Anterior Communicating Artery Aneurysm with a Peculiar Angiographic Appearance: A Case Study

We describe a case of pulsatile anterior communicating artery aneurysm (A-com AN) with a peculiar angiographic appearance. An 81-year-old man was referred to the department of neurosurgery for a large A-com AN artery aneurysm, which was detected incidentally. The patient hoped not to be treated but to be followed up. After 4 months, magnetic resonance imaging (MRI) revealed the presence of a cerebral edema and hematoma around the aneurysm, and partial thrombus in the upper wall of the aneurysm was suspected. Based on these findings, the patient underwent an immediate coil embolization a day after admission. However, the portion of the neck remnant increased in size after the first procedure. Therefore, 8 months after the initial procedure, he was treated with stent coil embolization. Contrary to the first procedure, angiographic evaluation revealed an active pulsating aneurysm. Moreover, MRI revealed the presence of a partial thrombus in the upper neck segment of the aneurysm, with an intensity that changed over time. The patient underwent cautious treatment and was discharged without any symptoms. This is the first case study to reveal an A-com AN with active pulsation and the relationship between the pulsatile portion of the aneurysm and thrombosed portion by MRI.

A case of internal trapping to a thrombosed giant rapidly growing aneurysm at the posterior cerebral artery

We describe a case of internal trapping including the vasa vasorum for a thrombosed giant rapidly growing posterior cerebral artery aneurysm and performing a detailed analysis. A 48-year-old woman was followed up in our hospital for a thrombosed large posterior cerebral artery aneurysm located in the P2 segment. She initially presented after experiencing a sudden headache on two occasions. Head computed tomography and magnetic resonance imaging indicated a larger aneurysm than before. Digital subtraction angiography with balloon occlusion test was assessed, and internal trapping was sequentially conducted. We detected that the vasa vasorum originated from the posterior temporal artery. Therefore, we embolized the posterior temporal artery including the vasa vasorum using N-butyl-2-cyanoacrylate and Lipiodol. Next, the anterior temporal artery was embolized with N-butyl-2-cyanoacrylate and Lipiodol, posterior temporal artery P3 segment and the aneurysm and finally the proximal P2 segment were embolized with coils. Final vertebral and internal carotid angiography showed complete obliteration of the aneurysm. On the day after the procedure her paresis worsened and she developed left upper quadrantanopia, however was finally discharged with no hemiparesis. We reported a case of a rapidly growing thrombosed giant posterior cerebral artery aneurysm treated by parent artery occlusion including the vasa vasorum with detailed image analysis.

Cardiac Arrest Induced by Carotid Sinus Reflex Activation During Flow-Diverter Stent Deployment

BACKGROUND

A 60-year-old female with multiple carotid aneurysms underwent endovascular treatment with a Pipeline Flex embolization device (PED) under local anesthesia via femoral puncture.

CASE DESCRIPTION

Cardiac arrest occurred when the delivery systems were pushed to promote adequate opening and apposition of the PED against the vessel wall and was recovered to sinus rhythm in approximately 30 seconds by pulling down the microcatheter. The carotid sinus reflex was suspected as the cause of this temporary asystole. Delivery of the PED was accompanied by application of forward pressure on the delivery system. This resulted in buckling of the delivery systems in the neck and likely excessive pressure on the carotid sinus. The procedure was continued and successfully completed with care not to excessively push the system and with the additional use of atropine.

CONCLUSIONS

Although it was a rare complication, the phenomenon and its mechanisms were known in the carotid artery stenting procedure. To the best of our knowledge, this is the first report of cardiac arrest induced by a carotid sinus reflex during PED deployment. It is important for an operator of PED deployment to recognize its possibility. Vital signs should be closely checked during PED deployment, particularly while pushing the catheter.

[A Case of Carotid Free-Floating Thrombus Treated by Carotid Ultrasonography-Guided Endovascular Approach]

We experienced a case of carotid free-floating thrombus treated by carotid ultrasonography-guided endovascular approach. A 63-year-old man was brought to our hospital with the chief complaint of sudden onset left hemiplegia. MRI revealed acute infarction of the right MCA territory due to the right M1 occlusion. Carotid ultrasonography showed a pedunculated, polypoid mobile plaque floating with the cardiac beat. We attempted ultrasonography-guided endovascular treatment. Under proximal balloon protection, the floating plaque was successfully aspirated into the Penumbra aspiration catheter. Carotid stent was also placed to stabilize the residual pedicle of the plaque. Aspirated plaque was identified as fresh thrombus by pathological examination. Carotid ultrasonography-guided endovascular approach was effective for getting the picture of real-time dynamics of the carotid FFT.

Intermittent administration of parathyroid hormone ameliorates periapical lesions in mice

INTRODUCTION

Intermittent administration of parathyroid hormone (PTH) promotes oral osseous wound healing and protects against ligature-induced alveolar bone loss. However, its therapeutic value on periapical periodontitis is unknown. The goal of this study was to determine the effect of intermittent PTH administration on the progression of periapical periodontitis.

METHODS

Seven lymphotoxin alpha-deficient mice received pulp exposures of mandibular first and second molars. Exposed pulp in the right mandible was covered with plaque-contaminated fibrin, whereas exposed pulp in the left mandible was left open. After 4 weeks, the periapical tissues were examined to determine the effect of plaque-contaminated fibrin to induce periapical lesions. Fourteen mice received pulp exposure covered with plaque-contaminated fibrin. PTH (40 μg/kg/d) was administered intermittently to half of the mice for 3 weeks beginning 1 week after pulp exposure. The remaining half received saline injections as the vehicle control. At sacrifice, mandibles and tibiae were harvested and processed for histologic examination. Evaluation of neutrophils and blood vessels was performed after staining with immunofluorescence, and periradicular bone was histomorphometrically analyzed.

RESULTS

The exposed pulp covered with plaque-contaminated fibrin resulted in significantly larger periapical lesions compared with the control. Intermittent PTH administration reduced the size of periapical lesions significantly. Significantly less neutrophil infiltration around the root apex was found in PTH-treated animals compared with the control.

CONCLUSIONS

PTH treatment suppressed periapical inflammation by reducing neutrophil infiltration and protected against tissue destruction by periapical periodontitis.

[CD56- and CD4-positive non-Hodgkin's lymphoma of probable T-cell origin]

A 65-year-old man was admitted with swelling of the right neck and bilateral inguinal lymph nodes. Endoscopic examination revealed no nasal infiltration. Pathological examination of a neck lymph node biopsy specimen revealed peripheral T-cell lymphoma according to the Revised European-American Classification of Lymphoid Neoplasms (REAL). The phenotype of the lymphoma cells was CD56+, CD16-, CD2+, surface CD3-, cytoplasmic CD3+, CD4+, CD8-, CD5+, CD7- and CD45RO+. May-Giemsa staining demonstrated no azurophilic granules in the lymphoma cells. Immunohistopathologic examination showed negativity for TIA-1 and granzyme B, and rearrangement of the TCR C beta 1 gene was also noted. These findings strongly suggested that this was a T-cell lymphoma. The patient received 8 courses of CHOP chemotherapy plus sobuzoxane. This led to a marked decrease of lymph node swelling, and currently the patient is still in remission. According to the REAL classification, T/NK-cell lymphomas are included among the peripheral T cell tumours, and seem to constitute a heterogeneous group of neoplasms. Although some cases of CD4+ CD56+ lymphoma have been reported, the present case appears to be the first example to show TCR gene rearrangement and negativity for TIA-1 and granzyme B. Since the classification of T/NK-cell lymphoma is still controversial, accumulation of such cases may help to better define T/NK-cell neoplasms.

[Rapidly progressive fibrosis and increased CD68-positive cells in the bone marrow at the terminal stage of adult T-cell leukemia accompanied by polycythemia vera]

We report a case of adult T-cell leukemia (ATL) accompanied by polycythemia vera (PV) in which rapid development of myelofibrosis and clinical features of hemophagocytic syndrome (HPS) were observed at the terminal stage. The patient, a 53-year-old man who was born in Oita Prefecture, Japan, was diagnosed as having PV in 1996. He had undergone venesection but had not received any chemotherapy. In June 1997, he showed systemic lymphadenopathy with positivity for serum HTLV-1 antibody (x 10,240). Pathological findings and Southern blotting analysis for detection of monoclonal integration of HTLV-1 provirus DNA in a lymph node biopsy sample revealed that he also had acute-type ATL. Although several courses of chemotherapy were transiently effective, high fever, pancytopenia, increased serum LDH, hypoproteinemia and hyperferritinemia appeared, all of which were compatible with the clinical features of HPS. In addition, cytomegalovirus infection became evident. He died of multiple organ failure with rapid progression of myelofibrosis in May 1998. Detection of both increased CD68-positive histiocytes by immunohistochemistry and iron-stained phagocytic cells in marrow biopsy specimens appeared to be helpful for diagnosis of HPS in this patient, whose marrow showed myelofibrosis with hypocellularity.

Circulating and tumor-infiltrating gamma delta T Cells in patients with B-cell lymphomas

In order to analyze the involvement of gamma delta T cells in the immune surveillance against B cell lymphomas (BCL), we investigated the proportion of circulating gamma delta T cells in 52 BCL patients using two-color flow cytometry, together with tumor-infiltrating gamma delta T cells in 22 of those patients. We found that the proportion of tumor-infiltrating gamma delta T cells in BCL patients was not different from that of lymph node gamma delta T cells in reactive hyperplasia patients. However, a decreased percentage of circulating gamma delta T cells were observed in indolent lymphoma (IL) and limited aggressive lymphoma (AL) patients when compared with normal controls. In contrast, as a result of a histogram, advanced AL patients were divided into two subgroups: the patients with increased circulating gamma delta T cells and those without any increase. However, there was no difference in the clinical features of between the two AL subgroups.

Comparative multi-color flow cytometric analysis of cell surface antigens in bone marrow hematopoietic progenitors between refractory anemia and aplastic anemia

Refractory anemia (RA) in myelodysplastic syndrome (MDS) without prominent dysplasia closely resemble the mild type of aplastic anemia (AA) in their hematological features. This sometimes makes it difficult to distinguish clearly between the two diseases. Using the multi-color flow cytometric technique, we compared cell surface antigen expression patterns on bone marrow hematopoietic progenitor cells which were isolated as a CD34 positive- CD45 dull positive with low side scatter intensity (CD34(+)CD45(dull+)SSC(low)) population in flow cytogram between RA (n=12) and AA (n=11). The antigens analyzed in CD34(+)CD45(dull+)SSC(low) mononuclear cells were: CD38 and CD71 for cell growth-related antigens, CD 33 and CD13 for myeloid and monocytoid lineage-associated antigens, CD7 and CD19 for lymphoid lineage, and CD14 for a monocytic lineage specific antigen. The percentages of CD34(+)CD45(dull+)SSC(low) cells in bone marrow non-erythroid mononuclear cells, and the expression frequencies of CD38, CD71, CD33 and CD13 antigens in CD34(+)CD45(dull+)SSC(low) progenitors were all significantly decreased in AA compared to normal bone marrows (n=7) (P<0.005). In contrast, in RA bone marrows the percentages of CD34(+)CD45(dull+)SSC(low) cells showed wide distribution and the cell surface antigen expression patterns varied among each case: some cases showed low frequencies of CD38 and CD71 expression as well as AA, whereas the others showed high expression frequency of specific antigen(s) which may reflect the clonal expansion of an abnormal clone in bone marrow. An MDS patient who had progressed from RA to RAEB showed further projecting pattern of expression of CD38 and CD33 in CD34(+)CD45(dull+)SSC(low) population in accordance with the disease progression. These data suggest that analysis of cell surface antigen expression patterns of CD34(+)CD45(dull+)SSC(low) progenitor cells by multi-color flow cytometry appears to be a useful method for qualitative and quantitative assessment of marrow progenitor states in AA and RA, therefore this method could be helpful for early detection of clonal evolution in MDS.

[Hypereosinophilic syndrome complicated by myelofibrosis]

Hypereosinophilic syndrome (HES) with myelofibrosis was diagnosed in a 36-year-old man on the basis of bone marrow biopsy findings and clinical features. Although the patient was treated with steroid (1 mg/kg), hydroxyurea, and immunosuppressive therapy, eosinophilia persisted. Patients with HES and myelofibrosis are usually unresponsive to antineoplastic agents and/or immunosuppressants. However, cyclosporin may be an effective alternative for such patients.

Vitamin K2 selectively induces apoptosis of blastic cells in myelodysplastic syndrome: flow cytometric detection of apoptotic cells using APO2.7 monoclonal antibody

We have previously reported that vitamin K2 (VK2) but not VK1 has a potent apoptosis-inducing effect on freshly isolated leukemia cells from patients with various types of leukemia. By multi-color flow cytometric analysis using monoclonal antibody (mAb), APO2.7, which detects mitochondrial 7A6 antigen specifically expressed by cells undergoing apoptosis, we further investigated the apoptosis-inducing effect of VK2 on minor populations of leukemic blast cells in bone marrow from patients with myelodysplastic syndrome (MDS) and overt myeloid leukemia (post-MDS AML). Limiting dilution of CD95 (anti-Fas) mAb-treated apoptotic Jurkat cells with nonapoptotic CTB-1 cells revealed that APO2.7-positive Jurkat cells were consistently detectable by flow cytometry when present at levels of at least 5% in the CTB-1 suspension. In patient samples the gating area for leukemic clone was determined using cell surface antigen-specific mAbs conjugated with either fluorescein isothionate (FITC) or phycoerythrin (PE) and subsequently the cells stained with phycoerythrin cyanine (PE-Cy5)-conjugated APO2.7 mAb were assessed within the gating area of the leukemic clone for monitoring apoptosis. Treatment of the bone marrow mononuclear cells with 3-10 microM of VK2 (menaquinone-3, -4 and -5) in vitro potently induced apoptosis of the leukemic blast cells as compared with the untreated control cells in all 15 MDS patients tested. This effect was more prominent on blastic cells than that on mature myeloid cells such as CD34-/CD33+ gated cells. In addition, VK2 performed much less effectively on CD3-positive lymphoid cells. In contrast to VK2, VK1 did not show apoptosis-inducing activity. These data suggest that VK2 may be used for treatment of patients with MDS in blastic transformation.

Localized diffuse large-cell lymphoma possibly coated with anti-tumor autoantibody: kappa lambda-dual-positive lymphoma

We report a case of diffuse large-cell lymphoma which pursued a clinically indolent course while remaining untreated. The tumor cells expressed surface IgG, CD10, CD19 and CD20, but not surface IgM, IgD, IgA, CD5, CD16, CD32 and CD64. In addition, these cells appeared to coexpress kappa- and lambda-light chains on their surface. JH and J lambda genes were monoclonally rearranged, but not the J kappa gene. The present lymphoma was found to have arisen from follicle center cells expressing IgG lambda, while the surface kappa-light chain seemed to be extrinsic. Furthermore, the extrinsic immunoglobulin bearing the kappa-light chain may have belonged to IgG because no surface immunoglobulins other than IgG were detected on the cell surface. Then, the extrinsic IgG may have combined with certain molecules on the tumor-cell surface through its Fab portion because the tumor cells lacked all three receptors for the IgG-Fe portion. Fc gamma RI (CD64). Fc gamma RII (CD32) and Fc gamma RIII (CD16). From these findings and the patient's history of never having received a blood transfusion, we concluded that the present case might be of a B-cell lymphoma possibly coated with an IgG-type autoantibody which appeared to have anti-idiotypic activity.

[Possible role of immunocompetent cells on periodic exacerbation of idiopathic thrombocytopenic purpura]

A 44 year-old man was admitted to our hospital in October, 1992 with epistaxis. Fifteen months before admission, thrombocytopenia had been pointed out, but he had no bleeding episode. At admission, neither hepatosplenomegaly nor lymph node swelling was observed. Hematological findings were as follows; WBC 10,000/microliter, Hb 14.0 g/dl, PLT 5,000/microliter, including giant platelets. Platelet associated IgG (PAIgG) was 471 ng/10(7) cells. Bone marrow aspiration revealed normocellularity with moderate increase in the number of mature megakaryocytes, but no dysplastic changes were seen. Biochemical and radiological examinations disclosed neither malignant diseases nor autoimmune diseases. Based on the diagnosis of idiopathic thrombocytopenic purpura, danazol therapy (300 mg/day) was started in November, 1992. After initiation of treatment, the platelet count changed cyclically every 4 weeks. To elecuidate the mechanism of this phenomenon, we periodically evaluated the patient's immunological background. T lymphocyte counts and subset proportions remained almost the same through out the course, whereas NK cell counts and NK activity coincided with the change of the platelet count. These results suggest that in this case NK cells may play a role in the cyclic fluctuation of platelet count by regulating the immune system.

[Effects of fluconazole on onychomycosis in the patients with collagen diseases]

Thirty-four patients with collagen diseases suffering from onychomycosis were treated with fluconazole and showed remarkable improvement. Thirty-one patients showed improvement while only four patients showed adverse reactions. More than half of the cases with onychomycosis in their fingers showed improvement within four weeks and complete recovery within 20 weeks after the administration of fluconazole. Patients with collagen diseases are liable to have onychomycosis as an opportunistic infection which is recalcitrant and resistant disease from the previous therapy. In this trial it became obvious that fluconazole was not only effective on onychomycosis but also a safe drug for the patients with collagen diseases.

[Effect of motilin agonist, EM-523 on gastrointestinal motility]

In this study, we investigated the effect of EM-523, one of the erythromycin derivatives, on gastrointestinal motility in conscious dogs, in which force transducers were chronically implanted in the gastrointestinal tract. As a result, intravenous administration of EM-523 (1-10 micrograms/kg) induced phase III-like contractions in the stomach, and the EM-523-induced contractions migrated along the entire small intestine. EM-523 also stimulated the lower esophageal sphincter and the gallbladder motility, quite similar to exogenous motilin. Furthermore, we have investigated the effects of EM-523 both in postoperative ileus dogs and truncally vagotomized dogs. The dogs 1 to 4-day after the operation showed continuous and irregular contractions in the entire gastrointestinal tract, instead of typical interdigestive contractions. In these conditions, EM-523 induced strong phasic contractions in the stomach and duodenum, although these contractions did not always migrate along the small intestine. In the vagotomized dogs, spontaneous phase III contractions tended to be weaker than those in the normal dogs. EM523 induced phase III-like contractions in vagotomized dogs as in the normal dogs, and the contractile activities were improved. These results indicated that EM-523 may be useful as a gastroprokinetic drug for postoperative ileus and the patients with vagotomy.

[A clinical phase I study on intramuscular imipenem/cilastatin sodium]

The safety and pharmacokinetics of imipenem/cilastatin sodium (IPM/CS) were evaluated in comparative studies using single intramuscular injection, intravenous infusion or multiple intramuscular administration. The studies were done employing 30 healthy volunteers. Adverse effects were observed in 5 of 18 volunteers in the single intramuscular dose study. One of them complained of mild itching and mild pain at the injection site, and the other 4 volunteers had mild pain at the injection sites. With the other methods of administration, no adverse effects were observed. No other abnormal physical findings nor abnormal laboratory test values were observed in any of the studies. Imipenem (IPM) was absorbed rather slowly through the muscles, resulting in a low maximum plasma concentration (Cmax) and a prolonged half life (T1/2) upon intramuscular injection compared to the results obtained upon intravenous infusion. The total areas under the curves obtained with these 2 methods were similar, however. Cilastatin (CS) was absorbed rapidly after intramuscular injection, and the Cmax obtained was higher than that obtained for IPM. The T1/2 and the AUC of CS obtained with intramuscular injection were similar to those obtained with intravenous infusion. Cumulative urinary recovery rates obtained with these 2 different routes of administration were not different. Detectable urinary levels of IPM were maintained much longer upon intramuscular injection than upon intravenous infusion. In the multiple dose study, neither IPM nor CS showed tendency to accumulate.