Identification of Vortex Cores in Cerebral Aneurysms on 4D Flow MRI

BACKGROUND AND PURPOSE

The complexity and instability of the vortex flow in aneurysms are factors related to the rupture risk of unruptured cerebral aneurysms. We identified aneurysm vortex cores on 4D flow MR imaging and examined the relationship of these factors with the characteristics of cerebral aneurysms.

MATERIALS AND METHODS

We subjected 40 aneurysms (37 unruptured, 3 ruptured) to 4D flow MR imaging. We visualized streamlines with velocities below the threshold-that is, a percentage value of the aneurysm maximum inflow velocity-and progressively decreased the threshold to identify vortex cores as thin, streamline bundles with minimum velocities. Complexity and stability were compared in aneurysms with a smooth surface and those with blebs or daughter sacs.

RESULTS

The threshold for visualizing vortex cores ranged from 3% to 13% of the maximum inflow velocity. Vortex cores could be visualized in 38 aneurysms; in 2, they were not visualized through the cardiac cycle. A simple flow pattern (single vortex core) was identified in 27 aneurysms; the other 13 exhibited a complex flow pattern. The cores were stable in 32 and unstable in 8 aneurysms. Significantly more aneurysms with-than-without blebs or daughter sacs had a complex flow pattern (P = .006). Of the 3 ruptured aneurysms, 1 aneurysm had an unstable vortex core; in the other 2, the vortex core was not visualized.

CONCLUSIONS

The identification of vortex cores on 4D flow MR imaging may help to stratify the rupture risk of unruptured cerebral aneurysms.

Fabry disease

Fabry disease resulting from a deficiency of α-galactosidase A leads to the accumulation of globotriaosylceramide in various organs. Because the disease is an X-linked recessive disorder, males tend to develop more symptoms and more severe symptoms than females. There are also some variants of Fabry disease, and cardiac variant (cardiac Fabry disease) has the dysfunctions only in heart. Cardiac manifestations in Fabry disease are initially symmetrical and concentric left ventricular hypertrophy, and later progressive cardiac dysfunction with localized thinning of the basal posterior wall. In recent years, enzyme replacement therapy has been performed as a treatment for Fabry disease, and the initiation of this therapy is expected before the cardiac fibrosis develops. Therefore, early diagnosis of Fabry disease is essential, and echocardiography is an indispensable tool for clinical practice of this disease. Then, it is necessary to remember this disease as a differential diagnosis when encountering unexplained left ventricular hypertrophy.

Chemical Sclerosis of the Gallbladder

Chemical ablation of the gallbladder with absolute ethanol and polidocanol 3% was attempted in 23 and 10 pigs, respectively, after open transhepatic cholecystostomy. Absolute ethanol caused complete necrosis of the gallbladder epithelium in 10 pigs and partial necrosis with focally present gallbladder epithelium in 9. An intact epithelium was observed in 4 pigs but it was not possible to determine whether this epithelium was the original one, not affected by the ethanol, or regenerated after previous damage. Gallbladders with hemorrhage and hydrops were frequently encountered. Gallbladders treated with polidocanol all had an intact epithelium.

Pre-Embolization Study of Ruptured Cerebral Aneurysms with Helical CT

Sixteen ruptured aneurysms in 16 patients considered endovascular embolizations were examined. The findings of axial source images (axial images) and reconstructed three-dimensional CT angiography (3D-CTA) of helical CT were compared to those of rotational digital subtraction angiography (DSA). The aneurysmal neck and arterial branches adjacent to the neck were closely investigated.

In seven out of 16 cases (43.8%), information provided by axial images and/or 3D-CTA was more useful than that of rotational DSA in evaluating the aneurysmal neck and arterial branches. Helical CT can provide valuable information on ruptured aneurysms that cannot be obtained by rotational DSA in some patients.

This technique is useful to obtain anatomical information about aneurysms and to select the best therapeutic method.

Inflow Jet Patterns of Unruptured Cerebral Aneurysms Based on the Flow Velocity in the Parent Artery: Evaluation Using 4D Flow MRI

BACKGROUND AND PURPOSE

Inflow jet characteristics may be related to aneurysmal bleb formation and rupture. We investigated the visualization threshold on the basis of the flow velocity in the parent artery to classify the inflow jet patterns observed on 4D flow MR imaging.

MATERIALS AND METHODS

Fifty-seven unruptured aneurysms (24 bifurcation and 33 sidewall aneurysms) were subjected to 4D flow MR imaging to visualize inflow streamline bundles whose velocity exceeded visualization thresholds corresponding to 60%, 75%, and 90% of the maximum flow velocity in the parent artery. The shape of the streamline bundle was determined visually, and the inflow jet patterns were classified as concentrated, diffuse, neck-limited, and unvisualized.

RESULTS

At the 75% threshold, bifurcation aneurysms exhibited a concentrated inflow jet pattern at the highest rate. At this threshold, the inflow jets were concentrated in 13 aneurysms (group C, 22.8%), diffuse in 18 (group D, 31.6%), neck-limited in 11 (group N, 19.3%), and unvisualized in 15 (group U, 26.3%). In 16 (28.1%) of the 57 aneurysms, the inflow jet pattern was different at various thresholds. Most inflow parameters, including the maximum inflow velocity and rate, the inflow velocity ratio, and the inflow rate ratio, were significantly higher in groups C and D than in groups N and U.

CONCLUSIONS

The inflow jet pattern may depend on the threshold applied to visualize the inflow streamlines on 4D flow MR imaging. For the classification of the inflow jet patterns on 4D flow MR imaging, the 75% threshold may be optimal among the 3 thresholds corresponding to 60%, 75%, and 90% of the maximum flow velocity in the parent artery.

The Preventive Effect of Endovascular Treatment for Recurrent Hemorrhage in Patients with Spinal Cord Arteriovenous Malformations

BACKGROUND AND PURPOSE

Spinal cord AVMs represent rare and insufficiently studied pathologic entities. Embolization is thought to play an important role in the management of spinal cord AVMs. Factors for recurrent hemorrhage and the impact of endovascular treatment on prevention of recurrent hemorrhage remain to be confirmed. We aimed to assess recurrent hemorrhagic incidence of spinal cord AVMs and its prevention by endovascular treatment.

MATERIALS AND METHODS

We reviewed 80 patients with spinal cord AVMs by spinal cord angiography who had hemorrhage before the first endovascular treatment at New York University Medical Center, Beth Israel Medical Center, or Roosevelt Hospital in New York. We compared the baseline and radiologic characteristics of patients with and without recurrent hemorrhage by the log-rank test and the Cox proportional hazards model.

RESULTS

We observed recurrent hemorrhage in 35 (44%) patients (1/41 patients with endovascular treatment and 34/39 patients without endovascular treatment). The median length of total follow-up was 659 days (interquartile range, 129-2640 days), and the median length from first-to-recurrent hemorrhage was 369 days (interquartile range, 30-1596 days). The log-rank test revealed that endovascular treatment and venous thrombosis reduced recurrent hemorrhage, and associated aneurysm was related to recurrent hemorrhage. Even in multivariate analysis, the endovascular treatment reduced (hazard ratio, 0.027; P < .0001) and associated aneurysm increased (hazard ratio, 3.4; P = .044) the risk of recurrent hemorrhage.

CONCLUSIONS

Endovascular embolization is the first choice of treatment for spinal cord AVMs and is effective in preventing recurrent hemorrhage.

Parent artery curvature influences inflow zone location of unruptured sidewall internal carotid artery aneurysms

BACKGROUND AND PURPOSE

Future aneurysmal behaviors or treatment outcomes of cerebral aneurysms may be related to the hemodynamics around the inflow zone. Here we investigated the influence of parent artery curvature on the inflow zone location of unruptured sidewall internal carotid artery aneurysms.

MATERIALS AND METHODS

In 32 aneurysms, the inflow zone location was decided by 4D flow MR imaging, and the radius of the parent artery curvature was measured in 2D on an en face image of the section plane corresponding to the aneurysm orifice.

RESULTS

The inflow zone was on the distal neck in 10 (group 1, 31.3%), on the lateral side in 19 (group 2, 59.4%), and on the proximal neck in 3 (group 3, 9.4%) aneurysms. The radius in group 1 was significantly larger than that in group 2 (8.3 mm [4.5 mm] versus 4.5 mm [1.9 mm]; median [interquartile range]; P < .0001). All 7 aneurysms with a radius of >8.0 mm were in group 1. All 18 aneurysms with a radius of <6.0 mm were in group 2 or 3. In two group 3 aneurysms, the inflow zone was located in a part of the neck extending beyond the central axis of the parent artery.

CONCLUSIONS

The inflow zone locations of sidewall aneurysms can be influenced by the parent artery curvature evaluated in 2D on an en face image of the section plane corresponding to the aneurysm orifice.

Visualization of angiographical arteriovenous shunting in perisylvian glioblastomas

BACKGROUND

Arteriovenous shunting visualized by angiography is one of the major features of glioblastomas, and the visualization is dependent on the presence of extensive shunting. Extensive arteriovenous shunting is associated with the risk of poorly controlled intraoperative bleeding. When a tumor with extensive arteriovenous shunting is located in close proximity to the eloquent regions of the brain, a meticulous surgical procedure is necessary. In the present study, the site-oriented visualization of angiographical arteriovenous shunting was evaluated from the perspective of surgical treatment, with a particular focus on the perisylvian region that is in close proximity to motor and language regions (dominant hemisphere), as well as large arteries and veins.

METHODS

Twenty-six consecutive patients underwent a resection of glioblastoma between February 2007 and September 2012. All patients were presurgically examined using digital subtraction angiography. The patients were subdivided into the following two groups based on the location of the tumor: 1) perisylvian glioblastoma (18 patients) and 2) non-perisylvian glioblastoma (eight patients). Angiography to detect the arteriovenous shunting was performed. In addition, the number of intratumoral vessels, tumor proliferative activity (MIB-1 labeling index), and volume of intraoperative bleeding were evaluated and compared between the two groups.

RESULTS

Angiographical arteriovenous shunting was definitively visualized in 13 of 18 (72 %) perisylvian glioblastomas, in contrast to only one of eight (13 %) non-perisylvian glioblastomas (p = 0.007). There were no significant differences between the two groups with respect to the number of intratumoral vessels, MIB-1 labeling index, and volume of intraoperative bleeding. However, massive intraoperative bleeding of > 2,000 mL occurred in one perisylvian glioblastoma patient.

CONCLUSIONS

Glioblastomas in the perisylvian region tend to be associated with extensive arteriovenous shunting that can be definitively visualized by performing an angiography. Because arteriovenous shunting carries the risk of intraoperative bleeding, perisylvian glioblastomas-particularly in the dominant hemisphere-should be resected with a meticulous surgical procedure and strategy.

Broad-Host Range Gene Transporter Particles Produced by Aliivibrio fischeri

Aliivibrio fischeri NCIMB1281(T) (basonym, Vibrio fischeri) spontaneously started broad-host range vector particle (AfVP) production by budding from the logarithmic phase, and stabilised at around 7.0×10(10)-7.4×10(11) particles mL(-1) without any accompanying change in the host population. AfVPs had a spherical shape and varied in diameter from 18.1 to 159.2 nm [median±SD, 58.4±11.9 nm, n=528], with 95.1% between 30.2 and 84.6 nm in diameter exhibiting a normal distribution. Their buoyant density and DNA content ranged from 1.3607 to 1.3980 g cm(-3), and 17.3 to 95.3 kbp, respectively. Regardless of UV treatment, AfVPs enhanced the efficiency of plating 116-136% at a multiplicity of infection of ca. 140 in Escherichia coli AB1157. Generalised transduction was observed with a frequency of between 10(-4) and 10(-6) cells per AfVP without UV treatment. Upon infection, the particle membrane remained outside the recipient cell, and a string-like structure coated with a fibrous proteinaceous-like material was present. The growth of the E. coli transductant (AfV-E-trans) reached a maximum of ca. 415% that of the parental E. coli recipient. AfV-E-trans acquired the ability to produce budding particles.

Spinal arteriovenous metameric syndrome: clinical manifestations and endovascular management

BACKGROUND AND PURPOSE

SAMS is a rare form of SCAVM. We discuss the clinical presentation, endovascular management, and outcome of this disease in our series.

MATERIALS AND METHODS

Retrospective review was performed in patients with SCAVM and SAMS who underwent angiography with intent to treat at our institution from 1980 to 2010.

RESULTS

One hundred forty-eight SCAVMs were identified, and 28 (19%) of these were SAMS. Of these 28 patients, 24 had nidus-type AVMs and 4 had fistulas. SAMS were more prevalent in females (71% versus 48%), and also presented earlier than non-SAMS SCAVMs. Intradural hemorrhage (SAH or hematomyelia) was the most common presentation and more common than in non-SAMS lesions. Twenty-six patients underwent embolization of the intradural lesion in 50 sessions. Thirteen patients underwent treatment of intradural aneurysms in 16 sessions. Six patients underwent embolization of extradural lesions in 16 sessions. Twenty-three patients had an average of 94 months of clinical follow-up (3-309 months) after the first treatment, during which 5 patients had hemorrhages. Angiographic follow-up was performed in 20 patients at an average of 85 months (range, 3-309 months), which showed new development or enlargement of an aneurysm in 5 patients. This type of angiographic progression was more common in patients with SAMS.

CONCLUSIONS

SAMS most commonly presents with hemorrhage from the SCAVM. Endovascular embolization can be performed safely with good functional outcome, though most patients clinically deteriorate in the long term. Periodic angiographic follow-up with intent to perform preventive target embolization is important to control the disease.

Application of high-intensity focused ultrasound for umbilical artery occlusion in a rabbit model

OBJECTIVES

To investigate the application of high-intensity focused ultrasound (HIFU) for fetal umbilical artery blood flow occlusion in a rabbit model.

METHODS

A prototype HIFU transducer in combination with an imaging probe with Doppler capability was constructed. Using this transducer, HIFU was applied at 1.4, 2.75 or 5.5 kW/cm(2) through the maternal abdominal skin to the fetal intra-abdominal umbilical arteries of four time-mated Japanese White rabbits (11 fetuses) on gestational day 25. Courses of 5-s HIFU exposure were performed until cessation of umbilical blood flow and cardiac arrest were confirmed by Doppler ultrasonography. Fetal necropsy was performed and exposed lesions were assessed by microscopic histological analysis.

RESULTS

The mean diameter of the fetal umbilical artery was 0.6 +/- 0.2 mm and the mean peak systolic velocity of arterial blood flow was 44.7 +/- 18.5 cm/s. When HIFU was applied at 5.5 kW/cm(2), blood flow was completely occluded within 15 courses. HIFU exposure brought about vacuolar degeneration and destruction of elastic fibers in the tunica media of the artery.

CONCLUSIONS

HIFU can be used to occlude umbilical artery blood flow in fetal rabbits.

Rapid identification of marine bioluminescent bacteria by amplified 16S ribosomal RNA gene restriction analysis

To rapidly identify natural isolates of marine bioluminescent bacteria, we developed amplified ribosomal DNA restriction analysis (ARDRA) methods. ARDRA, which is based on the restriction patterns of 16S rRNA gene digested with five enzymes (EcoRI, DdeI, HhaI, HinfI, RsaI), clearly distinguished the 14 species of marine bioluminescent bacteria currently known, which belong to the genera Vibrio, Photobacterium, and Shewanella. When we applied ARDRA to 129 natural isolates from two cruises in Sagami Bay, Japan, 127 were grouped into six ARDRA types with distinctive restriction patterns; these isolates represented the bioluminescent species, P. angustum, P. leiognathi, P. phosphoreum, S. woodyi, V. fischeri, and V. harveyi. The other two isolates showing unexpected ARDRA patterns turned out to have 16S rRNA gene sequences similar to P. leiognathi and P. phosphoreum. Nevertheless, ARDRA provides a simple and fairly robust means for rapid identification of the natural isolates of marine bioluminescent bacteria, and is therefore useful in studying their diversity.

LuxA gene of light organ symbionts of the bioluminescent fish Acropoma japonicum (Acropomatidae) and Siphamia versicolor (Apogonidae) forms a lineage closely related to that of Photobacterium leiognathi ssp. mandapamensis

A molecular phylogenetic analysis of luxA gene sequences of light organ symbionts of the fish Acropoma japonicum (Acropomatidae) and Siphamia versicolor (Apogonidae) revealed that the sequences were related to those of Photobacterium leiognathi ssp. mandapamensis, which is not known to occur as a light organ symbiont among bioluminescent P. leiognathi clades. The presence of another lux gene element, luxF, coding for nonfluorescent protein, provided additional support for the identity of the light organ symbionts of the fish. Cladogenesis of the light organ symbiont P. leiognathi may be influenced by the radiation of host fishes.

Endovascular Treatment of Multiple Severe Atherosclerotic Stenoses with Cerebral Hypoperfusion

A 60-year-old man presented with syncope and transient left-sided motor weakness. Cerebral angiography revealed multiple severe atherosclerotic stenoses of bilateral internal carotid arteries, bilateral intracranial vertebral artery (VA), and left VA origin. A SPECT study showed poor cerebral perfusion and vascular reserve in the right cerebral hemisphere and the posterior circulation. We performed angioplasty and stentings for the VA stenoses first by using balloon-expandable stents.

The patient had shown no syncope attack ever since, which might be due to an increased vascular reserve in the posterior circulation. The following bilateral carotid angioplasty and stentings could be performed safely. Angioplasty and stenting is feasible, and can improve cerebral perfusion even in a patient with multiple severe atherosclerotic stenoses by pre-operative appropriate haemodynamic assessment.

An in vitro interethnic comparison of monoamine oxidase activities between Japanese and Caucasian livers using rizatriptan, a serotonin receptor 1B/1D agonist, as a model drug

AIMS

Monoamine oxidase (MAO) is located in human liver, and catalyses the oxidative deamination step of many xenobiotics. However, whether there exists an interethnic difference in MAO activities has, to our knowledge, not been clarified. We aimed to assess the MAO type A (MAO-A) involvement in the metabolic pathway of rizatriptan (RIZ), an antimigraine 5-hydroxytryptamine (5-HT)1B/1D agonist, and the interethnic difference in MAO activities between Caucasians and Japanese using RIZ as a model drug in in vitro experiments.

METHODS

Oxidative deaminase activities were determined with the subcellular fractions of Japanese livers and the microsomal fraction of Caucasian livers using RIZ, 5-HT (MAO-A substrate) and 2-phenylethylamine (PEA) (MAO-B substrate) as substrates.

RESULTS

The oxidative deaminase activities of RIZ vs. 5-HT were highly (r = 0.87 and 0.96, P < 0.001) correlated with each other in both the microsomal and mitochondrial fractions of Japanese livers. Subsequent results were obtained from in vitro experiments using liver microsomes based upon these findings. The oxidative deaminase activities of RIZ were inhibited completely by the nanomolar-order concentration of clorgyline and Ro 41-1049 (MAO-A selective inhibitors), but not by that of Ro 16-6491 (MAO-B selective inhibitor). The majority of the mean Michaelis-Menten values for three substrates toward MAO obtained from six Japanese and six Caucasian liver microsomes reached no significant differences between the two ethnic groups. The mean microsomal oxidative deaminase activities assessed in 18 Japanese and 20 Caucasian livers using the three substrates also showed no significant differences between the two ethnic groups.

CONCLUSIONS

RIZ is mainly metabolized by MAO-A and the in vitro oxidative deaminase activities mediated via MAO-A and -B do not appear to differ between Japanese and Caucasians.

[The efficacy of switch therapy in community-acquired pneumonia in Japan]

To evaluate the efficacy of Switch therapy for community-acquired pneumonia, we conducted a prospective randomized controlled study in thirty-two hospitalized patients. These cases corresponded to Fine's risk classes II to IV. Using a table of random numbers, sixteen patients were assigned to a Switch therapy group, and the other sixteen, to a clinical pathway group. Both groups initially received intravenous antimicrobials. Within the Switch therapy group, when all the patients were afebrile for more than sixteen hours, their intravenous antimicrobials were switched to oral, and the patients were discharged on the following day. For all patients in the clinical pathway group, the critical pathway was defined as an eight-day planned hospitalization, with a time-task matrix formatted for disease treatment, laboratory testing, physical examination, oxygen saturation monitoring, ambulation, diet, patient education and clinical outcome. Switch therapy reduced the period of intravenous antimicrobial administration from 7.6 days to 4.0 days (p < 0.0001). The period required to switch to oral antimicrobials decreased from 8.3 days to 4.8 days (p < 0.0001); hospital stay length, from 9.8 days to 6.5 days (p = 0.0001); and medical resource utilization, from 330, 373 to 227,768 Japanese yen (p = 0.0002). No patient from either group required readmission. In conclusion, Switch therapy was more efficient than management with a clinical pathway for mild to moderate community-acquired pneumonia in hospitalized patients.

Plasma endothelin, nitric oxide and atrial natriuretic peptide levels in humans after abdominal angiography

PURPOSE

To clarify the effect of the contrast medium iopamidol on endothelial function and response of vasoactive peptide, as measured by changes in the levels of plasma endothelin, nitric oxide and atrial natriuretic peptide.

MATERIAL AND METHODS

Thirteen patients received iopamidol 300 mg I/ml intra-arterially during routine abdominal angiography. The mean volume of contrast medium administered was 208.1+/-32.5 ml. Endothelin, nitric oxide and atrial natriuretic peptide were measured before and after angiography.

RESULTS

Endothelin levels increased significantly (from 1.45+/-0.12 pg/ml to 1.90+/-0.10 pg/ml) after exposure to contrast medium. Nitric oxide levels decreased significantly (from 34.56+/-2.23 micromol/ to 25.43+/-1.83 micromol/l). Atrial natriuretic peptide levels increased significantly (from 11.43+/-1.68 pg/ml to 21.28+/-2.89 pg/ml).

CONCLUSION

Exposure to contrast medium in humans is associated with an increase in plasma endothelin levels and a decrease in nitric oxide levels, and atrial natriuretic peptide levels also increase following CM injection.

Paramedian supracerebellar transtentorial approach for a medial tentorial meningioma with supratentorial extension: technical case report

OBJECTIVE AND IMPORTANCE

The choice of surgical approach to treat medial tentorial meningiomas is crucial and sometimes difficult to make. Although the subtemporal approach is most commonly used for lesions that extend mostly supratentorially, it risks injury to the vein of Labbé or the veins coursing along the subtemporal surface. To avoid venous injury, a medial tentorial meningioma was removed transtentorially through the infratentorial space via the paramedian supracerebellar transtentorial (PSCTT) approach.

CLINICAL PRESENTATION

A 35-year-old right-handed woman presented with a generalized convulsion. Magnetic resonance imaging scans revealed a left medial tentorial meningioma with supratentorial extension at the dominant hemisphere. The main venous drainage route from the ipsilateral temporal lobe was a sphenopetrosal vein.

INTERVENTION

An operation was performed with the patient in a sitting position, and the tumor was resected totally via the paramedian supracerebellar transtentorial approach without perioperative complications.

CONCLUSION

The paramedian supracerebellar transtentorial approach is useful for supratentorially located medial tentorial meningiomas without retraction of the temporal lobe and without damage to the vein of Labbé or the sphenopetrosal vein.

Prevention of evaporation of small-volume sample solutions for capillary electrophoresis using a mineral-oil overlay

The suppression of evaporation of water from small volumes of sample solutions or reagents for capillary electrophoresis by the use of a mineral-oil overlay was investigated in affinophoresis applications, in which the affinity constant of a mutant protein of recombinant human galectin-1 to a lactose affinophore, a triply negative charged ion having a lactoside as an affinity ligand, was determined. When an injection was carried out from a minimum of 20 microL of an aqueous solution beneath the oil overlay, no oil contamination inside the capillary was observed, provided the capillary was cleanly cut so that the end was flat, and the polyimide coating had been removed for a distance of about 2 mm from the end. Affinophoresis was carried out using 20 microL of an affinophore solution covered with an oil overlay. The abnormalities in the electropherograms as the result of the evaporation of the water from the solution during storage prior to use in an automatic operation of a capillary electrophoresis instrument were suppressed, with respect to the formation of a base line gap, an increase in the detection time of a marker ion and an increase in the initial current. A solution in a vial could be used repeatedly for a longer period of time when overlaid with mineral oil than in the absence of an overlay. The use of a mineral-oil overlay is a simple but very efficient technique for solving the problem of the evaporation of water from small volumes of aqueous solutions for use in capillary electrophoresis.

CT during selective arteriography: anatomical assessment of unruptured intracranial aneurysms before endovascular treatment

Our aim was to investigate the usefulness of helical CT during selective angiography (CT arteriography) in pretreatment assessment of unruptured intracranial aneurysms. We studied 47 unruptured aneurysms in 34 prospectively recruited patients for whom endovascular embolisation was initially considered. As pretreatment assessment, we performed rotational digital subtraction angiography (DSA) followed by CT arteriography. The findings on axial source images (axial images) and reconstructed three-dimensional CT angiography (3D-CTA) of CT arteriography were compared to those of rotational DSA, with particular attention to the neck of the aneurysm and arterial branches adjacent to it. Information provided by CT arteriography was more useful than that of rotational DSA as regards the neck in 25 (53%) of 47 cases and as regards branches in 18 (49%) of 37 aneurysms. On axial images, small arteries such as the anterior choroidal artery were seen in some cases. CT arteriography can provide valuable additional information about unruptured aneurysms, which cannot be obtained by rotational DSA alone. This technique is useful for obtaining anatomical information about aneurysm anatomy and for deciding the therapeutic strategy.

Improved cerebral perfusion and metabolism after stenting for basilar artery stenosis: technical case report

OBJECTIVE

Recent advances in stent technology have allowed the introduction of more flexible stents that may be tracked more easily in the intracranial vessels. We present a patient with improved cerebral blood flow and metabolism as assessed by positron emission tomography after stent-assisted angioplasty for symptomatic basilar artery stenosis.

CLINICAL PRESENTATION

A 62-year-old man, who had undergone left superficial temporal artery to middle cerebral artery bypass surgery for left internal carotid artery occlusion 10 years previously, presented with dizziness, blurred vision, and memory disturbance. Angiography revealed severe stenosis of the proximal basilar artery. Positron emission tomographic scans revealed decreased cerebral blood flow associated with increased oxygen extraction fraction in the entire brain, particularly in the posterior circulation and the left middle cerebral artery territory. Despite medical treatment, the patient experienced worsening visual disturbance and right-sided motor weakness.

INTERVENTION

Ticlopidine and aspirin were used as antiplatelet agents. In addition, we used argatroban, which is a direct thrombin inhibitor, as an anticoagulant during the procedure. Predilation with a coronary artery balloon was performed, followed by placement of a GFX 3- by 8-mm stent (Arterial Vascular Engineering, Santa Rosa, CA), with excellent angiographic results. The patient made a good neurological recovery, and the postoperative positron emission tomographic scan demonstrated increases in both cerebral blood flow and cerebral metabolic rate of oxygen with a normalization of oxygen extraction fraction.

CONCLUSION

Stent-assisted angioplasty can provide a favorable clinical course as well as improved cerebral perfusion and metabolism for a patient with basilar artery stenosis. Long-term follow-up data and additional clinical experience are required to assess the durability of this approach.

Aneurysm clipping after partial endovascular embolization for ruptured cerebral aneurysms

SUMMARY

The aim of this study was to investigate the advantages and disadvantages of a two-stage treatment for ruptured cerebral aneurysms; partial embolization in acute stage followed by clipping in chronic stage of subarachnoid hemorrhage. Between April 1997 and August 1999, twenty ruptured cerebral aneurysms were initially treated endovasculary using Guglielmi detachable coils in our institution. Among them, complete embolization could not be achieved in 6 lesions. For these lesions, subsequent clipping was added. The radiological and operative findings, and outcomes of these cases were retrospectively reviewed. In 1 case, rerupture occurred during the endovascular procedure. Rerupture was not observed in any cases in the postembolization period. In 2 cases, complications related to the clipping but not the endovascular procedure occurred. These complications included impaired visual acuity for unverified reasons, and memory disturbance due to sacrifice of a perforator arising from the anterior communicating artery. In 3 cases, coil extraction was needed during the clipping, because the loops of the coil extended into the residual neck. Complications related to coil extraction were not observed in these 3 cases. Acute partial embolization of ruptured aneurysm appears to be effective for the prevention of subsequent rerupture during the subacute period, in which treatment for vasospasm should be performed, and the clipping procedure. However, in the case of relatively large aneurysms, small arteries or other normal structures behind the aneurysm cannot be observed directly during surgery, because of the immovability of the embolized aneurysm. Further, complete clip closure is impossible when loops of coil herniate into the neck. In such situations, coil extraction with or without resection of the aneurysm might be necessary, and care must be taken not to damage parent artery and surrounding vessels.

Significance of volume embolization ratio as a predictor of recanalization on endovascular treatment of cerebral aneurysms with guglielmi detachable coils

SUMMARY

The purposes of this study are, firstly, to define the relationship between volume embolization ratio (VER) and degree of angiographical occlusion in endovascular treatment with Guglielmi detachable coils, and secondly, to examine influences of neck and dome sizes of aneurysms on the VER and the angiographical treatment result, and thirdly, to determine the relationship between the VER and the recanalization of coiled aneurysms. Fifty-two aneurysms in 46 patients were examined. VER ranged 8.1-31.9% (mean 18.5%). The mean VERs of each categories based on angiographical treatment results were 23.1% in complete occlusion, 16.1% in neck remnant and 12.2% in incomplete occlusion, respectively. The VER correlated significantly with both neck and dome size, while the angiographical treatment result was only affected by neck size. Five aneurysms showed aneurysmal recanalization among followed-up 41 aneurysms. All recanalized aneurysms were large, and their VERs were in range of 10.4-17.6%. Measurement of VER is useful to estimate the degree of occlusion objectively and to predict the aneurysmal recanalization. A small aneurysms with a small neck is relatively easy to achieve high VER and angiographical complete occlusion, with the consequence of less recanalization. On the other hand, a large aneurysm is liable to recanalize due to low VER, even if there was little filling of contrast medium in the aneurysmal cavity.

[Usefulness of multiphase helical CT in the diagnosis of pituitary microadenoma]

The purpose of this study was to determine the value of multiphase helical CT (MHCT) in the diagnosis of pituitary microadenoma. Twenty-two patients with clinically suspected microadenoma were examined. Coronal pre-contrast CT was initially carried out. Three series of helical scanning using 1-mm collimation, 1-mm/s table speed, and 1-mm interval reconstruction covering the entire pituitary gland were performed with an intravenous injection of contrast medium. Immediately after MHCT, delayed CECT was performed. Twenty microadenomas (3-10 mm, mean: 5.5 mm) were surgically confirmed. MHCT could depict all 20 tumors, while pre-contrast CT and delayed CECT showed 4 and 12 of 20 tumors, respectively. MHCT was useful in the diagnosis of pituitary microadenoma owing to its high spatial resolution and extensive coverage.

[A case of giant cell tumor originating from the rib]

We have experienced a case of giant cell tumor originating from the rib. A 45-year-old male was admitted to our hospital because of a mass in the left chest wall. A tumor shadow was observed in the left side of chest X ray. Chest CT, bone scintigram showed tumor originating from the left 4th rib. The tumor was suspected giant cell tumor of bone by needle biopsy examination. The tumor was completely resected with chest wall surrounding the tumor. The defect of chest wall was reconstructed with Marlex mesh and the Latissimus dorsi muscle flap. The pathological diagnosis was a giant cell tumor of bone. The patient has been well for two years and one month since surgery, with no signs of recurrence.

Radiographic features of invasive lobular carcinoma of the breast

PURPOSE

To evaluate the radiographic features of invasive lobular carcinoma of the breast.

METHODS

We evaluated the radiographic features of 61 cases of histopathologically documented invasive lobular carcinoma. Mammography was performed in all cases. In seven of 61 cases, helical CT with contrast medium was also carried out. Mammographic findings were analyzed to determine true-positive and false-negative rates for the detection of neoplasm. Further, the diameter of the tumor as determined on mammography and helical CT was noted for comparison with the pathologic size.

RESULTS

Mammographic features were divided into six types: spiculated mass (38%), indistinct mass (5%), obscured mass (23%), asymmetric opacity (16%), architectural distortion (16%), and no findings (2%). Microcalcifications were present in 12 cases (20%). The overall sensitivity rate was 59%. However, 20 (56%) of 36 cases that were diagnosed as detectable on mammography were underestimated in terms of tumor size compared with the histopathologic findings. Four cases examined by helical CT with contrast medium were compared with the histopathologic findings in terms of extent of the lesion. In three cases, helical CT was more precise than mammography, but the histopathologic findings showed lesions beyond the region evaluated by helical CT.

CONCLUSION

Invasive lobular carcinoma is difficult to detect radiographically, and the extent of the lesion tends to be underestimated.

Ruptured irregularly shaped aneurysms: pseudoaneurysm formation in a thrombus located at the rupture site

OBJECT

The authors describe the clinical, radiological, and pathological findings of ruptured cerebral aneurysms with irregular configurations.

METHODS

Eight patients with subarachnoid hemorrhage due to ruptured irregularly shaped aneurysms were examined. The preoperative radiological findings in these cases were compared with the pathological and operative findings of endovascular or open surgery. All of the aneurysms exhibited delayed opacification and delayed washout of contrast medium from the irregularly shaped portion of the aneurysm on digital subtraction angiography and/or helical computerized tomography scanning. Endovascular embolization with platinum coils was attempted in the first four patients who underwent treatment. In three of these patients the aneurysm ruptured again during the endovascular procedure. In the fourth patient an intraaneurysm thrombus was observed during the procedure and clipping was performed. In the subsequent four patients, three underwent clipping without complication and one underwent partial aneurysm embolization because of poor general status. A thrombus adjacent to the aneurysm dome was observed in the patients who underwent open surgery. Pathological examination of the operative specimens revealed a pseudoaneurysm-like cavity in the thrombus that was adherent to the aneurysm.

CONCLUSIONS

Ruptured irregularly shaped aneurysms may be accompanied by fragile pseudoaneurysm-like cavities located at the rupture point. Because these aneurysms have a high risk of repeated rupture during an endovascular procedure, advancing microinstruments to the weaker portion of the aneurysm should be avoided.

The activity of fatty acid synthase of epidermal keratinocytes is regulated in the lower stratum spinousum and the stratum basale by local inflammation rather than by circulating hormones

The epidermal keratinocytes produce and secrete lipids to maintain the water barrier of the epidermis. To clarify the regulation of epidermal lipid synthesis, we investigated the hormonal effect on the activity of fatty acid synthase (FAS) of the keratinocytes, and the expression of FAS in the human skin. In cultured keratinocytes, the FAS activity, assayed by measuring the oxidation of NADPH, was slightly increased by hydrocortisone or testosterone, but not influenced by thyroid hormone, estrogen, progesterone or insulin. In immunohistochemical study of normal human epidermis, FAS was expressed strongly in the stratum granulosum and moderately in the uppermost layer of the stratum spinousum (SS), suggesting that fatty acid synthesis may increase during normal epidermal differentiation. In inflammatory disorders, such as psoriasis, lichen planus, and atopic dermatitis, FAS was also expressed in the lower SS and the stratum basale (SB), resulting in strong staining in the whole layers of the epidermis. Remarkable increase of FAS expression was only observed in the lower SS and the SB. Therefore, the activity of FAS in the epidermis may be regulated in the lower SS and the SB by local inflammation rather than by circulating hormones. In other components of the skin, FAS was strongly expressed not only in adipose tissue and sebaceous glands, which are known as active sites of lipid synthesis, but also in sweat glands, suggesting that the sweat glands can synthesize abundant fatty acids de novo.

Altered activity of MDR-reversing agents on KB3-1 cells transfected with Gly(185)-->Val human P-glycoprotein

P-glycoprotein (P-gp) is a transmembrane glycoprotein that confers multidrug resistance (MDR). It has been demonstrated that the Gly185 residue within the cytoplasmic loop between predicted transmembrane portions 2 and 3 plays an important role in substrate specificity of human P-gp. Derivatives of cyclosporin interact with and reverse the ability of P-gp to act as a drug efflux pump. To determine if the Gly185 residue of human P-gp is also important for the interaction of P-gp with closely related cyclosporin derivatives, we examined the effect of PSC-833 and CsA on P-gp in KB3-1 cells transfected with human wild-type P-gp (GSV-2) or with the mutant P-gp (VSV-1) that habored the Gly185-->Val substitution. While the ability of CsA to sensitize VSV-1 cells to anticancer agents was enhanced, no changes in the potency of PSC-833 against cells transfected with either the wild-type or mutant P-gp were observed. In addition, VSV-1 transfected cells were more sensitive to CsA inhibition of verapamil-stimulated ATPase activity than cells transfected with wild-type P-gp. Furthermore, the intracellular accumulation of CsA was low in GSV-2 P-gp-expressing cells, compared with its accumulation in VSV-1 cells and it was found to be as high as in non-P-gp expressing KB3-1 cells. These results indicated an enhanced sensitivity of Val185-P-gp expressing cells to CsA that correlated with increased intracellular accumulation in these cells. In contrast, no significant difference in the accumulation of PSC-833 was observed among the parental, wild-type or resistant cells. Since PSC-833 was found to be more potent than CsA, these studies provided insight into the effects of the structure of MDR modulators in mediating sensitivity to anticancer drugs.

Interaction between non-ionic contrast medium and prostaglandin E1 incorporated in lipid microspheres: in-vitro comparative study of direct and non-direct mixing

PURPOSE

To examine whether there is any interaction between non-ionic contrast medium and prostaglandin E1 incorporated in lipid microspheres (Lipo-PGE1) in direct and non-direct mixing.

MATERIALS AND METHODS

Iopamidol 300 and 370 mgI/ml, iohexol 300 and 350 mgI/ml, and iopromide 300 and 370 mgI/ml were mixed with Lipo-PGE1. In the direct mixing test, both agents were mixed directly in a tube. The appearance of the mixture, average size of the Lipo-PGE1 particles, and changes in pH were observed. In the non-direct mixing test, both agents were poured one after the other into a narrow luminal glass tube. The appearance of the mixture was observed. Lipo-PGE1 and the contrast agent were discharged sequentially via a catheter placed in 5 L of physiological saline. The appearance of the physiological saline was observed.

RESULTS

In the direct mixing test, no interaction was observed between iopamidol, iohexol, or iopromide 300 mgI/ml and Lipo-PGE1. Aggregation and creaming were observed in the mixture of iopromide 370 mgI/ml and Lipo-PGE1, and average particle size increased over time. However, there was no apparent change in pH. In the non-direct mixing test, none of the test contrast agents interacted with Lipo-PGE1.

CONCLUSION

The test non-ionic contrast media, even if they interacted with Lipo-PGE1 when mixed directly, did not appear to interact with Lipo-PGE1 when mixed in a non-direct manner, which represents the clinically used prescription in pharmacoangiography.

Contrast-enhanced computed tomography detection of occult breast cancers presenting as axillary masses

Some non-palpable breast cancers presenting as axillary metastases (occult breast cancer, OBC) are not clinically detectable by either mammography (MMG) or ultrasonography (US). We performed contrast-enhanced computed tomography (CE-CT) in order to locate the primary tumors in five cases of OBC and succeeded in locating all of them.

CD2-, CD4+, CD56+ agranular natural killer cell lymphoma of the skin

We present a case of CD56-positive cutaneous lymphoma with a clinical appearance resembling angiosarcoma. The biopsy specimen showed angiocentric infiltrates of small to medium-sized cells positive for CD4, CD45, and CD56 but negative for CD2, surface and cytoplasmic CD3, CD8, CD20, and CD57. There was no detectable clonal rearrangement of either TCRbeta or TCRgamma genes and no dense core granules in the cytoplasm. Epstein-Barr virus was not detected. The patient died of an unrelated disease 20 months after initial biopsy, although there was some response to interleukin-2, radiotherapy, and VP-16. The results suggest that our case does not precisely match the recently proposed variants of CD56-positive lymphoma, namely nasal T/natural killer cell lymphoma and blastic natural killer cell lymphoma. Agranular natural killer cell lymphomas similar to our case in the immunophenotype have been reported to be indolent and occur in the skin. These lymphomas may be a distinct subtype and have a predilection for involving the skin.

Determination of montelukast sodium in human plasma by column-switching high-performance liquid chromatography with fluorescence detection

MK-0476 (montelukast sodium) is a potent and selective cysteinyl leukotriene receptor antagonist that is being investigated in the treatment of asthma. A simple and sensitive method for the determination of MK-0476 in human plasma was developed using column-switching high-performance liquid chromatography (HPLC) with fluorescence detection. A plasma sample was injected directly onto the HPLC system consisting of a pre-column (Capcell pak MF) and an analytical column (Capcell pak C18) which were connected with a six-port switching valve. The column eluate was monitored with a fluorescence detector (excitation at 350 nm; emission at 400 nm). The calibration curve was linear in a concentration range of 1-500 ng ml(-1) for MK-0476 in human plasma. The intra-day coefficients of variation of all concentrations within the range was less than 9.2%, and the intra-day accuracy values were between 97.2 and 114.6%. This method was used to measure the plasma concentration of MK-0476 following oral administration of the drug in humans.

High transepidermal water loss induces fatty acid synthesis and cutaneous fatty acid-binding protein expression in rat skin

Stratum corneum lipids (SCLs) are responsible for the water barrier function (WBF) of the skin in mammals. Recent studies have indicated that epidermal lipid synthesis might be regulated by WBF of stratum corneum and that cutaneous fatty acid-binding protein (C-FABP) plays an important role in fatty acid metabolism in epidermis. To clarify the regulatory mechanism of lipid synthesis, we assessed the effects of barrier disruption induced by either acetone treatment or linoleic acid deficiency on epidermal lipid synthesis in rat. Transepidermal water loss (TEWL) was measured with an evaporimeter before and after treatment. The time course of re-establishing SCLs was examined biochemically and histochemically and the expression of C-FABP in the epidermis was immunohistochemically examined. When the rat skin was covered with a vapor-impermeable membrane after the acetone treatment removing SCLs and inducing WBF disruption, the usual recovery of SCLs was blocked and TEWL was kept high by 24 h. In the uncovered area, rapid redeposition of SCLs within 24 h was found and associated with normal compositions of epidermal lipids including sphingolipids, free fatty acids and sterol and, immunohistochemically, C-FABP was very weakly expressed in epidermis at 0.5 and 2 h, and then strongly in the whole layers at 4 h, and returned to a normal pattern by 8 h. The epidermis of the covered rat skin was kept weak in C-FABP expression by 24 h. In the linoleic acid-deficient rats, TEWL did not increase and the expression pattern of C-FABP showed no notable change until 28 weeks after initiation of the diets, indicating that C-FABP expression may not be affected by altered essential fatty acid metabolism. These results suggest that increase of TEWL itself stimulates C-FABP expression, leading to activation of fatty acid metabolism.

Diagnostic value of contrast-enhanced computed tomography for diagnosing the intraductal component of breast cancer

BACKGROUND

It is important to reduce local residual cancer to avoid local recurrence after breast conserving treatment. We therefore tried to detect the intraductal components and small invasive foci of breast cancers by contrast-enhanced helical computed tomography (CE-CT).

METHODS

In 122 women whose breasts were examined by CE-CT preoperatively, intraductal spread detected on ultrasound (US), mammography (MMG), and CE-CT, and extensive intraductal components (EICs) detected by histological examination were analyzed for correlations among the extent and subtypes of intraductal components, and deviations in tumor size.

RESULTS

EICs were present in 44 patients. The sensitivities of EIC detection by US, MMG, and CE-CT were 35%, 61%, and 88%, respectively, and the corresponding specificities were 83%, 86%, and 79%, respectively. The sensitivities of detecting EIC and small invasive foci were 34%, 57%, and 91%, respectively. In 5 patients, EIC could only be visualized by CE-CT. The median deviation of the size of intraductal spread revealed by CE-CT from pathological EIC was 0.0 cm (range + 3.0 to - 1.7 cm).

CONCLUSIONS

CE-CT is useful for visualizing intraductal spread and small invasive foci of breast cancer.

Alteration of E-cadherin and alpha N-catenin immunoreactivity in the mouse spinal cord following peripheral axotomy

We examined the effects of peripheral axotomy on the immunoreactivity of E-cadherin and cadherin-associated protein alpha N-catenin in the spinal cord. E-cadherin is known to be exclusively expressed in lamina II of Rexed in the spinal cord dorsal horn. This expression disappeared by day 7 after axotomy and reappeared following nerve ligature (partial axonal regeneration model) on day 63. In contrast, it remained undetectable following nerve clipping (complete degeneration model). Alpha N-catenin was diffusely stained in the gray matter, and the immunoreactivity was specifically intense in the central canal and superficial dorsal horn. The expression of alpha N-catenin in the superficial dorsal horn was similarly reduced by day 7 after axotomy, but recovered by day 63 after nerve ligature. In contrast, it remained at the reduced level after nerve clipping. The alteration of alpha N-catenin immunoreactivity showed a similar pattern consistent with that of E-cadherin. Administration of nerve growth factor (NGF) rescued the immunoreactivity of substance P, which is known to disappear after peripheral axotomy, but not influence that of both E-cadherin or alpha N-catenin. These results clearly showed that peripheral axotomy simultaneously alters the immunoreactivity of E-cadherin and alpha N-catenin in the spinal cord, suggesting a correlation in the expression of both E-cadherin and alpha N-catenin in vivo. E-cadherin-alpha N-catenin complex might be crucial for plasticity of the spinal cord dorsal horn after peripheral axotomy.

Determination of simvastatin and its active metabolite in human plasma by column-switching high-performance liquid chromatography with fluorescence detection after derivatization with 1-bromoacetylpyrene

By using a fluorescent derivatization and column-switching technique, a highly sensitive and selective high-performance liquid chromatographic (HPLC) method has been developed for the determination of simvastatin (I, beta-hydroxy-delta-lactone form) and its active hydrolyzed metabolite (II, beta,delta-dihydroxy acid form of I) in human plasma. A plasma sample spiked with internal standards was applied to a C8 solid-phase extraction column. Compounds I and II were separately extracted from plasma into two fractions. Compound I in one of the fractions was hydrolyzed to II. A fluorescent derivative was prepared by esterification of II with 1-bromoacetylpyrene in the presence of 18-crown-6 for both fractions. The pyrenacyl ester of II thus obtained was purified on a phenylboronic acid (PBA) solid-phase extraction column, and was measured by column-switching HPLC with fluorescence detection. The calibration curves for both I and II were linear in the concentration range of 0.1-10 ng/ml. The intra-day coefficients of variation were less than 11.0%, and the accuracies were between 91.7% and 117% within the concentration range for both analytes. The limits of quantification (LOQ) for both analytes were set to 0.1 ng/ml. This assay method has adequate sensitivity and selectivity to measure the concentrations of I and II in human plasma from clinical studies.

Abdominal actinomycosis: barium enema and computed tomography findings

A case of abdominal actinomycosis is described in a woman with recurrent right lower abdominal pain and low-grade fever without history of appendectomy. Past history included the use of an intrauterine device (IUD) until 10 years before manifestation of these symptoms. We followed up the patient, via diagnostic imaging, for 7 months. On initial barium enema, a polypoid lesion was visualized at the bottom of the cecum and there was constriction of the sigmoid colon; the appendix was not seen. Seven months later, poor extension at the cecum, severe constriction in the sigmoid colon, and narrowing of the terminal ileum were also visualized. On computed tomography (CT), the lesion was initially localized only in the ileocecal region adjacent to the sigmoid colon. After 7 months, the lesion had infiltrated adjacent anatomic components and showed direct infiltration of the pelvic space. Differential diagnosis was difficult, as it was not obvious whether this was a pelvic abscess due to inflammation or appendiceal carcinoma. Laparotomy was performed. Macroscopically, the lesion was not limited to the ileocecal region, but involved the right ureter, tubes the Fallopian and ovary, bladder, psoas muscle, and abdominal wall. Pathology findings showed, chronic inflammatory tissue with evidence of actinomycosis. Although previous reports have described a lack of specific findings in this disease. When actinomycosis is suspected, CT is recommended to define its extent.

Localization of E-cadherin in peripheral glia after nerve injury and repair

Peripheral nerve injury results in histological and histochemical changes in neurons and glia. We have recently found that Ca(2+)-dependent cell adhesion molecule E-cadherin plays an important role in the selective fasciculation of a particular subset of unmyelinated sensory fibers. In the present immunohistochemical and immunoblot analyses, the temporal profile of the subcellular expression of this molecule in spinal nerves was examined after crushing, transecting, or ligaturing the sciatic nerve in mice with special attention paid to E-cadherin expression in glial cells. After axotomy of the sciatic nerve, distal axons of the proximal stump and the fibers of the distal stump degenerated, but E-cadherin was still detectable at the outer mesaxons of the myelinated axons as long as they remained morphologically intact. Subsequently, Schwann cells proliferated and migrated to form Schwann cell columns (Büngner's bands) as initial responses to denervation, and expressed E-cadherin at their site of contact with each other and later with sprouting axons. At the initial stage of myelin formation, slender processes of a single Schwann cell interdigitated with an enveloped axons, and expressed E-cadherin at the contact site elaborated by a single Schwann cell. Immunoblot analysis on day 7 revealed that E-cadherin was detected in both the proximal nerve segments and the regenerative distal segments, but was negative in the degenerative distal segments. On the basis of present data, it is suggested that E-cadherin might be involved in the stabilization of the peripheral glial network which provides the guidance of sprouting axons and myelination.