Endovascular coil trapping for ruptured vertebral artery dissecting aneurysms by using double microcatheters technique in the acute stage

BACKGROUND

In the treatment of vertebral artery (VA) dissecting aneurysms, only proximal occlusion of the VA does not necessarily prevent rerupture. We evaluated the efficacy of coil trapping for the ruptured VA dissecting aneurysms using the double microcatheters technique.

METHODS

We treated 11 patients who presented with subarachnoid haemorrhage (SAH) due to rupture of a VA dissecting aneurysm which did not involve the posterior inferior cerebellar artery at the site of dissection. All patients tolerated the balloon occlusion test. Within 3 days of the SAH, the dissection site was trapped with a Guglielmi detachable coil (GDC) using the double microcatheters technique. The proximal and distal sites of the dissecting aneurysm were embolized simultaneously.

FINDINGS

GDC trapping at the affected site was successful in all 11 patients. Radiographic findings showed complete occlusion of the dissection site and patency of the unaffected artery. Although one patient experienced transient dysphagia, there were no major complications.

INTERPRETATION

The double microcatheters technique is effective for coil trapping of ruptured VA dissecting aneurysms in selected patients. The risks posed by this simple technique are minimal, even in the acute stage.

Treatment of dissecting vertebral aneurysm

SUMMARY

We report 17 patients with dissecting aneurysm of the vertebral artery (VA) who were treated by direct surgery (n=8) or interventional surgery (n=9). Eight patients presented with subarachnoid hemorrhage (SAH) and nine with ischemia. Ten patients were treated by trapping of the aneurysm that was occlusion of the VA on both sides of aneurysm (direct surgery, n=2; interventional surgery, n=8). The other seven patients were treated by ligation of the VA proximal to the aneurysm (direct surgery, n=6; interventional surgery, n=l). Two patients underwent transposition of the posterior inferior cerebellar artery (PICA). In 15 patients, there were no major complications. Two patients who had been treated by proximal occlusion of the VA developed rebleeding and ischemia due to persistent retrograde filling of the dissecting site. We suggest that angiographic evidence of retrograde filling of the dissecting site should have been considered as an indication for trapping. Trapping of VA dissecting aneurysms is easier and safer by interventional surgery than by direct surgery.

[Treatment of spontaneous carotid-cavernous fistula by the transvenous approach via the facial and angular route]

We report a case of a patient with a spontaneous carotid-cavernous sinus fistula (CCF) who was successfully treated by the facial vein approach. This 66-year-old female had a 3-month history of right chemosis and exophthalmos. Angiograms showed a spontaneous right CCF with primary drainage via the superior ophthalmic vein. As both inferior petrosal sinuses were hypoplastic, the transvenous approach could not be used to gain access to the right cavernous sinus. With effort, we were able to traverse the sharp angle at the corner of the angular vein and the superior ophthalmic vein with a microcatheter. Thereafter, it was easily navigated into the right cavernous sinus. Successful placement of Guglielmi detachable coils resulted in complete closure of the fistula. When it is difficult to gain access to the cavernous sinus via the inferior petrosal sinus, the facial vein approach is a useful alternative.

Intravenously injected FK506 failed to inhibit hippocampal calcineurin

FK506 (tacrolimus) is known as an inhibitor for calcineurin and is used in numerous research fields. It is not clear whether intravenously injected FK506 inhibits neuronal calcineurin. We measured the calcineurin activities of normal and postischemic rat hippocampi after intravenous injection of FK506 (3 mg/kg). Intravenously injected FK506 had no inhibitory effect on calcineurin activity in the hippocampi of normal and postischemic rats, whereas FK506 inhibited the calcineurin in vitro (purified enzyme, hippocampal homogenate, and hippocampal slice culture homogenate). Thus, it is considered that intravenously injected FK506 does not act on intraneuronal calcineurin and that several effects of FK506 are not due to the inhibition of neuronal calcineurin.

Expression of angiopoietin-2 in human glioma cells and its role for angiogenesis

In highly vascular malignant glioma, glioma cells themselves may express angiogenic factors and induce angiogenesis. Recent studies have shown that novel angiogenic factors, angiopoietin-1 (Ang1) and -2 (Ang2), play important roles in the modulation of vasculogenesis and angiogenesis. In this study, we determined Ang2 mRNA expression in cultured human malignant glioma cells (U105, U251, and U373 MG) by reverse transcriptase-PCR. Western blot analysis and immunocytochemical analysis with antihuman Ang2 antibody revealed that Ang2 protein was expressed and secreted by these cells. Furthermore, hypoxia increased the Ang2 protein level in cultured glioma cells. Serial sections of 32 human glioma tissues (14 glioblastomas, eight anaplastic astrocytomas, seven astrocytomas, and three pilocytic astrocytomas) were immunostained against Ang2, vascular endothelial growth factor, Tie2, von Willebrand factor, and alpha smooth muscle actin. The immunoreactivity of each angiogenic factor was higher in malignant gliomas than in low-grade gliomas. Ang2 protein was detected not only in endothelial cells but also in glioma cells, and its expression was prominent in both the area surrounding the necrosis and the periphery of glioblastomas. In the area surrounding necrosis, Ang2 was highly expressed and tumor vessels showed regression. In the tumor periphery, Ang2 was highly expressed and many small vessels stained positively for von Willebrand factor but not for alpha smooth muscle actin, suggesting angiogenesis. Statistical analysis revealed that the Ang2 expression was negatively correlated with vessel maturation in malignant gliomas and that vascular endothelial growth factor expression was positively correlated with vessel maturation in low-grade gliomas (P < 0.05). These results suggest that glioma cells themselves express Ang2 and that expression may be induced by hypoxic stimulation and may play a crucial role in the vessel maturation, angiogenesis, and vessel regression in malignant glioma.

Treatment for Giant Aneurysms in the Cavernous Portion of the Internal Carotid Artery using Detachable Coils

SUMMARY

We report 7 patients with symptomatic giant aneurysms in the cavernous portion of the internal carotid artery (ICA) who were treated by trapping the ICA on either side of the aneurysmal orifice using detachable coils. In all 7 patients the ICA was sacrificed; 5 patients subsequently underwent bypass surgery (STA-MCA bypass, n = 4; high-flow bypass, n = 1), the other 2 patients did not. In 6 patients, there were no post-treatment embolic episodes; one patient who had been treated by proximal occlusion of the ICA developed transient ischemia due to an intra-aneurysmal thrombus. Cranial nerve palsies were markedly improved in all patients. ICA trapping using detachable coils was a highly successful treatment method in these patients. We found the detachable coils effective and easy to use in the trapping methods applied in this series of 7 patients.

[Follow-up survey of dioxins in the blood of Yusho patients (in 1998-1999)]

Follow-up survey of the blood concentration of PCDDs, PCDFs and non-ortho-chlorine substituted PCBs in Yusho patients is very important for their health control. We determined the blood concentration of these dioxin isomers in 119 blood samples collected in 1998 and 1999 using by a high-resolution gas chromatograph/high-resolution mass spectrometry (HRGC/HRMS). Thirty years had passed since the Yusho occurrence, and the total blood concentrations of PCDFs in the blood of Yusho patients were still as high as ever, except the patients with the PCB pattern C. Among the different groups of PCB patterns, the concentration of 2,3,4,7,8-PeCDF, 1,2,3,4,7,8-HxCDF and 1,2,3,6,7,8-HxCDF showed significant differences, excluding the group BC because of the small number of cases. The findings indicate that these isomers are not decomposed in human body since they had highly contaminated the causal rice oil at the onset. In typical Yusho patients (Group A of PCB pattern), the mean TEQ concentrations of PCDDs, PCDFs and non-ortho-chlorine substituted PCBs in the blood collected in 1998 were 21, 206, and 14 pg-TEQ/g lipid, respectively, and in 1999, 30, 308 and 14 pg-TEQ/g lipid, respectively. The toxic contribution rate of PCDFs TEQ was still at high levels for total TEQ in both years. The patients of the group C, however, the mean blood levels of the dioxins TEQ in 1998 and 1999 did not differ from those of the normal controls determined in 1996 although some patients in this group showed a high toxic contribution rate of PCDFs TEQ for total TEQ. We will try the PCB isomer specific analysis of the Yusho patients blood, and will investigate the difference from normal controls blood.

[Endovascular treatment for facial arteriovenous malformations using new particles: report of two cases]

Facial arteriovenous malformations (FAVM) are difficult to treat because of their highly vascular networks. Intravascular treatment using liquid material to occlude the FAVM occasionally results in skin necrosis after embolization. The use of particulate materials to obliterate the nidus often fails to obtain a permanent cure due to arterial recanalization. We report two patients with FAVM who were successfully treated with endovascular embolization using a new type of particulate material. One patient was treated with embolization only, the other was treated with embolization followed by surgical resection. Both patients showed clinical and angiographic improvement. Intravascular treatment using particles with a smooth surface and optimal size is safe and effective in the treatment of patients with FAVM.

The utility of the microcrystalline cellulose sphere as a particulate embolic agent: an experimental study

BACKGROUND AND PURPOSE

Although various particulate materials have been developed as embolization agents, their biocompatibility remains unclear. We used an animal model to examine the possibility of using FDA-approved microcrystalline cellulose spheres (CELPHERE) as solid embolic material for the permanent occlusion of blood vessels.

METHODS

Angiographic and histologic studies in 12 canine renal arterial systems were conducted to evaluate the performance of CELPHERE beads at 1 hour, and at 4 and 12 weeks after embolization.

RESULTS

The CELPHERE beads traveled to vessels with diameters approximating their own. Larger vessels were occluded by aggregations of beads. There was no disruption of vessel walls and no evidence of perivascular hemorrhage or inflammatory changes.

CONCLUSION

Because CELPHERE beads are easy to handle, highly biocompatible, and have few adverse effects, they are suitable for intravascular applications.

Purification and characterization of NAD-dependent morphine 6-dehydrogenase from hamster liver cytosol, a new member of the aldo-keto reductase superfamily

Morphine 6-dehydrogenase, which catalyzes the dehydrogenation of morphine to morphinone, was purified 815-fold to a homogeneous protein from the soluble fraction of hamster liver with a yield of 15%. The enzyme was a monomeric protein with a molecular weight of 38 kDa and an isoelectric point of 5.6. Although both NAD and NADP served as cofactors, the enzyme activity with NADP was less than 5% that found with NAD at pH 7.4. With NAD, the enzyme gave the maximal activity at pH 9.3, and the K(m) and V(max) values toward morphine were 1.0 mM and 0.43 unit/mg protein, respectively. Among morphine congeners, normorphine exhibited higher activity than morphine, but codeine and ethylmorphine were poor substrates, and dihydromorphine and dihydrocodeine showed no detectable activity. The enzyme also exhibited significant activity for a variety of cyclic and alicyclic alcohols. In addition to xenobiotics, the enzyme catalyzed the dehydrogenation of 17beta-hydroxysteroids with much higher affinities than morphine. In the reverse reaction, the enzyme exhibited high activity for o-quinones, but morphinone, naloxone, and aromatic aldehydes and ketones were reduced at slow rates. Sulfhydryl reagents and ketamine strongly inhibited the enzyme, whereas pyrazole, barbital, and indomethacin had little effect on enzyme activity. 17beta-Hydroxysteroids inhibited the enzyme in a competitive manner against morphine. A total of 302 amino acid residues, which comprised approximately 94% of whole protein, were identified by sequencing of the peptides obtained by proteolytic digestion. This amino acid sequence of the enzyme showed significant homology to members of the aldo-keto reductase (AKR) superfamily and shared 63-64% identity with members of the AKR1C subfamily. These findings indicate that the enzyme is a new member of the AKR superfamily that is involved in steroid metabolism as 17beta-hydroxysteroid dehydrogenase as well as xenobiotic metabolism.

Purification and characterization of two major forms of naloxone reductase from rabbit liver cytosol, new members of aldo-keto reductase superfamily

Rabbit liver cytosol produced approximately equal amounts of 6alpha-naloxol and 6beta-naloxol from naloxone in the presence of NADPH at pH 7.4, and contained at least four forms of naloxone reductase. The two major forms, NR1 and NR2, which catalyze the stereospecific reduction of naloxone to 6alpha-naloxol and 6beta-naloxol, respectively, were purified to apparent homogeneity by various chromatographic techniques. Both enzymes are monomeric proteins with similar molecular weights of 35000-36000, but NR1 is a basic protein with an isoelectric point (pI) of 9.3, while NR2 is an acidic protein (pI of 5.9). NR1 and NR2 gave the maximal activities at pH 8.0 and 6.1, respectively. NR1 exhibited considerable activity with NADH as well as with NADPH, whereas NR2 showed highly restricted specificity for NADPH. The Km and Vmax values of NR1 and NR2 for naloxone were 1.0 and 0.06 mM, and 76 and 162 munits/mg, respectively. In addition to naloxone, naltrexone and dihydromorphinone served as good substrates for NR2 but were poor substrates for NR1. Both enzymes reduced aliphatic and aromatic aldehydes, cyclic and aromatic ketones, and quinones at higher rates. The two enzymes catalyzed the dehydrogenation of 17beta-hydroxysteroids with low Km values, and NR2 showed an additional 3alpha-hydroxysteroid dehydrogenase activity. Amino acid sequence data of NRI (99% of whole protein) and NR2 (66%) showed that both enzymes belong to the aldo-keto reductase (AKR) superfamily and can be classified into the AKR1C subfamily. These findings therefore indicate that they are new members of the AKR superfamily and may be involved physiologically in the steroid metabolism as well as in the detoxification of xenobiotic carbonyl compounds.

Cosmetic osteoplastic craniotomy with a chisel and hammer

BACKGROUND

Osteoplastic craniotomy has been performed recently with microfixation systems such as miniplates, burr hole buttons, and/or ceramic dust. However, these are costly methods of treatment. Without the use of these devices, we performed cosmetic osteoplastic craniotomy using an inexpensive chisel and hammer.

METHODS

Our osteoplastic craniotomy with a chisel and hammer was used on 19 lesions in 15 patients. Using a chisel, the bone flap was cut gently from the calvarium to the skull base, the lamina externa to the diploe (finally the lamina interna), and both ends to the midportion between two holes. The lamina interna in the cranium was trimmed easily after removal of the bone flap. The bone defect was minimal because of the absence of a narrow cutting groove and because craniectomy was not performed. The bone flap was replaced by tapping and was tightly fixed. No special fixation system was needed, except for threads.

RESULTS

Follow-up (mean follow-up, 5 months; range, 5 weeks to 9 months) skull X-ray and 3D-CT showed good fusion and inherent normal configuration of the bone flap. There were two minor dural tears and two minor bony fractures.

CONCLUSION

A good cosmetic effect without the use of any additional instruments was accomplished with osteoplastic craniotomy using a chisel and hammer.

Gene transfer of human prostacyclin synthase prevents neointimal formation after carotid balloon injury in rats

BACKGROUND AND PURPOSE

A disordered proliferative process in the vascular wall is thought to underlie the pathogenesis of restenosis after percutaneous transluminal angioplasty and carotid endarterectomy. A growth inhibitory property of overexpressed prostacyclin (PGI2) synthase (PGIS) was recently implicated in the pathological proliferation of vascular smooth muscle cells (VSMC) in vitro. Here, we investigated the effects of increased PGI2 synthesis on the pathological proliferation of VSMCs.

METHODS

The cDNA encoding human PGIS was transfected into endothelium-denuded rat carotid arteries after arterial balloon injury with the use of hemagglutinating virus Japan (HVJ). HVJ liposome vector complex without PGIS cDNA was used for vehicle control. The level of 6-keto PGF1alpha, a stable hydrolyzed metabolite of PGI2, the histological distribution of the immunoreactivity for human PGIS and the ratio of neointimal/medial area were analyzed.

RESULTS

In the analyses of 6-keto PGF1alpha, the level in the carotid arteries was significantly elevated 3 days after PGIS expression-vector transfection compared with that in the arteries after vehicle transfection. Seven days after human PGIS expression-vector transfection, the PGIS cDNA-transfected neointimal cells were strongly positive for human PGIS immunoreactivity in 81% sections examined. Fourteen days after the injury, the ratio of neointimal/medial area was 1.2+/-0.4 in the PGIS expression-vector transfected group, which was significantly smaller than that of the vehicle control group, 1.7+/-0.5; P<0.01.

CONCLUSIONS

It was thus demonstrated that the gene transfer of human PGIS expression-vector into rat carotid arteries resulted in the increased production of human PGI2 in the vascular wall, the expression of human PGIS in the developing neointima and significantly inhibited the neointimal formation generated after balloon injury.

Endosaccular embolization for internal carotid artery aneurysms at the c3 portion

SUMMARY

Direct surgery for the aneurysms at the C3 portion of the internal carotid artery (ICA) requires relatively complicated procedures. We present three patients with this aneurysm who underwent endovascular embolization. The remodelling technique was utilized in two of these patients with unruptured aneurysms. Sufficient obliteration was achieved in every case. Endovascular embolization may be an important alternative for ICA C3 aneurysms.

Expression of thioredoxin is enhanced in atherosclerotic plaques and during neointima formation in rat arteries

Thioredoxin (TRX) is an intracellular enzyme that has a variety of activities as a hydrogen donor for various intracellular molecules. In the present study, we investigated the role of TRX in atherosclerotic lesions. In human atherosclerotic specimens, TRX and TRX mRNA were enhanced in endothelial cells and macrophages in the atherosclerotic plaques. In balloon-injured rat arteries, TRX expression increased from 2 to 6 weeks after injury; TRX was induced in the neointimal regenerating endothelial cells. In hybridization experiments, TRX mRNA was also induced from 2 to 6 weeks in the endothelium. In this model, inducible nitric oxide synthase immunoreactivity in the neointimal smooth muscle cells and endothelial cells increased from 2 to 6 weeks after surgical procedures were performed. During this period, the immunoreactivity of nitrotyrosine, which is a marker of nitric oxide (NO) production, also increased. We focused on the association between TRX and NO. In vitro studies using a murine endothelial cell line showed TRX and TRX mRNA induction by NO and peroxynitrite donors. Enhanced expression of TRX was detected mainly within the cytoplasm in immunocytochemical studies. In addition, TRX-transfected cells showed resistance to peroxynitrite-induced cytotoxicity. These findings indicate that TRX and the cellular redox state modified by TRX play a crucial role in arterial neointima formation in atherosclerosis.

A microguide wire with a scale (scaler guide). Technical note

SUMMARY

There are various methods for measuring an affected vascular size during embolization or percutaneous transluminal angioplasty (PTA). Metallic balls, electrodes, grids, coins on the skin were simple and useful in this sense, but not stable and exact for measuring. A 0.014" or 0.016" microguide wire with 5 gold markers in the tip is newly developed and used clinically (a scaler guide). One marker measures 1 mm in length. There is a distance of 4 mm between two neighboring markers. A microcatheter is navigated using a standard microguide wire into the vessels of the lesion. Bilateral digital subtraction angiography (DSA) is performed after exchange of a microguide wire with a scaler guide. Magnification ratio between distance measured by DSA and real distance from markers is calculated. Thereafter, the size of the vessels will be measured. With this method, the size of vessels was measured in patients with aneurysm or arteriovenous malformation or stenotic lesion. Selection of coils or PTA balloons could be made easily and effectively. Interventions were more safely performed with this new scaler guide.

Mechanism of intracranial rebleeding in moyamoya disease

Intracranial hemorrhage is the major catastrophic event in the natural course of Moyamoya disease, and outcome of the patients with rebleeding is very poor. However, the mechanism underlying intracranial rebleeding is not well elucidated. We retrospectively analyzed 15 patients who bled two times or more among 46 bled patients with Moyamoya disease. The results indicated that there were two different types in the manner of rebleeding. One group consisted of seven cases, which bled two times or more at the same site than the original bleeding site. In four of these seven cases, a ruptured aneurysm was identified at the distal part of collateral vessel or on the major vessel. In the other three cases, no source of bleeding was identified. In all of these cases, rebleeding occurred within 2 months after the initial insult except for one case. Another group consisted of eight cases, which bled repeatedly but at different sites from the initial bleeding site. In any of these cases, neither aneurysms nor other vascular abnormalities were identified. In all of these cases, rebleeding occurred more than 2 months after the initial bleeding. The present result indicated that intracranial bleeding might occur as a result of rupture of a tiny aneurysm at the periphery of collateral vessels. These aneurysms may be blown out after initial bleeding. When they persist after the event, they may rupture again in a fairly short interval. In other cases, bleeding occur at different sites from the initial site. They are considered to be a result of ruptured weak Moyamoya vessels which are forced to act as collateral pathways and are under unusually increased hemodynamic stress.

Direct surgery for major artery aneurysm associated with moyamoya disease

Moyamoya disease is often accompanied by intracranial major artery aneurysms in the posterior circulation which acts as collateral channels in place of the stenotic internal carotid arteries. These major artery aneurysms are considered to have high risk of enlargement and rupture due to increased hemodynamic stress. Direct surgical intervention has been recommended for the treatment of these aneurysms, but the direct approach to them is often difficult due to interference by intertwined abnormal vessels. We have performed direct surgery for seven major artery aneurysms in five patients with Moyamoya disease. Of these three aneurysms located in the anterior circulation were successfully clipped via pterional or interhemispheric approach. Of four posterior circulation aneurysms (two at the junction of the basilar artery and the superior cerebellar artery and two at the P1-P2 junction of the posterior cerebral artery), one was approached via pterional route because collateral vessels in the basal cistern was judged not to be rich on angiograms. However, the operative field was interfered by abundant fragile collateral vessels and it was difficult to reach the distal portion of the basilar artery. In contrast, in the other three cases in which the subtemporal approach was employed, there weren't any problems in exposures of the aneurysms. Our experiences indicate that subtemporal approach is superior than the pterional approach to reach the distal portion of the basilar artery in patients with Moyamoya disease.

Resection of a large, high-flow arteriovenous malformation during hypotension and hypothermia induced by a percutaneous cardiopulmonary support system. Case report

The key to successful surgical resection of cerebral arteriovenous malformations (AVMs) is control of bleeding and cerebral swelling. Induced hypotension is one of the most valuable means of achieving this control. The authors introduced induced hypotension with mild hypothermia by using a percutaneous cardiopulmonary support system (PCPS) to resect a large, high-flow AVM. The efficacy and technical points of this method are discussed. The PCPS, whose entire intraluminal surface was coated with heparin, was established through a transfemoral route. During resection of the AVM, a mean arterial blood pressure of 60 mm Hg and a mean body temperature of 30 degrees C were easily maintained by regulating the flow rate of the PCPS and by blood cooling. The activated coagulation time was maintained at approximately 250 seconds with a minimum systemic administration of heparin. The authors report the case of a 30-year-old woman who presented with intraventricular hemorrhage and was diagnosed as having a large, high-flow AVM located in the left sylvian fissure. The AVM was fed by the left middle, posterior, and anterior cerebral arteries and drained by the many cortical ascending veins and the basal vein. The patient underwent surgery after hypotension and hypothermia had been induced via the PCPS method. Induced hypotension decreased the tension of the nidus and made its dissection easier. The AVM was totally resected and no hemostatic difficulties were encountered. On the basis of the authors' experience, they suggest that hypotension and hypothermia induced by using the PCPS is a powerful tool for the successful resection of large, high-flow AVMs.

[Detection of microemboli by transcranial Doppler sonography after carotid endarterectomy]

Transcranial Doppler sonography (TCD), a non-invasive monitoring technique, has potential for detecting microemboli caused by the extracranial internal carotid artery. Many previous reports have shown that TCD-detected microemboli may be a risk factor for stroke. The main purpose of this study is to verify whether microemboli cease after carotid endarterectomy (CEA). TCD monitoring was performed in 43 cases before and after CEA. TCD monitoring was carried out for an hour at the ipsilateral middle cerebral artery of each case using a 2-MHz pulse-wave transcranial Doppler device, and high intensity transient signals were counted as microemboli. Microemboli were detected preoperatively in 10 cases (23.3%). Microemboli were not detected in any case immediately after CEA, in either the subacute stage (from 14 to 21 days after CEA) or in the chronic stage (more than 3 months after CEA). In the acute stage (from 3 to 7 days after CEA), microemboli were detected in three cases (7.0%). The rate of TCD-detected microembolic was always significantly reduced after CEA. TCD monitoring can be helpful in assessing the effect of CEA for prevention of stroke by removing the suspected source of microemboli.

[Analysis of factors related to microemboli in cases with internal carotid artery stenosis]

Transcranial Doppler ultrasound (TCD) has been used to detect microemboli in cases with extracranial internal carotid artery stenosis. However, the mechanism causing microemboli has remained unclear. The purpose of this study is to clarify clinical characteristics and circumstances associated with the genesis of TCD-detected microemboli. Ninety-one cases with more than 30% stenosis of the internal carotid arteries were studied. TCD monitoring was carried out for an hour at the ipsilateral middle cerebral artery of each case using a 2-MHz pulse-wave transcranial Doppler device, and high intensity transient signals were counted as microemboli. Digital subtraction angiography, magnetic resonance imaging (MRI) and single photon emission computed tomography (SPECT) were also performed in all cases. Microemboli were detected in 30 of 91 cases. Microemboli were significantly well detected in cases with a history of ischemic event and/or cerebral infarction recognized by MRI. Detection of microemboli had no relation to sex, age or clinical risk factors (hypertension, hypercholesterolemia, diabetes mellitus and smoke habituation). In contrast, detection of microemboli was significantly related to decrease in cerebral blood flow recognized by SPECT, severity of stenosis and wall irregularity of lesion recognized by angiography. Microemboli can be found in a significantly high percentage of these clinical conditions, which may be risk factors for embolic stroke caused by extracranial internal carotid artery stenosis.

In vivo and in vitro formation of morphinone from morphine in rat

1. Morphinone, a toxic metabolite, and its glutathione adduct (MO-GSH) were identified in the bile of rat after subcutaneous injection of morphine (25 mg/kg) by hplc procedures. The amounts of morphinone and MO-GSH excreted in the 12-h bile were 0.8 +/- 0.3 and 8.4 +/- 4.3% respectively. 2. The 9000 g supernatants of rat, guinea pig, rabbit, mouse, hamster and bovine livers produced morphinone from morphine in the presence of either NAD+ or NADP+, NAD+ was a more efficient cofactor than NADP+ except in the guinea pig which equally utilized both cofactors. With NAD+ as cofactor, the amounts of morphinone formed in rat and guinea pig were 5.70 and 5.82 mumol/g liver/30 min respectively and were three-to-four times those in other species. 3. The enzyme activity responsible for formation of morphinone from morphine in the rat was almost exclusively distributed in the microsomal fraction, whereas guinea pig, hamster and bovine expressed the enzyme activity mainly in the cytosolic fraction. Rabbit and mouse gave higher activity in the cytosolic and microsomal fractions respectively, but other fractions of both species contained considerable activity. 4. The enzyme activities in male and female rat microsomes were characterized with respect to developmental pattern, kinetic parameters, pH dependency and susceptibility to inhibitors. 5. In conclusion the metabolism of morphine to morphinone in rat was confirmed by in vivo and in vitro experiments. It is also suggested that this pathway is a common route in morphine metabolism in several mammalian species.

Effect of SDZ PSC 833 ([3'-keto-Bmt1]-[Val2]-cyclosporin) on serum protein binding and distribution to blood cells of doxorubicin, vincristine and etoposide in vitro

SDZ PSC 833 ([3'-keto-Bmt1]-[Val2]-cyclosporin) is a P-glycoprotein-mediated multidrug resistance modulator currently undergoing clinical trials. SDZ PSC 833 modulates not only antitumor activity but also tissue distribution of doxorubicin in mice. Since protein binding in plasma/serum and distribution to blood cells are important factors affecting the tissue distribution and excretion of drugs, we investigated the effect of SDZ PSC 833 on serum protein binding and distribution to blood cells of doxorubicin, vincristine and etoposide in vitro. Unbound fractions in serum and fractions distributed to blood cells of either [14C]doxorubicin, [3H]vincristine or [3H]etoposide were determined using serum and blood obtained from mice and healthy volunteers. Effects of SDZ PSC 833 at 3 microg/ml, which was an achievable concentration in a clinical trial of SDZ PSC 833, on protein binding and distribution of the drugs to blood cells were negligible in mouse and human blood in vitro. The absence of interaction between PSC 833 and the anticancer drugs in protein binding and distribution to blood cells suggested the existence of other mechanisms. Possible interactions are speculated to be inhibition of P-glycoprotein function contributing to drug excretion and tissue distribution and inhibition of drug metabolism mediated by cytochrome P450 3A.

[Detection of microemboli in patients with extracranial carotid artery stenosis by transcranial Doppler sonography]

Embolism from a stenotic lesion of the extracranial internal carotid artery (ICS) is considered to be an important pathomechanism of cerebral infarction. The purpose of this study is to estimate the risk of cerebral infarction associated with microembolism in patients with ICS and thereby to determine the importance of TCD-detected microemboli in this condition. Seventy-one cases with more than 30% ICS and 10 cases without ICS were studied. TCD monitoring was carried out for an hour at the ipsilateral middle cerebral artery of each case using a 2-MHz pulse-wave transcranial Doppler device. High intensity transient signals were counted as microemboli. Microemboli were detected in 27 of 71 cases with ICS, but not in cases without ICS. Microemboli were detected more frequently in cases with 70% to 99% ICS (53.3%) compared with in cases with 30% to 69% ICS (12.5%). Cerebral infarctions were recognized in the ipsilateral hemisphere in 23 of 27 cases with microemboli (85.2%) by means of MRI. In contrast, cerebral infarctions were recognized only in 21 of 45 cases without microemboli (47.7%). These results suggest that a stenotic lesion of the extracranial internal carotid artery, especially high-grade stenosis, is a major source of cerebral embolism and that detection of microemboli by TCD is a useful tool capable of reliably assessing the risk of cerebral infarction due to ICS.

Intracranial chondromyxoid fibroma extending into the jugular foramen

A case is reported of an intracranial chondromyxoid fibroma (CMF) in a 67 year old man. The tumor originated in the petrous part of the temporal bone and extended into the jugular foramen. Microscopically, the tumor showed a lobular appearance, and was composed of spindle or stellate cells in an abundant myxoid, chondroid stroma. Immunohistochemically, S-100 protein was positive in the tumor cells and myxoid stroma. Intracranial CMF, especially in an elderly person, is exceedingly rare. Clinical and pathological findings are presented with reference to the previously reported articles.

Chiral inversion of drug: role of intestinal bacteria in the stereoselective sulphoxide reduction of flosequinan

Chiral inversion at a sulphoxide position of flosequinan enantiomers [(+/-)-7-fluoro-1-methyl-3-methylsulphinyl-4-quinolone] occurred in conventional rats but not in either germ-free rats or rats treated with antibiotics after an oral administration of each enantiomer. Thus, it was postulated that the chiral inversion occurred by mechanisms mediated by intestinal bacteria. The intestinal content isolated from conventional rats reduced R(+)- and S(-)-flosequinan to produce the sulphide, while intestinal content from rats treated with antibiotics did not reduce the drug. Several strains of facultative anaerobes possessed a high flosequinan reducing activity. Escherichia coli, Klebsiella oxytoca and Klebsiella pneumoniae reduced R(+)-flosequinan to the sulphide stereoselectively. On the other hand, Enterobacter aerogenes and Micrococcus agilis exclusively reduced S(-)-flosequinan. The sulphide, which could be produced by intestinal bacteria from R(+)- and S(-)-flosequinan, was readily absorbed upon an oral administration to rats, and was oxidized fairly rapidly to R(+)- and S(-)-flosequinan and further to the sulphone form. Based on these data, it has been confirmed that chiral inversion at the sulphoxide position of flosequinan enantiomers occur via stereoselective reduction of sulphoxide by intestinal bacteria to form the sulphide, followed by oxidation of the sulphide in the body to produce R(+)- and S(-)-flosequinan.

Stereoselective pharmacokinetics and interconversions of flosequinan enantiomers containing chiral sulphoxide in rat

1. In order to study the pharmacokinetics of flosequinan enantiomers ((+-)-7-fluoro-1-methyl-3-methylsulphinyl-4-quinolone) containing chiral sulphur, plasma levels of (+)-(R)- and (-)-(S)-flosequinan (R-FSO and S-FSO) and two metabolites (flosequinan sulphide (FS) and flosequinan sulphone (FSO2)) were measured after oral and i.v. administration of racemic flosequinan (rac-FSO), R-FSO and S-FSO in male rat. 2. The pharmacokinetic parameters of the enantiomers were different after oral and i.v. administration of R-FSO and S-FSO. The plasma clearance of R-FSO was higher than S-FSO. 3. The major metabolites of boh R-FSO and S-FSO was FSO2. A minor metabolite, FS, was also detected in plasma. 4. Interconversions occurred after the oral and i.v. administration of R-FSO and S-FSO. The amount of interconversion from S-FSO and R-FSO was greater than that from R-FSO to S-FSO. The rate of interconversion after oral administration was higher than that after i.v. administration. 5. After i.v. administration of FS, R-FSO and S-FSO were detected in plasma, suggesting that the interconversion occurred via formation of FS. 6. The pharmacokinetic parameters of R-FSO after administration of rac-FSO differed from that after administration of R-FSO, indicating the interaction between each enantiomer.

A new metabolic pathway of morphine: in vivo and in vitro formation of morphinone and morphine-glutathione adduct in guinea pig

The biliary excretion of morphine and its metabolites by guinea pigs after s.c. injection of morphine (25 mg/kg) was determined by high-performance liquid chromatography procedures. The amounts of morphinone (MO), morphinone-glutathione adduct (MO-GSH), morphine and morphine-3-glucuronide excreted over a 4-hr period were 1.27, 9.35, 1.13 and 7.54% of the administeral dose, respectively. In addition, trace amounts of morphine-GSH adduct and morphinone-cysteine adduct, derived from MO-GSH, were detected. Although MO-GSH formation from MO proceeded nonenzymatically with a relatively high rate, GSH S-transferases participated in the reaction, especially at lower GSH concentrations. Pretreatment of the animals with diethyl maleate and lithocholic acid-3-sulfate decreased the total biliary excretion of MO. On the other hand, pretreatment with naloxone increased the excretion of total MO. In vitro experiments using liver cytosolic preparations showed that lithocholic acid-3-sulfate inhibited the enzymatic formation of MO from morphine and of MO-GSH from MO. The effects of naloxone on MO formation in vitro were more complex. A reaction was stimulated at low and suppressed at higher concentrations. The results indicated that MO-GSH formation from morphine is inhibited by lithocholic acid-3-sulfate through actions on both morphine 6-dehydrogenase and GSH S-transferases. Low levels of naloxone were found to stimulate the morphine 6-dehydrogenase-mediated dehydrogenation of morphine to MO.

Stimulation mechanism of guinea pig liver-mediated reduction of naloxone by morphine

The mechanism of the stimulatory effect of morphine on the reduction of naloxone has been elucidated using guinea pig liver naloxone reductase that is identical with morphine 6-dehydrogenase. The reaction products were quantitated by means of HPLC. When naloxone was incubated with the enzyme in the presence of NAD(P)H at pH 7.4 or pH optima, the production of 6 alpha-naloxol increased according to the added amount of morphine. The stimulation was predominant with NADH at pH 7.4. Under these conditions, the production of morphinone also increased in proportion to the amount of morphine. The enzymatic reduction of naloxone proceeded even if NAD(P)H was replaced by NAD(P)+ and morphine. At a fairly low concentration of NADH (0.01 mM), the enzyme produced 6 alpha-naloxol (0.3 mM), exceeding the stoichiometric amount in the presence of 16 mM morphine. Although the Vmax values for naloxone was increased by the addition of morphine, the Km values for naloxone remained unaltered. Besides other substrates for guinea pig liver morphine 6-dehydrogenase such as codeine, normorphine and ethylmorphine also enhanced the reduction of naloxone. From these results we concluded that the stimulation of guinea pig liver-mediated reduction of naloxone by morphine is caused by the acceleration of the redox of pyridine nucleotides conducted by the enzyme. These phenomena were further supported by the experiments with the liver cytosol. In addition, we confirmed that, in the guinea pig, the biliary excretion of the metabolites, naloxol and naloxol-3-glucuronide, increased after sc injection of naloxone with morphine.