Prolonged lifespan in a spontaneously hypertensive rat (stroke prone) model following intravenous infusion of mesenchymal stem cells

Intravenous infusion of mesenchymal stem cells (MSCs) has been reported to provide therapeutic efficacy via microvascular remodeling in a spontaneously hypertensive rat. In this study, we demonstrate that intravenous infusion of MSCs increased the survival rate in a spontaneously hypertensive (stroke prone) rat model in which organs including kidney, brain, heart and liver are damaged during aging due to spontaneous hypertension. Gene expression analysis indicated that infused MSCs activates transforming growth factor-β1-smad3/forkhead box O1 signaling pathway. Renal dysfunction was recovered after MSC infusion. Collectively, intravenous infusion of MSC may extend lifespan in this model system.

Prediction model for 3-year rupture risk of unruptured cerebral aneurysms in Japanese patients

OBJECTIVE

To build a prediction model that estimates the 3-year rupture risk of unruptured saccular cerebral aneurysms.

METHODS

Survival analysis was done using each aneurysm as the unit for analysis. Derivation data were from the Unruptured Cerebral Aneurysm Study (UCAS) in Japan. It consists of patients with unruptured cerebral aneurysms enrolled between 2000 and 2004 at neurosurgical departments at tertiary care hospitals in Japan. The model was presented as a scoring system, and aneurysms were classified into 4 risk grades by predicted 3-year rupture risk: I, < 1%; II, 1 to 3%; III, 3 to 9%, and IV, >9%. The discrimination property and calibration plot of the model were evaluated with external validation data. They were a combination of 3 Japanese cohort studies: UCAS II, the Small Unruptured Intracranial Aneurysm Verification study, and the study at Jikei University School of Medicine.

RESULTS

The derivation data include 6,606 unruptured cerebral aneurysms in 5,651 patients. During the 11,482 aneurysm-year follow-up period, 107 ruptures were observed. The predictors chosen for the scoring system were patient age, sex, and hypertension, along with aneurysm size, location, and the presence of a daughter sac. The 3-year risk of rupture ranged from <1% to >15% depending on the individual characteristics of patients and aneurysms. External validation indicated good discrimination and calibration properties.

INTERPRETATION

A simple scoring system that only needs easily available patient and aneurysmal information was constructed. This can be used in clinical decision making regarding management of unruptured cerebral aneurysms.

The natural course of unruptured cerebral aneurysms in a Japanese cohort

BACKGROUND

The natural history of unruptured cerebral aneurysms has not been clearly defined.

METHODS

From January 2001 through April 2004, we enrolled patients with newly identified, unruptured cerebral aneurysms in Japan. Information on the rupture of aneurysms, deaths, and the results of periodic follow-up examinations were recorded. We included 5720 patients 20 years of age or older (mean age, 62.5 years; 68% women) who had saccular aneurysms that were 3 mm or more in the largest dimension and who initially presented with no more than a slight disability.

RESULTS

Of the 6697 aneurysms studied, 91% were discovered incidentally. Most aneurysms were in the middle cerebral arteries (36%) and the internal carotid arteries (34%). The mean (±SD) size of the aneurysms was 5.7±3.6 mm. During a follow-up period that included 11,660 aneurysm-years, ruptures were documented in 111 patients, with an annual rate of rupture of 0.95% (95% confidence interval [CI], 0.79 to 1.15). The risk of rupture increased with increasing size of the aneurysm. With aneurysms that were 3 to 4 mm in size as the reference, the hazard ratios for size categories were as follows: 5 to 6 mm, 1.13 (95% CI, 0.58 to 2.22); 7 to 9 mm, 3.35 (95% CI, 1.87 to 6.00); 10 to 24 mm, 9.09 (95% CI, 5.25 to 15.74); and 25 mm or larger, 76.26 (95% CI, 32.76 to 177.54). As compared with aneurysms in the middle cerebral arteries, those in the posterior and anterior communicating arteries were more likely to rupture (hazard ratio, 1.90 [95% CI, 1.12 to 3.21] and 2.02 [95% CI, 1.13 to 3.58], respectively). Aneurysms with a daughter sac (an irregular protrusion of the wall of the aneurysm) were also more likely to rupture (hazard ratio, 1.63; 95% CI, 1.08 to 2.48).

CONCLUSIONS

This study showed that the natural course of unruptured cerebral aneurysms varies according to the size, location, and shape of the aneurysm. (Funded by the Ministry of Health, Labor, and Welfare in Japan and others; UCAS Japan UMIN-CTR number, C000000418.).

Internal trapping following proximal clipping for a ruptured partially thrombosed giant aneurysm of the vertebral artery--case report

A 52-year-old woman presented with a partially thrombosed giant aneurysm of the vertebral artery (VA) manifesting as a 3-month history of left hemiparesis. She developed subarachnoid hemorrhage during hospitalization and underwent emergency surgery for surgical proximal clipping and ventricular drainage with decompressive suboccipital craniectomy. She underwent additional surgery for endovascular coil embolization of the aneurysm and the affected distal VA on the 7th postoperative day. Although she suffered transient lower cranial nerve pareses and respiratory failure, her neurological condition improved gradually and she returned home with only slight ataxia and hoarseness 3 months after surgery. Magnetic resonance imaging obtained 28 months postoperatively revealed a remarkable decrease in the size of the aneurysm as well as reduction of the mass effect on the brainstem. Combined proximal clipping and internal trapping can solve the problems associated with treatment of giant aneurysms of VA by either direct surgery or endovascular surgery, and should be considered as a therapeutic option for giant aneurysms of the VA.

Reversible diffusion-weighted imaging changes in the splenium of the corpus callosum and internal capsule associated with hypoglycemia - case report -

A 63-year-old man presented with hypoglycemia-induced hemiparesis manifesting as diffusion-weighted magnetic resonance (MR) imaging changes in the splenium of the corpus callosum and internal capsule which disappeared after glucose administration. Clinicians should be aware that hypoglycemia can cause reversible splenium abnormalities on MR imaging, although the underlying mechanism still remains unclear, as this may be helpful in the differential diagnosis of hypoglycemia-induced hemiparesis and stroke.

Alteplase at 0.6 mg/kg for Acute Ischemic Stroke Within 3 Hours of Onset

BACKGROUND AND PURPOSE

Based on previous studies comparing different recombinant tissue plasminogen activator (rt-PA) doses, we performed a clinical trial with 0.6 mg/kg, which is lower than the internationally approved dosage of 0.9 mg/kg, aiming to assess the efficacy and safety of alteplase in acute ischemic stroke for the Japanese.

METHODS

Our prospective, multicenter, single-arm, open-label trial was designed with a target sample size of 100 patients. The primary end points were the proportion of patients with a modified Rankin Scale (mRS) score of 0 to 1 at 3 months and the incidence of symptomatic intracranial hemorrhage (sICH) within 36 hours. Thresholds for these end points were determined by calculating 90% CIs of weighted averages derived from published reports. The protocol was defined according to the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA stroke study with slight modifications.

RESULTS

Among the 103 patients enrolled, 38 had an mRS of 0 to 1 at 3 months; this proportion (36.9%) exceeded the predetermined threshold of 33.9%. sICH within 36 hours occurred in 6 patients; this incidence (5.8%) was lower than the threshold of 9.6%.

CONCLUSIONS

In patients receiving 0.6 mg/kg alteplase, the outcome and the incidence of sICH were comparable to published data for 0.9 mg/kg. These findings indicate that alteplase, when administered at 0.6 mg/kg to Japanese patients, might offer a clinical efficacy and safety that are compatible with data reported in North America and the European Union for a 0.9 mg/kg dose.

Significant Improvement of Visual Functions after Removal of an Intracranial Giant Optic Nerve Glioma Revealing Exophytic Growth: Case Report

OBJECTIVE AND IMPORTANCE:

Intracranial giant optic nerve gliomas, usually presumed as optic chiasmatic gliomas, are much less common. The architectural tumor form of optic nerve glioma without neurofibromatosis type 1 is usually the expansile-intraneural pattern. The exophytic optic nerve gliomas without neurofibromatosis type 1 are relatively uncommon. Surgical decompression for intracranial optic gliomas frequently leads to clinical improvement, but obvious improvement of vision is rare. We report a case that demonstrated significant recovery of visual function after removal of the intracranial giant optic nerve glioma, revealing exophytic growth.

CLINICAL PRESENTATION:

A 13-year-old boy presented with visual impairment in both eyes. Magnetic resonance images (MRI) disclosed a 6 cm diameter mass in the suprasellar area. On heavily T2-reversed MRIs, it was obvious that the intracranial portion of right optic nerve was enlarged, and optic tracts were shifted to the left by the tumor. The relationship of the tumor to the chiasma could not be affirmed on MRIs.

INTERVENTION:

A right frontotemporal craniotomy for decompression of the optic apparatus was performed. After the majority of the tumor was resected, it became clear that the tumor originated in the right optic nerve. The tumor exophytically grew and dislocated the optic chiasma and optic tracts. Significant improvement of visual functions began from the first week after surgery and continued gradually thereafter. The histological diagnosis was pilocytic astrocytoma. A follow-up MRI taken 4 years after surgery showed no regrowth of the residual tumor.

CONCLUSION:

Giant exophytic gliomas without neurofibromatosis type 1 may arise from the intracranial portion of an isolated optic nerve. Direct visualization of optic component by heavily T2-reversed MRI could more precisely delineate the relationship of the intracranial optic nerve glioma to the optic apparatus. Surgery may be indicated in giant exophytic intracranial optic nerve gliomas and preoperative postulated optic chiasmatic gliomas. Microsurgical resection can induce postoperative visual improvement without regrowth of the residual tumor.

Surgical management of the recurrence and regrowth of craniopharyngiomas

Object. The authors performed a retrospective analysis of a consecutive series of craniopharyngiomas and their recurrences, which were managed with surgery alone.

Methods. In the past 20 years, 37 consecutive patients with craniopharyngiomas underwent surgery without adjuvant radiotherapy. During that period there was a consistent strategy that surgical management was the first choice of treatment whenever possible.

Of these 37 patients, 11 experienced tumor recurrence (29.7%) during the mean follow-up period of 11.1 years. Of these 11 patients, seven experienced recurrence after neuroimaging-confirmed total removal, and four patients experienced recurrence after partial or incomplete removal. In these 11 patients, surgical removal was performed 17 times. Using a proper surgical approach (mainly a basal interhemispheric approach) and meticulous microsurgical techniques, total removal of the recurrent tumor was achieved in nine surgeries (52.9). The mortality and morbidity rates associated with these 17 surgeries were 0% and 9.1%, respectively. In most cases, visual function was preserved or improved and intellectual performance was also preserved.

Conclusions. Recurrence of craniopharyngioma can be safely managed by using meticulous contemporary microsurgical techniques without additional radiotherapy. The role of surgery and adjuvant radiotherapy for craniopharyngiomas may vary in the future, depending on innovations in treatment and technology. Nevertheless, surgery can be still a major therapeutic option in the management of recurrent craniopharyngiomas.

Risk of rupture associated with intact cerebral aneurysms in the Japanese population: a systematic review of the literature from Japan

Object. Knowing the rate of rupture associated with unruptured cerebral aneurysms (UCAs) can help surgeons determine a case management strategy in patients harboring these lesions. According to large-scale cohort studies involving populations in North America and Europe, small unruptured aneurysms carry a very low risk of rupture. In Japan, however, there have been sporadic reports of higher rates of rupture. To identify the rupture risk associated with UCAs in the Japanese population, the authors systematically reviewed retrospective studies of the natural course of these lesions.

Methods. The authors searched Medline and the Japan Medical Abstract Society Index for reports of UCAs in Japan. Two of the authors verified the eligibility of the reports and extracted data independently. Additional information was directly obtained from the authors of the original reports.

Thirteen reports covering a total of 3801 patient-years fulfilled the criteria for our study. Subsequent rupture was documented in 104 patients and the annual rupture rate was 2.7% (95% confidence interval 2.2–3.3%). Large, posterior-circulation, and symptomatic aneurysms were associated with significantly higher rates of rupture (relative risks 6.4, 2.3, and 2.1, respectively). The risk of rupture determined by the authors' review was significantly higher than that reported by investigators from international cohort studies.

Conclusions. Although a selection bias of patients may be the cause of the higher rupture risk, untreated UCAs that have been followed in Japanese institutions have a considerably high rate of rupture. The natural course of UCAs should be carefully estimated in countries not included in the international studies.

Autologous transplantation of expanded neural precursor cells into the demyelinated monkey spinal cord

The objective of this study was to establish if neural precursor cells could safely be developed from biopsy of the subventricular zone (SVZ) in the non-human primate (marmoset), and to determine their myelinating potential after autologous transplantation into a demyelinated lesion. Small amounts of tissue were safely collected from the subventricular-subependymal zone of the adult primate brain under ultrasonography without any neurological deficit. Neural precursor cells were isolated and expanded in the presence of mitogen in vitro. The dorsal columns of the adult marmoset spinal cord were demyelinated by X-irradiation and intraspinal injections of ethidium bromide in the center of the radiation field. Cell suspensions of the neural precursors were microinjected through a micropipette into the demyelinated lesion site in the spinal cord. Lesions were histologically examined 3 weeks after transplantation. Light and electron microscopic examination of plastic embedded sections revealed a significant number of myelinating profiles in the transplantation zone; no myelination was observed in control lesions. The myelinated axons had predominantly peripheral patterns of myelination. These results demonstrate that autologous transplantation of neural precursor cells in the adult nonhuman primate can remyelinate demyelinated central nervous system (CNS) axons, thus suggesting the potential utility of such an approach in demyelinating lesions in humans.

A therapeutic window for intravenous administration of autologous bone marrow after cerebral ischemia in adult rats

The primary objective of this study was to test the hypothesis that intravenous administration of autologous bone marrow cells could improve functional recovery after middle cerebral artery occlusion (MCAO) for 45 min in the rat and to determine specific time windows for efficacy. Mononuclear cells from autologous bone marrow were transfected with the LacZ reporter gene, and injected intravenously into rats at 3-72 h after induction of MCAO. Histological analysis of the ischemic lesion at 14 days after transplantation revealed reduced ischemic lesion volume. Lesion volume was 250+/-45 mm(3) (n=6) after MCAO without cell transplantation. Lesions were minimally detected by absence of 2,3,5-triphenyltetrazolium chloride (TTC) staining when bone marrow cells were infused 3 h after lesion induction. Lesions were clearly detected beginning with the 6-h postlesion group and became progressively larger at 12, 24 and 72 h (80+/-25, 140+/-18, and 180+/-22 mm(3), respectively; n=6 for each group). Transplanted LacZ(+) bone marrow cells accumulated extensively in and around the ischemic lesions, and immunohistochemistry suggests some neuronal and glial lineage differentiation. Behavioral testing (Morris water maze and Treadmill stress test) indicated greater functional recovery in the treated group. These findings suggest that early intervention with intravenous administration of autologous mononuclear cells from bone marrow can reduce lesion size in the MCAO model in the rat, and improve functional outcome.

Performance of bipolar forceps during coagulation and its dependence on the tip material: a quantitative experimental assay. Technical note

The aim of this study was to measure objectively the adherence of burned tissue to bipolar forceps to evaluate the coagulation performance of forceps made of different types of metals. Coagulation performance of bipolar forceps made of gold, titanium, and stainless steel was determined by comparing the amount of protein in the adhered coagulum on the tips. The amount of adhered coagulum was significantly less on the gold-plated bipolar forceps than on those made of the other two materials. The ease with which coagulum could be removed was compared using the cleaning cycle of an ultrasonic rinsing device. This ease of removal was also significant with the gold-plated forceps. Electron microscopy observations of the surface of the forceps tips revealed a significant difference in roughness among these materials, and there were also significant differences in wetting tensions. Measuring adherence based on three different types of roughness and wetting tensions of forceps made from the same metal (titanium) also demonstrated a significant difference in the cleaning cycle. Histological examination of an artery coagulated with the gold-plated bipolar forceps showed that the structure had been completely collapsed without destruction of the layers, whereas arteries coagulated with the other materials revealed severely damaged structures. Adherence to bipolar forceps was dependent on both the material in the tips and the roughness of this material. The gold-plated bipolar forceps demonstrated the best performance.

Comparative analysis of remyelinating potential of focal and intravenous administration of autologous bone marrow cells into the rat demyelinated spinal cord

The remyelinating potential of autologous bone marrow cells was studied after direct injection and following intravenous injection into rats with a demyelinated lesion in the spinal cord. Both focal and intravenous injections of acutely isolated mononuclear bone marrow cell fractions resulted in varying degrees of remyelination. Suspensions of bone marrow cells collected from the same rat were delivered at varied concentrations (10(2) to 10(5) for direct injection and 10(4) to 10(7) for i.v. injections). The lesions were examined histologically 3 weeks after transplantation. Light microscopic examination revealed remyelination in the dorsal funiculus with both injection protocols, but the extent of remyelination was proportional to the number of injected cells. To attain the same relative density of remyelination achieved by direct injection, intravenous administration of cells required delivery of substantially more cells (two orders of magnitude). However, the availability of autologous bone marrow cells in large number and the potential for systemically delivering cells to target lesion areas without neurosurgical intervention suggest the potential utility of intravenous cell delivery as a prospective therapeutic approach in demyelinating disease.

Hypothermia with heparin-coated circuits and low dose systemic heparinization in neurosurgery

The purpose of this study was to evaluate the safety of profound hypothermic circulatory arrest with heparin-coated circuits and low dose systemic heparinization in the treatment of cerebral aneurysms. Surgery for giant intracranial aneurysms not operable using standard neurosurgical techniques was performed in 8 patients. All patients were placed on cardiopulmonary bypass using the closed-chest technique, except for the first patient who underwent open-chest bypass. Heparin was administered systemically (3,000 IU) and into the circuit (1,500 IU). Total circulatory arrest was begun at 20 degrees C. The D-dimer, alpha2 plasmin inhibitor-plasmin complex, thrombin-antithrombin III, and beta-thromboglobulin concentrations were measured to evaluate the changes in the coagulation and fibrinolytic systems during bypass. There were no neurologic or cardiac complications. None of the indicators of platelet activation, coagulation, or fibrinolysis were elevated. Hypothermic circulatory arrest combined with heparin-coated circuits and low dose systemic heparinization is safe for use in neurosurgery.

[111In-DTPA cisterno SPECT for the diagnosis of CSF rhinorrhea: case report]

The authors report on a patient with postoperative CSF (cerebrospinal fluid) leakage subsequent to transsphenoidal surgery where cisterno SPECT (single photon emission computed tomography) demonstrated the precise location of a CSF fistula. Seven months after surgery, the patient suffered from CSF rhinorrhea and headache. MRI (Magnetic Resonance Imaging) revealed significant contrast on T1-weighted images resulting from measurements in the right sphenoid sinus, which were hyperintense relative to CSF. On the basis of signal intensity differences, MRI could not distinguish between CSF leakage and postoperative scarring. Therefore, we performed cisterno SPECT at the same time as RI cisternography with intrathecal lumbar injection of 111In-DTPA which revealed dramatic accumulation of the tracer in the right sphenoid sinus. The patient underwent re-operation via a transsphenoidal approach, and the CSF leakage was repaired using fat-in-fibrin glue and the sella floor was reconstructed by hydroxyapatite platinge. These results suggest that cisterno SPECT may be useful in identifying the precise location of CSF fistulae, while other techniques fail to show evidence of CSF leakage.

[The role of transplanted astrocytes for the regeneration of CNS axons]

Long tract axons in the mammalian CNS do not normally regenerate for appreciable distance after they transected. But we reported transplantation of Schwann cells(SCs) or olfactory ensheathing cells induced regeneration of transected rat dorsal column (DC) axons and improved the conduction. Scar formation(gliosis), for which astrocytes(ACs) play an important role, may be one of strong and physical barriers for the regeneration of CNS axon. Oligodendrocyte and myelin associated protein or products also inhibit the regeneration of the axons, as chemical barriers. To investigate how effective the promotion or the reduction of scar or myelin formation may be for axonal regeneration, we transplanted AC into transected DCs, or radiated(X-ray) the DCs, and compared to normal DCs or regenerated DCs following by SC transplantation. DCs of adult rats were transected at Th 11 and transplanted with SCs(6 x 10(4)) of adult rats or ACs(6 x 10(4)) of neonatal rats. Five to six weeks later, the spinal cords were removed and pinned in a recording chamber, and compound action potentials (CAPs) along the DC through the transected lesion were recorded, to investigate conduction properties(conduction velocity and response after high frequency stimulations). Following transplantation of SCs or ACs, histological examination revealed regenerated axons with SC-like patterns of remyelination in transected DCs. X-ray irradiation did not enhance the regeneration of DC axons. SC transplantation improved the conduction properties of transected DCs and increased the number of regenerated axons, compared to transected DCs without cell transplantation. AC transplantation resulted in improvement of the conduction properties, but the number of regenerated axons was similar to that of transected DCs without the transplantation. X-ray irradiation (40 Gy) three days before DC transection and AC transplantation prevented the electrophysiological continuity of axons through the transected lesion. This evidence revealed that AC transplantation secondarily enhanced the regeneration of axons, probably endogeneous SCs of dorsal roots migrated into the transected lesion and enhanced the axonal regeneration.

Transplantation of clonal neural precursor cells derived from adult human brain establishes functional peripheral myelin in the rat spinal cord

We examined the myelin repair potential of transplanted neural precursor cells derived from the adult human brain from tissue removed during surgery. Sections of removed brain indicated that nestin-positive cells were found predominantly in the subventricular zone around the anterior horns of the lateral ventricle and in the dentate nucleus. Neurospheres were established and the nestin-positive cells were clonally expanded in EGF and bFGF. Upon mitogen withdrawal in vitro, the cells differentiated into neuron- and glia-like cells as distinguished by antigenic profiles; the majority of cells in culture showed neuronal and astrocytic properties with a small number of cells showing properties of oligodendrocytes and Schwann cells. When transplanted into the demyelinated adult rat spinal cord immediately upon mitogen withdrawal, the cells elicited extensive remyelination with a peripheral myelin pattern similar to Schwann cell myelination characterized by large cytoplasmic and nuclear regions, a basement membrane, and P0 immunoreactivity. The remyelinated axons conducted impulses at near normal conduction velocities. This suggests that a common neural progenitor cell for CNS and PNS previously described for embryonic neuroepithelial cells may be present in the adult human brain and that transplantation of these cells into the demyelinated spinal cord results in functional remyelination.

[Diagnosis of brain tumor with proton MR spectroscopy--the quantification of gliomas compared with normal brain]

We conducted quantification of proton MR spectroscopy (MRS) using water signal as an internal standard, in order to quantify the concentrations of metabolites in normal adult brains and in gliomas in vivo. Single-voxel spectra were acquired using a point-resolved spectroscopic (PRESS) pulse sequence as part of the Probe. P spectroscopy package on a GE Signa Horizon Hispeed LX1.5T scanner (TR/TE/Ave = 3000 msec/30 msec/64). The volume of interest (VOI) varied from 15.0 x 15.0 x 15.0 mm3 to 20.0 x 20.0 x 20.0 mm3 for the brain. The present study included 26 healthy volunteers and 12 patients with gliomas, whose diagnoses were verified by histologic examination. The calculated concentrations of N-acetyl-aspartate (NAA), creatine (Cre) and choline (Cho) in normal hemispheric white matter were 23.66 +/- 1.94 mM (mean +/- SD), 12.97 +/- 1.44 mM, and 4.38 +/- 0.60 mM, respectively. We found they were not necessarily uniform in different parts of the brain, for example, in the pons and basal ganglia. The concentrations of NAA and Cre decreased in all gliomas (p < 0.001). Cho concentration also decreased in the glioma (p < 0.005). The NAA/Cre, NAA/Cho, and Cre/Cho ratios can distinguish normal brain from gliomas, and NAA/Cho ratio can distinguish low-grade astrocytoma from the high-grade group. The results indicate that this noninvasive method offers reasonable estimation of metabolite concentrations in the brain in vivo and therefore is useful in diagnoses of gliomas.

[A case of tentorial meningioma presented with pure word deafness]

It has been known that an isolation of Wernicke's area from auditory input results in pure word deafness. In this report, a 73-year-old female case with tentorial meningioma suffering from pure word deafness is reported. The patient initially presented with hydrocephalus, and was treated with a ventriculo-peritoneal(V-P) shunt. A year after the V-P shunt, she suffered from a symptom of deafness. On admission, her repetition and auditory comprehension were severely impaired, while reading and visual comprehension were almost normal. Auditory brain stem response(ABR) revealed normal latency between wave I and V, while wave VI and VII was disappeared. Middle latency response(MLR) showed no wave peak. On MRI, tentorial meningioma compressed bilateral medial geniculate bodies, but not auditory radiation or temporal lobe. 99mTc-HMPAO single photon emission computed tomography(SPECT) showed hypoperfusion in the left temporal lobe, considered as a diaschisis resulting from the isolation of left temporal lobe from auditory input via bilateral medial geniculate bodies.

[Remyelination by Schwann cell transplantation for CNS demyelinated axons: functional comparison with developmental myelination]

Transplantation of Schwann cells(SCs) induced remyelination of demyelinated rat dorsal column(DC) axons and improved conduction. To investigate the difference between developmental oligodendrocytic myelination and SC myelination in conductive functions of axons, we compared normally developmental DCs(10 days old, 22-23 days old, and adult rat), demyelinated DCs, and remyelinated DCs by SC transplantation. DCs of adult rats were demyelinated at T 11 by X-ray irradiation and ethidium bromide, and transplanted with SCs(3 x 10(4)) of adult rats. Three weeks later, the spinal cord was removed and pinned in a recording chamber and compound action potentials (CAPs) were recorded, to investigate conduction properties(conduction velocity, amplitude of CAP and response after high frequency stimulation). Normal DCs were recorded in same manner. Following transplantation of SCs, histological examination revealed SC-like patterns of remyelination of demyelinated axons. The conduction velocities of 10 days old DCs(1.7 +/- 3.4 m/s, n = 4) increased early to 8.1 +/- 3.3 m/s(22-23 days old, n = 7) and 12.2 +/- 1.5 m/s (adult, n = 5). After SC transplantation the velocity significantly improved 7.7 +/- 1.5 m/s(n = 5) compared to demyelinated axons(1.2 +/- 0.4 m/s, n = 7), but less than adult. A 600 Hz 0.5 sec stimulus train led to an amplitude decrement of 7.1 +/- 7.5%(n = 7) in demyelinated axons. Following transplantation, amplitude decreased in 66.2 +/- 11.9%(SC, n = 5), same as 22-23 days(71.7 +/- 11.7%, n = 7) old or adult(76.6 +/- 15.6%, n = 6). The recovery properties after high frequency stimulation developed earlier than conduction velocity. Following SC transplantation, the recovery properties improved to that of normal adult, but not conduction velocity. Lower conduction velocity may be due to shorter internode distance of remyelination after transplantation, same as 22-23 days old pups, than normal adult rats. Though anatomical difference and/or time after transplantation influenced the conduction, these result suggested SC remyelination might result in insufficient for conduction velocity.

[Characteristic improvement of the function following Schwann cell transplantation for demyelinated spinal cord]

Transplantation of Schwann cells (SCs) induced remyelination of demyelinated rat dorsal column (DC) axons and improved conduction. To investigate the difference between oligodendrocyte (OL) and SC myelination in conductive functions of axons, we compared normal DCs, demyelinated DCs, demyelinated DCs remyelinated by SC transplantation, and normal dorsal roots. All of the axons was originated from dorsal root ganglion neurons. Dorsal roots of adult rats were demyelinated at T11 by X-ray irradiation and ethidium bromide, and transplanted with SCs (3 x 10(4)) of adult rats. Three weeks later, the spinal cord was removed and pinned in a recording chamber and compound action potentials (CAPs) were recorded, to investigate conduction properties (conduction velocity and response after high frequency stimulation). Normal DCs or dorsal roots were recorded in same manner. Following transplantation of SCs, histological examination revealed SC-like patterns of remyelination in demyelinated DCs. SC transplantation improved significantly conduction properties compared to demyelinated axons, but less than normal DC. Moreover, remyelinated axons by SC transplantation showed as low amplitude of CAP as dorsal roots, but lower conduction velocity than dorsal roots. Though anatomical difference and/or time after transplantation influenced the conduction, these result suggested that SC myelination resulted in lower amplitude of CAP than OL, and SC remyelination might be insufficient for conduction velocity.

[Comparison of myelin-forming cells as candidates for therapeutic transplantation in demyelinated CNS axons]

Demyelination of axons resulted in distinct reduction of conduction velocity or block of conduction. Remyelination by transplantation of myelin-forming cells may provide a therapeutic approach for demyelinated diseases. However, which cell type will be the most appropriate candidate for such a cell therapy is not established. To investigate how effective grafted neonatal brain cell (BC) (including oligodendrocyte and astrocyte) isolated from neonatal fronto-temporal lobes, adult olfactory ensheathing cell (OEC) or adult Schwann cell (SC) may be for demyelinated CNS axons in vivo, dorsal columns(DCs) of adult rat spinal cord were demyelinated at Th 11 by X-ray irradiation (day 0) and the injection of ethidium bromide (day 3), and transplanted 5 x 10(4) of BCs, 3 x 10(4) of OECs, or 3 x 10(4) of SCs into the lesion (day 6). Day 28-31, spinal cord were removed and transferred an in vitro recording chamber to record field potentials using glass micropipettes, to investigate conduction properties at 36 degrees. Normal DCs were recorded in same manner. Histological examination revealed that OECs and SCs resulted in substantial SC-like patterns of remyelination to equal degree, BC transplantation resulted in less myelination. The conduction velocities were significantly improved to 4.2 +/- 2.4 m/s(BC, n = 5), 8.5 +/- 3.3 m/s(OEC, n = 6) and 7.7 +/- 1.5 m/s(SC, n = 5), compared to demyelinated axons(1.2 +/- 0.4 m/s, n = 7). A 600 Hz 0.5 sec stimulus train led to an amplitude decrement of 7.1 +/- 7.5% (n = 7) in demyelinated axons. Following transplantation, the amplitude decreased in 31.3 +/- 18.7% (BC, n = 5), 49.9 +/- 19.9% (OEC, n = 6) and 66.2 +/- 11.9% (SC, n = 5). Transplanted OECs and SCs enhanced the remyelination of demyelinated CNS axons, and improved conduction properties were similar, and more effective than that induced from isolated CNS tissue which included oligodendrocyte.

Excitability changes of dorsal root axons following nerve injury: implications for injury-induced changes in axonal Na(+) channels

Electrophysiological recordings were obtained from rat dorsal roots in a sucrose gap chamber to study changes in Na(+) currents following nerve injury. Application of 4-aminopyridine unmasks a prominent and well-characterized depolarization (delayed depolarization) following the action potential. In our previous studies, this potential, which is only present in cutaneous afferent axons, has been shown to correlate with activation of a slow Na(+) current. The delayed depolarization in the dorsal root was reduced 1 week after sciatic nerve ligation, suggesting a reduction in the kinetically slow Na(+) currents on dorsal root axons [control: 44. 2+/-7.3% (n=5); injury: 7.3+/-4.7% (n=5), P<0.001]. The refractory period of the action potential was reduced following nerve injury, in agreement with biophysical studies indicating faster "repriming" of fast Na(+) currents on cutaneous afferent cell bodies. Dorsal root ligation near the spinal cord also results in a reduction in the delayed depolarization. These results indicate that changes in Na(+) channel organization occur on dorsal root axons following either central or peripheral target disconnection, suggesting trophic support can be derived from either the CNS or the PNS.

Family history of subarachnoid hemorrhage and the incidence of asymptomatic, unruptured cerebral aneurysms

OBJECT

Previously the authors reported a significant correlation between a family history of subarachnoid hemorrhage (SAH) and the discovery of an unruptured aneurysm in a group of healthy volunteers. This study corroborates and extends previous findings regarding the relationship between genetic and acquired factors in the formation of cerebral aneurysms.

METHODS

The incidence of asymptomatic, unruptured cerebral aneurysms was studied among patients with a family history of SAH within the second degree of consanguinity. Forty-one unruptured cerebral aneurysms were found in 34 (13.9%) of 244 patients. This incidence was significantly higher than that found in a control group of healthy volunteers (6%). Furthermore, patients who had a family history of SAH combined with multiple systemic risk factors were found to have the highest incidence of unruptured aneurysms (32%; odds ratio 3.49, 95% confidence interval 1.37-8.9).

CONCLUSIONS

These findings suggest that patients with a family history of SAH with or without the presence of more than one systemic risk factor are at significantly higher risk of harboring cerebral aneurysms. This high-risk group should be periodically screened and treated with appropriate surgical or other forms of therapy when necessary.

[Usefulness of galea suturing method for scalp closure]

A method for scalp closure to prevent alopecia along a suture line is described. Only the galea is sutured. By tacking a sufficient width of the galea on both sides with an absorbable suture material, the sutured wound forms a ridge. The outer layer is then closed with skin staples to keep the blood circulation undisturbed. This procedure contrasts with the traditional method in which the galea is sutured with the overlying subcutaneous tissue and consequently the hair follicles are strangled. By adopting the method of suturing the galea, development of alopecia along a suture line has been effectively prevented and scarring has become less conspicuous.

Operative approach to mediosuperior cerebellar tumors: occipital interhemispheric transtentorial approach

BACKGROUND

The transtentorial approach is well known as an approach to the pineal region. We have modified this approach for mediosuperior cerebellar tumors.

METHODS

We describe six cases of tumor excision in this region using an occipital interhemispheric transtentorial approach.

RESULTS

The lesions were easily accessible and the tumor was totally removed by this modified approach in all cases. Transient visual field disturbance with spontaneous recovery occurred in two patients. The lateral margin of the tumor was accessed easily up to 35 mm from the midline on the operative side and up to 17 mm from the midline on the contralateral side.

CONCLUSION

This approach proved to be very useful for mediosuperior lesions of the cerebellum, without causing any neural structural damage, and allowed for a wider operative field.

Intellectual functions and regional cerebral haemodynamics after extensive omental transplantation spread over both frontal lobes in childhood moyamoya disease

Most accepted operations for childhood moyamoya disease have attempted to increase cerebral blood flow (CBF) in the ischaemic cortical areas around the central fissure. Developed ischaemic brain damage in the prefrontal area may lead to poor intellectual outcome and restrict patients' daily lives. Thus, extensive cerebral revascularization in both the ischaemic anterior and middle cerebral artery territories is mandatory. We describe the long-term follow-up results for intellectual outcome and performance status and make an evaluation of regional cerebral haemodynamics after extensive omental transplantation spread over both frontal lobes performed as the initial management. In the past 10 years, 10 moyamoya patients less than 12 years of age consecutively underwent omental transplantation. The omental flap was spread over not only the symptomatic hemisphere but also the contralateral frontal lobe after a large craniotomy. Superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis was accomplished simultaneously. On the contralateral hemisphere, STA-MCA anastomosis combined with encephalomyosynangiosis was subsequently performed. The clinical observation period averaged 6.7 years (ranged 1.9 to 9.2 years). Apart from 2 patients in whom severe mental retardation had been disclosed pre-operatively, full-scale intelligence quotient scores have been maintained at over 90, that is, within the normal intellectual range. With respect to quality of life (QOL), these 8 patients have been leading normal daily lives since the operation. The focal decrease in CBF observed in the frontal lobe pre-operatively in 7 cases had disappeared after surgical treatment. In these patients, serial post-operative MR angiography revealed developed omental vessels and STAs. Deterioration of intellectual functions and QOL as well as cerebral ischaemic events in paediatric moyamoya patients can be prevented by extensive omental transplantation spread over both frontal lobes combined with STA-MCA anastomosis.

Chemical, metabolic and immunological characterization of gangliosides of human glioma cells

The patterns of ganglioside profiles were studied in 10 human glioma and one melanoma cell lines. Ganglio-series gangliosides, GM3 (NeuAc alpha2-3Gal beta1-4Glc beta1-Cer) and GM2 (GalNAc beta 1-4 (NeuAc alpha2-3)Gal beta1-4Glc beta 1-1Cer), and a neolacto-series ganglioside, sialylparagloboside (SPG) (NeuAc alpha 2-3Gal beta1-4GlcNAc beta1-3Gal beta1-4Glc beta1-1Cer), were the predominant constituents. The activities of the two key enzymes, GM3 synthetase and lactotriaosyl ceramide (Lc3Cer) synthetase, alone did not account for the ganglioside profile. Metabolic labeling with the use of [3H]glucosamine-HCl showed more pronounced difference in the synthetic rate of each ganglioside type, in which GM2 was the most strongly labeled in 7 out of the 10 glioma cell lines. On quantifying the chemical content of GM3 and GM2, the GM3/GM2 molar ratio of above 2.0 was arbitrarily classified into GM3 dominant type (KG-1C and Mewo); the ratio below 0.5 was designated as GM2 dominant type (H4, U138MG, U373MG, T98G and A172); and the ratio between 0.5 and 2.0 was regarded as GM3 and GM2-co-dominant type (U87MG, Hs683, SW1088 and U118MG). Subsequently, the capabilities of the antibody binding to these gangliosides were examined in native forms in the cell membrane and in chemically-isolated forms. The intensity of reaction against chemically isolated GM3 and GM2 gangliosides was dependent on the quantity, and GM2 was more reactive than GM3; however, the reactivities on the cell surface did not correlate with the chemical content indicating other factors to influence their immunoreactivities.

[Visual acuity outcome and recurrence in large or huge pituitary adenomas operated with transcranial approach: comparison between frontotemporal and interhemispheric approaches]

Pituitary macroadenomas which required transcranial removal were reviewed concerning visual acuity outcome as well as recurrence. We encountered 173 pituitary adenomas of which 27 (15.6%) were removed transcranially during the past 13 years. Eight cases were excluded due to inadequate information and improper utilization. Thus, a total of nineteen cases were reviewed in which the frontotemporal (FT) approach was utilized for seven cases and the interhemispheric (IH) approach for 12 cases. The mean size and volume of the tumors in the FT group were 3.0 x 3.7 x 3.1 cm and 18.2 cm3. The main reason for utilizing this approach was the fact that the tumors extended laterally involving the unilateral cavernous sinus or that unilateral preoperative visual acuity was obstructed. The visual acuity outcome was as follows: In six cases showing useful visual acuity on both sides before surgery, no apparent aggravation on either side was found in four cases, while in two cases there was complete obstruction on the operative side. The remaining case showed aggravation on both sides, though the approach side was decided upon because of the obstructed vision on that side. The mean size and volume of the tumors in the IH group were 4.6 x 4.8 x 4.9 cm and 71.1 cm3. This approach was used due to the extreme suprasellar extension because of the large size of the tumors. Although the tumors were relatively large and the visual acuity was assessed as fair prior to surgery, visual acuity showed no significant deterioration after the operation and was found to be satisfactory in 11 out of 12 cases. The complications in the FT group were oculomotor palsy in 3 cases, hemorrhage in one case, and frontal infarction in one case. On the other hand, three cases suffered hemorrhage in the tumor cavity of the IH group, though none needed surgical evacuation. Most of the cases in the IH group showed pituitary hypofunction following the surgical removal of the tumors as compared to the cases in the FT group. Recurrence had occurred, in some cases, several years after the operation. Furthermore, some of the tumors are still growing larger following only partial or subtotal removal. The prime aim of the treatment for huge pituitary adenomas which require the transcranial removal is to retain as much visual acuity as possible. In conclusion, the IH approach has been shown to be preferable in this situation. The FT approach was found to be more dangerous in terms of visual outcome than had been expected, even if the tumors were not particularly large.

The delayed depolarization in rat cutaneous afferent axons is reduced following nerve transection and ligation, but not crush: implications for injury-induced axonal Na+ channel reorganization

Two distinct populations of Na+ channels (kinetically fast and slow) are present on the cell bodies and axons of cutaneous afferent neurons; the fast current is increased and the slow current reduced in amplitude following nerve injury. The present study was undertaken to determine if similar changes occur on the axons of these neurons following peripheral nerve injury. The compound action potentials from rat sural nerves were recorded in a sucrose gap chamber. Following application of 4-aminopyridine, a prominent and well-characterized depolarization (the delayed depolarization) followed the action potential. This potential, only present on cutaneous afferent axons, has been correlated with activation of a slow Na+ current. The delayed depolarization was reduced after nerve transection. The refractory period of transmission of the action potential was shortened in the transected nerves, but that of the delayed depolarization was prolonged. The changes were largest when the sural nerve was cut and ligated [control: 38.1 +/- 1.7% (n = 5); injury: 24.5 +/- 2.8% (n = 5), P < 0.05], which prevented reconnection to its peripheral target. When the nerve was crushed and allowed to reestablish peripheral target connections, the delayed depolarization was minimally effected. These results indicate that the changes in Na+ channel organization following peripheral target disconnection observed on cutaneous afferent cell bodies also occur on their axons.

Characterization of a O-fatty-acylated sulfatide from equine brain

A sulfatide, O-fatty-acylated 3-sulfogalactosylceramide at C6-O on galactoside, was isolated from equine brain and the chemical structure was characterized by proton NMR and MS. The O-acylation site of the acylated sulfatide was determined by the down-field shift of protons attached to a carbon having an O-acyl group in the NMR spectrum and by analysis of a partially methylated derivative before and after acetalization of the intact sulfatide using GC-MS. The O-acyl chain length was determined by GLC, revealing that it exclusively had palmitoyl and stearoyl residues as the major fatty acids. The enzymatic conversion to the O-acyl sulfatide was further examined using equine brain microsomes as an enzyme source and different lipid substrates, resulting in O-acylation of 3-sulfogalactosylceramide from stearoyl CoA, while 6-O-acyl galactosylceramide was not O-sulfated from phosphoadenosine phosphosulfate. The results were supported by the comparably different N-linked fatty acid components between two lipid substrates, in which the component of 6-O-acyl sulfatide was mostly similar to that of sulfatide, but not to 6-O-acyl galactosylceramide.

Intracranial facial nerve neurinoma: surgical strategy of tumor removal and functional reconstruction

BACKGROUND

Three cases with intracranial facial neurinoma underwent tumor removal and facial nerve reconstruction with or without tympanoplasty. Surgical strategy for each case was tailored to: (1) the site of main tumor mass, (2) its extension along the facial nerve, and (3) involvement of the auditory organs.

METHODS

Surgeries adopted in the three cases were: transpetrosal approach with intracranial-intratemporal facial nerve anastomosis, middle fossa and transmastoid approach with intratemporal facial nerve anstomosis and tympanoplasty, and middle fossa and transmastoid approach with intracranial-intratemporal facial nerve anastomosis and tympanoplasty. The greater auricular nerve was used as the nerve graft for all three cases.

RESULTS

In the follow-up period of 8-13 months there was no tumor recurrence; facial function was scored 20/90 in modified May's scoring system in each case, but two are still in the process of functional recovery. One of the two cases who underwent tympanoplasty showed complete recovery of hearing within 1 month, and the other showed worsened hearing, which was not serviceable at 3 months postoperatively.

CONCLUSION

Systematic surgical approach for tumor removal, facial nerve reconstruction, and auditory reconstruction should be considered in cases with intracranial facial neurinoma due to its varied clinical features.

A case of abducens neurinoma mimicking acoustic neurinoma

Neurinoma arising from the abducens nerve independent of neurofibromatosis has been rarely reported in the existing literature. We present a case of abducens neurinoma which was confirmed during a surgical excision. A 31-year-old female had experienced a hearing disturbance for the past 8 months. Abduction of the right eye ball was almost full. Magnetic resonance images showed a tumor having a size of 44 x 33 X 33 mm at the right cerebellopontine angle. Neuro-otological examination revealed the findings specific to acoustic neurinoma. Surgical excision confirmed that the tumor originated from the abducens nerve. The tumor located at the cavernous sinus or cerebellopontine angle might originate from the abducens nerve, though the abduction of eye ball is not in any way impaired.

[Direct continuous observation of in situ thrombolysis in the cerebral embolic model of rabbits]

To investigate the occurrence of cerebral embolism, a rabbit embolic stroke model was used for the continuous monitoring of the change of the thrombus. Red thrombus was directly injected into the internal carotid artery via the catheter inserted into the external carotid artery. The migration of the thrombus into the middle cerebral artery was judged as the completion of an embolism. The change of the thrombus and its movement was observed for a period of two hours. The experimental group received recombinant tissue plasminogen activator (TPA) for the thrombolysis while the control group received a saline solution for 30 minutes. The thrombus in the middle cerebral artery was continuously observed for two and a half hours. 1. There was a spontaneous movement of the thrombus during the first two hours in six out of 18 cases. One case showed a spontaneous regression in size at the migration site. 2. White thrombus formation occurred around the thrombus in eight out of 18 cases. 3. In the TPA injected group, thrombolysis was observed in nine out of ten rabbits. The accompanied white thrombus was also found to be degraded. However, after the TPA injection, white thrombus was newly formed during the lysis of red thrombus. 4. In the saline solution injected control group, only partial recanalization occurred in three out of eight rabbits. There was no white thrombus formation in the control group. 5. There was no significant difference in the degree of Evans blue exudation between these two groups. Secondary activation of the platelet function easily occurred by the change of the blood flow during thrombus migration and also thrombolysis. In conclusion, thrombolysis therapy may be more effective when TPA is administered in conjunction with the suppression of platelet function.

[Direct surgical management of giant and large intracerebral aneurysms, associated with intraluminal thrombus and/or atherosclerotic thickening of aneurysmal neck]

Direct surgical management of giant or large cerebral aneurysms remains one of the most challenging topics in the neurosurgical field. Surgical results have remained unsatisfactory. We review 22 cases of large or giant aneurysms with intraluminal thrombus and/or atherosclerotic thickening of the aneurysmal neck that have received direct surgical management in our department during the period from 1984 to 1996. As initial symptoms, ten patients presented with mass effect, five with ischemic attack, and three with subarachnoid hemorrhage. Sixteen aneurysms were supratentorial and six were in the posterior fossa. Direct neck clipping was attempted in sixteen cases. Two giant basilar aneurysms among them were clipped under deep hypothermia with cardiac arrest. Simple trapping of the parent artery was performed in three aneurysms and trapping with bypass graft was also carried out in three aneurysms. Ten patients made an excellent clinical recovery. Eleven patients suffered mild to severe disability. One death resulted from brain stem infarction, not directly related with surgical management. Appropriate preoperative assessment and intraoperative management of the associated thrombus and atherosclerotic change of the aneurysmal neck are essential for obtaining acceptable surgical results of large or giant cerebral aneurysms.

Deletion of complex gangliosides of human glioma cells during mitotic cell division

Glycolipid compositions of the human glioma cell line T98G were studied during each phase of the cell cycle to see if those cell surface molecules are concerned with cell proliferation. In vitro cultured non-synchronized T98G cells are composed of ceramidemonohexoside (CMH), ceramidedihexoside (CDH), ceramidetrihexoside (CTH) and neolactotetraosylceramide (nLc4Cer) as neutral glycolipids, and of sulfatide (CS), gangliosides GM3, GM2, GD1a and several other gangliosides as acidic ones. While total glycolipid content per cellular weight was shown to be increased during the M phase, deletion of complex gangliosides particularly b-series gangliosides was recognized (p < 0.05). The glycolipid profile in other phases was fairly consistent, and there was no glycolipid molecule specific to a certain phase of the cell cycle. Relative enhancement of simple gangliosides with a decrease of complex ones during mitotic division may imply the functional involvement of complex gangliosides in cell-cell or cell-matrix attachment, which may have to be abandoned during the process of detachment from the matrix or cellular cleavage.