Non-aneurysmal subarachnoid hemorrhage in aplastic or twig-like middle cerebral artery: A case report and literature review

BACKGROUND

Aplastic or twig-like middle cerebral artery (Ap/T-MCA) is a rare vascular anomaly that can cause hemorrhagic and ischemic stroke. Ap/T-MCA can induce aneurysms due to the fragility of the vessel wall, consequently leading to subarachnoid hemorrhage. Herein, we report a case of Ap/T-MCA with subarachnoid hemorrhage without an aneurysm.

CASE PRESENTATION

A 67-year-old man presented to our hospital with a sudden onset of headache. Computed tomography of the head revealed subarachnoid hemorrhage (SAH) in the left Sylvian fissure; however, no aneurysm was observed on digital subtraction angiography. Following conservative treatment, follow-up imaging showed no aneurysm or no recurrent stroke.

CONCLUSION

Non-aneurysmal SAH is a possible indication of vessel wall fragility in Ap/T-MCA; however, a standardized treatment strategy for this condition remains to be established.

A Case of Tracheo-innominate Artery Fistula after Tracheostomy Successfully Treated with a Covered Stent

A 78-year-old man underwent a tracheostomy after embolization for a dural arteriovenous fistula. Seventy days after tracheostomy, arterial bleeding appeared through the tracheal stoma. The bleeding stopped spontaneously. However, two days later, arterial bleeding reappeared, and he was diagnosed with a tracheo-innominate artery fistula (TIF). He then underwent urgent endovascular covered stent placement. After the procedure, there was no bleeding. TIF can be a fatal complication after tracheostomy and it is generally treated with open chest surgery. However, a successful endovascular treatment for TIF has recently been reported and may yield better results.

A Case of Brainstem Infarction That Was Found to Be Vertebral Artery Dissection in a Short Period after the Diagnosis of Atherothrombotic Infarction

Objective

We report a case of vertebral artery dissecting aneurysm that caused right lateral medullary infarction, which was treated by endovascular therapy.

Case Presentations

A 57-year-old man developed right-side headache and dysarthria on the day before presentation, and exhibited mouth dropping and dysphagia the following day. Initial MRI demonstrated right lateral medullary infarction with atherothrombotic change with no vessel lesion, and we started infusion and medication administration. Later MRI revealed bilateral vertebral artery dissection, and we treated the growing right vertebral artery dissecting aneurysm by stenting and coils.

Conclusion

The possibility of dissecting lesions should be considered in cases of medullary infarction. Stenting and coil treatment is a useful option for bilateral dissecting vertebral aneurysms.

[A Case of Arteriovenous Malformation of the Parotid Gland Associated with Cowden Disease]

We report a rare case of arteriovenous malformation(AVM)of the parotid gland associated with Cowden disease successfully treated with preoperative embolization followed by surgical removal. A 39-year-old man with a history of Cowden disease presented with a pulsating and growing mass on his left lower jaw. Contrast-enhanced computed tomography(CT)and angiography revealed a high-flow AVM in the deep lobe of the left parotid gland. After intravascular embolization of the feeding arteries, surgery was performed using the NIM-response^®3.0, facial nerve monitoring system. The AVM was almost completely removed and the facial nerves were morphologically preserved. Interestingly, the intraoperative findings revealed that the enlarged vasa nervorum of the facial nerve also fed the AVM. Although left facial nerve palsy appeared after the surgery, the nerve function gradually improved over one year. No recurrence of the AVM has been observed for one year.

Optimal dose of plasmid vascular endothelial growth factor for enhancement of angiogenesis in the rat brain ischemia model

Vascular endothelial growth factor (VEGF) administration has recently been assessed as a therapeutic strategy for ischemic diseases including brain ischemia because of its angiogenic effect. However, VEGF also causes detrimental adverse effects by increasing vascular permeability. This study examined whether plasmid human VEGF (phVEGF) administration induced angiogenic effects in the rat brain ischemia model caused by permanent ligation of both common carotid arteries, and investigated the occurrence of adverse effects. Administration of various doses (0-200 microg) of phVEGF in the temporal muscle was followed by encephalo-myo-synangiosis. Thirty days after treatment, the numbers and areas of capillaries per field in the extracted brains were analyzed with the National Institutes of Health Image software program. The maximal angiogenic effect occurred with a 100 microg dose of phVEGF in the numbers and areas of capillaries in the VEGF-treated brains. Histological examination showed no apparent adverse effects in the brain parenchyma even at the highest administration dose (200 microg) of phVEGF. The maximal angiogenic effect at the optimal dose of phVEGF can be considered under the threshold to cause serious adverse effects in the rat brain.

Percutaneous balloon angioplasty for acute occlusion of intracranial arteries

BACKGROUND

The benefits of intravenous thrombolysis for acute ischemic stroke are still limited.

OBJECTIVE

To evaluate the safety and efficacy of double-lumen balloon catheter-based reperfusion therapy with or without intra-arterial thrombolysis for acute occlusion of intracranial arteries.

METHODS

Fifty-nine patients with acute occlusion of intracranial arteries were enrolled. A Gateway balloon catheter was used to disrupt clots or dilate atheromatous plaques in every patient. The technical details, technique-related complications, recanalization rates, and clinical outcomes were analyzed.

RESULTS

The occlusion sites were internal carotid arteries in 17 patients, M1 segments in 32 patients, the M2 segment in 1 patient, a vertebral artery in 1 patient, and basilar arteries in 8 patients. Twenty-four patients (41%) were treated with thrombolysis first, and 20 patients (34%) were treated with percutaneous transluminal angioplasty (PTA) followed by thrombolysis. PTA alone was performed in 15 patients (25%). The mean dose of urokinase was 205 x 10 U. The extent of recanalization was complete (Thrombolysis in Myocardial Infarction [TIMI] score of 3) in 17 patients (29%), and partial (TIMI 1/2) in 28 patients (47%). Functional independence at discharge was preserved in 76%, 25%, and 7% of patients with TIMI 3, TIMI 1/2, and TIMI 0, respectively. A combination of PTA and thrombolysis resulted in a significantly higher recanalization rate than PTA only. Seven patients (12%) experienced hemorrhagic events after treatment. Severe parenchymal hemorrhage with neurologic deterioration was observed in 2 patients (4%), and vessel rupture was encountered in 1 atherosclerotic case.

CONCLUSIONS

Mechanical angioplasty using a Gateway catheter combined with a low-dose thrombolytic agent is a safe and effective treatment for acute intracranial embolic and atherosclerotic occlusion with a low risk of hemorrhagic complications.

Training in Neurovascular Intervention Usefulness of in-Vitro Model and Clinical Practice

SUMMARY

We introduce our training tools and system of neurovascular intervention. An in vitro cerebral vascular model was used for the young residents to understand the basic interventional techniques and devices. The model included several vascular lesions such as cerebral aneurysm, dural arterio-venous fistula, or carotid artery stenosis. Endovascular procedures in the model were performed under fluoroscopic or direct visual control, and consecutive haemodynamic changes were visualized by using digital subtraction angiography and direct observation. Thus, traineess could have an easy understanding of clinical conditions. New medical devices, such as platinum coils, were successfully implanted in the model under stable conditions. After the initial training using vascular model, the residents had started clinical experiences under the control of senior surgeons. Although it is difficult to describe usefulness of our clinical training, we believe that we provide enough good quality and quantity of clinical cases to the residents. Because our endovascular team has recently had150-200 interventional procedures every year, one resident can have experienced more than 100 cases per year. The qualification of a Board Certified Specialist of the Japanese Society of Intravascular Neurosurgery (JSIN) requires that the applicant must have experienced more than 100 cases for four years. So our residents can have enough case materials to qualify the board examination.

Bilateral brachial pull-through technique for stenting in a patient with stenosis of the vertebral artery origin: technical case report

Stenting for stenosis of the proximal vertebral artery (VA) is commonly performed via a femoral approach. However, iliofemoral occlusive disease such as arteriosclerosis obliterans sometimes prevents safe transfemoral access. In certain situations where both femoral access and ipsilateral brachial access are difficult because of a concomitant vascular diseases or particular anatomic setting, a contralateral brachial approach using the brachiobrachial pull-through technique may allow efficient and accurate stenting. A case of VA origin symptomatic stenosis successfully treated with stenting using the new pull-through technique from the contralateral brachial artery to the brachial artery on the affected side is described.

[Usefullness of intrasacral fixation in an extremely unstable lumbosacral spine]

Intrasacral fixation technique devised by Jackson is said to provide rigid lumbosacral fixation. We treated 3 cases of lumbosacral lesions using this technique in which lumbosacral segment had become extremely unstable during surgical intervention adding to the effect of original lesions. In all cases, surgeries were performed in 2 stages, intrasacral fixation and anterior stabilization. Case 1: A 52-year-old male was diagnosed fungal discitis and spondylitis at L4 and L5. X-ray showed destruction of the vertebral bodies. L2, L3 and sacrum were fixed posteriorly using the intrasacral fixation technique. One week after the first operation, L4 and L5 vertebral bodies were replaced by long fibula grafts through the extraperitoneal approach. Case 2: A 25-year-old female with cauda equina syndrome and abnormal body form diagnosed as having spondyloptosis in which the entire vertebral body of L5 had descended below the endplate of S1. MR imaging revealed marked canal stenosis at the S1 level. In the first surgery, L5 vertebral body was resected through the transperitoneal approach. After 1 week of bed rest, posterior segments of L5 were resected, L4 was affixed to the sacrum and anterior stabilization was achieved with 2 mesh cages and lumbosacral spine was fixed using the intrasacral fixation technique. Case 3: A 64-year-old female was diagnosed as having pyogenic discitis and osteomyelitis at the L5-S1 level. In spite of successful medical treatment for infection, low back pain continued. Radiologically, L5 vertebral body was shown to have collapsed and slipped anteriorly over the sacrum. L3, L4 and sacrum were fixed by intrasacral fixation. One week after the first operation, the L5/S1 disc and the suppurtive vertebral bodies were resected through the extraperitoneal approach and anterior stabilization was performed with iliac bone grafts. At follow-up for a minimum of 6 months, initial fixation was maintained in all 3 cases and bony fusion was obtained. The intrasacral fixation technique was considered to be effective for extremely unstable lumbosacral lesions.

Combined Use of TruFill DCS Detachable Coil System and Guglielmi Detachable Coil for Embolization of Meningioma Fed by Branches of the Cavernous Internal Carotid Artery-Technical Case Report-

A 57-year-old female presented with a left petroclival meningioma fed by the meningohypophyseal trunk of the internal carotid artery (ICA). The enlarged tentorial marginal artery and inferior hypophyseal artery were successfully embolized with the TruFill DCS Detachable Coil System through a 0.019-inch inner diameter microcatheter. Superselective catheterization into the dorsal meningeal artery could not be achieved with the same microcatheter, because the catheter tip was too large to pass into the vessel. Subsequently the feeding artery was successfully embolized with a Guglielmi detachable coil (GDC) through a 0.016-inch inner diameter microcatheter. The patient underwent surgery without blood loss on the day after embolization. Our subjective impression was that the TruFill DCS was softer and had less resistance during insertion, whereas the GDC could be delivered through a smaller caliber system for smaller vessels. Appropriate use of the TruFill DCS and GDCs can allow efficient embolization of the feeding branches of the ICA.

Cooperative effects of adenoviral vector-mediated interleukin 12 gene therapy with radiotherapy in a preclinical model of metastatic prostate cancer

We investigated the potential benefits of combining adenoviral vector mediated in situ interleukin-12 (AdmIL-12) gene therapy with radiation therapy (XRT) to enhance therapeutic efficacy. In a metastatic mouse prostate cancer cell line, 178-2 BMA, AdmIL-12+XRT demonstrated enhanced therapeutic activities in vitro as determined by clonogenic survival, apoptosis, and mIL-12 levels. At the molecular level, increased expression of tumor necrosis factor-alpha mRNA was specific for the combined therapy. In a subcutaneous 178-2 BMA in vivo model, the combination of AdmIL-12+XRT produced statistically significant tumor growth suppression compared to control vector Adbetagal, Adbetagal XRT, or AdmIL-12 as monotherapy. In addition, significant prolongation of survival was demonstrated for the combination of AdmIL-12+XRT. The combination of AdmIL-12+XRT significantly suppressed both spontaneous and pre-established lung metastases, and led to a prolonged elevation of serum IL-12 and significantly increased natural killer (NK) activities. Importantly, in vivo depletion of NK cells resulted in significant attenuation of the antimetastatic activities of AdmIL-12 alone or AdmIL-12+XRT. These combined effects suggest that AdIL-12 gene therapy together with radiotherapy may achieve maximal tumor control (both local and systemic) in selected prostate cancer patients via radio-gene therapy induced local cytotoxicity and local and systemic antitumor immunity.

Therapeutic effects of adoptive splenocyte transfer following in situ AdIL-12 gene therapy in a mouse prostate cancer model

We developed a preclinical prostate cancer model to study the feasibility of adoptive immunotherapy for residual tumor following neo-adjuvant in situ adenoviral-vector-mediated interleukin 12 (AdIL-12) gene therapy. Splenocytes were obtained from mice with orthotopic 178-2 BMA metastatic mouse prostate cancers treated previously with AdIL-12, or a vector with the IL-12 genes plus the costimulatory gene B7-1 (AdIL-12/B7), or a control gene (Adbetagal). The splenocytes were subsequently injected intravenously into syngeneic mice bearing orthotopic 178-2 BMA tumors generated 3 days previously. Significant orthotopic tumor growth suppression was achieved with splenocytes derived from mice whose tumors had been injected with AdIL-12 compared to splenocytes from control Adbetagal mice (P = 0.0005) and splenocytes from AdIL-12/B7-treated mice significantly suppressed spontaneous lung metastases compared to splenocytes from control mice (P = 0.0356). Adoptive transfer of splenocytes from either AdIL-12 (P = 0.004) or AdIL-12/B7 (P = 0.009)-treated mice significantly prolonged survival relative to controls. Transfer of NK and tumor-specific CTL activities was detected and depletion of CD4+ and CD8+ T cells by in vitro antibody-mediated complement lysis of the splenocytes prior to injection abrogated the effects. Systemic IL-12 administration delivered by intramuscular AdIL-12 injection enhanced the antitumor effects of adoptive splenocyte transfer and boosted the CTL response. Our data provide evidence that this form of adoptive immunotherapy can enhance the effectiveness of neo-adjuvant in situ IL-12 gene therapy in cases of persistent malignancy.

[Embolization for aneurismal dilatation associated with ruptured dissecting anterior inferior cerebellar artery aneurysm with preservation of the parent artery: case report]

We report a rare case of a ruptured dissecting anterior inferior cerebellar artery (AICA) aneurysm treated by endosaccular embolization with a Guglielmi detachable coil (GDC). An 85-year-old female presented with headache. Computed tomographic (CT) scan showed subarachnoid hemorrhage and intraventricular hemorrhage in the fourth ventricule. Cerebral angiography and 3D-CT angiography revealed an aneurysmal dilatation at the anterior pontine segment of the right AICA with a diagnosis of arterial dissection. The right posterior inferior cerebellar artery (PICA) was absent and the right AICA supplied the territory normally nourished by the right PICA. The aneurismal dilatation was occluded by endosacullar embolization with preservation of the AICA. The distal AICA aneurysm is rare and only seven cases treated with endovascular embolization have been reported. In these, six cases were treated by parent artery occlusion with coil and the subsequent three cases presented with ischemic complications. Only one case was treated by endosaccular embolization with GDC. To our knowledge, this is the second report of the distal AICA aneurysm treated by endosaccular embolization with GDC. Distal AICA aneurysms are briefly discussed while reviewing the literature.

Adenoviral vector-mediated RTVP-1 gene-modified tumor cell-based vaccine suppresses the development of experimental prostate cancer

We previously identified a novel p53 target gene, RTVP-1, that possesses unique cytotoxic and immunostimulatory activities which make it potentially useful for cancer gene therapy. To test the therapeutic potential of RTVP-1 in a gene-modified tumor cell-based vaccine model, we used an adenoviral vector capable of efficient transduction and expression of RTVP-1 (AdRTVP-1), together with a highly metastatic mouse prostate cancer cell line (178-2 BMA). A vaccine was prepared with 178-2 BMA cells transduced with AdRTVP-1 or a control adenoviral vector expressing beta-galactosidase (Adbetagal). After irradiation of the cells, syngeneic 129/Sv mice were vaccinated three times at weekly intervals. After 3 weeks, they were challenged with orthotopic 178-2 BMA cells. After 21 days, fewer than 60% of the RTVP-1-cell-vaccinated mice developed tumors compared to 100% of the control mice. The RTVP-1-cell vaccine significantly reduced primary tumor wet weight compared with control Adbetagal-cell vaccine (P<0.0001 at 7 and 14 days). Experimental metastasis to lung was also significantly reduced (P=0.0377), and survival significantly increased (P=0.0002). In addition, significantly increased NK and CTL activities were demonstrated in the AdRTVP-1-cell-vaccinated mice. These findings indicate that RTVP-1 gene-modified cell-based vaccines may be useful in the prevention of recurrent prostate cancer.

Enhanced brain angiogenesis in chronic cerebral hypoperfusion after administration of plasmid human vascular endothelial growth factor in combination with indirect vasoreconstructive surgery

OBJECT

Vascular endothelial growth factor (VEGF) is a secreted mitogen associated with angiogenesis. The conceptual basis for therapeutic angiogenesis after plasmid human VEGF gene (phVEGF) transfer has been established in patients presenting with limb ischemia and myocardial infarction. The authors hypothesized that overexpression of VEGF using a gene transfer method combined with indirect vasoreconstruction might induce effective brain angiogenesis in chronic cerebral hypoperfusion, leading to prevention of ischemic attacks.

METHODS

A chronic cerebral hypoperfusion model induced by permanent ligation of both common carotid arteries in rats was used in this investigation. Seven days after induction of cerebral hypoperfusion, encephalomyosynangiosis (EMS) and phVEGF administration in the temporal muscle were performed. Fourteen days after treatment, the VEGF gene therapy group displayed numbers and areas of capillary vessels in temporal muscles that were 2.2 and 2.5 times greater, respectively, in comparison with the control group. In the brain, the number and area of capillary vessels in the group treated with the VEGF gene were 1.5 and 1.8 times greater, respectively, relative to the control group.

CONCLUSIONS

In rat models of chronic cerebral hypoperfusion, administration of phVEGF combined with indirect vasoreconstructive surgery significantly increased capillary density in the brain. The authors' results indicate that administration of phVEGF may be an effective therapy in patients with chronic cerebral hypoperfusion, such as those with moyamoya disease.

[A case of cervical endodermal cyst]

A very rare case involving an endodermal cyst of the cervical spinal canal was documented. In 1999, a 28-year-old male presented with mild tetraplegia due to a traffic accident and consequently, he was admitted to another hospital. Magnetic resonance imaging (MRI) performed at that time demonstrated a cervical cord cyst. He was treated conservatively and as a result, complete resolution of symptoms was achieved. Five years later, he presented with progressive right hemiparesis and was referred to our institute. MRI at the time of admission exhibited an intradural extramedullary cystic lesion on the ventral side of the spinal cord at the C5-6 levels, which was characterized by low intensity on T1-weighted, and by high intensity on T2-weighted images. The cyst, which had increased in size, compressed the spinal cord remarkably backward. The anterior central vertebrectomy approach was performed. Subtotal resection of the cyst wall was conducted due to its tight partical adhesion to the spinal cord. The vertebral defect was reconstructed with an autogenous iliac graft. According to histological findings the cyst wall consisted of a single layer of columnar epithelial cells with secretory granules and immunohistochemical examination revealed that the cyst wall was positive for cytokeratin 7. Symptoms improved immediately. Subsequently, the patient was discharged with good performance status. Endodermal cysts are very rare developmental cysts derived from the embryonic endodermal layer. Moreover, these lesions are usually located intradurally in the cervical and upper dorsal spine ventral to the spinal cord. Total removal of the cyst is recommended if it is possible. However, total resection is often difficult due to adhesion of the cyst wall to the neural tissue so invasive resection should be avoided. In such cases, follow-up MRI is necessary in order to exclude recurrence of the remnant lesion.

Adult unilateral moyamoya disease with familial occurrence in two definite cases: a case report and review of the literature

We documented an interesting case of adult "unilateral (probable)" moyamoya disease displaying familial occurrence in two "definite" cases. A 55-year-old female presented with motor aphasia, involuntary movement of the right hand and right homonymous hemianopia due to cerebral infarction. Cerebral angiography revealed typical angiographic findings on the left side and normal findings on the right side; consequently, the patient was diagnosed with probable moyamoya disease. Previously, her mother and nephew had been diagnosed with definite moyamoya disease with bilateral involvement. The patient continued to exhibit unilateral involvement on angiography for more than 4 years. Clinical features such as absence of familial occurrence suggest that most cases of probable moyamoya disease are distinct from definite cases, especially in adults. To the best of our knowledge, this report appears to be the first involving an adult probable case characterized by familial occurrence. The literature pertaining to adult probable moyamoya disease was reviewed and the etiology of this disease was discussed.

Combined Use of Electrolytically and Mechanically Detachable Platinum Coils for Endovascular Treatment of Cerebral Aneurysms

The combined use of Guglielmi detachable coils (GDCs) and newly developed mechanically detachable platinum coils (Detach Coil System: DCS) was evaluated for the endovascular treatment of 10 patients with cerebral aneurysms. The number and total length of detachable coils placed into the aneurysms, the detaching time for each coil, and any technical problems were recorded and evaluated. Sixty GDCs and 60 DCSs were used. The detachment time for the DCS (mean 21 seconds) was faster than that for the GDC (mean 2 minutes 35 seconds). One DCS moved inside the aneurysm during the mechanical detachment maneuver, but was successfully placed. Neither detachment system influenced the behavior of the other system during coil implantation. The DCS includes a useful J-shape coil, whereas the GDC can be detached safely in fragile aneurysms. The DCS is also cheaper. The coil systems complemented one another and the combination optimized cost and operating time.

Suicide gene therapy for urogenital cancer: current outcome and prospects

Viral-mediated transfer of the herpes simplex virus thymidine kinase (HSV-tk) gene has been demonstrated by several investigators to confer sensitivity to nucleoside analogs such as ganciclovir (GCV) in a variety of tumor cells including brain, prostate, bladder, kidney, ovary, head and neck, lung, pancreas, and liver cancers. Fourteen suicide gene clinical protocols using adenovirus vectors have been conducted, including four in prostate cancer. Two additional protocols for prostate cancer are in preparation in Japan and the Netherlands. A study conducted at Baylor College of Medicine was the first to demonstrate the safety of HSV-tk plus GCV therapy for human prostate cancer and the anticancer activity of gene therapy in this disease. However, it is still in the early stage of its development, with a number of problems to be overcome. Systemic delivery, specific introduction, and specific expression of the target gene are the major issues to be managed in order to establish a clinically relevant treatment strategy.

[A review of dural arteriovenous fistulas with hemorrhagic onset]

The majority of dural arteriovenous fistulas are considered to have a benign clinical course, but some behave more aggressively, causing progressive neurological symptoms and/or intracranial hemorrhage. Several classifications of angiographic findings have been reported to predict what findings might result in catastrophic presentation. Cortical venous drainage has been described as one of the major risk factors of hemorrhage. We reviewed the records of 50 patients with dural arteriovenous fistulas admitted to our institution from 1991 to 2001 and analyzed their venous drainage patterns with reference to Cognard's classification. Six patients had hemorrhagic episodes caused by dural arteriovenous fistula and all of them had retrograde drainage through cerebral veins. The frequency of hemorrhage in Type I and IIa was 0%, in Type IIb it was 33.3%, in Type IIa + b it was 9.1%, in Type III and Type IV it was 50%, and in Type V it was 100%. These results agreed with those of Cognard reported in 1994, and we reconfirmed the usefulness of Cognard's classification. In order to adapt a firm strategy and treat them promptly and aggressively, it is important to be able to recognize what type of dural arteriovenous fistulas are perilous.

[Usefulness of dynamic digitized cerebral parenchymography for cerebral vascular disease]

Aortic arch injections according to Theron's method have been performed in patients with cerebral ischemia. Digital subtraction angiograms with modified windowing (low and narrow) have been used for better visualization of cerebral parenchymal condition. This "cerebral parenchymography" allows much easier understanding of cerebral parenchymal vascularization on angiographic imaging. Although further study is necessary to estimate accurate cerebral blood flow, this technique can enable an easy and quick understanding of the overall cerebral hemodynamics.

The importance of venous hypertension in the formation of dural arteriovenous fistulas: a case report of multiple fistulas remote from sinus thrombosis

Various hypotheses have been reported concerning the pathogenesis of dural arteriovenous fistulas (DAVFs). However, it is still controversial whether sinus thrombosis or venous hypertension has a greater influence on the formation of DAVFs. We present a rare case of multiple DAVFs that developed after sinus thrombosis. Chronic venous hypertension secondary to sinus thrombosis in the left transverse-sigmoid sinus induced the multiple DAVFs, including one in the right cavernous sinus, which was remote from the occluded sinus. This case indicates the importance of venous hypertension in the formation of DAVFs.

[Usefulness of a new mechanical detachable coil for neurovascular intervention]

The electrolytically detachable platinum coil (Guglielmi Detachable Coil: GDC) is a safe and efficient endovascular tool for treatment of cerebral aneurysms. However, the GDC still has some problems, including a prolonged detaching time and high cost. The Detach Coil System (DCS) is a newly developed platinum detachable coil for the treatment of neurovascular diseases. This has a mechanical "screw" detachment system, which can be detached faster than the GDC. The platinum coil is mounted to the tip of the delivery wire by the "screw" system. For detaching the coil, 20-25 times anti-clockwise rotation of the delivery wire using a "detach locking device" is required. We report our preliminary clinical experience of using the DCS in 11 patients. This series included 5 sacral aneurysms, 3 dissecting aneurysms, and 3 dural arteriovenous fistulas. Seventy-five coils were used in total, of which 5 coils were retrieved and 70 coils were implanted. The detaching time of each DCS was 15-20 seconds, which was much faster than that of the GDC. All lesions were successfully treated without symptomatic complications. In the limited number of cases, our result suggest that the DCS allowed safe and fast endovascular treatment of neurovascular disease at a lower cost.

[Use of the GDC for embolization of a tumor fed by a cavernous branch of the internal carotid artery]

Currently, embolization of small branches of the internal carotid artery (ICA) can be embolized through superselective microcatheterization, followed by the injection of liquid or particulate embolic materials. Often, however, a microcatheter cannot be placed in a stable enough position to allow an endovascular surgeon to perform a safe embolization, and the reflux of embolic agents into the main trunk of the ICA is a major concern. Meticulous technique and a detailed knowledge of the vascular anatomy of the cavernous sinus region are necessary to maximize devascularization of the lesion and to minimize the risk of complications. This report describes the case of a patient with a hypervascular tumor whose feeding vessel from the cavernous ICA was successfully occluded with polyvinyl alcohol (PVA) combined with a regular Guglielmi detachable coil (GDC). A 62-year-old woman had a left-sided petroclival meningioma, which was diagnosed based on computed tomography and magnetic resonance studies. Transfemoral angiographic studies demonstrated that the tumor was fed by intracavernous branches of the left ICA. We believed that another embolic agent would have presented a risk of reflux into the ICA, with possible unwanted occlusion of normal intracranial arteries. A single GDC was sufficient to occlude the feeding artery, and the patient underwent successful surgery 3 days after the endovascular procedure. The GDC can eliminate the ICA supply to hypervascular tumors safely when liquid or particle embolic materials would present a risk of reflux into normal arteries. This device can be positioned and repositioned and can be detached without mechanical force. It may also decrease the risk of unwanted embolization of normal intracranial arteries.

Treatment of androgen-independent prostate cancer with dexamethasone: a prospective study in stage D2 patients

PURPOSE

In order to evaluate the efficacy of dexamethasone in the treatment of Japanese men with androgen-independent prostate cancer, a prospective study was conducted using prostate-specific antigen (PSA) as a primary end-point.

METHODS

Nineteen Japanese men with stage D2 androgen-independent prostate cancer were registered and treatment was started. After ruling out anti-androgen withdrawal syndrome, they were treated with dexamethasone (1.5 mg daily). Patients were monitored for PSA, symptoms, radiologic response, survival rate, time to disease progression, time to treatment failure and complications.

RESULTS

Prostate-specific antigen levels decreased in nine patients (50.0%); five (27.8%) showed a 50% or greater decrease and two (11.1%) showed an 80% or greater decrease. For the nine patients, the mean duration of PSA response was 7.3 months and the median duration was 2.1 months (range, 1.2-27.5+). Bone pain, which was noted in 13 patients at study entry, improved in seven patients (53.8%). Of nine patients who had serial radiographic examinations with bone scan, three (33%) showed partial response, two (22%) were stable and four (44%) showed disease progression. Treatment was well tolerated, except for one patient who suffered a severe pulmonary infection.

CONCLUSION

Dexamethasone decreased PSA levels and produced subjective symptomatic improvement in the patients with stage D2 androgen-independent prostate cancer.

The rebuilding of normal venous circulation for transverse-sigmoid dural arteriovenous fistulas by percutaneous transluminal angioplasty. A case report

The etiology of dural arteriovenous fistulas (DAVFs) remains controversial as is the issue of whether occlusion or stenosis of the transverse sinus and sigmoid sinus is a cause or a result of DAVFs. We report a case of DAVFs with transverse-sigmoid sinus occlusion and cortical venous reflux. In this case, the reconstruction of normal venous circulation by percutaneous transluminal angioplasty (PTA) for the occluded sinus was performed and cortical venous reflux diminished. PTA may be a useful treatment for DAVFs with occluded or stenotic sinus.

Transrectal ultrasound for monitoring murine orthotopic prostate tumor

BACKGROUND

The mouse orthotopic prostate tumor model has been recognized as an ideal preclinical animal model simulating the anatomical and biological milieu of the prostate. In comparison with the subcutaneous tumor model, the only disadvantage of this model is the difficulty of chronological tumor growth monitoring. We have applied recent endoluminal ultrasound technology, transrectal ultrasonography (TRUS), to the monitoring of mouse orthotopic prostate tumors.

METHODS

A 6 Fr. 20 MHz catheter-based radial scan probe was used and TRUS was performed without any prior preparation including anesthesia. Orthotopic tumors were initiated by inoculation of 5000 RM-9 cells into the dorsal prostate of 12-week-old C57BL/6 male mice. The tumor growth was monitored by TRUS from day 3 to day 21. In addition, TRUS was performed to detect tumor growth suppression after intraperitoneal administration of cis-diamminedichloroplatinum (CDDP).

RESULTS

By ultrasound, tumors became detectable 7 days after tumor cell inoculation. TRUS images were clear and parallel to actual tumor growth. The tumor volume (X) calculated by TRUS correlated significantly with the actual tumor weight (Y) measured at autopsy; Y = 101.653 + 1.174X (R = 0.930, P < 0.001). Similarly, tumor growth suppression induced by CDDP was clearly detected by TRUS with reasonable accuracy.

CONCLUSIONS

A high resolution TRUS allows simple and reliable monitoring of in situ tumor growth and growth suppression, making the mouse orthotopic prostate tumor model more efficient.

[Brain abscess and ventriculitis associated with entrapment of the lateral ventricle appearing more like remarkable brain edema than ventricular dilatation--a case report]

We present a case with brain abscess associated with entrapment of the lateral ventricle appearing more like remarkable brain edema in the temporo-occipital lobe than ventricular dilatation. A 72-year-old man suffering from headache and vomiting visited our clinic. CT and MRI showed brain abscess in the right parieto-occipital lobe, associated with ventriculitis. Lumbar puncture also revealed purulent meningitis. Both symptoms and CSF findings improved after administration of antibiotics. The improved condition continued for two months after admission, but disturbed consciousness and left hemiparesis than appeared. MRI and CT showed entrapment of the lateral ventricle and brain edema of the right temporo-occipital region without ventricular dilatation. Because brain edema was thought to be caused by transudate of the CSF through the ventricular wall, lobectomy of the right temporal lobe and opening of the temporal horn were carried out. Although left hemiparesis and disturbed consciousness and brain edema disappeared after the operation, subdural effusion appeared. Using a subdural-peritoneal shunt, the subdural effusion was prevented and disappeared. In this case, we thought Hounsfield Unit (HU) of the brain edema caused by transudate of CSF through the ventricular wall (12.6) was markedly lower than that of so-called vasogenic edema (25.1) due to active inflammation. Measurement of the HU seemed to be a useful means to differentiate the types of brain edema in this situation from that of vasogenic edema caused by brain abscess, and thus a means for selection of the appropriate treatment.

Coil embolization of intradural pseudoaneurysms caused by arterial injury during surgery: report of two cases

Intradural pseudoaneurysms arose in two patients as a result of arterial injury incurred during surgery. In the first patient, the pseudoaneurysm developed in the middle cerebral artery, at the site of vessel perforation during aneurysmal surgery. In the second patient, the pseudoaneurysm developed in the anterior communicating artery after removal of a tuberculum sellae meningioma. These aneurysms had small ostia and were successfully embolized with electrolytically detachable coils. The clinical features and the treatment of intracranial pseudoaneurysms are discussed.

[Transvenous embolization for cavernous dural arteriovenous shunts: about the intracranial venous approach to the cavernous sinus]

Recently, the first choice of therapy for cavernous dural arteriovenous shunts (CdAVS) is transvenous embolization. Usually the approach routes for cavernous sinus are the inferior petrosal sinus (IPS), the superior ophthalmic vein (SOV) in most cases and the superior petrosal sinus (SPS) in rare case. But, it is difficult for us to treat patients in whom there are no extracranial veins through which to approach the cavernous sinus, with transvenous embolization. We presented the case in which intracranial transvenous approach to the cavernous sinus and transvenous embolization were performed and in which we achieve good results. In this article, we presented a case with Barrow's type D CdAVS and cortical venous drainage. At first, transarterial embolization was performed to decrease the amount of venous drainage for the purpose of eliminate convulsions and consciousness disturbance. However, cortical venous drainage continued. Moreover bilateral dilated SOVs normalized and bilateral IPSs were not visible, so we decided that it was impossible to carry out the transvenous embolization via extracranial veins. Transvenous embolization to the left cavernous sinus via the intracranial ophthalmic vein between the superior ophthalmic fissure and the inferior ophthalmic fissure after craniotomy was performed. Then, the transvenous embolization to the right cavernous sinus was carried out through the right superficial middle cerebral vein after craniotomy. The results were good and chemosis and bilateral abducens palsy diminished immediately. Trans-intracranial venous embolization for CdVAS is a very useful therapy when no extracranial veins exist for transvenous embolization.

[A case of a scalp arteriovenous fistula associated with Rendu-Osler-Weber disease treated by direct percutaneous embolization]

We present a case of Rendu-Osler-Weber disease (hereditary hemorrhagic telangiectasia) accompanied by a scalp arteriovenous fistula, which was successfully treated by direct percutaneous embolization. A 51-year-old man, who had multiple vascular telangiectases and pulmonary arteriovenous fistulae, developed an enlarging pulsatile mass of the scalp anterior to the site of the previous craniotomy for a brain abscess in the right occipital lobe. Angiography demonstrated a high-flow arteriovenous fistula between the right superficial temporal artery and a varix. Percutaneous injection of pure ethyl alcohol was planned but seemed risky because of the major drainage being into the bilateral cavernous sinuses through the superior ophthalmic veins. A 24-gauge plastic needle was placed in the right superficial temporal artery just proximal to the fistula, and 0.7 ml of a mixture consisting of n-butyl cyanoacrylate and lipiodol in a ratio of 1:1 was injected. Then, the varix was directly punctured, and retention of the contrast medium was confirmed under manual compression by the placement of a circular ring. Embolization of the varix using 1.0 ml of 70% glucose solution and a subsequent 1.0 ml of pure ethyl alcohol was performed with compression, resulting in total occlusion of the fistula. The scalp mass resolved gradually and there was no evidence of recanalization. We conclude that direct percutaneous embolization is the first therapeutic choice for a scalp arteriovenous fistula with multiple shuntings associated with Rendu-Osler-Weber disease. Dangerous venous drainage should be eliminated before performing embolization with ethyl alcohol.

Development of multispectral autoradiography with solid state detector

Autoradiography is a useful imaging technique to understand biological function by using radio isotopes (RIs). However, conventional autoradiography using X-ray film or Imaging Plate can not easily image distributions of different RIs simultaneously. Each tracers describes each biological functions, therefore we constructed here a multispectral autoradiography. The system consists of a solid state detector (SSD) with high energy-resolution to acquire multispectral information, a collimator with small aperture to restrict the region of observing area, and a translational stage to scan the specimen. The distribution of the RI of interest agent can be obtained by mapping spectrum intensity within the energy-window to corresponding observed points. We confirmed the validity of this method by experiments with physical phantoms and tissues of rat's hearts. First, we imaged the phantom with 201Tl and 99mTc, and could specify the individual RIs. Next, from rectangular paper phantom soaked in 99mTc-labeled tracer, the spatial resolution of experimental system was estimated on about magnitude of x mm2. Finally, the sliced tissue of rat's heart was imaged. Here, we also propose a new imaging method to improve the spatial resolution and reduce data-acquisition time. It is based on reconstruction from projections like X-ray CT.

Prediction of the virulencies of some enveloped viruses from the structure of the cleavage recognition site of viral glycoproteins essential for infectivity. I. Calculation of interaction energy

Some evidences have been found that virulency in paramyxoviruses depends on the sensitivity of the cleavage recognition site of the F glycoprotein to serine type proteases. In this report, the interaction energies between the active site of trypsin and the cleavage recognition sites in paramyxoviruses are calculated. Results show that van der Waals energy and electrostatic energy contribute to the sensitivity. The virulencies of some myxo- and retro-viruses are then predicted on the basis of the two calculated interaction energy values.

Increased mucosal ornithine decarboxylase activity in large bowel with multiple tumors, adenocarcinoma, and adenoma

The polyamine biosynthetase, ornithine decarboxylase (ODC), involved in tumor promotion, was investigated in grossly normal mucosa obtained from surgically resected large bowel; 48 cases with and six cases without large bowel cancer. The mucosal ODC activity was significantly higher in 17 multiple tumor cases bearing adenocarcinoma(s) plus adenoma(s) than in 31 solitary tumor cases bearing one adenocarcinoma alone. It was higher in the mucosa of the two groups of cases than in the mucosa of individuals without large bowel cancer. Furthermore, the enzyme activity in left-sided cancer cases was significantly higher than that in right-sided cancer cases. Carcinoma tissue showed a remarkable high level of enzyme activity, compared with the normal mucosa. The results indicate the larger the number of tumors the higher the level of the ODC activity in the normal mucosa, particularly in left-sided cancer cases. It is concluded that the mucosal ODC may provide a good biological marker to detect individuals at higher risk for large bowel cancer due to exogenous or endogenous factors, and thus contribute to the prevention of mortality from large bowel cancer.

Metabolism of non-protein energy-substrates in septic rats receiving parenteral nutrition

The influences of sepsis on the metabolism of fatty acid and glucose in rats receiving parenteral nutrition were investigated. The caecum, with its blood supply, was ligated in 10 rats to produce peritonitis and sepsis (septic rats). Twelve rats (control rats) did not undergo this procedure. Five septic rats and six control rats received glucose as a sole nonprotein calorie (septic-glucose rats), and the remaining five septic rats (septic-lipid rats) and six control rats received the same parenteral solution for the first 44 hours, but 25% of the nonprotein calorie was replaced by 10% lipid emulsion for the last 24 hours. At the termination of the parenteral nutrition, 14C-linoleic acid or 14C-glucose was injected as a bolus in the tail vein, and their degradations to 14CO2 and incorporations into the endogenous fat were compared among the three groups. It was demonstrated that the sepsis accelerated the oxidation of fatty acid but did not affect that of glucose. Hepatic lipogenesis with both fatty acid and glucose was accelerated by an infusion of glucose under a septic condition, while it was inhibited by an infusion of lipid emulsion.

[Studies on the metabolism of lipid and glucose in rats with experimental peritonitis]

Metabolism of lipid and glucose in rats with experimental peritonitis was investigated. Thirty-two rats were divided into 3 groups; 12 receiving total parenteral nutrition (TPN) with glucose and having no peritonitis (Group G), 10 receiving TPN with glucose and having peritonitis (Group PG), and 10 receiving TPN with glucose and lipids and having peritonitis (Group PF). Linoleic acid or glucose labelled with radioisotope 14C was given intravenously at one hour after cessation of 68 hours of TPN, and the rate of oxidation to 14CO2, total hepatic lipids, each fraction of hepatic lipids, hepatic glycogen, total adipose lipids, and muscle glycogen were measured. Cumulative amounts of 14CO2 in the expired breath during 6 hours after administration of (1-14C) linoleic acid was significantly higher in the Group PF, whereas there was no significant difference of cumulative amounts of 14CO2 in the expired breath during 6 hours after administration of (U-14C) glucose among the 3 groups. All the results obtained from the present experiment suggested also that linoleic acid was superior to glucose as a fuel given to rats with peritonitis.

Nitrogen-sparing effect of lipid emulsion in septic dogs

Effects of intravenously administered lipid emulsion on the nitrogen balance in dogs with intraabdominal infection were investigated. The nitrogen balance in dogs supported by parenteral nutrition (PN) with glucose alone was superior to that in dogs supported by PN with glucose and lipid emulsion, in the absence of intraabdominal infection. On the other hand, the nitrogen balance in dogs supported by PN with glucose and lipid emulsion was superior to that with glucose alone, in the presence of intraabdominal infection. Dogs with intraabdominal infection had an insulin-resistance inability to effectively utilize glucose.

Clearance rate of intravenously administered lipid emulsion in canine endotoxemia

The effect of endotoxemia on the initial catabolism of intravenously given lipid emulsion was investigated in dogs. Two types of endotoxemia were prepared. One was produced by peritonitis which was established by ligation of the artery and vein of an isolated intestine (group 1, n = 6). The other was made by an intravenous injection of Escherichia coli lipopolysaccharide in a dose of 1.5 mg/kg of body weight (group 2, n = 6). Group 1 showed evident peritonitis with a positive limulus test 48 hr after the procedure, but no significant changes of blood sugar level and lactate/pyruvate ratio, while group 2 demonstrated profound hypoglycemia, significant elevation of lactate/pyruvate ratio, and low arterial pressure 3 to 5 hr after the injection of lipopolysaccharide. The clearance rate of intravenously administered lipid emulsion (K value) of group 1 before the peritonitis was 0.0105 +/- 0.0017 and after the peritonitis it was 0.0105 +/- 0.0019. The difference was not significant, while the K value of group 2 which was 0.0133 +/- 0.0056 before the injection of lipopolysaccharide decreased significantly to 0.0069 +/- 0.0024 after the injection of lipopolysaccharide. These results suggest that, in case of endotoxemia with normally maintained oxidation-reduction potential, the initial catabolism of intravenously given lipid emulsion is kept in a normal level, while oxidation-reduction potential is impaired, it is inhibited.

Effects of exogenous catecholamines on glucose and fat metabolism and on triglycerides in the rat liver during total parenteral nutrition

An experiment was undertaken to investigate the effects of a continuous infusion of catecholamines on glucose and fat metabolism as well as on nitrogen balance and the amount of triglycerides in the rat liver. The animals were nourished by total parenteral nutrition for 5 days and divided into six groups (n = 5 in each group) on the basis of nonprotein calories given with or without an infusion of catecholamines: group G received 100% of nonprotein calories with glucose, group F received 50% of nonprotein calories with glucose, and the remaining 50% with lipid emulsion, groups Epi-G and Epi-F received epinephrine (1 microgram/kg body weight/min) in addition to the same total parenteral nutrition solution as group G or F, and groups Nor-G and Nor-F received norepinephrine (1 microgram/kg/min) in a similar manner. Each group was administered the same number of total calories (252 cal/kg/day) and the same amount of nitrogen (1.49 g/kg/day). Nitrogen balance was better in group G than in group F. Under catecholamine infusion, there were no significant differences in nitrogen balance between groups Epi-G, Nor-G, Epi-F, and Nor-F, but this parameter improved significantly in group Nor-F in comparison to group F. Liver triglycerides was higher in groups Epi-G and Nor-G than in groups Epi-F and Nor-F. Liver triglycerides was directly related to the blood sugar level. These results indicate that nitrogen conservation is improved with lipid emulsion and that glucose rather than lipid plays a significant role in the genesis of fatty liver, when they are administered under catecholamine-induced stress.

Effects of hemodynamic changes induced by hyper- or hypothermia on intravenous lipid clearance rate and lipoprotein lipase activity in dogs

Hyper- and hypothermia was induced in dogs by peritoneal perfusion with warm or cold Lactate-Ringer's solution, the objective being to alter cardiac output. Changes in cardiac index, intravenous lipid clearance rate (K-value), and lipoprotein lipase (LPL) activity, concomitantly with changes of the temperature of the mixed venous blood were investigated. The cardiac index increased significantly with the hyperthermia and there was a close correlation between the cardiac index and the K-value. The LPL activity did not change significantly with changes in blood temperature, and the correlation between the LPL activity and the K-value was not significant. The hemodynamics has to be considered when attempting to discuss the intravenous lipid clearance rate.

Clearance rate of intravenously administered lipid in postoperative patients

Elimination rate (K) of intravenously given triglyceride was studied in seventeen patients who underwent elective abdominal operations, and levels of adrenaline, noradrenaline, insulin and blood sugar were simultaneously measured, as stress-indices. All these indices, except for the insulin/blood sugar ratio, increased post-operatively. The postoperative K value increased significantly in comparison with the preoperative value. There was no significant correlation between K value and any of the stress-indices. These results suggest that the initial catabolism of the lipid emulsion triglyceride is enhanced by surgical stress.