Safety and feasibility of intra-arterial nicardipine for the treatment of subarachnoid hemorrhage-associated vasospasm: initial clinical experience with high-dose infusions

BACKGROUND AND PURPOSE

Delayed cerebral ischemia from vasospasm is a major complication after aneurysmal subarachnoid hemorrhage (SAH), but complications and/or low efficacy are associated with current therapy. We report our initial experience with intra-arterial use of a calcium channel blocker, nicardipine.

MATERIALS AND METHODS

A retrospective review of a consecutive series of patients with clinical and angiographic vasospasm treated with intra-arterial nicardipine was performed. Standard criteria for definition of significant, intractable vasospasm after aneurysmal SAH were used. After catheter angiographic confirmation of vasospasm, arteries showing severe narrowing were targeted for superselective catheterization. Nicardipine was infused at a high dose rate (0.415-0.81 mg/min). Contrast injections were performed at 2-5-mg intervals to assess effective response (a 60% increase in arterial diameter of the most severely decreased in caliber vessel compared with the very first angiographic run).

RESULTS

Eleven consecutive patients underwent a total of 20 procedures; most had SAH with high Hunt and Hess grades (III or IV). All had depressed level of consciousness; others had paresis (7/20, 35%), aphasia (1/20, 5%), and facial nerve palsy (1/20, 5%). Between 10 and 40 mg of nicardipine was used. A 60% increase in diameter of the main affected artery compared with the initial diameter measured in the initial angiographic run was achieved in all procedures. Clinical improvement (resolved focal symptoms or increased Glasgow Coma Score) occurred in 10 of 11 patients (91%). One patient died from complications of the initial hemorrhage. No complications occurred after 16 of 20 procedures (80%); minor complications without sequelae occurred after the remaining procedures. Follow-up of at least 2 months in 10 survivors revealed minor or no deficits in most patients with a Glasgow Outcome Score of 1 or 2 in 9 of 10 patients (90%).

CONCLUSION

In this small series, high-dose intra-arterial nicardipine infusion to treat SAH-associated vasospasm seems to be safe and effective.

Virtual 3-Dimensional Preoperative Planning with the Dextroscope for Excision of a 4th Ventricular Ependymoma

OBJECTIVE AND IMPORTANCE

Advances in computer imaging and technology have facilitated enhancement in surgical planning with a 3-dimensional model of the surgical plan of action utilizing advanced visualization tools in order to plan individual interactive operations with the aid of the dextroscope. This provides a proper 3-dimensional imaging insight to the pathological anatomy and sets a new dimension in collaboration for training and education.

CLINICAL PRESENTATION

The case of a seventeen-year-old female, being operated with the aid of a preoperative 3-dimensional virtual reality planning and the practical application of the neurosurgical operation, is presented. This young lady presented with a two-year history of recurrent episodes of severe, global, throbbing headache with episodes of projectile vomiting associated with shoulder pain which progressively worsened. She had no obvious neurological deficits on clinical examination. CT and MRI showed a contrast-enhancing midline posterior fossa space-occupying lesion.

INTERVENTION

Utilizing virtual imaging technology with the aid of a dextroscope which generates stereoscopic images, a 3-dimensional image was produced with the CT and MRI images. A preoperative planning for excision of the lesion was made and a real-time 3-dimensional volume was produced and surgical planning with the dextroscope was made and the lesion excised.

CONCLUSION

Virtual reality has brought new proportions in 3-dimensional planning and management of various complex neuroanatomical problems that are faced during various operations. Integration of 3-dimensional imaging with stereoscopic vision makes understanding the complex anatomy easier and helps improve decision making in patient management.

Induction of CD16+ CD56bright NK cells with antitumour cytotoxicity not only from CD16- CD56bright NK Cells but also from CD16- CD56dim NK cells

The aim of this study was to examine the effect of cytokines on different subsets of NK cells, while especially focusing on CD16(-) CD56(dim) cells and CD16(-) CD56(bright) cells. When human peripheral blood mononuclear cells (PBMC) were cultured with a combination of IL-2, IL-12 and IL-15 for several days, a minor population of CD56(bright) NK cells expanded up to 15%, and also showed potent cytotoxicities against various cancer cells. Sorting experiments revealed that unconventional CD16(-) CD56(+) NK cells (CD16(-) CD56(dim) NK cells and CD16(-) CD56(bright) NK cells, both of which are less than 1% in PBMC) much more vigorously proliferated after cytokine stimulation, whereas predominant CD16(+) CD56(dim) NK cells proliferated poorly. In addition, many of the resting CD16(-) CD56(bright) NK cells developed into CD16(+) CD56(bright) NK cells, and CD16(-) CD56(dim) NK cells developed into CD16(-) CD56(bright) NK cells and also further into CD16(+) CD56(bright) NK cells by the cytokines. CSFE label experiments further substantiated the proliferation capacity of each subset and the developmental process of CD16(+) CD56(bright) NK cells. Both CD16(-) CD56(dim) NK cells and CD16(-) CD56(bright) NK cells produced large amounts of IFN-gamma and Fas-ligands. The CD16(+) CD56(bright) NK cells showed strong cytotoxicities against not only MHC class I (-) but also MHC class I (+) tumours regardless of their expression of CD94/NKG2A presumably because they expressed NKG2D as well as natural cytotoxicity receptors. The proliferation of CD16(+) CD56(bright) NK cells was also induced when PBMC were stimulated with penicillin-treated Streptococcus pyogenes, thus suggesting their role in tumour immunity and bacterial infections.

Spectroscopic polarimetry using channeled spectroscopic polarization state generator (CSPSG)

A novel method for the spectropolarimetric measurement of materials using the channeled spectrum is described. A pair of high order retarders are incorporated into the illuminating optics of a broadband spectropolarimeter, so that the sample under measurement is illuminated with the light that is modulated in the spectral-dependence of its polarization. The Fourier analysis of the channeled spectrum obtained from the spectropolarimeter allows determining the four spectrally-resolved polarimetric parameters of the sample simultaneously. This approach has a feature that it requires neither mechanically- nor electrically-controllable components for polarization modulation, similar to the previous method for the channeled spectropolarimetry in which the high-order retarders are placed in the receiving optics. The new method can offer the same information about the sample as has been obtained by the previous method, provided that all the optical components satisfy the principle of reciprocity. Furthermore, the new method has an additional advantage over the previous method that it is less susceptible to the sample-induced fluctuations of the wavefront or ray-direction. The effectiveness of this method is experimentally demonstrated with the measurement of a birefringent sample.

Extracranial vertebral artery aneurysm associated with neurofibromatosis type 1. A case report

SUMMARY

Extracranial vertebral artery aneurysm associated with neurofibromatosis (NF1) is very rare. The aneurysm was successfully treated by endovascular trapping of the aneurysm and proximal vertebral artery with coils.

Stabilization of a channeled spectropolarimeter by self-calibration

A novel method to stabilize a channeled spectropolarimeter is described. The fluctuating retardations of the high-order retarders used in the spectropolarimeter are calibrated in parallel to the measurement of the wavenumber-dependent state of polarization (SOP) of light. Both the calibration of the retarders and the measurement of the SOP can be made simultaneously using a single light to be measured, and hence the resultant wavenumber-dependent SOP is almost immune to fluctuation of the retardations. The effectiveness of this method is experimentally demonstrated with retardation fluctuations induced by a temperature change up to 40 degrees C.

Phagocytosis, Production of Nitric Oxide and Pro-inflammatory Cytokines by Macrophages in the Presence of Dematiaceus Fungi that Causes Chromoblastomycosis

Chromoblastomycosis is characterized by the slow development of polymorphic skin lesions (nodules, verrucas, tumores, plaques and scar tissue). Inside the host, infectious propagules adhere to epithelial cells and differentiate into sclerotic forms, which effectively resist destruction by host effector cells and allow onset of chronic disease. A cellular immune response against fungi is essential to control infection. Amongst the cells of the immune system, macrophages play the most important role in controlling fungal growth. In this study, we show that the fungicidal characteristic of macrophages is dependent on the fungal species that causes chromoblastomycosis. We began by observing that the phagocytic index was higher for Fonsecaea pedrosoi and Rhinocladiella aquaspersa compared with that of other fungi. Complement-mediated phagocytosis was more important for Phialophora verrucosa and R. aquaspersa and was inhibited by mannan when F. pedrosoi and R. aquaspersa conidia were phagocytosed by macrophages. We showed that macrophages killed significantly only R. aquaspersa. We also found that the phagocytosis of fungi has functional consequences for macrophages as phagocytosis resulted in down-modulation of MHC-II and CD80 expression as well as in the inhibition of the basal liberation of NO. However, the inhibition of the basal liberation of NO nor the down-modulation of MHC and co-stimulatory molecules were observed in the presence of R. aquaspersa.

Numerical simulation of the intra-aneurysmal flow dynamics

SUMMARY

Intra-aneurysmal flow dynamics is analyzed qualitatively and quantitatively with numerical simulation technique, and presented for the future clinical application in embolizing cerebral aneurysms. From the volumetric data obtained by three-dimensional computed tomographic angiography, patient-specific vessel models were created for 16 middle cerebral artery aneurysms. Intraaneurysmal flow dynamics was visualized and analyzed qualitatively, and the geometrical parameters of vessels and aneurysms that affect the intra- aneurysmal flow dynamics were determined quantitatively by correlation analysis. The flow velocity was delayed in the aneurysm cavity, especially at its tip where the rupture usually occurs. The intra-aneurysmal flow dynamics was considerably influenced by the geometrical parameters that are related to the width of the neck and the branching angle of larger branch artery. The intra-aneurysmal flow dynamics is complex, and the numerical flow simulations with patient-specific vascular models seems effective in understanding the flow dynamics and planning the endovascular treatment of cerebral aneurysms.

Two alleles of the sulfite resistance genes are differentially regulated in Saccharomyces cerevisiae

The sulfite resistance gene, SSU1-R, is widely distributed in wine yeasts. This gene has an upstream region distinct from that of the allelic gene, SSU1 and SSU1-R is expressed at a much higher level than SSU1. We characterized the promoters of both of these genes by analysis of their activity using the LacZ gene as a reporter. FZF1, the activator gene of SSU1, was shown to regulate SSU1-R expression indirectly. SSU1-R expression was activated under microaerobic conditions, and four 76-bp repeats, present within the SSU1-R promoter region, was essential for high expression. These results indicate that SSU1-R expression is regulated in different manner from that of SSU1. By deletion analysis of the SSU1-R promoter region, we found that at least two of the 76-bp repeats are necessary for promoter activity, and that the number of 76-bp repeats influences the activity. Hence, it was suggested that the number of 76-bp repeats increases in wine yeasts that require strong sulfite resistance.

[Ruptured lung abscess; report of a case]

We reported an extremely rare case of ruptured lung abscess. A 60-year-old male was admitted to our hospital with sudden loss of consciousness. Thoracocentesis demonstrated pneumopyothorax. Right middle and lower lobectomy for ruptured abscess was performed. The patient remains well with no recurrent lung abscess 2 years postoperatively. This case emphasizes that ruptured lung abscess is a cause of pneumopyothorax.

Distribution of the sulfite resistance gene SSU1-R and the variation in its promoter region in wine yeasts

The SSU1-R gene provides high sulfite resistance to the wine yeast Y9-16B. In this study, we examined the distribution of this gene in 61 wine yeasts and 4 laboratory yeasts. We also analyzed the number of repeats of a 76-bp promoter sequence and its relationship to sulfite resistance. We found that the SSU1-R gene was present in 31 of the 61 wine yeasts. Furthermore, we found that the number of repeats in the promoter region of SSU1-R varied from two to six. Using RsaI, which cuts only once in the repeat, we suggested that the repeats all consisted of the 76-bp sequence. Finally, we found that there was a complex relationship between the number of repeats and sulfite resistance.

Does Schumann resonance affect our blood pressure?

OBJECTIVES

To investigate whether Schumann resonance (SR) affects blood pressure (BP), heart rate (HR), and depression and, if so, whether the putative BP reactivity to SR (BPR-SR) is associated with health-related lifestyle (HLS), disease-related illnesses (DRI), and depression.

METHODS

A sample of 56 adults in Urausu, Hokkaido, Japan, wore an ambulatory BP monitor, except for the time in the shower, for seven consecutive days. They completed the Geriatric Depression Scale-Short Form and a health survey questionnaire on HLS and DRI. Group mean differences and within-individual differences in systolic (S) and diastolic (D) BP, mean arterial pressure (MAP), double product (DP), and HR were, respectively, compared between normal and enhanced SR days, using Student's t-test. Correlations between BPR-SR and other characteristics (i.e. age, gender, HLS, DRI, subjective health, and depression) were analyzed, using Pearson's product moment correlation.

RESULTS AND DISCUSSION

Group mean SBP, DBP, MAP, and DP for enhanced SR days were lower than those for normal days (P=0.005-0.036). DRI was negatively associated with BPR-SR in SBP, DBP, MAP, and DP (P=0.003-0.024), suggesting a better health status for those who showed lower BP on enhanced SR days. HLS was negatively associated with BPR-SR in DBP and MAP (P=0.016-0.029). Males showed higher BPR-SR in DBP and MAP than females (P=0.004-0.016). Neither subjective health nor depression was significantly associated with BPR-SR. Future studies based on larger sample sizes are planned to see whether possible health effects can be generalized.

Nocardia takedensis sp. nov., isolated from moat sediment and scumming activated sludge

Chemotaxonomic and morphological characterization of two actinomycete strains, MS1-3T and AS4-2, respectively isolated from moat sediment and scumming activated sludge, was carried out. This characterization clearly demonstrated that strains MS1-3T and AS4-2 belong to the genus Nocardia. 16S rRNA gene sequencing studies showed that these isolates are most closely related to Nocardia beijingensis (98.1-98.3 % similarity), Nocardia brasiliensis (97.9-98.0 %) and Nocardia tenerifensis (97.8-97.9 %). However, the results of DNA-DNA hybridizations and physiological and biochemical tests showed that strains MS1-3T and AS4-2 could be differentiated from their closest phylogenetic relatives both genotypically and phenotypically. It is proposed that the two isolates be classified as representatives of a novel species of Nocardia, Nocardia takedensis sp. nov. The type strain is MS1-3T (=NBRC 100417T=DSM 44801T); AS4-2 (=NBRC 100418=DSM 44802) is a reference strain.

Erythropoietin-producing renal cell carcinoma arising from autosomal dominant polycystic kidney disease

Erythropoietin (EPO)-producing renal cell carcinomas (RCC) in patients with chronic renal failure secondary to autosomal dominant polycystic kidney disease (ADPKD) has not previously been reported. We report a case of EPO-producing RCC associated with ADPKD in a 66-year-old woman, and discuss the clinical and radiological findings.

Assessing Prognosis of Areas of Acute Cerebral Ischemia Using Perfusion CT

SUMMARY

Vascular recanalization by the vascular reconstruction method can dramatically improve ischemic symptoms in patients with acute cerebral ischemia. However, this treatment method is frequently associated with haemorrhagic complications. The indications for this therapeutic approach have been described in a number of studies in the literature. The present paper discusses the possibility of assessing the prognosis of ischemic areas using perfusion CT (PCT) by comparing the results obtained before and after thrombolytic therapy. Twenty-six patients underwent vascular reconstruction at our hospital between July 2002 and March 2004. Of these patients, six who underwent PCT before treatment and showed adequate recanalization following vascular reconstruction were included in the present study. PCT images were obtained using the first-pass bolus-tracking method with a 16-row multislice helical CT scanner. Areas of cerebral ischemia were evaluated by CT before and after vascular reconstruction. A region of interest was placed in the area showing low density in CT images before vascular reconstruction. The mean average CBF (mL/min/100 g), CBV (mL/100 g), and MTT (s) values were calculated in areas with and without cerebral infarction after vascular reconstruction. The %CBF, % CBV, and %MTT values relative to the normal side were evaluated with reference to the time until recanalization. Transarterial vascular reconstruction resulted in full recanalization in four patients and partial recanalization in two. The mean time from onset to recanalization was 284.7 +/- 63.27 minutes and was not longer than six hours in any patient. The patient prognosis results in terms of GOS were GR in two patients, MD in three patients, and SD in one patient. Based on comparison of the time after examination to recanalization, the %CBF showed a significant positive correlation in the salvaged area (Y = 47.321 + 2.491 x %CBF:R(2) = 0.792, p < 0.05). A significant correlation was not observed in %CBV, but %MTT showed a significant negative correlation (Y = 269.45 - 0.356 x %MTT:R(2) = 0.794, p < 0.05). The %CBF and %MTT results obtained by PCT performed before transarterial vascular reconstruction suggest that it may be possible to estimate the time before vascular reconstruction and the relationship with prognosis. These findings are expected to help ensure the appropriate application of vascular reconstruction and to provide useful information for developing optimal therapeutic protocols, thus reducing complications. In addition, because the results are based on the time after examination, the appropriate therapeutic approach can be determined even when the time of onset of ischemia is uncertain.

Association of habitual long-distance running with the thickness of skeletal muscles and subcutaneous fat in the body extremities and trunk in middle-aged men

AIM

We investigated the association of habitual long-distance running with the thickness of skeletal muscles and subcutaneous fat in the body extremities and trunk in middle-aged men using ultrasonography.

METHODS

Three groups of healthy middle-aged men [mean (SD), 62.1 (2.8) years] took part in this investigation: a high-level group of 11 master runners who had competed in a 42.195 km race and run 51.6 (21.7) km every week, an intermediary-level group of 10 master runners who had competed in a 5-20 km race and run 9.3 (4.9) km every week, and a low-level group of 7 untrained men who continued to do no systematic training. The muscle thickness at 8 sites and the subcutaneous fat thickness at 10 sites were measured by B-mode ultrasonography, and were compared among the 3 groups.

RESULTS

The high-level group had 10.0(-1)5.2% higher values for muscle thickness at the erector spinae, hamstrings, tibialis anterior, and triceps surae, compared with the intermediary-level and the low-level groups (p<0.05-0.001). The thickness of the subcutaneous fat about the rectus abdominis and external oblique was lower in the high-level group than in the intermediary-level and the low-level groups (p<0.05).

CONCLUSIONS

Middle-aged male master athletes who habitually run at a high level have more muscle thickness in the lower extremities and trunk, and less subcutaneous fat thickness in the central regions of the body than do middle-aged men who habitually run at an intermediary level or do not run at all.

FLO11 is essential for flor formation caused by the C-terminal deletion of NRG1 in Saccharomyces cerevisiae

The flor strains of Saccharomyces cerevisiae form a flor on the surface of wine after alcoholic fermentation. High hydrophobicity of the cell surface is suggested to be important for flor formation by the flor wine yeasts. However, the molecular mechanism of flor formation is not clear. We found that expression of C-terminal deleted NRG1 lacking its two C2H2 zinc finger motifs (NRG1(1-470)) on the multicopy plasmid conferred the ability to form a flor to a non-flor laboratory strain. The cell surface hydrophobicity of NRG1(1-470) was higher than of the non-flor strain. Disruption of the Nrg1p-repressed gene FLO11, which encodes a cell surface glycoprotein that functions as a flocculin or an adhesin, abolished flor formation. Moreover, expression of FLO11 on a multicopy plasmid could also cause flor formation. These results indicate that FLO11 is essential for flor formation by NRG1(1-470). In addition, the results suggest that the C-terminal truncated form of Nrg1p exerts a dominant negative effect on FLO11 repression, resulting in FLO11 expression and, thus, flor formation.

Stent Assisted Coil Embolization: the Treatment of Wide-necked, Dissecting, and Fusiform Aneurysms

SUMMARY

Stent assisted coil embolization is a useful therapeutic modality for wide-necked and geometrically difficult aneurysms, as the stent provide a buttress that allows for coil deposition while preventing coil haerniation into the parent vessel lumen, and placement of an endovascular stent within the parent artery across the aneurysm neck may divert the blood from the aneurysm inflow tract and promote intra-aneurysm stasis and thrombosis.We report herein a 3 patients treated with endovascular stent-assisted coil embolization for symptomatic or enlarging wide-necked, dissecting, and fusiform aneurysms of the carotid and vertebrobasilar arteries. One patient had intracranial mass effect, the second had subarachnoid haemorrhage, and the third had angiographic evidence of enlarging aneurysm. The aneurysm was located in the petrous segment of internal carotid artery in one patient and in the intracranial vertebral artery in the other two patients. For all patients, we used balloon expandable stent (such as GFX, S-670) in this technique. Complete obliteration of the aneurysms could be achieved in all cases, with preservation of distal circulation.

Increased tacrolimus trough levels in association with severe diarrhea, a case report

It is well known that during diarrhea episodes decreased cyclosporine and tacrolimus levels are often observed, usually requiring an increase in dose. An increase in tacrolimus trough levels is infrequently recognized as a potential cause of the adverse effect of severe diarrhea. Herein, we report the case of a renal transplant patient who displayed increased tacrolimus trough levels during an episode of gastroenteritis with severe diarrhea. The patient is 32-year-old male who received a renal transplant from his mother. Immunosuppression was initiated with tacrolimus in combination with mycophenolate mofetil and prednisone. The postoperative course was uneventful. The function of the transplanted kidney was normal. Eight months after transplantation he presented to our hospital with a history of high fever, abdominal pain, nausea and severe diarrhea. He was admitted with a diagnosis of enterocolitis of unknown etiology. The blood trough level of tacrolimus had increased from 6.7 ng/mL to 28.7 ng/mL after the onset of diarrhea. A therapeutic trough level of tacrolimus was reached 6 weeks after complete relief of diarrhea. Tacrolimus shows large variability in bioavailability after oral administration, both due to intestinal metabolism by cytochrome P450 (CYP3A4) and active secretion from enterocyte into intestinal lumen by P-glycoprotein. The epithelial cells of the intestine, may be destroyed abrogating P-glycoproteins during the course of enterocolitis, thereby increasing the levels of tacrolimus. It is recommended to monitor trough levels of tacrolimus during severe diarrhea of any nature to prevent tacrolimus-related complications.

Characterization of Nocardia asteroides isolates from different ecological habitats on the basis of repetitive extragenic palindromic-PCR fingerprinting

Thirteen isolates of Nocardia asteroides from both soils and aquatic samples (lake and moat sediments, as well as scum from activated sludge), together with a type strain and two known clinical isolates of this species, were characterized by repetitive extragenic palindromic-PCR fingerprinting with the BOX-A1R primer. The resulting DNA fingerprint patterns proved to be strain specific, and cluster analysis distinguished the soil isolates, the aquatic isolates, and the known strains as being in separate groups.

Prediction of Impending Rupture in Aneurysms Using 4D-CTA: Histopathological Verification of a Real-Time Minimally Invasive Tool in Unruptured Aneurysms

The authors describe the use of a 4D-CT angiogram to predict impending rupture in intact aneurysms, as a real-time, less invasive imaging technique. Histopathological verification and immunostaining of the bleb site performed on the study population reveals the significant predictive value of this tool. The point of maximum amplitude of pulsation of the aneurysm wall in unison with the RR interval of the electrocardiogram determines the potential rupture point. This helps in prioritizing the intervention for unruptured aneurysm cases, provides an effective screening of the high-risk population, and aids preoperative planning of clip application.