A novel approach to evaluation of lumbar bone density using Hounsfield units in volume of interest on computed tomography imaging

OBJECTIVE

The purpose of this retrospective study was to evaluate the relationship between bone mineral density (BMD), as assessed with dual-energy x-ray absorptiometry (DEXA), and Hounsfield units (HU) measured in volumes of interest (VOIs) and regions of interest (ROIs) on lumbar spine CT.

METHODS

A retrospective analysis was performed on data of lumbar vertebrae obtained from patients who underwent both DEXA and lumbar spine CT scan within a 6-month period. Vertebrae with a history of compression fracture, infectious spondylitis, cement reinforcement, or lumbar surgery were excluded. HU measurements were performed in the VOI and ROI (midaxial, midcoronal, and midsagittal sections) with CT, whereas BMD was assessed with DEXA. Statistical analyses, including correlation assessments and receiver operating characteristic (ROC) curve analyses, were performed.

RESULTS

This analysis included 712 lumbar vertebrae, with a median patient age of 72.0 years. BMD values and HU measurements in the VOI increased sequentially from L1 to L4, whereas HU values in the ROI did not show a consistent pattern. HU values in the VOI consistently showed a stronger correlation with BMD than those in the ROI. ROC analysis revealed patient-level cutoff values for the diagnosis of osteoporosis at different lumbar vertebral levels with high sensitivity and specificity, as well as an excellent area under the curve.

CONCLUSIONS

This is the first study to introduce a novel approach using the HU value in the VOI to assess bone health at the lumbar spine. There is a strong correlation between the HU value in the VOI and BMD, and the HU value in the VOI can be used to predict osteoporosis.

Deep Brain Stimulation in a Patient with Parkinson's Disease and Cortical Superficial Siderosis

Cortical superficial siderosis (cSS) is a rare condition that is regarded as a potential magnetic resonance marker of cerebral amyloid angiopathy (CAA). We describe the case of a 68-year-old man with cSS and Parkinson's disease (PD) who subsequently exhibited incidental microhemorrhages, which were only detected on magnetic resonance imaging (MRI), at one week after deep brain stimulation (DBS) surgery. cSS is now considered to be a significant risk factor for CAA and future bleeding. Therefore, because DBS surgery is invasive and may increase the risk of intracerebral hemorrhage, the procedure should be performed carefully when managing patients with PD and CAA.

Novel Transdural Epiarachnoid Approach for Large Central Disk Herniation in Upper Lumbar Spine

BACKGROUND AND IMPORTANCE

The treatment for large central disk herniation (LCDH) at upper lumbar spine is often challenging. Previous reports showed various surgical strategies, such as microdiscectomy with posterior fixation, endoscopic surgery, and microdiscectomy through transdural approach. However, there is no consensus regarding which surgical option is better for LCDH at upper lumbar spine. In this report, we describe the novel transdural epiarachnoid approach (TDEA), which uses the corridor of epiarachnoid space for microdiscectomy. Compared with classical transdural approaches, this novel approach may reduce risks of postoperative cerebrospinal fluid leakage and the development of arachnoiditis.

CLINICAL PRESENTATION

A 69-yr-old man presented with progressive bilateral radiating leg pain, intermittent claudication, and low back pain. Magnetic resonance images and computed tomography scans revealed LCDH at L2/3 level. We performed microdiscectomy using the TDEA. Postoperative course was uneventful, and his symptoms were relieved after surgery.

CONCLUSION

The novel TDEA for LCDH at upper lumbar spine is illustrated with a video. This novel approach has an advantage of the preservation of subarachnoid components compared with classical transdural approaches.

Intracranial-Intracranial Bypass Using a Y-Shaped Artery Graft for Growing Unruptured Gemella morbillorum Infectious Aneurysm on Artery Supplying Sensory Cortex

BACKGROUND

Vascular reconstruction is required to treat infectious intracranial aneurysms (IIAs) on arteries supplying the eloquent area. However, extracranial-intracranial bypass is sometimes impossible because IIAs are frequently located distally on arteries and the length of a donor artery is limited. We report a rare case of an unruptured Gemella morbillorum IIA, which was successfully treated by intracranial-intracranial (IC-IC) bypass using a Y-shaped superficial temporal artery (STA) interposition graft.

CASE DESCRIPTION

A 52-year-old man presented with heart failure and an unruptured IIA in the right anterior parietal artery because of acute G. morbillorum endocarditis. The patient was treated with urgent replacement of cardiac valves and antibiotic therapy. However, the IIA increased in size during the following 1 month, and therefore was treated surgically to prevent the rupture. End-to-side IC-IC bypass using a Y-shaped STA graft followed by aneurysmal trapping was performed to overcome the limited length of the STA as a donor artery to prevent cerebral ischemia in the artery territory and to avoid direct injury to the sensory cortex adhering tightly to the IIA. Postoperative courses were uneventful, and he recovered from the infectious diseases.

CONCLUSIONS

This case suggests that end-to-side IC-IC bypass using a Y-shaped STA graft can be a good option for surgical treatment of IIAs, which are located in eloquent areas.

Abstract TP447: Tenascin-C: A Novel Therapeutic Target in Subarachnoid Hemorrhage

Introduction: Tenascin-C (TNC) is one of pleiotropic matricellular proteins, which are non-structural and secreted extracellular matrix proteins that exert diverse functions. Recently we showed that TNC is involved in the mechanisms of cerebral vasospasm and early brain injury (EBI) after subarachnoid hemorrhage (SAH). However, the role of TNC has not been sufficiently investigated in SAH.

Materials and Methods: First, TNC knockout (TNKO) mice SAH models were produced by endovascular perforation method, and examined the direct evidence that TNC is induced after SAH and causes cerebral vasospasm and EBI. Second, TNC was measured in serum from 156 aneurysmal SAH patients, and cilostazol (0-300 mg/day) was administered postoperatively, and investigated as to the dose-dependent effect of cilostazol on cerebral vasospasm, delayed cerebral ischemia and infarction.

Results: In experimental SAH, TNKO prevented blood-brain barrier disruption and brain edema formation by inhibiting mitogen-activated protein kinase (MAPK)-mediated matrix metalloproteinase-9 activation. TNKO also suppressed post-SAH induction of another matricellular protein, periostin, which aggravates post-SAH EBI. TNKO also prevented neuroinflammation and neuronal apoptosis via inhibiting upregulation of Toll-like receptor 4, phosphorylation of nuclear factor-κB, and induction of proinflammatory cytokines in neurons. TNKO suppressed post-SAH cerebral vasospasm via inhibiting the activation of MAPKs. In the clinical study, cilostazol treatment suppressed plasma TNC levels from days 1-3 to days 10-12 post-SAH, and showed dose-dependent effects against delayed cerebral infarction, leading to improved outcome. Multivariate analyses revealed that 300 mg/day cilostazol treatment was an independent determinant against poor outcomes post-SAH.

Conclusions: TNKO exerted protective effects against neuroinflammation, blood-brain barrier disruption, neuronal apoptosis, and cerebral vasospasm. The 300 mg/day cilostazol may improve post-SAH outcomes by reducing plasma TNC levels and delayed cerebral infarction. Further investigations may provide a novel therapeutic approach targeting TNC.

COT-22 TIMING OF SURGERY AND BEVACIZUMAB THERAPY FOR MALIGNANT GLIOMAS

BACKGROUND

The drug manufacturer recommends postponing initiation of bevacizumab for malignant gliomas at least 4 weeks later postoperatively. Malignant glioma patients with significant neurological deficits due to postoperative residual tumors are preferably needed earlier bevacizumab therapy that expecting improvement of neurological state and brain edema. There is a literature review indicating that the timing for administration of postoperative bevacizumab was at least 2 weeks. The authors assessed the safety,tolerability,efficacy for bevacizumab therapy less than 4 weeks later postoperatively.

METHODS

Six patients of malignant gliomas with residual tumors and neurological deficits were treated by bevacizumab (10mg /kg every 2 weeks) therapy 2–3 weeks later postoperatively with chemoradiotherapy. Patients included 31-year-old female with thalamic-midbrain glioblastoma (initial),11-year-old female with anaplastic ependymoma (recurrent),71-year-old female with initial cervical cord anaplastic astrocytoma (initial),88-year-old female bilateral frontal glioblastoma (initial),27-year-old female with thalamic midbrain glioblastoma (initial) and 3-year-old female with brain stem glioblastoma (initial).

RESULTS

All the patients did not experienced hemorrhage and impair wound healing. Every patient neurological state and perifocal brain edema following bevacizumab therapy demonstrated early improvement. Earlier bevacizumab therapy did not delay and cease postoperative chemoradiotherapy.

CONCLUSIONS

Initiation of bevacizumab therapy 2–3 weeks later postoperatively seems to be safe and effective for malignant glioma patients with worse neurological state due to residual tumor and perifocal edema. The optimal interval which balances the risk of complications and the risk of tumor progression should be considered.

Immobility reduces muscle fiber necrosis in dystrophin deficient muscular dystrophy

Duchenne/Becker muscular dystrophy is a progressive muscle disease, which is caused by the abnormality of dystrophin. Spina bifida is characterized by paralysis of the feet, with most of the upper extremities not being affected. We report here on the first case of Becker muscular dystrophy coinciding with spina bifida. The muscle biopsy specimens of the patient showed dystrophic changes in upper extremities, but clearly less in lower extremities. The results show that the restriction of excessive exercise is important for dystrophin deficiency disease.

The role of receptors in the maturation-dependent adenoviral transduction of myofibers

One of the major hurdles facing the application of adenoviral gene transfer to skeletal muscle is the maturation-dependent transduction of muscle myofibers. It was recently proposed that the viral receptors (Coxsackie and adenovirus receptor (CAR) and the integrins alphavbeta3/beta5) play a major role in the poor adenoviral transduction of mature myofibers. Here we report the findings of morphological studies designed to determine experimentally the role of receptors in the adenoviral transduction of mature myofibers. First, we observed that the expression of both attachment and internalization receptors did not change significantly during muscle development. Second, when an extended tropism adenoviral vector (AdPK) that attaches to heparan sulfate proteoglycan (HSP) is used, a significant reduction of adenoviral transduction still occurs in mature myofibers despite HSP's high expression in mature skeletal muscle fibers. Third, when the adeno-associated virus (AAV) is used, which also utilizes HSP as a viral receptor, muscle fibers at different maturities can be highly transduced. Fourth, the pre-irradiation of the skeletal muscle of newborn mice to inactivate myoblasts dramatically decreased the transduction level of Ad and AdPK, but had no effect on AAV-mediated viral transduction of immature myofibers. These results taken together suggest that the viral receptor(s) is not a major determinant in maturation-dependent adenoviral transduction of myofibers.

Observation of coherent cerenkov radiation from a solid dielectric with short bunches of electrons

Short bunches of 150-MeV electrons of a linear accelerator passed along the surface of a crystal quartz or a teflon and coherent Cerenkov radiation from the solid dielectrics has been observed in the wavelength range from 0.5 to 4 mm. Properties of the radiation have been experimentally investigated. The angular distribution of the observed radiation showed a maximum peak in the direction of the Cerenkov angle with several satellite peaks. The intensity increased linearly with increasing the length of the medium and was proportional to the square of the number of electrons in the bunch. The spectral intensity was enhanced by almost five orders of magnitude in comparison with the theoretical calculation of incoherent radiation.

Circular dystrophin RNAs consisting of exons that were skipped by alternative splicing

Exon skipping by alternative splicing and circular RNA formation are proposed to be interrelated events. Since multiple patterns of alternative splicing have been demonstrated in both the 5' and 3' regions of the dystrophin gene, the dystrophin transcript in skeletal muscle cells provides a model system in which this idea is tested. Nine circular RNAs that were expected to result from known exon skipping patterns in the 5' region of this gene were in fact identified, but three other circular RNAs expected to result from other known exon skipping reactions in this region could not be detected. The identification of two unexpected circular RNAs led to the discovery of two novel alternative splicing reactions. One circular RNA originating in the 3' region of the gene was identified but it lacked one small sized exon compared with the expected exon structure. Circular RNAs from the 5' region of the dystrophin gene could not be detected in Duchenne muscular dystrophy patients who have deletions of one or more exons in this segment of the gene, even though alternative splicing products were identified. These results showed that circular RNA formation is not necessarily linked to exon skipping and suggest that an undetermined factor regulates circular RNA formation.

Muscle fiber immaturity and inactivity reduce myonecrosis in Duchenne muscular dystrophy

We report on the first case of X-linked recessive myotubular myopathy (MTM1) coinciding with Duchenne muscular dystrophy (DMD). The muscle biopsy specimens of the patient show only the characteristic findings of MTM1, without the findings of DMD. We theorize that this was caused by the muscle fiber immaturity and inactivity.

MTM1 gene mutations in Japanese patients with the severe infantile form of myotubular myopathy

The severe infantile form of myotubular myopathy is a fatal muscle disease that predominantly affects male infants and is characterized by severe weakness and hypotonia from birth. X-linked myotubular myopathy was found to be associated with mutations in the MTM1 gene in Xq28 encoding the putative tyrosine phosphatase, myotubularin. We screened the MTM1 gene for mutations in seven Japanese patients (six males and one female) who had the diagnosis of severe infantile form of myotubular myopathy. We found five mutations, including three novel mutations based on sequence analysis of RT-PCR fragments covering the entire open reading frame. Two patients (one male and one female), who had similar clinicopathologic features, did not have any mutation in the MTM1 gene open reading frame, suggesting that they may have had an autosomal recessive disease.

Dystrophin gene analysis on 130 patients with Duchenne muscular dystrophy with a special reference to muscle mRNA analysis

On dystrophin gene analysis by multiplex polymerase chain reaction (PCR), 76 of 130 (58.5%) Japanese patients with Duchenne muscular dystrophy had a deletion or duplication in genomic DNA. Of the remaining 54 patients who had no identifiable gene mutations, muscle biopsy tissue was available in 16 for RNA extraction. The full length of the coding regions of dystrophin cDNA was amplified in 10 fragments by reverse transcription nested PCR (RT-PCR). Five of 16 patients (31%) had dystrophin cDNA of abnormal size. One patient had a deletion, and two duplications that were not covered by multiplex PCR, one an exon-skipping of exon 51 caused by a 5' consensus splice site mutation of intron 51, and one 172 bp or 202 bp insertion in the cDNA between exon 25 and 26. Nested RT-PCR from the total RNA extracted from muscle biopsy was useful for screening patients who had no identifiable gene abnormality by multiplex PCR.

Progressive myoclonus epilepsy: dentato-rubro-pallido-luysian atrophy (DRPLA) in childhood

A 22-year-old female with progressive myoclonus epilepsy (PME) considered to be due to hereditary dentato-rubro-pallido-luysian atrophy (DRPLA) was reported. Some of her family members showed progressive myoclonus, seizures, dementia, ataxia and choreoathetosis, with variation of onset from childhood to adult life, which suggested that they had been suffering from DRPLA. CT scan and MRI studies, including some on family members, revealed cerebral and cerebellar atrophy accompanied by dilatation of the fourth ventricle, compatible with the findings in DRPLA reported previously. We emphasize that a detailed family history may be essential in dealing with a PME patient and that DRPLA should be considered in the differential diagnosis of the PME syndrome with onset in childhood, in Japan.

[A case of aortitis syndrome which presented coarctation of aorta due to intraluminal flap formation in the middle of the thoracic aorta]

We present a rare case of aortitis syndrome associated with dilatation of aorta and coarctation-like effect due to the intraluminal flap formation originated from dissected wall of the aorta. A 31-year-old woman was admitted to our hospital complaining of shortness of breath, palpitation and cough. On admission, her physical status showed congestive heart failure and hypertension of upper extremities and hypotension of lower extremities. Bruits were audible over the neck, the anterior chest and the back. Serological studies showed active inflammation. Chest X-ray film showed upper mediastinal widening, cardiomegaly and pulmonary edema. Aortitis syndrome was strongly suggested by these clinical findings, so that prednisolone therapy was started on 3rd hospital day. Special examinations were performed several days later when inflammatory changes showed a tendency to improve. Chest CT scan, RI angiography and MRI studies showed an aneurysmal dilatation from the ascending aorta to the mid-thoracic aorta. Aortography demonstrated a flap at the terminal portion of this aneurysmal dilatation and grade II (Sellars) aortic regurgitation. There was a pressure difference of 80 mmHg between the parts abutting cranial and caudal sides of the flap. A surgical operation was, then, performed to correct the pressure difference. The dissected wall was extruded toward the aortic lumen creating a flap (2 cm in length). This flap was resected and an artificial graft was inserted. Histologically, the flap consisted of adventitia, media and intima.(ABSTRACT TRUNCATED AT 250 WORDS)