Clinical epidemiology and outcome of HIV-associated talaromycosis in Guangdong, China, during 2011-2017

OBJECTIVES

Talaromycosis is an invasive mycosis endemic to Southeast Asia. This study aimed to investigate the epidemiology, clinical features and prognostic factors of HIV-associated talaromycosis in Guangdong, China.

METHODS

We retrospectively evaluated HIV patients hospitalized with histopathology- or culture-confirmed talaromycosis between 2011 and 2017. Factors associated with poor prognosis were identified using logistic regression.

RESULTS

Overall, 1079 patients with HIV-associated talaromycosis were evaluated. Both the number and prevalence of talaromycosis among HIV admissions increased from 125 and 15.7% in 2011 to 253 and 18.8% in 2017, respectively, reflecting the increase in HIV admissions. Annual admissions peaked during the rainy season between March and August. Common clinical manifestations included fever (85.6%), peripheral lymphadenopathy (72.3%), respiratory symptoms (60.8%), weight loss (49.8%), skin lesions (44.5%) and gastrointestinal symptoms (44.3%). Common laboratory abnormalities were hypoalbuminaemia (98.6%), anaemia (95.6%), elevated aspartate aminotransferase level (AST) (76.9%), elevated alkaline phosphatase level (55.8%) and thrombocytopenia (53.7%). The median CD4 count was 9 cells/μL. Talaromyces marneffei was isolated from blood and bone marrow cultures of 66.6% and 74.5% of patients, respectively. The rate increased to 86.6% when both cultures were performed concurrently. At discharge, 14% of patients showed worsening conditions or died. Leucocytosis, thrombocytopenia, elevated AST, total bilirubin, creatinine and azole monotherapy independently predicted poor prognosis.

CONCLUSIONS

The incidence of HIV-associated talaromycosis has increased in Guangdong with the high HIV burden in China. Skin lesions were seen in less than half of patients. Induction therapy with azole alone is associated with higher mortality. Findings from this study should help to improve treatment of the disease.

Development of a fluorescent-intercalating-dye-based reverse transcription loop-mediated isothermal amplification assay for rapid detection of seasonal Japanese B encephalitis outbreaks in pigs

The standardization and validation of a one-step, single-tube, accelerated fluorescent-intercalating-dye-based reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay targeting the NS3 gene of Japanese B encephalitis virus (JEV) is described for rapid, simple, and high-throughput detection of JEV. The amplification can be completed in 35 min under isothermal conditions at 63°C by employing a set of six primers targeting the NS3 gene of JEV. The RT-LAMP assay described demonstrated high sensitivity for detecting JEV, with a detection limit in swine samples of 8.13 PFU/ml. The specificity of the selected primer sets was established by cross-reactivity studies with pathogens that exhibit similar clinical signs and testing of samples from healthy animals. The clinical applicability of the RT-LAMP assay was validated using either spiked samples or samples from seasonal outbreaks. The comparative evaluation of the RT-LAMP assay revealed 79.59 % concordance with conventional RT-PCR targeting the E gene of JEV. The RT-LAMP assay reported here is a valuable tool for rapid real-time and high-throughput seasonal infection surveillance and quarantine after outbreak through blood sampling by using ordinary real-time PCR thermocyclers without purchasing an expensive Loopamp real-time turbidimeter.

Monitoring peri-therapeutic cerebral circulation time: a feasibility study using color-coded quantitative DSA in patients with steno-occlusive arterial disease

BACKGROUND AND PURPOSE

Intracranial hemodynamics are important for management of SOAD. This study aimed to monitor peri-stent placement intracranial CirT of patients with SOAD.

MATERIALS AND METHODS

Twenty-five patients received stent placement for extracranial ICA stenosis, and 34 patients with normal CirT were recruited as controls. Their color-coded DSAs were used to define the Tmax of selected intravascular ROI. A total of 20 ROIs of the ICA, OphA, ACA, MCA, FV, PV, OV, SSS, SS, IJV, and MCV were selected. rTmax was defined as the Tmax at the selected region of interest minus Tmax at the cervical segment of the ICA (I1 on AP view and IA on lateral view). rTmax of the PV was defined as intracranial CirT. Intergroup and intragroup longitudinal comparisons of rTmax were performed.

RESULTS

rTmax values of the normal cohorts were as follows: ICA-AP, 0.12; ICA-LAT, 0.10; A1, 0.28; A2, 0.53; A3, 0.81; M1, 0.40; M2, 0.80; M3, 0.95; OphA, 0.35; FV, 4.83; PV, 5.11; OV, 5.17; SSS, 6.16; SS, 6.51; IJV, 6.81; and MCV, 3.86 seconds. Before stent placement, the rTmax values of arterial ROIs, except A3 and M3, were prolonged compared with values from control subjects (P < .05). None of the rTmax of any venous ROIs in the stenotic group was prolonged with significance. After stent placement, the rTmax of all arterial ROIs shortened significantly, except A1and M3. Poststenting rTmax was not different from the control group.

CONCLUSIONS

Without extra contrast medium and radiation dosages, color-coded quantitative DSA enables real-time monitoring of peri-therapeutic intracranial CirT in patients with SOAD .

Identification of anisakid nematodes with zoonotic potential from Europe and China by single-strand conformation polymorphism analysis of nuclear ribosomal DNA

Using genetic markers defined previously in the second internal transcribed spacer (ITS-2) of nuclear ribosomal DNA (rDNA), isotopic, and non-isotopic polymerase-chain-reaction-coupled single-strand conformation polymorphism (SSCP) were utilized to identify each of three anisakid species [Anisakis simplex (s.l.), Contracaecum osculatum (s.l.), and Hysterothylacium aduncum] from different host species and geographical locations in Poland and Sweden. While subtle microheterogeneity was observed within each of Anisakis simplex (s.l.) and H. aduncum, distinct SSCP profiles were displayed for each of the three species, allowing identification and differentiation of the three taxa. Subsequent sequencing of the ITS-1 and ITS-2 rDNA revealed that A. simplex (s.l.) represented Anisakis simplex s.s. and Contracaecum osculatum (s.l.) represented C. osculatum C. Application of the non-isotopic SSCP assay of ITS-2 to larval anisakid samples from different hosts and geographical locations in China revealed three distinct SSCP profiles, one of which was consistent with that of A. simplex (s.l.), and the other two had different SSCP profiles from that of C. osculatum C and H. aduncum. Sequencing of the ITS-1 and ITS-2 rDNA for representative Chinese anisakid samples examined revealed three anisakid species in China, i.e., Anisakis typica, Anisakis pegreffii, and Hysterothylacium sp. These molecular tools will be useful for identification and investigation of the ecology of anisakid nematodes in China and elsewhere.

Bilateral traumatic carotid-cavernous fistulae: Strategies for endovascular treatment

BACKGROUND

Most traumatic carotid-cavernous fistula/e (TCCF) are unilateral, and simultaneous bilateral TCCF are uncommon. The purpose of this study was to evaluate the angiographic architecture of bilateral TCCF and report our experience with their endovascular management.

METHOD

Over 15 years, 252 consecutive patients with TCCF were referred to our institute for endovascular treatment. Bilateral TCCF occurred in 5 men and 2 women with a mean age of 31 years. The angiographic architectures of bilateral TCCF were evaluated with cerebral angiography. All patients underwent a single session of transarterial embolisation by using various permanent embolic materials and were followed up clinically or with angiography for a mean of 22 months (range 9-36 months).

FINDINGS

All patients presented with neuro-ophthalmic symptoms and signs. No new instances of cerebrovascular ischemia or intracranial haematoma resulted from bilateral TCCF. All fistulae were associated with partial arterial steal and were successfully occluded by using a detachable balloon and/or a detachable coil with or without a liquid adhesive. Of 14 TCCF, 9 were completely obliterated with preserved flow of the internal carotid artery (ICA). In the other 5 fistulae, the ICA had to be sacrificed to achieve occlusion because the anatomy of the fistula was complex. All fistula related symptoms resolved immediately or gradually during clinical follow up. No clinically significant procedure related neurological complications or recurrent fistulae were observed.

CONCLUSIONS

All bilateral TCCF were associated with a partial arterial steal phenomenon. Single session endovascular treatment using various embolic materials was effective in managing these high-flow fistulae. In all patients, it was possible to preserve one or both ICAs.

Segmental Neurovascular Syndromes in Children

The concept of segmental vascular syndromes with different, seemingly unrelated, diseases is based on the embryology of the neural crest and the mesoderm migration of cells that share the same metameric origin. Migrating patterns of these cells link the brain, the cranial bones, and the face on the same side. A somatic mutation developing in the region of the neural crest or the adjacent cephalic mesoderm before migration can, therefore, be postulated to produce arterial or venous metameric syndromes, including PHACES, CAMS, Cobb syndrome, and Sturge-Weber syndrome. Although these diseases may be rare, their relationships among each other and their postulated linkage with the development of the neural crest and the cephalic mesoderm may shed light on the complex pathology and etiology of various cerebral vascular disorders.

Percutaneous vertebroplasty for patients with osteoporosis: a one-year follow-up

PURPOSE

To evaluate changes in height and wedge angle of treated vertebral bodies and kyphosis angle 1 year after vertebroplasty.

MATERIAL AND METHODS

We reviewed radiographs of 95 vertebral bodies treated with vertebroplasty in 60 patients with osteoporosis. Only vertebral bodies with imaging evidence of a new fracture or avascular necrosis received vertebroplasty. Images were obtained for evaluation before vertebroplasty (B), within 2 weeks after vertebroplasty (T), and after 1 year (T1).

RESULTS

The mean wedge angle decreased by 5.4 degrees from B to T1. Mean of the anterior, central, and posterior heights of the fractured bodies increased by 12.6%, 9.6%, and 3.1%, respectively, from B to T1. The kyphosis angle improved by 3.2 degrees initially from B to T, but the improvement later disappeared. In 48% of these patients, a new fracture developed after vertebroplasty, and 63% of the fractures were adjacent to a vertebroplasty-treated vertebral body.

CONCLUSION

The increase in height and wedge angle of the vertebral bodies generally lasted at least 1 year. Improvement in kyphosis angles was lost 1 year after vertebroplasty because new fractures occurred in 48% of these patients. Prevention of new fractures after vertebroplasty remains an important task.

Carotid blowout treated by direct percutaneous puncture of internal carotid artery with temporary balloon occlusion

SUMMARY

Direct percutaneous puncture of a cervical carotid pseudoaneurysm for coil placement or acrylic embolization is described for the endovascular management of acute carotid blowout. However, direct puncture of the internal carotid artery (ICA) for the endovascular management of carotid blowout has not been described. We report a difficult case of acute carotid blowout syndrome in a patient who had radiation- induced occlusion of the right common carotid artery with vasculopathy and pseudoaneurysm in the right cervical ICA. Collaterals from the branches of the controlateral external carotid artery (ECA) anastomosed with branches of right ECA supplied the vasculopathy. We performed direct percutaneous puncture of the bulb of the right ICA using a spinal needle and placed fiber coils to occlude antegrade flow of the artery. During the injection of a mixture of N-butyl cyanoacrylate and lipiodol oil for embolization of the remaining carotid bulb, we transiently inflated an occlusion balloon in the controlateral common carotid artery to further arrest antegrade flow in the ICA. The vasculopathy and pseudoaneurysm of the right cervical ICA were successfully embolized, with preservation of the distal branches of the right ICA.

PHACES syndrome: a review of eight previously unreported cases with late arterial occlusions

PHACE and PHACES are acronyms for a syndrome of variable expression comprising posterior cranial fossa malformations, facial haemangiomas, arterial anomalies, aortic coarctation and other cardiac disorders, ocular abnormalities and stenotic arterial disease. We review five girls and three boys aged 1 month-14 years with disorders from this spectrum. Six had large facial haemangiomas but recent reports suggest that small haemangiomas may occur; hence our inclusion of two possible cases. We also focus on the recently recognised feature of progressive intracranial arterial occlusions, present in four of our patients, later than previously recognised, from 4 to 14 years of age. We suggest that many elements of this disorder could reflect an abnormality of cell proliferation and apoptosis.

Concomitant conus medullaris arteriovenous malformation and sacral dural arteriovenous fistula of the filum terminale

SUMMARY

A patient with a spinal intradural arteriovenous malformation (AVM) at the conus medullaris concomitant with a sacral dural arteriovenous fistula (AVF) of the filum terminale is reported. A 44-year-old-male presentied with bilateral leg weakness and urinary incontinence for several months. Spinal angiography demonstrated two lesions: one was spinal intradural AVM at the conus medullaris supplied by the anterior spinal artery; the other was sacral dural AVF of the filum terminale supplied by the middle sacral artery. Although multifocal spinal cord AVMs have been reported, this is the first case report of two different types of vascular malformations coexisting in one patient. The arterial supply of the dural AVF of the filum by the middle sacral artery is also first demonstrated in the literature. The patient was treated successfully by surgical approach for both lesions in the same operation.

Tuberous sclerosis complex with an unruptured intracranial aneurysm: manifestations of contiguous gene syndrome

SUMMARY

With the advancement of molecular genetics, the deletion of the TSC2/PKD1 gene at chromosome 16p13.3 has been discovered to be responsible for the tuberous sclerosis complex sharing some of the clinical manifestations of autosomal dominant adult polycystic kidney disease such as multiple renal cysts and intracranial aneurysms. The unruptured aneurysm in tuberous sclerosis complex is far beyond the meaning it has in general population. The risk of aneurysmal hemorrhage in tuberous sclerosis complex may be higher than that in autosomal dominant adult polycystic kidney disease due to the synergistic effect of gene deletion and certainly much higher than that in the general population. For such high-risk patients with intracranial aneurysms doomed to subarachnoid hemorrh age, magnetic resonance angiography plays an important role in screening and follow-up, especially more critically for patients with contiguous gene syndrome. Endovascular coil embolization should be the first choice of treatment for un ruptured intracranial aneurysms.

Substance P and enkephalin containing fibers in the developing nucleus dorsalis of the human spinal cord

A peroxidase-antiperoxidase immunostaining method was employed to determine the initial stage of appearance and localization of substance P (SP) and enkephalin (ENK) in the nucleus dorsalis of the developing human spinal cord. Both SP- and ENK-positive fibers started to appear from the 10th week of gestation in regions surrounding the nucleus dorsalis. SP-positive fibers then reached the nucleus at 13 weeks and from 26 weeks to term, three strands of SP-positive fibers, which were predominantly originated from the superficial layers of the dorsal horn, penetrated into the nucleus dorsalis from its medial, median and lateral aspects. From 26 weeks onwards, ENK-positive fibers, originated from the superficial and the adjacent layers of the spinal cord, formed a thicker medial and a thinner lateral bundle projecting into the nucleus dorsalis. Our results show that both SP- and ENK-positive fibers started to appear at around 10 weeks and a consistent pattern of immunoreactivity was established by around 26-30 weeks of gestation.

Spontaneous healing and complete disappearance of a giant basilar tip aneurysm in a child

SUMMARY

We report a rare case of spontaneous total thrombosis of a giant basilar tip aneurysm resulting in compression of the brainstem, diagnosed in a two-year-old child who presented with neurological deficits and third cranial nerve impairment. After conservative treatment, the giant aneurysm was completely thrombosed and the clinical symptoms were remarkably improved. MRI demonstrated dramatic shrinkage and ultimately complete disappearance of the giant aneurysm at seven month follow-up.

Magnetic resonance imaging appearance of intradural spinal lipoma

Intradural spinal lipoma not associated with spinal dysraphism is a rare tumor often presenting with nonspecific symptoms and indolent clinical course. Its intradural location and fat component is the key for proper preoperative diagnosis, which could hardly be made by traditional imaging studies including plain film and myelography. Both CT and MRI can reveal the fat component of the tumor, but MRI is superior to CT in demonstrating its relationship with adjacent normal nerve tissue. We report a 32-year-old man who had back pain for years and the symptom progressed rapidly in recent two months. MRI revealed an intradural tumor at T12 level with high signal intensity on both T1- and T2-weighted images. The signal intensity dropped dramatically with fat saturation technique, which confirmed fat as its main component. The patient received surgery and the tumor was proved to be an intraspinal lipoma.

Wyburn-Mason or Bonnet-Dechaume-Blanc as Cerebrofacial Arteriovenous Metameric Syndromes (CAMS). A New Concept and a New Classification

SUMMARY

The diagnosis of Bonnet-Dechaume-Blanc or Wyburn-Mason syndrome encompasses a spectrum of phenotypic expression. Features of the syndrome as originally described, and common to all, include arteriovenous malformations of the brain and orbit (with retinal and/or retrobulbar lesions). A portion of these patients manifest the complete expression of the disease with additional high-flow arteriovenous malformations of the maxillofacial or mandibular regions. These present the distinct and additional risks of lifethreatening epistaxis or gingival haemorrhage. We suggest new diagnostic criteria for the syndrome. Applying insights from modern developmental biology to our series of 15 patients (the largest to date), together with a review of the literature, we have recognised metameric patterns of involvement in what we believe to be a disease of the neural crest or adjacent cephalic mesoderm. This allows us to propose a new rational classification reflecting the putative, underlying disorder and to suggest a new name: Cerebrofacial Arteriovenous Metameric Syndrome (CAMS).

Sequential MR studies of a patient with white matter disease presenting psychotic symptoms: ADEM versus single-episode MS

Acute disseminated encephalomyelitis (ADEM) and multiple sclerosis (MS) are both demyelinating white matter disorders. It is difficult to differentiate ADEM from single episode MS because of the similar clinical presentation, cerebral spinal fluid (CSF) analysis, histological finding and magnetic resonance image (MRI) appearance. We report an ADEM case with unusual clinical presentations of predominant psychiatric symptoms, and relatively long disease course. Initially, we were not able to distinguish it from single episode MS. By means of sequential MR images followed up 2 years and spectroscopy studies, and the dramatic clinical improvement after corticosteroid therapy, ADEM was diagnosed as the disease entity of this patient. In this case report we will present the MR findings of this patient and discuss the differentiation between the ADEM and MS.

Image evaluation of suprazygomatic masticator space lesions

In order to understand lesions involving the suprazygomatic masticator space (SZMS) demonstrated on computered tomography (CT) or magnetic resonance (MR) images, we collected 45 cases of lesions in SZMS. There were hematomas in 26 cases, tumors in 16 cases, and abscesses in 3 cases. The location of these lesions in compartments of the SZMS and adjacent structures was analyzed. Most commonly hematoma was found in the deep loose connective tissue (80.8%), followed by the superficial dense connective tissue (61.5%). Only 2 SZMS hematoma involved the superficial fat pad. Five patients had air accumulation in the SZMS, and all were in the deep fat pad and with maxillary sinus fracture. Of the sixteen cases which were tumors, 12 were extended from adjacent structures, and four were primary tumor. In cases of tumor, compartments of SZMS involved most frequently were temporal muscles (15 of 16 cases), followed by deep fat pad (8 of 16 cases). The connective tissue layer of SZMS is a communication pathway for superficial spread of infection, hematoma, or tumor invasion to or from the scalp and face. Compartments of deep fat pad and temporal muscle are also pathways for the spread of disease to or from the face, intracranium and orbit. The primary tumors in infratemporal fossa and SZMS are rare. Malignant tumors in SZMS usually come from surrounding spaces.

Percutaneous transluminal angioplasty as an adjunct to treat the carotid-cavernous fistula

We report a case of the direct carotid-cavernous fistula (CCF) with high-grade stenosis of the internal carotid artery (ICA) and treatment via the transarterial route after percutaneous transluminal angioplasty (PTA). A 46-year-old man was found to have a CCF after a motorcycle accident. Transarterial embolization was attempted, but it failed due to stenosis of the left cervical ICA. After the procedure of PTA for dilatation of the stenotic ICA, the fistula was successfully obliterated by detachable balloon subsequently. There were no complications or recurrence of the fistula at the three-year clinical follow up.

Endovascular embolization of carotid-cavernous fistula using the posterior communicating artery approach: a case report

We report a case of direct carotid-cavernous fistula complicated with occlusion of internal carotid artery (ICA) at attempted endovascular obliteration via ICA and subsequent successful embolization via the posterior communicating artery (PCoA) approach. After a thorough understanding of vascular anatomical alterations associated with initial technical failure with detachable balloons, a microcatheter was navigated to the fistula site via the vertebro-basilar-PCoA to the distal cavernous segment of the left ICA. Embolization of the fistula was performed with deposition of three platinum microcoils. Angiograms after embolization showed complete disappearance of the fistula. There was no procedural complication and no recurrence of fistula at one-year clinical follow up.

Pneumocephalus secondary to septic thrombosis of the superior sagittal sinus: report of a case

Pneumocephalus secondary to septic superior sagittal sinus thrombosis (SSSST) is extremely rare. We report computed tomography (CT) findings in a 63-year-old man with SSSST caused by the gas-forming organism Klebsiella pneumoniae. The patient presented with fever, chills, general weakness, and spontaneous progressive swelling of the right frontoparietal scalp. CT revealed a gas-containing abscess over the right frontoparietal subgaleal region and in the superior sagittal sinus. Surgical drainage of the subgaleal abscess was performed and blood and pus cultures grew Klebsiella pneumoniae. The patient died of sepsis on the 6th day of hospitalization.

Aneurysms of the fenestrated basilar artery treated with Gulielmi Detachabe Coils: case report

Multiple aneurysms at the site of a basilar artery fenestration (BAF) are extremely rare. We report a case of BAF in association with two aneurysms successfully treated with Guglielmi Detachable Coils (GDCs). A 42-year-old male presented with subarachnoid hemorrhage and consciousness change. Angiograms of the vertebrobasilar artery demonstrated fenestration of the proximal basilar artery associated with two aneurysms. Embolization of aneurysms was done by using GDCs. Aneurysms were almost completely obliterated with preservation of the flow and lumen of the vertebrobasilar system. The patient remains asymptomatic at clinical follow-up of 18 months.

Computed tomography and magnetic resonance imaging characteristics of giant pituitary adenomas

PURPOSE

The purpose of this study was to characterize the computed tomography (CT) and magnetic resonance (MR) imaging features of giant pituitary adenoma (GPA) and to demonstrate the pathways of the spread of GPA.

METHODS

CT and/or MR imaging scans of 356 patients evaluated preoperatively for single pituitary tumor were reviewed. Fourteen tumors (4%) fulfilled the radiologic criteria for GPA. There were 10 male and four female patients, ranging in age from 22 to 71 years (mean, 52 yr). We retrospectively reviewed the CT and MR imaging scans of these patients to characterize tumor appearances and identify the pathways of tumor extension.

RESULTS

Thirteen tumors (93%) extended upward to the suprasellar cistern, and/or hypothalamus and third ventricle. Infrasellar extension through the sellar floor and sphenoid sinus to the skull base, or to the ethmoid sinus or the nasopharynx, was identified in seven patients (50%). Eight patients (57%) had lateral invasion to the cavernous sinus. Temporal and frontal extension was apparent in seven patients (50%) and six patients (43%), respectively. Five patients (36%) had posterior subtentorial extension to the posterior fossa. Histologically, only two GPAs showed invasive features. There was no correlation among histologic features, pituitary hormone concentrations, and evidence of tumor aggressiveness on CT and MRI scans.

CONCLUSIONS

GPA has the potential for widespread, multi-directional extension. Our results indicate that any type of pituitary adenoma, regardless of its endocrinologic activity, may invade surrounding structures. Suprasellar invasion is the most common pathway of tumor spread, followed by infrasellar, lateral, anterior, and posterior routes.

Double-balloon technique for embolization of carotid cavernous fistulas

Embolization of a carotid cavernous fistula (CCF) by means of a detachable balloon is an established method for treating CCFs while preserving a patent parent internal carotid artery (ICA). However, failure to embolize the CCF may occur on a few occasions, such as when the balloon cannot pass through the fistula into the cavernous sinus by blood flow, or when the inflated balloon in the cavernous sinus retracts to the carotid artery. Under these circumstances, the ICA may have to be sacrificed in order to treat the CCF. Herein we describe a double-balloon technique for embolization of a CCF. By applying this technique, we successfully treated nine of 11 CCFs, without compromise of the parent ICA when the conventional one-balloon technique failed.

Cavernous sinus gas

Gas within the cavernous sinus is an unusual finding. We report three patients who demonstrated gas in the cavernous sinus on computerized tomography (CT). The clinical information of these patients was reviewed for the possible source of the gas and the symptoms induced by the gas. Cavernous sinus gas was seen in two patients with sphenoid sinus fracture and in one patient after intravenous fluid infusion. None of the patients had symptoms referable to the cavernous sinus gas, but one patient had a grave prognosis due to trauma. Identification of cavernous sinus gas on CT and correlation with the clinical information is mandatory for further management.

Endovascular embolization of intractable epistaxis

BACKGROUND

We undertook this study to define the role of angiography and endovascular embolization in the treatment of patients with intractable epistaxis.

METHODS

A series of 19 patients with massive intractable epistaxis, all treated with endovascular embolization were reviewed. There were 15 males and four females ranging in age from 18 to 70 years, with a mean age of 38 years. The predisposing factors of intractable epistaxis were head and neck tumors (n = 11), idiopathic symptoms (n = 3), surgical complications (n = 2), arteriovenous malformation of the face (n = 1), thrombocytopenia (n = 1) and trauma (n = 1). Polyvinyl alcohol (PVA) particles and gelfoam plugs were used as embolic agents in 11 patients for devascularization; detachable balloons with N-butyl-2-cyanoacrylate (NBCA) were used in four patients for vascular occlusion; NBCA and/or coils were used in four patients in the carotid and subclavian arteries for obliteration of pseudoaneurysms.

RESULTS

Complete cessation of epistaxis was achieved in all 19 patients immediately after embolization. Seven patients had also undergone surgical tumor removal at two to five days after embolization. Two patients experienced mild to moderate facial pain on the first day after the procedure, but the symptoms later subsided. No significant complication or recurrence was observed in 18 patients. One patient with advanced hypopharyngeal carcinoma died two weeks after embolization due to another episode of massive epistaxis. Clinical follow-up for these patients was 15 days to eight years, with a mean of 41 months.

CONCLUSIONS

Therapeutic endovascular embolization of intractable epistaxis is both efficient and safe. It should be considered as the primary treatment modality in intractable epistaxis.

Imaging of invasiveness of pituitary adenomas

The purpose of our study was to examine the tumor size, imaging invasiveness of the pituitary macroadenomas (PMA) and to evaluate the directions of PMA spread. One hundred and thirty-five patients with PMA were examined with MRI and/or CT for pre-operative evaluation. We retrospectively reviewed the CT and MRI to identify tumor size, extension and to evaluate the directions of tumor spread. One hundred and seventeen patients (87%) had suprasellar extension with compression of optic apparatuses, twelve patients (9%) had extension of tumor upward to hypothalamus and third ventricle. Infrasellar extension via the floor of the sella and sphenoid sinus was found in thirty-eight patients (28%), and further downward extension to ethmoid sinus, nasopharynx and/or skull base was depicted in five patients (4%). Twenty-two patients (16%) had lateral invasion to the cavernous sinus and associated cranial nerves. Temporal and frontal extensions were depicted in seven patients (5%) and six patients (4%), respectively. Five patients (4%) had posterior subtentorial extension to posterior fossa. Histologically, only two patients showed microscopic invasive features. There was no correlation between histologic features and imaging invasiveness. The PMA had the potential of multi-directional extension. This experience indicated any type of pituitary adenoma could invade surrounding structures. Suprasellar invasion was the most common direction of pituitary adenoma spread, followed by infrasellar, lateral, anterior and posterior routes.

Neurotransmitters and neuropeptides in the developing human central nervous system. A review

This is a review on the ontogenesis of major neurotransmitters and neuropeptides in the developing human central nervous system. In general, the molecules under study appeared early in development, usually in the first trimester. Cholinergic neurons were found to be present around the time of neuropeptide formation. The newly formed neuropeptidergic fibers extended towards the cholinergic centers where both might interact. In the major centers of the central nervous system, neuropeptides were also noted to colocalize with various neurotransmitters. For example, in the facial nucleus, enkepahlin and substance P fibers coexisted with cholinergic and catecholaminergic neurons, suggesting complex interactions. In the interpeduncular nucleus, peptidergic neurons acting as interneurons clearly modulated the afferent input to this nucleus. In the hippocampus and in sensory organs such as the retina, there were indications that neuropeptides and gamma-amino butyric acid coexisted. We hypothesize that interactions of neurotransmitters and peptides in neurons and fibers early in development play an indispensable role in the morphogenesis of the human central nervous system.

Orbital invasion in nasopharyngeal carcinoma: evaluation with computed tomography and magnetic resonance imaging

BACKGROUND

Ocular symptoms and tumor cranial nerve involvement are commonly observed in patients with nasopharyngeal carcinoma (NPC). These are primarily due to tumor invasion of the cavernous sinus and/or skull base, as direct tumor invasion of the orbit is very rare. This study was designed to assess computed tomography (CT) and magnetic resonance imaging (MRI) in documenting orbital invasion caused by NPC, with a special emphasis on the route of orbital extension.

METHODS

A total of 562 patients with histopathologically prove NPC were examined using CT and/or MRI for tumor staging or post-treatment follow-up. We retrospectively reviewed CT and MRI findings to identify tumor invasion to orbital cavities and to evaluate the pathway of tumor spread.

RESULTS

Eighteen patients had tumor extension into the orbital cavities. Seventeen patients had ocular complaints. Fourteen of 18 showed unilateral orbital involvement and four patients showed bilateral orbital involvement. The route from the pterygopalatine fossa and inferior orbital fissure into the orbital cavities was the most common pathway of NPC invasion (n = 13), followed by ethmoid sinus and/or sphenoid sinus into the orbits (n = 4). In one patient, the route of orbital invasion was difficult to determine due to massive tumor extension.

CONCLUSION

Direct orbital invasion is rare in NPC. The pterygopalatine fossa and inferior orbital fissure are the most common routes of invasion, followed by invasion via the ethmoid and/or sphenoid sinuses. Coronal sections best show these findings on CT or MRI. Our study also shows that either CT or MRI provide essential information in documenting orbital invasion and determining the pathway of tumor spread.

Verifying complete obliteration of carotid artery-cavernous sinus fistula: role of color Doppler ultrasonography

The purpose of this study was to evaluate the role of color Doppler ultrasonography in verifying obliteration of carotid artery-cavernous sinus fistula before and after therapeutic embolization or gamma knife radiosurgery. Before treatment, carotid artery-cavernous sinus fistula showed the following data on color Doppler ultrasonography: (1) increased blood flow in the common carotid artery (220 to 1264 ml/min with mean+/-SD of 728+/-378 ml/min); internal carotid artery (435 to 1097 ml/min with mean+/-SD of 834+/-216 ml/min) in fistulas of the direct type; and external carotid artery (85 to 257 ml/min with mean+/-SD of 170+/-75 ml/min) in fistulas of the indirect type in comparison to the contralateral side; (2) reverse pulsatile flow or spiculated wave form with turbulent flow in the engorged superior ophthalmic vein on the lesion side in all patients. All of the above abnormal hemodynamic changes became normal in six patients immediately after first embolization, in two patients with balloon embolization combined with subsequent direct embolization by direct puncture through the superior orbital fissure or internal carotid artery embolization, and in five patients after gamma knife radiosurgery at 4, 4, 8, 9, and 9 months, respectively. Color Doppler ultrasonography might be a good modality in long-term follow-up of carotid artery-cavernous sinus fistula after gamma knife radiosurgery and embolization.

Endovascular embolization of arteriovenous fistulas of the external carotid artery

BACKGROUND

External carotid arteriovenous fistulas (AVFs) are rare and most hospitals have limited experience with their management. This study was designed to evaluate the effectiveness and safety of endovascular embolization of AVFs of the external carotid artery under angiographic control.

METHODS

A series of 13 patients with AVFs involving the branches of the external carotid artery, all treated with endovascular embolization, were reviewed. There were 10 males and three females ranging in age from nine to 46 years, with a mean of 27 years. The most frequent presenting symptoms were pulsatile tinnitus, followed by bruit and/or thrill, ocular problems, headache and a pulsatile mass in the neck. The middle meningeal artery was most often involved, followed by the internal maxillary artery and the occipital artery. The AVFs were caused by trauma in 10 patients and occurred spontaneously in three. N-butyl-2-cyanoacrylate was used to embolize the fistula in 11 patients and a detachable balloon was used in two.

RESULTS

All the patients were cured and no significant complications were observed. No recurrence was noted after a clinical follow-up of three months to seven years (mean, 37 months).

CONCLUSIONS

Endovascular embolization proved to be a safe and effective procedure. It should be the treatment of choice for repair of external carotid AVFs.

Differential expression of calretinin, calbindin D28K and parvalbumin in the developing human cerebellum

Three calcium-binding proteins, calretinin, calbindin D28K and parvalbumin, were immunohistochemically localized in the human cerebellum at different developmental stages. Cells positive for calretinin were not detected during early development of the cerebellum until 21 weeks of gestation at which stage weak staining was found in Purkinje and basket cells of the cortex and in neurons of the dentate nucleus. Both the number of positive cells and the intensity of immunoreactivities were found to increase as the cerebellum became more mature. Calbindin D28K immunoreactivity was, however, detected early in development at 14 weeks of gestation. Positive cells were found in Purkinje, basket, stellate and granule cells of the cerebellar cortex and in neurons of fastigial, globose, emboliform and dentate nuclei. The number of positive cells and the staining intensity for calbindin in both the cerebellar cortex and deep nuclei decreased at more advanced developmental stages. At 21-31 weeks of gestation, positive staining was restricted to Purkinje and basket cells of the cortex. Parvalbumin immunoreactivity was also observed early in development at 14 weeks of gestation. Positivity was found in Purkinje, basket and stellate cells of the cerebellar cortex and in neurons of all the deep nuclei, with the highest number of positive cells in the fastigial nucleus followed by emboliform, globose and dentate nuclei. As the cerebellum became more mature, both the number of positive cells and the staining intensity for parvalbumin decreased in the cortex and deep nuclei. The results of the present study showed that among the three calcium-binding proteins examined, strong immunoreactivities for calbindin D28K and parvalbumin were found inthe human cerebellum early in development at 14 weeks of gestation, but there was a decrease in both the intensity and number of positive cells at more advanced stages. In contrast, calretinin positive cells were not detected until 21 weeks of gestation and the immunoreactivity increased as the cerebellum became more mature. A possible correlation between the developmentally regulated expression of the calcium-binding proteins and expression of different neurotransmitters during development is discussed.

Intracranial ganglioglioma: CT and MRI findings

Thirteen cases of pathologically proved intracranial gangliogliomas were reviewed in order to define the characteristic computed tomography (CT) and magnetic resonance image (MRI)-features. All patients were evaluated with CT and four of them were studied by MRI. Six tumors were cystic dominant mixed masses with remarkable focal contrast enhancement (6/13, 46%); and seven were solid in nature with variable contrast enhancement (7/13, 54%). Nine of them contained calcification (9/13, 69%). The temporal lobe was affected in six patients (6/13, 46%); the posterior fossa in four patients; the frontal lobe in two; the remaining huge one in the frontal, temporal and basal ganglion. On MRI, the findings were similar to those of the CT. Gangliogliomas do not have a characteristic CT and MRI features. They may appear as pure cystlike tumors, cystic dominant mixed tumors with remarkable focal contrast enhancement, solid tumors with variable contrast enhancement or diffuse involving the brain parenchyma and/or subarachnoid spaces. However, radiologists should include ganglioglioma in the differential diagnosis when we find patient has a long-standing process as well as a calcified tumor in the temporal lobe with following characteristic; cystic dominant mixed tumor with remarkable focal contrast enhancement, or a solid mass without hemorrhage or significant surrounding edema.

Immunohistochemical studies of GABA and parvalbumin in the developing human cerebellum

The localization of GABA and parvalbumin was studied in the developing cerebellum of human fetuses from 16 to 28 weeks of gestation. The avidin-biotin complex immunohistochemical method combined with silver staining were used to reveal the presence of GABA- and parvalbumin-positive neurons and nerve fibres. As early as the 16th week of gestation, GABA immunopositivity was observed in the cerebellar cortex and the deep nuclei. GABA-positive neurons included Purkinje cells, stellate and basket cells of the cerebellar cortex and neurons in the deep nuclei. The gradient of immunoreactivity increased with the maturing cells, being weak at 16 weeks and becoming markedly pronounced at 28 weeks of gestation. GABA-immunopositive mossy fibres were observed in the granular cell layer at 16 weeks, and by 28 weeks, a robust fibre network was present in the cortex and deep nuclei. Immunohistochemical localization for parvalbumin indicates that weak immunoreactivity was observed in Purkinje cells, stellate and basket cells at 16 weeks of gestation, increasing in intensity with advancing age, notably in the Purkinje cells which had acquired an elaborate arbor of neurites at 28 weeks of gestation. In the deep nuclei, parvalbumin-positive cells and nerve fibres were observed throughout the 16 to 28 week period. These results indicate that GABA- and parvalbumin-positive neurons and fibres appeared as early as 16 weeks of gestation, expressing a high degree of immunoreactivity by the 28 week of fetal age.

Tyrosine hydroxylase- and dopamine-beta-hydroxylase-positive neurons and fibres in the developing human cerebellum--an immunohistochemical study

Six human fetuses of gestational ages 16-28 weeks were employed. The immunocytochemical avidin-biotin-peroxidase complex method combined with the silver Bodian technique was used to evaluate the presence of tyrosine hydroxylase and dopamine-beta-hydroxylase neurons and afferent and efferent fibres in the cerebellum during development. Our results illustrated that by 16-18 weeks, immunoreactivity of the Purkinje cells and the granule cells was evident. By 23 weeks, the positive Purkinje cells were tightly packed together and the perinuclear granules began to extend into the processes. The positive cells next to Purkinje cells were the basket cells and stellate cells. By 26-28 weeks, all positive cells increased in number and size. Mossy and climbing fibres appeared early in development (16-18 weeks of gestation) and were seen synapsing with the positive granule cells. At the same time, some parallel fibres were observed. At later stages, the tyrosine hydroxylase- and dopamine-beta-hydroxylase-positive Purkinje cells were surrounded by abundant climbing fibres, while parallel fibres were also evident in the molecular layer. In the deep cerebellar nuclei, positive tyrosine hydroxylase and dopamine-beta-hydroxylase neurons were present by 16-18 weeks of development. Those in the dentate nucleus were more polymorphic but smaller in size. Some afferent fibres were also spotted around 16-18 weeks of gestation and their numbers increased later. Positive efferent fibres were present by 26 weeks. All these observations point to an early presence of tyrosine hydroxylase and dopamine-beta-hydroxylase components in cerebellar development.

Distribution of neuropeptide Y in the developing human spinal cord

The distribution of neuropeptide Y at different levels of the spinal cord of 23 human fetuses aged from 10-41 weeks of gestation was studied using immunocytochemical staining. Neuropeptide Y-immunoreactive neurons were identified at all levels of the spinal cord examined as early as 10 weeks of gestation. These cells were localized in the superficial layers (laminae I and II of Rexed) of the dorsal gray matter. As the age of the fetuses increased, their cell number increased and the region containing positive neurons extended from the superficial to deep layers (laminae III and VI). Immunoreactive fibers started to appear in fetuses at 10 weeks of gestation. They were found not only in the gray and white matters, but also in the pia mater lining the spinal cord. As the fetuses aged, the neuropeptide Y-immunoreactive fibers became mostly concentrated in the intermediate zones of the thoracic and sacral segments corresponding to the developing autonomic centers. Our results suggest that neuropeptide Y may play a role in the early development of the autonomic system.

An immunohistochemical study of neuropeptide Y positive sites in the developing human hippocampal formation

Neuropeptide Y (NPY)-positive sites were evaluated by immunohistochemistry in the hippocampal formation of human fetuses aged from 15 to 41 weeks of gestation. Immunopositive cells and fibers were identified in the hippocampus as early as 15 weeks of gestation. These cells were localized in the polymorphic and pyramidal layers and their numbers increased with the age of the fetuses. NPY-positive cells were observed to be closely apposed to blood vessels and some NPY fibers, present mainly in the polymorphic layer, would infiltrate the alveus.

Habenulo-interpeduncular descending pathways and their relationship to enkephalin- and somatostatin-immunoreactive neurons in the interpeduncular nucleus of human fetuses

The interpeduncular nucleus of six human fetuses aged 15 (one specimen), 26 (one specimen), 38 (one specimen) and 40 (three specimens) gestation weeks was studied by immunohistochemistry for enkephalin and somatostatin localization and immunohistochemistry coupled with silver staining. Enkephalin-positive and somatostatin-positive cells were detected, the former initially at 15 weeks gestation and the latter at 26 weeks gestation. They appeared to receive long afferents from the habenular region and projected short efferents to adjacent cells devoid of enkephalin and somatostatin positivity. We postulate that these enkephalin- and somatostatin-positive neurons function as modulatory interneurons in the habenulo-interpeduncular and related pathways.

Immunohistochemical localization of enkephalin and substance P in the nucleus caudalis of the spinal trigeminal V in the medulla oblongata of the human fetus

The distribution of enkephalin-positive neurons, substance P-positive and enkephalin-positive fibers was studied in the nucleus caudalis of the trigeminal spinal V in the medulla oblongata regions of developing humans (12 weeks gestation to 40 weeks gestation). Enkephalin-positive neurons were identified in all the subnuclei of the nucleus caudalis as early as 12 weeks of gestation and increased in number as the fetus aged. Substance P-positive neurons were absent in this area throughout development. On the other hand, substance P-positive and enkephalin-positive fibers were present in all the subnuclei, again commencing as early as 12 weeks of gestation. These fibers tended to be linked to each other in the different subnuclei and to the reticular formation in this area and to increase significantly in quantity by the latter quarter of pregnancy. These results show the early presence of these neurons and fibers in the first trimester of development.

Acetylcholinesterase-containing neurons, substance P and enkephalin fibers in the ventral horns of developing human embryos and fetuses

The presence of the acetylcholinesterase neurons and substance P-like and enkephalin-like fibers in the various nuclear columns of the ventral horns of the spinal cords was studied in the developing human by acetylcholinesterase histochemistry and substance P and enkephalin immunohistochemistry. Acetylcholinesterase-positive neurons initially appeared in the lateral neuronal columns and eventually were also observed in the medial columns as well as the median columns at various levels of the spinal cord by 10 weeks' gestation. Acetylcholinesterase-positive neurons in the lower sacral levels were not detected until 11-12 weeks' gestation. Diffused substance P- and enkephalin-like fibers were demonstrated as early as 10 weeks' gestation but did not align with any particular nuclear column until after 15 weeks' gestation. These fibers further increased in length and adopted reticular branching patterns and many of these tended to surround the cell bodies of the nuclear columns. Possible interaction of acetylcholinesterase neurons and substance P and enkephalin fibers would commence by 15 weeks' gestation.

Localization of acetylcholinesterase positive neurons and substance P and enkephalin positive fibers by histochemistry and immunohistochemistry in the sympathetic intermediate zone of the developing human spinal cord

Localization of acetylcholinesterase positive neurons and substance P and enkephalin fibers were studied by histochemistry and immunohistochemistry in the intermediate sympathetic zone of the spinal cords of 39 human embryos/fetuses from gestation ages five to 40 weeks. Acetylcholinesterase positive neurons were observed in the nucleus intermediolateralis pars principalis as early as the fifth week of gestation. By the ninth to 13th weeks of gestation, positive neurons were also seen in the nuclei intermedialis pars funicularis, intercalatus spinalis and intercalatus pars paraependymalis. Increase in amount of these positive acetylcholinesterase neurons was demonstrated till term. Substance P and enkephalin fibers were initially observed by the eighth gestation week in the intermediolaterlis pars principalis nucleus and positive fibers were then detected in the nucleus intermedialis pars funicularis as well as the nucleus intercalatus spinalis by the 14th week of gestation. By the 26th week of gestation, all the major nuclei intermediolateralis par principalis, intermedialis pars funicularis, intercalatus spinalis and intercalatus pars paraependymalis has substance P and enkephalin fibers. Initial demonstration of acetylcholinesterase positive neurons appeared to be at an earlier stage than that of our substance P and enkephalin positive fibers.

Development and localization of enkephalin and substance P in the nucleus of tractus solitarius in the medulla oblongata of human fetuses

The presence of enkephalin and substance P-positive neurons and fibers were studied by immunohistochemistry (peroxidase-antiperoxidase or avidin-biotin-peroxidase complex methods) in 26 human fetuses ranging from 11 weeks of gestation to 40 weeks of gestation. Enkephalin-positive neurons were localized in the commissural, medial and intermediate subnuclei as early as 11-12 weeks' gestation. Positive enkephalin fibers were localized around 12 weeks' gestation and in many subnuclei, notably the medial, commissural, intermediate, ventrolateral, ventral and dorsolateral subnuclei. Substance P-positive neurons were localized in the commissural and medial subnuclei around gestation age 13 weeks. Positive substance P fibers appeared even earlier, around 11 weeks of gestation in many subnuclei, notably the medial, intermediate, ventral, ventrolateral and dorsolateral subnuclei. Increase in both enkephalin- and substance P-positive fibers was evident in the later stages of development (e.g. around 26 weeks of gestation). The importance of the early appearance of enkephalin and substance P neurons and fibers of the pain pathways in the major subnuclei connecting with the cardiovascular, gastrointestinal and respiratory functions in the human has to be stressed.

Localization of substance P and enkephalin by immunohistochemistry in the spinal cord of human fetus

The peroxidase-antiperoxidase method was used to study the distribution of substance P and enkephalin during development of the spinal cords of human fetuses. Thirty-seven cases were collected, ranging from 5- to 40-weeks-old (fetal ages). Both types of transmitters were present initially around the fifth week in the mantle layer of the base of the dorsal horn, around the tenth week at the anterior gray and the intermediate gray and around the sixth week at the marginal layer at the base of the ventrolateral funiculus. Substance P- and enkephalin-positive sites at the marginal layers at the base of the dorsolateral funiculus were evident in the same area at 5-6 weeks. The positive fibers in the dorsal horn were initially located in the superficial layers. By the eleventh week, the positive sites spread to other surface layers at the lateral sides of the dorsal horns bilaterally at all spinal levels above the sacral. In the sacral levels adjacent to the conus medullaris, the spreading to surface layers was not apparent bilaterally until the seventeenth week. By weeks 18-26 the positive sites penetrated deeper in the dorsal horn and by week 27 assumed the adult path. The enkephalin cell bodies were present in the Rexed layers I and II of the dorsal horn and the substance P-positive sites were apparent in the dorsal ganglia of the 28-40-week-old fetuses.