[Staged bilateral VA embolization for SAH due to bilateral VA dissection: case report]

Vertebral artery (VA) dissections are uncommon, but are increasingly recognized as a cause of posterior circulation stroke in young adults. We describe a patient with bilateral VA dissection who presented SAH. The patient was successfully treated by proximal coil occlusion of the bilateral vertebral arteries in two stages. In the treatment of SAH due to bilateral VA dissection, it is important to estimate the status of the treated vessels or contralateral vessels by follow-up angiography. Staged bilateral proximal VA occlusions should be considered in the case of recurrent VA dissection or progressive aneurysm enlargement.

Fas ligand expression and depletion of T-cell infiltration in astrocytic tumors

Fas (APO-1/CD95) ligand (FasL) and its receptor, Fas, play a key role in the regulation of apoptosis in the immune system. FasL acts as a cytotoxic effector molecule to Fas-expressing malignant tumor cells; however, it has recently been suggested that FasL also acts as a possible mediator of tumor immune privilege. We studied FasL expression in glioblastoma cell lines and a series of human glioma specimens by Western blotting and immunohistochemistry. In addition, quantitative analysis of T-cell infiltration in these tumors was performed. FasL expression was seen in all cell lines and in 9 of 14 specimens by Western blotting and immunohistochemistry. The distribution of FasL was recognized in the cytoplasm of tumor cells (5 of 9) and in the vascular endothelium (4 of 9). Both types of FasL expression were associated with a significant reduction (p < 0.05) in T-cell infiltration when compared with FasL-negative areas within the same tumor or FasL-negative specimens. Since T-cell apoptosis could be induced by FasL-expressing tumor cells, the present findings suggest that apoptosis induction by FasL expressed on tumor cells and/or vascular endothelium might be one mechanism for T-cell depletion in astrocytic tumor tissues.

Embryonic neuronal death due to neurotrophin and neurotransmitter deprivation occurs independent of Apaf-1

Apoptotic protease-activating factor-1 (Apaf-1), dATP, and procaspase-9 form a multimeric complex that triggers programmed cell death through the activation of caspases upon release of cytochrome c from the mitochondria into the cytosol. Although cell death pathways exist that can bypass the requirement for cytochrome c release and caspase activation, several gene knockout studies have shown that the cytochrome c-mediated apoptotic pathway is critical for neural development. Specifically, the number of neuronal progenitor cells is abnormally increased in Apaf-1-, caspase-9-, caspase-3-deficient mice. However, the role of the cytochrome c cell death pathway for apoptosis of postmitotic, differentiated neurons in the developing brain has not been investigated in vivo. In this study we investigated embryonic neuronal cell death caused by trophic factor deprivation or lack of neurotransmitter release by analyzing Apaf-1/tyrosine kinase receptor A (TrkA) and Apaf-1/Munc-18 double mutant mice. Histological analysis of the double mutants' brains (including cell counting and terminal (TdT)-mediated dUTP-biotin nick end labeling (TUNEL) staining) reveals that neuronal cell death caused by these stimuli can proceed independent of Apaf-1. We propose that a switch between apoptotic programs (and their respective proteins) characterizes the transition of a neuronal precursor cell from the progenitor pool to the postmitotic population of differentiated neurons.

Expression of vascular endothelial growth factors and their receptors in and around intracranial arteriovenous malformations

OBJECTIVE

The precise mechanisms responsible for the development and growth of intracranial arteriovenous malformations (AVMs) remain unclear, but it has been hypothesized that vascular endothelial growth factors (VEGFs) might be involved in their pathogenesis. The aim of this study was to examine immunohistochemically the presence of the VEGF family (VEGF-A to -D) and their receptors (Flt-1, Flk-1, and Flt-4) in the surgically resected AVM nidus.

METHODS

The AVM nidus was surgically obtained from 31 patients with AVMs (mean age, 40.5 yr, range 13-73 yr). The mean size of the nidus was 31.6 mm (range, 15-60 mm). Formalin-fixed, paraffin-embedded specimens were stained immunohistochemically by the labeled streptavidin-biotin method with antibodies against VEGF-A to -D, as well as Flt-1, Flk-1, and Flt-4.

RESULTS

Positive staining for VEGF-A to -D was observed in the endothelial cells of the abnormal vessels involved in the AVM nidus and in the cytoplasm of astroglia surrounding it. Samples from 30 (96.8%) of 31 patients stained positive for VEGF-A, 4 (9.7%) for VEGF-B, 17 (54.5%) for VEGF-C, and 16 (51.6%) for VEGF-D. Flt-1, Flk-1, and Flt-4 were also positive chiefly, but not exclusively, in the cytoplasm of vascular endothelium and smooth muscle cells of the vascular wall. With regard to VEGF receptors, it was found that among the 31 patients studied, 19 (61.3%) were immunohistochemically positive for Flt-1, 6 (19.4%) for Flk-1, and 19 (61.3%) for Flt-4. A comparison of mean nidus size and average age at operation revealed significant differences between patients positive for VEGF-C, VEGF-D, Flt-1, or Flt-4. In contrast, there were no significant differences in nidus size and age in patients positive for VEGF-A, VEGF-B, and Flk-1.

CONCLUSION

These results strongly suggest a possible contribution of the VEGF-VEGF receptor system to the growth of intracranial AVMs.

Brain specific human genes, NELL1 and NELL2, are predominantly expressed in neuroblastoma and other embryonal neuroepithelial tumors

NELL1 and NELL2 encode cysteine-rich amino acid sequences including six epidermal growth factor-like motifs, which contain signal peptides at the N-terminals. The deduced amino acid sequences of both genes are 55% identical and their cysteine stretch structures are conserved. NELL1 is expressed in the brain and kidney, whereas NELL2 is expressed specifically in the brain. The cell lineage expressing NELLs in the nervous system was investigated in established cell lines and central nervous system tumor tissues obtained from patients by Northern blot and reverse transcriptase-polymerase chain reaction analyses. NELL1 and NELL2 were predominantly expressed in neuroblastoma cell lines and little expressed in glioblastoma cell lines. NELL1 and NELL2 were also expressed in central neurocytoma, medulloblastoma, and some astrocytic tumors. Immunohistochemical analysis revealed that NELL2 protein was localized in the cytoplasm of neurons. These results suggest that NELL2 is predominantly expressed in the neuronal cell lineage in the human nervous system. NELL1 is expressed mainly in tumors in the neuronal cell lineage.

Transnasal bamboo foreign body lodged in the sphenoid sinus

Transnasal sphenoid sinus foreign body is a rare condition. We report a very rare case of transnasal bamboo foreign body lodged in the sphenoid sinus without damages to the orbital wall or skull base. A 69-year-old man fell down onto a bamboo stick, which snapped after penetrating his face through the right nostril. CT demonstrated that the bamboo stick stuck into the middle meatus, penetrated the ethmoid sinus just medial to the lamina papyracea and reached to the sphenoid sinus. No abnormal findings were detected in the orbit or skull base. The foreign body was removed from the nasal cavity without any complication. The endoscope was useful for evaluating possible injuries in the orbit and skull base and confirming the absence of residual foreign bodies.

Ischemia-reperfusion injury of the cochlea: effects of an iron chelator and nitric oxide synthase inhibitors

Release of free iron from cellular stores and activation of nitric oxide synthase (NOS) has been implicated in a wide variety of cochlear injuries. In order to evaluate the effects of deferoxamine (a iron chelator), 3-bromo-7-nitroindazole (a relatively selective neuronal NOS (nNOS) inhibitor) or aminoguanidine (a relatively selective inducible NOS (iNOS) inhibitor) on the post-ischemic cochlear dysfunction, albino guinea pigs were subjected to 30 min ischemia, and the threshold shifts of the compound action potential (CAP) from pre-ischemic values were compared with those of control animals 4 h after the onset of reperfusion. A statistically significant reduction in the post-ischemic CAP threshold shift was observed in the animals treated with deferoxamine or 3-bromo-7-nitroindazole. However, aminoguanidine did not affect the post-ischemic CAP threshold shift. These results suggest that free iron and nNOS play deleterious roles in the cochlear injury induced by transient ischemia.

Expression of prostaglandin H synthase-2 in human brain tumors

Numerous studies have demonstrated that prostaglandin H synthase-2 (PHS-2) is involved in gastrointestinal carcinogenesis, and that nonsteroidal anti-inflammatory drugs (NSAIDs), which inhibit PHS, can reduce the risk of colon cancer. In brain tumors, elevated prostaglandin production and its correlation to anaplastic grade of gliomas have been demonstrated. To determine whether the increased prostaglandin production is due to enhanced expression of PHS-2 and whether the up-regulation of PHS-2 has any correlation to histopathological findings in brain tumors, we evaluated the profile of PHS expression in several human glioma cell lines and surgical specimens from patients with various types of brain tumors. In glioma cell lines, five out of six cell lines showed constitutive expression of PHS-2, whereas PHS-1 was weakly expressed in all of them. All surgical specimens, except an ependymoma, which expressed both isozymes equally, expressed PHS-2 mRNA predominantly. Immunohistochemistry of various types of brain tumors, including six glioblastomas, nine astrocytomas, six meningiomas, five medulloblastomas, four craniopharyngiomas, three ependymomas, three neurinomas, two oligodendrogliomas, two malignant lymphomas, two dysembryoplastic neuroepitherial tumors and one metastatic brain tumor showed PHS-2 staining in most cases. In gliomas, astrocytomas (grade 2 and 3) were strongly stained, but the staining intensity of glioblastomas was relatively weak. Meningiomas and a metastatic brain tumor were also strongly stained. Our data thus suggest that most brain tumors express PHS-2, which may also play a role in tumorigenesis in the brain.

Adoptive immunotherapy for malignant brain tumors using human peripheral blood mononuclear cells activated by the Streptococcal preparation OK-432

Adoptive immunotherapy using OK-432-activated mononuclear cells (OK-MCs) offers cell-mediated and cytokine-mediated pathways for antitumor activity. The effectiveness of direct intratumoral administration of OK-MCs via a catheter/reservoir system was studied in patients with malignant brain tumors. Seventeen patients, 12 with malignant glioma, four with metastatic adenocarcinoma, and one with primary sarcoma of the brain, were treated by OK-MC therapy (1.0 to 11.2 x 10(7) cells/person) between June 1989 and April 1999. The OK-MC therapy was given to patients with tumors progressing despite previous cytoreductive surgery, radiation, or chemotherapy. Adverse effects seen after the therapy were fever in 10 patients, seizure in two patients, and hypotension in one patient. Evaluation by computed tomography or magnetic resonance imaging revealed that seven patients showed no change including three with minor response, and 10 showed progressive disease. Adoptive immunotherapy using OK-MC was safe and well tolerated, but the therapeutic potential is limited.

Protection of outer hair cells from reperfusion injury by an iron chelator and a nitric oxide synthase inhibitor in the guinea pig cochlea

To examine whether an active process of the cochlea was injured by ischemia-reperfusion, time courses of distortion-product otoacoustic emissions (DPOAEs) were examined before, during and after 30 min cochlear ischemia using albino guinea pigs. DPOAEs decreased to the minimum level when the animals were subjected to ischemia. When the cochlea was recirculated, DPOAEs initially recovered with time until 20 min after the onset of reperfusion. However, thereafter the amplitude of DPOAEs gradually decreased toward the noise level. Administration of deferoxamine (an iron chelator) or N-nitro-L-arginine (a nitric oxide synthase inhibitor) ameliorated this decrease of DPOAEs during reperfusion and significantly increased the DPOAE amplitudes 60 min after the onset of reperfusion as compared with those in non-treated animals. These results suggest that cochlear reperfusion as well as ischemia injured the active process of the cochlea and that free radicals and nitric oxide play important roles in this injury.

Expression of ICAD-l and ICAD-S in human brain tumor and its cleavage upon activation of apoptosis by anti-Fas antibody

ICAD / DFF is a downstream molecule of caspases, participating in nuclear DNA fragmentation during apoptosis. ICAD / DFF binds CAD / DFF40 and inhibits its DNase activity. ICAD / DFF has two alternative isoforms, long isoform (ICAD-L / DFF45) and short isoform (ICAD-S / DFF35). We have studied the presence and functional status of ICAD / DFF in human glioma cell lines. All cell lines tested expressed both ICAD-L and ICAD-S. When the cultured glioma cells were exposed to anti-Fas antibody, these isoforms were degraded prior to the fragmentation of the nuclear DNA, indicating that the ICAD / DFF expressed in cultured glioma cells was potentially functional. In primary brain tumors and normal brain tissues, there was a difference in the expression level between ICAD-L and ICAD-S. In glioblastomas, ICAD-S was more abundant than ICAD-L. In contrast, ICAD-L was more abundant than ICAD-S in medulloblastomas. The present findings suggest that primary brain tumors and normal brain constitutively express ICAD / DFF, and that there is a difference between the expression levels of ICAD-L and ICAD-S.

[Brown-Séquard syndrome and cervical CSF leakage due to a knife injury: a case report]

We report a case of Brown-Séquard syndrome and cervical CSF leakage caused by a knife injury. A 34-year-old man was involved in a fight and was stabbed on his occiput and back with a knife. Neurological examination on admission showed right hemiparesis, right hemihypesthesia and left hemihypalgesia, indicating Brown-Séquard syndrome. Furthermore, cerebrospinal fluid was leaking from the occipital stab wound. Head CT scan showed massive accumulation air in the subarachnoid space. Cervical MRI showed that the injury tract reached to the space between the occipital bone and the atlas. One week after admission, suboccipital craniectomy and duraplasty were performed because of continuous CSF leakage. Although, the CSF leakage recurred due to the wound infection, it disappeared naturally as the patient's general condition improved. Follow-up MRI studies demonstrated the cervical spinal lesion as hyperintensity on T2WI, which localized at the right side of the spinal cord. The patient's hemiparesis gradually improved and he underwent rehabilitation. Spinal cord injury due to a stab wound by a knife is rare in Japan. In this case, we suppose that the mechanism of spinal cord injury was due to direct injury by a knife avoiding the lateral corticospinal tract because his right hemiparesis obviously improved.

Detection of simian virus 40 DNA sequence in human primary glioblastomas multiforme

OBJECT

Deoxyribonucleic acid oncoviruses can induce neoplastic transformation of cells because their viral proteins interfere with antiproliferative cellular proteins. Simian virus 40 (SV40) is a DNA virus that induces the emergence of ependymomas, choroid plexus tumors, mesotheliomas, osteosarcomas, sarcomas, and various tumors when injected into newborn hamsters. Recently, approximately 60% of human ependymomas, choroid plexus tumors, and mesotheliomas were reported to contain and express SV40 DNA sequences. In this study the presence of SV40 DNA sequences was investigated in human brain tumors.

METHODS

Three of 32 glioblastomas mutiforme (GBMs), but none of two ependymomas and five medulloblastomas, were found to possess SV40 DNA sequences when examined using polymerase chain reaction (PCR). The DNA sequence analysis of PCR-amplified fragments disclosed that the samples were identical to the regulatory region of SV40. All three GBMs, which arose in elderly patients with wild-type p53, were considered to be primary (de novo) tumors. Although each of the three tumors was immunohistochemically negative for SV40 T antigen, in situ hybridization successfully demonstrated the messenger RNA for SV40 T antigen.

CONCLUSIONS

The results of this study indicate that latent infection of SV40 in elderly people may be implicated in the tumorigenesis of certain primary GBMs.

Dermal thymus: case report and review of the literature

An aberrant thymus is not uncommon; it is usually located in the subcutaneous tissue and attaches to deeper structures, but it rarely occurs within the dermis (dermal thymus). We report on an 8-month-old male infant with a dermal thymus. He was born with a skin tumor on the right side of the neck, located just over the sternocleidomastoid muscle. The tumor was soft, dark red, and elevated. It measured 10 by 21 mm in diameter. The surface was erosive and partially covered with crust. The infant also had a unilateral cleft lip and a deformity of the bilateral auricles. Because of recurrent episodes of infection, the tumor was resected and histologically diagnosed as a dermal thymus.

Phylogenetic analysis of the Erysipelothrix rhusiopathiae and Erysipelothrix tonsillarum based upon 16S rRNA

The nucleotide sequences of 16S rRNA genes of Erysipelothrix rhusiopathine and Erysipelothrix tonsillarum were determined. The sequences are almost similar (99.8%) with only three nucleotides mismatched.

Coronary artery bypass in dialysis patients

This study evaluated the operative outcome of dialysis patients undergoing coronary artery bypass (CAB). In the past 6 years, 38 dialysis patients with a mean age of 57.5 years underwent CAB. Thirty-one operations were elective, and 7 were nonelective operations. Thirty-two operations were performed under cardiac arrest, 3 operations were performed under fibrillatory arrest, and 3 operations were performed without cardiopulmonary bypass. The average number of bypass grafts was 2.8. In all patients, the internal thoracic artery was used. Hospital mortality was 5.3%. Actuarial survival rates at 1, 3, and 5 years including all causes of death were 88%, 80%, and 72%, respectively. With improvements in perioperative management, coronary artery bypass can be performed with acceptable mortality and morbidity in dialysis patients. Complete revascularization without cardiopulmonary bypass is the ideal method and will increase in usage. However, the conventional CAB also provides acceptable results.

Relief of Post-Tonsillectomy Pain by Release of Lidocaine From Fibrin Glue

OBJECTIVES

Pain inevitably develops after resection of the palatine tonsil (tonsillectomy). Therefore, we applied a mixture of lidocaine and fibrin glue to the tonsillar fossae immediately after tonsillectomy and evaluated its analgesic effects.

STUDY DESIGN

A prospective randomized trial.

METHODS

Seventy-four consecutive patients who had undergone tonsillectomy by the same surgeon (S.K.) were allocated by the sealed envelope method into three groups. After routine tonsillectomy, the operation was terminated in group A (control group), but the bilateral tonsillar fossae were covered with 1 mL fibrin glue using CaCl2 as solution to dissolve thrombin in group B and using 4% lidocaine chloride instead of CaCl2 in group C. No significant difference was observed in age or sex among the three groups. Analgesic effects were evaluated in terms of the postoperative days required until the patient began to eat normally and the postoperative days on which the patient desired analgesic administration.

RESULTS

The mean postoperative days until the patient began to eat normally were 4.22 in group A and 3.78 in group B, showing no significant difference, but 2.83 in group C, being significantly shorter (P <.05). The mean postoperative days on which analgesic administration was necessary were 4.56 in group A and 4.91 in group B, showing no significant difference, but 2.88 in group C, being significantly shorter (P <.05).

CONCLUSION

This method can be readily performed, requires no special treatment, and appears to have adequate pain-relieving effects.

[Fatal pulmonary embolism developing after tympanoplasty: a case report and incidence of pulmonary embolism at Toyooka Hospital]

We report a case of fatal pulmonary embolism (PE) developing after tympanoplasty. A 69-year-old woman underwent type III tympanoplasty for a middle ear cholesteatoma under general anesthesia. Operating time was 3 hours 27 minutes and anesthesia lasted 5 hours 9 minutes. The next morning, 14 hours 5 minutes after returning to the recovery room, the patient lost consciousness while getting out of bed. Although consciousness recovered transiently, she went into shock with cardiopulmonary arrest. Heart beat was regained after resuscitation with artificial respiration and cardiac massage, but her blood pressure was unstable. Echocardiography revealed right ventricular overload and pulmonary hypertension. Because PE was suspected, thrombolytic therapy was conducted to stabilize hemodynamics. Enhanced computed tomography (CT) of the chest showed bilateral pulmonary thromboembolism. The patient died of hypoxic encephalopathy 23 days after PE onset. We have seen 40 cases of PE at our hospital in the last 70 months. Five patients developed PE after surgery with a postoperative occurrence rate of 0.03% (5/16, 277), and 3 of them died. Enhanced CT in 19 of 21 cases (90.5%) before or just after the start of therapy for PE was useful in establishing the diagnosis. Although PE is rare in the field of otolaryngology and head and neck surgery, it may develop rapidly after any type of surgery resulting in a fatal outcome. It is thus important to establish diagnosis early and prevent such serious complications.

Does xanthine oxidase contribute to the hydroxyl radical generation in ischemia and reperfusion of the cochlea?

We investigated the effect of a hydroxyl radical scavenger, 1,3-dimethyl-2-thiourea (dimethylthiourea), and two xanthine oxidase inhibitors, oxypurinol and allopurinol, on the threshold shift of the compound action potential (CAP) after transient ischemia of the cochlea. Transient ischemia of 30 min duration was induced in albino guinea pigs via a skull base approach. The animals were treated with perilymphatic perfusion of dimethylthiourea, oxypurinol or allopurinol from 10 min before the onset of ischemia to 4 h after the termination of ischemia. Dimethylthiourea ameliorated the CAP threshold shifts at 4 h after the onset of reperfusion in a dose-dependent manner. However, oxypurinol and allopurinol did not affect the post-ischemic cochlear dysfunction. These results imply that the hydroxyl radical plays an important role in generation of cochlear dysfunction induced by ischemia-reperfusion and that xanthine oxidase may not be the primary source of this radical.

Detection and investigation of Campylobacter jejuni by polymerase chain reaction-restriction fragment length polymorphism analysis

A molecular typing approach for Campylobacter jejuni with restriction fragment length polymorphism (RFLP) analysis of the flagellin gene flaA in C. jejuni, was generated and studied. Using polymerase chain reaction (PCR)-RFLP with the restriction endonuclease Mbo I, it was demonstrated that C. jejuni could be divided into four types. Genotypic analysis of C. jejuni by PCR-RFLP is a valuable technique for epidemiological typing.