S2 Alar Screw Insertion Accuracy and Factors Associated With Screw Loosening and Lumbosacral Nonunion

OBJECTIVE

To investigate S2 alar screw (S2AS) accuracy and factors associated with S2AS loosening and lumbosacral nonunion.

METHODS

We retrospectively reviewed patients who underwent lumbosacral fusion surgery with S2AS addition under fluoroscopy. S2AS loosening and lumbosacral nonunion were analyzed using a 1-year postoperative computed tomography. S2AS insertion accuracy was originally classified as accurate, short, anterior perforation, lateral perforation, and sacroiliac joint (SIJ) deviation among lateral perforation. Clinical data including sex, age, body mass index, fused segments, fusion procedure, primary or revision surgery, Japanese Orthopedic Association scores and complications were collected. Factors associated with S2AS loosening and lumbosacral nonunion were analyzed.

RESULTS

A total of 37 patients (74 screws, age: 63.78 ± 13.57 years, female/male: 14/23 patients, body mass index: 23.11 ± 2.53, fused segments: 1-4 levels, revision: 38%) were included. S2AS loosening and lumbosacral nonunion were observed in 18 screws (13%) and 8 patients (22%) respectively. Only 35 screws (47%) were inserted accurately in our classification. Short, lateral perforation, and anterior perforation were observed in 14 screws (19%), 22 screws (30%), and 3 screws (4.1%). SIJ deviation was seen in 15 screws (20%) Factors associated with S2AS loosening were older age (P = 0.038), fusion levels (P = 0.011), and SIJ deviation (P < 0.001). S2AS loosening affects S1 pedicle screw (S1PS) loosening (P = 0.001). Furthermore, S2AS loosening is a risk factor for lumbosacral nonunion (P = 0.046).

CONCLUSIONS

S2AS insertion under fluoroscopy is inaccurate. S2AS loosening induces S1PS loosening and lumbosacral nonunion. Surgeons should avoid deviating to SIJ, especially in older patients and relatively longer fusion.

Feasibility of total and partial uncinectomy during anterior cervical approach: MRI-based analysis of 176 patients regarding vertebral artery location

PURPOSE

To determine the technical feasibility of uncinate process (UP) resection (uncinectomy) during anterior cervical approach with risk-avoidance of vertebral artery (VA) injury.

METHODS

One hundred and seventy-six magnetic resonance imaging images with cervical spondylosis were evaluated. The diameter between UP and VA (UP-VA distance), the presence of a fat plane, and the VA's anterior-posterior position relative to UP (anterior[A], middle[M], posterior[P]) at C3-4 to C6-7 segments were investigated. Subsequently, easy-to-use classifications were developed according to the feasibility of total and partial uncinectomy. Total uncinectomy: easy (distance: > 2 mm); moderate (distance: ≤ 2 and fat plane: +); advanced (no fat plane). Partial uncinectomy: easy (distance: > 2 mm and P, A, or M position); moderate (distance: ≤ 2; fat plane: + and P position), and advanced (no fat plane and P position).

RESULTS

UP-VA distance of C5-6 on the right side (left/right: 0.41/0.31 mm) was the smallest. The ratio of no fat plane of C5-6 (46.6%/49.4%) was the highest. C5-6 had a high rate of P position (7.4%/8.5%) while C6-7 had a high rate of A position (19.3%/18.2%). More than 90% individuals were classified as easy for partial uncinectomy at any vertebral segment (C3-7), while more than 30% were classified as advanced at C4-7 with the highest rate at C5-6 for total uncinectomy.

CONCLUSION

When performing uncinectomy during the anterior cervical approach, the C5-6 segment may be at the greatest risk of VA injury. Hence, preoperative MR images should be thoroughly evaluated to avoid VA injury.

CT-based analysis of sagittal and coronal lumbar endplate morphology: multivariate analysis of factors associated with endplate depth

PURPOSE

Lumbar endplate morphology varies in individuals; thus, custom-made implants are sometimes more useful than standardized implants. This study aimed to analyze endplate morphology and factors associated with endplate depth using computed tomography (CT) in a non-symptomatic population.

METHODS

In total, 118 lumbar CT images of non-symptomatic individuals without severe degenerative change (aged 20-79 years) were retrospectively reviewed. The following radiographic parameters were measured in each lumbar vertebral segment (T12-S1) to determine endplate depth: superior/inferior endplate depth in the midsagittal and midcoronal planes, disk angle, and height. The relationship between baseline demographics (age, sex, body mass index [BMI], Hounsfield unit of the L1 vertebral body, and pelvic incidence [PI]) and endplate depth was analyzed.

RESULTS

Toward the caudal level, the superior endplate depth increased, sagittal inferior depth decreased, and coronal inferior depth increased. Multivariate analysis revealed that endplate depth was significantly associated with age (p < 0.001), while inferior endplate depth was associated with PI (p = 0.01). Superior endplate depth was associated with female sex (sagittal: p = 0.005, coronal: p = 0.002). Endplate depth, except for the inferior coronal region, was associated with low BMI (sagittal superior: p = 0.005; coronal superior and sagittal inferior: p = 0.02).

CONCLUSION

Endplate depths tend to be larger toward the caudal level, particularly in the superior endplate. Surgeons should thoroughly evaluate the preoperative CT image because various endplate morphologies require attention to cage shape when performing lumbar interbody fusion, especially in patients who are older, are female, have low BMI, and have large PI.

LEVEL OF EVIDENCE I

Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Non-invasive early prediction of immune checkpoint inhibitor efficacy in non-small-cell lung cancer patients using on-treatment serum CRP and NLR

PURPOSE

We determined the clinical relevance of early C-reactive protein (CRP) and neutrophil-lymphocyte ratio (NLR) change in blood as surrogate markers of pro-tumor inflammation (PTI) for predicting clinical outcome of programmed cell death (PD)-1/programmed cell death ligand (PD-L) 1 inhibitor treatment in non-small-cell lung carcinoma (NSCLC).

METHODS

We retrospectively reviewed NSCLC patients treated with anti-PD-1 or PD-L1 inhibitors. Early CRP change was defined as the ratio of 6 weeks CRP to baseline CRP, and early NLR change was defined as that of the 6 weeks NLR to baseline NLR. PTI index was determined by combinatorial evaluation of early CRP change and early NLR change, PTI index low: both of these were low, intermediate: either of these was low, high; both of these were high.

RESULTS

The study included 217 patients. Early CRP change and early NLR change were both associated with PFS and OS. The combinatorial evaluation using these two markers enabled the clear stratification of PFS and OS. The median PFS in patient with PTI index low was 13.9 months, while the median PFS in those with PTI index high was 2.5 months (p < 0.01, log-rank test). The median OS in patients with PTI index low was not reached; the median OS in those with PTI index high was only 15.4 months (p < 0.01, log-rank test).

CONCLUSIONS

The combinatorial early CRP change and early NLR change as PTI biomarkers have clinical potential in identifying NSCLC patients who can achieve a durable response and long-term survival using PD-1/PD-L1 inhibitors.

Non‐invasive transcriptomic analysis using mRNAs in skin surface lipids obtained from children with mild‐to‐moderate atopic dermatitis

Background

Specimens for analysing the molecular pathology of skin disease are generally obtained through invasive methods, such as biopsy. However, less burdensome methods are desirable for paediatric patients. We recently established a method that comprehensively analyses RNA present in sebum (skin surface lipid–RNAs: SSL‐RNAs) using a next‐generation sequencer. Using this method, biological information can be obtained from the skin in a completely non‐invasive manner.

Objectives

To verify the applicability of the SSL‐RNA method for analysis of paediatric skin and analyse the molecular pathology of mild‐to‐moderate atopic dermatitis (AD) in children.

Methods

We collected sebum specimens from the whole faces of 23 healthy children and 16 children with mild‐to‐moderate AD (eczema area and severity index (EASI) score: 5.9 ± 2.6) ranging in age from 6 months to 5 years, using an oil‐blotting film. We then extracted SSL‐RNAs from the samples and performed an AmpliSeq transcriptomic analysis.

Results

The expressions of genes related to keratinization (LCE, PSORS1C2, IVL and KRT17), triglyceride synthesis and storage (PLIN2, DGAT2 and CIDEA), wax synthesis (FAR2), ceramide synthesis (GBA2, SMPD3 and SPTLC3), antimicrobial peptides (DEFB1) and intercellular adhesion (CDSN), all of which are related to the skin barrier, are lower in children with AD than in healthy children. The children with AD also have higher expression of CCL17, a Th2‐cytokine and an increased Th2‐immune response as demonstrated by a gene set variation analysis. Moreover, KRT17 and CCL17 expression levels are significantly correlated with the EASI score.

Conclusions

Molecular changes associated with abnormal immune responses and the epidermal barrier in children with mild‐to‐moderate AD can be determined using the SSL‐RNA method. This non‐invasive method could therefore be a useful means for understanding the molecular pathology of paediatric AD.

Lateral Interbody Fusion for Hyperlordosis and Negative Sagittal Vertical Axis Because of Accordion Phenomenon: A Case Report

CASE

The accordion phenomenon is defined as the difference in the disc space observed on x-ray or computed tomography images taken in both standing and supine positions, which results in a discrepancy of local spinal alignment. Oblique lateral interbody fusion (OLIF) is a less invasive method of potentially correcting both coronal and sagittal spinal alignment. We present the case of a 66-year-old woman with rheumatoid arthritis treated with OLIF for degenerative disc disease presenting with hyperlordosis and negative sagittal vertical axis (SVA) because of the accordion phenomenon.

CONCLUSION

OLIF for severe degenerative disc disease presenting with hyperlordosis and negative SVA because of the accordion phenomenon may be effective.

Tibial Tubercle-Trochlear Groove Distance Influences Patellar Tilt After Total Knee Arthroplasty

BACKGROUND

Tibial tubercle-trochlear groove (TT-TG) distance is associated with a greater risk of recurrent patellar dislocation in young, active patients. However, the effect of TT-TG distance after total knee arthroplasty (TKA) has not been investigated. The purpose is to analyze the effect of TT-TG distance and component rotation on patellar tilt and patellar shift after TKA.

METHODS

After TKA, axial computed tomography scans and axial radiograph were taken in 115 consecutive knees. TT-TG distance was measured between the most anterior point of the tibial tuberosity and the deepest point of the femoral component relative to a line connecting the anterior condyles. Femoral and tibial component rotation was measured relative to the femoral and tibial rotational axis, respectively. Pearson correlation coefficients were calculated.

RESULTS

TT-TG distance had a significant correlation with patellar tilt in extension (R = 0.220, P = .018), patellar tilt in flexion (R = 0.438, P < .001), and patellar shift (R = 0.330, P < .001). Tibial component rotation had a significant correlation with patellar tilt in flexion (R = -0.251, P = .007) and patellar shift (R = -0.360, P < .001). Femoral component rotation had no significant correlations. Tibial component rotation had a significant correlation with TT-TG distance (R = -0.573, P < .001), whereas femoral component rotation had no correlation (P = .192).

CONCLUSION

TT-TG distance had a significant correlation with patellar tilt and patellar shift. Surgeons need to understand the factors affecting TT-TG distance and to pay attention to avoiding excessive TT-TG distance after TKA.

An Experience of Stereotactic Radiation Therapy for Primary Intracranial Choriocarcinoma

We report on a patient with choriocarcinoma in the pineal region who was successfully treated with stereotactic radiation therapy (SRT). The increased level of serum human chorionic gonadotropin (HCG) was lowered during chemotherapy with etoposide, cisplatin, and ifosfamide. However, HCG was not normalized and magnetic resonance images still showed an enhanced tumor mass with gadolinium. The patient underwent SRT of 40 Gy at an 80% isodose line per 10 fractions over'two weeks, followed by conventional craniospinal irradiation of 32.4 Gy. The level of HCG dropped below the detection limit. The patient has been in good condition for more than four years after the completion of treatment, without any signs of recurrence. We propose SRT as a valid treatment option for malignant germ cell tumors in the pineal region.

Optimization of DARTEL Settings for the Detection of Alzheimer Disease

BACKGROUND AND PURPOSE

Although Diffeomorphic Anatomical Registration Through Exponentiated Lie Algebra (DARTEL) has been introduced as an alternative to conventional voxel-based morphometry, there are scant data available regarding the optimal image-processing settings. The aim of this study was to optimize image-processing and ROI settings for the diagnosis of Alzheimer disease using DARTEL.

MATERIALS AND METHODS

Between May 2002 and August 2014, we selected 158 patients with Alzheimer disease and 198 age-matched healthy subjects; 158 healthy subjects served as the control group against the patients with Alzheimer disease, and the remaining 40 served as the healthy data base. Structural MR images were obtained in all the participants and were processed using DARTEL-based voxel-based morphometry with a variety of settings. These included modulated or nonmodulated, nonsmoothed or smoothed settings with a 4-, 8-, 12-, 16-, or 20-mm kernel size. A z score was calculated for each ROI, and univariate and multivariate logistic regression analyses were performed to determine the optimal ROI settings for each dataset. The optimal settings were defined as those demonstrating the highest χ² test statistics in the multivariate logistic regression analyses. Finally, using the optimal settings, we obtained receiver operating characteristic curves. The models were verified using 10-fold cross-validation.

RESULTS

The optimal settings were obtained using the hippocampus and precuneus as ROIs without modulation and smoothing. The average area under the curve was 0.845 (95% confidence interval, 0.788-0.902).

CONCLUSIONS

We recommend using the precuneus and hippocampus as ROIs without modulation and smoothing for DARTEL-based voxel-based morphometry as a tool for diagnosing Alzheimer disease.

Impact of screening with thyroid ultrasonography in myasthenia gravis patients

OBJECTIVES

This study was conducted to screen thyroid abnormality evaluated with ultrasonography (US) in patients with myasthenia gravis (MG) and investigate further when malignancy is suspected.

METHODS

Thyroid screening using US was conducted in 162 patients with MG. In cases where malignancy was suspected, further investigations were performed.

RESULTS

Abnormal US findings were detected in 125 of 162 patients with MG (72 patients with nodules, 74 patients with cysts, 27 patients with diffuse findings such as enlargement, atrophy, a hypoechoic pattern or a heterogenous echoic pattern, and 28 patients with calcification). From among these 125 subjects, 30 patients underwent further examinations such as needle aspiration cytology. As a result, six patients (3.7% of 162 cases) were positive for papillary carcinoma. The size of the carcinoma in three patients was <10 mm, yet the stage of thyroid carcinomas was high (stage III or IVa) in all six cases.

CONCLUSIONS

Our data suggest that the prevalence of thyroid carcinoma in cases of MG may be higher than that of the general population. Furthermore, in patients with MG, there is a possibility that the stage of the carcinoma is higher even when the carcinoma is of a very small size. Patients with MG, when diagnosed, should be advised to undergo US screening of the thyroid because most cases of thyroid carcinoma are highly curable.

[A case of pulmonary carcinosarcoma with pleural effusion, progressive pleural thickening and a calcification-like lesion]

A 70-year-old man was admitted to our hospital with dyspnea. Chest X-ray film revealed right pleural effusion. Chest CT showed right pleural effusion with slight pleural thickening and a patchy calcification-like lesion. Adenocarcinoma cells were detected in pleural effusion, but upper gastrointestinal endoscopy, barium enema examination and ultrasonography of the abdomen failed to show the primary lesion. We made a diagnosis of primary adenocarcinoma of the lung. Chemotherapy was performed after pleurodesis. However there was gradual increase of right pleural thickening and expansion of the calcification-like lesions. The patient died 16 months after his first visit. Pathological findings of the autopsy specimen revealed the tumor composed of an adenocarcinomatous component and an osteosarcomatous component. The final diagnosis was primary carcinosarcoma of the lung.

[A case of pulmonary inflammatory pseudotumor accompanied with increased serum immunoglobulin G levels and autoimmune pancreatitis]

A 77-year-old man with increased serum immunoglobulin G levels and autoimmune pancreatitis was found to have a chest X-ray abnormality. The chest X-ray and CT films showed a mass shadow in the right lower lobe and lymphadenopathy. Since transbronchial tumor biopsy did not obtain diagnostic material, CT-guided cutting needle biopsy was performed. The microscopic findings showed plasma cells and lymphocytes infiltrating the pleura and alveolar interstitium. A diagnosis of inflammatory pseudotumor was suspected, but it was difficult to exclude malignancy. Therefore, wedge resection of the right lower lobe including the mass and incisional biopsy of mediastinal lymph nodes were performed. Histopathologic examination of the resected specimen revealed inflammatory pseudotumor that was predominantly composed of mature plasma cells infiltrating in the bronchiolar wall, peribronchiolar interstitial tissue, alveolar wall, visceral pleura, the diaphragmatic area of the parietal pleura and mediastinal lymph nodes. Immunohistochemical staining revealed many IgG4-positive plasma cells diffusely infiltrated in the resected mass and lymph nodes. In this case, there is a possibility that patient developed autoimmune pancreatitis, pulmonary inflammatory pseudotumor and lymphadenopathy as part of systemic IgG4-related

Pathophysiology and diagnosis of spontaneous intracranial hypotension

BACKGROUND

Spontaneous intracranial hypotension (SIH) has become a well-recognized syndrome. However, diagnosis of SIH is still challenging. The problem with SIH is that the precise mechanism of cerebrospinal fluid (CSF) leakage remains largely unknown and there is no definite diagnostic criterion in the imaging.

METHODS

The clinical findings of our ten cases and 301 literature reports on SIH were investigated in a retrospective analysis to clarify the pathophysiology of CSF leakage, correlate the findings of imaging studies and determine the most adequate diagnostic criteria.

RESULTS

The events precede symptoms of SIH were categorized as traumatic, secondary and strictly spontaneous (62%). The location of the spinal CSF leak remains undetectable in approximately 50% of cases reported. In 93% of patients, the CSF leakage sites were detected at the cervical or thoracic level of the spine. On recent MRI studies, 88% of patients showed spinal epidural fluid collections that most likely represent CSF leakage. MR myelography using heavily T2-weighted fast-spin-echo sequence can clearly demonstrate the site of CSF leakage. Although numerous treatment options are available, none of the treatments have been evaluated by randomized clinical trials. In 48% of papers, autologous epidural blood patch (EBP) was the treatment of choice in patients who have failed initial conservative management. Forty-nine percent of patients showed relief of symptoms after up to three repeated EBPs.

CONCLUSION

We propose new diagnostic criteria of SIH to avoid misdiagnosis.

Osteopontin as biomarker in early invasion by squamous cell carcinoma in tongue

BACKGROUND

Osteopontin (OPN) expression in squamous cell carcinoma (SCC) of the tongue has not been clearly elucidated.

METHODS

We selected 46 cases of tongue SCC and investigated the expression of OPN by immunohistochemical staining. The immunopositive reaction and score for each case were semiquantitatively evaluated.

RESULTS

Scores were significantly higher in carcinoma nests than in neighboring normal epithelium or epithelial dysplasia. The OPN was expressed clearly in the cytoplasm of carcinoma cells. In cases of early invasive carcinoma, in particular, expression of OPN showed a remarkable increase at the invasion front compared with the non-invaded regions. However, there was no significant correlation between expression of OPN in the primary tumor nest and lymphatic metastasis, recurrence, or survival rate.

CONCLUSION

This suggests that OPN is a useful biomarker of early invasion by SCC in tongue.

Correlation between reduction of syndecan-1 expression and clinico-pathological parameters in squamous cell carcinoma of tongue

We examined expression of syndecan-1 in squamous cell carcinoma (SCC) of tongue using immunohistochemistry. Forty-three cases of SCC arising in lateral border of tongue were investigated. From the immunohistochemical staining pattern, the cases were divided into two groups based on expression of syndecan-1 at the supra-peripheral cells of the tumor nest: Group A, completely or mainly positive; Group B, sporadically positive or negative. Most poorly differentiated SCC cases were classified into Group B (81.8%). The number of Group B cases in T1-2 was different from that in T3-4. The number of cases where syndecan-1 expression was reduced was much greater in T3-4, and represented the majority of Group B (86.7%). More than 80% of Grade 4D cases were in Group B (83.3%) based on the Yamamoto-Kohama criteria. These results indicate that reduction of syndecan-1 correlates to histological grade, tumor size and mode of invasion in tongue SCC.

Alteration of gap junction proteins (connexins) following lateral fluid percussion injury in rats

Gap junctions are intercellular channels that mediate the cytoplasmic exchange of small hydrophilic molecules and are formed by a family of integral membrane proteins called connexins (Cxs). Cx43 is expressed predominantly in astrocytes, while Cx36 is expressed in neurons. In this study, we show alteration of Cx43 and Cx36 in the hippocampus after traumatic brain injury in rats. Adult male Sprague-Dawley rats were subjected to lateral fluid percussion injury of moderate severity. Brain coronal sections were used for immunohistochemistry with Cx43 and Cx36 antibodies. Cx43 immunoreactivity was increased in reactive astrocytes in the damaged hippocampus 24 hours after injury, and persisted for 72 hours. On the other hand, Cx36 immunoreactivity increased in CA3 neurons 1 hour after injury, and decreased later. These results indicate that gap junctions might participate in the pathophysiological process after traumatic brain injury.

[Three cases of transcatheter embolization for pulmonary arteriovenous fistula using detachable coils]

We report three cases of transcatheter embolization for pulmonary arteriovenous fistula (PAVF) using Interlocking detachable coils (IDC) and detachable fibered coils (DFC), and evaluate the outcome of transcatheter embolization with reference to previous reports. The three patients were women aged 56, 70 and 71 years. They had no symptoms, but chest radiographs were abnormal. None of them had Rendu-Osler-Weber disease. The three PAVFs were of the simple type, with a single feeding vessel and a single draining vein. In case 1, the feeding vessel arose from the left A4, while the feeding vessels in case 2 and 3 arose from the left A5. In case 1, we embolized the venous sac with detachable coils because the feeding vessel was short and kinked. In case 2 and 3, we embolized the feeding vessels closer as to the neck of the venous sac using detachable coils. The three PAVFs were all successfully embolized without severe complications, and transcatheter embolization seems to be an effective therapy.

Magnetic resonance imaging and computed tomography in the diagnoses of brain metastases of lung cancer

We evaluated the usefulness of double-dose (0.2 mmol/kg of gadoteridol) contrast-enhanced magnetic resonance imaging (C-E MRI) in detecting brain metastases of lung cancer. We prospectively enrolled 134 patients with lung cancer who had no neurologic symptoms and who underwent a staging work-up. Patients were assigned to receive both contrast-enhanced computerized tomography (C-E CT) and double-dose C-E MRI. Double-dose C-E MRI detected brain metastases in 19 patients, while C-E CT detected brain metastasis in only 12 of the 19 (P = 0.02). The 3-month survival rate for patients in double-dose C-E MRI group was found to be 2.06 times that of patients in a C-E CT group (P = 0.029), although the survival rate fell to 1.45 (P = 0.387) at 6 months. The results imply that double-dose C-E MRI changed the clinical stage of lung cancer patients. We concluded that double-dose C-E MRI improves the rate of detection of brain metastases during the initial staging of lung cancer.

MRI analysis of hydrocephalus associated with acoustic neurinoma

We investigated the hydrocephalus in 24 patients associated with acoustic neurinoma. We found the high incidence of homo-lateral ventricular dilatation to the side of the acoustic neurinoma. Utilizing magnetic resonance imaging, the diameter of the tumor parallel to the pyramidal bone, diameter of the tumor perpendicular to the pyramidal bone, grade of the 4th ventricle deviation, and the shape of the tumor (round or oval) were analyzed. Ten (42%) of the 24 patients with acoustic neurinoma were found to have hydrocephalus. Seven (70%) of the 10 patients with hydrocephalus exhibited asymmetrical lateral ventricle dilatation: in all cases the lateral ventricle in the hemisphere homolateral to the acoustic neurinoma was larger than that of the contralateral side. The hydrocephalus was not related to the grade of the 4th ventricle deviation but rather to the diameter of the tumor parallel to the pyramidal bone (p < 0.01). The diameter of the tumor parallel to the pyramidal bone was also related to the asymmetrical lateral ventricular dilatation (p < 0.05).

Focal brain edema and natriuretic peptides in patients with subarachnoid hemorrhage

Central salt wasting syndrome may be caused by pathological increases in serum natriuretic peptides after subarachnoid hemorrhage (SAH). However, it is unclear as to why the serum concentration of atrial natriuretic peptide (ANP) or brain natriuretic peptide (BNP) increases in the subacute phase of SAH. The present study was designed to assess the correlation between focal brain edema and serum concentration of ANP or BNP in patients with SAH. Focal brain edema was found in 8 SAH-patients and peaked between days 4 and 7 of SAH. The mean serum ANP and BNP levels in patients with focal brain edema were significantly higher than those in patients without focal brain edema between days 4 and 14 of SAH. These results suggest that focal brain edema might correlate with increased levels of ANP and BNP in the subacute phase of SAH.

Vascular endothelial growth factor expression in pituitary adenomas

Vascular endothelial growth factor (VEGF) is known to be a mediator of angiogenesis and vascular permeability. A cystic component and hemorrhage are often found in pituitary adenomas. In the present study we assess the VEGF expression based on immunohistochemical examinations in 48 pituitary adenomas. All the adenomas showed some VEGF immunoreactivity mainly in the cytoplasm of tumor cells. Of the 48 adenoma-cases, 16 cases had a strong VEGF immunoreactivity, 26 cases had a moderate one, and 6 cases had a weak one. On the MR images, a cystic component was found in 16 cases (33.3%), and a hemorrhage was found in 18 cases (37.5%). The VEGF immunoreactivity had a significant relationship with the cystic component but neither the hemorrhage, size, recurrence, or HE classification. These findings suggest that VEGF might play a potential role in the pathogenesis of cystic formation in pituitary adenomas.

Characteristic phosphorylation of the extracellular signal-regulated kinase pathway after kainate-induced seizures in the rat hippocampus

Extracellular signal-regulated kinase (ERK) pathways play a crucial role in cell growth and long-lasting neuronal plasticity. Several studies have shown that phosphorylated-ERK (p-ERK) significantly increases after kainic acid (KA) administration. However, little or no information is available about the spatial distribution of p-ERK after KA-induced seizures. We herein show that KA-induced seizures significantly increase p-ERK in both neurons and astrocytes in rat brain using Western blots and immunohistochemistry. A strong immunoreactivity for p-ERK was induced in the dentate hilar neurons and CA3 neurons 30 mins and 6 hrs after KA injection. In addition, immunoreactivity for p-ERK was seen in astrocytes 6 hrs after KA injection. 72 hrs after KA injection, all pyramidal neurons had died. These findings suggest that the ERK pathway participates in the KA-induced neurotoxicity in the rat hippocampus.

Extracellular superoxide dismutase following cerebral ischemia in mice

We describe the changes in extracellular superoxide dismutase (EC-SOD) following cerebral ischemia in mice. Mice were subjected to transient forebrain ischemia and reperfusion. The measurements of EC-SOD using ELISA showed increased brain EC-SOD after 24 h of reperfusion. The immunohistochemical examination showed that EC-SOD immunoreactivity in cortical and striatal capillary wall was conspicuous after 3 h. EC-SOD immunoreactivity was also noted in cortical neurons after 24 h. Northern blot analysis showed an increased EC-SOD mRNA expression in the brain after 24 h. In situ hybridization study demonstrated no mRNA expression of EC-SOD following ischemia and reperfusion in the capillary wall. These findings suggest that serum EC-SOD might accumulate on brain endothelial cells, while cortical neurons produce EC-SOD themselves after cerebral ischemia with reperfusion.

A role of glial fibrillary acidic protein in hippocampal degeneration after cerebral trauma or kainate-induced seizure

Astrocytes perform a variety of functions in the adult central nervous system (CNS). Recent evidence suggests the robust upregulation of glial fibrillary acidic protein (GFAP) after CNS insult. However, little is known about the role of GFAP in the hippocampal degeneration after brain injury. We herein compared the GFAP knockout (KO) and wild type (WT) mice on the histological and behavioral outcome in response to cerebral trauma or kainic acid (KA)-induced seizure. Although all KO mice showed hippocampal CA3 neuronal degeneration. WT mice did not show any neuronal degeneration in CA3 subfield at 72 hrs after trauma. Thereafter, KO mice showed a higher susceptibility to KA-induced seizures and an increased number of pyknotic CA3 neurons 72 hrs after KA administration. These results indicate that GFAP plays a crucial role in the hippocampal neurodegeneration after CNS insult.

Mitogen-activated protein kinases phosphorylation in posttraumatic selective vulnerability in rats

Mitogenic stimulation of the Mitogen-activated protein kinase (MAPK) pathway modulates the activity of many transcriptional factors leading to biological responses. Of these, three MAPK cascades are well characterized as extracellular signal-regulated protein kinase (ERK), c-Jun NH(2)-terminal kinase (JNK), and p38 pathways. The aim of this study was to investigate the topographic distribution and the role of activated MAPK pathways after fluid percussion injury (FPI) in rats. In the present results, FPI significantly induced ERK- and JNK-phosphorylation, but not p38-phosphorylation in the cortex and hippocampus at the injury site. The immunoreactivity for phospho-ERK was localized in the superficial neuronal layers, dentate hilar neurons, and the damaged CA3 neurons after 30 mins of FPI. Double immunostaining showed that phospho-ERK was prominent in astrocytes 6 hrs after TBI. The current results suggest that MAPK pathways are involved in signal transduction after FPI.

ICP monitoring following bilateral carotid occlusion in GFAP-null mice

To investigate the possible role of glial fibrillary acidic protein (GFAP) in cerebral ischemia, we have monitored the intracranial pressure (ICP) and local cerebral blood flow (ICBF) following bilateral carotid artery occlusion (BCAO) in GFAP-null mice and their wild type littermates. GFAP-null mice (B6, 129-GfaptmlMes) were obtained from Jackson Laboratories. The ICP and ICBF was continuously monitored during 15 minutes BCAO and reperfusion. The variation of the circle of Willis was also investigated in both GFAP-null and wild type mice. The breakdown of blood brain barrier (BBB) was assessed by immunohistochemical staining against mouse immunogloblins (IgG). A significantly more profound and immediate decrease in ICBF after BCAO was observed in GFAP-null mice (p < 0.04, ANOVA). GFAP-null mice also showed a significant increase (% change) in ICP after reperfusion (p < 0.05, ANOVA). There were no gross differences in the circle of Willis between GFAP-null and wild type mice. No abnormal IgG immuno-reactivity was observed in the forebrain of both animals. These results indicate a high susceptibility to cerebral ischemia in GFAP-null mice and suggest an important role for astrocytes and GFAP in the progress of ischemic brain damage and increased ICP after cerebral ischemia with reperfusion.

Hydrostatic brain edema: basic mechanisms and clinical aspect

The term hydrostatic brain edema results from unfavorable hydrtostatic pressure gradiernts between blood vessels and brain tissue. Arterial hypertension combined with decompressive craniectomy produces extensive brain edema in the arterial boundary zone of the decompressive area. The increased hydrostatic pressure gradient enhances tissue damage and causes the biphasic opening of the blood-brain barrier (BBB). The hydrostatic pressure alone is capable of causing the initial BBB opening and this induced edema results in derangement of cerebral microcirculation and metabolism. With morphological opening and metabolic damage of the vascular wall, the second BBB opening is elicited by the amplified hydrostatic pressure gradient, which is similar to that in vasogenic edema. In the clinical aspect, the beneficial effect of decompressive craniectomy in the treatment of uncontrollable ICP and brain edema remains controversial. External decompression may have adverse effects on severe brain edema and swelling. In this regards, control of driving force for the formation of brain edema could be the treatment of choice as an initial step. In addition, recent reports provided by MR imaging indicated new information on the pathophysiological features of the patients with acute hypertension. In the patients with hypertension due to reversible posterior leucoencephalopathy (RPL) syndrome, MR images show reversible signal abnormalities in the bilateral occipital lobes, suggesting hydrostatic brain edema.

Female gender as a risk factor for hypokalemia and QT prolongation after subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) often causes hypokalemia and QT prolongation. The sex disparities among 73 patients with SAH and 96 control subjects were examined. On the first day of SAH, the mean serum potassium level was significantly lower and the mean corrected QT interval was significantly longer in the female SAH group compared with either the female control or male SAH group. These findings suggest female susceptibility to hypokalemia and QT prolongation after SAH.

Immunohistochemical expression of CA19-9 and CA125 in mucoepidermoid and adenoid cystic carcinomas of the salivary gland

This study examined the immunohistochemical expression of carbohydrate antigens CA19-9 and CA125 and their relationship to various biological parameters in 27 mucoepidermoid carcinomas (MEC) and 18 adenoid cystic carcinomas (ACC) arising from salivary glands. The series showed higher immunopositivity for CA125 (67% for MEC; 33% for ACC) than for CA19-9 (59% for MEC; 11% for ACC). CA19-9 epitope was mainly expressed in cystic (MEC) and cribriform/tubular (ACC) components of carcinoma tissues. Solid components in MEC occasionally showed positive staining for CA19-9. CA125 was evenly expressed in both ACC and MEC tissues regardless of their different histological components. The positive expression of CA19-9 and CA125 in the carcinoma tissues did not influence the clinical course of patients with MEC and ACC. A significant relationship was only demonstrated between the immunohistochemical expression of CA125 and the low proliferative activity (LI) evaluated by Ki-67 immunohistochemistry. However, no significant relationship was found between LI and the patients' clinical course. These results suggest that the immunostaining for CA19-9 and CA125 provide no reliable data to predict the clinical course of patients with MEC and ACC of the salivary glands.

Anomalous internal carotid artery associated with ipsilateral cerebral arteriovenous malformation--case report

A 15-year-old girl presented with an extremely rare anomalous origin of the internal carotid artery (ICA) from the common carotid artery, associated with an arteriovenous malformation in the brain and aberrant course of the ICA in the temporal bone. These anomalies, which were found on the same side, may be due to a maldevelopment of the vascular network including the aortic arches.

Cisternal MHPG level inversely correlates with Glasgow coma scale after aneurysmal subarachnoid hemorrhage

We measured the concentrations of monoamines and amino acids in the cisternal cerebrospinal fluid obtained from 15 patients after aneurysmal subarachnoid hemorrhage. Based on the Glasgow Coma Scale (GCS), the patients were divided into two conscious (GCS always 14 or better from the third post-operative day to Day 12; n = 8) and unconscious groups (n = 7). We examined the concentrations of monoamines and amino acids between the two groups and evaluated the correlation between the concentrations and the GCS at CSF sampling. The concentration of MHPG was significantly higher in the unconscious than in the conscious group from Days 4 to 12. A significant inverse correlation was observed between the MHPG concentration and the GCS (r = approximately 0.635, p < 0.0001). Measuring the cisternal MHPG concentration may be useful for estimating convalescence after subarachnoid hemorrhage.

Primary central nervous system lymphoma with paraproteinemia

BACKGROUND

Although 34% to 54% of cases of extraneural non-Hodgkin's lymphoma (NHL) of the B-cell type are associated with monoclonal paraproteinemia, primary central nervous system NHL (PCNSL) with paraproteinemia has rarely been reported. The authors present herein a case of PCNSL with monoclonal immunoglobulin M (IgM) paraproteinemia.

METHODS AND RESULTS

A 78-year-old woman was referred to our hospital because of hemiparesis and epilepsy. Magnetic resonance imaging showed a round mass in the left frontal region. Serum IgM was 3,820 mg/dL, and immunofixation revealed an IgM kappa monoclonal paraprotein. No lymphoplasmacytic infiltration was observed on bone marrow aspiration. The brain tumor was totally resected. The pathological diagnosis was NHL (diffuse, large B cell). The results of immunohistochemical staining for IgM were strongly positive in the tumor cells.

CONCLUSION

This type of PCNSL has rarely been reported and little is known about it. It is possible that the true incidence of paraproteinemia caused by PCNSL is higher than has been thought. The clinical features of the tumor and pertinent literature are reviewed.