Utility of digital subtraction angiography-based collateral evaluation in medically treated acute symptomatic basilar artery stenosis

BACKGROUND AND PURPOSE

Although a stroke from atherosclerosis in the basilar artery (BA) often presents with mild initial stroke severity, it has heterogeneous clinical courses. We investigated the efficacy of digital subtraction angiography (DSA)-based collateral perfusion evaluation in association with long-term outcomes of medically treated symptomatic basilar artery stenosis.

METHODS

From a registry database of all consecutive patients with stroke, we included 98 medically treated patients (due to mild initial stroke severity) [National Institute of Health Stroke Scale (NIHSS) scores ≤ 4; symptomatic basilar artery stenosis, 70-99%] with available initial diagnostic DSA. Basilar collateral scoring was performed via the DSA, using a modified version of the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grading system in both the superior cerebellar artery and anterior/posterior-inferior cerebellar artery territories (score 0-8). The outcomes were designated as the 90-day modified Rankin Scale (mRS90) score (poor, 3-6). Student's t-test, chi-square test and logistic regression analyses were used to identify factors associated with a poor outcome.

RESULTS

The median initial NIHSS score was 2 [interquartile range (IQR), 0-3], median posterior circulation Alberta Stroke Program Early CT Score was 8 (IQR, 7-10), median collateral score was 7 (IQR, 7-8) and 20 (20.4%) had poor mRS90 scores. In multivariate analysis, poorer collateral scores (P = 0.003), higher NIHSS scores (P = 0.005) and lower posterior circulation Alberta Stroke Program Early CT Score (P = 0.017) were independently associated with a poor mRS90 score.

CONCLUSIONS

The DSA-based collateral scoring of the BA large branches might predict long-term outcome in medically treated symptomatic basilar artery stenosis with mild initial severity. Evaluation of BA collateral perfusion status might be useful to determine appropriate treatment strategies.

Oxaliplatin and 5-FU/folinic acid (modified FOLFOX6) with or without aflibercept in first-line treatment of patients with metastatic colorectal cancer: the AFFIRM study

BACKGROUND

The combination of aflibercept with FOLFIRI has been shown to significantly prolong overall survival in patients with metastatic colorectal cancer (mCRC) after progression on oxaliplatin-based therapy. This trial evaluated the addition of aflibercept to oxaliplatin-based first-line treatment of patients with mCRC.

PATIENTS AND METHODS

Patients with mCRC were randomized to receive first-line therapy with mFOLFOX6 plus aflibercept (4 mg/kg) or mFOLFOX6 alone. The primary end point of this phase II study was the progression-free survival (PFS) rate at 12 months in each arm. The analysis of efficacy between the arms was a pre-planned secondary analysis.

RESULTS

Of 236 randomized patients, 227 and 235 patients were evaluable for the primary efficacy analysis and safety, respectively. The probabilities of being progression-free at 12 months were 25.8% [95% confidence interval (CI) 17.2-34.4] for the aflibercept/mFOLFOX6 arm and 21.2% (95% CI 12.2-30.3) for the mFOLFOX6 arm. The median PFS was 8.48 months (95% CI 7.89-9.92) for the aflibercept/mFOLFOX6 arm and 8.77 months (95% CI 7.62-9.27) for the mFOLFOX6 arm; the hazard ratio of aflibercept/mFOLFOX6 versus mFOLFOX6 was 1.00 (95% CI 0.74-1.36). The response rates were 49.1% (95% CI 39.7-58.6) and 45.9% (95% CI 36.4-55.7) for patients treated with and without aflibercept, respectively. The most frequent treatment-emergent grade 3/4 adverse events (AEs) excluding laboratory abnormalities reported for aflibercept/mFOLFOX6 versus mFOLFOX6 were neuropathy (16.8% versus 17.2%) and diarrhea (13.4% versus 5.2%). Neutropenia grade 3/4 occurred in 36.1% versus 29.3%. The most common vascular endothelial growth factor inhibition class-effect grade 3/4 AEs for aflibercept/mFOLFOX6 versus mFOLFOX6 were hypertension (35.3% versus 1.7%), proteinuria (9.2% versus 0%), deep vein thrombosis (5.9% versus 0.9%) and pulmonary embolism (5.9% versus 5.2%).

CONCLUSION

No difference in PFS rate was observed between treatment groups. Adding aflibercept to first-line mFOLFOX6 did not increase efficacy but was associated with higher toxicity.

CLINICAL TRIAL NUMBER

NCT00851084, www.clinicaltrials.gov, EudraCT 2008-004178-41.

Efficacy of Pre- and Postoperative Chemotherapy in Patients with Osteosarcoma of the Extremities

PURPOSE

We evaluated the treatment efficacy including survival and recurrence, and factors associated with recurrence in osteosarcoma patients treated with preoperative chemotherapy, surgery, and adjuvant chemotherapy.

MATERIALS AND METHODS

Forty nine patients with osteosarcoma were treated with preoperative chemotherapy with intra-arterial cisplatin and adriamycin infusion for 3 cycles, followed by surgery. According to the pathologic response, if tumor was necrotized more than 90%, the same adjuvant chemotherapy was reintroduced for 3 cycles, and if the response was not enough, then the salvage regimen was introduced. Plain chest film and chest CT scan were taken monthly and every 3 months, respectively. When tumor recurred, the metastasectomy was performed whenever possible.

RESULTS

Forty three patients were evaluable with amedian follow up of 53 months. Five-year disease-free and overallsurvival rate was 47.0% and 66.9%, respectively. The recurrence was observed in 22 patients (51.2%) with median time of 12.5 months. Baseline alkaline phosphatase (ALP) was the only significant factor for recurrence (p=0.03) and the patients with the possibility of metastasectomy recurrence showed higher post-relapse survival compared to other treatment modalities (26 momths vs 5~12 months).

CONCLUSION

These results indicates that pre- and postoperative chemotherapy with intra-arterial cisplatin and adriamycin infusion showed comparable treatment efficacy and acceptable toxicities.

Effects of celecoxib on hematoma and edema volumes in primary intracerebral hemorrhage: a multicenter randomized controlled trial

BACKGROUND AND PURPOSE

We investigated the effect of celecoxib, a selective inhibitor of cyclo-oxygenase 2, in patients with intracerebral hemorrhage (ICH).

METHODS

We conducted a multicenter, randomized, controlled, and open with blinded end-point trial of 44 Korean patients 18 years or older with ICH within 24 h of onset. The intervention group (n = 20) received celecoxib (400 mg twice a day) for 14 days. The control group (n = 24) received the standard medical treatment for ICH. The primary end-point was the number of patients with a change in the volume of perihematomal edema (PHE) from the 1st to the 7th ± 1 day (cut-off value, 20%).

RESULTS

The time from onset to computed tomography scan slightly differed between groups (177 ± 160 min for control vs. 297 ± 305 min for the celecoxib group; P = 0.10). In the primary end-point analysis using cut-off values, there was a significant shift to reduced expansion of PHE in the celecoxib group (P = 0.005). With respect to the secondary end-points, there was also a significant shift to reduced expansion of ICH in the celecoxib group (P = 0.046). In addition, the expansion rate of PHE at follow-up tended to be higher in the control group than in the celecoxib group (90.6 ± 91.7% vs. 44.4 ± 64.9%; P = 0.058).

CONCLUSIONS

In our small, pilot trial, administration of celecoxib in the acute stage of ICH was associated with a smaller expansion of PHE than that observed in controls.

Clinical features and treatment outcomes of advanced stage primary hepatic angiosarcoma

BACKGROUND

Primary hepatic angiosarcoma is a very rare malignancy with a poor prognosis. While surgical resection has been validated as curative choice, most cases are diagnosed too late for resection. Nonetheless, treatment protocols have not been established and also there are very few reports on the clinical features and treatment outcomes.

PATIENTS AND METHODS

Among 11,939 patients diagnosed with primary hepatic tumors from January 1985 to December 2007 at two centers, five patients were diagnosed with primary hepatic angiosarcoma. We analyzed patients' demographics, tumor characteristics, treatment modality, and outcomes using imaging, serology, and pathology.

RESULTS

All five patients were diagnosed at advanced stage with distant metastases. The most common symptom was abdominal pain. The levels of the tumor markers were within the normal range and serological tests were negative for hepatitis B and C viruses. Two of four patients who received chemotherapy died <3 months after diagnosis, but the other two patients survived >6 months.

CONCLUSIONS

A combination of chemotherapy resulted in an improved outcome for two of four patients, suggesting the potential usefulness of palliative chemotherapy to improve survival. This case study may aid in planning chemotherapy for patients with advanced hepatic angiosarcoma.

Changing ischaemic lesion patterns in adult moyamoya disease

OBJECTIVES

Ischaemic stroke is a frequent manifestation in patients with adult moyamoya disease (MMD), but the relationship between the lesion pattern and disease severity has rarely been investigated.

METHODS

Data were collected on a consecutive series of 65 adult patients with MMD who visited our hospital between 1999 and 2006. Among them, 32 patients with first ever ischaemic stroke were included. The ischaemic lesions were categorised by location and compared as follows: (1) cortical versus subcortical involvement and (2) anterior (fronto-temporal) versus posterior (parieto-occipital) involvement. The lesions were also compared by disease severity, as determined by the extent of intracranial artery involvement (Suzuki's grading method) and by perfusion status visualised on single photon emission computed tomography (SPECT).

RESULT

Disease severity was significantly greater in patients with cortical involvement than in those with subcortical involvement (Suzuki's grade 4.17 (0.72) vs 2.70 (0.73); p<0.001). Disease severity was also significantly greater in patients with posterior involvement than in those with anterior involvement (4.50 (0.53) vs 2.83 (0.76); p<0.001). In most of the patients (83.3%) the perfusion defect area shown on SPECT was larger than the ischaemic lesion area shown on MRI.

CONCLUSIONS

Patients with advanced stage adult MMD tended to have ischaemic lesions involving the cortex and posterior part of the brain and the stroke mechanism in these patients was largely associated with haemodynamic compromise. Our results suggest that the lesion pattern of ischaemic stroke may change along with the extent of arterial involvement.

Association of the ABCB1 gene polymorphisms 2677G>T/A and 3435C>T with clinical outcomes of paclitaxel monotherapy in metastatic breast cancer patients

BACKGROUND

ABCB1 is responsible for multidrug resistance, the principal mechanism by which many cancers develop resistance to chemotherapeutic drugs. There is a controversy whether ABCB1 gene polymorphisms correlate with survival and response in cancer patients treated with chemotherapy. We evaluated the association between clinical outcome (safety and efficacy) of paclitaxel monotherapy in metastatic breast cancer patients with ABCB1 gene polymorphisms 2677G>T/A or 3435C>T.

PATIENTS AND METHODS

Patients with metastatic breast cancer were treated with 175 mg/m(2) paclitaxel per 3-week cycle. Peripheral blood mononuclear cells from patients were used to genotype ABCB1 2677G>T/A and 3435C>T polymorphisms. Genotypes were investigated for their association with tumor response, survival, toxicity, and chemoresistance.

RESULTS

ABCB1 3435 CT showed a significantly lower disease control rate than the CC genotype (P = 0.025). ABCB1 3435 CT was correlated with shorter overall survival (OS) in Cox regression analysis (P = 0.026). The 2677 GG genotype showed a significant association with chemoresistance to paclitaxel and anthracycline (P = 0.04 and 0.04, respectively). None of the ABCB1 genotypes correlated with toxicity.

CONCLUSIONS

ABCB1 genotypes may be a predictor of paclitaxel activity as well as a prognostic factor in metastatic breast cancer patients.

Does microbleed predict haemorrhagic transformation after acute atherothrombotic or cardioembolic stroke?

OBJECTIVES

Cerebral microbleeds (MBs) are known to be indicative of bleeding-prone microangiopathy and may predict incident intracerebral haemorrhage. However, there is controversy concerning the causal relationship between the presence of MBs and haemorrhagic transformation (HTf) after ischaemic stroke.

METHODS

Of the 1034 patients with acute ischaemic stroke who were consecutively admitted to our hospital, 377 patients with stroke due to large-artery atherothrombosis or cardioembolism were selected for participation in this study. We examined the MBs using T2*-weighted gradient-echo MRI performed within 24 hours after admission, and the incidence of HTf was assessed using follow-up brain MRI during the hospitalisation period.

RESULTS

Of the 377 patients with stroke, 234 were male (62.1%) and the mean age was 66.2 +/-11.7 years. MBs were initially found in 109 patients (28.9%), and newly incident HTf was noted during the hospitalisation period in 74 patients (19.6%). The presence of MBs was not increased in the patients with HTf (24.3% vs. 30.0% in the patients without HTf; p = 0.331). In addition, the number of MBs was not higher in the patients with HTf (0.7+/-1.5 vs. 1.8+/-8.1; p = 0.234). This lack of significance between MBs and HTf persisted after stratification by stroke mechanism.

CONCLUSIONS

This study suggests that underlying MBs do not predict incident HTf after acute ischaemic stroke. The clinical significance of MBs should be differentially evaluated according to the type of disease (intracerebral haemorrhage vs. HTf).

Phase III trial of adjuvant 5-fluorouracil and adriamycin versus 5-fluorouracil, adriamycin, and polyadenylic-polyuridylic acid (poly A:U) for locally advanced gastric cancer after curative surgery: final results of 15-year follow-up

BACKGROUND

This phase III trial was to compare 5-fluorouracil (5-FU), adriamycin, and polyadenylic-polyuridylic acid (poly A:U) against 5-fluorouracil plus adriamycin (FA) for operable gastric cancer.

PATIENTS AND METHODS

From 1984 to 1989, patients who had D(2-3) curative resection were randomly assigned to receive chemotherapy or chemoimmunotherapy. Chemotherapy consisted of 12 mg/kg 5-FU every week for 18 months and 40 mg/m2 adriamycin every 3 weeks for 12 cycles. Chemoimmunotherapy consisted of FA plus 100 mg of poly A:U weekly for six cycles and was followed 6 months later by six weekly 50-mg booster injections.

RESULTS

A total of 292 patients were enrolled. After excluding 12 ineligible patients, 142 and 138 patients were allocated to each treatment. Patients were balanced with prognostic variables: age, sex, tumor location, differentiation, degree of tumor invasion (T2-T4a), and lymph node status (N0-N2). During the 15-year follow-up, chemoimmunotherapy significantly prolonged overall (P = 0.013) and recurrence-free (P = 0.005) survivals compared with chemotherapy alone. The survival benefits were prominent in the subset of patients with T3/T4a, N2, or stage III. Treatments were generally well tolerated in both arms.

CONCLUSIONS

These results indicate a survival advantage of chemoimmunotherapy with a regimen of FA and poly A:U in curatively resected gastric adenocarcinoma.

A phase II study of S-1 monotherapy administered for 2 weeks of a 3-week cycle in advanced gastric cancer patients with poor performance status

Systemic chemotherapy for gastric cancer is often associated with treatment-related toxicity, which is particularly severe in patients with a poor performance status. In this paper, we describe the first study to evaluate S-1 monotherapy as an option for advanced gastric cancer patients who are not candidates for combination chemotherapy due to poor clinical condition. Fifty-two patients with Eastern Cooperative Oncology Group (ECOG) performance scale 2-3, whose general condition had made use of combination chemotherapy impossible, were enrolled. S-1 was administered to 30 patients as second- or third-line therapy. The initial dose of S-1 was 35 mg m(-2), administered b.i.d for 14 days every 3 weeks. With a median follow-up period of 33 weeks, the median progression-free survival, and overall survival were 11 weeks (95% CI, 8-14) and 33 weeks (95% CI, 19-47), respectively. The overall 1-year survival rate was 29% by intent-to-treat analysis. The overall response rate was 12% (95% CI, 3-21), and the percentage of stable disease was 35%, resulting in the disease control rate of 47% (95% CI, 32-60). Significant drug-related toxicity included grade 3 diarrhoea (14%), anorexia (14%), fatigue (10%), neutropenia (10%), and leucopenia (6%). In conclusion, this study indicated the modest activity of S-1 in gastric cancer patients with poor performance status.

Lack of carcinogenicity of lyophilized Agaricus blazei Murill in a F344 rat two year bioassay

The Brazilian mushroom Agaricus blazei Murill has antimutagenic, antioxidant, immunostimulatory and antitumorigenic activities, and is increasingly consumed as a health food worldwide. We undertook the present study to evaluate the chronic toxicity and oncogenicity of A. blazei Murill in F344 rats. To establish a no-observed-adverse-effect level (NOAEL), four treatment groups of 100 rats each (50 males and 50 females) were fed a powder diet containing lyophilized A. blazei aqueous extract at 0, 6250, 12,500, and 25,000 ppm for up to 2 years. During this period, there was no remarkable change in mean body weight, body weight gain, hematologic or serum chemistry parameters, or absolute or relative organ weights in control or treatment groups. Mortality in male treatment groups (26%, 16%, and 30%), however, was significantly lower than in controls (48%). Histopathological studies showed no increased incidence of tumors in any treatment group, and total tumor incidence across all groups was comparable to historical data. In conclusion, an A. blazei Murill lyophilized powder diet even at 25,000 ppm (1176 mg/kgb x w x /day for male rats and 1518 mg/kgb.w./day for female rats) resulted in no remarkable carcinogenic effects in F344 rats over a 2-year period. Therefore, the dietary NOAEL is 25,000 ppm.

Metabolic syndrome is more associated with intracranial atherosclerosis than extracranial atherosclerosis

To elucidate the relationship between metabolic syndrome (MetS) and cerebrovascular stenosis, we performed comparative studies of MetS and its components between ischemic stroke patients with intra- and extracranial atherostenosis. We evaluated 378 acute ischemic stroke patients who underwent brain magnetic resonance (MR) imaging and MR angiography. Stenosis was diagnosed in cases showing a degree of luminal narrowing of > or = 50%. The stroke subtypes were categorized as large artery atherosclerosis (LAA), small artery occlusion (SAO), cardioembolism (CE), and stroke of undetermined etiology (SUE). MetS was defined using the criteria of the Adult Treatment Panel III. The mean carotid intimal medial thickness values showed increased tendency as the number of MetS components increased (P < 0.001). Regardless of stroke subtype, the MetS (+) group showed an increasing tendency toward stenosis (LAA, SAO, all P < 0.001; CE, P = 0.001; SUE, P = 0.077). MetS was independently associated with intracranial atherosclerosis (odds ratio, 3.58; 95% CI, 2.28-5.63), which was prominent with more severe MetS components after adjustment for other risk factors (P < 0.001). Amongst the component conditions, elevated blood pressure, increased blood glucose/hyperglycemia, and abdominal obesity were dominantly associated with stenosis (all P < 0.001). Modifications of the individual MetS components need to be considered for stroke prevention because of intracranial atherogenic progression.

A phase II trial of S-1 monotherapy in metastatic colorectal cancer after failure of irinotecan- and oxaliplatin-containing regimens

This is the first phase II study of S-1 monotherapy for patients with metastatic colorectal cancer after failure of both irinotecan- and oxaliplatin-containing regimens. The initial dose of S-1 was 35 mg m⁻², administered twice daily for 14 days every 3 weeks. Treatment was repeated until the occurrence of disease progression. Twenty-eight patients were enrolled. S-1 was administered to 21 patients as third-line therapy and to the remaining seven patients as fourth-line therapy. Of 26 evaluable patients, the overall response rate was 14.3% (95% CI, 0.4–28.1), and the disease control rate was 42.9% (95% CI, 23.3–62.4). With a median follow-up period of 227 days, median time to progression and overall survival duration were 91 and 414 days, respectively. The 1-year survival rate of all patients was 60.7%. There was no grade 4 toxicity. Grade 3 haematological toxicities were documented only in two patients. In conclusion, S-1 shows potential as a salvage regimen in heavily pretreated colorectal cancer patients. The twice-daily dose of 35 mg m⁻² was well tolerated and can be used in designing further combination chemotherapy.

Irofulven as first line therapy in recurrent or metastatic gastric cancer: a phase II multicenter study by the Cancer Therapeutics Research Group (CTRG)

BACKGROUND

The purpose of this study was to evaluate the tolerability and efficacy of irofulven, a DNA interacting acylfulvene analog, as first line therapy for patients with recurrent or metastatic gastric cancer.

PATIENTS AND METHODS

Twenty-three patients with recurrent or metastatic gastric cancer received irofulven at a dose of 0.45 mg/kg administered intravenously over 30-min infusion (up to a maximum of 50 mg), on days 1 and 8, every 3 weeks.

RESULTS

The median number of cycles delivered per patient was 2 (range 1-6). Two patients (9%) had >or= 1-week delay in administration of subsequent cycle of chemotherapy. For the day 8 chemotherapy, dose reductions were required in seven patients (30%); dose omitting occurred in five patients (22%). Grade 3/4 anemia and neutropenia occurred in 22 and 17% of patients, respectively. There was no grade 4 thrombocytopenia and no neutropenic fever was observed. Of the 20 evaluable patients, there were no responses observed, 3 patients had stable disease after 2 cycles of treatment which was not confirmed by a further assessment. Median overall survival was 6.05 months (95% CI 4.55-9.39).

CONCLUSIONS

Irofulven was tolerated at the dose of 0.45 mg/kg on days 1 and 8, every 3 weeks but showed no evidence of antitumor activity in patients with advanced gastric cancer.

Rotational vertebral artery syndrome: oculographic analysis of nystagmus

In four patients with rotational vertebral artery syndrome (RVAS), the initial nystagmus was mostly downbeat, with the horizontal and torsional components beating toward the compressed vertebral artery side (n = 3) or directed away (n = 1). Three patients showed spontaneous reversal of the nystagmus and two exhibited no or markedly diminished responses on immediate retrial of head rotation (habituation). The patterns of nystagmus suggest that RVAS may result from differing mechanisms.

Medial medullary infarction: abnormal ocular motor findings

In 20 consecutive patients with isolated medial medullary infarction, abnormal ocular motor findings included nystagmus (n = 8), ocular contrapulsion (n = 5), and contralesional ocular tilt reaction (n = 2). The nystagmus was ipsilesional (n = 4), gaze-evoked (n = 5), upbeating (n = 4), and hemiseesaw (n = 1). The ocular motor abnormalities may be explained by involvements of the nucleus prepositus hypoglossi, medial longitudinal fasciculus or efferent fibers from the vestibular nuclei, climbing fibers, and cells of the paramedian tracts.

Different role of functional domains of hTR in DNA binding to telomere and telomerase reconstruction

Even if template sequence of hTR played an essential role in telomere binding, a 326 nucleotide fragment of hTR containing template, pseudoknot, and CR4-5 domains is critical for both binding with telomeric DNA and reconstitution of telomerase activity. A functional study with antisense oligonucleotides suggested that targeted disruption of the template region efficiently abrogated both telomeric DNA binding and telomerase activity, whereas disruption of the CR4-5 region induced only loss of telomerase activity. hTR interacts with telomeric DNA via structural region composed of the template, pseudoknot, and CR4-5 domains, however, each structural domain plays a distinct role in telomere binding and telomerase activity reconstitution.

Left ventricular hypertrophy is associated with cerebral microbleeds in hypertensive patients

BACKGROUND

Cerebral microbleeds (CMBs) are indicative of hemorrhage-prone microangiopathy and known to be closely associated with chronic hypertension. However, no studies have been undertaken on the association between left ventricular (LV) hypertrophy and the severity of CMB.

METHODS

One hundred two consecutive stroke patients with hypertension were examined. CMBs were counted using T2*-weighted gradient echo MRI data. With use of ordinal logistic regression analysis, the associations between LV mass index and other vascular risk factors and CMBs were analyzed.

RESULTS

Hypertensive patients with CMBs showed a higher LV mass index than patients without. The grades of LV mass index were significantly correlated with the grades of CMB in the whole brain (p = 0.02), in the central gray matter (p < 0.01), and in the infratentorial area (p < 0.01), but not with those in the subcortical white matter. Ordinal regression analysis revealed that the LV mass index was independently associated with increased CMB severity (p = 0.01), regionally in the central gray matter (p < 0.01) and in the infratentorial area (p < 0.01), but not in the subcortical white matter (p = 0.63). After excluding patients with cerebral amyloid angiopathy, the association between the LV mass index and the CMB severity in the subcortical white matter became significant (p < 0.01).

CONCLUSIONS

There is a close relationship between CMBs and LV hypertrophy in hypertensive patients with stroke. Thus, CMBs should be understood as one type of cerebral target organ damage by chronic hypertension.

Comparative analysis of the spatial distribution and severity of cerebral microbleeds and old lacunes

BACKGROUND

Cerebral microbleeds, which result from microangiopathic changes following chronic hypertension, may reflect bleeding-prone microangiopathy. However, the distribution of these lesions has not been compared with that of lacunes, which represent occlusive type microangiopathy.

OBJECTIVES

To compare the cerebral distribution of microbleeds and lacunes and correlate their severity.

METHODS

The study population comprised 129 hypertensive patients who underwent brain magnetic resonance imaging (MRI), including gradient echo (GE) sequences. Cerebral microbleeds were counted using GE-MRI data, and lacunes were also counted by comparing T1 and T2 weighted MRI. To investigate the distributions, the number of patients with each type of lesion was compared, and the occurrence index (the total number of the specific lesions divided by the total number of patients) was examined statistically. Correlation analyses were done on the relations between the different grades of microbleeds, lacunes, and leukoaraiosis.

RESULTS

Cerebral microbleeds and lacunes were found at various foci in the brain, with a preference for the cortico-subcortical region and the deep grey matter. The occurrence index of microbleeds, but not of lacunes, was significantly higher in the cortico-subcortical region than in the deep grey matter. The severity of the microbleeds was positively correlated with the severity of lacunes, and both types of lesion were closely correlated with the degree of leukoaraiosis.

CONCLUSIONS

These data suggest that microbleeds and lacunes tend to occur to a similar extent in long standing hypertension, but not necessarily in the same locations.

Cerebral microbleeds are regionally associated with intracerebral hemorrhage

BACKGROUND

Cerebral microbleeds (CMB) may be indicative of a hemorrhage-prone microangiopathy.

OBJECTIVE

To determine if increased numbers of these lesions are predictive of intracerebral hemorrhage (ICH), especially in terms of a distributional association.

METHODS

The authors examined consecutively 227 patients with acute stroke. CMB were counted using T2*-weighted gradient echo MRI data, and old lacunes and leukoaraiosis were also evaluated. The associations between the vascular risk factors and ICH were analyzed. With use of multivariate logistic regression analysis, the locations of the CMB or the old lacunes, which were categorized as being in the corticosubcortical area, the deep gray matter area, or the infratentorial area, were examined with regard to their relationships to the locations of the ICH.

RESULTS

The degrees of the CMB (r = 0.43, p < 0.01) and leukoaraiosis (r = 0.20, p < 0.01) were well correlated with the presence of ICH. Multivariate analysis revealed that the grades of the CMB were associated with the presence of ICH (p < 0.01, odds ratio [OR] = 2.67). CMB in the corticosubcortical area (p < 0.01, OR = 5.50) or deep gray matter (p < 0.01, OR = 2.55) were strongly associated with the presence of ICH in the same area, but no such association was observed in the case of CMB in the infratentorial area or in the case of old lacunes in any area.

CONCLUSIONS

Cerebral microbleeds are strongly associated with the presence of intracerebral hemorrhage, and the distributional associations are also quite strong.

Idiopathic normal pressure hydrocephalus predominantly with prolonged fever and hyponatremia

Described is a patient with hydrocephalus and a gait disorder with associated prolonged fever and hyponatremia. The authors made a diagnosis of normal pressure hydrocephalus (NPH) and performed a ventriculoperitoneal shunt, which improved the gait disturbance, accompanied by resolution of the fever and hyponatremia.

Targeted hsp70.1 disruption increases infarction volume after focal cerebral ischemia in mice

BACKGROUND AND PURPOSE

Heat-shock proteins (HSPs) are highly conserved proteins that are induced by a variety of stresses. HSP70 is a 70-kDa HSP family known to have cytoprotective effects against various insults. The role of HSP70 in cerebral ischemia remains to be elucidated in vivo.

METHODS

To investigate the effect of reduced HSP70 levels on cerebral ischemia, focal cerebral ischemia by intraluminal occlusion of the middle cerebral artery was induced in hsp70.1 knockout mice. The expressions of hsp70.1 and hsp70.3 mRNAs and HSP70 protein were determined, and infarction volumes were measured and compared.

RESULTS

Northern blots confirmed the absence of hsp70.1 mRNA expression in the knockout mice. The mean infarction volume was significantly larger in hsp70.1 knockout mice (92.5+/-8.3 mm(3)) than in the wild-type mice (59.3+/-8.9 mm,(3) P<0.001). Western blots showed increased HSP70 expression in the ischemic hemisphere in both knockout and wild-type mice, but HSP70 expression levels in knockout mice were significantly lower than those in their wild-type littermates. Immunohistochemistry did not show any significant differences between the knockout and wild-type animals and showed increased HSP70 immunoreactivity in the ischemic hemisphere, with predominance in the cerebral cortex, especially in the penumbra.

CONCLUSIONS

Our results suggest that hsp70.1 plays an important role in the early protection of the brain, at least after acute focal cerebral ischemia in mice.

Diffusion-weighted magnetic resonance in cerebral venous thrombosis

BACKGROUND

Cerebral venous thrombosis (CVT) is a cause of stroke with obscure pathophysiologic properties that differ from arterial stroke. Its main mechanisms of pathophysiology are the breakdown of the blood-brain barrier and the coexistence of cytotoxic and vasogenic edema. However, conventional magnetic resonance imaging (MRI) cannot differentiate between vasogenic and cytotoxic edema.

OBJECTIVES

To describe the diffusion-weighted imaging (DWI) findings and characterize the clinical applications of DWI in CVT.

SETTING

A tertiary referral center, neurology department.

DESIGN AND METHODS

From November 1998 to March 2001, 14 patients (5 men, 9 women; mean age, 43 +/- 10 years) with CVT underwent DWI, conventional MRI, MR venography, or conventional cerebral angiography. Abnormal findings on DWI and conventional MRI indicated the necessity of MR venography and conventional angiography to confirm the diagnosis of CVT. Apparent diffusion coefficient (ADC) values were measured in all of the abnormal lesions with visual inspection of DWI and T2-weighted echo planar imaging.

RESULTS

Findings on DWI were grouped according to 3 patterns: (1) Heterogeneous signal intensity (SI) (10 patients) showed mixed bright high SI and low SI and the corresponding ADC values were inversely correlated to the DWI SI. The areas of prominent low SI on DWI were reversed with adequate treatment on follow-up MRI in 1 patient. (2) Multifocal high SI (3 patients) was similar to that observed in acute arterial stroke. The corresponding ADC values were decreased and DWI was performed in the acute stages. (3) Intravascular clot with high SI was found with (1 patient, also in heterogeneous SI group) or without (1 patient) parenchymal lesions. In 1 patient, DWI demonstrated T2-negative and fluid attenuated inversion recovery-negative lesions without correlative symptoms.

CONCLUSIONS

These data suggest that DWI with ADC maps can be used to discriminate between types of edema for tissue viability and to provide information about stages and diagnostic clues in CVT.

Squamous cell carcinoma of the cornea

In this paper, a case of corneal squamous cell carcinoma is reported. Invasive squamous cell carcinoma of the cornea is a rare disorder and has not been previously described in the Korean literature. In this case, the invasive squamous cell carcinoma of the cornea was treated by complete excision and cryotherapy. No evidence of metastasis or recurrence has been found since the procedure. Complete excision and adjunctive cryotherapy has become the treatment of choice because of the higher recurrence rate following a simple excision.

Monthly 5-days 5-fluorouracil and low-dose leucovorin for adjuvant chemotherapy in colon cancer

We investigated the dose-related effect of the 5-fluorouracil (5-FU)/leucovorin regimen on survival in 139 colon cancer patients with Dukes' B2 and C2 stage disease. Chemotherapy consisted of 400 mg/m(2) of 5-FU and 20 mg/m(2) of leucovorin injected daily for 5 days in every 4 weeks for a maximum of 12 cycles. The total dose of 5-FU administered per body surface area had a significant effect on the 5-year disease-free survival and 5-year overall survival in stage B2 and C2 colon cancer patients (P=0.0018, P=0.0011). Analysis with reference to the median DSDI demonstrated that there was a significant difference in 5-year survival in Dukes' C2 (P=0.0016), but survival was not affected by the dose intensity. Multivariate analysis demonstrated that only the total dose of 5-FU administered per surface area affected the 5-year disease-free survival and 5-year overall survival (P=0.0016, P=0.0007, respectively). It can be concluded that the total dose of 5-FU administered is important in planned dosage schedule of adjuvant chemotherapy in colon cancer.

Sensory dermatomal representation in the medial lemniscus

BACKGROUND

Restricted sensory deficits along the somatotopic topography of the medial lemniscus rarely develop in medial medullary infarction. We describe a patient with medial medullary infarction who presented with dermatomal sensory deficits caused by a medial lemniscal lesion.

CASE DESCRIPTION

A 58-year-old man presented with sudden right-sided hemiparesis and paresthesia. He had noticed the paresthesia below the level of the right L5 dermatome, where his vibration and position senses were mildly diminished. His paresthesia was more severe over the right calf and foot. Magnetic resonance images of the brain showed an acute small infarct in the medial-ventral portion of the left rostral medulla oblongata. A nerve conduction study and electromyography showed no abnormalities. At follow-up, the patient's motor and sensory deficits had improved considerably.

CONCLUSIONS

The patient showed lemniscal sensory deficits below the right L5 dermatome that were caused by the partial involvement of the medial lemniscus. These findings suggest that lemniscal sensory dermatomal representation is preserved at least up to the level of the medulla oblongata.

Cerebral venous thrombosis associated with tentorial subdural hematoma during oxymetholone therapy

Androgen was reported to cause cerebral venous thrombosis (CVT) during replacement therapy for aplastic anemia. Oxymetholone, a synthetic androgen analogue, has been widely used in the treatment of aplastic anemia. A 40-year-old woman with aplastic anemia visited our hospital because of severe headache, nausea, vomiting, blurred vision and diplopia for a period of 1 month. She had taken oxymetholone for 2 years. Neurological examination revealed bilateral papilledema and bilateral sixth nerve palsies. Brain magnetic resonance imaging (MRI), performed at the time of admission, demonstrated left-sided tentorial SDH, and focal cerebral thrombosis of the left superficial sylvian vein and sigmoid sinus. MR venography revealed multiple irregularities in the superior sagittal sinus and left transverse sinus. CVT with tentorial subdural hematoma (SDH) caused by oxymetholone was strongly suggested. Oxymetholone was immediately discontinued, and her symptoms and signs disappeared. Because of the thrombocytopenia, anticoagulation was not started. She was discharged and visited the outpatient clinic without neurological symptoms for 6 months. This report supports the cautions given about the risk of CVT with oxymetholone supplementation in aplastic anemia. To the best of our knowledge, this is the first report of CVT associated with tentorial SDH that was probably caused by oxymetholone.

Early postoperative intraperitoneal chemotherapy with mitomycin C, 5-fluorouracil and cisplatin for advanced gastric cancer

OBJECTIVE

The long-term survival of patients who undergo surgery for stage IV gastric cancer is poor, due to metastatic spread of the tumor. Intraperitoneal chemotherapy (IPT) as a possible treatment for peritoneal dissemination has been investigated in a number of different tumors. The aim of this study was to investigate the toxicity and impact of early postoperative IPT on the survival of patients with advanced gastric cancer.

METHODS

Between 1993 and 1997, a total of 91 patients with stage IV gastric cancer who underwent potentially curative or palliative resection received intraperitoneal mitomycin C before closure of the abdominal wound. 5-Fluorouracil and cisplatin were administered intraperitoneally on postoperative days 1-4, and this was repeated at 4-week intervals.

RESULTS

All patients received a median of 3 IPT perfusions. There were 24 (26.4%) postoperative complications and 1 (1.1%) mortality. The most frequent hematologic toxicity (grade 3-4) was leukopenia. The major nonhematologic toxicities (grade 3-4) were emesis and nephrotoxicity. After a median follow-up period of 26 months, 14 patients remain alive without evidence of recurrence, whereas 75 patients died due to recurrence or progression of disease. The median survival period for all 91 patients was 15.4 months. When survival according to the residual tumor was analyzed, median survival was 36.0 months in the R0 (curative resection) group, 20.6 months in the R1 group (margins of resected specimens showing microscopic residual tumor or diameter of each residual tumor less than 3 mm) and 9.0 months in the R2 group (macroscopic residual tumor larger than 3 mm) (p < 0.001).

CONCLUSIONS

IPT was found to be safe, and it appears to improve the prognosis in patients with minimal residual tumors. However, complete cytoreductive surgery is mandatory for achieving the beneficial effect of IPT.

Intravenous 5-fluorouracil versus oral doxifluridine as preoperative concurrent chemoradiation for locally advanced rectal cancer: prospective randomized trials

BACKGROUND

Preoperative radiation treatment with concomitant intravenous infusion of 5-fluorouracil (5-FU) is known to be effective in shrinking and downstaging of tumors. However, chemotherapy has often been limited by its toxicity and poor patient compliance. Oral 5-FU is known to have several advantages over conventional intravenous 5-FU infusion such as lower toxicity and higher quality of life without compromising the efficacy of the treatment. The aim of this study was to compare intravenous 5-FU with oral doxifluridine with respect to tumor response, toxicity and quality of life.

METHODS

Twenty-eight patients with rectal cancer, staged as over T3N1 or T4 by transrectal ultrasonography between July 1997 and December 1998, were included in this study. Intravenous 5-FU (450 mg/m2) and leucovorin (20 mg/m2) were given for five consecutive days during the first and fifth weeks of radiation therapy (50.4 Gy) (n = 14). Oral doxifluridine (700 mg/m2/day) and leucovorin (20 mg/m2) were given daily during radiation treatment (n = 14). Quality of life was scored according to 22 activity items (good, >77; fair, >58; poor, <57). Surgical resection was performed 4 weeks after completion of concurrent chemoradiation treatment. Tumor response was classified into CR (complete remission), PR (partial response; 50% diminution of tumor volume or downstaging ) and NR (no response).

RESULTS

Tumor response was CR 3/14 (21.4%), PR 7/14 (50%) and NR 4/14 (28.6%) in the IV arm versus CR 2/14 (14.2%), PR 6/14 (42.9%) and NR 6/14 (42.9%) in the Oral arm (p = 0.16, 0.23, 0.24), respectively. The quality of life was poor (36.4% versus 33.3%), fair and good (63.6% versus 66.7%) between the IV arm and Oral arm, respectively. Gastrointestinal toxicity was 2/14 (14.3%) in the IV arm versus 5/14 (35.7%) in the Oral arm, respectively. Stomatitis was only observed in the IV arm (1/14, 7.1%). Hematological toxicity was 3/14 (21.4%) in the IV arm versus 4/14 (28.5%) in the Oral arm, respectively. Systemic recurrence during the follow-up periods were 1/14 (7.1%) in the IV arm and 2/14 (14.3%) in the Oral arm, respectively (p = 0.307). One local recurrence was observed in the Oral arm.

CONCLUSION

Even though the results were not entirely reliable owing to the small number of patients enrolled, oral doxifluridine-based chemotherapy as preoperative chemoradiation for advanced rectal cancer did not show any significant advantages over intravenous infusion.

Intracranial cerebral artery disease as a risk factor for central nervous system complications of coronary artery bypass graft surgery

BACKGROUND AND PURPOSE

Although extracranial carotid artery disease (ECAD) is accepted as a risk factor for central nervous system (CNS) complications after coronary artery bypass graft (CABG) surgery, it remains to be clarified whether intracranial cerebral artery disease (ICAD) may also increase the risk. We conducted a prospective study to elucidate the relation between ICAD and CNS complications after CABG surgery.

METHODS

We prospectively studied 201 patients undergoing nonemergency isolated CABG surgery during a 39-month period (from March 1995 to June 1998). Each patient was evaluated before surgery with neurological examination, transcranial Doppler, and carotid duplex ultrasonography. Magnetic resonance angiography was used to determine the presence and severity of ECAD and ICAD in patients with abnormal findings on clinical examination, carotid duplex ultrasonography, or transcranial Doppler. Patients were followed after surgery and evaluated for the development of CNS complications. Association between CNS complications and their potential predictors was analyzed.

RESULTS

One hundred nine patients (54.2%) were found to have ECAD and/or ICAD. ECAD alone was found in 48 patients (23.9%), ICAD alone in 33 (16.4%), and both ECAD and ICAD in 28 (13.9%). Fifty-one patients (25.4%) had single or multiple CNS complications: 23 (11.4%) had delirium; 18 (9.0%) had hypoxic-metabolic encephalopathy; 7 (3.5%) had stroke; and 7 (3. 5%) had seizure. In multivariate analysis, ICAD was found to have an independent association with the development of CNS complications (prevalence OR, 2.28; 95% CI, 1.04 to 5.01) after controlling for covariates including age, occurrence of intraoperative events, and reoperation. The joint effect of ECAD and ICAD was also statistically significant and stronger than ICAD alone (prevalence OR, 3.87; 95% CI, 1.80 to 6.52).

CONCLUSIONS

Our results suggest that ICAD may be an independent risk factor for CNS complications after CABG surgery. These results support pre-CABG evaluation of the intracranial arteries for the risk assessment of CABG surgery, at least in black and Asian patients, in whom there may be a higher prevalence of intracranial arterial stenosis.

Scrub typhus encephalomyelitis with prominent focal neurologic signs

BACKGROUND

Encephalomyelitis with prominent focal neurologic signs and associated neuroradiologic abnormalities has not been previously described in scrub typhus.

CASE DESCRIPTION

A 22-year-old woman was admitted because of fever and an altered mental state. Neurologic examination revealed bilateral sixth and seventh nerve palsies, bilateral gaze evoked nystagmus, anarthria, dysphagia, quadriparesis, and sensory level at T1. Serum and cerebrospinal fluid samples were positive for tsutsugamushi antibody. The patient's magnetic resonance images demonstrated the lesions responsible for the neurologic dysfunctions: in the lower brainstem, cerebellar peduncles, and spinal cord. It was interesting that the gray matter of the spinal cord was predominantly involved.

CONCLUSIONS

The recognition of unusual manifestations and the clinical suspicion of this treatment-responsive disease may be important, particularly in the face of increasing international and intranational travel.

Neuroprotective effect of low dose riluzole in gerbil model of transient global ischemia

Riluzole is a neuroprotective agent the efficacy of which was proven in amyotrophic lateral sclerosis in human and in animal models of cerebral ischemia. However, the dosage used in animal experiments was much higher than that in human. We investigated the efficacy of low dose riluzole, which was similar to the dose used in human trials, in animal model of global ischemia. Global ischemia was induced in male Mongolian gerbils for 5min under monitoring of rectal temperature. Riluzole (0.8 mg/kg) were injected intraperitoneally 30min before ischemia. Seven days after ischemia, animals were decapitated and surviving nerve cells in hippocampal CA1 area were quantified. The number of surviving cells was compared between in riluzole-treated and control groups and the former showed statistically significant better survivals than the latter (P<0.001).

Diffusion-weighted imaging in Wallerian degeneration

We report two patients displaying hyperintensities on diffusion-weighted imaging (DWI) in the area of Wallerian degeneration (WD) at 12 days after stroke. High signal intensities were more conspicuous on DWI than on T2-weighted images. Both patients showed decreased diffusion anisotropy resulting in elevated apparent diffusion coefficient in the area of WD. These patients illustrate that DWI may be useful in the detection of the early stage of WD.

Tissue urokinase-type plasminogen activator receptor levels in breast cancer

Cancer invasion is induced by several proteolytic enzyme systems associated with the destruction of basement membrane and extracellular matrix. Urokinase-type plasminogen activator (uPA) and plasminogen activator inhibitor-1 (PAI-1) have been reported as prognostic factors in breast cancer patients and plasminogen activation is regulated by various factors such as uPAR and growth factors. Thus, we examined the tissue levels of urokinase-type plasminogen activator receptor (uPAR) in breast cancer patients. Tissue uPAR levels were measured by ELISA assay in 268 breast cancer patients. The median and mean values of tissue uPAR level in breast cancer were 3.5 ng/mg cytosol protein and 4.8+/-3.6 ng/mg cytosol protein, respectively. Tissue uPAR level was the highest in T1 stage, but there was no statistical significance between the T stages (p>0.05), nor in nodal stage, in the value of uPAR according to progression. And the value of uPAR expression was not associated with estrogen and progesterone receptor status, number of involved node and percent of node involvement. In TNM stage, tissue uPAR levels were higher in patients with stage I-II than in patients with stage III-IV (p=0.027). In univariate analysis, nodal factor (p=0.002) and TNM stage (p=0.0004) were significant. But, multivariate analysis showed that TNM stage was the only significant prognostic factor (p=0.0002). These results suggest that uPAR is mainly associated with initial tumor invasion and other factors might be involved in later stages of cancer progression.

Transduction effect of antisense K-ras on malignant phenotypes in gastric cancer cells

The antitumoral effects of antisense RNA to K-ras were investigated in gastric cancer cell lines by examining the level of K-ras expression and the tumorigenicity in vitro and in vivo. Polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP), DNA sequencing, and immunoblotting analysis revealed that YCC-1 gastric cancer cells overexpressed wild type K-ras, whereas YCC-2 cells had a homozygous mutation in codon 12 from GGT (glycine) to AGT (serine), while SNU-1 cells had a heterozygous mutation to GAT (asparagine) in the identical position. Both YCC-1 and YCC-2 cells were transduced by LNC-AS/K-ras containing the antisense 2.2 kb genomic K-ras DNA fragment covering exon 2 and exon 3 specific for K-ras. The application of antisense K-ras significantly downregulated the expression of K-ras and had no influence on the expression of either H-ras or N-ras. The antisense-transduced YCC-2 cells grew considerably slower than the control group transduced by LNCX, whereas the growth inhibition of antisense-transduced YCC-1 cells was less prominent than that of transduced YCC-2 cells. In addition, the tumorigenicity of YCC-2 cells transduced by LNC-AS/K-ras was totally lost. Therefore, our results imply that the specific inhibition of K-ras p21 protein can be accomplished by introducing the antisense covering the K-ras- specific region to gastric cancer cells with aberrant K-ras expression, resulting in a reduction of the growth rate and suppression of tumorigenicity.

Acute bilateral cerebellar infarcts in the territory of posterior inferior cerebellar artery

The authors report 12 patients with acute bilateral cerebellar infarcts in posterior inferior cerebellar artery (PICA) territory. They found three topographic patterns: A) bilateral medial PICA in six patients; B) unilateral whole + contralateral medial PICA in four; and C) bilateral small multiple in two. Nine patients in Groups A and B had unilateral PICA or vertebral artery disease, and both patients in Group C had bilateral vertebral artery disease. These findings support that unilateral supply to both medial PICA territories may be the most relevant pathogenesis of this syndrome.

Combined peripheral facial and abducens nerve palsy caused by caudal tegmental pontine infarction

Isolated peripheral facial and abducens nerve palsy could theoretically be caused by a caudal pontine infarction, but as far as we know, there has been no published case history which has demonstrated this point. We describe the cases of two hypertensive patients who showed combined peripheral facial and abducens nerve palsy without other neurologic symptoms or signs. Other than hypertension, there was no identifiable etiology. Magnetic resonance imaging demonstrated compatible isolated ipsilateral ischemic infarction of the caudal tegmental pons. The present cases indicate that a well-placed small pontine infarction can cause isolated peripheral facial and abducens nerve palsy.

Hypoglycemia-induced cerebellar dysfunction and quantitative positron emission tomography study

OBJECTIVE

To describe an unusual case of hypoglycemia-induced bilateral cerebellar dysfunction.

BACKGROUND

The cerebellum is known to be resistant to hypoglycemia, and selective cerebellar dysfunction caused by hypoglycemia has not been reported. Previous studies showed that the ratio between the rate constants for glucose uptake and phosphorylation (K1 and k3) is reversed in the cerebellum compared with the cerebral cortex; higher K1 in the cerebellum and higher k3 in the cerebral cortex.

METHODS

Quantitative dynamic PET scanning with labeled fluorodeoxyglucose (18F-FDG) was performed to prove altered glucose kinetics in the cerebellum of a patient who presented with episodic cerebellar dysfunction associated with hypoglycemia. Four control subjects underwent the same study.

RESULTS

The ratio between K1 and k3 was not reversed in the cerebellum of our patient (K1 = 0.082, k3 = 0.192). On the contrary, the ratio was reversed in the control subjects (mean K1 = 0.109, mean k3 = 0.080). In addition, the patient's cerebellar metabolic rate of glucose (rCMRglu = 27.9 micromol/100 g/minute) and the rate constant of glucose egress (k2 = 0.543) were relatively increased compared with those of control subjects (mean rCMRglu = 21.9 micromol/100 g/minute, mean k2 = 0.352).

CONCLUSIONS

In a case of episodic bilateral cerebellar dysfunction caused by hypoglycemia, quantitative dynamic PET study demonstrated decreased glucose uptake-to-utilization ratio and increased leak of glucose in the cerebellum. The cerebellum is not invariably resistant to hypoglycemia.