A Case of Scurvy Associated With Intracerebral Hemorrhage in a Patient With Alcohol Use Disorder

Vitamin C deficiency, also known as scurvy, causes abnormalities in connective tissues and varied symptoms. We describe a patient with putaminal hemorrhage, a very rare presentation of scurvy. A 39-year-old man presented with weakness in the left arm and left leg. Right putaminal hemorrhage was initially diagnosed, and he underwent evacuation of the intracerebral hemorrhage. Scurvy was suspected when repeated physical examinations revealed a bleeding tendency and multiple untreated dental caries, missing teeth, and gingivitis. A diagnosis of scurvy was further supported by the patient's history of smoking, alcohol use disorder, poor diet, and low plasma vitamin C concentration. After receiving oral nutritional supplementation including vitamin C, the bleeding tendency quickly improved. This case highlights the importance of including scurvy in a differential diagnosis for patients with bleeding tendencies, especially those with a poor diet or unknown dietary history. Empirical administration of vitamin C is a reasonable treatment.

Retrospective Observational Study of Patients With Subdural Hematoma Treated With Idarucizumab

Use of anticoagulants is increasing with the aging of societies. The safe first-line drug is likely to be a direct oral anticoagulant (DOAC), but outcomes of treatment of traumatic brain injury (TBI) with anticoagulants are uncertain. Therefore, we examined the clinical effect of idarucizumab as reversal therapy in elderly patients with TBI who were treated with dabigatran. A retrospective multi-center observational study was performed in patients ≥65 years of age who developed acute traumatic subdural hematoma during treatment with dabigatran and underwent reversal therapy with idarucizumab. The items examined included patient background, neurological and imaging findings at arrival, course after admission, complications, and outcomes. A total of 23 patients were enrolled in the study. The patients had a mean age of 78.9 years. Cause of TBI was fall in 60.9% of the subjects. Mean Glasgow Coma Scale score at arrival was 8.7; anisocoria was present in 31.8% of cases. Exacerbation of consciousness was found in 30.4%, but only in 13.3% of subjects treated with idarucizumab before consciousness and imaging findings worsened. Dabigatran was discontinued in 81.8% of cases after hematoma development, with a mean withdrawal period of 12.1 days. The favorable outcome rate was 21.7%, and mortality was 39.1%. In multi-variate analysis, timing of idarucizumab administration was associated with a favorable outcome. There were ischemic complications in 3 cases (13.1%), and all three events occurred ≥7 days after administration of idarucizumab. These findings suggest that in cases that develop hematoma during treatment with dabigatran, it is important to administer idarucizumab early and restart dabigatran after conditions stabilize.

Carotid Artery Stenting for Symptomatic Carotid Artery Dissection Developing from Stanford Type A Aortic Dissection: A Report of Two Cases

Objective

Stanford type A acute aortic dissection (AAD) is associated with carotid artery dissections (CADs). We report two cases of carotid artery stenting (CAS) for symptomatic CAD after ascending aortic replacement (AAR) for AAD.

Case Presentation

Case 1: A 51-year-old man with AAD was transferred to our institute. He had no notable paralysis symptoms on initial presentation. However, after AAR for AAD was performed, left paralysis developed within a few hours. Emergency angiography revealed right CAD and pseudo-occlusion. CAS was performed successfully using intravascular ultrasound (IVUS). He was transferred to a rehabilitation hospital with a modified Rankin Scale (mRS) score of 2.Case 2: A 55-year-old man underwent AAR for AAD, but asymptomatic left CAD remained. Two weeks after the operation, he presented with slight signs of aphasia. Aspirin was prescribed and follow-up was performed, but his symptoms did not improve. He underwent magnetic resonance imaging in our department, which revealed acute cerebral infarction on the left pars opercularis and an artery-to-artery embolism from CAD. CAS was performed via the retrograde approach with direct puncture of the normal left common carotid artery using IVUS. He was discharged with no complications and a mRS score of 1.

Conclusion

IVUS can be useful for CAS to confirm the true lumen and extension of long CAD lesions developing from AAD.

Reverse takotsubo cardiomyopathy caused by patent foramen ovale-related cryptogenic stroke: a case report

Background

Reverse takotsubo cardiomyopathy (rTTC) is recognized as an atypical type of TTC. It has been suggested that neurological events are typical trigger of rTTC, especially in young individuals.

Case summary

In this case report, we describe a 16-year-girl who presented with neurological deficits due to embolic stroke and acute heart failure. Transthoracic echocardiography on admission revealed a severely reduced left ventricular (LV) function with akinesis of basal to mid LV, but normal contraction in apex. Coronary computed tomography angiography confirmed unobstructed coronary arteries. Two weeks later, her LV wall motion and ejection fraction were completely normalized. Transthoracic echocardiography and transoesophageal echocardiography demonstrated no evidence of intracardiac thrombus but showed a patent foramen ovale (PFO) with large shunt. After thorough work-up and brain–heart team discussion, we concluded that the patient developed rTTC due to cryptogenic stroke related with her PFO. She underwent percutaneous PFO closure for secondary prevention with good clinical course.

Discussion

Reverse TTC is a rare condition. It should be considered in stroke patients with acute heart failure. Quick diagnosis and management with brain–heart team is crucial for better prognosis.

Spontaneous Subclavian Artery Dissection Causing Ischemia of the Medulla Oblongata and Cerebellum

BACKGROUND

Spontaneous subclavian artery dissection is a rare etiology. Spontaneous artery dissection causing brain ischemia is rare in all ischemic strokes. However, in young to middle-aged patients with brain ischemia, spontaneous carotid or vertebral artery dissection causing ischemic stroke accounts for 10-25%.

CASE REPORT

A 58-year-old man with a history of hypertension presented to the Emergency Department with a sudden onset of left-arm paresthesia and numbness followed by symptoms of vertigo and vomiting. A neurological examination showed left-arm paresthesia, horizontal-rotational nystagmus, and left-side dysmetria according to a finger-to-nose test. Contrast-enhanced computed tomography showed left subclavian artery dissection. Diffusion-weighted imaging demonstrated hyperintensity in the left medulla oblongata and inferior part of the cerebellum. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous artery dissection is an important etiology of ischemic stroke among young patients. Cervical magnetic resonance angiography is the gold standard for the diagnosis of arterial dissection. Cervical disc disease is a common etiology in a patient with neck and shoulder pain without cause or neurologic symptoms, when cervical MRI is negative, however, spontaneous subclavian artery dissection should be considered in the differential diagnosis when a patient, especially in a case of younger patient, presents with acute new-onset neck and shoulder pain followed by the onset of neurological symptoms.

Cerebral hyperperfusion syndrome after endovascular covered stent grafting for a giant extracranial aneurysm of the internal carotid artery

Symptomatic giant extracranial internal carotid artery (ICA) aneurysm is a rare and surgically intractable disease. Several authors have described successful treatments for extracranial ICA aneurysm. None, however, have described a perioperative evaluation of cerebral perfusion or a postoperative complication of cerebral hyperperfusion syndrome (CHS). We present a rare case of CHS after endovascular covered stent grafting for a giant extracranial ICA aneurysm. The CHS was successfully managed on the basis of hemodynamic monitoring. CHS can appear after endovascular reconstruction of an extracranial ICA aneurysm, and perioperative repeated evaluation of cerebral perfusion allows safe and effective management of CHS.

A molecular screening approach to identify and characterize inhibitors of glioblastoma stem cells

Glioblastoma (GBM) is among the most lethal of all cancers. GBM consist of a heterogeneous population of tumor cells among which a tumor-initiating and treatment-resistant subpopulation, here termed GBM stem cells, have been identified as primary therapeutic targets. Here, we describe a high-throughput small molecule screening approach that enables the identification and characterization of chemical compounds that are effective against GBM stem cells. The paradigm uses a tissue culture model to enrich for GBM stem cells derived from human GBM resections and combines a phenotype-based screen with gene target-specific screens for compound identification. We used 31,624 small molecules from 7 chemical libraries that we characterized and ranked based on their effect on a panel of GBM stem cell-enriched cultures and their effect on the expression of a module of genes whose expression negatively correlates with clinical outcome: MELK, ASPM, TOP2A, and FOXM1b. Of the 11 compounds meeting criteria for exerting differential effects across cell types used, 4 compounds showed selectivity by inhibiting multiple GBM stem cells-enriched cultures compared with nonenriched cultures: emetine, n-arachidonoyl dopamine, n-oleoyldopamine (OLDA), and n-palmitoyl dopamine. ChemBridge compounds #5560509 and #5256360 inhibited the expression of the 4 mitotic module genes. OLDA, emetine, and compounds #5560509 and #5256360 were chosen for more detailed study and inhibited GBM stem cells in self-renewal assays in vitro and in a xenograft model in vivo. These studies show that our screening strategy provides potential candidates and a blueprint for lead compound identification in larger scale screens or screens involving other cancer types.

Siomycin A targets brain tumor stem cells partially through a MELK-mediated pathway

Glioblastoma multiforme (GBM) is a devastating disease, and the current therapies have only palliative effect. Evidence is mounting to indicate that brain tumor stem cells (BTSCs) are a minority of tumor cells that are responsible for cancer initiation, propagation, and maintenance. Therapies that fail to eradicate BTSCs may ultimately lead to regrowth of residual BTSCs. However, BTSCs are relatively resistant to the current treatments. Development of novel therapeutic strategies that effectively eradicate BTSC are, therefore, essential. In a previous study, we used patient-derived GBM sphere cells (stemlike GBM cells) to enrich for BTSC and identified maternal embryonic leucine-zipper kinase (MELK) as a key regulator of survival of stemlike GBM cells in vitro. Here, we demonstrate that a thiazole antibiotic, siomycin A, potently reduced MELK expression and inhibited tumor growth in vivo. Treatment of stemlike GBM cells with siomycin A resulted in arrested self-renewal, decreased invasion, and induced apoptosis but had little effect on growth of the nonstem cells of matched tumors or normal neural stem/progenitor cells. MELK overexpression partially rescued the phenotype of siomycin A-treated stemlike GBM cells. In vivo, siomycin A pretreatment abraded the sizes of stemlike GBM cell-derived tumors in immunodeficient mice. Treatment with siomycin A of mice harboring intracranial tumors significantly prolonged their survival period compared with the control mice. Together, this study may be the first model to partially target stemlike GBM cells through a MELK-mediated pathway with siomycin A to pave the way for effective treatment of GBM.

Maternal embryonic leucine zipper kinase is a key regulator of the proliferation of malignant brain tumors, including brain tumor stem cells

Emerging evidence suggests that neural stem cells and brain tumors regulate their proliferation via similar pathways. In a previous study, we demonstrated that maternal embryonic leucine zipper kinase (Melk) is highly expressed in murine neural stem cells and regulates their proliferation. Here we describe how MELK expression is correlated with pathologic grade of brain tumors, and its expression levels are significantly correlated with shorter survival, particularly in younger glioblastoma patients. In normal human astrocytes, MELK is only faintly expressed, and MELK knockdown does not significantly influence their growth, whereas Ras and Akt overexpressing astrocytes have up-regulated MELK expression, and the effect of MELK knockdown is more prominent in these transformed astrocytes. In primary cultures from human glioblastoma and medulloblastoma, MELK knockdown by siRNA results in inhibition of the proliferation and survival of these tumors. Furthermore, we show that MELK siRNA dramatically inhibits proliferation and, to some extent, survival of stem cells isolated from glioblastoma in vitro. These results demonstrate a critical role for MELK in the proliferation of brain tumors, including their stem cells, and suggest that MELK may be a compelling molecular target for treatment of high-grade brain tumors.

BMPing off glioma stem cells

Brain tumor stem cells (BTSC) bear some similarities to neural stem cells (NSC). Bone morphogenetic proteins (BMPs) have a proproliferative effect on early embryonic NSC, and a prodifferentiative effect on postnatal NSC. In this issue of Cancer Cell, Lee et al. demonstrate that BMPs have differing effects on different BTSC lines, either promoting or inhibiting an astrocytic-like differentiation program. This latter effect is the result of epigenetic silencing of the BMP receptor 1B (BMPR1B). These findings document the importance of the BMP signaling system in BTSC as well as that of taking heterogeneity into account when studying BTSC as potential targets for therapy.

RGC32, a novel p53-inducible gene, is located on centrosomes during mitosis and results in G2/M arrest

To identify target genes for the hemizygous deletions of chromosome 13 that are recurrently observed in malignant gliomas, we performed genome-wide DNA copy-number analysis using array-based comparative genomic hybridization and gene expression analysis using an oligonucleotide-array. The response gene to complement 32 (RGC32) at 13q14.11 was identified as a deletion target, and its expression was frequently silenced in glioma cell lines compared with normal brain. Levels of RGC32 mRNA tended to decrease toward higher grades of primary astrocytomas, especially in tumors with mutations of p53. Expression of RGC32 mRNA was dramatically increased by exogenous p53 in a p53-mutant glioma cell line, and also by endogenous p53 in response to DNA damage in p53+/+ colon-cancer cells, but not in isogenic p53-/- cells. Chromatin immunoprecipitation and reporter assays demonstrated binding of endogenous p53 protein to the promoter region of the RGC32 gene, implying p53-dependent transcriptional activity. Transiently and stably overexpressed RGC32 suppressed the growth of glioma cells, probably owing to induction of G2/M arrest. Immunocytochemical analysis revealed a concentration of RGC32 protein at the centrosome during mitosis. RGC32 formed a protein complex with polo-like kinase 1 and was phosphorylated in vitro. These observations implied a novel mechanism by which p53 might negatively regulate cell-cycle progression by way of this newly identified transcriptional target. Our results provide the first evidence that RGC32 might be a possible tumor-suppressor for glioma, that it is directly induced by p53, and that it mediates the arrest of mitotic progression.

Overexpressed Skp2 within 5p amplification detected by array-based comparative genomic hybridization is associated with poor prognosis of glioblastomas

To better understand the pathogenesis of glioblastoma multiforme (GBM) and to increase the accuracy of predicting outcomes for patients with this disease, we performed genome-wide screening for DNA copy-number aberrations in 22 glioma-derived cell lines using a custom-made comparative genomic hybridization-array. Copy-number gains were frequently detected at 3q, 7p, 7q, 20q, Xp and Xq, and losses at 4q, 9p, 10p, 10q, 11q, 13q, 14q, 18q, and 22q. Among several non-random chromosomal aberrations, the gain/amplification of DNA at 5p, which has never been reported before in GBM, was detected with a relatively high ratio (log2 ratio = 0.41-1.19) in four cell lines. Amplification and subsequent overexpression of SKP2, a possible target of amplification within 5p, were detected in four of the 22 cell lines. We also investigated the expression of the gene product in primary GBM by immunohistochemistry, which revealed increased levels of Skp2 in 11 of the 35 tumors examined (31.4%). Heightened expression of Skp2 was associated with shorter overall survival (P = 0.001, logrank test), especially in patients younger than 65 years. These results suggest that overexpression of Skp2 through gene amplification may contribute to the pathogenesis of GBM, and that overabundance of the protein might be a useful prognostic tool in patients with this disease.

[Benign intracranial hypertension resulting from corticosteroid withdrawal: case report]

We report a case of benign intracranial hypertension (BIH) resulting from corticosteroid withdrawal. A 36-year-old woman was admitted to hospital because of an intractable headache. A neurological examination on admission showed no abnormalities other than a headache and nausea. CT, MRI, and angiogram examinations showed no abnormalities. Hematological and laboratory data were also normal. Continuous monitoring of her cerebrospinal fluid (CSF) pressure showed a value of over 25 mmHg during sleep, but papilledema was not observed. A diagnosis of BIH was made, with corticosteroid withdrawal considered to be the most probable cause. The patient was given isosorbide solution for 3 months. However, her clinical condition continued to deteriorate; she eventually began to develop visual loss, photopsia, and memory disturbances. She underwent lumboperitoneal shunt surgery, which immediately eliminated the headache, photopsia, and memory disturbances. She regained her vision over a five-month period. BIH should be considered as a differential diagnosis when an intractable headache develops after corticosteroid withdrawal, especially in young women.

A histological study on the mechanism of epidermal nuclear elongation in electrical and burn injuries

Epidermal nuclear elongation is one of the most important signs for the diagnosis of electrical injury. In this study, we investigated the mechanism responsible for this phenomenon by comparing the findings from burn injuries and those from contusions. Electrical and burn injuries were made in the dorsal skin of rats using energy ranging from 100 to 790 joules for electrical injury, and 170-690 joules for burn injury. Contusions were also made by compressing the skin with a vice. In electrical and burn injuries, the dermis under the epidermal elongated nuclei was homogeneous and without empty spaces between collagen bundles and the number of dermal fibroblasts per 0.01 mm2 below the damaged epidermis decreased significantly (P < 0.05). The incidence of this change correlated with the depth of denatured dermal collagen fibres and in both types of injuries, dermal cells had no nuclear antigenicity for ubiquitin. The width of the injured epidermis with nuclear elongation decreased significantly (P < 0.05) and the elongated nuclei were parallel to the basal membrane. In electrical injury however, nuclear elongation occurred more frequently near the external root sheath. Nuclear elongation of fibroblasts and external root sheath cells was also found, but those of sebaceous gland cells were not detected. Epidermal elongated nuclei were also found in contusions. The evidence strongly suggests that epidermal nuclear elongation in electrical and burn injuries is due to dermal expansion by heat.

Hypoplasia of the left lobe of the liver

In a forensic autopsy, hypoplasia of the left lobe (lateral segment) of the liver was found. Although the cause was unknown, the morphologic anomaly observed in this case was regarded as congenital because there was no history of surgery. Moreover, the main vessels of the left lobe were present despite complete absence of the parenchyma.

Comparison of the likelihood ratio and identity-by-state scoring methods for analyzing sib-pair test cases: a study using computer simulation

To assess the power and significance of the likelihood ratio (LR) and the identity-by-state scoring (IBS) methods for a pair of siblings, we performed computer simulations by use of 10 DNA markers (HLA-DQalpha, D1S80, and 8 short tandem repeat loci) that were frequently analyzed in paternity tests in Japan. The combined power of discrimination of these 10 markers in the Japanese population is 0.999 999 999 98. Pedigrees each consisting of 10,000 pair of full-siblings, half-siblings and unrelated individuals were generated and typed on all markers as random samples. Both the summation of log10 LR and IBS of each group had approximate standard normal distribution with significant differences between the means. Statistical studies showed that the LR method has 91% power to detect unrelated individuals and 38% power to detect half-siblings as not full-siblings with a 5% false-positive rate, whereas the IBS method does 87% and 42% powers, respectively. In 62% of full-siblings, in contrast with only 0.2% of unrelated individuals, the values of LR exceeded 100 which was equivalent to 0.99 of probability of full-sibship at 50% prior probability. The advantage of the LR method over IBS method was convincing especially for the detection of unrelated individuals as not half-siblings, however, the latter would be also informative for sib-pair tests if sufficient number of polymorphic markers are available.

Forced oral opening for cadavers with rigor mortis: two approaches for the myotomy on the temporal muscles

Forensic dentistry plays an essential role in personal identification procedures. An adequate interincisal space of cadavers with rigor mortis is required to obtain detailed dental findings. We have developed intraoral and two directional approaches, for myotomy of the temporal muscles. The intraoral approach, in which the temporalis was dissected with scissors inserted via an intraoral incision, was adopted for elderly cadavers, females and emaciated or exhausted bodies, and had a merit of no incision on the face. The two directional approach, in which myotomy was performed with thread-wire saw from behind and with scissors via the intraoral incision, was designed for male muscular youths. Both approaches were effective to obtain a desired degree of an interincisal opening without facial damage.

An application of PCR-single strand conformation polymorphism to MN genotyping

A PCR-based genotyping of MN blood group system was investigated for DNA samples taken from a population of 409 northern Japanese. DNA fragment (257bp) including exon 2 of glycophorin A (GPA) gene, in which encodes the determinants of MN antigens, was specifically amplified. On the analysis of PCR-single-strand conformation polymorphism (PCR-SSCP) for M alleles, band patterns of M(G) and M(T) were easily discriminated each other. For N alleles, three band patterns were observed, and we tentatively named these alleles as N(1), N(2) and N(V). The N(1) allele appeared predominantly and N(2) had two base substitutions at 1st (C-->A) and 56th (C-->T) in exon 2 of N(1). The other N(V), which was detected from a pair of a mother and her child, possessed a single base substitution at 23rd (A-->G) in intron 2. The allele frequencies of M(G), M(T), N(1) and N(2) were 0.4450, 0.0978, 0.4303 and 0.0269, respectively. The polymorphism information content and the probability of paternity exclusion by this MN genotyping were estimated to be 0.5252 and 0.3219, respectively.

Sudden infant death with anomalous origin of the left coronary artery from the pulmonary artery

Autopsy of a 2-month-old boy revealed an anomalous origin of the left coronary artery from the pulmonary trunk. The endomyocardial fibrosis associated with myocardial ischemia was noted in the left ventricular wall of the enlarged heart. Death was attributed to silent heart failure due to the anomalous left coronary artery. Significant clinical symptoms are generally observed in patients with such anomalies, however, they might cause sudden death in childhood.

Simple methods of forced oral opening for cadavers oriented to causes of fixed jaw

Forensic dentistry plays an essential role in personal identification procedures. An adequate interincisal space of relatively fresh cadavers would be required to obtain detailed dental findings. We developed novel and simple procedures of oral opening which are oriented to the causes of the fixed jaw and conscious of facial damage. Preliminary inspection disclosed three causes of the difficulty of oral opening, namely exceptional drying or parchmenting, rigor mortis and loss of extensibility of the temporalis muscles. Tenotomy on the temporalis muscles for cases with the last two factors, and/or mandibular periosteal stripping for those with the first one were employed to approach the oral cavity of cadavers, and a desired degree of interincisal opening was attained. Single or combinational operation of these methods is definitely effective to obtain odontological data without altering facial configuration.