Factors Associated with Early and Late Seizure Related to Aneurysmal Subarachnoid Hemorrhage

Post-stroke epilepsy may occur after aneurysmal subarachnoid hemorrhage (aSAH). Both early and late seizures could cause severe neurocognitive deficits if administration of appropriate antiseizure medication is delayed. Therefore, it is important to elucidate the risk factors for early and late seizures, which could be shared with medical teams to promptly manage seizures. There are aspects of both hemorrhage and ischemia in aSAH, and thus, numerous risk factors are considered for early and late seizures. We examined factors associated with aSAH-related early and late seizures. Among 297 patients who had aSAH and underwent direct or endovascular surgery, 25 had early seizures and 20 had late seizures. Patients who did not experience any seizures in at least 2-years of follow-up (n = 81) were used as the control group. Early seizures were associated with older age and acute severe nonneurological infection, whereas late seizures were associated with intraparenchymal lesion volume >10 mL and shunt placement. In patients with late seizures, consistency was frequently observed between electroencephalogram and the presence of intraparenchymal lesions. The frontopolar electrode on electroencephalogram was highly sensitive to abnormality in early seizures. Early seizures were induced by the patient's systemic factors, which may lower the threshold for cortical excitability. Patients with intraparenchymal lesions who undergo shunt placement should be carefully followed up for late seizures.

Extremely slow-growing cerebellar ganglioglioma in an elderly patient

Background

Gangliogliomas account for 0.4% of primary brain tumors. They mainly occur in the supratentorial compartment and typically affect only children and young adults. We present an especially rare case of cerebellar ganglioglioma in an elderly patient.

Case Description

A 76-year-old Japanese woman presented with headache and nausea from 1 month previously. She had been diagnosed with a cerebellar tumor in her childhood, but the lesion was asymptomatic at that time, and there was no evidence of an increase in size, so it had been monitored without surgery. At the time of presentation, she had not been examined for approximately ten years. On admission, magnetic resonance imaging indicated a T2 hypertense cyst in the cerebellar vermis. Post-contrast T1 imaging showed an enhanced mural nodule in the cyst. Cerebral angiography showed that none of the vertebral arteries were significant feeders. The tumor was removed through posterior fossa craniotomy. The histopathological diagnosis was ganglioglioma. The patient's headache and nausea improved after surgery.

Conclusion

Our patient presented a very rare case of extremely slow-growing elderly ganglioglioma in the cerebellum. In patients with gangliogliomas, long-term follow-up is important because the disease may become symptomatic at an older age.

Hemangioblastoma of the medulla oblongata that caused isolated fourth ventricle after stereotactic radiosurgery: A case report

Isolated fourth ventricle is a rare complication following shunt insertion of the lateral ventricles for hydrocephalus. The present report describes a rare case of a hemangioblastoma of the medulla oblongata that caused isolated fourth ventricle due to intraventricular deposition of fibrin. A 34-year-old man presented with headache a month before admission. Magnetic resonance imaging indicated multiple tumors in the medulla oblongata and the bilateral cerebellar hemisphere with surrounding edema, and the patient was diagnosed with hemangioblastoma. The patient began to develop progressive headache and nausea after stereotactic radiosurgery, and computed tomography showed obstructive hydrocephalus. Endoscopic third ventriculostomy was performed, and the intraoperative view of this showed that the walls of the lateral and third ventricles were covered with a white membrane-like substance. Endoscopic third ventriculostomy and then ventriculoperitoneal shunt did not improve the hydrocephalus. The patient's consciousness deteriorated due to isolated fourth ventricle and upward herniation. The patient underwent posterior fossa craniotomy and the tumor in the medulla oblongata was removed via a telovelar approach. Intraoperatively, the fourth ventricle was filled with a white membrane-like substance, which was surgically removed and pathologically diagnosed as fibrin. The patient's consciousness and obstructive hydrocephalus improved after surgery. The present case suggests that isolated fourth ventricle may occur after VP shunt placement for the hydrocephalus with hyperproteinorachia.

Hemorrhagic brain metastasis from small-cell carcinoma of the urinary bladder

Background:

Small-cell carcinoma of the urinary bladder (SCCB) accounts for 1% of all bladder tumors. We present a rare case of hemorrhagic metastatic brain tumor from SCCB diagnosed by navigation-guided endoscopic biopsy.

Case Description:

A 76-year-old man presented with sudden onset of aphasia and right hemiplegia from 3 weeks previously. He had a medical history of prostate cancer and SCCB. Computed tomography showed a mixed density mass in the left basal ganglia. On magnetic resonance imaging, the mass showed mixed intensity in both T1-weighted images and T2-weighted images, suggesting subacute hemorrhage. The mass was partially enhanced with gadolinium. The patient underwent endoscopic hematoma evacuation and partial removal of the tumor. Histopathological diagnosis was neuroendocrine carcinoma, which was consistent with SCCB metastasis. After surgery, the patient underwent whole-brain radiation therapy of 30 Gy. His general condition gradually deteriorated, however, and he died 4 months after surgery.

Conclusion:

Our patient had a rare case of brain metastasis derived from SCCB which presented with cerebral hemorrhage. Navigation-guided endoscopic biopsy was useful for the diagnostic sampling of deep localized brain tumors with hemorrhage.

COT-1 Clinical Questions and Answers about Glioma-Related Epilepsy (GRE): Real-world data in Wakayama Medical University Hospital

Introduction: In glioma patients, epilepsy not infrequently occurred and anti-epileptic drugs (AEDs) are commonly used. In this study, we revealed the real-world data on clinical practice of glioma-related epilepsy in Wakayama Medical University Hospital (WMUH). Methods. We collected clinical and molecular data of glioma patients operated at WMUH from January 1996 to December 2020 and analyzed the data to answer clinical questions as follows: 1) location/histology related GRE, 2) molecular features related GRE, 3) prophylactic AEDs and postoperative seizure, 4) tumor progression and convulsion, 5) GRE and survival. Results. Fifty-five of 113 glioma patients (49%) presented with seizure. CQ1. In tumors located at frontal, temporal and parietal lobe, the occurrence rate of GRE was 27/39 (69%), 13/19 (69%) and 9/14 (64%), respectively. Patients with glioblastoma, astrocytic tumors and oligodendroglial tumors presented with GRE at the rate of 26/54 (48%), 14/30 (47%) and 12/13 (92%), respectively. CQ2. GRE occurred in tumors with IDH mutated (16 cases, 29%), TERT mutated (32 cases, 58%) and MGMT methylated (32 cases, 58%). CQ3. Seizure in peri- or postoperative period occurred in 14 cases (12%); 4 cases in AED(+) group (4/29, 14%) and 10 cases in AED(-) group (10/84, 12%). CQ4. Tumor progression became apparent at the time of seizure in 12 cases (12/55, 22%). CQ5. According to the prognostic IDH/TERT classification of diffuse glioma cases (n = 94), overall survival (OS) times of GRE(+) cases tended to be longer than that of GRE(-) ones, especially in IDH wildtype/TERT mutated group (22.7 months vs. 8.3 months, p = 0.0397). Conclusion. GRE is likely associated with specific clinical and molecular features. Seizure in glioma patients can occur in specific situation regardless of the use of AEDs. Possible better prognosis of GRE(+) cases requires further investigation.

Regional abnormality of functional connectivity is associated with clinical manifestations in individuals with intractable focal epilepsy

We explored regional functional connectivity alterations in intractable focal epilepsy brains using resting-state functional MRI. Distributions of the network parameters (corresponding to degree and eigenvector centrality) measured at each brain region for all 25 patients were significantly different from age- and sex-matched control data that were estimated by a healthy control dataset (n = 582, 18-84 years old). The number of abnormal regions whose parameters exceeded the mean + 2 SD of age- and sex-matched data for each patient were associated with various clinical parameters such as the duration of illness and seizure severity. Furthermore, abnormal regions for each patient tended to have functional connections with each other (mean ± SD = 58.6 ± 20.2%), the magnitude of which was negatively related to the quality of life. The abnormal regions distributed within the default mode network with significantly higher probability (p < 0.05) in 7 of 25 patients. We consider that the detection of abnormal regions by functional connectivity analysis using a large number of control datasets is useful for the numerical assessment of each patient's clinical conditions, although further study is necessary to elucidate etiology-specific abnormalities.

Three-dimensional morphology of the superior cerebellar artery running in trigeminal neuralgia

The superior cerebellar artery (SCA) is the most frequent offending vessel in trigeminal neuralgia. This study aims to elucidate the patterns of the SCA running in 34 patients with typical trigeminal neuralgia using three-dimensional computer graphics. The SCA which runs in the medial aspect of the trigeminal nerve compressed predominantly the root entry zone at the distal segment of the caudal loop. Meanwhile, the SCA which runs in the cranial or lateral aspect of the trigeminal nerve compressed predominantly the mid-third portion at the proximal segment of the caudal loop. The site of neurovascular compression differed depending on the shape of the initial segment of SCA. Transposition methods could not be performed in several patients with arch-shaped SCA. Three-dimensional computer graphics revealed different characteristics of the SCA running in trigeminal neuralgia depending on the site of neurovascular compression and shape of the SCA. These differences might affect procedures for microvascular decompression.

Aphasic status epilepticus of frontal origin treated by resective surgery

Aphasic status epilepticus (SE) is a clinical entity of SE, but it has not been well recognized. We report a 43-year-old female with a chronic drug-resistant epilepsy with aphasic SE, treated by resective surgery. The patient showed long-lasting weekly episodes of hypokinesia, slow verbal response, and dysphasia, which were diagnosed as symptoms of aphasic SE. Magnetic resonance imaging showed encephalomalacia in the left frontal lobe with a hemosiderin rim. Intracranial electroencephalography revealed continuous spikes, predominantly on the left superior frontal gyrus with hemosiderin deposit. The aphasic symptoms were seen when ictal discharges gradually spread to the wide area of the left anterior frontal lobe, including the language area. The episodes of recurrent aphasic SE had disappeared by one year after the left anterior frontal resection. We should consider aphasic SE when language impairment is episodic, and consider surgical intervention in cases where it repeatedly occurs despite appropriate medical therapy.

•

Long-lasting slow verbal response and dysphasia could be manifestations of aphasic status epilepticus of frontal origin

•

Epilepsy surgery should be considered for repeat aphasic SE under appropriate medical treatment after definite diagnosis

•

Precise time correlations between aphasic symptoms and ictal discharges could be unclear even by intracranial electroencephalography.

[Tentorial Dural Arteriovenous Fistula Presenting with Ocular Symptoms:A Case Report]

Tentorial dural arteriovenous fistula(dAVF)is classified as Cognard 4 with a high risk of aggressive feature, such as intracranial hemorrhage, venous infarction, and intracranial hypertension. We report a rare case presenting with ocular symptoms caused by tentorial dAVF. A 59-year-old man presented with progressive chemosis and exophthalmos of his left eye. Angiography showed a tentorial dAVF that was primarily fed by the middle meningeal artery and the meningohypophyseal artery. The AVF drained into the superior ophthalmic vein and the cerebellar cortical vein via an enlarged petrosal vein. Because transarterial Onyx embolization resulted in incomplete obliteration of the fistula, he underwent microsurgery via a suboccipital approach to obliterate the shunt. Postoperative angiography showed complete obliteration of the shunt. His ocular symptoms rapidly cured. We present this rare case and discuss the pathomechanism associated with the development of ocular symptoms secondary to a tentorial dAVF from the viewpoint of microvascular anatomy.

Rapid regression of glioblastoma following carmustine wafer implantation: A case report

Carmustine wafers, which are locally delivered chemotherapy in the form of biodegradable implants, confer a survival benefit to patients with glioblastoma (GB) following surgical resection. While the adverse events of this method, including gas retention and perifocal edema, have been extensively investigated, the immediate efficacy of the implant has rarely been reported. To the best of our knowledge, this is the first reported case of GB in which the tumor rapidly regressed after partial surgical removal followed by implantation of carmustine wafers. A 77-year-old woman presented with motor aphasia and right hemiparesis. Neuroimaging revealed a tumor located in the left frontal lobe of the brain. The tumor was partially removed under 5-aminolevulinic acid fluorescence guidance and 8 carmustine wafers were implanted in the resection cavity. The histopathological findings suggested the diagnosis of GB. Genetic and immunohistochemical analyses revealed O⁶-methylguanine-DNA methyltransferase (MGMT) gene promoter methylation and low MGMT protein expression, respectively, in the tumor cells. One month after the operation, when adjuvant temozolomide chemotherapy was planned, computed tomography and magnetic resonance imaging revealed a marked regression of the residual tumor and perifocal edema. The patient's symptoms and signs had improved. As adjuvant temozolomide without radiation was therapeutically beneficial, the tumor gradually regressed and the patient has remained progression-free for >12 months after the operation. Therefore, adjuvant local chemotherapy with carmustine wafer implants was able to induce rapid regression of GB.

Reduced pallidal output causes dystonia

Dystonia is a neurological disorder characterized by sustained or repetitive involuntary muscle contractions and abnormal postures. In the present article, we will introduce our recent electrophysiological studies in hyperkinetic transgenic mice generated as a model of DYT1 dystonia and in a human cervical dystonia patient, and discuss the pathophysiology of dystonia on the basis of these electrophysiological findings. Recording of neuronal activity in the awake state of DYT1 dystonia model mice revealed reduced spontaneous activity with bursts and pauses in both internal (GPi) and external (GPe) segments of the globus pallidus. Electrical stimulation of the primary motor cortex evoked responses composed of excitation and subsequent long-lasting inhibition, the latter of which was never observed in normal mice. In addition, somatotopic arrangements were disorganized in the GPi and GPe of dystonia model mice. In a human cervical dystonia patient, electrical stimulation of the primary motor cortex evoked similar long-lasting inhibition in the GPi and GPe. Thus, reduced GPi output may cause increased thalamic and cortical activity, resulting in the involuntary movements observed in dystonia.

Cortically evoked responses of human pallidal neurons recorded during stereotactic neurosurgery

Responses of neurons in the globus pallidus (GP) to cortical stimulation were recorded for the first time in humans. We performed microelectrode recordings of GP neurons in 10 Parkinson's disease (PD) patients and 1 cervical dystonia (CD) patient during surgeries to implant bilateral deep brain stimulation electrodes in the GP. To identify the motor territories in the external (GPe) and internal (GPi) segments of the GP, unitary responses evoked by stimulation of the primary motor cortex were observed by constructing peristimulus time histograms. Neurons in the motor territories of the GPe and GPi responded to cortical stimulation. Response patterns observed in the PD patients were combinations of an early excitation, an inhibition, and a late excitation. In addition, in the CD patient, a long-lasting inhibition was prominent, suggesting increased activity along the cortico-striato-GPe/GPi pathways. The firing rates of GPe and GPi neurons in the CD patient were lower than those in the PD patients. Many GPe and GPi neurons of the PD and CD patients showed burst or oscillatory burst activity. Effective cathodal contacts tended to be located close to the responding neurons. Such unitary responses induced by cortical stimulation may be of use to target motor territories of the GP for stereotactic functional neurosurgery. Future findings utilizing this method may give us new insights into understanding the pathophysiology of movement disorders.

Nondominant parietotemporal cortical dysplasia manifesting as hypermotor seizures

We describe the case of a 33-year-old man with nondominant right parietotemporal cortical dysplasia. Habitual seizures were violent, ballistic movements of the extremities with pelvic thrusting, resembling complex gestural automatisms or "hypermotor seizures." Scalp electroencephalography (EEG) and interictal [(123)I]iomazenil single-photon-emission computed tomography revealed an epileptogenic zone including a lesion observed on magnetic resonance imaging. Corticectomy of the inferior parietal lobule was performed via invasive EEG monitoring, but resulted in failed seizure control. The middle and posterior temporal cortices were additionally resected in the second surgery. The patient experienced contralateral hemianopsia postoperatively, but no hemispatial neglect. Hypermotor seizures have not been seen for 1.5years since surgery. This is the first description of a patient with a parietal lobe lesion experiencing hypermotor seizures. The middle and posterior temporal cortices were considered epileptogenic together with the inferior parietal lobule in the present case.

Closed-lip schizencephaly around the central sulcus with intractable epilepsy treated by peri-lesional focus resection

A 24-year-old man presented with closed-lip schizencephaly around the right central sulcus manifesting as an 11-year history of intractable epilepsy. Mild motor paresis in the left extremities and mental retardation were observed. Tonic posture with bilateral facial tonic contraction was asymmetrical, predominantly in the left extremities. Magnetic resonance imaging demonstrated closed-lip schizencephaly around the right central sulcus. The epileptogenic zone was determined in the supplementary motor area, and premotor and primary sensorimotor cortices using invasive recordings. As the thickened cortex was considered functional, corticectomy of the supplementary motor area and premotor area was performed, preserving the primary sensorimotor area. Histological examination revealed marked cortico-subcortical gliosis, particularly in the medial part of the resection. Asymmetrical tonic postural seizure disappeared completely after surgery. Medically intractable epilepsy with schizencephaly represents a considerable challenge in epilepsy surgery. Partial corticectomy adjacent to the thickened cortex was effective for seizure control in a patient with closed-lip schizencephaly around the central sulcus.

Neurocytoma manifesting as intraventricular hemorrhage--case report

A 43-year-old man presented with a neurocytoma manifesting as severe headache and disturbance of consciousness. Computed tomography revealed intraventricular hemorrhage, and a small mass lesion with calcification on the wall of the left lateral ventricle. The lesion appeared as mixed intensity regions on both T(1)- and T(2)-weighted magnetic resonance imaging, and heterogeneous enhancement with gadolinium-diethylenetriaminepenta-acetic acid. Angiography showed the pooling sign near the calcification in the late venous phase. Neurologically, amnestic syndrome was demonstrated in the subacute phase. Gross total removal of the lesion was performed through a transcallosal approach. His transient memory disturbance resolved. The histological diagnosis was neurocytoma. Intraventricular hemorrhage is rare as the initial presentation of neurocytoma. Surgery should avoid fornix injury and the risk of permanent memory disturbance.

[A case of high grade astrocytoma arising in the hand area of precentral gyrus]

A 23-year-old man presented with the right upper monoparesis. The right little finger paresis was apparent at first, and ring finger two weeks later, and middle, index, thumb were simultaneously four weeks later. Then the monoparesis gradually progressed to the proximal upper limb. Magnetic resonance imaging showed a small lesion at the knob of the left precentral gyrus. The lesion was low-intensity on T1-, and high-intensity on T2-weighted images, and clearly detected on high-intensity on FLAIR images, but showed no enhancement by gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA). Angiography and thallium scintigraphy showed no remarkable findings. Proton MR spectroscopy demonstrated lower N-acetylaspartate (NAA) and higher choline (Cho) level compared to the contralateral cortico-subcortical area. Diffusion weighted images demonstrated low apparent diffusion coefficient (ADC) value and high intensity on b = 1,000. To clarify the diagnosis of the lesion, we performed open biopsy by using the neuronavigation system to detect the lesion accurately and minimize the biopsy. Histological examination revealed an high grade astrocytoma with high MlIB-1 index over 30%. The progressive symptoms were due to highly infiltrative and proliferative nature of the tumor arising in the focal hand area of the primary motor cortex, according to the homunculus. We discuss herein the neuroimagings of the case that was considered to be in the initial stage of a malignant tumor.

Pineal Germinoma With Granulomatous Reaction-Case Report-

A 20-year-old man presented with diplopia. Neurological examination revealed mild skew deviation and upbeat nystagmus. Computed tomography showed a clover-shaped isodense mass in the pineal region with homogeneous enhancement. The lesion was isointense on both T(1)- and T(2)-weighted magnetic resonance (MR) imaging with homogeneous enhancement by gadolinium-diethylenetriaminepenta-acetic acid. Cerebral angiography showed no tumor staining. Serum and cerebrospinal fluid were negative for beta-human chorionic gonadotropin, alpha-fetoprotein, and placental alkaline phosphatase. Open biopsy was performed using a right occipital transtentorial approach. Histological examination revealed a tumor consisting of clusters of germinoma cells, but with prominent infiltration of lymphocytes, plasma cells, and macrophages, and proliferation of small vessels. The histological diagnosis was germinoma with granulomatous reaction. MR imaging showed complete disappearance of the tumor after chemoradiotherapy. Neurosurgeons should be aware of this rare tumor to avoid misdiagnosis as granulomatous inflammation.

Myositis Ossificans of the Temporal Muscle as a Primary Scalp Tumor-Case Report-

A 38-year-old woman presented with a rare case of myositis ossificans in the temporal muscle manifesting as left temporal scalp mass with mild pain. The mass was elastic-hard and seemed to be located in the temporal muscle. Magnetic resonance imaging revealed a heterogeneously enhanced mass in the muscle. The tumor was resected. The histological diagnosis was myositis ossificans. The clinicopathological features of scalp myositis ossificans may mimic other soft tissue tumors, requiring care for the differential diagnosis.

Long-term seizure outcome following resective surgery at National Epilepsy Center in Shizuoka, Japan

We analyzed the seizure outcome of 357 patients who were followed for at least 2 years after resective surgeries; 282 underwent temporal lobe resection and 75 had extratemporal lobe resection. This study confirmed that resective surgery provides sustained, positive benefits with a high seizure-free rate of nearly 80% for most medically refractory patients. In patients with no MRI-detectable lesion who underwent extratemporal lobe resection, however, Engel's class I-II (seizure-free or rare seizures) was achieved in less than 50% of patients. High-resolution MRI should be performed at the early stage of disease in all patients with partial epilepsies. The findings would certainly urge clinicians to actively select surgical intervention.

An increased number of CD40-high monocytes in patients with Crohn's disease

OBJECTIVE

CD40-CD40 ligand (CD40L) interaction is essential for the T-lymphocyte-dependent immune response. This interaction may be operational in the pathogenesis of inflammatory bowel diseases (IBD). The present study examined the expression of CD40 in peripheral blood mononuclear cells (PBMNCs) and tissue specimens, and CD40-stimulated interleukin (IL)-12 release from PBMNCs in IBD.

METHODS

The expression of CD40 in PBMNCs and tissue inflammatory cells was examined by flowcytometry and immunohistochemistry, respectively. IL-12 release was measured in cultured media of PBMNCs by an enzyme-linked immunosorbent assay.

RESULTS

Most peripheral blood B-lymphocytes expressed CD40 in all subjects. However, in ulcerative colitis (UC) patients, a significantly increased mean fluorescence intensity (MFI) of CD40 on B-lymphocytes was detected, compared with control subjects and patients with Crohn's disease (CD). In contrast, both the percentage positivity and MFI of CD40 on monocytes of active CD subjects were significantly increased, compared with the other groups. In active CD patients, a high level of IL-12 release from PBMNCs was observed by CD40 stimulation, compared with those of the other groups. When primed with IFN-gamma, PBMNCs from inactive CD patients released a significantly high level of IL-12, probably via stimulation by the CD40 monoclonal antibody. In the affected mucosa of CD, numerous CD40-positive cells were demonstrated, and they were also CD68-positive, suggesting these double CD40/ CD68-positive cells are tissue macrophages.

CONCLUSIONS

These results suggest that the examination of CD40 expression in PBMNCs might enable the differentiation of CD from UC. CD40-high monocytes in CD patients may play a role in the pathogenesis of CD.

Morphological and functional restoration of parietal cells in helicobacter pylori associated enlarged fold gastritis after eradication

BACKGROUND/AIM

Helicobacter pylori infections are associated with hypochlorhydria in patients with pangastritis. It has previously been shown that eradication of H pylori leads to an increase in acid secretion in H pylori associated enlarged fold gastritis, suggesting that H pylori infection affects parietal cell function in the gastric body. The aim of this study was to evaluate the effects of H pylori infection on parietal cell morphology and function in hypochlorhydric patients.

PATIENTS/METHODS

The presence of H pylori infection, mucosal length, and inflammatory infiltration were investigated in six patients with enlarged fold gastritis and 12 patients without enlarged folds. Parietal cell morphology was examined by immunohistochemistry using an antibody against the alpha subunit of H(+),K(+)-ATPase and electron microscopy. In addition, gastric acid secretion and fasting serum gastrin concentration were determined before and after the eradication of H pylori.

RESULTS

In the H pylori positive patients with enlarged fold gastritis, fold width, foveolar length, and inflammatory infiltration were increased. In addition, the immunostaining pattern of H(+), K(+)-ATPase was less uniform, and the percentage of altered parietal cells showing dilated canaliculi with vacuole-like structures and few short microvilli was greatly increased compared with that in H pylori positive patients without enlarged folds. After eradication, fold width, foveolar length, and inflammatory infiltrates decreased and nearly all parietal cells were restored to normal morphology. On the other hand, altered parietal cells were negligible in H pylori negative patients. In addition, the basal acid output and tetragastrin stimulated maximal acid output increased significantly from 0.5 (0.5) to 4.1 (1.5) mmol/h and from 2.5 (1.2) to 13.8 (0.7) mmol/h (p<0.01), and fasting serum gastrin concentrations decreased significantly from 213.5 (31.6) to 70.2 (7.5) pg/ml (p<0.01) after eradication in patients with enlarged fold gastritis.

CONCLUSION

The morphological changes in parietal cells associated with H pylori infection may be functionally associated with the inhibition of acid secretion seen in patients with enlarged fold gastritis.

[When do strokes occur?--analysis of diurnal variation and activity during the onset]

The diurnal variation and activity during the onset of stroke were examined in more than 700 consecutive patients. 304 cases with hypertensive intracerebral hemorrhage (HIH), 214 cases with subarachnoid hemorrhage (SAH) and 201 cases with obstructive cerebrovascular disease (OCVD) were investigated about the time of onset. Concerning the activity during the onset, 296 cases with HIH, 215 cases with SAH and 198 cases with OCVD were examined. HIH occurred frequently between 1500-1800 hours, 0600-0900 hours and 1800-2100 hours. SAH occurred frequently between 0900-1200 hours, 1500-1800 hours and 1800-2100 hours. Both HIH and SAH were least likely to occur between 0000-0300 hours. OCVD exhibited a small peak incidence between 0900-1200 hours, but there were no differences between the groups for the other time periods. Both HIH and SAH were likely to occur frequently in the lavatory, while bathing and during meals. HIH also occurred frequently during physical work, while SAH occurred as frequently during mental work or housework as during hard physical labor. OCVD commonly occurred during sleep or relaxation. The relationship between diurnal variation in stroke and the circadian variation of blood pressure is discussed. The incidence of all three types of strokes during work was higher in the non-aged group (patients under 66 years) than in the aged group (patients over 66 years). HIH and SAH occurred associated with alcohol consumption more frequently in the non-aged group than in the aged group. It is likely that the difference of the time and of the activity during the onset between aged group and non-aged group reflects the difference of life-style between aged and non-aged people.

Mucosal interleukin-1 beta production and acid secretion in enlarged fold gastritis

BACKGROUND

We have previously shown that eradication of Helicobacter pylori increases acid secretion in H. pylori-associated enlarged fold gastritis.

AIM

To investigate whether locally produced interleukin-1 beta is possibly involved in the inhibition of acid secretion in H. pylori gastritis.

METHODS

IL-1 beta release from the gastric body mucosa was determined by short-term culture of biopsy specimens in 13 patients with enlarged fold gastritis (all H. pylori-positive), five H. pylori-positive and 10 H. pylori-negative patients without enlarged folds. The acid-inhibitory effect of locally produced IL-1 beta was examined by [14C]-aminopyrine uptake assay using isolated rabbit gastric glands.

RESULTS

IL-1 beta release was significantly greater in patients with enlarged fold gastritis, significantly correlated with both basal and tetragastrin-stimulated acid outputs in the H. pylori-positive patients (r = -0.591 and r = -0.641, respectively; P < 0.01), and significantly decreased with concomitant increases in acid secretions after eradication of H. pylori. [14C]-aminopyrine uptake was inhibited by IL-1 beta in a dose-dependent manner.

CONCLUSIONS

Increased production of IL-1 beta caused by H. pylori infection is possibly involved in the inhibition of acid secretion in enlarged fold gastritis.

Delayed gastric emptying during interferon-alpha therapy in patients with chronic hepatitis C: relief by cisapride

BACKGROUND

Patients receiving interferon-alpha often experience symptoms such as upper abdominal discomfort, anorexia, and nausea, which suggest a delay in gastric emptying. Reduction of the dosages of interferon-alpha or even interruption of the treatment is sometimes required because of these symptoms. The present study was designed to investigate the effect of interferon-alpha on gastric emptying and to evaluate the effects of cisapride on gastric emptying and upper abdominal symptoms during interferon-alpha therapy.

METHODS

Gastric emptying in 14 patients with chronic hepatitis C was estimated by the sulfamethizole capsule method before and 1 and 2 weeks after the beginning of interferon-alpha (6 million U/day) therapy.

RESULTS

Before therapy none of the patients complained of upper abdominal symptoms, and all had normal gastric emptying. Interferon treatment delayed gastric emptying in 12 of the patients and induced discomfort and anorexia in 9 of the patients. The administration of cisapride reversed the delayed gastric emptying in six of seven patients and relieved abdominal discomfort and anorexia.

CONCLUSIONS

These findings indicate that interferon-alpha delays gastric emptying and suggest that cisapride administration corrects the delayed gastric emptying and relieves the abdominal symptoms associated with interferon-alpha therapy.

Increased production of interleukin 1 beta and hepatocyte growth factor may contribute to foveolar hyperplasia in enlarged fold gastritis

BACKGROUND AND AIMS

It has been reported that eradication of Helicobacter pylori improves fold width in H pylori associated enlarged fold gastritis. The aim of this study was to clarify the mechanism of fold thickening in this condition.

PATIENTS AND METHODS

In eight patients with enlarged fold gastritis and 13 patients without enlarged folds, the presence of H pylori infection, inflammatory infiltrates, mucosal plasia, and epithelial cell proliferation in the body mucosa were investigated, and production of transforming growth factor alpha (TGF alpha), hepatocyte growth factor (HGF), and interleukin 1 beta (IL 1 beta) was determined by a competitive reverse transcription/polymerase chain reaction method and in vitro short-term culture of biopsy specimens.

RESULTS

In the patients with enlarged fold gastritis, inflammatory infiltrates including macrophages increased with H pylori colonisation in the body. Foveolar thickness and proliferating cell nuclear antigen (PCNA) labelling index were increased. Messenger RNA levels of HGF, but not TGF alpha, were increased, and release of HGF and IL 1 beta was increased. HGF release, which was positively correlated with IL 1 beta release and foveolar thickness, decreased in the presence of IL 1 receptor antagonist. After eradication of H pylori, inflammatory infiltrates, IL 1 beta and HGF release decreased with concomitant decreases in PCNA labelling index, foveolar thickness and fold width.

CONCLUSIONS

Increased IL 1 beta and HGF production caused by H pylori infection may contribute to fold thickening of the stomach by stimulating epithelial cell proliferation and foveolar hyperplasia in patients with enlarged fold gastritis.

Effects of erythromycin in chronic idiopathic intestinal pseudo-obstruction

The prokinetic effects of erythromycin, a macrolide antibiotic, on the gastrointestinal tract as a motilin receptor agonist and its potential value for the treatment of gastrointestinal motility disorders have recently attracted interest. The effects of erythromycin on the clinical symptoms and gastrointestinal motility of patients with chronic idiopathic pseudo-obstruction have not been investigated extensively. We presented a case of chronic idiopathic intestinal pseudo-obstruction, in a 67-year-old man in whom oral erythromycin (900 mg/day) dramatically improved postprandial abdominal distention, nausea, and vomiting. Other agents with prokinetic effects on intestinal motility, i.e., cisapride, domperidone, metoclopramide, and trimebutine maleate did not have a favorable effect. Gastric emptying, measured by the sulfamethizole method; and intestinal transit, evaluated using radio-opaque markers, were markedly improved by treatment with erythromycin. Our experience suggests that the prokinetic effects of erythromycin may be of therapeutic value in chronic idiopathic intestinal pseudo-obstruction.

Unilateral spatial neglect due to a haemorrhagic contusion in the right frontal lobe

We report two cases of unilateral spatial neglect associated with an isolated right frontal lobe lesion. Case 1 was a 59-year-old, right-handed man, who developed a left hemiplegia, disorientation, and frontal lobe neglect associated with a haemorrhagic contusion following a head injury. Case 2 was a 55-year-old, right-handed man, who also developed disorientation and frontal lobe neglect secondary to a haemorrhagic contusion following a head injury. 99mTc HM-PAO SPECT revealed an isolated reduction in the regional cerebral blood flow (CBF) around the haematoma in the frontal lobe; blood flow to remaining parts of the brain was normal. Damage to the right frontal lobes of these patients was confirmed as being the cause of the unilateral spatial neglect in accordance with the results of CBF studies.

[Clinical analysis of ascitic fluid in patients with liver cirrhosis and hepatocellular carcinoma]

To investigate the clinical significance of ascitic fluid in patients with a malignancy, an abdominal paracentesis to evaluate the ascitic fluid was performed in 10 patients with a hepatocellular carcinoma (HCC) and in 7 patients with liver cirrhosis (LC). The AFP levels in the ascitic fluid and in the serum of the HCC patients was found be significantly higher than that of the LC patients. In addition, the ratio of albumin/total protein in ascitic fluid was also higher in the HCC patients. However, no significant findings were uncovered with regard to the concentration of lipid in ascitic fluid, in either type of patient although 2 HCC patients were found to have a very high concentration of total cholesterol. The cytological findings provided no reliable marker because of significant number of false negatives in the HCC patients. Also, there was no significant difference between the fibronectin levels in the ascitic fluid of either type of patients. This finding differs from previous studies, and suggests that the fibronectin levels in the ascitic fluid may not be a useful marker in determining a malignancy.

[A clinical study of complements as a marker of a hepatocellular carcinoma]

Serum complement C3, C4, and C3 proactivator (C3PA) have been evaluated for their diagnostic power in detecting a hepatocellular carcinoma (HCC) in patients with liver cirrhosis (LC). It was found that serum complement levels were lower in LC patients than in HCC patients and that difference of the serum C4 and C3PA levels between LC patients and HCC patients were statistically significant. In addition, serum C3 PA levels were found to correlate significantly with the serum gamma-GTP levels in HCC patients. Thus, using the cutoff values of C4 and C3PA as the mean values for HCC patients, examination of serum complement levels enabled the detection of 38% of the HCC patients with low AFP levels. These findings suggest that the examination of the serum complements may be a useful a tool for the detection of HCCs in LC patients.

[A clinical study of serum erythropoietin concentrations in patients with liver cirrhosis and hepatocellular carcinomas]

We have measured the serum erythropoietin concentrations in 14 patients with liver cirrhosis and in 14 patients with a hepatocellular carcinoma. Among these patients, 2 with liver cirrhosis (14.3%) and 7 with a hepatocellular carcinoma (50.0%) were found to have raised serum erythropoietin concentrations, ranging up to 40 mU/ml. Negative correlations were found between erythropoietin and the RBC, and the Hb and Ht in the cases with liver cirrhosis. In contrast, a positive correlation which was not significant was found only between the erythropoietin and the RBC in cases involving a hepatocellular carcinoma. This has suggested that the relationship between the erythropoietin and the RBC in cases of a hepatocellular carcinoma differs from the relationship seen under the usual physiological circumstances of those with liver cirrhosis.