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.

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.

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.

Salivary Alpha-Amylase Activity and Mild Cognitive Impairment among Japanese Older Adults: The Toon Health Study

BACKGROUND

There is growing interest in examining objective markers for early identification and behavioral intervention to prevent dementia and mild cognitive impairment in clinical and community settings.

OBJECTIVE

To investigate the association between salivary alpha-amylase as an objective measure of psychological stress response and mild cognitive impairment for the implication of psychological stress in the development of mild cognitive impairment.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study involved 865 participants aged ≥ 65 years. A saliva sample was collected in the morning, and the levels of salivary alpha-amylase were assayed. Mild cognitive impairment was evaluated using the Japanese version of the Montreal Cognitive Assessment; a score < 26 was indicative of mild cognitive impairment. A multivariable logistic regression model was used to examine the association of salivary alpha-amylase and mild cognitive impairment after adjusting for age, sex, current drinking status, current smoking status, body mass index, hypertension, diabetes mellitus, physical activity, education, social support, social network, and heart rate variability.

RESULTS

Salivary alpha-amylase was associated with mild cognitive impairment (the multivariable-adjusted odds ratio [95% confidence interval] for the 1-standard deviation increment of log-transformed salivary alpha-amylase was 1.24 [1.07-1.44]). This significant association persisted after adjusting for various confounding factors.

CONCLUSION

Elevation of salivary alpha-amylase was associated with mild cognitive impairment among Japanese community-dwelling older adults. This suggests that salivary alpha-amylase is a useful objective marker of psychological stress responses associated with mild cognitive impairment.

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.

Reduction of thromboembolic complications during the endovascular treatment of unruptured aneurysms by employing a tailored dual antiplatelet regimen using aspirin and prasugrel

Background

Thromboembolic complications (TECs) are frequent during the endovascular treatment of unruptured aneurysms. To prevent TECs, dual antiplatelet therapy using aspirin and clopidogrel is recommended for the perioperative period. In patients with a poor response, clopidogrel is a risk factor for TECs. To prevent TECs, our study assessed the stratified use of prasugrel.

Methods

Patients who underwent endovascular therapy for unruptured cerebral aneurysms from April 2017 to August 2019 were enrolled in this clinical study and given premedication with aspirin and clopidogrel for 2 weeks prior to the procedure. P2Y12 reaction units (PRU) were measured using the VerifyNow assay on the day before the procedure (tailored group). In subgroups with PRU <240, the clopidogrel dose was maintained (CPG subgroup). In subgroups with PRU ≥240, clopidogrel was changed to prasugrel (PSG subgroup). We compared the occurrence of TECs with retrospective consecutive cases from January 2015 to March 2017 without PRU assessments (non-tailored group). The frequency of TECs within 30 days was assessed as the primary endpoint.

Results

The tailored and non-tailored groups comprised 167 and 50 patients, respectively. TECs occurred in 11 (6.6%) and 8 (16%) patients in the tailored and non-tailored groups (P=0.048), respectively. The HR for TECs was significantly reduced in the tailored group (HR 0.3, 95% CI 0.11 to 0.81); P=0.017) compared with the non-tailored group.

Conclusion

The results suggest that tailored dual antiplatelet therapy medication with PRU significantly reduces the frequency of TECs without increasing hemorrhagic complications.

Experimental Analysis of Intra-luminal Pressure by Contrast Injection during Mechanical Thrombectomy: Simulation of Rupture Risk of Hidden Cerebral Aneurysm in Tandem Occlusion with Blind Alley

Mechanical thrombectomy using a retrograde approach is performed for tandem occlusion of the internal carotid artery (ICA). In our patient, a guiding catheter was easily passed by the stenosed lesion despite severe stenosis at the ICA origin. Therefore, we aimed to recanalize the occlusion of the terminal ICA without angioplasty for the stenosed lesion. When contrast was injected, a massive extravasation of contrast from the C2 portion of the ICA was observed. It was speculated that the bleeding was caused by rupture of an aneurysm at that site due to increased intra-arterial pressure caused by the contrast injection to a blind alley, which was created by a wedged guiding catheter at severe stenosis at the ICA origin and the occlusion of the terminal ICA. Our simulation experiment using a silicon vascular model in this situation demonstrated that the elevation of intra-arterial pressure in such blind alley reached over 50, 100, and 200 mmHg by injection of contrast from a microcatheter, a 4-Fr inner catheter, and a 9-Fr balloon-guiding catheter, respectively. When a retrograde approach is planned for tandem occlusion of the ICA, even when the proximal lesion is easily passed, prior angioplasty for the proximal lesion should be considered to avoid wedging by catheter.

Variations in the gonadal artery with a single common trunk: embryological hypotheses by observation

BACKGROUND

A gonadal artery originates as a branch of the abdominal aorta and renal artery inferior to the level of origin of the renal arteries. Variations in multiple right testicular arteries (RTAs) arising from the abdominal aorta are common. We aimed to re-evaluate the unusual courses of gonadal arteries with a single common trunk in relation to the inferior vena cava and left renal vein and explain the developmental anatomy.

MATERIALS AND METHODS

The observational cross-sectional study was performed on 54 Japanese adult cadavers (29 men and 25 women). We examined the literature and developed embryological hypotheses on the single common trunk of the gonadal artery.

RESULTS

The gonadal artery, testicular artery, and ovarian artery arose from the abdominal aorta in 93.1%, 96.3%, and 89.6% of cases, respectively, and from the renal artery in 4.9%, 3.7%, and 6.3% of cases, respectively. We found two rare variations in the RTAs observed during the routine dissection of two male cadavers; in these two cases, a single common trunk of the RTAs originated from the abdominal aorta. A single common trunk was found in 3.7% of cadavers, 2.0% of sides, and 2.0% of arteries in the gonadal artery and in 6.9% of cadavers, 3.8% of sides, and 3.7% of arteries in the testicular artery. All cases of the single common trunk, including those in past reports, were observed only in men.

CONCLUSIONS

Knowledge of the variations in RTAs has important clinical consequences for invasive and non-invasive arterial procedures. In addition, this variation provides a new interpretation of the embryology of the gonadal artery. Variations similar to our findings have not been previously reported. Therefore, different variations concerning the RTA should be considered during surgical and non-surgical evaluations.

Abstract TP583: Consideration on Surgical Treatment of Arteriovenous Fistula at the Craniocervical Junction

Objective: Management of arteriovenous fistula at the craniocervical junction (CCJ-AVF) is challenging, because CCJ-AVF is quite rare, most cases are difficult to treat by the endovascular treatment only, and difficult to understand its complicated anatomy preoperatively. The aim of this presentation is to propose several tips and pitfalls regarding the surgical strategy for CCJ-AVF, particularly focused on anatomical relationships with shunting point and key structures.

Methods: We experienced 9 cases of CCJ-AVF during about 4 years since April 2015. These patients presented by as follows, 3 subarachnoid hemorrhage, 2 hematomyelia, 1 cerebellar hemorrhage, and 3 incindentally. We performed surgical ligation for 8 cases and endovascular treatment for 2 cases, including combined therapy for one case in each. Direct surgery was usually performed as follows: general anesthesia, park-bench position, transcondylar fossa approach and C1 laminectomy, cut the dentate ligament with MEP/SEP and NIM monitoring and ICG video angiography repeatedly.

Results: Postoperative DSA showed a complete cure in every case. One case treated by surgical ligation had a transient neurological deficit, while another case treated by endovascular treatment showed deterioration of preoperative motor dysfunction.

Conclusions: For CCJ-AVFs, we prefer direct surgical ligation, because this lesion has a dangerous anastomoses between radiculo-meningeal and pial supply which cannot be detect preoperatively. Our approach can provide a suitable operative field to ensure understanding of its complicated structure. In our series, the patients who underwent surgical ligation had a good result except one patient with transient neurological deficit caused by postoperative excessive venous thrombosis of the drainer which required temporary anticoagulation.

[A Case of Bone Marrow Metastasis of Oligodendroglioma with IDH Mutation and 1p/19q Codeletion]

A 71-year-old woman was transferred to our hospital, complaining of a seizure for the first time. A tumor was detected in the right frontal lobe, and a craniotomy was performed with a partial tumor resection. The pathological diagnosis was oligodendroglioma with IDH mutation and 1p/19q codeletion, and irradiation therapy was performed. Six months later, the patient's lactate dehydrogenase(LDH)level elevated remarkably, and the fluoro-deoxyglucose-positron emission tomography/computed tomography showed abnormal uptake in multiple bone marrow locations. Bone marrow aspiration was performed, and the pathological diagnosis was oligodendroglioma metastasis. The patient was given two cycles of chemotherapy with temozolomide(TMZ), and her LDH level reduced to normal. After a few months, the LDH level elevated again, so we gave her two more cycles of TMZ;however, her LDH level did not change. Thereafter, the patient was hospitalized because of paraplegia, which started a few days prior, and right lower jaw swelling. Her CT and magnetic resonance imaging showed metastasis to the thoracic vertebrae and right mandibular bone. Irradiation therapy was performed to these locations, and the patient was given chemotherapy using nimustine(ACNU), procarbazine, and vincristine(PAV). Her LDH levels reduced temporarily, but elevated again. The patient deteriorated slowly and died 20 months after she presented with a seizure. Oligodendroglioma with extracranial metastasis is extremely rare, and this case report is the 68th report. The chemotherapy approach with TMZ or PAV/PCV may be effective against oligodendroglioma metastasis to the bone marrow.

[A Ruptured Middle Cerebral Artery Dissecting Aneurysm Operation in a 2-Year-Old Boy]

We report the case of a ruptured dissecting aneurysm in an infant. A 2-year-old boy suffered sudden headache and nausea. CT scan revealed a subarachnoid hemorrhage, and digital subtraction angiography(DSA)revealed a dissecting aneurysm(3.9mm)at a branch of the right middle cerebral artery(MCA). Eight days after onset, carotid angiography revealed enlargement of the aneurysm(up to 6.8 mm). Right frontotemporal craniotomy and aneurysm trapping with STA-MCA bypass was performed. Two years and two months later, the aneurysm recurred as assessed by magnetic resonance angiography(MRA). DSA revealed the recurrence of the aneurysm(7.8mm)proximal to the previous aneurysm and displayed development of collateral flow through leptomeningeal anastomosis between the branches of the MCA. During the second operation, the aneurysm extended to the artery branch proximal to the previous trapping. Parent artery occlusion without bypass was performed. Postoperative DSA revealed collateral flows through leptomeningeal anastomosis between the branch of the MCA and the branch of anterior cerebral artery. At the 3-year follow-up period, abnormal findings on MRI did not appear and he was healthy without any neurologic abnormalities.

Common and separate origins of the left and right inferior phrenic artery with a review of the literature

In a 94-year-old male cadaver, upon which routine dissection was being conducted, a rare variation was found in the gastrophrenic trunk (GPT), the common trunk of the left gastric artery (LGA), right inferior phrenic artery (RIPA), and left inferior phrenic artery (LIPA); the GPT arises from the abdominal aorta. A hepatosplenic trunk accompanied the variation. In this variation, the RIPA first branched from the GPT and then to the LIPA and LGA. Variations in the common trunk of the LIPA and RIPA in the GPT are common, but to our knowledge, a variation (separate inferior phrenic artery in the GPT) similar to our findings has not been previously reported. We discuss the incidence and developmental and clinical significance of this variation with a detailed review of the literature. Knowledge of such a case has important clinical significance for invasive and non-invasive arterial procedures. Therefore, different variations concerning the LGA and inferior phrenic artery should be considered during surgical and non-surgical evaluations.

Randomized phase III study of bevacizumab plus FOLFIRI and bevacizumab plus mFOLFOX6 as first-line treatment for patients with metastatic colorectal cancer (WJOG4407G)

BACKGROUND

FOLFIRI and FOLFOX have shown equivalent efficacy for metastatic colorectal cancer (mCRC), but their comparative effectiveness is unknown when combined with bevacizumab.

PATIENTS AND METHODS

WJOG4407G was a randomized, open-label, phase III trial conducted in Japan. Patients with previously untreated mCRC were randomized 1:1 to receive either FOLFIRI plus bevacizumab (FOLFIRI + Bev) or mFOLFOX6 plus bevacizumab (mFOLFOX6 + Bev), stratified by institution, adjuvant chemotherapy, and liver-limited disease. The primary end point was non-inferiority of FOLFIRI + Bev to mFOLFOX6 + Bev in progression-free survival (PFS), with an expected hazard ratio (HR) of 0.9 and non-inferiority margin of 1.25 (power 0.85, one-sided α-error 0.025). The secondary end points were response rate (RR), overall survival (OS), safety, and quality of life (QoL) during 18 months. This trial is registered to the University Hospital Medical Information Network, number UMIN000001396.

RESULTS

Among 402 patients enrolled from September 2008 to January 2012, 395 patients were eligible for efficacy analysis. The median PFS for FOLFIRI + Bev (n = 197) and mFOLFOX6 + Bev (n = 198) were 12.1 and 10.7 months, respectively [HR, 0.905; 95% confidence interval (CI) 0.723-1.133; P = 0.003 for non-inferiority]. The median OS for FOLFIRI + Bev and mFOLFOX6 + Bev were 31.4 and 30.1 months, respectively (HR, 0.990; 95% CI 0.785-1.249). The best overall RRs were 64% for FOLFIRI + Bev and 62% for mFOLFOX6 + Bev. The common grade 3 or higher adverse events were leukopenia (11% in FOLFIRI + Bev/5% in mFOLFOX6 + Bev), neutropenia (46%/35%), diarrhea (9%/5%), febrile neutropenia (5%/2%), peripheral neuropathy (0%/22%), and venous thromboembolism (6%/2%). The QoL assessed by FACT-C (TOI-PFC) and FACT/GOG-Ntx was favorable for FOLFIRI + Bev during 18 months.

CONCLUSION

FOLFIRI plus bevacizumab was non-inferior for PFS, compared with mFOLFOX6 plus bevacizumab, as the first-line systemic treatment for mCRC.

CLINICAL TRIALS NUMBER

UMIN000001396.

A Comparison of Objective Physical Activity, Muscle Strength, and Depression among Community-dwelling Older Women Living in Sloped Versus Non-sloped Environments

OBJECTIVE

To examine the relationship between the living location and outcomes of physical activity level and physical and psychological functioning in older women. The specific aim was to understand the association between living in a sloped versus non-sloped environment and these outcomes.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

108 older women aged 65 years or older who resided in Nagasaki prefecture participated.

MEASUREMENTS

Physical activity, lung function, muscle strength (hand grip and quadriceps force) and depressive symptoms were assessed objectively.

RESULTS

In logistic regression, activity counts per day (OR 0.779, 95%CI 0.715-0.841, p<0.01), activity times per day (OR 0.821, 95%CI 0.801-0.913, p<0.01), hand grip force (OR 0.666, 95%CI 0.558-0.796, p<0.001), and depressed (Center for Epidemiological Studies Depression Scale score ≥16) (OR 1.093, 95%CI 1.019-1.427, p<0.05) showed statistically significant inverse associations with living in a sloped ground.

CONCLUSIONS

Since dwelling on sloped ground was associated with negative (lower physical activity levels, lower grip strength, and more depression) outcomes, a comprehensive geriatric assessment, related to all aspects of older women, is recommended. Planning of home exercise programs for the elderly should take such environmental factors into consideration.

Endovascular treatment of intractable bleeding from a traumatic pseudoaneurysm of the internal maxillary artery

Traumatic pseudoaneurysms of the internal maxillary artery (IMA) are rare and difficult to treat. A 58-year-old man with a traumatic pseudoaneurysm of the IMA presented with intractable nasal and oral hemorrhage during dual antiplatelet therapy. Transcatheter artery embolization with N-butyl cyanoacrylate (NBCA) completely occluded the pseudoaneurysm. Transcatheter artery embolization with NBCA is a feasible and effective treatment because of its shorter treatment time and lower incidence of recurrence.

Phasic synaptic incorporation of GluR2-lacking AMPA receptors at gonadotropin-releasing hormone neurons is involved in the generation of the luteinizing hormone surge in female rats

Reproductive success depends on a robust and appropriately timed preovulatory luteinizing hormone (LH) surge, which is induced by the activation of gonadotropin-releasing hormone (GnRH) neurons in response to positive feedback from increasing estrogen levels. Here we document an increase in postsynaptic GluR2-lacking Ca2+ -permeable AMPA-type glutamate receptors (CP-AMPARs) at synapses on GnRH neurons on the day of proestrus in rats, coincident with the increase in estrogen levels. Functional blockade of CP-AMPARs depressed the synaptic responses only on the day of proestrus and concomitantly attenuated the LH surge. Thus, the phasic synaptic incorporation of postsynaptic CP-AMPARs on GnRH neurons is involved in the generation of the LH surge.

"Brush Sign" on susceptibility-weighted MR imaging indicates the severity of moyamoya disease

BACKGROUND AND PURPOSE

SWI is a high spatial resolution MR imaging technique showing magnetic inhomogeneity that could demonstrate increased oxygen extraction in focal cerebral ischemia. The aim of this study was to investigate the characteristics in the signal intensity of DMVs by using SWI and to determine whether this method could indicate the severity of the hemodynamics in MMD by evaluating the correlation between SWI stage and hemodynamics on SPECT.

MATERIALS AND METHODS

Consecutive MMD patients were prospectively analyzed before treatment. Routine MR imaging including SWI was performed, and the number of the conspicuous DMVs draining into the subependymal veins was classified: stage 1, mild (< 5); stage 2, moderate (5-10); and stage 3, severe (> 10). The SWI stage was evaluated in correlation with clinical presentations, and CBF and CVR were quantified by using a SPECT iodine 123 N-isopropyl-p-iodoamphetamine split-dose method.

RESULTS

Patients were 12 males and 21 females (range, 8-66 years), consisting of 4 asymptomatic patients, 13 patients with TIA, 9 patients with infarct, and 7 patients with hemorrhage. There was a significant difference in CVR among clinical presentations, though there was no difference in age, Suzuki stage, or CBF. Conversely, SWI stage was significantly higher in patients with TIA and infarct than asymptomatic patients (P < .01). Higher SWI stage significantly had lower CBF and CVR in the middle cerebral artery area (P < .05).

CONCLUSIONS

SWI stage strongly correlates with ischemic presentations in MMD and also correlates with hemodynamics on SPECT, especially CVR. Increased conspicuity of DMVs, known as "brush sign", could predict the severity of MMD.

Characterization of microbial consortia that reductively dechlorinate 4-chlorophenol and transform phenol to benzoate enriched from estuarine sediment of Lake Shinji

Monochlorophenols were degraded to benzoate via phenol by the initial dechlorination and the subsequent conversion of phenol to benzoate in anaerobic sediment samples of estuarine Lake Shinji under methanogenic conditions. To characterize bacteria that dechlorinate 4-chlorophenol and transform phenol to benzoate, we analyzed the microbial community structure of the enrichment culture with each 4-chlorophenol and phenol by the limiting dilution method with polymerase chain reaction-denaturing gradient gel electrophoresis (PCR-DGGE) of 16S rRNA gene. After serial dilution of the culture, the 4-chlorophenol-dechlorinating culture consisted of two dominant bacteria, one of which was most homologous with Dehalobacter sp. In the enriched culture with phenol, minor band homologous with Cryptanaerobacter phenolicass corresponded to the transformation activity.

An 8-month-old boy with congenital fibromuscular dysplasia presenting with shock caused by sudden renal hemorrhage

Fibromuscular dysplasia (FMD) is a non-atheromatous, non-inflammatory, multifocal segmental angiopathy. FMD is the most common cause of pediatric renovascular hypertension. Aneurysmal formation of the main renal artery and distal branches is a rare complication of FMD in infancy. We report an 8-month-old boy with FMD presenting with shock caused by sudden renal hemorrhage that necessitated removal of one kidney. A diagnosis of renovascular hypertension resulting from intimal type FMD with aneurysmal formation was made on the basis of the presence of hypertension, elevation of PRA and aldosterone activity, pathological findings and the results of renal angiography. Our findings suggest that it is therefore necessary to consider FMD with aneurysmal formation as a possible cause of hypertension and renal hemorrhage in infants.

Effects of herbicides on Lemna gibba and recovery from damage after prolonged exposure

To determine the potential impact of contaminants on the aquatic vascular plants Lemna sp., toxicity tests are usually conducted for a 4- to 14-day exposure, and the toxicity is usually expressed as EC50. However, the effects of longer exposure and the recovery potential after exposure to chemicals are other important factors which should be considered. We present the relative risks of a variety of exposure scenarios and recovery potentials from damage, using herbicides with different modes of action. Toxicity was assessed on the basis of both EC50 and relative growth rate (RGR) compared with untreated controls in exposure and recovery. The EC50 of atrazine was found to be 89 ppb, and its phytostatic concentrations were 1600 and 800 ppb for exposure periods of 14 and 28 days, respectively, and no phytocidal effects were observed up to 3200 ppb for a 28-day exposure. The RGR in recovery was not affected by the RGR in exposure, and regrowth was possible even after complete inhibition of growth for 28 days at the highest concentration tested. Alachlor, with an EC50 of 31 ppb, was phytostatic at 400 ppb for a 14-day exposure and phytocidal at 200 ppb for 21- and 28-day exposures. Paraquat, with an EC50 of 31 ppb, showed phytocidal rather than phytostatic effects. All phytostatic fronds could not grow in the recovery period, and the phytocidal concentration decreased with exposure period, from 80 ppb for a 7-day exposure to 20 ppb for 21- and 28-day exposures. The RGR of alachlor and paraquat in recovery was dependent on the RGR in exposure. In the case of cyclosulfamuron, phytostatic concentrations were 100 and 50 ppb for 7- and 14-day exposures, respectively. In the case of exposures longer than 21 days, however, it exhibited phytocidal activity at 10 ppb. The results of this study suggest that it is important to examine the effects of chemicals over a longer exposure period as well as the recovery potential from damage for reliable ecological risk assessment.

Efficacy of DynaCT digital angiography in the detection of the fistulous point of dural arteriovenous fistulas

BACKGROUND AND PURPOSE

Identifying the precise hemodynamic features, including the fistulous point, is essential for treatments of dural arteriovenous fistulas (DAVFs). This study illustrates the efficacy of DynaCT digital angiograms obtained from a 3D C-arm CT to directly visualize the location of the fistulous points in DAVFs.

MATERIALS AND METHODS

This retrospective study observed 14 consecutive patients with DAVFs, which included 7 cavernous sinuses, 4 transverse-sigmoid sinuses, 2 convexity-superior sagittal sinuses, and 1 tentorial sinus. In the assessment of the practical applicability for the diagnosis of DAVFs, images obtained from 2D digital subtraction angiography (DSA) and DynaCT were comparatively evaluated.

RESULTS

In all patients, DynaCT digital angiography could clearly demonstrate the feeding arteries, the fistulous points, and the draining veins. Significant anatomic landmarks for the fistulous points with relationships to osseous structures were also provided. Compared with 2D DSA, DynaCT digital angiograms demonstrated 12 additional findings in 8 patients (57%), including the detection of the fistulous points (n = 7), the feeders (n = 1), the retrograde leptomeningeal drainage (n = 1), the draining veins (n = 1), and the venous anomaly (n = 2).

CONCLUSIONS

In comparison with 2D DSA, DynaCT may provide more detailed information to evaluate DAVFs. DynaCT digital angiograms have a high contrast and isotropic spatial resolution, allowing a reliable visualization of small vessels and fine osseous structures. Such detailed information, especially for the location of the fistulous points, could be very useful for either the endovascular or the surgical treatments of DAVFs.

Surgical treatment of unruptured cerebral aneurysms in the elderly

We retrospectively analyzed the prevalence and surgical outcomes of unruptured cerebral aneurysms in the elderly for the past five years. Between 1998 and 2002, we collected data from 575 subjects with unruptured aneurysms who had no history of subarachnoid hemorrhage (SAH). One hundred and eighty-two of these patients (31.7%) were aged > or = 70 years and they had 233 aneurysms. The proportion of older patients among all subjects increased significantly from 21.4% in 1998 to 40.3% in 2002. Unruptured aneurysms found in the elderly had a predominance of female, higher frequency of multiple aneurysms, and lower frequency of anterior communicating artery aneurysms when compared with those in the younger patients. The majority of intradural aneurysms detected in the elderly were less than 10 mm in diameter (84.8%). One hundred and eleven out of 224 intradural aneurysms in the elderly were treated (49.6%); most aneurysms were directly clipped, while only 13 aneurysms including six basilar artery aneurysms were coiled endovascularly. Among the 83 elderly subjects who underwent direct surgery, perioperative complication appeared in seven subjects (morbidity 8.4%, mortality 1.2%). No SAH occurred postoperatively and conservatively during 1-5 years of follow-up. Since the rupture rate of small unruptured aneurysms without SAH history is reported to be low, surgical indication should be considered with care particularly in the elderly.

Impact of biochemical failure on long-term clinical outcome after radical prostatectomy for prostate cancer in Japan

Detailed information is needed to understand the impact of biochemical failure (bF) on long-term outcome after definitive therapy for prostate cancer. In all, 223 consecutive men treated with radical retropubic prostatectomy were followed and long-term clinical outcome was investigated. Pathological examination revealed more locally advanced tumors in this study compared with the typical cohorts seen in the Western series. The Cox proportional hazards model indicates pretreatment prostate-specific antigen levels and risk group stratification to be a significant predictors for bF (P<0.05), but not for overall survival. Seminal vesicle involvement was a significant predictor of systemic progression, cancer death and overall survival (P<0.05). Positive surgical margin and bF were also found to be independent predictors of overall survival (P<0.05). In contrast to reports from Western countries, this study found a significant correlation between bF after radical prostatectomy and overall survival. This may reflect years-later detection of prostate cancer in Japan compared with Western series. Biochemical failure may ultimately be translated into decreased overall survival after sufficient follow-up.

Changes in prostate-specific antigen and hormone levels following withdrawal of prolonged androgen ablation for prostate cancer

We conducted a study in order to characterize changes after withdrawal of androgen ablation (AA) for prostate cancer. AA was withdrawn in 38 Japanese patients with prostate cancer who had undergone this therapy for various periods. Patients were stratified into those who had undergone AA for less than 24 months (Group 1, n=12) and those with longer periods of AA (Group 2, n=26). Serial changes in hormones and prostate-specific antigen (PSA) were prospectively monitored following cessation of AA. The median durations of AA in the two groups were 8.5 and 54.5 months, respectively. Levels of total testosterone (T), luteinizing hormone and PSA increased significantly with time. At the end of 2 y, 30/38 patients (78.9%) had T levels above 50 ng/dl and 19/38 (50%) had levels above 320 ng/dl. Patients in Group 2 required significantly longer duration for T recovery. Complete T recovery is not always accompanied by rising PSA. Recovery of T levels is often slow following cessation of prolonged AA. Expression of PSA after AA is often variable and unpredictable. Thus, interpretation of outcomes in clinical trials incorporating AA needs caution and careful consideration.

Probability of prostate cancer at various levels of per cent free prostate specific antigen in Japanese men with total PSA of 4.1-10.0 ng/ml

Estimates for the likelihood of prostate cancer at different levels of per cent free prostate specific antigen (PSA) were derived from experience with consecutive Japanese male patients with intermediate total PSA values who underwent ultrasound-guided biopsies and/or transurethral resection of the prostate. Receiver operating characteristic (ROC) curve analysis showed that in patients with a total PSA of 4.1-10.0 ng/ml, per cent free PSA identified those with prostate cancer better than did total PSA; per cent free PSA also proved superior in the subgroup whose glands appeared benign on palpation. The probabilities of prostate cancer at per cent free PSA values of <or=10.0, >10-15, >15-20, >20-26 and >26% were 58.3, 40.8, 25.3, 14.3 and 7.6%, respectively, when analyzed without regard to findings on palpation. In patients with palpably benign glands, the corresponding values were 55.3, 35.4, 19.6, 9.7, and 4.6%, respectively. These probabilities are lower than those reported in Western countries, probably reflecting both different patterns of practice and racial differences. Race-specific assessment is recommended before applying a clinical test.

Abnormal response to sodium channel blockers in patients with Brugada syndrome: augmented localised wall motion abnormalities in the right ventricular outflow tract region detected by electron beam computed tomography

OBJECTIVE

To investigate the relation between the wall motion abnormalities and sodium channel abnormalities in cases of the Brugada syndrome.

DESIGN

Consecutive prospective case-control study in a single hospital.

SETTING

Tertiary referral centre.

PATIENTS

13 consecutive patients with Brugada syndrome and 13 age and sex matched control subjects.

INTERVENTIONS

Each subject underwent electron beam computed tomography (EBT) and a 12 lead ECG before and after disopyramide injection.

MAIN OUTCOME MEASURES

QRS width and the magnitude of ST segment elevation in the 12 lead ECG; wall motion by EBT.

RESULTS

After disopyramide, EBT revealed deterioration of focal wall motion abnormalities in the right ventricular outflow tract region in eight of the 13 patients (62%). Prolongation of the QRS width after disopyramide injection in lead V2, which usually reflects the electrical activity in right ventricular outflow tract region, was greater in these eight patients (p < 0.01) than in the other five patients, in whom wall motion did not change after disopyramide. The degree of augmentation of ST segment elevation did not differ significantly between the two groups

CONCLUSIONS

The deterioration of wall motion abnormalities in the right ventricular outflow tract region after disopyramide suggests the presence of functional abnormalities of the sodium channel. Some patients with Brugada syndrome may have arrhythmogenic substrates with abnormal responses to sodium channel blockers.

Gene-specific response of dynamic ventricular repolarization to sympathetic stimulation in LQT1, LQT2 and LQT3 forms of congenital long QT syndrome

AIMS

Differences in the sensitivity of the genotype of the congenital long QT syndrome to sympathetic stimulation have been suggested. This study compared the influence of sympathetic stimulation on continuous corrected QT (QTc) intervals between LQT1, LQT2 and LQT3 forms of the congenital long QT syndrome.

METHODS AND RESULTS

We recorded a 12-lead electrocardiogram continuously before and after bolus injection (0.1 microg x kg(-1)) of epinephrine followed by continuous infusion (0.1 microg x kg(-1) min(-1)) in 12 LQT1, 10 LQT2, 6 LQT3, and 13 control patients. The QT intervals and previous RR intervals of all beats were measured semi-automatically, and the QTc intervals of all beats were calculated by Bazett's method. The dynamic response of the RR interval to epinephrine was no different between the four groups. The QTc was prolonged remarkably (477+/-42 to 631+/- 59 ms; P<0.0005, % delta prolongation =+32%) as the RR was maximally decreased (at peak of epinephrine), and remained prolonged at steady state conditions of epinephrine (556+/-56 ms; P<0.0005 vs baseline, +17%) in LQT1 patients. Epinephrine also prolonged the QTc dramatically (502+/-23 to 620+/-39 ms; P<0.0005, +24%) at peak of epinephrine in LQT2 patients, but this shortened to baseline levels at steady state (531+/-25 ms; P=ns vs baseline, +6%). The QTc was much less prolonged at peak of epinephrine in LQT3 (478+/-44 to 532+/-41 ms; P<0.05, +11%) and controls (394+/-21 to 456+/-18 ms; P<0.0005, +16%) than in LQT1 and LQT2 patients, and shortened to the baseline levels (LQT3; 466+/-49 ms, -3%, controls; 397+/-16 ms, +1%; P=ns vs baseline) at steady state.

CONCLUSION

Our data suggest that the dynamic response of ventricular repolarization to sympathetic stimulation differs between LQT1, LQT2 and LQT3 syndromes, and may explain why the trigger of cardiac events differs between the genotypes.

High-performance liquid chromatographic quantification of allysine as bis-p-cresol derivative in elastin

The first step in normal cross-linking in elastin is the formation of alpha-aminoadipic-delta-semialdehyde, allysine, through oxidative deamination of specific peptidyl lysine by the enzyme lysyl oxidase (EC 1.4.3.13). For the analysis of allysine, allysine was derivatized with p-cresol. The derivatization was carried out by acid hydrolysis (6N HCl containing 5% (w/v) p-cresol at 110 degrees C for 48 h) accompanied with the hydrolysis of elastin. A bis-p-cresol derivative of allysine was isolated from bovine ligamentum nuchae elastin hydrolysates, and was characterized by UV, FAB-MS and NMR. This derivative was identified as 2-amino-6,6-bis(2-hydroxy-5-methylphenyl)hexanoic acid. A rapid, sensitive reverse-phase high-performance liquid chromatographic method with UV detection was developed for the quantitative determination of allysine as its bis-p-cresol derivative. The lower limit of detection of the bis-p-cresol derivative was 58 pmol in the standard sample with a 20-microl injection at a signal-to-noise ratio of 3. This method was applied to the determination of allysine in bovine ligamentum nuchae, aorta, lung, and rat aorta elastin. The allysine content in rat aorta elastin dramatically increased from 1 week to 2 weeks of age.

Acute effects of different atrial pacing sites in patients with atrial fibrillation: comparison of single site and biatrial pacing

It has been reported that a trial single site or biatrial pacing can suppress the occurrence of AF. However, its mechanism remains unclear. The study population included 32 patients with AF (n = 20: AF group), or without paroxysmal AF (n = 12: control group). The mechanism and efficacy of atrial pacing were investigated by electrophysiological studies to determine which was more effective for suppressing AF induction; single site pacing of the right atrial appendage (RAA) or distal coronary sinus (CS-d), or biatrial (simultaneous BAA and CS-d) pacing. In the AF group, AF inducibility was significantly higher with BAA extrastimulus during RAA (12/20; P < 0.0001) or biatrial paced drive (7/20; P < 0.01) than during CS-d paced drive (0/20). In the control group, AF was not induced at any site paced. In the AF group, the conduction delay and other parameters of atrial vulnerability significantly improved during CS-d paced drive. The atrial recovery time (ART) at RAA and CS-d was measured during each basic pacing mode. ART was defined as the sum of the activation time and refractory period, and the difference between ARTs at RAA and CS-d was calculated as the ART difference (ARTD). The ARTD was significantly longer during BAA pacing in the AF group than in control group (155.0 +/- 32.8 vs 128.8 +/- 32.9 ms, P < 0.05). In the AFgroup, ARTDs during biatrial (52.0 +/- 24.2 ms) and CS-d pacing (51.7 +/- 26.0 ms) were significantly shorter than ARTD during RAA pacing. The CS-d paced drive was more effective for suppressing AF induction than biatrial or RAA paced drive by alleviating conduction delay. CS-d and biatrial pacing significantly reduced ARTD compared with RAA pacing.

Asymptomatic brain tumor detected at brain check-up

Brain check-up was performed in 4000 healthy subjects who underwent medical and radiological examinations for possible brain diseases in our hospital from April 1996 to March 2000. Magnetic resonance imaging revealed 11 brain tumors which consisted of six meningiomas, three pituitary adenomas, one astrocytoma, and one epidermoid cyst. The detection rate of incidental brain tumor in our hospital was 0.3%. Nine patients underwent surgery, with one case of morbidity due to postoperative transient oculomotor nerve paresis. The widespread use of brain check-up may increasingly detect asymptomatic brain tumors. Surgical indications for such lesions remain unclear, and the strategy for treatment should be determined with consideration of the patient's wishes.

Coagulation process proceeds on cultured human mesangial cells via expression of factor V

BACKGROUND

In a previous clinicopathological study, we observed mesangial factor V expression accompanied by the intact form of cross-linked fibrin deposition in the active type of IgA nephropathy. The conversion of prothrombin to thrombin by factor Xa is potently accelerated more than 104-fold by the presence of factor V, which is a membrane-bound cofactor. Another membrane-bound cofactor, tissue factor, is known to play an initiating role in the coagulation cascade and to be synthesized in mesangial cells (MCs) by the stimulation of tumor necrosis factor-alpha (TNF-alpha). However, the synthesis of factor V, which plays on the terminating stage of prothrombin activation, has not been reported previously in MCs by in vitro study. Our current study tested the coagulation process via expression of factor V by the stimulation of proinflammatory cytokine, TNF-alpha, in cultured human MCs.

METHODS

To evaluate factor V protein expression, immunoperoxidase staining with densitometric evaluation and Western blot analysis were conducted after stimulation of TNF-alpha. To test factor V activity, stimulated MCs were incubated in combination with factor Xa, prothrombin, fibrinogen and factor XIII, and fibrin production on MCs was assessed after immunoperoxidase staining on the cell surface. In a blocking test using an antibody against factor V, suppression of fibrin production was evaluated to clarify the role of factor V activity. For the evaluation of factor V mRNA expression in cultured human MCs, in situ hybridization and Northern blot analysis were performed.

RESULTS

Factor V protein expression in MCs after TNF-alpha stimulation increased both time- and dose-dependently. As a marker of factor V activity with exogenous factor Xa, fibrin production on TNF-alpha-stimulated MCs was increased in a time-dependent manner and was inhibited by the addition of anti-factor V antibody. Factor V mRNA was identified in MCs by in situ hybridization and showed an increase after stimulation with TNF-alpha on Northern blot analysis.

CONCLUSIONS

Our data suggest that the coagulation process proceeds on MCs as the result of increased expression of endogenous factor V activity on its cell surface in cooperation with exogenous factor Xa.

[A case of gastrointestinal stromal tumor of rectum, difficult to differentiate from leiomyosarcoma of prostate]

A 70 year-old male was seen at the hospital with the chief complaints of frequent miction and incomplete urinary retention. A hen's egg-sized firm mass was palpable in anterior wall of rectum by digital rectal examination. Intravenous urography showed severe bilateral hydronephroureter. Transrectal ultrasound, CT scan and MRI revealed a mass with 5 cm in diameter between prostate and rectum, and the margin of them were unclear. On needle biopsy of the tumor, leiomyosarcoma of the prostate was suspected. We performed radical cytectomy and created continent urinary reserver. Because the tumor and rectum could not be lysed, part of the rectum was resected. Histological examination showed gastrointestinal stromal tumor (GIST) of rectum. GIST of rectum is a rare entity, and in case of contact with the prostate, it is difficult to differentiate from leiomyosarcoma of prostate.

Up-regulated TGF-beta mRNA expression in splenic T cells of high IgA-prone mice: a murine model of IgA nephropathy with glomerulosclerosis

BACKGROUND/AIMS

Recently, we established a high serum IgA-prone inbred (HIGA) mouse strain as a murine model of spontaneous IgA nephropathy by selective mating of high serum IgA ddY mice, and found that they showed enhanced production of glomerular extracellular matrix components with increased expression of TGF-beta mRNA and protein in the kidneys. In this study, we examined the roles of lymphocytes in the development of high serum IgA in this strain.

METHODS

We performed flow cytometric analyses of T and B cells in splenic mononuclear cells (SMNCs) from these mice using BALB/c mice as normal controls. We also compared serum TGF-beta1 concentrations and TGF-beta mRNA expression levels in the B-cell-depleted (T-cell-rich) fraction of SMNCs in these mice.

RESULTS

HIGA mice showed significantly fewer CD3-positive cells compared with BALB/c mice when young, but not when aged. The CD4/CD8 ratio of HIGA mice was lower than that of BALB/c mice, but this difference was not significant. Although the number of B220-positive cells did not vary significantly, the ratio of surface IgA-positive B cells was significantly increased in both young and adult HIGA mice. The B-cell-depleted SMNCs from HIGA mice exhibited higher levels of expression of TGF-beta and TGF-beta1 mRNA than controls from a young age, which were maintained throughout life, but there were no differences in PDGF, MCP-1 or bFGF expression between these two strains. In contrast to local mRNA expression, serum TGF-beta1 concentration was decreased in HIGA mice compared with BALB/c controls.

CONCLUSION

These findings suggest that the mating procedure performed to establish HIGA mice selected for a unique phenotype of local up-regulation of TGF-beta production in the kidneys, as well as T cells that may contribute to both the early and consistently high serum IgA expression and enhanced production of renal extracellular matrix components in HIGA mice. Additionally, TGF-beta1 may act locally, not systemically, in a paracrine or autocrine manner.