Intracellular amyloid and the neuronal origin of Alzheimer neuritic plaques

Genetic analysis of familial forms of Alzheimer's disease (AD) causally links the proteolytic processing of the amyloid precursor protein (APP) and AD. However, the specific type of amyloid and mechanisms of amyloid pathogenesis remain unclear. We conducted a detailed analysis of intracellular amyloid with an aggregation specific conformation dependent monoclonal antibody, M78, raised against fibrillar Aß42. M78 immunoreactivity colocalizes with Aß and the carboxyl terminus of APP (APP-CTF) immunoreactivities in perinuclear compartments at intermediate times in 10month 3XTg-AD mice, indicating that this represents misfolded and aggregated protein rather than normally folded APP. At 12months, M78 immunoreactivity also accumulates in the nucleus. Neuritic plaques at 12months display the same spatial organization of centrally colocalized M78, diffuse chromatin and neuronal nuclear NeuN staining surrounded by peripheral M78 and APP-CTF immunoreactivity as observed in neurons, indicating that neuritic plaques arise from degenerating neurons with intracellular amyloid immunoreactivity. The same staining pattern was observed in neuritic plaques in human AD brains, showing elevated intracellular M78 immunoreactivity at intermediate stages of amyloid pathology (Braak A and B) compared to no amyloid pathology and late stage amyloid pathology (Braak 0 and C, respectively). These results indicate that intraneuronal protein aggregation and amyloid accumulation is an early event in AD and that neuritic plaques are initiated by the degeneration and death of neurons by a mechanism that may be related to the formation of extracellular traps by neutrophils.

Cranial arachnoid protrusions and contiguous diploic veins in CSF drainage

BACKGROUND AND PURPOSE

Studies have suggested that arachnoid villi or granulations found in the walls of the cranial dural sinuses, olfactory mucosa, and cranial nerve sheaths function as outlets for intracranial CSF. However, their role as CSF outlets has not yet been verified. Here we show that arachnoid protrusions and contiguous diploic veins provide an alternative drainage route for intracranial CSF.

MATERIALS AND METHODS

Four hundred patients with intact skull, dura mater, and dural sinuses underwent MR imaging to explore arachnoids protruding into the skull and diploic veins. Patients with symptoms of increased intracranial pressure or intracranial hypotension were excluded. For 15 patients undergoing craniotomy, both peripheral and diploic venous blood was collected. Albumin and the CSF-specific biomarkers were measured by enzyme-linked immunosorbent assay.

RESULTS

With MR imaging, arachnoid protrusions into the skull and contiguous diploic veins were consistently identified throughout the cranium with their characteristic appearance depending on the cranial region. In addition, elevated amounts of prostaglandin D synthase and cystatin C were confirmed in diploic veins compared with peripheral venous blood.

CONCLUSIONS

Diploic veins are distributed ubiquitously throughout the cranium. A portion of the intracranial CSF may be drained through arachnoid protrusions and contiguous diploic veins.

De novo EEF1A2 mutations in patients with characteristic facial features, intellectual disability, autistic behaviors and epilepsy

Eukaryotic elongation factor 1, alpha-2 (eEF1A2) protein is involved in protein synthesis, suppression of apoptosis, and regulation of actin function and cytoskeletal structure. EEF1A2 gene is highly expressed in the central nervous system and Eef1a2 knockout mice show the neuronal degeneration. Until now, only one missense mutation (c.208G > A, p.Gly70Ser) in EEF1A2 has been reported in two independent patients with neurological disease. In this report, we described two patients with de novo mutations (c.754G > C, p.Asp252His and c.364G > A, p.Glu122Lys) in EEF1A2 found by whole-exome sequencing. Common clinical features are shared by all four individuals: severe intellectual disability, autistic behavior, absent speech, neonatal hypotonia, epilepsy and progressive microcephaly. Furthermore, the two patients share the similar characteristic facial features including a depressed nasal bridge, tented upper lip, everted lower lip and downturned corners of the mouth. These data strongly indicate that a new recognizable disorder is caused by EEF1A2 mutations.

RISING beamline (BL28XU) for rechargeable battery analysis

The newly installed BL28XU beamline at SPring-8 is dedicated to in situ structural and electronic analysis of rechargeable batteries. It supports the time range (1 ms to 100 s) and spatial range (1 µm to 1 mm) needed for battery analysis. Electrochemical apparatus for battery charging and discharging are available in experimental hutches and in a preparation room. Battery analysis can be carried out efficiently and effectively using X-ray diffraction, X-ray absorption fine-structure analysis and hard X-ray photoelectron spectroscopy. Here, the design and performance of the beamline are described, and preliminary results are presented.

[Acute encephalitis presenting with symmetrical involvement of the bilateral basal ganglia]

A 8-year-old girl was hospitalized with consciousness disturbance and involuntary movements five days after the onset of fever. Cranial MRI revealed symmetrical involvement of the bilateral basal ganglia with elevated ADC mapping, suggesting vasogenic edema.Her clinical symptoms improved with methylprednisolone pulse therapy without neurological sequelae. The rapid antigen test for group A beta-hemolytic streptococcus was positive and serum ASO was elevated. Myelin basic protein in cerebrospinal fluid was elevated. We suggest that the pathophysiological mechanism in the present case was not necrotic/cytotoxic but autoimmune inflammation, which is compatible with acute disseminated encephalomyelitis associated with streptococcal infection.

Visual-statistical interpretation of (18)F-FDG-PET images for characteristic Alzheimer patterns in a multicenter study: inter-rater concordance and relationship to automated quantitative evaluation

BACKGROUND AND PURPOSE

The role of (18)F-FDG-PET in the diagnosis of Alzheimer disease is increasing and should be validated. The aim of this study was to assess the inter-rater variability in the interpretation of (18)F-FDG-PET images obtained in the Japanese Alzheimer's Disease Neuroimaging Initiative, a multicenter clinical research project.

MATERIALS AND METHODS

This study analyzed 274 (18)F-FDG-PET scans (67 mild Alzheimer disease, 100 mild cognitive impairment, and 107 normal cognitive) as baseline scans for the Japanese Alzheimer's Disease Neuroimaging Initiative, which were acquired with various types of PET or PET/CT scanners in 23 facilities. Three independent raters interpreted all PET images by using a combined visual-statistical method. The images were classified into 7 (FDG-7) patterns by the criteria of Silverman et al and further into 2 (FDG-2) patterns.

RESULTS

Agreement among the 7 visual-statistical categories by at least 2 of the 3 readers occurred in >94% of cases for all groups: Alzheimer disease, mild cognitive impairment, and normal cognitive. Perfect matches by all 3 raters were observed for 62% of the cases by FDG-7 and 76 by FDG-2. Inter-rater concordance was moderate by FDG-7 (κ = 0.57) and substantial in FDG-2 (κ = 0.67) on average. The FDG-PET score, an automated quantitative index developed by Herholz et al, increased as the number of raters who voted for the AD pattern increased (ρ = 0.59, P < .0001), and the FDG-PET score decreased as those for normal pattern increased (ρ = -0.64, P < .0001).

CONCLUSIONS

Inter-rater agreement was moderate to substantial for the combined visual-statistical interpretation of (18)F-FDG-PET and was also significantly associated with automated quantitative assessment.

Crystal structure of a conformation-dependent rabbit IgG Fab specific for amyloid prefibrillar oligomers

BACKGROUND

Although rabbit antibodies are widely used in research, no structures of rabbit antigen-binding fragments (Fab) have been reported. M204 is a rabbit monoclonal antibody that recognizes a generic epitope that is common to prefibrillar amyloid oligomers formed from many different amyloidogenic sequences. Amyloid oligomers are widely suspected to be a primary causative agent of pathogenesis in several age-related neurodegenerative diseases, such as Alzheimer's disease. The detailed structure of these amyloid oligomers is not known nor is the mechanism for the recognition of the generic epitope by conformation-dependent monoclonal antibodies.

METHOD

As a first approach to understanding the mechanism of conformation-dependent antibody recognition, we have crystallized the Fab of M204.

RESULTS

We have determined the structure of the Fab of M204 at 1.54Å resolution. The crystal structure reveals details of the M204 antigen combining site and features unique to rabbit Fabs such as an interdomain disulfide bond on its light chain.

GENERAL SIGNIFICANCE

Based on the structural features of the antigen-combining site of the M204, we rule out a "steric zipper" formation, as found in numerous amyloid fibril structures, as a mechanism of antibody-antigen recognition. The details of the first rabbit immunoglobulin Fab structure might also be useful for exploiting the potential of rabbit monoclonal antibodies for the development of humanized rabbit antibodies as therapeutic agents.

[Aortic valve surgery for autoimmune disease]

Aortic valve disease of autoimmune disease is complicated in pre-, peri- and post-operative care. Recommended care in aortitis, ankylosing spondylitis, systemic lupus erythematosus and rheumatoid arthritis were described. Surgical strategy should be determined depending on basic disease, degree of inflammation and region of disease. Because of the fragile tissue of autoimmune disease patient, modified Bentall procedure is recommended to prevent a prosthetic valve dropping off for aortitis. Perioperatively, it is important to control the inflammation of basic disease, thus a steroid cover is necessary perioperatively. Some complications such as infection, out-of-control of anti-coaguration or gastro-intestinal bleeding should be avoided. Post operation, a strict follow up of prosthetic valve and aorta around suture line and control of autoimmune disease should be achieved.

Endovascular therapy of 500 small asymptomatic unruptured intracranial aneurysms

BACKGROUND AND PURPOSE

Although the natural course of UIAs remains unclear, the risk of aneurysmal SAH due to small (<10 mm) asymptomatic UIAs is low. Endovascular therapy for UIAs has increased because of device development and the need for less invasive treatment. We report the results, safety, and efficacy of endovascular therapy of small asymptomatic UIAs.

MATERIALS AND METHODS

A total of 457 patients with 500 small asymptomatic UIAs (maximum diameter < 10 mm) underwent endosaccular coil embolization at Juntendo University Hospital and affiliated hospitals. We retrospectively evaluated the technical feasibility, immediate and short-to-midterm follow-up anatomic results, procedure-related complications, and clinical outcomes.

RESULTS

Endosaccular coil embolization was completed in 481 aneurysms (96.2%) and attempted in 19 (3.8%). Completed aneurysms were treated with the simple (39.5%), balloon-assisted (51.4%), and double-catheter (9.1%) techniques. Immediate angiographic outcomes were CO for 309 (64.2%) aneurysms, RN for 72 (15.0%), and RA for 100 (20.8%). Procedure-related complications occurred in 38 aneurysms (7.6%): 19 ischemic, 11 hemorrhagic, and 8 others. Permanent morbidity and mortality were 0.8% and 0.2%, respectively. Anatomic outcome of 427 aneurysms followed up for >6 months with conventional catheter or MR angiographies showed recanalization in 72 (16.9%) aneurysms, necessitating retreatment in 9.9% (mean, 31.4 months). No patients had aneurysmal SAH during the clinical follow-up period (mean, 34.7 months).

CONCLUSIONS

In this series, endovascular therapy of small asymptomatic UIAs was highly feasible with low morbidity and mortality rates.

Lung cancer associated with an azygos lobe successfully treated with video-assisted thoracoscopic surgery

Primary lung cancer associated with an azygos lobe is extremely rare. Herein, we report the case of a 64-year-old woman with lung adenocarcinoma arising in the right upper lobe with an azygos lobe. The patient underwent a right upper lobectomy and lymph node dissection with video-assisted thoracoscopic surgery. Video-assisted thoracoscopic surgery lobectomy for lung cancer of this variant has yet to be reported. We demonstrate the intraoperative findings and the resected pulmonary lobe. This is the first case of primary lung cancer associated with the azygos lobe treated by lobectomy with video-assisted thoracoscopic surgery.

Brain localization of leucine-rich α2-glycoprotein and its role

OBJECTIVES

We have previously reported that the level of leucine-rich alpha-2-glycoprotein (LRG) expression is specifically increased in cerebrospinal fluid (CSF) of idiopathic normal pressure hydrocephalus (INPH). The objective of this study is to examine the localization of LRG - the cerebral areas where it is expressed.

METHOD

The histological sections of autopsied brain specimens from ten subjects, five adult cases (mean age 43.6 years; range 34-50 years) and five senile cases (mean age 76.0 years; range 67-88 years) were prepared, multistained with antibodies against human LRG, glial fibrillary acidic protein (GFAP), CD31, and aquaporin-4 (AQP4), and reviewed for the expression sites of LRG.

RESULTS

Immunostains of GFAP and LRG were compared in standard brain specimens from elderly patients. The results indicated that LRG is distributed throughout the entire brain, with especially high expression in the deep cerebral cortex. In addition, the cells that express LRG showed similar morphology to astrocytes. Double staining of CD31 and LRG revealed a significant expression of LRG in the pericapillary regions. The expression was observed in resident astrocytes, as well as in the capillary vessel to which astrocytic processes grow and adhere. When age-related comparisons were made between senile and adult specimens, LRG expression increased with age.

CONCLUSION

LRG expression in resident astrocytes increased with age.

Effective multidisciplinary treatment for ovarian granulosa cell tumor with multiple metastases--a case report

Ovarian granulosa cell tumor (GCT) is among the ovarian sex-cord stromal tumors that are classified as borderline malignancies. We report a case of GCT with multiple metastases for which multidisciplinary treatment including surgery, chemotherapy and radiotherapy was effective. A 41-year-old woman underwent left salpingo-oophorectomy because of an ovarian tumor in 2004. Final pathology confirmed a granulosa cell tumor adult type, FIGO Stage IC. In 2008, tumorectomy of the lower abdominal wall metastases was also performed. After three cycles of BEP chemotherapy for metastases of the right lung, liver, paraaortic lymph node and rectus, surgical resection was performed in 2009. In 2010, local radiation was performed for the first lumbar vertebral metastasis. Ovarian GCTs exhibit slow growth but if the surgical stage is IC or higher, there is the possibility of recurrence. It is important to treat recurrent tumors with the combination of surgery, chemotherapy, and radiation therapy.

Reconstruction of scalp and cranium defect utilizing latissimus dorsi musculocutaneous and serratus anterior muscle free flaps with interpositional anastomosis of T-shaped flap artery: case report

The use of a combination musculocutaneous free flap, consisting of a latissimus dorsi flap and a serratus anterior flap, for reconstruction of a large scalp and cranium defect is described. The recipient artery, the superficial temporal artery (STA), was anastomosed to the flap artery, without sacrificing blood flow, by means of a special technique: forming the end of the flap artery into a T shape and interposing it between the two stumps of the transected STA, because the STA was crucial for tissue adjacent to the defect. The flap vein was anastomosed to the external jugular vein with a vein graft. The extensive defect was immediately closed with sutures, and there were no remarkable complications.

Altered vitamin E status in Niemann-Pick type C disease

Vitamin E (α-tocopherol) is the major lipid-soluble antioxidant in many species. Niemann-Pick type C (NPC) disease is a lysosomal storage disorder caused by mutations in the NPC1 or NPC2 gene, which regulates lipid transport through the endocytic pathway. NPC disease is characterized by massive intracellular accumulation of unesterified cholesterol and other lipids in lysosomal vesicles. We examined the roles that NPC1/2 proteins play in the intracellular trafficking of tocopherol. Reduction of NPC1 or NPC2 expression or function in cultured cells caused a marked lysosomal accumulation of vitamin E in cultured cells. In vivo, tocopherol significantly accumulated in murine Npc1-null and Npc2-null livers, Npc2-null cerebella, and Npc1-null cerebral cortices. Plasma tocopherol levels were within the normal range in Npc1-null and Npc2-null mice, and in plasma samples from human NPC patients. The binding affinity of tocopherol to the purified sterol-binding domain of NPC1 and to purified NPC2 was significantly weaker than that of cholesterol (measurements kindly performed by R. Infante, University of Texas Southwestern Medical Center, Dallas, TX). Taken together, our observations indicate that functionality of NPC1/2 proteins is necessary for proper bioavailability of vitamin E and that the NPC pathology might involve tissue-specific perturbations of vitamin E status.

Yokukansan, a traditional Japanese medicine, ameliorates memory disturbance and abnormal social interaction with anti-aggregation effect of cerebral amyloid β proteins in amyloid precursor protein transgenic mice

The deposition of amyloid β protein (Aβ) is a consistent pathological hallmark of Alzheimer's disease (AD) brains. Therefore, inhibition of Aβ aggregation in the brain is an attractive therapeutic and preventive strategy in the development of disease-modifying drugs for AD. An in vitro study demonstrated that yokukansan (YKS), a traditional Japanese medicine, inhibited Aβ aggregation in a concentration-dependent manner. An in vivo study demonstrated that YKS and Uncaria hook (UH), a constituent of YKS, prevented the accumulation of cerebral Aβ. YKS also improved the memory disturbance and abnormal social interaction such as increased aggressive behavior and decreased social behavior in amyloid precursor protein transgenic mice. These results suggest that YKS is likely to be a potent and novel therapeutic agent to prevent and/or treat AD, and that this may be attributed to UH.

CT-guided radiofrequency liver tumour ablation: use of a two-step coaxial system with a fine guide needle wire unit for high-risk cases

Accurate radiofrequency (RF) needle targeting to liver lesions under CT guidance is technically difficult and generally requires multiple needle manipulations, which carries potential risk. This approach is hardly applicable for precariously located lesions or for patients who have difficulty holding their breath. The aim of this study was to develop a novel two-step coaxial system to facilitate CT-guided RF ablation in difficult cases. The study group comprised 11 patients with 12 hepatic lesions. The coaxial system consisted of two parts: a 21-gauge pencil-tip guide needle wire (GNW) unit comprising a 150-mm-long needle segment and a 250-mm-long wire segment; and a 140-mm-long outer cannula with its stylet, which accepts a 17-gauge RF electrode needle. The GNW was inserted until the route of the GNW was confirmed to be positioned correctly. The cannula with the stylet was then advanced along the GNW. Lesions were successfully accessed using the GNW, even in patients who could not hold their breath, and manipulation was feasible within the limited space of the CT gantry. The light GNW also facilitated step-by-step CT-guided angular manipulations, unlike heavy RF electrodes, which are unstable during hands-free use unless deeply inserted. Therefore, this system enabled sequential ablations of large tumours by ensuring three different routes in advance by using the GNW. Insertion of the cannula along the GNW was simple. In conclusion, the two-step coaxial system enabled CT-guided RF tumour ablation to be performed in cases conventionally contraindicated owing to high risk of serious complications.

Three children with plastic bronchitis associated with 2009 H1N1 influenza virus infection

We report the cases of 3 children with plastic bronchitis associated with 2009 H1N1 influenza virus infection. These 3 children shared common clinical and radiologic features: rapid and progressive respiratory distress with whole lung atelectasis on chest radiograph. In children with severe respiratory symptoms accompanied by H1N1 influenza, plastic bronchitis should be considered.

Neuroradiologic features of CASK mutations

Mutations of the CASK gene are associated with X-linked mental retardation with microcephaly and disproportionate brain stem and cerebellar hypoplasia in females. The areas of the cerebrum, corpus callosum, pons, midbrain, and cerebellar vermis and hemisphere and a ratio of cerebrum/corpus callosum areas were measured in 5 female patients with CASK mutations, 67 female controls, and 5 patients with pontine hypoplasia. MR imaging in patients with CASK mutations revealed a normal size of the corpus callosum and a low ratio of the cerebrum/corpus callosum with a reduced area of the cerebrum, pons, midbrain, and cerebellar vermis and hemispheres. The 5 patients with pontine hypoplasia showed thinning of the corpus callosum and a high ratio of the cerebrum/corpus callosum, irrespective of the size of the cerebrum. The normal size of the corpus callosum, which gives an impression of callosal thickening at first glance, may be an imaging clue to detect patients with CASK mutations.

Transvenous embolization of dural carotid cavernous fistulas: a series of 44 consecutive patients

BACKGROUND AND PURPOSE

Endovascular TVE for DCCF is used for curative purposes, but serious complications can be caused with inadequate embolization. Our aim was to report clinical characteristics, angiographic findings, and results of endovascular TVE in patients presenting with DCCF.

MATERIALS AND METHODS

We performed a retrospective analysis of 44 consecutive patients with DCCF treated by TVE. Approach routes, angiographic results, clinical outcomes, and complications were assessed.

RESULTS

An approach via the internal jugular vein and inferior petrosal sinus was possible in 90% of patients, with complete occlusion of the fistula in 81.6% of patients. A minor residual shunt remained in 13.6% of patients, while a significant shunt remained in 4.5%. In 4 patients, add-on management with transarterial embolization was useful, and in 2 patients with residual shunt, radiosurgery was used. With long-term follow-up (6-40 months), we encountered recanalization/recurrence in 4 patients (9.1%). Complications were seen in the form of permanent morbidity in 3 patients (7%) and transient morbidity in 6 patients (14%).

CONCLUSIONS

For endovascular treatment of DCCF, a transvenous approach was effective in most of our patients; however, some adverse effects were encountered. If AV shunts remain after transvenous treatment, additional modalities must be considered.

[Heart positioners and proximal anastomotic devices in off-pump coronary artery bypass grafting]

Owing to development of device technology, off-pump coronary artery bypass grafting (OPCAB) has become a safe, reproducible and reliable procedure. Surgeons must understand the advantages and limitations of each device and select appropriate devices in individual case to avoid device-related complication and a waste of cost. The directions and pitfalls of heart positioners, stabilizers and proximal anastomotic devices were described. With the improved heart positioners and stabilizers all coronary targets have been well visualized and accessible, maintaining hemodynamic stability. Automated proximal anastomotic devices and proximal anastomotic assist devices have reduced the occurrence of cerebral complications compared with the side-clamp of the ascending aorta. The appropriate use of devices in OPCAB would be a promising and cost-effective procedure for revascularization of ischemic heart disease.