Multidrug chemotherapy, whole-brain radiation and cytarabine therapy for primary central nervous system lymphoma in elderly patients with dose modification based on geriatric assessment: study protocol for a phase II, multicentre, non-randomised study

INTRODUCTION

Multidrug chemoimmunotherapy with rituximab, high-dose methotrexate, procarbazine and vincristine (R-MPV) is a standard therapy for younger patients with primary central nervous system lymphoma (PCNSL); however, prospective data regarding its use in elderly patients are lacking. This multi-institutional, non-randomised, phase II trial will assess the efficacy and safety of R-MPV and high-dose cytarabine (HD-AraC) for geriatric patients with newly diagnosed PCNSL.

METHODS AND ANALYSIS

Forty-five elderly patients will be included. If R-MPV does not achieve complete response, the patients will undergo reduced-dose, whole-brain radiotherapy comprising 23.4 Gy/13 fractions, followed by local boost radiotherapy comprising 21.6 Gy/12 fractions. After achieving complete response using R-MPV with or without radiotherapy, the patients will undergo two courses of HD-AraC. All patients will undergo baseline geriatric 8 (G8) assessment before HD-AraC and after three, five and seven R-MPV courses. Patients with screening scores of ≥14 points that decrease to <14 points during subsequent treatment, or those with screening scores <14 points that decrease from the baseline during subsequent treatment are considered unfit for R-MPV/HD-AraC. The primary endpoint is overall survival, and the secondary endpoints are progression-free survival, treatment failure-free survival and frequency of adverse events. The results will guide a later phase III trial and provide information about the utility of a geriatric assessment for defining chemotherapy ineligibility.

ETHICS AND DISSEMINATION

This study complies with the latest Declaration of Helsinki. Written informed consent will be obtained. All participants can quit the study without penalty or impact on treatment. The protocol for the study, statistical analysis plan and informed consent form have been approved by the Certified Review Board at Hiroshima University (CRB6180006) (approval number: CRB2018-0011). The study is ongoing within nine tertiary and two secondary hospitals in Japan. The findings of this trial will be disseminated through national and international presentations and peer-reviewed publications.

TRIAL REGISTRATION

jRCTs061180093.

NQPC-6 CHANGE ON STANDING OF HEALTH RELATED QOL IN BRAIN TUMOR AND STROKE PATIENTS ON A VOCATIONAL REHABILITATION PROGRAM

Introduction

It is important for brain tumor and stroke patients to evaluate not only prognosis but also health related QOL (HRQoL). In this study, we have evaluated HRQoL and reviewed the related factors to improve HRQoL through in hospital to after discharge.

Methods

One hundred-eighteen brain tumor (n=21) and stroke patients (n=97) of one hundred-thirty-one patients in our vocational rehabilitation program were enrolled. We evaluated HRQoL using EORTC QLQ-C30/BN-20 on admission, pre- and six months after discharge and examined the influence factor.

Results

In QLQ-C30 assessment on admission, although physical functioning (F), role F, social F and financial difficulties were lower than borderline, improved up to the standard healthy level by discharge. While future uncertainty score in BN-20 improved from 40points (p) to 30p, that has averaged higher value of 49p to 47p in brain tumor patients. On an individual basis, the score of 30% of global health status cases, 9% of physical F, 37% of financial F and 18% of future uncertainty deteriorated during the course of hospitalization significantly. While scores of all categories in stroke patients were improved, those of emotional F (-15.4p), social F (-14.3%), pain (+10.5p) and insomnia (+21.2p) in brain tumor patients were deteriorated, the tendency of which was especially prominent in malignant brain tumor. KPS and motor FIM in brain tumor patients correlated to physical F, and mRS and motor FIM in stroke to functioning scale strongly, to symptom scale moderately.

Conclusion

QOL evaluation can reveal the HRQoL deterioration in patients hard to detect the symptom. Appropriate intervention is needed because some cases deteriorate on an individual basis, especially brain tumor patients while HRQoL has almost improved with time. Rehabilitation therapy could contribute to HRQoL improvement because that strongly correlates to examination data of motor function.

NQPC-2 Cognitive function of a low-grade glioma patient treated with radiation therapy 28 years ago

While there are many reports that long-term survivors of low-grade glioma patients treated with radiation therapy cannot lead a healthy social life due to cognitive dysfunction, we report a low-grade glioma patient with almost normal cognitive function even after radiation therapy 28 years ago. CASE REPORT. A 64-year-old woman developed with sudden left hemiparesis and was diagnosed as a small infarction in the left corona radiata. After treated by anticoagulant therapy, she was admitted to our hospital for rehabilitation. Twenty-eight years ago, she underwent surgical resection and radiation therapy with 60 Gy for astrocytoma (WHO grade 2) in the right insular cortex. At the time of this admission, she presented with a good MMSE score of 30 points, but she couldn’t walk and her left hand was less maneuverable. After 109 days of intensive rehabilitation in our hospital, she was discharged on a cane walk, and returned to work as a gas station clerk. COGNITIVE FUNCION. We evaluated her cognitive function on TMT-A/B test, CAT (Clinical Assessment for Attention)and WAIS-4. The TMT test was normal with age adjustments. In CAT, the percentage of correct answers for the 7 constituent items was within the standard range, but in the task of evaluating the required time, a slight delay in processing speed was observed. In WAIS-4, the Full scale IQ was 98 points (normal range) including normal 3 of 4 constituent items. But, only the PSI (processing speed) of 75 point was below the standard range. CONCLUSION: We observed a slight delay in processing speed on her high-level cognitive function tests, but determined that she would be well-adapted to a familiar job in a small community. In fact, she was doing well on the job 10 months after her discharge.

NQPC-3 A short-time intensive rehabilitation for brain tumor patients with Karnofsky Performance Status of 60-30

OBJECTIVE: Brain tumor patients with KPS of 60 to 30 after the initial treatment are not able to spend independent life at home. The goal of this study is to return these patients to their home with minimal family support by delivering intensive rehabilitation to them. Seventy-five brain patients were evaluated every 10 days from the beginning to the end of rehabilitation treatment, according to clinical scales of Functional Independence Measure (FIM) of 1–7 points depending on the degree of independence. The rehabilitation effect was judged by the degree of improvement of 11 out of 13 motor FIM items, excluding stair climbing and bathing movements. When more than half number of the 11 motor FIM items requiring physical assistance (4 points or less) improved up to non-assistance (5 points or more), it was judged as a significant effect. In addition, when all 11 items present with 6 points (independence possible) or more and all 5 of FIM recognition items are 5 points or more (understand the domestic rules), it was judged that the patients acquired independent living ability. RESULTS: 1. Of the 75 patients, 54 (72%) showed a significant effect, and 38 of them (50.7% of the total) aquired independence at home. The acquisition-rate of independent living ability by tumor was 44.7% for 38 malignant gliomas, 53.8% for 13 metastatic tumors, 50% for 14 meningiomas, and 71.4% for 7 vascular tumors, and there was no significant difference between them. 2. The median time to reach the maximum rehabilitation effect was 35 days. CONCLUSION: Intensive rehabilitation for brain tumor patients with KPS of 60 to 30 is effective and should be incorporated into the palliative treatments in the brain tumor treatment guidelines.

NQPC-7 Rehabilitation program toward reinstatement support based on network construction among related departments for the patients after treatment of brain disease including brain tumor

Introduction: We have conducted a rehabilitation program to support a return to work for patients with brain disease since 2019. The program focuses on independence in the home environment; physical ability for desk work, commuting and conversation; and concentration and executive ability in the office. The “Promotion of Health and Employment Support” document of the Ministry of Health, Labour and Welfare has been used to update the program since May 2021. Here, we report the status of this program.Methods: Patients desiring employment reinstatement attended the program. A doctor first gave an overview. Social workers then used the QLQ-C30/BN-20 questionnaire to assess mental and physical health, a therapist evaluated physical and higher cognitive function, and nurses advised on work-life balance and mental state. This information was used to develop suitable rehabilitation for each patient. The employment situation was surveyed after discharge. Results: The program included 77 patients (55 men, 22 women, mean age 54) from January 2019 to July 2021, after treatment for stroke (n=55), brain tumor (n=14), and traumatic brain injury or other conditions (n=8). FIM (94.2) and MMSE (26.3) at admission indicated that almost all patients were independent in ADL. A return to work was achieved by 25 (83%) of the 30 patients that could be investigated, including all 4 with brain tumors. The period until reinstatement was &lt;1 month in 16 cases, but &gt;1 month in 3 with brain tumors. The program was found useful by 26 patients (86%). Employment reinstatement was not achieved due to company reasons and family circumstances. Only 4 patients were interviewed by an industrial physician. Conclusion: The physical and cognitive functions of patients wishing for employment reinstatement were relatively well maintained. Cooperation with the company, information sharing with an industrial physician, and adjustment to the home environment were also important for reinstatement.

NQPC-08 Short-time intensive rehabilitation for patients with newly diagnosed glioblastoma

PURPOSE: Many reports presented that patients with GBM had stable HRQoL during their remission time. However, there are few reports on the situation of ADL that is the basis of QOL. This prospective study was designed to evaluate the effectiveness of intensive rehabilitation for physically disabled patients with GBM after the initial treatment. PATIENTS and METHOD: Sixteen patients with newly-diagnosed glioblastoma presenting with severe physical disabilities were registered after the completion of postsurgical radiation therapy combined with TMZ. All patients were evaluated by means of a core set of clinical scales of Functional Independence Measure (FIM), Sitting Balance score, Standing Balance score, and Mini-mental State Examination (MMSE). Patients were evaluated before the beginning and at the end of rehabilitation treatment. The daily rehabilitation program consisted of individual 180-min. sessions of treatment, seven days a week, for four to six consecutive weeks. Speech therapy was included when aphasia was diagnosed. RESULTS: Fifteen of 16 patients presented with improved physical functioning score, and seven of 16 patients returned to their independent life at home, CONCLUSION: A short-time intensive rehabilitation (4 to 6seeks) is effective for GBM patients during TMZ withdrawal period after the postoperative radiation therapy. This effective program requires close teamwork with the medical cooperation teams in the medical and rehabilitation hospitals: explanation to patients of the significance of the short-term rehabilitation, which is different from stroke rehabilitation, adjustment of hospitalization date considering radiotherapy and chemotherapy schedule, and adjustment of MRI imaging or bevacizumab administration schedule during rehabilitation.

Successful treatment of a case of tentorial dural arteriovenous fistula causing subarachnoid hemorrhage with invagination of the brainstem by huge and multiple venous pouches

Background:

We present a case of tentorial dural arteriovenous fistula (TDAVF) causing subarachnoid hemorrhage with mass effect of large venous pouches, which was struggling to diagnosis and management due to complex vasculature and severe general condition.

Case Description:

A 43-year-old man was transferred to our hospital due to sudden consciousness disturbance. A neurological examination revealed tetraparesis and pupil dilatation with no light reflex. Imaging findings showed a large lesion in the brainstem with subarachnoid and intraventricular hemorrhage. Since there were multiple feeding arteries and large and multiple venous pouches on vascular imaging, we diagnosed the patient with TDAVF. Because of a high-flow arteriovenous shunt and the presence of large venous pouches, it appeared to be very difficult to approach the shunting point by direct surgery. Therefore, we first performed transarterial endovascular treatment with 25% n-butyl-2-cyanoacrylate to shrink the venous pouches and to reduce the pressure of the posterior fossa, followed by direct radical interruption of the shunting point using the craniotomy maneuver. Postoperative vascular imaging revealed disappearance of abnormal feeding arteries, draining veins, and venous pouches. The patient was discharged and transferred to a rehabilitation hospital with a modified Rankin Scale Score of 3. Accurate interpretation of the detailed vasculature preoperatively and an appropriate treatment strategy using endovascular and direct surgical technique are required to achieve a satisfactory outcome for difficult-to-treat dural arteriovenous fistulas.

Conclusions:

This combined maneuver with endovascular embolism as complementary pretreatment for radical surgery is useful for a case with high-flow shunting and large venous pouches.

A surgical strategy using a fusion image constructed from 11C-methionine PET, 18F-FDG-PET and MRI for glioma with no or minimum contrast enhancement

The objective of this study was to investigate the distribution of 11C-methionine (MET) and F-18 fluorodeoxyglucose (FDG) uptake in positron emission tomography (PET) imaging and the hyperintense area in T2 weighted imaging (T2WI) in glioma with no or poor gadolinium enhancement in magnetic resonance imaging (GdMRI). Cases were also analyzed pathologically. We prospectively investigated 16 patients with non- or minimally enhancing (< 10% volume) glioma. All patients underwent MET-PET and FDG-PET scans preoperatively. After delineating the tumor based on MET uptake, integrated 3D images from FDG-PET and MRI (GdMRI, T2WI or FLAIR) were generated and the final resection plane was planned. This resection plane was determined intraoperatively using the navigation-guided fencepost method. The delineation obtained by MET-PET imaging was larger than that with GdMRI in all cases with an enhanced effect. In contrast, the T2WI-abnormal signal area (T2WI+) tended to be larger than the MET uptake area (MET+). Tumor resection was > 95% in the non-eloquent area in 4/5 cases (80%), whereas 10 of 11 cases (90.9%) had partial resection in the eloquent area. In a case including the language area, 92% resection was achieved based on the MET-uptake area, in contrast to T2WI-based partial resection (65%), because the T2WI+/MET- area defined the language area. Pathological findings showed that the T2WI+/MET+ area is glioma, whereas 6 of 9 T2WI+/MET- lesions included normal tissues. Tissue from T2W1+/MET+/FDG+/GdMRI+ lesions gave an accurate diagnosis of grade in six cases. Non- or minimally enhancing gliomas were classified as having a MET uptake area that totally or partially overlapped with the T2WI hyperintense area. Resection planning with or without a metabolically active area in non- or minimally enhancing gliomas may be useful for accurate diagnosis, malignancy grading, and particularly for eloquent area although further study is needed to analyze the T2WI+/MET- area.

Metastatic cerebellar tumor of papillary thyroid carcinoma mimicking cerebellar hemangioblastoma

INTRODUCTION

Well-differentiated papillary thyroid carcinoma generally (PTC) have a favorable prognosis. This metastasis is rare in the central nervous system. Brain metastasis has a relatively poor prognosis. We present a rare case of cerebellar metastasis, one that mimics a solid type cerebellar hemangioblastoma and because of which it was very hard to reach accurate preoperative diagnosis. Accurate diagnosis was challenging because of the similar imaging and histopathological findings for these two tumors.

CASE DESCRIPTION

A brain lesion was detected by routine medical checkup of the brain with MRI in a 49-year-old woman 2 years after thyroidectomy for well-differentiated PTC. Gadolinium-enhanced MRI showed a homogeneous prominently enhanced lesion with surrounding enhanced dilated vessels in the left cerebellar hemisphere. Digital subtraction angiography showed a strongly stained lesion fed by the peripheral branch of the left posterior inferior cerebellar artery with drainage into the inferior vermian vein, revealing arteriovenous shunting. The most like likely preoperative diagnosis was felt to be that of a solid cerebellar hemangioblastoma. Gross total resection of the tumor was achieved by bilateral suboccipital craniotomy, and intraoperative pathological analysis suggested hemangioblastoma. Histopathological findings showed proliferation of vacuolated sheeted tumor cells with clear and eosinophilic cytoplasm and numerous thin-walled microvessels, consistent with hemangioblastoma. However, the final diagnosis was brain metastasis of the follicular variant of PTC due to a partial thyroid follicle-like pattern including eosinophilic fluid pathologically and positive TTF-1 immunostaining.

DISCUSSION AND EVALUATION

Since presented rare case of cerebellar metastasis of PTC was very similar to solid type cerebellar hemangioblastoma on imaging and histopathological findings, accurate diagnosis was challenging. Moreover, it is extremely rare for a cerebellar metastasis to occur as an initial distant metastasis of PTC, and hemangioblastoma is the most common primary cerebellar neoplasm in adults. This epidemiological data was also one of the reason of difficulty to reach preoperative accurate diagnosis.

CONCLUSIONS

To the best of our knowledge, there are no other reports of challenging diagnosis case of these two tumors in the literature. Brain metastasis of a well-differentiated PTC could be a relatively poor prognostic factor, and accurate diagnosis and suitable surgical therapy or radiotherapy are needed.

Avoidance of ischemic complications after resection of a brain lesion based on intraoperative real-time recognition of the vasculature using laser speckle flow imaging

OBJECTIVE To avoid ischemic complications, it is important to consider the arteries in resection planning for lesions such as a vascular intraparenchymal tumor and arteriovenous malformation. Here, the clinical application of laser speckle flow imaging (LSFI) as a complementary method for the management of mass lesion-related arteries during surgery was evaluated. METHODS LSFI was performed in 12 patients with mass lesion-related arteries and brain tumor or arteriovenous malformation. The portable LSFI device was centered over the surgical field, and the relative cerebral blood flow (CBF) before and after the temporary interruption of the arteries was measured through continuous recording. CBF fluctuations permitted the classification of 3 kinds of artery-a feeding artery (FA), a "passing through" artery (PA), and a combined FA and PA (FA+PA)-based on decreased relative CBF in the inner resection area and unchanged CBF in the surrounding area (FA), unchanged CBF in the inner area and decreased CBF in the surrounding area (PA), or decreased CBF in both areas (FA+PA). This information allowed the appropriate management of these arteries and avoidance of postoperative ischemic complications. RESULTS Good visualization of CBF in the surgical field and relative CBF measurements in the regions of interest were achieved in real time with excellent spatiotemporal resolution. In 11 patients (92%) and 20 regions of interest, a decline in CBF was observed after temporary interruption of the FA (n = 8), PA (n = 2), and FA+PA (n = 2) types. There was a significant average reduction in CBF of 15.3% ± 29.0%. There were no ischemic complications, and only 1 patient had a postoperative ischemic lesion caused by resection through an artery that could not be viewed by LSFI due to a positional problem. CONCLUSIONS LSFI permits noninvasive and rapid intraoperative real-time recognition of mass lesion-related vasculature. This information can be used to avoid ischemic complications as a procedure complementary to neurophysiological monitoring.

Strategies and Pitfalls of Motor-Evoked Potential Monitoring during Supratentorial Aneurysm Surgery

BACKGROUND

The aims of this study were to reveal the strategies and pitfalls of motor-evoked potential (MEP) monitoring methods during supratentorial aneurysm surgery, and to discuss the drawbacks and advantages of each method by reviewing our experiences.

METHODS

Intraoperative MEP monitoring was performed in 250 patients. Results from 4 monitoring techniques using combinations of 2 stimulation sites and 2 recording sites were analyzed retrospectively.

RESULTS

MEP was recorded successfully in 243 patients (97.2%). Direct cortical stimulation (DCS)-spinal recorded MEP (sMEP) was used in 134 patients, DCS-muscle recorded MEP (mMEP) in 97, transcranial electrical stimulation (TES)-mMEP in 11 and TES-sMEP in 1. TES-mMEP during closure of the skull was used in 21 patients. DCS-mMEP was able to detect waveforms from upper and/or lower limb muscles. Alternatively, DCS-sMEP (direct [D]-wave) could accurately estimate amplitude changes. A novel "early warning sign" indicating ischemia was found in 21 patients, which started with a transiently increased amplitude of D-wave and then decreased after proximal interruption of major arteries. False-negative findings in MEP monitoring in 2 patients were caused by a blood insufficiency in the lenticulostriate artery and by a TES-sMEP recording, respectively.

CONCLUSIONS

The results of this study suggest that to perform accurate MEP monitoring, DCS-mMEP or DCS-sMEP recording should be used as the situation demands, with combined use of TES-mMEP recording during closure of the skull. DCS-sMEP is recommended for accurate analysis of waveforms. We also propose a novel "early warning sign" of blood insufficiency in the D-wave.

Fatty acid binding protein 7 as a marker of glioma stem cells

Glioblastomas are the most aggressive brain tumors. Glioblastoma stem cells (GSCs) are thought to be responsible for the recurrence, chemoresistance, and poor prognosis of glioblastoma. Fatty acid binding protein 7 (FABP7), which is a cellular chaperone for a variety of omega-3 fatty acids, is a known marker for neural stem cells. In this study, using a newly developed anti-FABP7 antibody and patient-derived GSC lines, we evaluated the expression of FABP7 in GSCs. Using immunocytochemistry, Western blotting, and qPCR analyses, FABP7 was found to be highly enriched in GSCs and its localization was found in cytosol and nuclei. FABP7 expression was significantly downregulated in differentiated GSCs induced by the addition of serum. In the glioma surgical specimens, FABP7 was highly expressed in the majority of glioblastoma. Double immunostaining for FABP7 and Sox2 showed that FABP7(+) Sox2(+) tumor cells were significantly increased in glioblastoma (grade IV) compared with diffuse astrocytoma (grade II) and anaplastic astrocytoma (grade III). Our data introduces FABP7 as a marker for GSCs and further highlights its possible significance for glioma diagnosis and treatment.

Characteristics of intraoperative abnormal hemodynamics during resection of an intra-fourth ventricular tumor located on the dorsal medulla oblongata

Abnormal hemodynamics during extirpation of a para-medulla oblongata (MO) tumor is common and may be associated with direct vagal stimulation of the medullary circuit. However, resection of tumors on the dorsal MO may also induce hemodynamic instability without direct vagal stimulus. The objective of this study was to examine the characteristics of hemodynamic instability unrelated to vagal stimulus during dissection of an intra-fourth ventricular tumor with attachment to the dorsal MO. A retrospective analysis was performed in 13 patients. Abnormal hemodynamics were defined as a > 20% change from the means of the intraoperative mean arterial pressure (MAP) and heart rate (HR). Relationships of intraoperative hemodynamics were evaluated with various parameters, including the volume of the MO. Six patients (46.2%) had intraoperative hypertension during separation of the tumor bulk from the dorsal MO. The maximum MAP and HR in these patients were significantly greater than those in patients with normal hemodynamics (116.0 ± 18.0 mmHg versus 85.6 ± 6.5 mmHg; 124.3 ± 22.8 bpm versus 90.5 ± 14.7 bpm). All six cases with abnormal hemodynamics showed hemodynamic fluctuation during separation of the tumor bulk from the dorsal MO. The preoperative volume of the MO in these patients was 1.11 cc less than that in patients with normal hemodynamics, but the volume after tumor resection was similar in the two groups (5.23 cc and 5.12 cc). This suggests that the MO was compressed by the conglutinate tumor bulk, with resultant fluctuation of hemodynamics. Recognition of and preparation for this phenomenon are important for surgery on a tumor located on the dorsal MO.

Cortical region-specific engraftment of embryonic stem cell-derived neural progenitor cells restores axonal sprouting to a subcortical target and achieves motor functional recovery in a mouse model of neonatal hypoxic-ischemic brain injury

Hypoxic-ischemic encephalopathy (HIE) at birth could cause cerebral palsy (CP), mental retardation, and epilepsy, which last throughout the individual's lifetime. However, few restorative treatments for ischemic tissue are currently available. Cell replacement therapy offers the potential to rescue brain damage caused by HI and to restore motor function. In the present study, we evaluated the ability of embryonic stem cell-derived neural progenitor cells (ES-NPCs) to become cortical deep layer neurons, to restore the neural network, and to repair brain damage in an HIE mouse model. ES cells stably expressing the reporter gene GFP are induced to a neural precursor state by stromal cell co-culture. Forty-hours after the induction of HIE, animals were grafted with ES-NPCs targeting the deep layer of the motor cortex in the ischemic brain. Motor function was evaluated 3 weeks after transplantation. Immunohistochemistry and neuroanatomical tracing with GFP were used to analyze neuronal differentiation and axonal sprouting. ES-NPCs could differentiate to cortical neurons with pyramidal morphology and expressed the deep layer-specific marker, Ctip2. The graft showed good survival and an appropriate innervation pattern via axonal sprouting from engrafted cells in the ischemic brain. The motor functions of the transplanted HIE mice also improved significantly compared to the sham-transplanted group. These findings suggest that cortical region specific engraftment of preconditioned cortical precursor cells could support motor functional recovery in the HIE model. It is not clear whether this is a direct effect of the engrafted cells or due to neurotrophic factors produced by these cells. These results suggest that cortical region-specific NPC engraftment is a promising therapeutic approach for brain repair.

Stereotactic radiosurgery/radiotherapy for pituitary adenomas: a review of recent literature

The recent clinical results are reviewed of stereotactic radiosurgery/radiotherapy for the treatment of pituitary adenomas. The outcomes of pituitary adenomas treated by stereotactic radiosurgery/radiotherapy with gamma knife, CyberKnife, or linear accelerator (LINAC) radiosurgery were evaluated from articles published after 2004. Each study was evaluated for the number of patients, radiosurgical parameter (marginal dose), length of follow up, tumor growth control, rate of hormonal normalization in secretary adenomas, and adverse events. After gamma knife radiosurgery, the tumor reduction rates varied from 42.3% to 89% in non-secreting adenomas. However, the tumor control rates in non-secreting adenomas were more than 90% in most studies. In growth hormone-secreting adenomas, the rates of insulin-like growth factor-1 normalization ranged from 36.9% to 82%. In adrenocorticotropin-secreting adenomas, the rates for 24-hour urine free cortisol normalization ranged from 27.9% to 54%. In prolactin-secreting adenomas, the prolactin normalization ranged from 17.4% to 50%. New hormonal deficits ranged from 0% to 34%. New visual deficits were relatively low. The number of patients treated with CyberKnife and LINAC radiosurgery/radiotherapy was small and follow-up periods were relatively short compared to those with gamma knife treatment, but the clinical outcomes after these therapies were similar to those after gamma knife therapy. Image-guided stereotactic radiosurgery/radiotherapy with the gamma knife, CyberKnife, or LINAC system is effective and safe against pituitary adenomas. Careful long-term follow up of the patients is necessary because of long-term anti-tumor effects and delayed adverse events.

The effect of hypothermia therapy on cortical laminar disruption following ischemic injury in neonatal mice

Hypothermia has been proposed as a treatment for reducing neuronal damage in the brain induced by hypoxic ischemia. In the developing brain, hypoxic ischemia-induced injury may give rise to cerebral palsy (CP). However, it is unknown whether hypothermia might affect the development of CP. The purpose of this study was to investigate whether hypothermia would have a protective effect on the brains of immature, 3-day old (P3) mice after a challenge of cerebral ischemia. Cerebral ischemia was induced in P3 mice with a right common carotid artery ligation followed by hypoxia (6% O2, 37°C) for 30 min. Immediately after hypoxic ischemia, mice were exposed to hypothermia (32°C) or normothermia (37°C) for 24 h. At 4 weeks of age, mouse motor development was tested in a behavioral test. Mice were sacrificed at P4, P7, and 5 weeks to examine brain morphology. The laminar structure of the cortex was examined with immunohistochemistry (Cux1/Ctip2); the number of neurons was counted; and the expression of myelin basic protein (MBP) was determined. The hypothermia treatment was associated with improved neurological outcomes in the behavioral test. In the normothermia group, histological analyses indicated reduced numbers of neurons, reduced cortical laminar thickness in the deep, ischemic cortical layers, and significant reduction in MBP expression in the ischemic cortex compared to the contralateral cortex. In the hypothermia group, no reductions were noted in deep cortical layer thickness and in MBP expression in the ischemic cortex compared to the contralateral cortex. At 24 h after the hypothermia treatment prevented the neuronal cell death that had predominantly occurred in the ischemic cortical deep layers with normothermia treatment. Our findings may provide a preclinical basis for testing hypothermal therapies in patients with CP induced by hypoxic ischemia in the preterm period.

[Insular psammomatous meningioma presenting intractable complex partial seizures]

We describe a 30-year-old female with intractable symptomatic epilepsy caused by an insular calcified mass, which was histologically proved as psammomatous meningioma. Seizures were described as consciousness impairment, motionless stare and automatism. After total removal of the tumor with a neuronavigation system and motor evoked potential (MEP) monitoring, seizures completely disappeared without neurological deficit. We emphasize that insular meningioma presents complex partial seizures which mimic medial temporal lobe epilepsy and seizures are controlled by total resection of the tumor.

Abstract 2456: Quantitative Analysis Of Hemorrhage Volume For Predicting Cerebral Vasospasm After Subarachnoid Hemorrhage Between Surgical Clipping And Coil Embolization

Objective: Subarachnoid clots are important in development of delayed vasospasm after subarachnoid hemorrhage (SAH). The purpose of this study was to define the association between the subarachnoid clot volume and the incidence of symptomatic vasospasm (SV) after surgical clipping and embolization with Guglielmi detachable coils (GDCs) for aneurysmal SAH.

Methods: The subjects were 155 patients with aneurysmal SAHs that were detected with a CT scan at admission and were treated by surgical clipping (Clip group, n=112) or GDC embolization (Coil group, n=43) within 72 hours of ictus between January 22, 2002 and November 22, 2009. Software-based volumetric quantification of the subarachnoid clot was performed using the voxel count method (AZE Virtual Place Fujin Raijin, AZE Ltd.). Subarachnoid clot was defined as cisternal high density areas with a Hounsfield number from 43 to 90 in the CT scan.

Results: SV occurred in 24.1% and 16.3% of the patients in the Clip group (age, 63.5±12.8; male, 33.9%) and the Coil group (age, 63.0±12.6; male, 18.6%), respectively. The area under the ROC curve for subarachnoid clots for SV patients was 0.588 (95% confidence interval: 0.472-0.704; Clip group) and 0.849 (95% confidence interval: 0.714-0.985; Coil group). Using subarachnoid clot volumes of 19.6 ml (Clip group) and 32.1 ml (Coil group) as the cut-off values, the sensitivity and specificity were 89 and 39% (Clip group) and 100 and 61% (Coil group), respectively. A χ 2 test also identified that subarachnoid clots (>19.0 ml) were associated with the development of SV compared to lower blood volumes in the Clip group (≤19.0 ml, p=0.017) and that subarachnoid clots (>32.0 ml) were associated with development of SV compared to lower blood volumes in the Coil group (≤32.0 ml, p=0.03). The hemorrhage volumes of the patients with SV in the Clip group were lower than those in the Coil group at admission (37.7±21.5 vs. 58.5±23.1 ml, p=0.034), on the day after the operation (16.5±14.6 vs. 38.3±17.4 ml, p=0.002), and on Day 3-10 after SAH (5.5±4.1 vs. 11.4±9.3 ml, p=0.017). The hemorrhage volume at admission did not differ significantly between the groups (Clip group: 32.5±22.9 ml, Coil group: 32.8±22.4 ml).

Conclusions: A threshold of cisternal hemorrhage volume (>19.0 ml in the Clip group and >32.0 ml in the Coil group) may exist above which patients are very likely to develop SV. Aneurysm surgery itself may be harmful to the brain (brain retraction, use of a temporary clip, and mechanical manipulation of cerebral arteries) and can lead to the onset of cerebral vasospasm.

Intracranial yolk sac tumor in a patient with Down syndrome

The authors report a rare case of intracranial yolk sac tumor in a 13-year-old boy with Down syndrome who presented with left hemiparesis. Admission MR imaging revealed a tumor in the right basal ganglia. Serum α-fetoprotein was markedly elevated. Yolk sac tumor was diagnosed radiologically and serologically. The standard therapy for intracranial yolk sac tumor is platinum-based chemotherapy with concomitant radiotherapy. However, the authors used reduced-dose chemotherapy and asynchronized radiotherapy because of the well-known low tolerance of patients with Down syndrome to chemotherapy. This treatment was successful with no complications. Blood cancers are frequently associated with Down syndrome, whereas solid tumors occur less frequently in these patients, and the risk of chemoradiotherapy is unclear. The results indicate that dose-reduction therapy can be effective for treatment of a brain tumor in a patient with Down syndrome.

Vaccine therapy with dendritic cells transfected with Il13ra2 mRNA for glioma in mice

OBJECT

The Il13ra2 gene is often overexpressed in brain tumors, making Il13ra2 one of the vaccine targets for immunotherapy of glioma. In this study, using a mouse glioma model, the authors tested the hypothesis that vaccination using dendritic cells transfected with Il13ra2 mRNA induces strong immunological antitumor effects.

METHODS

A plasmid was constructed for transduction of the mRNAs transcribed in vitro into dendritic cells. This was done to transport the intracellular protein efficiently into major histocompatibility complex class II compartments by adding a late endosomal/lysosomal sorting signal to the Il13ra2 gene. The dendritic cells transfected with this Il13ra2 mRNA were injected intraperitoneally into the mouse glioma model at 3 and 10 days after tumor cell implantation. The antitumor effects were estimated based on the survival rate, results of histological analysis, and immunohistochemical findings for immune cells.

RESULTS

The group treated by vaccination therapy with dendritic cells transfected with Il13ra2 mRNA survived significantly longer than did the control groups. Immunohistochemical analysis revealed that greater numbers of T lymphocytes containing CD4+ and CD8+ T cells were found in the group vaccinated with dendritic cells transfected with Il13ra2 mRNA.

CONCLUSIONS

These results demonstrate the therapeutic potential of vaccination with dendritic cells transfected with Il13ra2 mRNA for the treatment of malignant glioma.

Continuous hypertension and tachycardia after resection of a hemangioblastoma behind the dorsal medulla oblongata: relationship to sympathetic overactivity at the neurogenic vasomotor center

A very rare case of continuous hypertension and tachycardia after excision of a cerebellar hemangioblastoma at the dorsal medulla oblongata is presented. This 21-year-old man was admitted to the authors' hospital with a headache and dizziness. Radiological examination revealed a tumor located behind the dorsal medulla oblongata and compressing it substantially. The tumor was completely resected, but after the surgery the patient experienced prolonged hypertension and tachycardia. Postoperative MR imaging showed a small injury at the dorsocaudal medulla that was located at the caudal site of the nucleus of the tractus solitarius (NTS). Because the NTS has been reported to play a central role in cardiovascular regulation along with the rostral ventrolateral medulla, the authors considered it possible that the NTS injury was the cause of the prolonged elevation of sympathetic tone.

Navigation-guided fence-post tube technique for resection of a brain tumor: technical note

INTRODUCTION

A new technique using a navigation system to minimize the influence of brain shift and to perform precise resection of brain tumors is demonstrated. To determine the resection plane, one to six tubes were inserted around the tumor under the guidance of a navigation system before dural incision.

RESULTS

This technique termed the "navigation-guided fence-post tube" (NGFP) procedure was used to treat 34 patients with intraaxial brain tumors including gliomas (23 cases), malignant lymphomas (4 cases) and metastatic tumors (7 cases). Tumors were removed totally in 23 cases (67.6%), subtotally (95% or more removal) in 6 cases (17.6%) and partially (less than 95% removal) in 5 cases (14.7%). The cases with subtotal or partial resection contained tumors that were close to or involved the eloquent area, or disseminated lesions. No complications due to tube insertion occurred.

CONCLUSION

NGFP is a useful and safe technique for brain tumor surgery with no influence of brain shift during tumor resection.

Benign fibrous histiocytoma of the skull with increased intracranial pressure caused by cerebral venous sinus occlusion

The authors present a very rare case of benign fibrous histiocytoma of the skull with increased intracranial pressure caused by sinus occlusion. A 33-year-old woman was referred for investigation of a right occipital protrusion with tenderness and double vision. She had only mild divergence insufficiency and bilateral papilledema neurologically. Imaging findings showed that the skull tumor was located at the right occipital bone with bone disruption and a compressed right sigmoid sinus. When planning the resection, caution was required to spare the collateral flow so as to manage the intracranial pressure. Immunohistochemical analysis showed that the tumor was positive for CD68, α1-antichymotrypsin, and α1-antitrypsin. From these findings, the tumor was diagnosed as a primary benign fibrous histiocytoma of the skull.

Immune or inflammatory response by the host brain suppresses neuronal differentiation of transplanted ES cell-derived neural precursor cells

Embryonic stem (ES) cells are a promising donor source for transplantation therapy, but several problems must be solved before they can be clinically useful. One of these is the host immune reaction to allogeneic grafts. In this article, we examine the effect of the host immune reaction on survival and differentiation of grafted ES cell-derived neural precursor cells (NPCs). We induced NPCs from mouse ES cells by stromal cell-derived inducing activity and then transplanted them into mouse brains with or without administering the immunosuppressant cyclosporine A (CsA). Two and 8 weeks following transplantation, the accumulation of host-derived microglia/macrophages and lymphocytes was observed around the graft. This effect was reduced by CsA treatment, although no significant difference in graft volume was observed. These data suggest that an immune response occurs in allografts of ES cell-derived NPCs. Intriguingly, however, the ratio of neurons to astrocytes in the graft was higher in immunosuppressed mice. Because inflammatory or immune cells produce various cytokines, we examined the effect of IL-1beta, IL-6, IFN-gamma, and TNF-alpha on the differentiation of NPCs in vitro. Only IL-6 promoted glial cell fate, and this effect could be reversed by the addition of an IL-6 neutralizing antibody. These results suggest that allogeneic ES cell-derived NPCs can cause an immune response by the host brain, but it is not strong enough to reject the graft. More important, activated microglia and lymphocytes can suppress neuronal differentiation of grafted NPCs in vivo by producing cytokines such as IL-6.

Association of intra- and extradural developmental venous anomalies, so-called venous angioma and sinus pericranii

INTRODUCTION

We report a case of cerebellar venous angioma and parietal sinus pericranii.

DISCUSSION

Venous angioma is classified as a developmental venous anomaly (DVA) because it is not a neoplasm but a variant that develops during embryogenesis. Sinus pericranii should be classified as extradural-type DVA. Although there have been few reports of association between these conditions, both are suspected to have the same pathogenesis, i.e., transient venous hypertension in the late embryonic period influencing venous development.

Generation of graftable dopaminergic neuron progenitors from mouse ES cells by a combination of coculture and neurosphere methods

Parkinson's disease is characterized by a loss of midbrain dopamine (DA) neurons and is generally viewed as a potential target for stem cell therapy. Although several studies have reported the generation of postmitotic DA neurons from embryonic stem (ES) cells, it is unknown whether the proliferative progenitors of DA neurons can be isolated in vitro. To investigate this possibility, we have developed a combined approach in which ES cells are cocultured with PA6 stromal cells to expose them to stromal cell-derived inducing activity (SDIA) and are then cultured as neurospheres. Mouse ES cell colonies were detached from PA6 feeder cells after 8 days of SDIA treatment and then expanded as spheres for another 4 days in serum-free medium supplemented with fibroblast growth factor-2. The spheres exhibited neural stem cell characteristics and contained few DA neurons at this stage of culture. After being induced to differentiate on polyornithine/laminin-coated dishes for 7 days, these spheres generated DA neurons in vitro at a relatively low frequency. Intriguingly, addition of PA6 cell conditioned medium to the sphere culture medium significantly increased the percentage of DA neurons to 25-30% of the total number of neurons. Transplantation of conditioned medium-treated day 4 spheres, which contained DA neuron progenitors, into the mouse striatum resulted in the generation of a significant number of graft-derived DA neurons. These findings suggest that progenitors of DA neurons are generated and can proliferate in ES cell-derived neurospheres induced by serial SDIA and PA6 conditioned medium treatment.

Dopaminergic neurons generated from monkey embryonic stem cells function in a Parkinson primate model

Parkinson disease (PD) is a neurodegenerative disorder characterized by loss of midbrain dopaminergic (DA) neurons. ES cells are currently the most promising donor cell source for cell-replacement therapy in PD. We previously described a strong neuralizing activity present on the surface of stromal cells, named stromal cell-derived inducing activity (SDIA). In this study, we generated neurospheres composed of neural progenitors from monkey ES cells, which are capable of producing large numbers of DA neurons. We demonstrated that FGF20, preferentially expressed in the substantia nigra, acts synergistically with FGF2 to increase the number of DA neurons in ES cell-derived neurospheres. We also analyzed the effect of transplantation of DA neurons generated from monkey ES cells into 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-treated (MPTP-treated) monkeys, a primate model for PD. Behavioral studies and functional imaging revealed that the transplanted cells functioned as DA neurons and attenuated MPTP-induced neurological symptoms.

Vaccine Therapy for Murine Glioma Using Tumor Cells Genetically Modified to Express B7.1

OBJECTIVE

In a syngeneic mouse brain tumor model, we tested the hypothesis that vaccination with tumor cells genetically modified to express B7.1 molecules induces tumor-specific T cells and immunological antitumor effects.

METHODS

Malignant glioma cells (RSV-MG) derived from a C3H/He mouse induced by Schmidt-Ruppin Rous sarcoma virus (RSV) were infected with an adenovirus encoding the B7.1 gene (AdB7). To investigate the effects of B7.1 expression on the tumorigenicity of RSV-MG cells, infected cells were implanted subcutaneously into C3H/He mice. The C3H/He mice were vaccinated with AdB7 transfectants injected subcutaneously and 2 weeks later were challenged intracerebrally with wild-type RSV-MG cells to determine whether or not the expression of B7.1 would enhance the immunogenicity of RSV-MG cells.

RESULTS

Immunocytochemistry confirmed the expression of B7.1 and major histocompatibility complex Class I antigen on the infected cells. The growth of subcutaneous tumors was markedly retarded in the AdB7 group, whereas tumors had formed and progressively increased in size in the other control groups. In the vaccine experiments, the mice immunized with AdB7 transfectants survived longer than did the mice of the other groups, and a significant difference in survival times was noted. Immunocytochemistry revealed that brain tumors in mice previously vaccinated with AdB7 infectants had been infiltrated by a larger number of CD3(+) lymphocytes and that these CD3(+) lymphocytes contained not only CD4(+) and CD8(+) T cells but also CD25(+)-activated T cells. In addition, a cytotoxicity assay confirmed that vaccination with the AdB7 transfectants induced tumor-specific cytotoxicity.

CONCLUSION

These results demonstrate the therapeutic potential of vaccination with tumor cells expressing B7.1 for the treatment of malignant glioma.

Ictal Onset and Spreading of Seizures of Parietal Lobe Origin

The characteristics of seizures associated with parietal lobe epilepsy were investigated in six consecutive patients with medically intractable epilepsy due to parietal lobe lesions. Intracranial electrode recordings were retrospectively reviewed to investigate the seizure onset symptoms and spreading patterns associated with the disorder. All six patients underwent implantation of subdural or depth electrodes and subsequent video/electroencephalography monitoring. Common symptoms included motionless stare, contralateral eye deviation, and head turn. Tonic posturing, contralateral sensory disturbance, and motor weakness were also seen. Asymmetrical generalized tonic and clonic seizures were seen in all six patients. All seizure activities began in the parietal lobe harboring the lesions, and then spread immediately to the adjacent lobes in most seizures, where the clinical symptoms were produced. The parietal lobe is a pure generator of seizures, whereas most clinical symptoms originate from adjacent lobes following seizure onset. No apparent specific symptoms other than sensory disturbance arising from the parietal lobe proper were recognized. Regardless of clinical symptoms, the seizure onset occurred in the parietal lobe harboring the lesion.

[A case of a ruptured dermoid cyst in the sylvian fissure]

A 22-year-old woman was admitted to our department after developing a headache. The neurological findings were unremarkable on her first visit, but CT demonstrated a lot of low-density masses in the subarachnoid space. The largest mass was in the right sylvian fissure. These lesions appeared hyper-intense in T1, T2 and diffusion-weighted MR images. A right frontotemporal craniotomy was performed to remove the main mass lesion in the right sylvian fissure. During surgery, thickening of the arachnoid membrane and floating oily globules were seen in the subarachnoid space. The histopathological examination revealed that the tumor was a dermoid cyst. Follow-up MRI revealed that some of the small lesions had moved since the operation. These findings suggested that the tumor was a ruptured dermoid cyst. The patient's postoperative course was uneventful and her headache disappeared completely.

Adenovirus-mediated gene transfer of B7.1 induces immunological anti-tumor effects in a murine brain tumor

The purpose of the present study was to determine if adenovirus-mediated transfection of a syngeneic mouse brain tumor with the gene encoding B7.1 enhances immunogenicity against tumor. Malignant astrocytoma cells were transfected with adenoviral vectors carrying the B7.1 gene (AdB7). Immunocytochemical analysis confirmed the expression of B7.1 in vitro and in vivo. To investigate the effects of B7.1 expression on tumorigenicity of the malignant astrocytoma, mice were implanted intracerebrally with B7.1-transfected glioma cells. There was no significant difference in proliferation between B7.1-transfected cells and controls in vitro. Nevertheless, mice implanted with B7. 1-transfected cells survived significantly longer than those in the control groups. Immunocytochemical analysis of the tumors showed that there was infiltration of a number of CD8+ T-cells and CD25+ activated T-cells in the brain implanted with B7.1-transfected glioma cells. The results showed the possibility that adenovirus-mediated B7.1 gene transfection to a brain tumor induced activation of CD8+ cytotoxic T-lymphocytes.

Surgical strategy for cavernous angioma in hypothalamus

A very rare case of cavernous angioma in the hypothalamus is presented. The patient was successfully treated by total excision of the haematoma and angioma, and there was no regrowth of the lesion on follow-up MRI. Complete excision of the angioma is the recommended surgical strategy even for patients with deep-seated lesions.

Co-administration of adenovirus vector expressing CTLA4-Ig prolongs transgene expression in the brain of mice sensitized with adenovirus

The duration of transgene expression in the brain is known to be shortened by previous sensitization to adenovirus. In order to prolong transgene expression, adenovirus vectors expressing CTLA4-Ig (AdCTLA), which blocks the B7-CD28 co-stimulatory signals required for T-cell activation, were used. Local administration of AdCTLA into the brain suppressed both the cellular and humoral immune responses to adenovirus vectors, and prolonged the duration of transgene expression. AdCTLA may be an effective tool for repeated gene transfer.

Microvascular decompression for cochlear symptoms

OBJECT

The object of this study was to evaluate the efficacy of a new neurovascular decompression technique in relieving symptoms of cochlear nerve dysfunction.

METHODS

Nineteen patients with slowly progressive hearing loss, low-frequency fluctuating hearing loss, and high-pitched tinnitus due to neurovascular compression (NVC) of the eighth cranial nerve in a triangular space between the seventh and eighth cranial nerves (the VII-VIII triangle) of the cerebellopontine angle (CPA) were treated using a new technique for microvascular decompression that was developed by anatomical study in 24 cadaver specimens of the CPA. In 12 of 19 patients the anterior inferior cerebellar artery (AICA) was observed to cause compression in the VII-VIII triangle and this vessel was easily mobilized medially for placement of a silicone sponge or Teflon cushion between the compressing artery and nerve. Postoperatively, hearing loss of 20 dB or more that was present in 11 of the 19 patients with NVC improved by more than 5 dB in seven (64%), including the patient with the most severe hearing loss. Of 18 patients presenting with tinnitus preoperatively, eight (44%) had no tinnitus and an additional nine (for a total of 94%) had good improvement in tinnitus after surgery and at long-term follow up.

CONCLUSIONS

The microvascular decompression technique described is highly successful in treating symptoms due to direct or indirect compression of the cochlear nerve, with minimal risk of complications. Recordings of auditory brainstem responses confirmed the clinical diagnosis of NVC of the eighth cranial nerve and correlated with clinical results after microvascular decompression of the cochlear nerve.

Immune gene therapy of experimental mouse brain tumor with adenovirus-mediated gene transfer of murine interleukin-4

We examined the antitumor activity of replication-deficient adenoviral vectors carrying the murine interleukin-4 (IL-4) gene (AdCIL4) using a syngeneic brain tumor model in mice. Mice implanted with malignant astrocytoma cells infected with AdCIL4 survived significantly longer than those in the control groups. Immunocytochemical analysis of the tumors showed that AdCIL4 caused the strong up-regulation of MHC class II antigen expression by the tumor cells and macrophages, and consequent infiltration by CD8+ T lymphocytes. This study demonstrates the efficacy of IL-4 gene transfection mediated by adenoviral vectors for intracerebral tumor and characterizes the immunoreaction caused by AdCIL4.

Local adenovirus-mediated CTLA4-immunoglobulin expression suppresses the immune responses to adenovirus vectors in the brain

The effect of local administration of two adenovirus vectors, one of which expressed CTLA4-immunoglobulin (AdCTLA), which blocks the B7-CD28 co-stimulatory pathway of T cell activation in the inflammatory response to adenovirus vectors was investigated. Mice injected with AdCTLA and an E1-deleted adenovirus vector that encodes the lacZ gene (AdRL) into the brain showed inflammatory cell infiltration from the early phase until day 6 after injection that was not different from that seen in control mice injected with an E1-deleted adenovirus vector containing no transgene (Ad0) and AdRL. After day 6 the inflammation in the control mice increased, peaked by day 15 and then decreased gradually but persisted until day 60. By contrast, in mice treated with AdCTLA and AdRL the inflammation, especially T cell infiltration, was suppressed after day 15. The anti-adenovirus antibody titer increased gradually until day 60 in the Ad0-AdRL control group, and whereas the mice injected with AdCTLA and AdRL showed lower anti-adenovirus antibody titers than the control group mice after day 15. Neutralizing antibody was not detected in either group. Expression of beta-galactosidase, the gene product of AdRL, at the injection site in the striatum and corpus callosum peaked on day 6 and remained until day 60 although it was very low in both groups; beta-galactosidase expression was similar in the two groups in spite of the difference in the degree and extent of the local immune response in the brain. This study demonstrated that the injection of an adenovirus vector expressing CTLA4-immunoglobulin into the brain suppressed not only local cell infiltration in the brain but also reduced the humoral immune response to adenovirus vectors.

[Diagnosis and treatment of nontraumatic dissecting aneurysm in the middle cerebral artery]

Two cases of nontraumatic dissecting aneurysm of the middle cerebral artery (MCA) are reported. A 59-year-old woman presented with subarachnoid hemorrhage, mainly in the right sylvian fissure. On admission, the right carotid angiogram revealed a dissecting aneurysm with a double lumen extending from segment M1 to M2 of the right MCA, and an unruptured saccular aneurysm in the right internal carotid artery. Emergency surgery revealed a discolored protrusion of the arterial wall in the right MCA, which was thought to be the cause of her subarachnoid hemorrhage. The protrusion of the arterial wall was clipped and coated with Bemsheet soaked in Biobond. However, disturbance of consciousness persisted and she died of paralytic ileus two months after the operation. The other patient was a hypertensive 33-year-old woman with right hemiparesis and motor dysphasia. CT scans obtained on the day of admission showed no abnormalities. She was treated conservatively with clinical improvement, but CT scans obtained 3 days after the ictus revealed an infarction deep in the left frontal lobe. A left carotid angiogram was made 4 days after ictus and demonstrated severe stenosis of the proximal segment of the left MCA with poor filling of its superior trunk. Despite improvement of her hemiparesis, CT scans obtained 3 weeks after the ictus showed hemorrhagic infarction in the left frontal lobe. Repeat left carotid angiogram revealed a double lumen in the C1 and M1 portions with improvement of the previous severe stenosis of the M1. The 23 reported cases of DA in the MCA with our cases are reviewed and their neuroradiological and clinical features are discussed.

Pilocytic astrocytoma of the velum interpositum

A 72-year-old male presented with a pilocytic astrocytoma in the velum interpositum manifesting as a 5-day history of dizziness attacks and unstable gait. Computed tomography and T1-weighted magnetic resonance imaging with gadolinium enhancement demonstrated a small, homogeneously enhanced mass in the velum interpositum. The tumor was removed subtotally, and the structure of the splenium was intact. The histological diagnosis was pilocytic astrocytoma. The MIB-1 growth fraction was 5%. The tumor may have originated from the splenium or the thalamus. The aggressive histology indicates the need for close neuroimaging follow-up.

A case of acute renal failure due to ethylene glycol intoxication

We describe an 18-year-old man with acute renal failure due to inadvertent ingestion of antifreeze that contained ethylene glycol (EG). A relatively small amount of EG was ingested, but nausea and vomiting were observed soon after ingestion. During admission to a local hospital, consciousness became impaired and generalized convulsion was noted. He was transferred to our hospital because of rapid deterioration of renal function. Emergency hemodialysis was begun. The patient underwent one treatment session of hemodialysis each day, for a total of 8 hemodialytic sessions before his renal function recovered. Examination of the renal biopsy specimen revealed degeneration of the renal tubular epithelium and presence of intratubular calcium oxalate crystals. The clinical features of the patient were mild except for acute renal failure. These findings suggest that even a small amount of EG will have toxic effects on the kidney.