The Movement Disorder Society Criteria: Its Clinical Usefulness in Multiple System Atrophy

Objective In 2022, Wenning et al. proposed the Movement Disorder Society Criteria (MDS Criteria) for the Diagnosis of Multiple System Atrophy (MSA). These criteria were expected to provide useful alternatives to the second consensus statement. We examined trends in these diagnostic criteria. Methods We used patient data registered with the Hokkaido Rare Disease Consortium for Multiple System Atrophy, which has been recruiting patients with MSA through medical facilities in Hokkaido since November 2014. Patients were evaluated according to the MDS criteria based on neurological examinations and imaging findings at three separate times: the first evaluation, the time of enrollment (diagnosis), and the most recent evaluation (final evaluation). Results The MDS criteria were examined in 68 of 244 patients enrolled between November 2014 and July 2022. At the initial evaluation, the classifications were as follows: clinically established (n=27; 39.7%); clinically probable (n=13; 19.1%); possible prodromal (n=12; 17.6%); and negative (did not meet criteria (n=16; 23.5%). At the time of diagnosis, the classifications were as follows: clinically established (n=45; 66.2%); clinically probable (n=12; 17.6%); possible prodromal (n=4; 5.9%); and negative (n=7; 10.3%). At the final evaluation, the classifications were as follows: clinically established (n=52; 76.5%); clinically probable (n=9; 13.2%); possible prodromal (n=2; 2.9%); and negative (n=5; 7.4%). Conclusions We were able to clarify the changes in the criteria values and transition of patients due to the clarification of imaging and supportive findings in the MDS criteria.

An autopsy case report of adult-onset Krabbe disease: Comparison with an infantile-onset case

Krabbe disease is a lysosomal storage disease caused by a deficiency of the galactocerebrosidase (GALC) enzyme, which leads to demyelination of the central and peripheral nervous systems. Almost all patients with Krabbe disease are infants, and this is the first report of adult-onset cases that describe pathological findings. Here, we present two autopsy cases: a 73-year-old female and a 2-year-old male. The adult-onset case developed symptoms in her late thirties and was diagnosed by the identification of GALC D528N and L634S mutations and by T2-weighted magnetic resonance imaging; she had increased signal in the white matter along the pyramidal tract to the bilateral precentral gyrus, as well as from the triangular part to the posterior horn of the lateral ventricle. Microscopically, Klüver-Barrera staining was pale in the white matter of the precentral gyrus and occipito-thalamic radiation, and a few globoid cells were observed. The GALC mutations that were identified in the present adult-onset case do not completely inactivate GALC enzyme activity, resulting in focal demyelination of the brain.

Voxel-based analysis of age and gender effects on striatal [123I] FP-CIT binding in healthy Japanese adults

OBJECTIVE

Although previous studies have investigated age and gender effects on striatal subregional dopamine transporter (DaT) binding, these studies were mostly based on a conventional regions of interest-based analysis. Here, we investigated age and gender effects on striatal DaT binding at the voxel level, using a multicenter database of [(¹²³)I] N-omega-fluoropropyl-2beta-carbomethoxy-3beta-{4-iodophenyl}nortropane ([(¹²³)I] FP-CIT)-single photon emission computed tomography (SPECT) scans in 256 healthy Japanese adults.

METHODS

We used the Southampton method to calculate the specific binding ratios (SBRs) of each subject's striatum and then converted the [¹²³I] FP-CIT SPECT images to quantitative SBRs images. To investigate the effects of age and gender effects on striatal DaT binding, we performed a voxel-based analysis using statistical parametric mapping. Gender differences were also compared between young to middle-aged subjects and elderly subjects (age threshold: 60 years).

RESULTS

When all subjects were explored as a group, DaT binding throughout the striatum decreased with advancing age. Among all subjects, the females showed higher DaT binding in the bilateral caudate compared to the males. In the young to middle-aged subjects, the females showed higher DaT binding throughout the striatum (with a slight caudate predominance) versus the males. In the elderly, there were no gender differences in striatal DaT binding.

CONCLUSION

Our findings of striatal subregional age- and gender-related differences may provide useful information to construct a more detailed DaT database in healthy Japanese subjects.

Intravenous fosphenytoin therapy for rescue of acute trigeminal neuralgia crisis in patients awaiting neurosurgical procedures: A cross-sectional study

Few treatments exist for acute attacks of trigeminal neuralgia. Therefore, this study aimed to investigate the efficacy and safety of an intravenous fosphenytoin therapy protocol in a trigeminal neuralgia crisis. We conducted a single-center, retrospective, observational study of the records of 20 patients with trigeminal neuralgia who received intravenous fosphenytoin therapy (15 mg/mL in normal saline at 50 mg/min for 15 min, total 750 mg) during hospitalization between September 2015 and August 2020. Serum phenytoin concentration was measured 30 min post-infusion. Pain severity was evaluated using a numerical rating scale and was analyzed for statistical significance. The mean age of the patients was 67.5 years (female, 50.0%). The median numerical rating scale score (interquartile range) of pain severity was 2.35 (0-10), 0.65 (0-5), 0.15 (0-1), 2.00 (0-8), and 4.30 (0-10) at 15, 30, and 60 min, and 12 and 24 h, respectively (p < .001); the numerical rating scale score was 10 before treatment. Reduction in pain 24 h following treatment was significant. The mean phenytoin concentration was 12.8 μg/mL 30 min post-treatment. While mild dizziness occurred in four patients, all could walk independently within 60 min. The mean age and weight of patients with mild dizziness were significantly higher and lower, respectively (p < .001), than those of other patients. These results may provide physicians with new insights into the innovative therapeutic option of intravenous fosphenytoin and contribute to advancements in treating acute trigeminal neuralgia crisis.

Multiple system atrophy in Hokkaido, Japan: a prospective registry study of natural history and symptom assessment scales followed for 5 years

OBJECTIVES

Multiple system atrophy (MSA) is a refractory neurodegenerative disease, but novel treatments are anticipated. An accurate natural history of MSA is important for clinical trials, but is insufficient. This regional registry was launched to complement clinical information on MSA.

SETTING

Patient recruitment started in November 2014 and is ongoing at the time of submission. The number of participating facilities was 66. Postal surveys were sent to medical facilities and patients with MSA in Hokkaido, Japan.

PARTICIPANTS

After obtaining written consent from 196 participants, 184 overview surveys and 115 detailed surveys were conducted.

PRIMARY AND SECONDARY OUTCOME MEASURES

An overview survey evaluated conformity to diagnostic criteria and a detailed survey implemented an annual assessment based on the Unified Multiple System Atrophy Rating Scale (UMSARS).

RESULTS

At the time of registration, 58.2% of patients were diagnosed with cerebellar symptoms predominant type MSA (MSA-C) and 29.9% were diagnosed with parkinsonism predominant type MSA (MSA-P). UMSARS Part Ⅳ score of 4 or 5 accounted for 53.8% of participants. The higher the UMSARS Part Ⅳ score, the higher the proportion of MSA-P. At baseline, levodopa was used by 69 patients (37.5%) and the average levodopa dose was 406.7 mg/day. The frequency of levodopa use increased over time. Eleven cases changed from MSA-C to MSA-P during the study, but the opposite was not observed. Information about survival and causes of death was collected on 54 cases. Half of deaths were respiratory-related. Sudden death was recorded even in the group with UMSARS Part Ⅳ score of 1.

CONCLUSIONS

This study is the first large-scale prospective MSA cohort study in Asia. MSA-C was dominant, but the use of antiparkinsonian drugs increased over the study period. Changes from MSA-C to MSA-P occurred, but not vice versa.

Japanese multicenter database of healthy controls for [123I]FP-CIT SPECT

PURPOSE

The aim of this multicenter trial was to generate a [¹²³I]FP-CIT SPECT database of healthy controls from the common SPECT systems available in Japan.

METHODS

This study included 510 sets of SPECT data from 256 healthy controls (116 men and 140 women; age range, 30-83 years) acquired from eight different centers. Images were reconstructed without attenuation or scatter correction (NOACNOSC), with only attenuation correction using the Chang method (ChangACNOSC) or X-ray CT (CTACNOSC), and with both scatter and attenuation correction using the Chang method (ChangACSC) or X-ray CT (CTACSC). These SPECT images were analyzed using the Southampton method. The outcome measure was the specific binding ratio (SBR) in the striatum. These striatal SBRs were calibrated from prior experiments using a striatal phantom.

RESULTS

The original SBRs gradually decreased in the order of ChangACSC, CTACSC, ChangACNOSC, CTACNOSC, and NOACNOSC. The SBRs for NOACNOSC were 46% lower than those for ChangACSC. In contrast, the calibrated SBRs were almost equal under no scatter correction (NOSC) conditions. A significant effect of age was found, with an SBR decline rate of 6.3% per decade. In the 30-39 age group, SBRs were 12.2% higher in women than in men, but this increase declined with age and was absent in the 70-79 age group.

CONCLUSIONS

This study provided a large-scale quantitative database of [¹²³I]FP-CIT SPECT scans from different scanners in healthy controls across a wide age range and with balanced sex representation. The phantom calibration effectively harmonizes SPECT data from different SPECT systems under NOSC conditions. The data collected in this study may serve as a reference database.

Effects of extracranial-intracranial bypass for patients with hemorrhagic moyamoya disease: results of the Japan Adult Moyamoya Trial

BACKGROUND AND PURPOSE

About one half of those who develop adult-onset moyamoya disease experience intracranial hemorrhage. Despite the extremely high frequency of rebleeding attacks and poor prognosis, measures to prevent rebleeding have not been established. The purpose of this study is to determine whether extracranial-intracranial bypass can reduce incidence of rebleeding and improve patient prognosis.

METHODS

This study was a multicentered, prospective, randomized, controlled trial conducted by 22 institutes in Japan. Adult patients with moyamoya disease who had experienced intracranial hemorrhage within the preceding year were given either conservative care or bilateral extracranial-intracranial direct bypass and were observed for 5 years. Primary and secondary end points were defined as all adverse events and rebleeding attacks, respectively.

RESULTS

Eighty patients were enrolled (surgical, 42; nonsurgical, 38). Adverse events causing significant morbidity were observed in 6 patients in the surgical group (14.3%) and 13 patients in the nonsurgical group (34.2%). Kaplan-Meier survival analysis revealed significant differences between the 2 groups (3.2%/y versus 8.2%/y; P=0.048). The hazard ratio of the surgical group calculated by Cox regression analysis was 0.391 (95% confidence interval, 0.148-1.029). Rebleeding attacks were observed in 5 patients in the surgical group (11.9%) and 12 in the nonsurgical group (31.6%), significantly different in the Kaplan-Meier survival analysis (2.7%/y versus 7.6%/y; P=0.042). The hazard ratio of the surgical group was 0.355 (95% confidence interval, 0.125-1.009).

CONCLUSIONS

Although statistically marginal, Kaplan-Meier analysis revealed the significant difference between surgical and nonsurgical group, suggesting the preventive effect of direct bypass against rebleeding.

CLINICAL TRIAL REGISTRATION URL

http://www.umin.ac.jp/ctr/index.htm. Unique identifier: C000000166.

Measurement of beam characteristics from C(6+) laser ion source

We developed a C(6+) laser ion source for a heavy-ion accelerator. A carbon target was irradiated with a Q-switched Nd:YAG laser (1064 nm wavelength, 1.4 J maximum laser energy, 10 ns pulse duration) to generate a high-density plasma. The laser ion source employed a rotating carbon target for continuous operation. Ion beams were extracted from the plasma through a drift space using a direct plasma injection scheme [B. Yu. Sharkov, A. V. Shumshurov, V. P. Dubenkow, O. B. Shamaev, and A. A. Golubev, Rev. Sci. Instrum. 63, 2841 (1992)] up to a maximum voltage of 40 kV. We measured the characteristics of the ion beams from the laser ion source and present the results of experiments here.

[A case of cerebral syphilitic gumma mimicking a brain tumor]

We report a case of young immunocompetent woman who was presented with a left parieto-temporal mass as the first and single manifestation of syphilis. A 23 year-old woman with no significant past medical history was reffered to our hospital due to 3 month history of headache. She had a single unprotected sexual intercourse with a promiscuous man 6 month before the time of admission. Physical and neurological examinations revealed no obvious abnormalities. A brain tumor was firstly suggested according to the findings of brain magnetic resonance imaging (MRI). However, the serologic and cerebrospinal fluid test of syphilis proved to be positive, syphilitic gumma was most likely suspected. She responded dramatically to benzylpenicillin potassium. Cerebral syphilitic gumma is a rare manifestations of the neurosyphilis. Treponemal invasion of the cerebrospinal fluid occurs in approximately 25 to 60% of patients after the infection, but most cases spend asymptomatic. Cerebral gumma should be considered in differential diagnosis of any intracranial mass lesions, even in the early syphilitic stages.

[Efficacy of intravenous phenobarbital treatment for status epilepticus]

PURPOSE

Intravenous phenobarbital (IV-PB) therapy was launched in Japan in October 2008. We retrospectively investigated its efficacy and tolerability in patients with status epilepticus.

METHODS

Forty-three consecutive patients received IV-PB for status epilepticus between June 2009 and April 2011. Among them, 39 patients had underlying diseases, which included acute diseases in 19 patients and chronic conditions in 20 patients. Although 18 patients had been taking antiepileptic drugs (AEDs) before the occurrence of status epilepticus, the blood AED concentrations in 8 patients was below the therapeutic levels. Before the administration of IV-PB, 39 patients were treated with intravenous benzodiazepine, 17 patients were treated with intravenous phenytoin, and 15 patients with intravenous infusion of lidocaine.

RESULTS

The initial doses of IV-PB ranged from 125 to 1,250 mg (1.9-20.0 mg/kg). Additional doses of IV-PB were required in 12 patients. Seizures were controlled in 35 patients (81%) after IV-PB administration. Cessation of status epilepticus was attained in 24 patients after the initial dose and in 11 patients after additional doses. There were no serious adverse effects, although respiratory suppression was observed in 3 patients and drug eruption was observed in 1 patient.

CONCLUSION

IV-PB is relatively safe and effective for controlling status epilepticus. If the first dose is not effective, additional doses are required up to the recommended maximum dose.

Prevention of CSF Leakage by Staged Operation for Clival Metastatic Tumor

The transoral approach is a direct route to the clivus. However, application of this approach is infrequent because of the risk of cerebrospinal fluid (CSF) fistula and subsequent meningitis. We report a case of clival metastatic tumor treated by staged operation without CSF leakage. A 39-year-old man was found to have a tumor in clivus extending to the intradural space. Two-staged resection through the lateral suboccipital and transoral approach was performed and the dural defect was replaced by a fascia in the first operation. CSF leakage was prevented by this procedure. The patient received radiotherapy postoperatively.

Dystonic posturing associated with putaminal hyperperfusion depicted on subtraction SPECT

PURPOSE

Dystonic posturing (DP) is one of the most reliable lateralizing indicators for temporal lobe epilepsy (TLE). We evaluated the ictal hyperperfusional areas in patients with DP by using ictal-interictal subtraction single-photon emission computed tomography (SPECT).

METHODS

Ninety-seven patients were treated surgically for intractable TLE, and 39 patients underwent ictal and interictal SPECT studies with the same isotope. These patients were divided into three groups: group I with DP of the contralateral side extended to the epileptogenic focus, group II with elevated muscle tonus but without DP, and group III without DP or alteration of muscle tonus. Ictal, interictal SPECT and thin-slice magnetic resonance imaging (MRI) were overlaid by using the automatic multimodality registration program to construct ictal-interictal subtracted images of SPECT on MRI.

RESULTS

Thirteen patients belonged to group I; 14, to group II; and 12, to group III. A statistically significant difference in hyperperfusion rate was observed in the putamen (10 patients in group I, three in group II and two in group III; p < 0.01) and mesial temporal lobe (10 patients in group I, seven in group II, and two in group III; p < 0.05) on the ipsilateral side of the epileptogenic focus. No statistically significant difference was observed for other ictal symptoms except ipsilateral upper-limb automatism (eight patients in group I, three in group II, and none in group III; p < 0.01).

CONCLUSIONS

A strong correlation between DP and hyperperfusion in the putamen and mesial temporal lobe was demonstrated. Some patients showed a wide hyperperfusion area extending from the mesial temporal lobe to putamen, which may correspond to the propagation of epileptic discharges. Our results suggest a correlation between hyperperfusion of putamen and contralateral dystonic posturing.

A new index, the core erosion ratio, of compression-coated timed-release tablets predicts the bioavailability of acetaminophen

Although compression-coated tablets are a commonly used timed-release drug delivery technology, their utility is often limited by poor bioavailability. To try to improve the bioavailability of these tablets, the effect of their core composition of compression-coated tablet on in vivo pharmacokinetics was investigated. First, the extent of mass reduction of cores in different compression-coated tablet core formulations was used to establish a new index, the core erosion ratio. The data show that adding excipients with high water solubility to the core results in a greater core erosion ratio. Next, to elucidate the effect of core erosion ratio on in vivo acetaminophen (AAP) release, three compression-coated tablet formulations with similar in vitro AAP release profiles but different core erosion ratios were administered to four fasted dogs. The time for first appearance (TFA) of AAP in plasma did not differ significantly among formulations, indicating that the in vivo lag time was the same for all formulations. In separate experiments, necroscopy revealed that 3h after oral administration, the tablets were located in the ileum and colon and that all three formulations had identical GI transit times. However, the area under the AAP plasma concentration-time curve was greater in dogs given formulations with larger core erosion ratios. These results suggest that a formulation with a large core erosion ratio can significantly increase in vivo drug release from compression-coated tablets, leading to increased drug absorption from the lower GI tract.

Diagnosis and treatment of progressive space-occupying radiation necrosis following stereotactic radiosurgery for brain metastasis: value of proton magnetic resonance spectroscopy

BACKGROUND

There have been some reports that radiation necrosis can be controlled conservatively. There are rare cases showing progressive space-occupying radiation necrosis (PSORN). It is very difficult to control PSORN by conservative treatment. The purpose of this study was to evaluate the early diagnosis of those cases and the timing of surgery for patients with PSORN.

METHOD

We have experienced some cases where quality of life was improved by the removal of PSORN after stereotactic radiosurgery (SRS) for brain metastases. Therefore, we evaluated retrospectively the diagnosis and treatment of six cases of symptomatic PSORN at approximately 6-12 months after SRS for metastatic brain tumours.

FINDINGS

In all six cases, on Magnetic Resonance Imaging with Gd contrast material (Gd-MRI), PSORN was revealed as a ring-like enhanced mass with large perifocal oedema coupled with the appearance of neurological deficit. Proton Magnetic Resonance Spectroscopy ((1)H-MRS) enabled us to differentiate PSORN from recurrence of metastases in all six cases. Single Photon Emission Computed Tomography with thallium-201 chloride (201TlCl-SPECT) enabled us to do this in four cases of the six. In four cases of the six, lesionectomy of the ring-like enhanced mass (PSORN) was performed, and in two of these cases the removal was performed within 4 weeks from the time when conservative treatment became ineffective, and the neurological deficit and perifocal oedema was improved as was the quality of life. However, in the other two patients who were left for more than 16 weeks, the deficit was gradually progressive. The two patients who did not receive lesionectomy were treated by conservative means with steroids and/or heparin and warfarin and they had progressive neurological symptoms.

INTERPRETATION

Although, the number of patients is small in this study, and more data will be needed, it is recommended that lesionectomy is performed at an early stage, if possible, when conservative management has failed.

In vivo single-voxel proton MR spectroscopy in brain lesions with ring-like enhancement

It is often difficult to make a correct diagnosis of ring-like enhanced lesions on Gd-enhanced MR brain images. To differentiate these lesions using proton MR spectroscopy (1H-MRS), we retrospectively evaluated the correlation between the 1H-MR spectra and histopathological findings. We evaluated proton MR spectra obtained from the lesions in 45 patients, including metastasis (n = 19), glioblastoma (n = 10), radiation necrosis (n = 7), brain abscess (n = 5), and cerebral infarction (n = 4). The rate of misdiagnosis was found to be lowest at the threshold level of 2.48 for the (choline containing compounds)/(creatine and phosphocreatine) ratio (Cho/Cr) obtained from the whole lesions, which include the enhanced rim and the non-enhanced inner region. That is, the positively predictive values of a Cho/Cr greater than 2.48 for diagnosing metastasis or glioblastoma was 88.9 and 60.0%, respectively, and the positively predictive value of a Cho/Cr less than 2.48 for diagnosing radiation necrosis or cerebral infarction was 71.4 and 100%, respectively. For further differentiating between metastasis and glioblastoma, information about the presence and absence of an N-acetyl-aspartate (NAA) peak and lipid- or lactate-dominant peak was found to be useful. In 73.7% of metastasis cases a lipid-dominant peak was observed in the whole lesion without an NAA peak in the inner region, whereas the same pattern was observed in only 10% of the glioblastoma cases. Correlation with the histopathological findings showed that a high Cho signal is suggestive of neoplasm. Lipid signal in the non-enhanced central region was correlated to necrosis. Lactate signals were often observed in glioblastoma, abscess and sometimes metastasis, presumably reflecting the anaerobic glycolysis by the living cells in the ring-like enhanced rim. Single-voxel proton MR spectroscopy may serve as a potential tool to provide useful information of differentiation of ring-like enhanced lesions that cannot be diagnosed correctly using enhanced MR images alone.

Discrimination value of the new western prognostic system (CLIP score) for hepatocellular carcinoma in 662 Japanese patients. Cancer of the Liver Italian Program

To reliably estimate the prognoses of patients with hepatocellular carcinoma (HCC), both liver function and tumor-related factors should be accounted for. However, there are few worldwide staging systems that assess prognostic value in the context of selecting individual patients for randomized stratification in therapeutic and clinical trials. We investigated the value of known prognostic systems and verified the usefulness of the new scoring system proposed by the Cancer of the Liver Italian Program (CLIP), as determined from 662 Japanese patients. A retrospective analysis of the HCC diagnoses at 4 Japanese institutions from 1990 and 1998 was performed. Overall survival was the only end point used in the analysis. Discriminatory ability and predictive power of the CLIP score were compared with those of Okuda stage and AJCC TNM stage. Compared with the Okuda and AJCC staging systems, the CLIP score's enhanced discriminatory capacity, which was tested by the linear trend test and Harrels' c-index, revealed a class of patients with an impressively more favorable prognosis and another class with a relatively shorter life expectancy. Moreover, the likelihood ratio test showed that the CLIP score had additional homogeneity of survival within each score above that of the Okuda stage or the AJCC stage. This was true for 3 subgroups of patients who received surgery, transcatheter arterial chemoembolizations, and percutaneous ethanol injections. Collectively, these findings indicate that the CLIP score has the highest stratification ability with regard to prognosis in patients with HCC. The CLIP score could be used internationally to stratify randomization groups in therapeutic and clinical trials.

Putaminal hyperperfusion in dystonic posturing on subtracted SPECT: a case report

Dystonic posturing (DP) is one of the most reliable lateralizing symptoms for mesial temporal lobe epilepsy, although the mechanism remains unclear. We demonstrated a hyperperfusion area in the right putamen on subtracted postictal SPECT by using the automatic registration technique in one patient with ictal DP of the left hand. The putamen may play a key role in DP, similar to other diseases with dystonia.

Potato Tuber Necrotic Ringspot Disease Occurring in Japan: Its Association with Potato virus Y Necrotic Strain

Unfamiliar necrotic symptoms on or within potato tubers of cultivars Nishiyutaka and Dejima were observed in Nagasaki prefecture, Japan, in 1992. Symptoms were typically on the surface of the tuber, which either protruded at first and then became sunken, or showed necrotic spots, with necrosis within the tubers. Symptoms sometimes appeared at harvesting but more often appeared after storage for several months. Investigations revealed that the causal agents of the disease were isolates of Potato virus Y necrotic strain (PVY^NTN) and the disease was potato tuber necrotic ringspot disease (PTNRD), previously reported in Europe and Lebanon. Five potato cultivars were inoculated with an isolate from necrotic tubers. The highest percentage of progeny tubers showing PTNRD was found in cv. Nishiyutaka (23.3%). In contrast, cvs. Shima-bara, Mayqueen, and Danshaku showed a low percentage of PTNRD. Additional potato tubers with PTNRD were also observed after storage of the tubers. To investigate the relatedness between isolates of PVY^NTN and of necrotic strain PVY^N, previously isolated in Japan, Nishiyu-taka was inoculated with an isolate of PVY^N, which also induced PTNRD. Nucleotide sequences of coat protein (CP) genes of six PVY^NTN isolates were determined. The CPs were 267 amino acids in length, with a substitution of one or no amino acid among each of the six isolates. The phylogenetic relationship based on nucleotide sequences of CP genes showed that these six PVY^NTN isolates clustered together with PVY^N isolates. This is the first report of PTNRD caused by PVY^NTN isolates in Asia.

[Muscle involvement of Stormorken's syndrome]

We described two patients, a mother and daughter, of Stormorken's syndrome. The syndrome is characterized clinically by autosomal dominant inheritance, congenital miosis, thrombocytopenia, asplenia and muscle weakness. Both patients had bleeding tendency, ichthyosis of arms, and muscle weakness. The daughter additionally had short stature (146 cm), low body weight (32 kg) and muscle cramp. Neurological findings of the patients included migraine-like headache, cognitive dysfunction, limitation of upward and lateral gaze, and amydriasis. Femoral muscle MRI of the daughter demonstrated decreased volume with patchy high intensity areas in the hamstrings. A muscle biopsy from the daughter showed myogenic changes with muscle fiber necrosis and regeneration, variation in fiber size, tubular aggregates in approximately 5% of fibers, and fibrous tissue proliferation. Dystrophin, dystrophin-associated proteins and dysferlin were normally expressed. Although both patients had elevated creatine kinase levels and generalized muscle wasting, muscle weakness was mild with slow progression. A certain membrane defect in the platelet and muscle fiber might be responsible for the pathogenesis of this syndrome.

[A case of intracerebral and subarachnoid hemorrhage of unknown origin with preceding headache]

We report a case of a 31-year-old female with multiple intracerebral hemorrhage and subarachnoid hemorrhage. She presented with headache one week before hemorrhage, and a CT scan performed at that time showed no abnormal findings. Neurological examination on admission revealed mild disturbance of consciousness, papilledema, and mild left hemiparesis. CT scans demonstrated intracerebral hemorrhage in the right caudate head and left frontal subcortex, and diffuse subarachnoid hemorrhage. Cerebral angiogram and laboratory examination revealed no abnormal findings. Erythrocyte sedimentation rate, C reactive protein and antiphospholipid antibody were within normal ranges. The patient underwent removal of hematoma by craniotomy. One week after the operation, a subcutaneous hematoma in the area of the craniotomy was found. Cerebral angiography demonstrated an aneurysm of the right superficial temporal artery, which was remote from the craniotomy. This aneurysm was surgically removed and examined. Histopathological examination revealed the presence of a pseudoaneurysm but no inflammation. Although primary angitis of the central nervous system was suspected to be the cause of this disease, a definite diagnosis could not be obtained.

Increased band 3 protein aggregation and anti-band 3 binding of erythrocyte membranes on treatment with sesamol

The influence of sesamol, an antioxidant in processed sesame oil, on oxidative modification of human erythrocyte membrane proteins was investigated. Human erythrocytes were incubated with sesamol at various concentrations up to 10 mM at 37 degrees C for 1 h. The amounts of hemoglobin bound to the membranes and detergent C12E8-insoluble membrane protein aggregates were increased as the concentration of sesamol increased. Western blot analysis indicated that aggregates of band 3 protein were increased by the treatment. Binding of anti-band 3 antibody to the erythrocytes was increased by the treatment. Isolated cell membranes were incubated with sesamol similarly. Aggregates of band 3 protein were also increased, indicating that the band 3 protein aggregation was little affected by hemoglobin bound to the membranes. Aggregation of band 3 protein in the treatment of isolated cell membranes was partially prevented when the treatment was conducted under anaerobic conditions, suggesting that augmentation of the protein aggregation by sesamol involved both oxygen-dependent and oxygen-independent pathways. Among phenolics, sesamol showed a distinctive feature to increase band 3 protein aggregation in erythrocyte membranes and to enhance anti-band 3 binding to erythrocytes.

Factors that predict intrahepatic recurrence of hepatocellular carcinoma in 81 patients initially treated by percutaneous ethanol injection

BACKGROUND

In Japan, where liver transplantation has not been used to treat patients with hepatocellular carcinoma (HCC), percutaneous ethanol injection (PEI) has been employed for those with small HCCs that are not amenable to surgical resection. In the current study, the authors evaluated PEI as a treatment for HCC patients by studying recurrence rates and survival after treatment. They then examined the clinicopathologic factors that predicted patterns of local and distant intrahepatic recurrence.

METHODS

For 81 patients who underwent PEI as initial therapy between 1990 and 1997, the cumulative recurrence and survival rates and their correlations with 16 clinicopathologic factors were studied using the Kaplan-Meier method.

RESULTS

The 3-year overall cumulative rates of intrahepatic recurrence and survival were 81% and 84%, respectively. At the end of the observation period, intrahepatic recurrence was detected in 56 patients (69%). In 21 (38%) of 56 patients, local recurrences were significantly associated with earlier stages of underlying cirrhosis, decreased indocyanine green retention at 15 minutes (ICG R15), larger tumor size, and histologically advanced tumor grade. Distant intrahepatic recurrence was also significantly associated with liver function and ICG R15.

CONCLUSIONS

PEI is most effective as the initial treatment for patients with well-differentiated HCC when the tumor is less than 15 mm in greatest dimension. However, local recurrence depends predominantly on the biologic characteristics of the tumor, regardless of the efficacy of PEI. Surgical resection of HCC should be considered, especially for patients with mild liver dysfunction.

Factors that predict intrahepatic recurrence of hepatocellular carcinoma in 81 patients initially treated by percutaneous ethanol injection

BACKGROUND

In Japan, where liver transplantation has not been used to treat patients with hepatocellular carcinoma (HCC), percutaneous ethanol injection (PEI) has been employed for those with small HCCs that are not amenable to surgical resection. In the current study, the authors evaluated PEI as a treatment for HCC patients by studying recurrence rates and survival after treatment. They then examined the clinicopathologic factors that predicted patterns of local and distant intrahepatic recurrence.

METHODS

For 81 patients who underwent PEI as initial therapy between 1990 and 1997, the cumulative recurrence and survival rates and their correlations with 16 clinicopathologic factors were studied using the Kaplan-Meier method.

RESULTS

The 3-year overall cumulative rates of intrahepatic recurrence and survival were 81% and 84%, respectively. At the end of the observation period, intrahepatic recurrence was detected in 56 patients (69%). In 21 (38%) of 56 patients, local recurrences were significantly associated with earlier stages of underlying cirrhosis, decreased indocyanine green retention at 15 minutes (ICG R15), larger tumor size, and histologically advanced tumor grade. Distant intrahepatic recurrence was also significantly associated with liver function and ICG R15.

CONCLUSIONS

PEI is most effective as the initial treatment for patients with well-differentiated HCC when the tumor is less than 15 mm in greatest dimension. However, local recurrence depends predominantly on the biologic characteristics of the tumor, regardless of the efficacy of PEI. Surgical resection of HCC should be considered, especially for patients with mild liver dysfunction.

Unidirectional olfactory hallucination associated with ipsilateral unruptured intracranial aneurysm

PURPOSE

We describe a patient with complex partial seizure with unidirectional olfactory aura associated with ipsilateral unruptured aneurysm.

METHODS AND RESULTS

The patient felt a sweet pleasant smell coming from behind her right side every time before the attack. Cranial magnetic resonance imaging (MRI) and three-dimensional computed tomography (CT) angiography revealed a large aneurysm at the bifurcation of the right middle cerebral artery and compression of the right orbitofrontal cortex. Small spikes were recorded from the right orbitofrontal and superior temporal gyri and from the uncus by the cortical electrodes during clipping of the aneurysm.

CONCLUSIONS

The orbitofrontal cortex may have a function related to the ipsilateral directional olfactory sensation.

Using Gaussian-like input rate function in the two-compartment model. Formulation and application to analysis of didanosine plasma concentration in two Japanese hemophiliacs

We used a time-dependent input rate function in the two-compartment model to simulate drug plasma concentrations after an oral administration. The input rate term has a Gaussian-like structure with two parameters, time to maximum absorption rate (tm) and measure of the duration of the absorption process (s). This structure corresponds to the scenario in which the absorption rate of the drug into the central compartment changes unimodally with respect to time after administration with a single peak at time tm. We demonstrate the applicability of this formulation in the simulation of plasma concentration of didanosine after oral administration in two Japanese hemophiliacs. We found that we were able to simulate the time courses of the didanosine plasma concentrations in both patients using the theoretical equation with the input term included, and that we were able to determine the six parameters in the equation by the least squares estimation. Pharmacokinetic values derived from the best-fit curve were almost comparable to those reported in other literature except that the Cmax and AUC0-infinity seemed to be slightly higher than those reported elsewhere. Although we are unable to verify the accuracy of this formulation because of the lack of sufficient Japanese data, we are able to demonstrate its efficacy and convenience in the application presented here.

Consecutive in vivo measurement of nitric oxide in transient forebrain ischemic rat under normothermia and hypothermia

The effects of hypothermia on production of nitric oxide (NO) in ischemic brain were investigated by using in vivo microdialysis. Male Wistar rats were randomly divided into three groups; saline-treated normothermic group (37 degreesC, n=6), 30 mg/kg N-nitro-l-arginine methyl ester(l-NAME)-treated normothermic group (n=6), and saline-treated hypothermic group (30 degreesC, n=6). Transient forebrain ischemia was produced by bilateral common carotid artery occlusion combined with hypotension (MABP=50 mmHg). Saline-treated normothermic animals resulted in a reduction of LCBF to 9% of baseline. Saline-treated hypothermic rats revealed the similar changes of LCBF. In contrast, l-NAME administration reduced the basal CBF to 85% of saline-treated group and to 8% after ischemia. NO products were decreased during ischemia and transiently increased after reperfusion in saline-treated groups. However, the increase of NO products after reperfusion was less significant in the hypothermia. l-NAME-treated group showed a constant reduction of NO production during ischemia and after reperfusion.

Hypothermia attenuates hyperglycolysis in the periphery of ischemic core in rat brain

Hypothermia has proven to be neuroprotective against ischemic brain injury. However, the exact mechanism has not yet been fully understood. In this study, we investigated the effects of hypothermia on cerebral glucose metabolism and blood flow in focal ischemic rats. Rats were divided into normothermic (37+/-0.5 degrees C) and hypothermic (30+/-0.5 degrees C) groups. Focal cerebral ischemia was induced by middle cerebral and ipsilateral common carotid arteries occlusion. Two hours after ischemia, autoradiographic studies of 2-deoxyglucose and iodoantipyrine were performed to measure local cerebral glucose utilization (LCGU) and cerebral blood flow. LCGU in the ischemic core was excessively reduced in both groups. However, a marked increase in LCGU was observed in the boundary zone of the ischemic core in normothermic rats. On the other hand, hyperglycolysis in the boundary zone of the ischemic core was suppressed in hypothermia. This attenuation of hyperglycolysis might be closely related to survival of the ischemic penumbra in hypothermia.

[The effect of hippocampal dentate granule cell lesions upon the limbic seizure model of rats]

The purpose of this study was to determine the role of dentate granule cells upon limbic seizure of Wistar rat caused by unilateral intra-amygdaloid administration of kainic acid (KA). Stereotactic surgery was performed in Wistar rats and stainless steel injection chemitorode was inserted in the left amygdala. Left dentate granule cells lesion were induced by microinjection of colchicine. The rats obtained recovery period for 7 days, postoperatively. The rats were divided into two groups. One group were used for observation of symptoms and electroencephalographic findings during the limbic seizure for 6 hours after the KA injection. Another group was processed for measuring local cerebral glucose utilization (LCGU) during limbic seizure status. The histological study demonstrated a selective loss of dentate granule cells in the left hippocampus 7 days after the colchicine injection. After the KA injection, initiation of the spike discharge was significantly retarded not only in the hippocampus (from 6.01 min. to 37.25 min.) but also in the amygdala (from 2.96 min. to 10.8 min.). Progression, frequency and intensity of the KA induced seizures were also inhibited by the colchicine-induced dentate granule cells lesion. During limbic seizure status, LCGU obtained by 14C-deoxyglucose autoradiography were significantly decreased not only in the hippocampus but also in the amygdala on the site of KA injection. These data suggest that hippocampal dentate granule cells play an important role on initiation and progression of the KA induced limbic seizure. The result suggested that there was an acceleration mechanism of the limbic seizure between amygdala and hippocampus.

Temporary arterial occlusion during anterior communicating or anterior cerebral artery aneurysm operation under tibial nerve somatosensory evoked potential monitoring

BACKGROUND

Median nerve somatosensory evoked potentials (SEP) have been used as an indicator of cerebral ischemia in the territory of the middle cerebral artery. This study was designed to examine whether tibial nerve SEPs are a useful technique for detecting ischemia in the territory of the anterior cerebral artery (ACA) during aneurysm surgery.

METHODS

Tibial nerve SEP monitoring was employed in 15 patients who underwent temporary arterial occlusion during surgery for aneurysms of the anterior communicating artery (ACoA) or ACA. To evaluate tibial nerve SEPs, the data after anesthesia induction but before the start of surgery were used as the control and a more than 50% decrease in the amplitude of P40-N50 was regarded as a significant change.

RESULTS

Changes in SEP were recognized in 11 of these 15 patients. Unilateral A1 occlusion resulted in SEP changes in 4/7, while bilateral A1 interruption caused changes in 6/8 of the patient group. The allowable duration of interruption of the ACA cannot be determined by A1 dominance or the extent of development of the ACoA that can be recognized by angiography. The significance of the collateral circulation via the leptomeninges was indicated. Following the release of the occlusion, SEPs were restored to the control level in all patients and no new motor deficits were found.

CONCLUSIONS

It was concluded that tibial nerve SEP monitoring is a useful system to determine the extent of cerebral ischemia of the ACA territory during temporary arterial occlusion associated with surgery for aneurysms involving the ACA system.

Hypothermia attenuates the activation of protein kinase C in focal ischemic rat brain: dual autoradiographic study of [3H]phorbol 12,13-dibutyrate and iodo[14C]antipyrine

Using phorbol 12,13-dibutyrate (PDBu) autoradiography, we investigated the effect of hypothermia or protein kinase C (PKC) activation in rat brain 2 h after focal ischemia. In normothermia, a significant increase of PDBu binding was observed in ischemic brain. Hypothermia suppressed the increase of PDBu binding in degree and extent. These observations suggest that intraischemic hypothermia attenuates the activation of PKC, and this may in part be participate in the protective effect of hypothermia.

Dumbbell-shaped jugular foramen schwannoma

The authors present a case of dumbbell-shaped schwannoma arising from the vagus nerve. A 40-year-old woman was admitted with a 3-month history of hearing loss on the left ear without vertigo. Neuro-otological examinations revealed retrocochlear deafness with abnormal left vestibular function. Magnetic resonance imaging revealed a dumbbell-shaped tumor of the jugular foramen. The tumor was removed through a cervical-transmastoid approach using Cavitoron ultrasonic surgical aspiration. Two months after the operation, the patient's hearing loss had improved, although she still had some aspiration of saliva and hoarseness.

Suppression of acute experimental allergic encephalomyelitis in Lewis rats with a mycophenolic acid derivative

Oral administration of ethyl O-[N-(p-carboxyphenyl-carbamoyl]-mycophenolate (CAM), a derivative of mycophenolic acid (MPA) and an inosine monophosphate dehydrogenase inhibitor, dose-dependently suppressed acute experimental allergic encephalomyelitis in Lewis rats without exerting any serious adverse effects. A daily dose of 50 mg/kg of CAM almost completely abolished both the clinical disease and the inflammation in the CNS. In the CAM-treated rats, a weight loss and fluctuations of peripheral lymphocyte subsets were minimized. The CAM treatment was effective when started at the time of sensitization but ineffective when deferred till day 10. Furthermore, CAM reduced the percentage of CD4+CD45RC- cells in the peripheral blood. The only detectable adverse effect was moderate anemia but it was rapidly improved after withdrawal of the drug. This drug could be a useful adjunct for the long-term immunosuppressive therapy for inflammatory diseases of the CNS.

Dissociation of 99mTc-ECD and 99mTc-HMPAO distributions in herpes simplex encephalitis

In herpes simplex encephalitis (HSE), the authors noted an evident dissociation between the 99mTc-ethyl cysteinate dimer (ECD) and 99mTc-d,l-hexamethyl-propylene-amine oxime (HMPAO) single photon emission computed tomographies (SPECTs). The patient was a 5-year-old boy with diffuse type of pontine glioma, which was treated with hyperfractionated radiotherapy. Two weeks after the completion of radiation therapy, a lesion suggesting that of HSE was noted in the right fronto-temporal region on magnetic resonance images. 99mTc-HMPAO SPECT showed an increased accumulation of the tracer in this lesion. On the 99mTc-ECD dynamic SPECT, an exaggerated accumulation of the tracer was noted within 80 s of administration, followed by a rapid drop in the accumulation, resulting in a low accumulation in 10 min. It was assumed that this dissociation was due to the different mechanisms to trap HMPAO and ECD in the brain tissue.

Aneurysms located at the horizontal segment of the anterior cerebral artery or the middle cerebral artery

Aneurysms at the horizontal segment of the middle cerebral artery or anterior cerebral artery are relatively rare. The characteristics of 13 cases were analyzed retrospectively. Six of the 13 cases had multiple aneurysms, nine had aneurysmal rupture, and three of these nine were complicated by intracerebral hematoma. Neck clipping of the aneurysm was performed in 11 cases and four developed new cerebral infarction in the territory of the perforating arteries. Overall mortality and morbidity was 15% and 38%, respectively. The outcome for patients with aneurysms at these sites was evidently poorer than for those with aneurysms at other sites.

Protein kinase C in focal ischemic rat brain: dual autoradiographic analysis of [14C]iodoantipyrine (IAP) and [3H]phorbol-12,13-dibutyrate (PDBu)

Protein kinase C (PKC) activity was measured in rat brain with 2 h of middle cerebral artery (MCA) and common carotid artery (CCA) occlusion, using dual autoradiography of [14C]iodoantipyrine (IAP) and [3H]phorbol-12,13-dibutyrate (PDBu). In the ischemic brain, it required more than 120 min of incubation to obtain a plateau in PDBu binding. In contrast, the binding of PDBu in non-ischemic brain reached a plateau with incubation for 60 min. This delay of PDBu binding in the ischemic brain suggests that the affinity of this ligand is reduced due to a change in structure of the cell membrane caused by ischemia. PDBu binding in the ischemic brain increased significantly compared to the non-ischemic brain. This finding provides further evidence that excessive activation of PKC in the ischemic brain may play an important role in ischemic neuronal damage.

Glial cyst in the thalamus with intracystic hemorrhage--case report

A 19-year-old female presented with an unusual glial cyst of the thalamus that caused development of acute hydrocephalus due to hemorrhage and manifested as headache and fainting attacks. Computed tomography showed a large cystic mass lesion in the left thalamus with intracystic hemorrhage. The cyst was subtotally removed. Microscopic examination revealed mild gliosis with marked hemosiderin deposits. The inner surface of the cystic wall lacked an epithelial lining. The diagnosis was glial cyst. Magnetic resonance (MR) imaging 2 months after surgery showed a residual cyst in the left thalamus. However, after 12 months she was asymptomatic, neurologically intact, and MR imaging showed no regrowth of the cyst. Treatment of glial cyst must provide sufficient communication between the cyst and the cerebral ventricles rather than attempt total removal of the cyst, which may present a considerable challenge.

Sequential changes in cerebrovascular reserve capacity in three-vessel occlusion rats

To understand the pathophysiology of hemodynamic compromise, we evaluated the cerebrovascular reserve capacity of a cerebral hemisphere in rats with 3-vessel occlusion (3VO). The bilateral vertebral and left common carotid arteries were occluded in Wistar rats. Sequential changes in local cerebral blood flow (LCBF) and local cerebral plasma volume (LCPV) were measured by [14C]iodoantipyrine and [14C]dextran autoradiography, respectively. There was no significant difference in LCBF between 3VO and control rats at rest. After acetazolamide administration, however, an increase of LCBF in the left hemisphere was less significant compared to that in the right side in the 3VO rats. The left and right ratio was 0.67 +/- 0.15 (P < 0.05) in the parietal cortex and 0.70 +/- 0.10 (P < 0.01) in the caudate nucleus. This asymmetrical response to acetazolamide administration gradually corrected by 7 days after 3VO. A significant increase of the LCPV in the ischemic side was observed between day 0 and the 5th day. The 3VO rat is a useful model for studies on the pathophysiology of a hemodynamically compromised state.

[Familial multiple cavernous angioma in the brain and spinal cord]

We reported two patients from the same family underwent operation for neurological symptoms due to vascular lesions that were proved on pathological examination to be cavernous angiomas. Case 1, a 64-year-old woman was admitted to our hospital because of paraparesis. MRI revealed a mass lesion with high signal intensity in T1 and T2 weighted images at T3-4 level. Complete excision was carried out and diagnosis of cavernous angioma was made. Three years later, she experienced a mild headache and dizziness. CT scan demonstrated a subcortical hematoma in the right frontal lobe. Postoperative pathological diagnosis was cavernous angioma. Case 2, a 65-year-old woman (younger sister of case 1) was operated for the tumor of spinal cord, and diagnosed as a cavernous angioma. Two years later, she developed diplopia and ataxic gait. MRI showed multiple cavernous angioma in the brain including pons. Pontine lesion which was responsible for this episode was removed, and diagnosis was a cavernous angioma histopathologically.