Difficulty in identification of the frontal language area in patients with dominant frontal gliomas that involve the pars triangularis

OBJECTIVE Identification of language areas using functional brain mapping is sometimes impossible using current methods but essential to preserve language function in patients with gliomas located within or near the frontal language area (FLA). However, the factors that influence the failure to detect language areas have not been elucidated. The present study evaluated the difficulty in identifying the FLA in dominant-side frontal gliomas that involve the pars triangularis (PT) to determine the factors that influenced failed positive language mapping. METHODS Awake craniotomy was performed on 301 patients from April 2000 to October 2013 at Tokyo Women's Medical University. Recurrent cases were excluded, and patients were also excluded if motor mapping indicated their glioma was in or around the motor area on the dominant or nondominant side. Eighty-two consecutive cases of primary frontal glioma on the dominant side were analyzed for the present study. MRI was used for all patients to evaluate whether tumors involved the PT and to perform language functional mapping with a bipolar electrical stimulator. Eighteen of 82 patients (mean age 39 ± 13 years) had tumors that showed involvement of the PT, and the detailed characteristics of these 18 patients were examined. RESULTS The FLA could not be identified with intraoperative brain mapping in 14 (17%) of 82 patients; 11 (79%) of these 14 patients had a tumor involving the PT. The negative response rate in language mapping was only 5% in patients without involvement of the PT, whereas this rate was 61% in patients with involvement of the PT. Univariate analyses showed no significant correlation between identification of the FLA and sex, age, histology, or WHO grade. However, failure to identify the FLA was significantly correlated with involvement of the PT (p < 0.0001). Similarly, multivariate analyses with the logistic regression model showed that only involvement of the PT was significantly correlated with failure to identify the FLA (p < 0.0001). In 18 patients whose tumors involved the PT, only 1 patient had mild preoperative dysphasia. One week after surgery, language function worsened in 4 (22%) of 18 patients. Six months after surgery, 1 (5.6%) of 18 patients had a persistent mild speech deficit. The mean extent of resection was 90% ± 7.1%. Conclusions Identification of the FLA can be difficult in patients with frontal gliomas on the dominant side that involve the PT, but the positive mapping rate of the FLA was 95% in patients without involvement of the PT. These findings are useful for establishing a positive mapping strategy for patients undergoing awake craniotomy for the treatment of frontal gliomas on the dominant side. Thoroughly positive language mapping with subcortical electrical stimulation should be performed in patients without involvement of the PT. More careful continuous neurological monitoring combined with subcortical electrical stimulation is needed when removing dominant-side frontal gliomas that involve the PT.

Solvent free oxidative coupling polymerization of 3-hexylthiophene (3HT) in the presence of FeCl3 particles

Solvent free oxidative coupling reaction of 3HT within a nanocavity is demonstrated. The side reaction at the 4-position is regulated.

Treatment of ectopic eruption of permanent mandibular first molars with innovative dental appliances

AIM

Ectopic eruption (EE) of a first permanent molar occurs during mixed dentition. However, treatment of first permanent mandibular molar EE has been seldom reported.

CASE REPORT

The cases of an 8-year-old girl and a 7-year-old boy are described, whose EE first permanent mandibular molars were correctly positioned after treatment with a dental appliance comprising a lingual arch, sectional arch, crimpable hook, and power chain or a simple molar controller, respectively. Both dental appliances are technically easy to construct, require short chair time, induce little discomfort on the patient, and ensure high-level treatment efficiency.

Updated therapeutic strategy for adult low-grade glioma stratified by resection and tumor subtype

The importance of surgical resection for patients with supratentorial low-grade glioma (LGG) remains controversial. This retrospective study of patients (n = 153) treated between 2000 to 2010 at a single institution assessed whether increasing the extent of resection (EOR) was associated with improved progression-free survival (PFS) and overall survival (OS). Histological subtypes of World Health Organization grade II tumors were as follows: diffuse astrocytoma in 49 patients (32.0%), oligoastrocytoma in 45 patients (29.4%), and oligodendroglioma in 59 patients (38.6%). Median pre- and postoperative tumor volumes and median EOR were 29.0 cm(3) (range 0.7-162 cm(3)) and 1.7 cm(3) (range 0-135.7 cm(3)) and 95%, respectively. Five- and 10-year OS for all LGG patients were 95.1% and 85.4%, respectively. Eight-year OS for diffuse astrocytoma, oligoastrocytoma, and oligodendroglioma were 70.7%, 91.2%, and 98.3%, respectively. Five-year PFS for diffuse astrocytoma, oligoastrocytoma, and oligodendroglioma were 42.6%, 71.3%, and 62.7%, respectively. Patients were divided into two groups by EOR ≥90% and <90%, and OS and PFS were analyzed. Both OS and PFS were significantly longer in patients with ≥90% EOR. Increased EOR resulted in better PFS for diffuse astrocytoma but not for oligodendroglioma. Multivariate analysis identified age and EOR as parameters significantly associated with OS. The only parameter associated with PFS was EOR. Based on these findings, we established updated therapeutic strategies for LGG. If surgery resulted in EOR <90%, patients with astrocytoma will require second-look surgery, whereas patients with oligodendroglioma or oligoastrocytoma, which are sensitive to chemotherapy, will be treated with chemotherapy.

Advanced Image Coregistration within the Leksell Workstation for the Planning of Glioma Surgery: Initial Experience

Background Leksell GammaPlan (LGP) and SurgiPlan (ELEKTA Instruments AB, Stockholm, Sweden) may be used effectively for the detailed evaluation of regional neuroanatomy before open neurosurgical procedures. We report our initial experience in the cases of cerebral gliomas. Methods LGP v.8.3 was used before the surgical resection of cerebral gliomas for (1) the delineation of subdural grid electrodes and a detailed evaluation of their position relatively to cortical structures, and (2) for the fusion of structural magnetic resonance imaging and diffusion tensor imaging (DTI) for a detailed visualization of the corticospinal tract (CST) and optic radiation. Results Delineation of the subdural grid within LGP in a patient with seizures caused by left parietal glioma permitted a detailed assessment of the location of electrodes relative to the cortical gyri and sulci and significantly facilitated interpretation of brain mapping before tumor resection. In another patient with parieto-occipital glioma, simultaneous three-dimensional visualization of the tumor, CST, and optic radiation with the use of LGP permitted us to perform tumor resection without postoperative neurologic complications. Finally, incorporation of DTI into SurgiPlan resulted in precise planning of stereotactic biopsy for bilateral thalamic glioma. Conclusion The possibility for detailed evaluation of regional neuroanatomy based on various images within LGP and SurgiPlan may facilitate effective and safe surgical management of intracranial gliomas.

Development of multichannel array transducer of displacement mechanical-myogram

The myoelectric signal (EMG) recorded on the skin surface is a time-related and spatial aggregate of the action potentials of motor units of skeletal muscle, and it indicates the input information for muscle contraction. The mechano-myographic signal (MMG) is a vibration of skin/muscle surface caused by muscle contraction and it directly reflects the activity of muscle contraction. The two-dimensional generation mechanism of MMG is still n ot clarified in detail. In this study, the displacement MMGs were recorded at 25 measuring points using 5 × 5 displacement MMG array transducer within 50× 50 mm, while the motor point of the biceps brachii was electro-stimulated. The spatial propagation map of twitch waveform of displacement MMG was drawn.

Neonatal dural arteriovenous fistula at the confluence presenting with paralysis of the orbicularis oris muscle

A male neonate presented a dural arteriovenous fistula (DAVF) at the confluence with paralysis of the orbicularis oris muscle. The interesting features in our case were the clinical symptoms (orbicularis oris muscle paralysis at birth), angioarchitecture (high-flow arteriovenous shunts at the confluence) and the size and hemodynamic flow (mid-sized venous pouch) of the fistula. Additionally, the embolization technique (i.e., occipital artery approach, closing shunts with pure glue) automatically resulted in the immediate and complete closure of accessory feeders without any additional treatment, and the midterm clinical outcome was good. We succeeded improving the symptoms of a neonate with a congenital high-flow DAVF by closing a fistula using a small amount of glue.

Outcome after Gamma Knife surgery for intracranial arteriovenous malformations in children

Object

The focus of the present study was the evaluation of outcomes after unstaged and staged-volume Gamma Knife surgery (GKS) in children harboring intracranial arteriovenous malformations (AVMs).

Methods

Twenty-two children (median age 9.5 years) underwent GKS for AVMs and were followed up for at least 2 years thereafter. The disease manifested with intracranial hemorrhage in 77% of cases. In 68% of patients the lesion affected eloquent brain structures. The volume of the nidus ranged from 0.1 to 6.7 cm3. Gamma Knife surgery was guided mainly by data from dynamic contrast-enhanced CT scans, with preferential targeting of the junction between the nidus and draining vein. The total prescribed isodose volume was kept below 4.0 cm3, and the median margin dose was 22 Gy (range 20–25 Gy). If the volume of the nidus was larger than 4.0 cm3, a second radiosurgical session was planned for 3–4 years after the first one. Nine patients in the present series underwent unstaged radiosurgery, whereas staged-volume treatment was scheduled in 13 patients.

Results

Complete obliteration of the AVM was noted in 17 (77%) of 22 patients within a median period of 47 months after the last radiosurgical session. Complete obliteration of the lesion occurred in 89% of patients after unstaged treatment and in 62.5% after staged GKS. Four (67%) of 6 high-grade AVMs were completely obliterated. Complications included 3 bleeding episodes, the appearance of a region of hyperintensity on T2-weighted MR images in 2 patients who had no symptoms, and reappearance of the nidus in the vicinity of the completely obliterated AVM in 1 patient.

Conclusions

Radiosurgery is a highly effective management option for intracranial AVMs in children. For larger lesions, staged GKS may be applied successfully. Initial targeting of the nidus adjacent to the draining vein and application of a sufficient radiation dose to a relatively small volume (≤ 4 cm3) provides a good balance between a high probability of obliteration and a low risk of treatment-related complications.

Axonal gradient of arachidonic acid-containing phosphatidylcholine and its dependence on actin dynamics

Phosphatidylcholine (PC) is the most abundant component of lipid bilayers and exists in various molecular forms, through combinations of two acylated fatty acids. Arachidonic acid (AA)-containing PC (AA-PC) can be a source of AA, which is a crucial mediator of synaptic transmission and intracellular signaling. However, the distribution of AA-PC within neurons has not been indicated. In the present study, we used imaging mass spectrometry to characterize the distribution of PC species in cultured neurons of superior cervical ganglia. Intriguingly, PC species exhibited a unique distribution that was dependent on the acyl chains at the sn-2 position. In particular, we found that AA-PC is enriched within the axon and is distributed across a proximal-to-distal gradient. Inhibitors of actin dynamics (cytochalasin D and phallacidin) disrupted this gradient. This is the first report of the gradual distribution of AA-PC along the axon and its association with actin dynamics.

High-flow Neonatal Macrocerebral Arteriovenous Fistulas in Hereditary Hemorrhagic Telangiectasia

Although some cases of vein of Galen aneurysmal malformation (VGAM) present initial clinical symptoms such as cardiopulmonary disturbance in the neonatal period, pial arteriovenous fistula is very seldom present as a clinical symptom immediately after birth. A neonatal patient, the first-born to his family, presented with tachypnea postpartum. This baby had a family history of hereditary hemorrhagic telangiectasia. A cerebral MR image revealed multiple macrocerebral arteriovenous fistulas (MCAVFs), resulting in a large partially thrombosed venous pouch within the cerebral cortex. Trans-arterial embolizations of the main two fistulas were performed using N-butyl cyanoacrylate (NBCA) with tantalum powder six months after birth. Post-embolization angiography confirmed the obliteration of the fistulas and magnetic resonance imaging (MRI) revealed thrombosis and reduction in size of the venous component. His tachypnea disappeared completely. There were no neurological complications due to the treatment. The prognosis of multiple MCAVFs mainly depends on the presence of medullar signs and symptoms and a delay before treatment. Pure glue endovascular intervention, as used in our case, is considered to be the first therapeutic choice to decrease the risk of neurological consequences.

Relationship between quadriceps femoris muscle volume and muscle torque at least 18 months after anterior cruciate ligament reconstruction

The purpose of this study was to evaluate motor unit recruitment in the quadriceps femoris (QF) after anterior cruciate ligament (ACL) rupture and repair. Subjects included 24 patients at ≥ 18 months after ACL reconstruction and 22 control subjects with no history of knee injury. A series of cross-sectional magnetic resonance images were obtained to compare the QF of patients' injured side with that of their uninjured sides and that of uninjured control subjects. Muscle torque per muscle volume was calculated as isokinetic peak torque divided by QF muscle volume (cm(3)). The mean muscle torque per unit volume of the injured side of patients was not significantly different from that of the uninjured side or control subjects (one-way ANOVA) Results of the present study were contrary to the results of a previous study that evaluated patients at ≤ 12 months after ACL reconstruction. The present study found that high-threshold motor unit recruitment was restored at ≥ 18 months after ACL reconstruction. Thus, clinicians must develop techniques that increase the recruitment of high-threshold motor units in the QF from the period immediately after the injury until approximately 18 months after ACL reconstruction.

Identification of tubulin deglutamylase among Caenorhabditis elegans and mammalian cytosolic carboxypeptidases (CCPs)

Tubulin polyglutamylation is a reversible post-translational modification, serving important roles in microtubule (MT)-related processes. Polyglutamylases of the tubulin tyrosine ligase-like (TTLL) family add glutamate moieties to specific tubulin glutamate residues, whereas as yet unknown deglutamylases shorten polyglutamate chains. First we investigated regulatory machinery of tubulin glutamylation in MT-based sensory cilia of the roundworm Caenorhabditis elegans. We found that ciliary MTs were polyglutamylated by a process requiring ttll-4. Conversely, loss of ccpp-6 gene function, which encodes one of two cytosolic carboxypeptidases (CCPs), resulted in elevated levels of ciliary MT polyglutamylation. Consistent with a deglutamylase function for ccpp-6, overexpression of this gene in ciliated cells decreased polyglutamylation signals. Similarly, we confirmed that overexpression of murine CCP5, one of two sequence orthologs of nematode ccpp-6, caused a dramatic loss of MT polyglutamylation in cultured mammalian cells. Finally, using an in vitro assay for tubulin glutamylation, we found that recombinantly expressed Myc-tagged CCP5 exhibited deglutamylase biochemical activities. Together, these data from two evolutionarily divergent systems identify C. elegans CCPP-6 and its mammalian ortholog CCP5 as a tubulin deglutamylase.

Imaging mass spectrometry revealed the production of lyso-phosphatidylcholine in the injured ischemic rat brain

To develop an effective neuroprotective strategy against ischemic injury, it is important to identify the key molecules involved in the progression of injury. Direct molecular analysis of tissue using mass spectrometry (MS) is a subject of much interest in the field of metabolomics. Most notably, imaging mass spectrometry (IMS) allows visualization of molecular distributions on the tissue surface. To understand lipid dynamics during ischemic injury, we performed IMS analysis on rat brain tissue sections with focal cerebral ischemia. Sprague-Dawley rats were sacrificed at 24 h after middle cerebral artery occlusion, and brain sections were prepared. IMS analyses were conducted using matrix-assisted laser desorption/ionization time-of-flight mass spectrometer (MALDI-TOF MS) in positive ion mode. To determine the molecular structures, the detected ions were subjected to tandem MS. The intensity counts of the ion signals of m/z 798.5 and m/z 760.5 that are revealed to be a phosphatidylcholine, PC (16:0/18:1) are reduced in the area of focal cerebral ischemia as compared to the normal cerebral area. In contrast, the signal of m/z 496.3, identified as a lyso-phosphatidylcholine, LPC (16:0), was clearly increased in the area of focal cerebral ischemia. In IMS analyses, changes of PC (16:0/18:1) and LPC (16:0) are observed beyond the border of the injured area. Together with previous reports--that PCs are hydrolyzed by phospholipase A(2) (PLA(2)) and produce LPCs,--our present results suggest that LPC (16:0) is generated during the injury process after cerebral ischemia, presumably via PLA(2) activation, and that PC (16:0/18:1) is one of its precursor molecules.

Effect of maternal stress on fetal heart rate assessed by vibroacoustic stimulation

This study was designed to determine whether maternal stress levels, state and trait anxiety levels, and stress hormones affect fetal heart rate (FHR) patterns after vibroacoustic stimulation (VAS) at 30 weeks of gestation. A total of 24 healthy pregnant women with a single fetus pregnancy were enrolled. Corticotropin releasing hormone (CRH) and adrenocorticotropic hormone in maternal plasma and cortisol, and chromogranin A in saliva were measured. The FHR patterns after VAS were divided into three types: type I, a long period of acceleration or one acceleration lasting > 1 min or at least two accelerations lasting > 15 s; type II, a biphasic response with acceleration followed by deceleration; and type III, no response or prolonged deceleration. In the high trait anxiety group, CRH levels were significantly higher than in the low trait anxiety group, and FHR patterns after VAS showed mostly a type II response pattern. These findings suggest that stress in pregnant women with high trait anxiety may influence FHR patterns after VAS.