Present status of Moyamoya disease in Japan

To gain an overview of the current status of Moyamoya disease in Japan, we reviewed the 2002-2004 report of the Research Committee on Moyamoya Disease and the clinical data of Moyamoya patients treated at Gifu University Hospital during the past 2 years. According to the report, a nationwide epidemiological survey performed in 2004 revealed that approximately 7500 Japanese were treated for Moyamoya disease; their number doubled during the last 10 years. Moyamoya associated with headache was newly added as a subtype; as many as 5% of Moyamoya patients experience headache. Three-dimensional (3D) stereotactic statistical cerebral blood flow (CBF) analysis was reported as useful for the stratification of the cerebral hemodynamics in Moyamoya disease. To develop treatment guidelines for hemorrhagic Moyamoya, a prospective randomized control trial begun in 2001 is ongoing. During the past 2 years, 23 patients with Moyamoya disease were treated at our hospital. Of these, 17 presented with transient ischemic attacks/infarction, 4 with intracranial hemorrhage (ICH), and 2 with headache. One patient who presented with ICH died during the acute stage, the remaining 22 patients were successfully treated by direct bypass surgery.

[An infant case of a rupture of chordae tendineae; report of a case]

We report a case of 5-month-old boy with severe mitral regurgitation due to a rupture of chordae tendinae. Cardiac echography showed a prolapse of the anterior cusp of the mitral valve. He was progressively deteriorated despite maximal medical treatment, and a surgical intervention was performed 15 hours after the onset. The operative finding was a rupture of chordae tendinae attached to the anterior cusp of the mitral valve. The infant underwent mitral valve plasty using artificial chordae together with partial annulo-plasty. A rupture of chordae tendineae is extremely rare in infants, and its cause is yet unknown. Chordal reconstruction is feasible even at this early stage of life, although the long-term follow-up is mandatory.

NAD(P)H oxidase p22phoxC242T polymorphism and ischemic stroke in Japan: the Fukuoka Stroke Registry and the Hisayama study

The C242T polymorphism of p22phox, a component of NAD(P)H oxidase, may have an impact on cardiovascular diseases; however, the association between this polymorphism and brain infarction is not fully understood. Here, we investigate the relationship between the C242T polymorphism and brain infarction in Japan. We recruited 1055 patients with brain infarction and 1055 control subjects. A chi-squared test revealed that the T-allele frequency was lower in patients with cardioembolic infarction (5.6%) than in control subjects (11.0%, P < 0.001); however, allele frequencies in patients with lacunar and atherothrombotic infarction (11.2%) were not significantly different from those in control subjects (11.0%). A multivariate-adjusted conditional logistic regression analysis also revealed no association between CT + TT genotype, and lacunar and atherothrombotic infarction (odds ratio = 0.97, 95% confidence interval: 0.72-1.32). To investigate the functional effects of the C242T polymorphism, we examined superoxide production in COS-7 cells cotransfected with Nox4 and p22phox of each genotype. The superoxide-producing activity in those cells expressing p22phox with the T allele was not significantly different from that in cells expressing p22phox with the C allele. The present results suggest that the p22phox C242T polymorphism may have a protective effect against cardioembolic infarction, but is not related to lacunar and atherothrombotic infarction in Japan.

Prevention of in vitro and in vivo acute ischemic neuronal damage by (2S)-1-(4-amino-2,3,5-trimethylphenoxy)-3-{4-[4-(4-fluorobenzyl) phenyl]-1-piperazinyl}-2-propanol dimethanesulfonate (SUN N8075), a novel neuroprotective agent with antioxidant properties

(2S)-1-(4-Amino-2,3,5-trimethylphenoxy)-3-{4-[4-(4-fluorobenzyl) phenyl]-1-piperazinyl}-2-propanol dimethanesulfonate (SUN N8075) is a novel antioxidant with neuroprotective properties. We examined whether SUN N8075 inhibited the neuronal damage resulting from permanent focal cerebral ischemia, and examined its neuroprotective properties in vivo and in vitro mechanism. Focal cerebral ischemia was induced by permanent middle cerebral artery occlusion in mice, and the resulting infarction, brain swelling, and neurological deficits were evaluated after 24 h or 72 h. Brain damage was assessed histochemically using terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) staining and antibody recognizing 4-hydroxynonenal histidine adduct (4-HNE). In the in vitro study, we examined the effects of SUN N8075 on 1) lipid peroxidation in mouse brain homogenates and 2) cell viability and caspase-3 protease activity under a hypoxic insult or FeSO(4) in rat cultured cerebrocortical neurons. SUN N8075 administered either 10 min before or at 1 h after the occlusion reduced both infarction size and neurological deficits. SUN N8075 reduced brain swelling when administered 10 min before, 1 h, or 3 h after occlusion. Furthermore, only pretreatment (administered 10 min before) decreased infarct volume and brain swelling at 72 h after middle cerebral artery occlusion. SUN N8075 reduced the number of TUNEL-positive cells and decreased the level of oxidative damage, as assessed by immunopositive staining to 4-HNE. SUN N8075 inhibited lipid peroxidation, leakage of lactate dehydrogenase, caspase-3 activation induced by in vitro hypoxia, and the neuronal damage induced by in vitro FeSO(4) exposure. These findings indicate that SUN N8075 has neuroprotective effects against acute ischemic neuronal damage in mice and may prove promising as a therapeutic drug for stroke.

[An initial experience of endotherine-1 dual-receptor blockade in the treatment of sustained pulmonary hypertension early after congenital cardiac surgery in infancy]

We report an initial experience of successful application of bosentan (BOS), a endotheline-1 dual-receptor blocker, in the treatment of sustained pulmonary hypertension (PH) early after surgical correction of congenital heart disease. Two infants (5 and 9-months-old girls undergone repair of complete atrioventricular septal defect and closure of ventricular septal defect, respectively) suffered from PH-relating symptoms after extubation despite oral sildenafil (SIL) treatment. After administration of BOS (1.5 mg/kg/day), the symptoms were dramatically relieved and SIL was uneventfully discontinued. Although BOS caused a transient increment of liver transaminase in the 5-month-old girl, BOS is a possible alternate in the treatment of the postoperative sustained PH as reported in a various type of chronic PH.

Predictive factors associated with prolonged survival in patients with advanced non-small-cell lung cancer (NSCLC) treated with gefitinib

This study aimed to identify predictive factors associated with prognostic benefits of gefitinib. A total of 221 Japanese patients who received gefitinib (250 mg day(-1)) were examined retrospectively and potential predictive factors analysed. Overall response rate (ORR) was 24.4% and median survival time (MST) was 8.0 months. In a log-rank test, survival was significantly better in females, patients with adenocarcinoma, never-smokers, favourable performance status (PS) and patients with epidermal growth factor receptor (EGFR) mutation. The lower the smoking exposure (Brinkman Index (BI)=cigarettes per day x years smoked), the better the MST (BI 0: 14.5 months, BI <500: 9.5 months, BI 500 to <1000: 6.9 months, BI > or =1000: 4.0 months). Positive-EGFR mutation status and PS 0-1 were independent predictors of favourable prognosis by multivariate analysis. Prognosis was significantly different according to EGFR mutation status (with the same smoking status), but not according to smoking status (with the same EGFR mutation status). EGFR mutation status is the most important independent predictor of survival benefit with gefitinib treatment. Although differences in prognosis were observed according to relative smoking status and smoking exposure, the results suggested that smoking is not a direct predictor of prognosis, yet is a surrogate marker of EGFR mutation status.

Local Intra-Arterial Fibrinolysis in Acute Basilar Artery Occlusion

Acute basilar artery (BA) occlusion is typically associated with poor outcome; however newer diagnostic and treatment modalities have the potential to improve prognosis. In this study, six patients with acute BA occlusion were followed and the effectiveness of local intra-arterial fibrinolysis (LIF) and subsequent percutaneous transluminal angioplasty (PTA) with a balloon catheter were assessed. Of the six patients with BA occlusion observed in this study, two had extended brain stem infarction on diffusion weighted image (DWI) and were treated conservatively. The other four patients received LIF at an average of 5.2 hours from occlusion onset. Three of these four patients received additional PTA with compliant balloon catheters. All four of the patients who received LIF achieved recanalization of the BA trunk and showed a favorable clinical outcome. These findings suggest that LIF is beneficial for selected patients with BA occlusion and that successful recanalization is indicative of a good prognosis. Because of the poor prognosis associated with conservative therapy, we conclude that LIF should be attempted even for comatose patients or in cases of prolonged occlusion time.

Carotid-compression technique for the insertion of guiding catheters

Inserting a guiding catheter into a tortuous artery for neurointerventional procedures can be difficult. In our technique, the carotid artery is manually compressed to stabilize and/or straighten the inserted wire before advancing the guiding catheter. Although this technique is not risk-free and care must be taken to avoid vascular injury by excessive compression, it is useful for the insertion of a guiding catheter into the carotid artery.

The predictive factors and patient-selection associated with the survival benefits of gefitinib in patients with advanced non-small cell lung cancer (NSCLC)

17020

Background: Gefitinib, an inhibitor of epidermal growth factor receptor (EGFR) tyrosine kinase, has shown meaningful antitumor activity for advanced NSCLC. Survival benefit of treatment with gefitinib has not been shown in unselected patients, however heterogeneity in survival outcomes between sub-group (histological types, gender, smoking status and ethnicity) of patients has been observed. The aim of this study was to identify the potential predictive features associated with the survival benefit of treatment with gefitinib. Methods: All NSCLC patients who began taking gefitinib during the period from July 2002 until July 2005 in our institute were retrospectively reviewed. Potential factors analyzed included age, gender, smoking history, performance status (PS), histology, stage, and prior chemotherapy. Results: Overall 221 patients were analyzed. The overall response rate of gefitinib was 26.7%. Median survival time (MST) was 8.0 months. MST of patients whose tumor response was partial response (PR) was 34.5 months. Univariate analysis revealed that the predictive factors of favorable survival were female (p = 0.001), never-smoker (p < 0.0001), good PS (p < 0.0001) and adenocarcinoma (p < 0.0001). Multivariate analysis showed that never-smoking history (p = 0.005), adenocarcinoma (p = 0.004), and better PS (P < 0.001) were significant independent predictors of long survival. The Brinkman index (BI), number of cigarettes per day multiplied by number of years smoked, was associated with survival benefit. MST was 17.6 months in the BI = 0 group (never-smokers), 9.7 months in 1 ≤BI <500, 6.9 months in 500 ≤BI <1000, 4.4 months in 1000 ≤BI <1500, and 4.0 months in BI ≥1500. Conclusion: Never-smokers and adenocarcinoma are predictive factors for prolonged survival. As for smoking status, lower BI is associated with better prognosis after treatment with gefitinib. Therefore, histological factors and smoking status must be considered when treating with gefitinib.

No significant financial relationships to disclose.

Conventional microsurgical treatment of paraclinoid aneurysms: state of the art with the use of the selective extradural anterior clinoidectomy SEAC

Surgical treatment of paraclinoid aneurysms is considered to be difficult due to their complicated anatomical location in the vicinity of important neural, vascular and bony structures. We present our clinical experience of the past 10 years of conventional microsurgical treatment of 81 paraclinoid aneurysms in 75 patients with the use of selective extradural anterior clinoidectomy SEAC and discuss the method of therapy option by reviewing recent reports on results of endovascular coiling method and the combination of these with conventional microsurgical therapy. The favorable surgical results with the use of SEAC and no recurrence of the treated aneurysm after clipping procedure in our series indicate that direct surgery can still be a standard technique for paraclinoid aneurysms in view of the fact that the endovascular aneurysm coiling methods are still associated with a considerable percentage of incomplete occlusion and present the problem of coil packing.

p53-Independent ceramide formation in human glioma cells during gamma-radiation-induced apoptosis

Although the p53 tumor-suppressor gene product plays a critical role in apoptotic cell death induced by DNA-damaging chemotherapeutic agents, human glioma cells with functional p53 were more resistant to gamma-radiation than those with mutant p53. U-87 MG cells with wild-type p53 were resistant to gamma-radiation. U87-W E6 cells that lost functional p53, by the expression of type 16 human papillomavirus E6 oncoprotein, became susceptible to radiation-induced apoptosis. The formation of ceramide by acid sphingomyelinase (A-SMase), but not by neutral sphingomyelinase, was associated with p53-independent apoptosis. SR33557 (2-isopropyl-1-(4-[3-N-methyl-N-(3,4-dimethoxybphenethyl)amino]propyloxy)benzene-sulfonyl) indolizine, an inhibitor of A-SMase, suppressed radiation-induced apoptotic cell death. In contrast, radiation-induced A-SMase activation was blocked in glioma cells with endogenous functional p53. The expression of acid ceramidase was induced by gamma-radiation, and was more evident in cells with functional p53. N-oleoylethanolamine, which is known to inhibit ceramidase activity, unexpectedly downregulated acid ceramidase and accelerated radiation-induced apoptosis in U87-W E6 cells. Moreover, cells with functional p53 could be sensitized to gamma-radiation by N-oleoylethanolamine, which suppressed radiation-induced acid ceramidase expression and then enhanced ceramide formation. Sensitization to gamma-radiation was also observed in U87-MG cells depleted of functional p53 by retroviral expression of small interfering RNA. These results indicate that ceramide may function as a mediator of p53-independent apoptosis in human glioma cells in response to gamma-radiation, and suggest that p53-dependent expression of acid ceramidase and blockage of A-SMase activation play pivotal roles in protection from gamma-radiation of cells with endogenous functional p53.

Treatment of Cervical Carotid Artery Stenosis

As treatment for cervical carotid artery stenosis, medical treatment, carotid endarterectomy (CEA), and percutaneous transluminal angioplasty (PTA) with/without stenting are known. In this report, we review the history and current status of these treatments.

Comparison between CEA and PTA/stenting is further discussed based on recent clinical reports and evidence.

Clinical and Angiographic Results of Intra-Aneurysmal Embolization for Cerebral Aneurysms and Histopathological Findings in an Aneurysm Treated with GDC

SUMMARY

We describe follow-up clinical and angiographic results in patients with cerebral aneurysms treated with IDC or GDC. In 175 patients, 116 patients with ruptured aneurysm and 59 patients with non-ruptured aneurysm who underwent endovascular occlusion of aneurysms, there was no mortality and nine cases (4.7%) with morbidity in the periprocedural period. During follow up period, four cases (2.3%) experienced bleeding, and three cases (1.7%) experienced thrombo-embolic events. On the follow-up angiograms (median angiographic follow-up period 24.8 months), 12.5% of incompletely obliterated aneurysms exhibited progressive thrombosis, 20% remained unchanged and 67.5% showed aneurysmal recanalization or regrowth. Histological examination of a small ruptured A-com aneurysm treated seven months before harvesting, demonstrated that formation of an incomplete endothelium- lined layer of connective tissue at the orifice, and no complete fibrous obliteration of the aneurysm lumen could be detected, various amounts of unorganized clot were still present in the center of the aneurysm. Coil embolization is a safe treatment for cerebral aneurysms with a lower incidence of peri-procedural morbidity, wheareas follow-up results are less satisfactory in cases involving incompletely obliterated lesions.

Considerations in the surgical treatment of superior-wall type aneurysm at the proximal (M1) segment of the middle cerebral artery

OBJECTIVE

To present our experience and analyze the risks of neck clipping for superior-wall type aneurysms of the proximal segment of the middle cerebral artery (M1-Sup aneurysm).

METHODS

Of 14 patients with M1-Sup aneurysms, 4 suffered postoperative infarctions in the territory of the lenticulostriate arteries (LSA) or fronto-orbital arteries. We re-examined our intraoperative findings and clinical records in an effort to identify possible causes.

RESULTS

The patency of the LSA was confirmed at the end of surgery in all 14 cases. We posit that temporary occlusion of the LSA by a permanent clip resulted in delayed obstruction of the LSA in 3 patients. Other possibilities we considered were relatively long temporary occlusion of the M1, slipping of the clips and twisting of the clip blades after release of the brain retractors.

CONCLUSION

M1-Sup aneurysms are some of the most complicated aneurysms; they carry the risk of perforator injury during neck clipping. Surgical considerations to avoid perforator injury are discussed.

Antigen presentation by murine dendritic cells is nuclear factor-kappa B dependent both in vitro and in vivo

Antigen presentation is a key rate-limiting step in the immune response. Dendritic cells (DCs) have been reported to be the most potent antigen-presenting cells for naïve T cells, but little is known about the biochemical pathways that regulate this function. We here demonstrate that mature murine DC can be infected with adenovirus at high efficiency (>95%) and that an adenovirus transferring the endogenous inhibitor IkappaBalpha blocks nuclear factor-kappa B (NF-kappaB) function in murine DC. This result indicates that antigen presentation in the mixed leucocyte reaction is NF-kappaB dependent, confirming data with human DC in vitro. However, the importance of this finding depends on verifying that this is true also in vivo. Using delayed type hypersensitivity with allogeneic cells, we show that NF-kappaB inhibition had a marked immunosuppressive effect in vivo. These results thus establish NF-kappaB as an effective target for blocking DC antigen presentation and hence inhibiting T-cell-dependent immune responses. This finding has potential implications for the development of therapeutic agents for use in various pathological conditions of the immune system, including allergy and autoimmunity, and also in transplantation.

Mutations in the ST7/RAY1/HELG locus rarely occur in primary colorectal, gastric, and hepatocellular carcinomas

Human cancers frequently show a loss of heterozygosity on chromosome 7q31, which indicates the existence of broad-range tumour-suppressor gene(s) at this locus. Truncating mutations in the ST7 gene at this locus are seen frequently in primary colon cancer and breast cancer cell lines. Therefore, the ST7 gene represents a novel candidate gene for the tumour suppressor at this locus. However, more recent studies have reported that ST7 mutations are infrequent or absent in primary cancer and cell lines. To ascertain the frequency of mutations of the ST7 gene in cancer cells, we examined mutations in the ST7 coding sequence in 48 colorectal, 48 gastric, and 48 hepatocellular carcinomas using polymerase chain reaction-single-strand conformational polymorphism and direct sequencing. We detected somatic mutations, which were located near the exon-intron junction in intron 8, in only three out of 144 cases. We conclude that mutations in the ST7 gene are rare in primary colorectal, gastric, and hepatocellular carcinomas.

Surgical prognosis of unruptured cerebral aneurysms. Report of 40 cases in University Hospital Zurich

A series of 40 patients admitted to University Hospital Zurich (1996-97) with unruptured cerebral aneurysms is reported. Fifty-two aneurysms were treated in 40 operations. The age of surgically treated patients ranged from 31 to 78 year old (mean 53.6). The main locations of the aneurysms were: MCA 21 (40.4%), AcomA 10 (19.2%), ICA (posterior communicating and bifurcation) 6 (11.5%), carotid-ophthalmic segment 4 (7.7%), ACA 4 (7.7%), basilar tip 3 (5.8%), vertebral artery 2 (3.8%). The circumstances of diagnosis were: incidental 15 (37.5%), other cranial lesions 9 (22.5%), symptomatic 8 (20%), multiple aneurysm 8 (20%). The overall outcome of surgery was: good recovery in 39 cases (97.5%), moderately disabled in 1 case (2.5%) who was 56 year-old and had three aneurysms including basilar tip. There was no operative mortality. Though this series has small number of patients, it suggests that location of the aneurysm is an important factor affecting surgical outcome among patient age, the circumstances of the diagnosis, size and location of aneurysm.

ABO and Rh phenotyping by absorption-elution technique using cerebral dura maters

Phenotyping of ABO and Rh blood groups was performed by the absorption-elution technique using cerebral dura maters. For the ABO system, the cerebral dura maters extracted from nine autopsied cadavers including two burnt bodies, two putrefied corpses, and one half-mummified and one skeletal structure were tested with commercially available Wako antisera (animal polyclonal antibodies). At the same time, blood, fingernails or bones were sampled. In all the cases, the phenotypes could be typed correctly and more clearly with the use of 2 x 2 x 0.3 mm dura maters (0.6 mm thick dura maters were sliced to 0.3 mm thickness) than the phenotyping using 2 x 2 mm fingernails or 2 x 2 x 1 mm bones. For the Rh system, the cerebral dura maters extracted from eight autopsied cadavers within 2 days after death including two burnt bodies were tested with commercially available Ortho Bioclone anti-C, anti-c, anti-E and anti-e sera (human monoclonal antibodies), and Ortho anti-D serum (human polyclonal antibody). The eluate of anti-D antibody was needed to perform the indirect anti-globulin test (Ortho Coombs serum). At the same time, blood was sampled. In all the cases, the Rh blood groups of cerebral dura maters were in agreement with those of blood.

High-performance liquid chromatographic method for mycophenolic acid and its glucuronide in serum and urine

OBJECTIVE

To develop a simple analytical method for monitoring serum and urine concentrations of mycophenolic acid (MPA), an active metabolic constituent of the immunosuppressive pro-drug mycophenolate mofetil, and its glucuronide.

METHODS

Serum samples were prepared by solid-phase extraction (SPE), while urine samples were simply diluted with water. Serum was added to an SPE cartridge, then washed twice with 5% methanol solution. The analytes were eluted with methanol containing benzoic acid as internal standard for mycophenolic acid glucuronide (MPAG). The resultant eluate was directly injected into a high-performance liquid chromatograph (HPLC) to determine MPAG. For the assay of MPA, the remaining eluate was dried under nitrogen and resolved in a mixture of acetonitrile and 20 mM phosphate buffer (pH 3.0).

RESULTS

The present methods were reproducible and accurate based on the intra- and inter-assay, and had detection limits of 0.225 microg/mL for MPA and 9.0 microg/mL for MPAG. The present methods enabled us to monitor the time course of changes in the concentrations of MPA and MPAG in serum and urine in a patient with a renal transplant during 12 h after ingestion of mycophenolate mofetil.

CONCLUSION

The HPLC method described should be useful for the routine monitoring of serum and urine concentrations of MPA and MPAG during immunosuppressive medication for renal transplantation.