Mechanical thrombectomy for occlusion of the fenestrated middle cerebral artery M1 segment: A case report and review of the literature

It is impossible to predict underlying anomalies in acute large vessel occlusion and it could be a problem when performing mechanical thrombectomy (MT). We report a case of MT for occlusion of the fenestrated middle cerebral artery (MCA) M1 segment. A 49-year-old woman presented to our hospital with dysarthria and left hemiparesis. Acute ischemic stroke due to right occluded MCA was diagnosed. During performing emergent MT, a part of the M1 segment was revealed to be slit-shaped by digital subtraction angiography, suggesting a fenestrated MCA. The aspiration catheter could not be advanced through the narrow limb of the fenestration, and the distal thrombus was retrieved using a stent retriever, additionally. Postoperatively, the patient's symptoms improved without complications. When occlusion of the fenestrated MCA is suspected, it is necessary to consider converting the strategy from an aspiration catheter alone to the combined use of a stent retriever.

Efficacy and Safety of Dual Antiplatelet Therapy with the Routine Use of Prasugrel for Flow Diversion of Cerebral Unruptured Aneurysms

PURPOSE

Prasugrel is not approved for patients treated with flow diverters, which have a high metal coverage ratio. However, robust antiplatelet therapy with prasugrel may prevent thromboembolic complications. We administered prasugrel and aspirin to all patients treated with flow diverters and reported the safety of the antiplatelet therapy regimen.

METHODS

This retrospective, single-center study evaluated the angiographic and clinical data of consecutive patients treated with flow diverters for cerebral unruptured aneurysms between June 2020 and May 2022. All patients received dual antiplatelet therapy, including prasugrel and aspirin. The administration of prasugrel ended 3 or 6 months after the procedure, whereas aspirin use continued for at least 12 months. Periprocedural complications (< 30 days post-procedure) and delayed complications (> 30 days post-procedure) were recorded.

RESULTS

During the study period, 120 unruptured aneurysms were treated with flow diverters in 110 patients. All patients, except one, survived longer than 12 months after the procedure. The rate of thromboembolic complications was 6.4%, and more than half of the patients had transient symptoms; one (0.9%) had a major ischemic stroke. One patient (0.9%) each had an asymptomatic, small subarachnoid hemorrhage and significant hemorrhagic complications with melena. The rate of permanent neurological deficits was 1.8%, and the mortality rate was 0.9%.

CONCLUSIONS

Dual antiplatelet therapy comprising routine use of prasugrel and aspirin for flow diverter-implanted patients possibly contributed to a low rate of thromboembolic complications and low risk of hemorrhagic complications.

Superiority of Endovascular Coiling Over Surgical Clipping for Clinical Outcomes at Discharge in Patients With Poor-Grade Subarachnoid Hemorrhage: A Registry Study in Japan

BACKGROUND AND OBJECTIVES

The differences in clinical outcomes between endovascular coiling (EC) and surgical clipping (SC) in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) are controversial. Therefore, this study aimed to evaluate whether EC is superior to SC and identify risk factors in patients with poor-grade aSAH.

METHODS

We used data from the "Predict for Outcome Study of aneurysmal SubArachnoid Hemorrhage." World Federation of Neurological Societies (WFNS) grade III-V aSAH was defined as poor-grade aSAH, and unfavorable clinical outcomes (modified Rankin Scale scores 3-6) were compared between SC and EC after propensity score matching (PSM). In-hospital mortality was similarly evaluated. Predictors of unfavorable clinical outcomes were identified using multivariable analysis.

RESULTS

Ultimately, 1326 (SC: 847, EC: 479) and 632 (SC: 316, EC: 316) patients with poor-grade aSAH were included before and after PSM, respectively. Unfavorable clinical outcomes at discharge were significantly different between SC and EC before (72.0% vs 66.2%, P = .026) and after PSM (70.6% vs 63.3%, P = .025). In-hospital mortality was significantly different between groups before PSM (10.5% vs 16.1%, P = .003) but not after PSM (10.4% vs 12.7%, P = .384). Predictors of unfavorable clinical outcomes in both SC and EC were WFNS grade V, older than 70 years, and Fisher computed tomography (CT) grade 4. Predictors of unfavorable clinical outcomes only in SC were WFNS grade IV (odds ratio: 2.46, 95% CI: 1.22-4.97, P = .012) and Fisher CT grade 3 (4.90, 1.42-16.9, P = .012). Predictors of unfavorable clinical outcome only in EC were ages of 50s (3.35, 1.37-8.20, P = .008) and 60s (3.28, 1.43-7.52, P = .005).

CONCLUSION

EC resulted in significantly more favorable clinical outcomes than SC in patients with poor-grade aSAH, without clear differences in in-hospital mortality. The benefit of EC over SC might be particularly remarkable in patients with WFNS grade IV and Fisher CT grade 3.

Factors influencing early obliteration during flow diverter treatment of cerebral aneurysms: Establishment of an early obliteration inhibition score

OBJECTIVE

This retrospective study aimed to investigate factors associated with inhibition of early aneurysm obliteration after flow diverter (FD) treatment. We also created the early obliteration inhibition (EOI) score for pre-operative evaluation.

METHODS

We examined 110 cerebral aneurysms in 104 patients who underwent FD treatment. The following parameters were investigated: age, sex, symptoms, aneurysm location and type, maximum aneurysm diameter, parent vessel diameter, neck diameter, and dome-neck ratio. We also noted aneurysm location relative to the curvature of the parent artery and any branches arising from the aneurysm dome. Procedural factors such as FD diameter and length, number of FDs placed, type of FD, and use of adjunctive coiling were also investigated. Aneurysm obliteration was evaluated using digital subtraction angiography 3 months after the procedure. Adequate obliteration was defined as grade C or D on the O'Kelly-Marotta scale.

RESULTS

The following factors inhibited early obliteration: 1) extradural location, 2) saccular aneurysm, 3) aneurysm neck located at the outer convexity of the parent artery, and 4) arterial branch arising from the aneurysm dome. Odds ratios were used to create an EOI score. Receiver operating characteristic curve analysis showed that the optimal cut-off EOI score for adequate obliteration was 1.5 (area under the curve, 0.81; 95% confidence interval, 0.73-0.9; sensitivity, 0.9; specificity, 0.57).

CONCLUSION

The EOI score, which is based on factors that inhibit early obliteration, may predict early treatment outcomes of FD placement.

Persistent contrast-filling in the woven endobridge device three months after its implantation for cerebral aneurysm: Incidence, predictive factors, and outcome

OBJECTIVE

The Woven EndoBridge (WEB) was developed to treat wide-neck bifurcation intracranial aneurysms. Occasionally, persistent contrast-filling has been observed in the WEB after treatment. The purpose of our study was to investigate its incidence, predictive factors, and clinical impact.

METHODS

All patients treated with the WEB between January 2021 and September 2021 at our institute were reviewed. Age, gender, antiplatelet therapy, and angioarchitecture were compared between the persistent-filling group and the no-filling group at the three-month follow-up angiography.

RESULTS

We included 20 patients with 20 unruptured aneurysms. Ten of the 20 intracranial aneurysms (50 %) showed contrast-filling in the WEB after three months. Two of the 10 had contrast not only inside, but around the device. Statistically significant differences were observed between the persistent-filling group and the no-filling group in neck size (median: 4.5 mm vs. 3.8 mm), deviation of the aneurysm axis from the inlet flow line where the orifice of the bifurcated arteries overlaps (mean: 15.1° vs. 33.0°), and postoperative dual antiplatelet therapy (DAPT) for at least a month (90 % vs. 20 %). One case had additional coil embolization six months after the WEB implantation. Including this case, one year after the treatment or the re-treatment, the filling in the device had disappeared in nine of 10 cases. No bleeding was observed during the mean follow-up period of 24 months.

CONCLUSION

Persistent contrast-filling was associated with postoperative DAPT for at least a month, a wide neck, and less deviation of the aneurysm axis from the inlet flow line. If the contrast-filling is only within the WEB and not between the aneurysmal wall and the WEB, we are not concerned. To further assess the clinical impact of this phenomenon, long-term follow-up will be needed.

Decision-making tree for optimal Woven EndoBridge device sizing with ideal Woven EndoBridge-aneurysm volume (iWAVe) ratio

PURPOSE

Optimal size selection is important for successful Woven EndoBridge (WEB) treatment. Conventional recommendations for WEB sizing based on aneurysm width and height sometimes require device exchange. We aimed to design a novel volume-based parameter, the ideal WEB-aneurysm volume (iWAVe) ratio, for optimal WEB sizing.

METHODS

Consecutive patients who underwent WEB treatment for wide-neck bifurcation aneurysms between January 2021 and May 2022 were retrospectively reviewed. Aneurysm volume was automatically calculated using software. We measured the aneurysm volume based on the expected position of the device within the aneurysm. The WAVe ratio was defined as the ratio of the aneurysm volume to WEB volume. We dichotomized aneurysms treated with a successful sizing or unsuccessful sizing for WEB (successful group and unsuccessful group, respectively).

RESULTS

Thirty-five patients were eligible for study enrollment. Ten patients (28.6%) needed to exchange the WEB on the first attempt and required another WEB on the second attempt resulting in deployment success. Hence, 35 aneurysms were in the successful group and 10 were in the unsuccessful group. The median WAVe ratio was 1.0 (range 0.76-1.31) in the successful group and 1.27 (0.58-1.89) in the unsuccessful group. Using logistic regression, iWAVe ratio was from 0.90-1.16 to secure a >80% probability of success by the 95% lower confidence limit. The sensitivity and specificity of the iWAVe ratio for optimal size selection on the first attempt were 0.60 and 1.00, respectively.

CONCLUSION

Decision-making based on aneurysm width and the iWAVe ratio could promote optimal WEB sizing.

Analysis of Factors Influencing Delayed Presentation in Japanese Patients with Subarachnoid Hemorrhage

OBJECTIVE

Some aneurysmal subarachnoid hemorrhage (SAH) patients are delayed in their presentation. This can cause a washout of the subarachnoid hematoma and a potential misdiagnosis. As a result, they may suffer rerupture of the aneurysm and preventable deterioration. We investigated the factors that influence delayed SAH presentation.

METHODS

Aneurysmal SAH patients treated at 9 stroke centers from 2002 to 2020 were included. Age, gender, pre-SAH modified Rankin scale, World Federation of Neurological Surgeons grade, Fisher group, day of presentation, aneurysm treatment method, past history of cerebral stroke, comorbidity of hypertension and/or diabetes mellitus, and modified Rankin scaleat discharge were assessed retrospectively. We formed 2 groups based on the day of presentation after the onset of SAH: day 0-3 (early) and other (delayed). Logistic regression analyses detected the factors that influenced the day of presentation and outcome for SAH. A P- value <0.05 was considered significant.

RESULTS

Delayed presentation comprised 282 cases (6.3%) of 4507 included cases. Logistic regression analyses showed that patients in an urban area, of male gender, low WFNS grade and low Fisher group correlated significantly with a delayed presentation. But delayed presentation did not influence outcome at discharge.

CONCLUSIONS

Area of residency and gender correlated with delayed presentation after SAH in Japan. Urbanization, male gender, and mild SAH lead patients to delay presentation. The factors underlying these tendencies will be analyzed in a future prospective study.

Delays in initial workflow cause delayed initiation of mechanical thrombectomy in patients with in-hospital ischemic stroke

Objectives

The benefit of mechanical thrombectomy for acute ischemic stroke is highly time dependent. However, time to treatment is longer for in-hospital stroke patients than community-onset stroke patients. This study aimed to clarify the cause of this difference.

Methods

A retrospective single-center study was performed to analyze patients with large vessel occlusion who underwent mechanical thrombectomy between January 2017 and December 2019. Patients were divided into in-hospital stroke and community-onset stroke groups. Clinical characteristics and treatment time intervals were compared between groups.

Results

One hundred four patients were analyzed: 17 with in-hospital stroke and 87 with community-onset stroke. Patient characteristics did not significantly differ between groups. Median door (stroke recognition)-to-computed tomography time (36 min vs. 14 min, P<0.01) and door-to-puncture time (135 min vs. 117 min, P=0.02) were significantly longer in the in-hospital stroke group than the community-onset stroke group. However, median computed tomography-to-puncture time (104 min vs. 104 min, P=0.47) and puncture-to-reperfusion time (53 min vs. 38 min, P=0.17) did not significantly differ.

Conclusions

Longer door-to-puncture time in in-hospital stroke patients was mostly caused by longer door-to-computed tomography time, which is the initial part of the workflow. An in-hospital stroke protocol that places importance on early stroke specialist consultation and prompt transportation to the computed tomography scanner might hasten treatment and improve outcomes in patients with in-hospital stroke.

Early spontaneous occlusion of a vertebral artery dissecting aneurysm caused by subarachnoid hemorrhage: A case report

We report a case of vertebral artery dissecting aneurysm (VADA) that developed with subarachnoid hemorrhage and was found to be occluded based on subsequent digital subtraction angiography. Few reports have been published on ruptured VADA in which ipsilateral vertebral arteries are occluded. The proper management of this type of aneurysm is controversial. A 44-year-old woman developed a sudden onset headache. Computed tomography and three-dimensional computed tomography were immediately performed and showed subarachnoid hemorrhage and VADA distal to the right posterior inferior cerebellar artery bifurcation. We decided to treat the VADA immediately and performed digital subtraction angiography but found the VADA had spontaneously occluded. We performed coil embolization, including the aneurysm and the parent artery, with reference to the findings of three-dimensional computed tomography. On Day 16, recurrence was considered due to the finding of dilation of the distal end where the coil was embolized. An additional embolization was performed via the posterior communicating artery. No cases of endovascular treatment have been reported in VADA cases in which the rupture site is spontaneously occluded. In such cases, the treatment may be incomplete, so strict follow-up is required.

Staged Hybrid Techniques With Straightforward Bypass Surgery Followed by Flow Diverter Deployment for Complex Recurrent Middle Cerebral Artery Aneurysms

Background

Recurrent complex middle cerebral artery (MCA) aneurysms after combined clipping and endovascular surgery are challenging, and if conventional techniques are adapted, advanced surgical, endovascular, and a combination of both techniques are often required. For such complex aneurysms, safe and effective straightforward techniques for all neurovascular surgeons are warranted. We describe the details of staged hybrid techniques with straightforward bypass surgery followed by flow diverter deployment in a patient with complex MCA aneurysm.

Illustrative Case

A 69-year-old woman presented with left recurrent large MCA aneurysm enlargement 25 years after direct surgery and coil embolization for ruptured aneurysm. The recurrent MCA aneurysm had large and complex morphology and was adhering to the brain tissues. Therefore, it was unsuitable to treat such aneurysm with conventional surgical and endovascular techniques with a high risk of morbidity. We performed (1) M2 ligation following superficial temporal artery-M2 bypass and (2) flow diverter deployment assisted with coil packing in two sessions. Three months after the second session, the aneurysm was completely occluded with endothelialization of the neck. Angiographic findings revealed no recurrence 12 months after the treatment.

Conclusions

Staged hybrid techniques with straightforward bypass surgery followed by flow diverter deployment may be a safe and effective treatment for complex recurrent MCA aneurysms.

Efficacy of the Flow Re-direction Endoluminal Device for cerebral aneurysms and causes of failed deployment

Purpose

The Flow Re-direction Endoluminal Device (FRED) has recently become available for flow diversion in Japan. We have encountered cases that failed to deploy the FRED. In this study, we report our initial experience with the FRED for cerebral aneurysms and clarify the causes of failed FRED deployment.

Methods

A retrospective data analysis was performed to identify patients treated with the FRED between June 2020 and March 2021. Follow-up digital subtraction angiography was performed at 3 and 6 months and assessed using the O’Kelly-Marotta (OKM) grading scale.

Results

Thirty-nine aneurysms in 36 patients (average age: 54.4 years) were treated with the FRED. The average sizes of the dome and neck were 9.9 mm and 5.2 mm, respectively. In nine patients, additional coiling was performed. In one patient (2.6%), proximal vessel injury caused direct carotid-cavernous fistula during deployment. Ischaemic complications were encountered in one patient (2.6%) with transient symptoms. Angiographic follow-up at 6 months revealed OKM grade C or D in 86.6% of patients. FRED deployment was successful in 35 (92.1%) procedures. In the failure group, the differences between the FRED and the minimum vessel diameter (P = 0.04) and the rate of the parent vessel having an S-shaped curve (P = 0.04) were greater than those in the success group.

Conclusions

Flow diversion using the FRED is effective and safe for treating cerebral aneurysms. The use of the FRED for patients with an S-shaped curve in the parent vessel and oversizing of more than 2 mm should be considered carefully.

Combination of flow reversal and distal filter for cerebral protection during carotid artery stenting

BACKGROUND

Carotid artery stenting (CAS) with distal filter protection allows continuous cerebral perfusion, although it is associated with a greater risk of cerebral ischemic complications than other protection systems. To reduce cerebral ischemic complications, CAS was performed under combined cerebral protection using both flow reversal (FR) and a distal filter.

METHODS

Fifty-six stenoses of 52 patients were treated with CAS using the combined protection of FR and a distal filter, with intermittent occlusion of both the common carotid artery (CCA) and the external carotid artery. The blood flow was reversed into the guiding catheter to the central venous system via an external filter, which collected the debris. Clinical outcomes, the rates of capturing visible debris, and new ischemic signals on diffusion-weighted magnetic resonance imaging (DWI-MRI) were evaluated.

RESULTS

The overall technical success rate was 92.9% (52/56). Successful stent deployment was achieved in 100% (56/56) of the cases. No procedural-related emboli causing a neurologic deficit were observed. In 38.5% (20/52) of the cases, visible debris were captured by only the external filter, and in 17.3% (9/52), visible debris were captured by both external and distal filters. In no case was visible debris noted in only the distal filter. New ischemic signals on DWI-MRI were detected in 9.6% (5/52). The 30-day myocardial infarction, stroke, and death rates were 0%.

CONCLUSIONS

The additional use of a distal filter captures emboli in 17.3% of cases, and because the occlusion is only intermittent, the procedure is potentially applicable even in those who cannot tolerate prolonged balloon occlusion of the CCA.

Initial experience with an extremely soft bare platinum coil, ED coil-10 Extra Soft, for endovascular treatment of cerebral aneurysms

BACKGROUND AND PURPOSE

The ED coil-10 Extra Soft (EDC-10 ES) is an extremely soft coil with excellent operability for embolization of cerebral aneurysms and is frequently used as a 'finishing coil'. The aim of this study was to evaluate the efficacy and safety of this coil.

METHODS

Clinical data were analyzed retrospectively for 92 consecutive aneurysms for which at least one EDC-10 ES was used. Follow-up angiography at 6 months was available for 69 aneurysms. Initial and follow-up outcomes were evaluated using three-category occlusion grading. Factors that affect the packing density were also investigated.

RESULTS

Of the 92 aneurysms, 63 (68.5%) were classified as complete occlusion, 11 (12.0%) as having a neck remnant and 18 (19.6%) with dome filling immediately after the embolization procedure. The mean ± SD packing density was 29.5 ± 10.6%. Periprocedural complications were observed in three cases (3.3%). At 6 months the rate of completely occluded cases increased to 78.3% (54/69) and those for neck remnant and dome filling decreased to 11.8% (8/69) and 10.1% (7/69), respectively. Recanalization occurred in six aneurysms and one aneurysm was retreated during the follow-up period, giving an overall recurrence rate of 10.0% (7/70). Linear regression analysis showed a significant association of packing density with the percentage EDC-10 ES volume (p<0.001) and with the maximum aneurysm size (p<0.001).

CONCLUSIONS

Use of the EDC-10 ES permits safe and effective embolization of a cerebral aneurysm and contributes to a reduction in the rate of recanalization.

Quantitative analysis of mast cells in benign and malignant colonic lesions: immunohistochemical study on formalin-fixed, paraffin-embedded tissues

BACKGROUND

Comparison of the number of mast cells in the active stage and that in remission in the same patients with ulcerative colitis with immunohistochemical staining remains to be elucidated, and analysis of the number of mast cells in benign and malignant colonic lesions is insufficient.

METHODS

Using immunohistochemical methods, morphological examinations of mast cells were undertaken in colonic tissues from 8 patients with ulcerative colitis and 10 patients with colonic primary cancer, which were formalin-fixed and paraffin-embedded. Changes in the number of mast cells in the active stage and in remission in the same patients with ulcerative colitis were investigated. Then, the number of mast cells in malignant tissues and adjacent healthy tissues obtained from the same patients with colonic primary cancer were compared, and finally the number of mast cells was compared among the samples from benign and malignant colonic lesions.

RESULTS

Accumulation of mast cells was found to be significant in the active stage of ulcerative colitis compared with remission in the same patients. The number of mast cells in colonic primary cancer was significantly increased compared with that in adjacent healthy tissues. The number of mast cells in ulcerative colitis was significantly greater than that in adjacent healthy tissues from patients with colonic primary cancer, irrespective of the stages of ulcerative colitis.

CONCLUSIONS

We were the first to analyse mast cells in the active stage and in remission in the same patients with ulcerative colitis using immunohisto-chemical methods, and compared the number of mast cells between benign and malignant colonic lesions.

Gastric emptying for liquids and solids after distal gastrectomy with Billroth-I reconstruction

BACKGROUND/AIMS

Although distal gastrectomy followed by Billroth-I reconstruction has been a standard surgical procedure for over 100 years, gastric emptying of liquid and solids after this procedure remains poorly understood, despite its contribution to postgastrectomy complications such as dumping syndrome and reflux esophagitis. A simple way to standardize measurement and generate normal values is needed. This study proposed a new, accurate and easy method, "dual phase method", for gastric emptying after distal gastrectomy.

METHODOLOGY

Liquid- and solid-phase gastric emptying were measured using a combined test consisting of acetaminophen and sulfamethizole capsule ingestion, respectively. Data from 12 patients (B-I group) who had undergone distal gastrectomy with D2 lymph node dissection and truncal vagotomy followed by Billroth-I reconstruction were compared with those from 14 healthy volunteers (control group).

RESULTS

A two-factor repeated measures ANOVA (analysis of variance) demonstrated a highly significant difference in the sequential changes in the serum acetaminophen concentration after ingestion between the two groups (p<0.0001). On the other hand, the sequential changes in the serum sulfamethizole concentration after ingestion was similar in the two groups (p=0.91).

CONCLUSIONS

Gastric emptying of liquids is rapid after distal gastrectomy followed by Billroth-I reconstruction. However, emptying of solids is unchanged. The data obtained in this study can be a point of reference for comparing gastric emptying following gastrectomy.

Antitumor effects of vaccination with dendritic cells transfected with modified receptor for hyaluronan-mediated motility mRNA in a mouse glioma model

OBJECT

The receptor for hyaluronan-mediated motility (RHAMM) is frequently overexpressed in brain tumors and was recently identified as an immunogenic antigen by using serological screening of cDNA expression libraries. In this study, which was conducted using a mouse glioma model, the authors tested the hypothesis that vaccination with dendritic cells transfected with RHAMM mRNA induces strong immunological antitumor effects.

METHODS

The authors constructed a plasmid for transduction of the mRNAs transcribed in vitro into dendritic cells, which were then used to transport the intracellular protein RHAMM efficiently into major histocompatibility complex class II compartments by adding a late endosomal-lysosomal sorting signal to the RHAMM gene. The dendritic cells transfected with this RHAMM mRNA were injected intraperitoneally into the mouse glioma model 3 and 10 days after tumor cell implantation. The antitumor effects of the vaccine were estimated by the survival rate, histological analysis, and immunohistochemical findings for immune cells. Mice in the group treated by vaccination therapy with dendritic cells transfected with RHAMM mRNA survived significantly longer than those in the control groups. Immunohistochemical analysis revealed that greater numbers of T lymphocytes containing T cells activated by CD4+, CD8+, and CD25+ were found in the group vaccinated with dendritic cells transfected with RHAMM mRNA.

CONCLUSIONS

These results demonstrate the therapeutic potential of vaccination with dendritic cells transfected with RHAMM mRNA for the treatment of malignant glioma.

[MALT-type lymphoma of lacrimal gland: case report]

A 72-year-old female presented with a lump in the left superior-lateral eyelid. The magnetic resonance imaging showed a well-delineated mass in the left lacrimal gland. The tumor was isointense on both the T1 and T2 weighted images, and it was homogenously enhanced with Gd-DTPA. Surgery via the trans-cranial approach revealed a pinkish and elastic-hard tumor. Total resection was successfully performed. The hematoxilyn-eosin staining of the surgical specimen showed a dense infiltrate of lymphocytes, which were composed predominantly of small lymphocytes, centrocyte-like cells, monocytoid cells, and occasionally transformed lymphocytes. The immunohistochemical findings for CD20, CD3, UCHL-1, CD23, CD5, cyclinD1, and bcl-2 were compatible with Mucosa Associated Lymphoid Tissue (MALT)-type lymphoma. The patient received local radiation therapy (30 Gy/15 fractions). She remained in complete clinical remission of the disease about one and a half years after treatment.

Accumulation of mast cells in the interstitium of eosinophilic colitis

INTRODUCTION

The mechanism of eosinophilic colitis remains unclear, and no case has been reported in which the number of mast cells was examined.

CASE REPORT

A 35-year-old man presented to our hospital with chief complaints of chills and consistent watery diarrhea after eating raw fresh-water fish. In blood examination, peripheral blood eosinophilia was found. Histological examination from biopsy specimens of both the ascending colon and rectum showed a prominent eosinophilic infiltration in the intestinal mucosa. Although a provocation test could not be performed due to lack of informed consent, a diagnosis of eosinophilic colitis was made on the basis of other findings. Immunohistochemical staining for human mast cell tryptase using monoclonal antibody against human mast cell tryptase showed an accumulation of mast cells in the colonic interstitium.

CONCLUSIONS

We report a case of eosinophilic colitis in which an accumulation of mast cells in the colonic interstitium was demonstrated.

Surgery for spontaneous intracerebral hemorrhage has greater remedial value than conservative therapy

BACKGROUND

The aim of this study was to compare the efficacy of surgery for spontaneous intracerebral hemorrhage with that of medical treatment, based on data from the Japan Stroke Registry Study.

METHODS

From 1999 to 2001, 1010 patients with spontaneous intracerebral hemorrhage were registered in the Japan Standard Stroke Registry Study from 45 stroke center hospitals in Japan. The National Institutes of Health Stroke Scale (NIHSS), Japan Stroke Scale (JSS), and modified Rankin Scale scores were used to compare severity and improvement in patients given surgical and medical treatment.

CONCLUSIONS

Surgically treated patients, especially those with cerebellar hemorrhage, had significantly greater improvement in NIHSS or JSS score compared with medically treated patients. Our findings indicated that the patients who underwent surgery appeared to have better outcomes. But, because the study was not randomized, this observation cannot be interpreted as indicating that surgery is advantageous.

Improvement of functional outcome after radical surgery in glioblastoma patients: the efficacy of a navigation-guided fence-post procedure and neurophysiological monitoring

This retrospective study investigated the functional outcomes of patient with glioblastoma receiving radical surgery before and after the adoption of the navigation-guided fence-post (NGFP) procedure and neurophysiological monitoring. We investigated 42 glioblastoma patients receiving radical surgery in our institute between 1980 and 2005. Of the 42 patients, 18 patients from 1980 to 1996 (1st term) underwent radical surgery without navigation system guidance, NGFP, or neurophysiological monitoring; 11 patients from 1997 to 2002 (2nd term) underwent surgery with simple navigation system guidance but without NGFP procedure or neurophysiological monitoring, and 13 patients from 2003 to 2005 (3rd term) underwent surgery with the NGFP procedure and neurophysiological monitoring as appropriate. There were no significance differences between any of the three term groups in age, gender, preoperative KPS score, or 'surgical staging for glioma' according to the difficulty of surgery. The rates of 95% or greater volume reduction in each term were 38.9%, 54.5% and 76.9%. The rates of morbidity were 38.9%, 18.1% and 0%. The change in KPS scores (delta KPS) before and after the perioperative period in each term were -16.1 +/- 6.6 SEM, -9.0 +/- 5.8 SEM and +8.5 +/- 3.7 SEM, respectively. The delta KPS in the 3rd term was significantly better than those of 1st and 2nd terms (P < 0.01, Kruskal-Wallis rank test). The rate of patients who were discharged to home and who resumed daily useful life without assistance was 38.9%, 63.6% and 84.6% in each term, respectively. The mean survival times in each term were 9.9, 14.0 and 16.8 months. The introduction of the NGFP procedure and neurophysiological monitoring in glioblastoma radical surgery improved the functional outcome of patients.

Acute pancreatitis possibly caused by allergy to bananas

We are reporting a forty-seven year old female who had three attacks of acute pancreatitis after having; eaten bananas. She was treated with a light diet and intravenous fluids during each of her admissions. The treatment concluded with the disappearance of clinical symptoms such as epigastralgia, nausea, vomiting and diarrhea within a few days. In addition, elevated serum and urine amylase levels returned to normal values in parallel with the clinical symptoms. The data during her three attacks of acute pancreatitis were as follows: serum total IgE level = 644 IU/mL, specific IgE to bananas = 2.18 UA/ml. No remarkable abnormalities were present in sonography, computed tomography, magnetic resonance imaging of the abdomen, and magnetic resonance cholangiopancreatography. Endoscopic examination of the upper digestive tract showed the ampulla of Vater swollen and edematous, thus a biopsy was performed. Toluidine blue staining and immunohistochemical staining against human mast cell tryptase with the biopsy specimens showed mast cells accumulating in mucosa and submucosa. By avoiding consumption of bananas, she has not suffered from any additional attacks of pancreatitis since the third attack in the last thirty-four months up to this day of December 10, 2004.

Vaccine Therapy for Murine Glioma Using Tumor Cells Genetically Modified to Express B7.1

OBJECTIVE

In a syngeneic mouse brain tumor model, we tested the hypothesis that vaccination with tumor cells genetically modified to express B7.1 molecules induces tumor-specific T cells and immunological antitumor effects.

METHODS

Malignant glioma cells (RSV-MG) derived from a C3H/He mouse induced by Schmidt-Ruppin Rous sarcoma virus (RSV) were infected with an adenovirus encoding the B7.1 gene (AdB7). To investigate the effects of B7.1 expression on the tumorigenicity of RSV-MG cells, infected cells were implanted subcutaneously into C3H/He mice. The C3H/He mice were vaccinated with AdB7 transfectants injected subcutaneously and 2 weeks later were challenged intracerebrally with wild-type RSV-MG cells to determine whether or not the expression of B7.1 would enhance the immunogenicity of RSV-MG cells.

RESULTS

Immunocytochemistry confirmed the expression of B7.1 and major histocompatibility complex Class I antigen on the infected cells. The growth of subcutaneous tumors was markedly retarded in the AdB7 group, whereas tumors had formed and progressively increased in size in the other control groups. In the vaccine experiments, the mice immunized with AdB7 transfectants survived longer than did the mice of the other groups, and a significant difference in survival times was noted. Immunocytochemistry revealed that brain tumors in mice previously vaccinated with AdB7 infectants had been infiltrated by a larger number of CD3(+) lymphocytes and that these CD3(+) lymphocytes contained not only CD4(+) and CD8(+) T cells but also CD25(+)-activated T cells. In addition, a cytotoxicity assay confirmed that vaccination with the AdB7 transfectants induced tumor-specific cytotoxicity.

CONCLUSION

These results demonstrate the therapeutic potential of vaccination with tumor cells expressing B7.1 for the treatment of malignant glioma.

Adenovirus-mediated gene transfer of B7.1 induces immunological anti-tumor effects in a murine brain tumor

The purpose of the present study was to determine if adenovirus-mediated transfection of a syngeneic mouse brain tumor with the gene encoding B7.1 enhances immunogenicity against tumor. Malignant astrocytoma cells were transfected with adenoviral vectors carrying the B7.1 gene (AdB7). Immunocytochemical analysis confirmed the expression of B7.1 in vitro and in vivo. To investigate the effects of B7.1 expression on tumorigenicity of the malignant astrocytoma, mice were implanted intracerebrally with B7.1-transfected glioma cells. There was no significant difference in proliferation between B7.1-transfected cells and controls in vitro. Nevertheless, mice implanted with B7. 1-transfected cells survived significantly longer than those in the control groups. Immunocytochemical analysis of the tumors showed that there was infiltration of a number of CD8+ T-cells and CD25+ activated T-cells in the brain implanted with B7.1-transfected glioma cells. The results showed the possibility that adenovirus-mediated B7.1 gene transfection to a brain tumor induced activation of CD8+ cytotoxic T-lymphocytes.

Functional magnetic resonance imaging-controlled neuronavigator-guided brain surgery: a case report

The effectiveness of functional magnetic resonance imaging (f-MRI)-controlled and navigator-guided brain surgery for a patient with a recurrent astrocytoma is demonstrated. Preoperative f-MRI was performed in order to identify the motor area and ensure that the tumour was in the left prefrontal area. A more aggressive operation was planned for the recurrent tumour. The f-MRI data were input to the MKM navigation system and during the operation the contours of the tumour and motor area were visualised b y the microscope of the navigation system. The tumour and surrounding gliotic brain tissue were removed completely. The diagnosis was a grade III astrocytoma. The combination of the navigation system and f-MRI was useful for preoperative design of the surgical strategy, and tumour orientation during the operation, enabling aggressive surgery to be performed without functional deficits ensuing.

Co-administration of adenovirus vector expressing CTLA4-Ig prolongs transgene expression in the brain of mice sensitized with adenovirus

The duration of transgene expression in the brain is known to be shortened by previous sensitization to adenovirus. In order to prolong transgene expression, adenovirus vectors expressing CTLA4-Ig (AdCTLA), which blocks the B7-CD28 co-stimulatory signals required for T-cell activation, were used. Local administration of AdCTLA into the brain suppressed both the cellular and humoral immune responses to adenovirus vectors, and prolonged the duration of transgene expression. AdCTLA may be an effective tool for repeated gene transfer.

[Effects of topical prostaglandin analogues on the aqueous flare intensity in rabbit eyes at an early phase of endotoxin-induced uveitis]

PURPOSE

We examined the effects of prostaglandin analogues on the blood-aqueous barrier(BAB) permeability in rabbit eyes at an early phase of endotoxin-induced uveitis(EIU).

SUBJECTS AND METHODS

One drop of 0.005% latanoprost or 0.12% unoprostone were applied to rabbit eyes. Escherichia coli lipopolysaccharides were injected to induce uveitis. The changes in flare intensity in normal eyes and EIU eyes after application of eye drops were evaluated. The effect of cyclooxygenase inhibitor on the flare intensity changes caused by the application of unoprostone was also examined.

RESULTS

Flare intensity increased significantly after a single instillation of unoprostone, and the increase was not prevented by pretreatment with cyclooxygenase inhibitor. In eyes with EIU, unoprostone caused an additional increase of flare intensity to uveitis induced flare change. Latanoprost had no effects on BAB in eyes with normal and with uveitic conditions.

CONCLUSION

Latanoprost and unoprostone did not cause an excessive inflammatory reaction in rabbit eyes at an early phase of EIU.

Development of a novel enzyme-linked immunosorbent assay for blood and urinary eosinophil-derived neurotoxin: a preliminary study in patients with bronchial asthma

BACKGROUND

Eosinophil-derived neurotoxin (EDN), also called eosinophil protein X (EPX), has been suggested to be a useful marker of eosinophilic inflammation. However, no commercial enzyme-linked immunosorbent assay (ELISA) kit for EDN is available yet.

METHODS

EDN was purified from pooled urine from healthy male volunteers. Polyclonal and monoclonal anti-EDN antibodies were subsequently raised, and a sandwich ELISA for EDN was established. EDN levels in serum, plasma and urine from asymptomatic patients with bronchial asthma were measured by the ELISA method. Some of the blood samples were also measured by a commercial radioimmunoassay (RIA) kit.

RESULTS

The ELISA method detected human EDN with a minimum detection limit of less than 0.62 ng/ml and did not cross-react with other eosinophil granule cationic proteins including eosinophil cationic protein. The intra- and interassay coefficients of variation of the ELISA method ranged from 2.6 to 3.6% and from 6.5 to 9.4%, respectively. Good linearity was observed with serially diluted different samples, and the recoveries of the purified EDN added to serum samples ranged from 85 to 110%. Median EDN concentrations in serum (36.9 vs. 19.1 ng/ml), plasma (23.0 vs. 14.5 ng/ml) and urine (118.2 vs. 72.1 microg/mmol Cr) were significantly raised in asymptomatic asthmatic patients compared with healthy control subjects. EDN levels in serum, plasma and urine from the patients significantly correlated with the number of peripheral blood eosinophils, but not total serum IgE levels. A significant relationship between EDN values measured by the EPX-RIA kit and the EDN-ELISA method was observed.

CONCLUSIONS

We have developed a novel efficient ELISA method to specifically measure blood and urinary EDN, which may be useful to study the role of eosinophils in allergic diseases including bronchial asthma.

Case report: intrahepatic portal-hepatic venous shunts associated with a huge pelvic leiomyoma

We present a case of portal-systemic encephalopathy due to intrahepatic multiple portal-hepatic venous shunts. A 71-year-old woman was admitted to our hospital because of recurrent episodes of disturbed consciousness. She showed no clinical signs of portal hypertension. Liver function was normal, except for an indocyanine green retention rate of 34% at 15 min and blood ammonia level of 282 microg/dL. Portal venography revealed dilatation of the portal vein and multiple portal-hepatic venous shunts, and a liver biopsy specimen revealed almost normal liver. Further clinical examination revealed a huge pelvic tumour. At laparotomy, two dilated veins were seen to arise from the pelvic tumour with blood flow into the mesentery. The tumour was resected successfully and a histological diagnosis of leiomyoma was made. The blood ammonia concentration decreased to the normal range postoperatively. A follow-up portal venogram demonstrated decreased portal vein dilatation and minor portal-hepatic venous shunts, considered to be congenital in origin. It is concluded that hepatic encephalopathy was produced in this patient due to an excess portal blood flow from the huge pelvic leiomyoma via the mesentery, with portosystemic shunting through pre-existent (probably congenital) intrahepatic anastomoses.