 GG genotypes, are related to low BMD in postmenopausal Korean women.

Drought-inducible-but ABA-independent-thaumatin-like protein from carrot (Daucus carota L.)

Drought treatment induces the accumulation of dcTLP, which is similar in structure to the thaumatin-like proteins (TLPs) found in the embryogenic calli, seedlings, and mature plants of carrot (Daucus carota). We isolated a full-length dcTLP cDNA clone from carrot and characterized the 5' upstream sequences. The coding region of dcTLP consisted of 645 nucleotides; the theoretical pI value was 4.9, and its molecular weight was approximately 22 kDa. The production of dcTLP transcripts in the seedlings increased dramatically with dehydration treatment but was not affected by abscisic acid (ABA), salicylic acid, or jasmonic acid. The expression patterns of dcTLP mRNA at different developmental stages and in response to a variety of signal molecules was analyzed using reverse transcriptase-PCR and promoter analysis with fused genes of 0.5-kb 5' upstream sequences in which beta-glucuronidase (GUS) reporter genes (gus) were established. The induction of dcTLP was found to be highly specific to drought stress in the embryogenic calli, seedlings, and mature plants. Our results suggest that this new isoform of TLP that has been isolated from carrot is a drought-specific, ABA-independent, non-organ-specific, and non-developmental-stage-specific protein.

Malignant peripheral nerve sheath tumor with divergent mesenchymal differentiations in a dog

A malignant peripheral nerve sheath tumor with divergent osteogenic, myxomatous, and myoblastic differentiations is described in a 10.5-year-old male Labrador Retriever dog. The tumor involved the sixth and seventh cervical spinal cord segments and nerves. The diagnosis was based on the results of histopathology, electron microscopy, and immunohistochemistry.

Transcutaneous blood gas monitoring in the rat

Transcutaneous blood gas (TCBG) analysis is a noninvasive alternative method of estimation of blood gas tensions. The objective of the study reported here was to validate this method against standard blood gas (STBG) analysis in adult and juvenile Sprague-Dawley rats. We sought to establish the optimal TCBG probe site and temperature, to establish probe temperatures that would not cause thermal burns, to evaluate correlations between blood gas values (PaCO2 and PaO2) determined by use of TCBG and STBG, and to evaluate the sensitivity of the TCBG unit to changes in arterial blood gas partial pressures. Our results indicated that: in general, the xyphoid area was the optimal site for probe placement, with 44.5 degrees C being the optimal probe temperature for the highest correlation, but thermal burns may be a problem; probe temperatures of 42.5 degrees C (adults) and 42.0 degrees C (juveniles) do not cause thermal burns when left in place for three hours; probe temperatures of 44 degrees C (adults) and 42 degrees C (juveniles) resulted in moderate correlation between PaCO2 and PtcCO2; and the TCBG unit adequately responded to changes in arterial blood gas partial pressures. Neither PtcCO2 or PtcO2 reflect actual values of PaCO2 or PaO2, respectively. We concluded that TCBG analysis may be used as an indicator of change in PaCO2 with sufficient animal numbers under tightly controlled conditions, but not as an indicator of change in PaO2 in adult and juvenile rats.

Eosinophilic granuloma with acute epidural hematoma: a case report

The most common symptoms of eosinophilic granuloma are local tenderness and an enlarged skull mass. The presence of epidural hematoma is a very rare symptom of eosinophilic granuloma. To our knowledge, this is only the second reported case of eosinophilic granuloma with epidural hematoma. A 2-year-old boy with a soft tumor on the occipital scalp, palpable at the age of 3 months, yet with no obvious history of trauma, was admitted due to a sudden onset of loss of consciousness. A brain computed tomography scan showed a lytic lesion on the occipital skull with a large epidural and subcutaneous hematoma, causing brain compression. He underwent an emergency craniectomy with removal of both the tumor and hematoma. The patient regained consciousness and had no residual neurological damage. Pathological reports showed abnormal proliferation of Langerhans' cells, eosinophilic cells and multinucleated cells. A whole-body bone nuclide scan revealed no other bone lesions. The patient was discharged uneventfully. The causes of hematomas are not very clear. They may be due to tumor necrosis or minor trauma. In our presented case, the cause of the epidural hematoma may have been tumor bleeding which ruptured into the epidural space. A solitary eosinophilic granuloma of the skull with acute epidural hematoma and loss of consciousness is extremely uncommon. Craniectomy with removal of the tumor and hematoma decompression may produce good results.

Symptomatic spinal intradural arachnoid cysts in the pediatric age group: description of three new cases and review of the literature

Spinal arachnoid cysts are a relatively uncommon lesion that may be either intra- or extradural, and intradural spinal arachnoid cysts are even less common. These cysts are usually asymptomatic but may produce symptoms by compressing the spinal cord or nerve roots suddenly or progressively. We present three cases in the pediatric age group with spinal intradural arachnoid cysts without a preceding history of trauma. Three patients with symptomatic intradural arachnoid cysts were investigated with conventional T1- and T2-weighted magnetic resonance imaging (MRI). The MRI scans demonstrated the intradural arachnoid cysts with slightly lower CSF signal intensity on the gradient echo images and slightly higher signal intensity on T1-weighted images. The first cyst was located at the level T12-L1 and compressed the conus medullaris, with neurogenic bladder and cauda equina syndrome for 2 months. The second was located at the level C5-T1 ventrally, with spastic gait and neurogenic bladder for 4 years. The other was located at T2-3 ventrally, with sudden onset of quadriplegia after jumping rope. The combined treatment of total resection and wide fenestration in our three patients produced an excellent return of neurologic function in each one, except for residual urinary disturbance in case 2. Intradural spinal arachnoid cysts appear to result from an alteration of the arachnoid trabeculae; some such cysts are ascribed anecdotally to previous trauma or arachnoiditis, whereas the majority are idiopathic and congenital. The majority of intradural spinal arachnoid cysts occur in the thoracic region and most are dorsal to the neural elements. Only 10 cases have been reported in which the intradural arachnoid cysts were located anterior to the cervical spinal cord, of which 8 were in the pediatric age group, like our case 2. Myelography, postcontrast CT myelography and MRI have been demonstrated as useful for the diagnosis of intradural arachnoid cysts. MRI is the imaging modality of choice, and the extent, size and nature of the lesion in our cases were well demonstrated by MRI. Surgical treatment is necessary if progressive neurological dysfunction appears in the course of spinal cord compression. Complete surgical excision of the cysts is the best choice of treatment, and wide fenestration and shunting of the cyst to the peritoneum, pleural cavity or right atrium were the modalities of choice. MRI offers a noninvasive and effective means to make the diagnosis of arachnoid cysts easier. Intradural arachnoid cysts may cause progressive myelopathy; however, the postoperative prognosis is good if the operation is performed prior to neurologic deficits.

Rhinosinusitis in transplant patients

The control of perioperative infection has become more important to increase the success rate of organ transplantation. Thorough examination for occult infection prior to transplantation, careful postoperative monitoring and prompt treatment of infections are required. We reviewed the medical records of 278 patients who received organ transplantation over 4 years and analysed the clinical course of rhinosinusitis during the pre- and post-transplantation period. Thirty-two (11.5%) patients had rhinosinusitis. Nineteen were detected during preoperative examination and 13 were postoperative. Sinus surgery was performed in nine patients before organ transplantation. Ten out of 13 patients who had rhinosinusitis detected after transplantation required sinus surgery and three patients had invasive fungal infections. In the immunocompromised host, the clinical presentation of rhinosinusitis may be subtle, but the subsequent clinical course may be fulminant or even fatal. If the transplant recipient has unexplained fever or any nasal symptom, thorough evaluation with a high index of suspicion and prompt management are required.

Familial cerebellar ataxia with hydrocephalus in bull mastiffs

Familial cerebellar ataxia with concurrent hydrocephalus has previously been described in a family of bull mastiff pups, and recently has been identified in a litter from Louisiana. The 4 affected pups had ataxia, hypermetria, conscious proprioceptive deficits, behavioral abnormalities, and a visual deficit. In magnetic resonance imaging of the brain of two of the pups, there were symmetric hydrocephalus and two focal areas of increased signal intensity within the central nuclei of the cerebellum. Histopathologically there was vacuolization and mild astrogliosis within the deep cerebellar nuclei (dentate, interpositus, fastigial), caudal colliculi, and lateral vestibular nuclei. Although the postmortem results were not exactly the same as in the previously published report, the clinical features and histopathologic findings strongly support the diagnosis. This disorder is most likely inherited in an autosomal recessive manner.

Se-methylselenocysteine induces apoptosis through caspase activation in HL-60 cells

Apoptosis, a programmed process of cell suicide, has been proposed as the most plausible mechanism for the chemopreventive activities of selenocompounds. In our study, we found that Se-methylselenocysteine (MSC) induced apoptosis through caspase activation in human promyelocytic leukemia (HL-60) cells. Measurements of cytotoxicity, DNA fragmentation and apoptotic morphology revealed that MSC was more efficient at inducing apoptosis than selenite, but was less toxic. Moreover, MSC increased both the apoptotic cleavage of poly(ADP-ribose) polymerase (PARP) and caspase-3 activity, whereas selenite did not. We next examined whether caspases and serine proteases are required for the apoptotic induction by MSC. A general caspase inhibitor, z-VAD-fmk, dramatically decreased cytotoxicity in MSC-treated HL-60 cells and several other apoptotic features, such as, caspase-3 activation, the apoptotic DNA ladder, TUNEL-positive staining and the DNA double-strand break. Interestingly, a general serine protease inhibitor, AAPV-cmk, also effectively inhibited MSC-mediated cytotoxicity and apoptosis. These results demonstrate that MSC is a selenocompound that efficiently induces apoptosis in leukemia cells and that proteolytic machinery, in particular caspase-3, is necessary for MSC-induced apoptosis. On the other hand, selenite-induced cell death could be derived from necrosis rather than apoptosis, since selenite did not significantly induce several apoptotic phenomena, including the activation of caspase-3.

Antley-Bixler syndrome, description of two new cases and review of the literature

OBJECTIVE

Antley-Bixler syndrome (ABS) is a rare disorder characterized by multiple malformations of cartilage and bone including multisynostotic osteodysgenesis, midface hypoplasia, choanal atresia or stenosis, femoral bowing, neonatal fractures and multiple joint contractures and, occasionally, urogenital, gastrointestinal or cardiac defects. Since the first report in 1975, at least 34 cases (including this report) have been described. We present 2 cases of congenital hydrocephalus, suggesting the cause of craniosynostosis and midface hypoplasia is associated with ABS.

CLINICAL PRESENTATION

The first case was a 1-day-old female with Arnold-Chiari malformation, multiple cranial synostosis, obstructive hydrocephalus and radioulnahumeral synostosis. Ventriculoperitoneal (V-P) shunting was performed when she was 7 days old. She died 42 days later due to cardiopulmonary failure. The second case was a 2-month-old female with bilateral coronal synostosis, obstructive hydrocephalus and brachycephaly. V-P shunting was done soon after her admission, and bilateral lateral canthal advancement with the floating forehead procedure was performed 1 month later. She is still alive with good development.

DISCUSSION

The main anomalies of the ABS can be divided into 4 categories: craniofacial, skeletal, extremity and urogenital anomalies. They may be the result of mutation in the fibroblast growth factor receptor 2 (Ser351Cys) gene, which was confirmed in our case 2. Craniosynostosis combined with hydrocephalus created congenital increased intracranial pressure (IICP). Early V-P shunt implantation and surgical release of the closed suture and lateral canthal advancement should be done as soon as possible, ideally when the patient is younger than 3 months.

CONCLUSION

Early correction of craniosynostosis was feasible and safe for one of our patients. We offer our experience in the treatment of hydrocephalus and correction of craniosynostosis to relieve IICP.

Expression of thymidylate synthase in gastric cancer patients treated with 5-fluorouracil and doxorubicin-based adjuvant chemotherapy after curative resection

We evaluated the expression of thymidylate synthase (TS) in locally advanced gastric cancer patients treated with adjuvant chemotherapy after curative resection and investigated the association between TS expression and clinicopathologic characteristics including prognosis of the patients. TS expression was evaluated by immunohistochemical staining using TS106 monoclonal antibody in 103 locally advanced gastric cancer patients (stage IB-IV) who underwent 5-fluorouracil (5-FU) and doxorubicin-based adjuvant chemotherapy after curative resection. 65 patients (63%) had primary tumours with high TS expression (> or = 25% of tumour cells positive), and 38 patients (37%) demonstrated low TS expression (< 25% of tumour cells positive or no staining). High TS expression was associated with male gender (P = 0.002), poorly differentiated histology (P = 0.015), and mixed type in Lauren's classification (P = 0.027). There were no statistically significant differences in 4-year disease-free survival (60.0% vs. 57.2%, P = 0.548) and overall survival (59.6% vs. 59.3%, P = 0.792) between high-TS group and low-TS group. In conclusion, although high TS expression was associated with poorly differentiated histology and mixed type in Lauren's classification, it did not predict poor disease-free and overall survival in gastric cancer patients treated with 5-FU and doxorubicin-based adjuvant chemotherapy after curative resection. Further prospective studies including the evaluation of other biological markers associated with the resistance to 5-FU and doxorubicin are necessary.

Increased expression of cyclooxygenase-2 protein in human gastric carcinoma

Gastric adenocarcinoma is one of the most common malignancies in the world, and yet little is known about its molecular process of development and progression. Recent studies have suggested that ingestion of nonsteroid anti-inflammatory drugs reduces the risk of colon cancer, presumably by inhibiting the cyclooxygenase (COX) enzyme. COX-2, one isoform of the COX enzyme, is the rate-limiting enzyme in prostaglandin synthesis, and the function of this enzyme is thought to relate to inflammatory processes and carcinogenesis. To understand the role of COX enzyme in gastric cancer, we measured COX-2 expression in 104 human gastric carcinoma tissues by immunohistochemical analysis. We obtained tissue specimens from 104 surgically resected gastric adenocarcinoma patients. We performed immunohistochemical stain for human COX-2 with polyclonal antibody in gastric carcinoma. After curative resection and extensive lymph node dissection, all patients received adjuvant chemotherapy containing 5-fluorouracil. Expression of COX-2 showed cytoplasmic staining, not only in cancer cells but also in precancerous lesions such as metaplastic and adenomatous cells. We confirmed up-regulation of COX-2 in gastric cancer tissues compared with normal paired mucosa using Western blot analysis. There was no correlation between clinicopathological characteristics of gastric cancer patients and intensity of COX-2 protein expression. This study indicates that COX-2 protein over-expression may contribute to an early event of gastric cancer development, and it further suggests that selective inhibition of COX-2 may provide a chemopreventive effect against gastric carcinogenesis.

An 80-kilodalton protein that binds to the pre-S1 domain of hepatitis B virus

It has been suggested that hepatitis B virus (HBV) binds to a receptor on the plasma membrane of human hepatocytes via the pre-S1 domain of the large envelope protein as an initial step in HBV infection. However, the nature of the receptor remains controversial. In an attempt to identify a cell surface receptor for HBV, purified recombinant fusion protein of the pre-S1 domain of HBV with glutathione S-transferase (GST), expressed in Escherichia coli, was used as a ligand. The surface of human hepatocytes or HepG2 cells was biotinylated, and the cell lysate (precleared lysate) which did not bind to GST and glutathione-Sepharose beads was used as a source of receptor molecules. The precleared lysate of the biotinylated cells was incubated with the GST-pre-S1 fusion protein, and the bound proteins were visualized by Western blotting and enhanced chemiluminescence. An approximately 80-kDa protein (p80) was shown to bind specifically to the pre-S1 domain of the fusion protein. The receptor binding assay using serially or internally deleted segments of pre-S1 showed that amino acid residues 12 to 20 and 82 to 90 are essential for the binding of pre-S1 to p80. p80 also bound specifically to the pre-S1 of native HBV particles. Analysis of the tissue and species specificity of p80 expression in several available human primary cultures and cell lines of different tissue origin showed that p80 expression is not restricted to human hepatocytes. Taken together the results suggest that p80 may be a component of the viral entry machinery.

Induction of apoptosis by selenite and selenodiglutathione in HL-60 cells: correlation with cytotoxicity

Effects of selenite and selenodiglutathione, an initial metabolite of selenite, on the induction of apoptosis and cytotoxicity were investigated in human promyelocytic leukemia HL-60 cells. Treatment of selenite or selenodiglutathione resulted in concentration-dependent cytotoxicity, measured by lactate dehydrogenase leakage assay, and by tetrazolium salt reduction assay. Selenodiglutathione has been shown to exert more cytotoxic effect than selenite in both assay systems. Time-course study of cellular selenium uptake suggests that the higher cytotoxicity of selenodiglutathione be largely due to faster and greater selenium uptake rate. Treatment with selenite or selenodiglutathione also induced apoptosis in a dose-dependent manner, as detected by enzyme-linked immunosorbent assay and by DNA fragmentation assay. The dose-response data of apoptosis induced by selenite or selenodiglutathione were similar to those of cytotoxicity, implicating a relationship between the induction of apoptosis and cytotoxicity. Zn, which is a well-known inhibitor of apoptosis, dose-dependently blocked not only the induction of apoptosis, but also the membrane damage induced by selenium, corroborating this hypothesis. It was noted that the inhibition of apoptosis by Zn exerted little protective effect on cytotoxicity at higher concentrations of selenium, compared with a perfect protective effect at low concentration of selenium. These results suggest that cytotoxicity induced by selenium may be partially correlated with apoptosis.

Endosonographic criteria for an internal opening of fistula-in-ano

PURPOSE

The aim of the present study was to define endosonographic criteria for an internal opening of fistula-in-ano.

METHODS

118 patients with a diagnosis of fistula-in-ano and a control group of 201 cases underwent endosonography in an outpatient setting. Confirmation of an internal opening was performed by intraoperative procedures.

RESULTS

Of the 139 cases of fistula-in-ano, the internal opening of 130 cases was confirmed. Analysis of endosonographic findings of the confirmed cases revealed that 122 cases showed positive findings for predictive location of an internal opening, and 8 cases demonstrated negative findings. Fifty-seven cases showed an appearance of a root-like budding formed by the intersphincteric tract that contacts the internal sphincter, classified as Criterion I. Fifty cases demonstrated the appearance of a root-like budding with an internal sphincteric defect, classified as Criterion II. Fifteen cases showed a subepithelial breach connecting to the intersphincteric tract through an internal sphincteric defect, classified as Criterion III. Using the combination of these three criteria, the accuracy was as follows: sensitivity, 94 percent; specificity, 87 percent; positive predictive value, 81 percent; negative predictive value, 96 percent.

CONCLUSION

These combined criteria would be of particular help in performing preoperative location of an internal opening with endosonography.

A brain MRI study in subjects with borderline personality disorder

BACKGROUND

There have been only a few brain computed tomography imaging studies, with mostly negative findings, in subjects with borderline personality disorder (BPD). This is the first MRI study which evaluated the structural abnormalities of the brain in subjects with the sole diagnosis of BPD.

METHODS

Twenty-five subjects with BPD were compared with age-, gender-matched healthy comparison subjects (n=25) on volumes of the frontal lobes, the temporal lobes, the lateral ventricles, and the cerebral hemispheres in brain magnetic resonance imaging.

RESULTS

Subjects with BPD had a significantly smaller frontal lobe compared to comparison subjects (multivariate regression analysis, t=2.225, df=46, P=0.031). There were no significant differences in volumes of the temporal lobes, the lateral ventricles, and the cerebral hemispheres between subjects with and without BPD.

LIMITATIONS

Strict inclusion and exclusion criteria employed in the present study may make it difficult to generalize our findings. The gray matter and white matter of the brain were not measured separately. Differences in head tilt during image acquisition were not corrected.

CONCLUSIONS

The current study reports a smaller frontal lobe volume on brain MRI in subjects with BPD compared with healthy comparison subjects. This finding may serve as a potentially useful biological variable that may allow for subtyping BPD.

Acute subdural hematoma with subarachnoid hemorrhage caused by an intracranial aneurysm: a case report

The occurrence of a subdural hematoma caused by the rupture of an intracranial aneurysm is rare. In our case, the patient is a 43-year-old woman who suffered from sudden onset of severe headache. Computed tomographic (CT) scan disclosed a subdural hematoma associated with subarachnoid hemorrhage. CT angiography and digital subtraction angiography revealed an elongated aneurysm adhering to the dura in the left Sylvian fissure. The subdural hematoma was evacuated and the aneurysm clipped. The patient made a full recovery.

Comparison of the APACHE III, APACHE II and Glasgow Coma Scale in acute head injury for prediction of mortality and functional outcome

OBJECTIVES

This study examines the efficacy of the predicting power for hospital mortality and functional outcome of three different scoring systems for head injury in a neurosurgical intensive care unit (NICU).

DESIGN

On the day of admission, data were collected from each patient to compute the Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II and III, and Glasgow Coma Scale (GCS) scores. Hospital mortality was defined as the deaths of patients before discharge from hospital. Early mortality was defined as death before the 14th day after admission. Late mortality was defined as death after the 15th day from admission. Functional outcome was evaluated by Index of Independence in Activities of Daily Living (Index of ADL).

SETTING

An 8-bed NICU in a 1270-bed medical center in Taichung Veterans General Hospital.

PATIENTS AND PARTICIPANTS

Two hundred non-selected patients with acute head injury were included in our study in a consecutive period of 2 years. Patients less than 14 years old were not included.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Sensitivity, specificity and correct prediction outcome were measured by the chi-square method in three scoring systems. The Youden index was also obtained. The best cut-off point in each scoring system was determined by the Youden index. The difference in Youden index was calculated by Z score. A difference was also considered if the probability value was less than 0.05. The area under Receiver Operating Characteristic (ROC) curve was computed. Then the area under ROC of each scoring system was compared by Z score. There was statistical significance if p was less than 0.05. For prediction of hospital mortality, the best cut-off points are 55 for APACHE III, 17 for APACHE II and 5 for GCS. The correct prediction outcome is 82.4% in APACHE III, 78.4% in APACHE II and 81.9% in the GCS. The Youden index has best cut-off points at 0.68 for APACHE III 0.59 for APACHE II, and 0.56 for GCS. The area under Receiver Operating Characteristic (ROC) curve is 0.90 in the APACHE III, 0.84 in the APACHE II and 0.86 in the GVS. There are no statistical differences among APACHE III and II, and GCS in terms of correct prediction outcome, Youden Index and the area under the ROC curve. Other physiological variables excluding GCS in APACHE III and II (AP III-GCS, AP II-GCS) have less statistical value in the determination of mortality for acute head injury. For the prediction of late mortality, APACHE III and II yield significantly better results in the area under the ROC curve, correct prediction and Youden index than those of GCS. Other physiological variables (AP III-GCS and AP II-GCS) play an important role in the prediction of late mortality in APACHE scores. For prediction of the functional outcome of surviving patients with acute head injury, the APACHE III yields the best results of correct prediction outcome, Youden index and the area under the ROC curve.

CONCLUSION

The APACHE III and II may not replace the role of GCS in cases of acute head injury for hospital or early mortality assessment. But for prediction of the late mortality, the APACHE III and II have better accuracy than GCS. Other physiological variables excluding GCS in the APACHE system play a crucial contribution for late mortality. GCS is simple, less time-consuming and economical for patients with acute head injury for the prediction of hospital and early mortality. The APACHE III provides better prediction for severe morbidity than GCS and APACHE II. Therefore, the APACHE III provides a good assessment not only for hospital and late mortality, but also for functional outcome.

Primary intrasellar mixed germ-cell tumor with precocious puberty and diabetes insipidus

We report an 8-year-old boy with a primary intrasellar mixed germ-cell tumor who underwent the trans-sphenoidal approach for tumor removal. Initially he suffered from diabetes insipidus. Precocious puberty and left abducens nerve palsy were also observed. Elevation of serum testosterone, beta-human chorionic gonadotropin (HCG), and alpha-fetoprotein (AFP) were found on admission. The histological study revealed mixed cellular types of tumor including germinoma, choriocarcinoma, embryonic cell carcinoma, and teratoma. Postoperative radiation to a total of 5000 cGy was performed. Adjuvant chemotherapy was administered before and after radiation. The boy was disease-free during a 6-month follow-up period. Follow-up magnetic resonance imaging showed no presence of tumor. The signs of precocious puberty disappeared, and the diabetes insipidus was easily controlled. The abducens nerve regained normal function. Serum HCG, AFP, and testosterone levels all returned to normal. Serum antidiuretic hormone increased to reach the lower limit of the normal range.

Liposarcoma associated with a glass foreign body in a dog

An 11-year-old spayed female mixed-breed dog was referred for evaluation of a mass on the right forelimb of 4 months' duration. Cytologic examination of a fine-needle aspirate of the mass resulted in a diagnosis of liposarcoma. The 3 x 3 x 1.5-cm firm mass was surgically removed. Histopathologic observations confirmed the diagnosis of liposarcoma. During processing, a 1 x 0.8-cm piece of glass was found within the mass. Association between a glass foreign body and liposarcoma is discussed.

Juvenile rhabdomyosarcomas in two dogs

Juvenile rhabdomyosarcomas were diagnosed in two young dogs based on the results of histopathology, phosphotungstic acid-hematoxylin stain, immunohistochemistry, and the age of the dogs. One dog, an 11-month-old Rottweiler, had tumor masses in the maxillary gingiva and the urinary bladder. Histologically, the gingival mass was an alveolar type of rhabdomyosarcoma and the urinary bladder mass was an embryonal type. The other dog, a 1.5-year-old Basset Hound, had an embryonal rhabdomyosarcoma involving the oropharynx and the temporal muscles, with metastasis to the regional lymph node and lungs.

Lysosomal storage disease in an emu (Dromaius novaehollandiae)

Lysosomal storage disease involving the brain, spinal cord, liver, and spleen was discovered in a 6-month-old male emu (Dromaius novaehollandiae). The diagnosis was based on light and electron microscopic studies and histochemical staining characteristics. This is the first case of lysosomal storage disease reported in a ratite.

Intradural metastasis to the cauda equina from carcinoma of the anus

STUDY DESIGN

This is a report of a man with carcinoma of the anus and intradural metastasis to the cauda equina.

OBJECTIVE

To perform a laminectomy with tumor removal for relief of pain.

SUMMARY OF BACKGROUND DATA

Only 25 cases of intradural spinal metastasis have been reported in the English literature. This is the first report of a metastatic case, moving from the carcinoma of the anus to the cauda equina.

METHODS

Magnetic resonance imaging showed an ill-defined mass, with central necrosis, to the cauda equina. The possibility of intradural metastasis to the cauda equina was indicated by unique pain symptoms.

RESULTS

The patient's back pain subsided after total laminectomy of L3-L5 with subtotal removal of the tumor. The residual tumor became smaller with postoperative radiation.

CONCLUSION

Magnetic resonance imaging is a good diagnostic choice in this situation. The cause of the metastasis was unclear, but it was presumed to have occurred through the perineural lymphatic ducts. Laminectomy with tumor removal is feasible for relieving pain and demonstrating pathology.

Comparison of APACHE III, II and the Glasgow Coma Scale for prediction of mortality in a neurosurgical intensive care unit

OBJECTIVES

This study examined the efficacy of predicting power for hospital mortality of three different scoring systems in a neurosurgical intensive care unit (NICU).

SETTING

An eight-bed NICU in a 1,270-bed medical centre (Taichung Veterans General Hospital).

SUBJECTS

Two hundred patients with head injury, brain tumour, hypertensive intracerebral haemorrhage, rupture of aneurysm or arteriovenous malformation, or other categories were included in our study in a consecutive period of 14 months. Patients less than 14 years old were not included.

DESIGN

On the first day of admission, data were collected from each patient to compute the Acute Physiology and Chronic Health (APACHE) II and III, and Glasgow Coma Scale (GCS) scores. Hospital mortality was defined as when death occurred before discharge from hospital.

INTERVENTIONS

none.

MEASUREMENTS

Sensitivity, specificity and correct prediction outcomes were measured by logistic regression in three scoring systems. The Youden index was also obtained. The best cutoff point in each scoring system was determined by logistic regression or by the Youden index. Data obtained by logistic regression were compared by McNemar's test. The differences in Youden index were calculated by the Student's t-test. The area under the Receiver Operating Characteristic (ROC) curve was computed and the area of each scoring system was then compared by the Wilcoxon Mann-Whitney test.

MAIN RESULTS

The correct prediction of outcome was 85.5% in APACHE III, 77.5% in APACHE II and 75.0% in GCS. The area under the Receiver Operating Characteristic (ROC) curve was 0.892 in APACHE III, 0.826 in APACHE II and 0.868 in GCS. For the prediction of dead patients at the best cutoff point, APACHE III and GCS were better than APACHE II, (both p < 0.01 respectively). For the prediction of alive patients at the best cutoff point, APACHE III was better than GCS and APACHE II (p < 0.01 respectively).

CONCLUSION

The APACHE III system seems to be the most reliable. The results reveal that the APACHE III system is better in predicting power for hospital mortality than either the GCS or APACHE II systems in our NICU patients.

Decompressive craniotomy for acute shaken/impact baby syndrome

To estimate the surgical efficacy of decompressive craniotomy, 23 children under 2 years of age with acute shaken/impact baby syndrome were treated with medical or surgical methods over the past 6 years. Six children (group A) with lower intracranial pressure (ICP, less than 30 mm Hg) were treated with medical therapy, and 17 children with high ICP (more than 30 mm Hg) of which 7 children were treated with medical therapy (group B) and another 10 children (group C) were treated with decompressive craniotomy. Bifrontal craniotomy was performed on 5 children with generalized brain swelling. A large frontotemporoparietal craniotomy was performed on another 5 children with unilateral swelling. A mean of 32 ml of subdural hematoma was removed. The mean ICP was reduced by 80% in the craniotomy group, p < 0.05. Children in groups A and C performed better on the Children's Outcome Scale than those in group B, p < 0.05. Mortality was significantly lower (0/10) in group C than in group B (3/7), p < 0.05. Hearing preservation was better in group C than in group B, p < 0.05. Bifrontal and frontotemporoparietal craniotomies may reduce mortality and morbidity for acute shaken/impact baby syndrome with high ICP. Patients with ICP less than 30 mm Hg may be treated successfully with medical therapy and patients with ICP more than 30 mm Hg are better treated with decompressive craniotomy.

Helix-stabilizing compounds CC-1065 and U-71,184 bind to RNA-DNA and DNA-DNA duplexes containing modified internucleotide linkages and stabilize duplexes against thermal melting

CC-1065 and U-71,184 bind and hyperstabilize DNA duplexes, but little is known about their effects on nucleic acid duplexes of different structure. A 20 mer DNA sequence (5'-TTACTTCAGTTATGAGACCA) containing a drug binding sequence (5'-AGTTA) was selected as the target sequence, and this was duplexed with complementary antisense sequences containing phosphodiester (PO), phosphorothioate (PS), and methylphosphonate (MP) bonds. The duplexes containing PO or PS bound 2 CC-1065 molecules per duplex, presumably at both the target site and at a lower affinity site (5'-AGTAA) on the antisense strand. The duplex containing MP bound only 1 CC-1065, and all duplexes bound only 1 U-71,184. Both CC-1065 and U-71,184 bound to 20 mer duplexes comprised of oligo(dA)-oligo(dT) (2.5 and 2 drugs per duplex, respectively) and poly(rA)-oligo(dT) (1 drug per 20 base pairs). CC-1065 also bound to duplexes between the PO- or PS-based antisense structures and a complementary synthetic 20 mer RNA sequence, with about 1 drug per duplex in each case. CC-1065 increased the Tm for the 20 mer DNA duplexes 17 to 29 degrees C, and the corresponding values for U-71,184 ranged from 7 to 19 degrees C. CC-1065 raised the Tm of oligo(dA)-oligo(dT) and poly(rA)-oligo(dT) 29 degrees C. U71,184 increased the Tm for oligo(dA)-oligo(dT) 30 degrees C but did not significantly elevate the Tm for the corresponding RNA-DNA duplex. The results show that CC-1065 and U-71,184 are capable of binding and stabilizing a variety of nucleic acid duplexes. These agents or their analogs may become useful ligands for antisense oligonucleotide applications.

Helix-stabilizing agent, CC-1065, enhances suppression of translation by an antisense oligodeoxynucleotide

The antitumor antibiotic CC-1065 is known to bind at selected sequences in the minor groove of duplex nucleic acids and to hyperstabilize the duplexes against thermal melting. These properties suggested that CC-1065 may enhance translation inhibition by antisense oligonucleotides directed against a specific mRNA. A 585 bp mRNA transcript containing the equine infectious anemia virus (EIAV) S2 gene and a portion of the env gene was prepared. Also, a complementary 20 mer antisense oligodeoxynucleotide (5'-TGTTGGGTAATAGG-GGTTGA-3') was prepared against a target sequence in the mRNA located near the translational initiation sites of the overlapping S2 and env genes. The center of the target sequence had an expected CC-1065 recognition sequence (5'-UAUUA-3'). Translation in the presence of CC-1065 and antisense was markedly suppressed compared with that of antisense alone. Addition of a sense 20 mer strand, with or without CC-1065, had little or no effect on translation. CC-1065 and related compounds may be useful as ligands for enhancing the stability of sense-antisense duplexes and for promoting the inhibition of translation by antisense oligonucleotides.

Repeat operations in failed microvascular decompression for trigeminal neuralgia

For the study of pathogenesis and treatment of recurrent trigeminal neuralgia, we performed 31 repeat operations from among 400 patients with trigeminal neuralgia in the past 10 years. Initially, of these 400 patients, 376 underwent microvascular decompression only, and 24 underwent partial sensory rhizotomy with or without microvascular decompression. Fifty-three patients (14%) had recurrences after microvascular decompression, of which 31 patients underwent repeat operations. Among the repeat operations, there was negative exploration in 16 patients (52%), arterial loop compression in 7 (22%), venous compression in 4 (13%), and Teflon compression or adhesion in 4 (13%). Twenty-one patients had early recurrences within 1 year, and 10 patients had late recurrences. Negative exploration and arterial compression were more likely in early recurrence (P = 0.01). Continuing demyelination might occur in patients with negative exploration, even when adequate decompression had been initially performed. Seventy percent of the patients had no recurring pain by way of partial sensory rhizotomy for negative explorations, redecompression of arterial loops, division of offending veins, or lysis and reposition of Teflon. About half of the patients had positive findings that were amenable without rhizotomy in the repeat operations. A repeat operation for failed microvascular decompression is a good choice if the condition of the patient is tolerant.

Subependymal giant cell astrocytoma with tuberous sclerosis--case report

Tuberous sclerosis is a rare disease of autosomal dominant inheritance and may affect any organ, and less than 2% have a subependymal giant cell astrocytoma. In the present report, a 6-year-old girl with clinical features of tuberous sclerosis had an intraventricular tumor. CT scan and MRI of brain showed a tumor in the lateral ventricles extended into the Foramina of Monro and third ventricle causing severe hydrocephalus. She underwent left frontal craniotomy with partial removal of the tumor. The pathology was subependymal giant cell astrocytoma. Patient's neurological condition improved postoperatively and postoperative CT scan showed no hydrocephalus. Clinical and radiological follow-up of patients with tuberous sclerosis who had subependymal nodules in early childhood is important due to its possibility of subsequent transformation into intraventricular tumor.

Chlamydiosis in commercial rheas (Rhea americana)

Mild to marked splenomegaly was observed in three of four rheas that died acutely in three unrelated commercial ratite facilities in Southeastern Louisiana. Mortalities occurred within a 5-week period in birds ranging from 2 months to 3 years of age. Multifocal hepatic and splenic necrosis with mononuclear cell infiltrates, typical of chlamydiosis in other avian species, was present on histopathologic sections. The diagnoses were confirmed by demonstration of inclusion bodies in splenic impression smears and fluorescent-antibody testing performed on Vero cell cultures.

Mucinous hyperplasia in the kidney and ureter of a horse

A case of mucinous hyperplasia in the right renal pelvis and ureter is reported in a 23-year-old, male, Quarter horse. The affected right renal pelvis was markedly distended and filled with inspissated yellowish-green mucous material compressing the adjacent cortical and medullary parenchyma. Multiple, similar masses were present protruding from the right urethral mucosa. Histologically, the masses were characterized by a cystic glandular and papillary hyperplasia of the mucosa of the renal pelvis and ureter. This is believed to be the first reported case in an equine species.

Hypertrophic osteopathy associated with Mycobacterium fortuitum pneumonia in a dog

Mycobacterium fortuitum was isolated from the lung of a dog that had new periosteal bone formation consistent with hypertrophic osteopathy. Fever, weight loss, and bilateral hind limb lameness were the initial clinical signs. The tarsi were swollen and a pain response was elicited on palpation of the hind limb. Radiography revealed periosteal new bone formation on the metatarsi, femurs, and ischii. Thoracic radiography revealed pulmonary mass lesions in the right middle and left caudal lung lobes. After right middle and left caudal lung lobectomy, M fortuitum was isolated from the excised tissues. Amoxicillin trihydrate/clavulanic acid and amikacin were administered, on the basis of susceptibility test results.

Reconstruction of the anterior cruciate ligament with Achilles tendon autograft

The increasingly serious complications of artificial ligaments and allografts have brought them into disrepute. Recently, autografts have drawn more attention. A new type of autograft, the Achilles tendon autograft, has been developed and applied to anterior cruciate ligament reconstructions. This report describes the advantages of the Achilles tendon autograft used and presents the results of a prospective study of 21 patients with minimum 2 year follow up. Of the 21 cases, 16 patients (75%) had a rating of excellent; 2 (10%) good, 2 (10%) fair, and 1 (5%) poor. Preoperative knee scores of 56.7 were improved to 89.5 postoperatively. The authors removed less than half of the Achilles tendon with the calcaneal bone incorporated. Through magnetic resonance imaging we confirmed that the remaining Achilles tendon of the donor site regained its volume and strength within a year without significant complication. Achilles tendon autograft offers the advantages of length, elastic strain modulus, reproducibility in technique, and consistency of the result without significant complications.

Eastern equine encephalitis in a flock of emus (Dromaius novaehollandiae)

Eastern equine encephalitis (EEE) was diagnosed in a flock of emus in southeastern Louisiana. The outbreak involved juvenile and adult breeders ranging in age from 20 to 36 months, with an attack rate of 76% and a case fatality rate of 87%. The diagnosis was confirmed by isolation and characterization of the viral agent, and by detection of EEE antibody in two recovered emus. High mortality was preceded by marked depression, hemorrhagic diarrhea, and emesis of blood-stained ingesta. On postmortem examination, hemorrhagic enteritis and multiple petechia of viscera were observed. Microscopic changes included severe necrosis of hepatocytes, intestinal mucosa, and necrotizing vasculitis of the spleen and lamina propria of the intestine. No nervous system lesions were observed. This outbreak occurred concurrently with EEE in horses and was attributed to unseasonably heavy rainfall with an abundance of arthropod vectors and proximity to free-living reservoir host species.

Surgical management of an ethmoid cyst in a horse

A 2-year old Thoroughbred filly was examined for a 1-month history of persistent nasal discharge. Contrast radiography revealed a circumscribed mass within the right maxillary sinus which extended to the frontal sinus and ethmoid labyrinth. A discrete attachment of the mass to the ethmoid labyrinth was identified at surgery. Surgical removal of the mass eliminated the nasal discharge. On gross examination, the external structure of the mass was similar to a turbinate with a thin bony wall covered by a smooth mucosal membrane. The internal structure of the lesion had a lining membrane with multiple 1-3 cm in diameter fluid filled cystic structures. The histological appearance of the multiloculated structure was similar to the ethmoid labyrinth. This, combined with the single site of attachment to the ethmoid labyrinth, suggested that the cyst was ethmoidal in origin.

Intracranial lipoma in the medulla oblongata

Intracranial lipoma in the medulla oblongata has been rarely reported. Only two cases have been documented in the literature. This report concerns a patient who complained of nuchal soreness and an unstable gait for 6 months. An olivelike lipoma, arising from the posterior aspect of the medulla oblongata and embedded in the lower cranial nerves, was found at suboccipital craniectomy and posterior laminectomy of C1-2. Partial removal of the lipoma was performed for decompression; radical removal would have been hazardous. The clinical symptoms subsided postoperatively. The computed tomography scan and magnetic resonance image proved useful for properative diagnosis.

[Intracranial meningiomas--5 year analysis]

Intracranial meningiomas account for 18.2% of all intracranial tumors. During Jan. 1982-Dec. 1986, 65 cases of intracranial meningiomas were diagnosed after operations and pathologic examinations at Taichung Veterans General Hospital. There were 36 females and 29 males, aged from 18 to 80 with a mean of 52 years. Average period of follow-up was 23.7 months. All patients received craniotomy or craniectomy with or without microscopic technique to remove the tumors & 3 cases received postoperative radiotherapy. The most common sites of meningiomas were the posterior fossa, convexity, parasagittal area and falx. The complete removal rate was 84.8%, the mortality rate 9.1% and the morbidity rate 33%. The major complications were intracerebral hemorrhage, infection of central nerve system, and hydrocephalus. There were 3 cases (4.6%) of multiple meningiomas. The most common symptoms and signs in order were headache, hemiparesis, seizure, nausea and vomiting, conscious disturbance & trigeminal neuralgia. The average duration of symptoms was 18.5 months. There were 9 cases of trigeminal neuralgia and 2 cases of hemifacial spasm. There were 3 cases (5.6%) of recurrence and 4 cases (6.1%) of malignancy. The most frequently found subtypes of meningiomas were the meningotheliomatous type and the transitional type. Mean size of the tumors was 5 cm. Tumor location and its biological behavior were closely related to the removal rate, prognosis and recurrence, while tumor size was of less importance. Ability of daily life was improved and seizure was better controlled by antiepileptic drugs in postoperative days.