Characterization of chronic subdural hematoma fluid proteome

BACKGROUND

Chronic subdural hematoma (CSDH) is commonly caused by head injury, but the progression of CSDH is recognized as an inflammatory process. The protein composition of the CSDH fluid has not been fully elucidated, nor has the contribution of its components to the enlargement of the hematoma cavity and to its chronic manifestation.

OBJECTIVE

To characterize the protein content of CSDH fluid and study the differences between CSDH fluid and serum to identify proteins putatively involved in the pathogenesis of CSDH.

METHODS

CSDH fluid and serum of 5 patients were investigated with 2-dimensional gel electrophoresis followed by glycosylation-specific fluorescence staining and mass spectrometry.

RESULTS

Two-dimensional gel electrophoresis revealed approximately 1100 protein spots in the CSDH fluid. We identified 213 spots representing 57 different proteins, most of which were glycosylated. The comparison with serum revealed 11 proteins with elevated levels in the CSDH fluid including carbonic anhydrase I, catalase, ferritin light chain, fibrinogen (α, β, γ), hemoglobin (α, β), malate dehydrogenase, peroxiredoxin 2, and transforming growth factor-β-induced protein ig-h3. The levels of haptoglobin and a fragment of complement C4 were decreased. Changes in spot positions were detected for apolipoprotein A1 and a fragment of complement C3.

CONCLUSION

The hematoma fluid originates mainly from blood and the results suggest the involvement of coagulation and fibrinolysis cascades. However, proteins with a potential role in CSDH pathogenesis were detected including carbonic anhydrase I, transforming growth factor-β-induced protein ig-h3, and the altered components of the complement system. Inflammation and fibrosis indicate targets for further studies in the pathogenesis of CSDH.

Prospective flutemetamol positron emission tomography and histopathology in normal pressure hydrocephalus

BACKGOUND/OBJECTIVE: To determine the level of association between uptake of the amyloid positron emission tomography (PET) imaging agent [(18)F]flutemetamol and the level of amyloid-β measured by immunohistochemical and histochemical staining in a frontal cortical region biopsy site.

METHODS

Seventeen patients with probable normal pressure hydrocephalus (NPH) underwent prospective [(18)F]flutemetamol PET and subsequent frontal cortical brain biopsy during ventriculoperitoneal shunting. Tissue amyloid-β was evaluated using the monoclonal antibody 4G8, thioflavin S and Bielschowsky silver stain.

RESULTS

Four of the 17 patients (23.5%) had amyloid-β pathology based on the overall pathology read and also showed increased [(18)F]flutemetamol uptake. [(18)F]Flutemetamol standardized uptake values from the biopsy site were significantly associated with biopsy specimen amyloid-β levels (Pearson's r = 0.67; p = 0.006). There was also good correlation between the biopsy specimen amyloid-β level and uptake of [(18)F]flutemetamol in the region contralateral to the biopsy site (r = 0.67; p = 0.006), as well as with composite cortical [(18)F]flutemetamol uptake (r = 0.65; p = 0.008). The blinded visual read showed a high level of agreement between all readers (κ = 0.88). Two of 3 readers were in full agreement on all images; 1 reader disagreed on 1 of the 17 NPH cases. Blinded visual assessments of PET images by 1 reader were associated with 100% sensitivity to the overall pathology read, and assessments by the 2 others were associated with 75% sensitivity (overall sensitivity by majority read was 75%); specificity of all readers was 100%.

CONCLUSIONS

[(18)F]Flutemetamol detects brain amyloid-β in vivo and shows promise as a valuable tool to study and possibly facilitate diagnosis of Alzheimer's disease both in patients with suspected NPH and among the wider population.

Factors related to acute hydrocephalus after subarachnoid hemorrhage

PURPOSE

To evaluate the influence of the amount and distribution of blood on acute ventricular enlargement in subarachnoid hemorrhage (SAH).

MATERIAL AND METHODS

In a retrospective study, non-contrast computed tomography (CT) images of 180 patients with aneurysmal SAH were analysed by two neuroradiologists. The amount and distribution of the hemorrhage were scored, and prospective hydrocephalus was identified on the basis of acute CT images by calculating the cella media index, by measuring the width of the third ventricle, and by visual impression. Statistical analysis was done using the logistic regression model, analysis of variance, and chi-square test.

RESULTS

The incidence of acute hydrocephalus was higher among the patients with blood distributed in the anterior, lateral, and basal regions (70.8%) than among the patients who did not have blood distributed in all three areas (P=0.010). The proportion of acute hydrocephalus differed depending on the type of hemorrhage (P<0.001). Intraventricular hemorrhage was the most consistent predictive factor in the logistic regression model, while the other predictive factors included the total blood amount score and the volume of intracerebral hemorrhage.

CONCLUSIONS

A positive correlation was found between acute hydrocephalus and the amount of subarachnoid and, more importantly, intraventricular blood. This is consistent with the literature and confirms the current pathophysiologic concepts that the acute hydrocephalus following SAH is an obstructive form of hydrocephalus.

Presacral arteriovenous fistula: case report

OBJECTIVE AND IMPORTANCE

We describe a case of arteriovenous fistula in front of the sacrum. Drainage induced epidural venous dilation in the sacral spinal canal. The fistula was embolized endoarterially with n-butyl-2-cyanoacrylate via its iliac arterial feeders. In follow-up digital subtraction angiography 1 month later, the fistula was found to be totally closed. The patient was followed up clinically for 2.5 years. She has remained symptom-free.

CLINICAL PRESENTATION

A previously healthy 43-year-old woman presented with severe gluteal and perineal pain and a local sensation of hyperesthesia. The primary computed tomographic scan of the lumbosacral spine was normal, and emergency laparoscopy showed no signs of any pathological lesions. Magnetic resonance imaging discovered an unidentified mass in the sacral spinal canal, and the patient was hospitalized for neurosurgery. However, surgery on this mass had to be discontinued because of profuse bleeding, and the patient was referred for angiography.

INTERVENTION

Diagnostic catheter angiography revealed a high-flow arteriovenous fistula anterior to the sacrum, and the mass detected earlier by magnetic resonance imaging seemed to be a dilated epidural vein draining the fistula. The feeders of the fistula originated in both internal iliac arteries, and the fistula was occluded via these arteries in two angiographic sessions.

CONCLUSION

A paraspinal arteriovenous fistula may have venous drainage through the epidural venous plexus, and the ectatic veins may induce radicular symptomology. To the best of our knowledge, a paraspinal fistula at such a presacral location has not been documented previously. An unidentified mass in the sacral spinal canal should be suspected of being a dilated vascular structure. Prompt angiographic examinations with an option for embolization should be performed, and open surgical intervention should be avoided.

Value of the quantity and distribution of subarachnoid haemorrhage on CT in the localization of a ruptured cerebral aneurysm

BACKGROUND

Computed tomography (CT) is the "gold standard" for detecting subarachnoid haemorrhage (SAH) and digital subtraction angiography (DSA) for visualising the vascular pathology. We studied retrospectively 180 patients with subarachnoid haemorrhage (SAH) who underwent first non-enhanced computed tomography (CT), then digital subtraction angiography (DSA) and finally operative aneurysm clipping. Our aim was to assess if the location of the ruptured aneurysm could be predicted on the basis of the quantity and distribution of haemorrhage on the initial CT scan.

METHODS

180 patients with SAH were retrospectively studied. All the CT and DSA examinations were performed at the same hospital. CT was performed within 24 hours after the initial haemorrhage. DSA was performed after the CT, within 48 hours after the initial haemorrhage. Two neuroradiologists, blind to the DSA results, analysed and scored independently the quantity and distribution of the haemorrhage and predicted the site of the ruptured aneurysm on the basis of the non-enhanced CT. DSA provided the location of the ruptured aneurysm. All the patients were operated upon, and the location of the ruptured aneurysm was determined.

FINDINGS

The overall reliability value (kappa-value) between the two neuroradiologists for locating all ruptured aneurysms was 0.780. The corresponding value for the right MCA was 0.911, that for the left MCA 0.877 and that for the AcoA 0.736. Not all of the kappa-values were calculated, either because the location of the rupture was constant or because the number of ruptures in the vessel was too small. Subarachnoid haemorrhage with a parenchymal hematoma is an excellent predictor of the site of the ruptured aneurysm with a statistical significance of p=0.003.

INTERPRETATION

The quantity and pattern of the blood clot on CT within the day of onset of SAH is a reliable and quick tool for locating a ruptured MCA or AcoA aneurysm. It is not, however, reliable for locating other ruptured aneurysms. Subarachnoid haemorrhage with a parenchymal hematoma is an excellent predictor of the site of a ruptured aneurysm.

High concentrations of procollagen propeptides in chronic subdural haematoma and effusion

Procollagen propeptides increase in the CSF after subarachnoid haemorrhage, reflecting increased collagen synthesis in the arachnoid. We studied the induction of dural collagen synthesis after cerebral trauma by measuring the carboxyterminal propeptide of type I procollagen (PICP) and the aminoterminal propeptide of type III procollagen (PIIINP) in 17 subdural haematoma or effusion fluid samples obtained at operation on days 10-85 after head trauma. The concentration of PICP was 78-fold higher and that of PIIINP 156-fold higher, relative to that in the serum. These results indicate that meningeal trauma is followed by a long lasting increase in dural collagen synthesis, and suggest that enhanced synthesis of the various extracellular matrix components may have a role in the development of chronic subdural haematoma or effusion.

Transient increase in procollagen propeptides in the CSF after subarachnoid hemorrhage

BACKGROUND

Meningeal fibrosis following subarachnoid hemorrhage (SAH) has been verified histologically in experimental animals and in human autopsy samples, but the clinical course of the intrathecal fibroproliferative reaction is unknown. The authors therefore studied time-related changes in the CSF concentrations of type I (PICP) and type III (PIIINP) procollagen propeptides in patients with recent SAH.

METHOD

Fifty-two CSF samples were obtained from 39 patients with SAH treated surgically and eight samples from eight patients with SAH who were not surgically treated. The samples were analyzed for PICP and PIIINP by using radioimmunoassays.

RESULTS

The authors found a time-dependent increase in PICP and PIIINP in the CSF of the patients with SAH. Two weeks after the hemorrhage, concentrations were four times higher in patients with SAH than the concentrations in the control subjects. Concentrations in patients with SAH then declined steadily, but remained slightly but significantly elevated even at 10 weeks. PICP and PIIINP did not correlate with the age or sex of the patient or the amount of blood in the initial CT scan. Four patients developed late posthemorrhagic hydrocephalus; their PICP and PIIINP levels were higher than in matched patients with SAH without hydrocephalus.

CONCLUSIONS

Time-dependent changes in CSF concentrations of PICP and PIIINP suggest a transient fibroproliferative reaction in the meninges after SAH. The considerable magnitude and extended time course of the changes make the measurement of PICP and PIIINP practicable for the diagnosis of a fibroproliferative state in patients with recent meningeal disease. Furthermore, the results suggest a role for meningeal fibrosis in the development of late posthemorrhagic hydrocephalus.

Increase of collagen synthesis and deposition in the arachnoid and the dura following subarachnoid hemorrhage in the rat

Arachnoidal fibrosis following subarachnoid hemorrhage (SAH) has been suggested to play a pathogenic role in the development of late post-hemorrhagic hydrocephalus in humans. The purpose of this study was to investigate the rate of collagen synthesis in the arachnoid and the dura in the rat under normal conditions and to study the time schedule and the localization of the increased collagen synthesis following an experimental SAH. We found that the activity of prolyl 4-hydroxylase, a key enzyme in collagen synthesis, was 3-fold higher in the dura than that in the arachnoid and was similar to the activity in the skin. We then induced SAH in rats by injecting autologous arterial blood into cisterna magna. After SAH, we observed an increase in prolyl 4-hydroxylase activity of the arachnoid and the dura at 1 week. At this time point the enzyme activity in both tissues was 1.7-1.8-fold compared to that in the controls and after this time point the activities declined but remained slightly elevated at least till week 4. The rate of collagen synthesis was measured in vitro by labeling the tissues with [(3)H]proline. The rate increased to be 1.7-fold at 1 to 2 weeks after the SAH in both of the tissues. Immunohistochemically we observed a deposition of type I collagen in the meninges at 3 weeks after the SAH. SAH is followed by a transient increase in the rate of collagen synthesis in the arachnoid and, surprisingly, also the dura. Increased synthesis also resulted in an accumulation of type I collagen in the meningeal tissue, suggesting that the meninges are a potential site for fibrosis. The time schedule of these biochemical and histological events suggest that meningeal fibrosis may be involved in the pathogenesis of late post-hemorrhagic hydrocephalus.

Detection of meningeal fibrosis after subarachnoid haemorrhage by assaying procollagen propeptides in cerebrospinal fluid

OBJECTIVE

To study whether meningeal collagen synthesis under normal conditions is reflected in the CSF and whether a meningeal fibroproliferative reaction or fibrosis after subarachnoid haemorrhage can be detected by measuring markers of collagen synthesis in the CSF.

METHODS

Serum samples and CSF were collected from 56 patients with various neurological symptoms and from nine patients with a recent subarachnoid haemorrhage. The concentrations of the carboxyterminal propeptide of type I procollagen (PICP) and the aminoterminal propeptide of type III procollagen (PIIINP) were measured using radioimmunoassays.

RESULTS

The mean(SD) concentration of PICP was 75.2 (SD 13.6) microgram/l and that of PIIINP 3.56 (SD 0.91) microgram/l in the CSF of the controls, and the CSF/serum ratios were 0.74 (SD 0.24) for PICP and 1.34 (SD 0.48) for PIIINP. A 1.4-fold increase in both the PICP (p=0.001) and the PIIINP (p=0.001) concentration was found in patients with a neurological disease and with an abnormal CSF leucocyte count or protein concentration. In eight patients with a recent subarachnoid haemorrhage the PICP was 5.9-fold higher (p<0.001) and the PIIINP concentration 7.7-fold higher (p<0.001) than that in the controls, whereas no difference was found in the serum values. Similar high concentrations were also found in a patient from whom the CSF sample was obtained before operation for aneurysm.

CONCLUSIONS

The intrathecal compartment is a site for active collagen synthesis under normal conditions. The synthesis rate is markedly increased in patients with a recent subarachnoid haemorrhage, suggesting a fibroproliferative reaction or fibrosis. Assays of procollagen propeptides may be useful in the clinical diagnosis of meningeal fibrosis and their use may enable the identification of diseases and symptoms aetiologically related to meningeal fibrosis.

The protective effect of guar gum against stress-induced gastric ulcers in the rat

After the methodology had been studied and pilot studies conducted, nine groups of rats (10 rats per group) were fed solutions of different compositions via orogastric tube during induction of stress ulcers by resistant and a cold ambient temperature. The first group was a control group and received no feeding. Group 2 rats received distilled water, group 3 rats guar gum in distilled water, group 4 rats wheat flour (placebo) in distilled water, group 5 rats a 10% solution of glucose in distilled water, group 6 rats guar gum in the 10% glucose solution, group 7 rats wheat flour in the 10% glucose solution, group 8 rats a 30% glucose solution and group 9 rats cimetidine, intraperitoneally. Cimetidine provided the best protection against stress-induced ulcers. Guar gum in distilled water was almost as effective as cimetidine. Slightly fewer rats (30%) exhibited ulcers in the guar gum group than in the cimetidine group (40%). However, the ulcers in the guar gum group were larger than those in the cimetidine groups. The percentage of rats with ulcers and the percentage of the largest category of ulcers decreased as the energy content of the solutions changed from 10% to 30% glucose and from the control percentages. The protective effect of guar gum in distilled water was reduced when it was infused in a 10% glucose solution. In the latter solution, the effect of guar gum was similar to that in the rats given wheat flour (placebo) in a 10% glucose solution.(ABSTRACT TRUNCATED AT 250 WORDS)

The protective effect of nutrients against stress induced gastric ulcers in the rat

The first part of the study consisted of 110 rats in 11 groups with ten rats in each. Nine of the groups were fed nutrient solutions of different compositions, antacid and sucralfate through orogastric tube during induction of stress ulcer by restraint and a cold ambient temperature. One group served as a control group and received no feeding and the 11th group was given cimetidine intraperitoneally. The extensiveness of the stress effect was estimated in each group by the number of rats with ulcer as percentage, the mean number of ulcers in each rat, the mean distribution of ulcers of different sizes, the mean total of mucosal damage in each rat and the contribution of ulcers of a different size to the total mucosal damage. The results showed that cimetidine is an effective protector against stress ulcer. Guar gum, Intralipid (fat emulsion), egg protein and 30 per cent glucose are slightly weaker protectors than cimetidine but much stronger than 10 per cent glucose wheat flour and distilled water. Sucralfate increased the susceptibility to stress ulcer. The second part of the study consisted of 86 rats. It showed, that guar gum increased the healing rate of stress ulcers. During a 30 hour treatment period after four hours of stress, the rats fed guar gum (n = 30) showed a lower (p less than 0.001) number of ulcers than the control rats fed normal rat food (n = 26) or immediately after the four hours of stress (n = 30). The mechanisms suggested for ulcer prevention and increased ulcer healing rate found herein may be due to reduced acidity, increased local mucosal supply of energy and mechanical protection.