Transient ischemic attack without self-awareness of symptoms witnessed by bystanders: analysis of the PROMISE-TIA registry

Background and purpose

A transient ischemic attack (TIA) can occur without self‐awareness of symptoms. We aimed to investigate characteristics of patients with a tissue‐based diagnosis of TIA but having no self‐awareness of their symptoms and whose symptoms were witnessed by bystanders.

Methods

We used data from the multicenter registry of 1414 patients with a clinical diagnosis of TIA. For patients without evidence of ischemic lesions on imaging, clinical characteristics were compared between patients with and without self‐awareness of their TIA symptoms.

Results

Among 896 patients (559 men, median age of 70 years), 59 (6.6%) were unaware of their TIA symptoms, but had those symptoms witnessed by bystanders. Patients without self‐awareness of symptoms were older and more frequently female, and more likely to have previous history of stroke, premorbid disability, and atrial fibrillation, but less likely to have dyslipidemia than those with self‐awareness. Patients without self‐awareness of symptoms arrive at hospitals earlier than those with self‐awareness (P < 0.001). ABCD² score was higher in patients without self‐awareness of symptoms than those with self‐awareness (median 5 vs. 4, P = 0.002). Having no self‐awareness of symptoms was a significant predictor of ischemic stroke within 1 year after adjustment for sex, ABCD² score, and onset to arrival time (hazard ratio = 2.44, 95% confidential interval: 1.10–4.83), but was not significant after further adjustment for arterial stenosis or occlusion.

Conclusions

Patients with a TIA but having no self‐awareness of their symptoms might have higher risk of subsequent ischemic stroke rather than those with self‐awareness, suggesting urgent management is needed even if patients have no self‐awareness of symptoms.

Intracranial Aneurysm Embolization Using Interlocking Detachable Coils

The relationship between volume embolization ratio and coil compaction on the intracranial aneurysm occluded using interlocking detachable coils (IDCs) was determined.

From February 1994 to October 1996, 7 intracranial aneurysms were embolized using IDCs. Aneurysm capacity (volume) was calculated assuming that aneurysms are ellipsoid of the diameter in 3 planes. Coil volume was calculated assuming that IDCs are cylinders of primary coil.

Coil compaction was observed in aneurysms embolized at a volume embolization ratio under 25%. There was no coil compaction in aneurysms embolized at a volume embolization ratio of over 25%.

Measurement of the volume embolization ratio is useful to predict coil compaction. Intracranial aneurysms should be embolized at a volume embolization ratio of 25–33%.

Measurement of Volume Ratio to Predict Coil Compaction, on Aneurysmal Embolization

The relationship between volume embolization ratio and coil compaction on the intracranial aneurysms occluded using Guglielmi detachable coils (GDCs) was determined. From March 1997 to February 1998, 38 intracranial aneurysms were embolized using GDCs. Aneurysm volume was calculated assuming that aneurysms are ellipsoids of the diameter in three planes. Coil volume was calculated assuming that detachable coils are cylinder of primary coil. Coil compaction was observed in aneurysms embolized at a volume embolization ratio under 21%. There was no coil compaction in aneurysms embolized at a volume embolization ratio of over 21%. Measurement of the volume embolization ratio is useful to predict the coil compaction. Intracranial aneurysms should be embolized at a volume embolization ratio of 25–33%.

Endovascular Treatment Using Detachable Coils for Non-Ruptured Intracranial Aneurysm

Detachable coil embolization was performed on 34 non-ruptured cerebral aneurysms in 33 patients. Patients consisted of 28 females and five males, with an age range of 26 to 77 years.

Angiographic examination after coil embolization revealed complete or near-complete occlusion in 24 aneurysms (70.5%) and partial occlusion in three (8.8%). Detachable coil embolization was attempted unsuccessfully in seven aneurysms (20.5%).

Transient ischemic attack occurred in one case with coil migration. The combined mortality/morbidity rate was 0%.

Correlation between radiation dose and histopathological findings in patients with gliblastoma treated with boron neutron capture therapy (BNCT)

The purpose of this study was to clarify the correlation between the radiation dose and histopathological findings in patients with glioblastoma multiforme (GBM) treated with boron neutron capture therapy (BNCT). Histopathological studies were performed on specimens from 8 patients, 3 had undergone salvage surgery and 5 were autopsied. For histopathological cure of GBM at the primary site, the optimal minimal dose to the gross tumor volume (GTV) and the clinical target volume (CTV) were 68Gy(w) and 44Gy(w), respectively.

Cell type-specific localization of optineurin in the striatal neurons of mice: implications for neuronal vulnerability in Huntington's disease

Striatal neuropathology of Huntington's disease (HD) involves primary and progressive degeneration of the medium-sized projection neurons, with relative sparing of the local circuit interneurons. The mechanism for such a patterned cell loss in the HD striatum continues to remain unclear. Optineurin (OPTN) is one of the proteins interacting with huntingtin and plays a protective role in several neurodegenerative disorders. To determine the cellular localization pattern of OPTN in the mouse striatum, we employed a highly sensitive immunohistochemistry with the tyramide signal amplification system. In this study, we show that OPTN appeared as a cytoplasmic protein within the subsets of the striatal neurons. Of particular interest was that OPTN was abundantly expressed in the interneurons, whereas low levels of OPTN were observed in the medium projection neurons. This cell type-specific distribution of OPTN in the striatum is strikingly complementary to the pattern of neuronal loss typically observed in the striatum of patients with HD. We suggest that OPTN abundance is an important cellular factor in considering the cell type-specific vulnerability of striatal neurons in HD.

Cyclin-dependent kinase 5 with phosphorylation of tyrosine 15 residue is enriched in striatal matrix compartment in adult mice

Accumulating evidence suggests that the striosome-matrix systems have a tight link with motor and behavioral brain functions and their disorders. Cyclin-dependent kinase 5 (Cdk5) is a versatile protein kinase that plays a role in synaptic functions and cell survival in adult brain, and its kinase activity is stimulated by phosphorylation at tyrosine 15 residue (pY15). In this study, we used an immunohistochemical method to show differential localization of Cdk5-pY15 in the striatal compartments of adult mice, with a heightened density of Cdk5-pY15 labeling in the matrix relative to the striosomes. Our findings indicate that Cdk5-pY15 can be a new marker for the striatal matrix compartment, and suggest a possible involvement of Cdk5-mediated signaling in compartment-specific neurotransmission and disease pathology in the striatum.

Identification and localization of a neuron-specific isoform of TAF1 in rat brain: implications for neuropathology of DYT3 dystonia

The neuron-specific isoform of the TAF1 gene (N-TAF1) is thought to be involved in the pathogenesis of DYT3 dystonia, which leads to progressive neurodegeneration in the striatum. To determine the expression pattern of N-TAF1 transcripts, we developed a specific monoclonal antibody against the N-TAF1 protein. Here we show that in the rat brain, N-TAF1 protein appears as a nuclear protein within subsets of neurons in multiple brain regions. Of particular interest is that in the striatum, the nuclei possessing N-TAF1 protein are largely within medium spiny neurons, and they are distributed preferentially, though not exclusively, in the striosome compartment. The compartmental preference and cell type-selective distribution of N-TAF1 protein in the striatum are strikingly similar to the patterns of neuronal loss in the striatum of DYT3 patients. Our findings suggest that the distribution of N-TAF1 protein could represent a key molecular characteristic contributing to the pattern of striatal degeneration in DYT3 dystonia.

Multiple cystic cavernous angiomas associated with hemorrhage

A 29-year-old man presented with impaired mental concentration and inability to remember. Magnetic resonance and computed tomography studies revealed multiple calcified cysts. Craniotomy was performed and one of the lesions was resected. The histological diagnosis was cavernous angioma. The first report of multiple cystic cavernous angiomas is reported.

Radiation injury of boron neutron capture therapy using mixed epithermal- and thermal neutron beams in patients with malignant glioma

The purpose of this study was to clarify the radiation injury in acute or delayed stage after boron neutron capture therapy (BNCT) using mixed epithermal- and thermal neutron beams in patients with malignant glioma. Eighteen patients with malignant glioma underwent mixed epithermal- and thermal neutron beam and sodium borocaptate between 1998 and 2004. The radiation dose (i.e. physical dose of boron n-alpha reaction) in the protocol used between 1998 and 2000 (Protocol A, n = 8) prescribed a maximum tumor volume dose of 15 Gy. In 2001, a new dose-escalated protocol was introduced (Protocol B, n = 4); it prescribes a minimum tumor volume dose of 18 Gy or, alternatively, a minimum target volume dose of 15 Gy. Since 2002, the radiation dose was reduced to 80-90% dose of Protocol B because of acute radiation injury. A new Protocol was applied to 6 glioblastoma patients (Protocol C, n = 6). The average values of the maximum vascular dose of brain surface in Protocol A, B and C were 11.4+/-4.2 Gy, 15.7+/-1.2 and 13.9+/-3.6 Gy, respectively. Acute radiation injury such as a generalized convulsion within 1 week after BNCT was recognized in three patients of Protocol B. Delayed radiation injury such as a neurological deterioration appeared 3-6 months after BNCT, and it was recognized in 1 patient in Protocol A, 5 patients in Protocol B. According to acute radiation injury, the maximum vascular dose was 15.8+/-1.3 Gy in positive and was 12.6+/-4.3 Gy in negative. There was no significant difference between them. According to the delayed radiation injury, the maximum vascular dose was 13.8+/-3.8 Gy in positive and was 13.6+/-4.9 Gy in negative. There was no significant difference between them. The dose escalation is limited because most patients in Protocol B suffered from acute radiation injury. We conclude that the maximum vascular dose does not exceed over 12 Gy to avoid the delayed radiation injury, especially, it should be limited under 10 Gy in the case that tumor exists in speech center.

Diagnosis of acute brain-stem infarcts using diffusion-weighed MRI

There are many reports on acute cerebral infarcts diagnosed by diffusion-weighted MRI (DWI), but few describe brain-stem infarcts diagnosed by this method. Using the apparent diffusion coefficient (ADC), we studied 18 consecutive patients with brain-stem infarcts who underwent DWI during the acute phase. We calculated and compared the ADC ratio (lesion ADC/contralateral ADC) in 10 patients with brain-stem and 23 with supratentorial cortical infarcts examined within 24 h of the onset of stroke. Ischaemic brain-stem lesions were detected in all 15 patients who underwent DWI more than 3 h after the onset, but not in two who had DWI within 3 h of the onset; their ADC ratio was more than 0.95. ADC ratios in patients with brain-stem infarcts decreased as the interval between onset and DWI increased; the decrease was slower than in patients with supratentorial cortical infarcts.

Raised plasma oxidised LDL in acute cerebral infarction

BACKGROUND

The association between oxidised low density lipoprotein (OxLDL) and cerebral infarction is suspected but not established.

OBJECTIVES

To determine whether plasma OxLDL is a useful marker for monitoring oxidative stress in stroke patients.

METHODS

Plasma OxLDL concentrations were determined in 56 stroke patients with cerebral infarction (n = 45) or cerebral haemorrhage (n = 11), and in 19 age matched controls, using a novel sandwich enzyme linked immunosorbent assay.

RESULTS

Compared with the controls (0.130 (0.007) ng/ micro g LDL, mean (SEM)), OxLDL was significantly raised in patients with cerebral infarction (0.245 (0.022); p < 0.0001) but not in those with haemorrhage (0.179 (0.023)). Patients with cortical ischaemic infarcts (n = 22) had higher OxLDL levels than either the controls (p < 0.0001) or the patients with non-cortical ischaemic infarcts (n = 23) (p < 0.001). Increased OxLDL concentrations in patients with cortical infarcts persisted until the third day after stroke onset. The National Institutes of Health stroke scales in patients with cortical infarction were higher than in those with non-cortical infarction (p < 0.01).

CONCLUSIONS

There is a significant association between raised plasma OxLDL and acute cerebral infarction, especially cortical infarction. Plasma OxLDL may reflect oxidative stress in stroke patients.

Guglielmi detachable coil embolization for ruptured lower-midbasilar trunk aneurysms--a report of five cases

Detachable coil embolization currently plays an essential role for patients with ruptured basilar artery aneurysms, even though it may have an unfavorable outcome and there may be some technical problems of embolization. We describe Guglielmi detachable coil (GDC) embolization for five ruptured lower-mid basilar trunk aneurysms, using a variety of techniques. The patients' ages ranged from 61 to 78 years; Hunt and Kosnik grade was distributed from 2 to 4, and three patients were found to have fenestrations of the lower basilar arteries. All patients underwent aneurysmal embolization at the subacute or chronic stage. The transfemoral route was used in three patients--one of whom, with a wide-necked aneurysm, was treated by the balloon remodeling technique. The transbrachial approach was chosen for the fourth patient, while vertebral artery origin exposure followed by a direct puncture was achieved in the fifth. All patients were assessed with 80-100% aneurysmal obliteration. No patient re-bled after the embolization. Small cerebellar infarction, possibly due to embolism from the obliterated aneurysmal sac, occurred 11 days after the treatment. Of the five patients, four achieved a good recovery, and one became severely disabled. Ruptured basilar trunk aneurysms can be successfully treated with GDC embolization. In addition to the routine transfemoral route, the transbrachial route, direct vertebral artery puncture, and balloon remodeling technique are also useful for the embolization of this location of aneurysm.

Optimal timing of neutron irradiation for boron neutron capture therapy after intravenous infusion of sodium borocaptate in patients with glioblastoma

PURPOSE

A cooperative study in Europe and Japan was conducted to determine the pharmacokinetics and boron uptake of sodium borocaptate (BSH: Na(2)B(12)H(11)SH), which has been introduced clinically as a boron carrier for boron neutron capture therapy in patients with glioblastoma.

METHODS AND MATERIALS

Data from 56 patients with glioblastoma who received BSH intravenous infusion were retrospectively reviewed. The pharmacokinetics were evaluated in 50 patients, and boron uptake was investigated in 47 patients. Patients received BSH doses between 12 and 100 mg/kg of body weight. For the evaluation, the infused boron dose was scaled linearly to 100 mg/kg BSH.

RESULTS

In BSH pharmacokinetics, the average value for total body clearance, distribution volume of steady state, and mean residence time was 3.6 +/- 1.5 L/h, 223.3 +/- 160.7 L, and 68.0 +/- 52.5 h, respectively. The average values of the boron concentration in tumor adjusted to 100 mg/kg BSH, the boron concentration in blood adjusted to 100 mg/kg BSH, and the tumor/blood boron concentration ratio were 37.1 +/- 35.8 ppm, 35.2 +/- 41.8 ppm, and 1.53 +/- 1.43, respectively. A good correlation was found between the logarithmic value of T(adj) and the interval from BSH infusion to tumor tissue sampling. About 12-19 h after infusion, the actual values for T(adj) and tumor/blood boron concentration ratio were 46.2 +/- 36.0 ppm and 1.70 +/- 1.06, respectively. The dose ratio between tumor and healthy tissue peaked in the same interval.

CONCLUSION

For boron neutron capture therapy using BSH administered by intravenous infusion, this work confirms that neutron irradiation is optimal around 12-19 h after the infusion is started.

Quantitative evaluation of cerebral metabolites and cerebral blood flow in patients with carotid stenosis

We examined the metabolic and hemodynamic status of patients with severe carotid stenosis and evaluated the effectiveness of carotid endarterectomy (CEA) by comparing pre- and post-operative results of quantitative proton magnetic resonance spectroscopy (1H-MRS) and single-photon emission computed tomography (SPECT). Quantitative 1H-MRS and SPECT were performed in 17 patients with severe carotid stenosis before CEA; in 10 patients the examinations were repeated after CEA. There was a significant correlation between the degree of internal carotid artery (ICA) stenosis and the N-acetyl-aspartate (NAA) concentration, and between CBFand NAA in the basal ganglia. In 10 of the 17 patients (58.8%) we noted a decrease of NAA on 1H-MRS. After CEA in these patients, NAA was significantly increased, and in 7 of 8 patients whose pre-operative SPECT had indicated impairment of cerebral vasoreactivity, it was improved. Quantitative 1H-MRS and CBF measurements can indicate the severity of metabolic and hemodynamic impairment in patients with severe carotid stenosis, and can help to assess the effectiveness of CEA.

Combined therapeutic approach of intra-arterial thrombolysis and carotid endarterectomy in selected patients with acute thrombotic carotid occlusion

PURPOSE

The feasibility and clinical outcome of intra-arterial thrombolysis followed by carotid endarterectomy (CEA) for acute thrombotic occlusion of the internal carotid artery (ICA) were evaluated.

METHODS

Intra-arterial thrombolysis and CEA were performed in four patients with acute thrombotic ICA occlusion. Computed tomography scans, cerebral angiograms, and the severity of carotid plaques were examined, and the patients' clinical outcome was evaluated.

RESULTS

All 4 patients had severe hemiparesis; 3 patients were alert, and 1 patient was lethargic at the time of hospital admission. New lesions were not shown by means of the initial computed tomography scan. ICA occlusion was indicated in all four patients by means of cerebral angiograms; in three patients, middle cerebral artery occlusion was noted. Collateral circulation was manifested in all patients. Partial recanalization of the occluded ICA was obtained in all patients. Two patients with severe residual ICA stenosis underwent an emergency CEA soon after thrombolysis; the other two patients were treated by means of CEA in the subacute or chromic stage. Plaque rupture and intraplaque hemorrhage were seen in all four patients. All four patients recovered completely, and restenosis of the ICA was not shown by means of follow-up angiograms.

CONCLUSION

Intra-arterial thrombolysis followed by CEA may be an effective therapeutic approach for treating acute thrombotic ICA occlusion. The optimal timing of CEA remains controversial.

Identification of the carotid artery dural ring by using three-dimensional computerized tomography angiography. Technical note

The carotid artery (CA) dural ring is an important structure in aneurysm surgery of the paraclinoid region. The authors used three-dimensional computerized tomography (3D-CT) angiography to study the CA dural ring. Three-dimensional computerized tomography angiography was performed in patients with cerebral aneurysms and other cerebrovascular diseases. The paraclinoid segment of the internal carotid artery (ICA) was examined by the shaded surface reconstruction method on targeted 3D-CT angiography. The concavity was recognized in the paraclinoid segment of the ICA. The relationship between the concavity and the dural ring was investigated with anatomical studies and surgical findings. In anatomical studies, the concavity in the paraclinoid segment of the ICA on 3D-CT angiography coincided with the level of attachment of the dural ring. Using 3D-CT angiography, it is possible to identify the location of the dural ring in patients being considered for aneurysm surgery.

Anterior ischemic optic neuropathy after combined ophthalmic artery embolization and craniofacial surgery--case report

A 57-year-old man developed visual loss following craniofacial surgery for an inflammatory ethmoidal sinus mass. Surgery was preceded by endovascular occlusion of the ophthalmic artery distal to central retinal artery (CRA). Routine angiography obtained immediately after endovascular ophthalmic artery occlusion showed patency of the CRA. He complained of visual loss one day after craniofacial surgery (2 days after embolization). Repeat emergency angiography confirmed the patent CRA. Ophthalmic examination and fluorescein angiography showed that the visual loss was due to anterior ischemic optic neuropathy (AION). Preservation of the CRA is critical during ophthalmic artery embolization to avoid visual complications. Neurosurgeons should be aware of the possibility of AION as a complication of ophthalmic artery embolization.

Endolymphatic sac tumor associated with a von Hippel-Lindau disease patient: an immunohistochemical study

The authors report a case of endolymphatic sac tumor (ELST) associated with Von Hippel-Lindau disease (VHL). A 20-year-old female VHL patient received a resection of a cerebellar hemangioblastoma 3 years ago and she had a co-existing of left petrous tumor. The petrous tumor showed a remarkable progression in 3 years and was resected subtotally. Histologically, the resected petrous tumor showed a papillary structure containing cuboidal or columnar cells with fibrous stroma and numerous microvessels and destructed temporal bone, all of which are consistent with ELST. We studied the expression of various kinds of cytokeratins (CKs) immunohistochemically and found distinct expression of CKs (CAM 5.2, 34betaE-12, CK7, CK8 and CK19), but not for CK10/13 or CK20. Vascular endothelial growth factor and neuron specific enolase showed strong immunoreactivity in the tumor cells. CD34 also had weak expression. Ki-67 antigen (MIB-1) immunoreactivity was found in focal areas, and the labeling index in the highest-density area was 48.9%. These findings suggest that vascular endothelial growth factor overexpression is an important factor for angiogenesis in ELST, much like other VHL-associated tumors, and that ELST may have a more highly aggressive component than the low-grade malignancy noted in previous reports.

Carotid endarterectomy with external shunt: a new device and indication for use: technical note

OBJECTIVE

We designed a new external shunt system and evaluated its indications and efficacy in patients undergoing carotid endarterectomy (CEA).

METHODS

In 8 of 332 CEA procedures, external shunts were placed between the common carotid artery and the internal carotid artery (ICA). This procedure was implemented for one of two indications: 1) a change in electroencephalographic and/or somatosensory evoked potential readings immediately after ICA occlusion, or 2) elongation of the ICA made safe insertion of an internal shunt impossible. In addition, a shunt was placed between the common carotid artery and the external carotid artery to establish collateral circulation from the external carotid artery to the intracranial circulation, which is essential during ICA occlusion.

RESULTS

All external shunts were functional, and electroencephalography and somatosensory evoked potentials demonstrated no significant abnormalities during the CEAs. All patients awoke from surgery without manifestation of new neurological deficits.

CONCLUSION

Our new external shunt device proved safe and efficacious in cases that did not permit the placement of an internal shunt.

Hyperperfusion phenomenon after percutaneous transluminal angioplasty for atherosclerotic stenosis of the intracranial vertebral artery

✓ The authors report on a patient who underwent percutaneous transluminal angioplasty (PTA) for stenosis of the intracranial vertebral artery (VA). This 67-year-old man's dizziness while walking was caused by infarction of the left cerebellar peduncle. On angiograms, his left VA manifested 90% stenosis at the intracranial portion and his right VA ended at the posterior inferior cerebellar artery. Because single-photon emission computerized tomography (SPECT) showed low perfusion and poor perfusion reserve in the posterior circulation, the authors performed PTA of the left VA, which was only 35% dilated due to stenosis. Although the patient's postoperative course was uneventful, postoperative hemodynamic studies (SPECT and transcranial Doppler [TCD] ultrasonography) revealed the hyperperfusion phenomenon. A 100% increase of regional cerebral blood flow in the posterior circulation was demonstrated on SPECT studies and TCD ultrasonography revealed a doubling of blood flow velocity in the VA compared with preoperative values. Careful control of the patient's blood pressure resulted in resolution of the hyperperfusion phenomenon within 1 week post-PTA. Although hyperperfusion syndrome following carotid endarterectomy is not rare, it is seldom seen after reconstruction of the posterior circulation, and the possibility of its occurrence must be kept in mind when the posterior circulation is reconstructed.

Cerebellar hemorrhage caused by dural arteriovenous fistula: a review of five cases

OBJECT

In this study the authors performed a retrospective analysis of five cases in which the patients (three women and two men) were treated for intracranial dural arteriovenous fistulas (AVFs) associated with cerebellar hemorrhage. On the basis of their findings, the authors evaluated the characteristics of this unusual symptom.

METHODS

The dural AVFs were located in the right cavernous sinus in one patient, the left transverse-sigmoid sinus in three patients, and the right superior petrosal sinus (SPS) in one patient. All patients presented with severe headache and/or loss of consciousness. Computerized tomography scans revealed a small cerebellar hemorrhage near the fourth ventricle and hydrocephalus in four cases, and a massive hemispheric cerebellar hemorrhage in the remaining case. The four patients with small hemorrhages underwent ventriculostomy and endovascular treatment; all recovered. The patient suffering from a massive hemorrhage because of a dural AVF in the SPS was treated by suboccipital craniectomy, hematoma evacuation, and removal of the vascular anomaly. This patient remains in a persistent vegetative state. In four cases, results of angiography demonstrated retrograde leptomeningeal venous drainage through the SPS to the anastomotic lateral mesencephalic vein (ALMV) and/or to the vein of the lateral recess of the fourth ventricle (VLR4V). Retrograde leptomeningeal venous drainage to the ALMV and/or VLR4V was responsible for cerebellar hemorrhage in these cases.

CONCLUSIONS

Thus, it is important to consider dural AVF in cases in which there is even a small hemorrhage near the fourth ventricle accompanied by intraventricular perforation and a decreased level of consciousness.

Phenotypic modulation of smooth muscle cells in human cerebral aneurysmal walls

We used immunohistochemical methods to analyze the phenotypes of smooth muscle cells (SMCs) in human cerebral arteries and aneurysmal walls. Thirty-two aneurysmal walls were studied; 31 aneurysmal walls were resected at operation and 1 aneurysm was obtained at autopsy. Seven control arteries were obtained at autopsy. Semiserial sections were subjected to immunohistochemical staining with antibodies to alpha-smooth muscle actin (alpha-SMA), desmin and smooth muscle myosin heavy chain isoforms: SM1, SM2 and SMemb. In control cerebral arteries, SMCs in the media were strongly immunostained for alpha-SMA, desmin, SM1 and SM2; immunoreactivity for SMemb was faint or weakly positive. SMCs in both non-ruptured and ruptured aneurysmal walls showed no staining for desmin; the expression of alpha-SMA was well preserved. Compared with control cerebral arteries, in 4 of 11 non-ruptured aneurysmal walls, the staining intensity of SMCs for SMemb was clearly increased. In ruptured aneurysmal walls, the expression of SM2 was lower than in control cerebral arteries and non-ruptured aneurysmal walls. Our study suggests that the phenotype of SMCs in aneurysmal walls is different from the contractile type in the media of normal cerebral arteries, at least partially changing to the synthetic type in some non-ruptured aneurysms. SMCs in ruptured aneurysmal walls may have lost both phenotypes before rupture. Phenotypic modulation of SMCs in the aneurysmal walls appears to be related to a remodeling of the aneurysmal wall and to a rupture mechanism.

Gel microdroplet technique leaving microorganisms alive for sorting by flow cytometry

Fluorescent labels used to disclose cellular function and the like are generally needed for cytometric analysis, but suitable ones are not always available. Thiamin, an example of such a label, was used as a model in this study. Thiamin in cells of bakers' yeast can be chemically converted to thiochrome, which fluoresces strongly, but the reaction kills cells not protected inside a gel microdroplet (GMD). Our new procedure for preparation of a small amount of GMDs uses a glass filter with micropores uniform in size to make an emulsion of molten agar in mineral oil that is then chilled for gelation of the agarose. Cells were suspended and mixed with the warm agarose, which was used to make GMDs. Cells were grown into microcolonies in the GMDs, which were then treated to convert thiamin to thiochrome. The thiochrome in microcolonies in single GMDs could be detected by flow cytometry. Plating showed that enough cells survived for this method to be used for screening. This technique can be used for all applications of GMDs.

Meningioma with granulofilamentous inclusions

The authors report a case of intracranial meningioma with granulofilamentous inclusions. A 50-year-old man had right trigeminal neuralgia due to trigeminal nerve compression by a petroclival tumor and received tumor resection. Microscopically, tumor cells containing eccentric nuclei and intracytoplasmic hyaline inclusions were arranged in sheets and whorls. The inclusions were negative for periodic acid-Schiff reaction. No histological anaplasia was seen. Immunohistochemistry showed epithelial membrane antigen reactivity on the cytoplasmic membrane. Immunoreactivity for vimentin was recognized in cytoplasm adjacent to inclusions. However, confocal laser microscopic study revealed immunoreactivity for vimentin even inside some inclusions. Ultrastructurally, interdigitation of cytoplasmic processes and desmosomes connecting adjacent cells were noted. Inclusions were composed of numerous fine osmiophilic granules attached by intermediates filaments. These findings were consistent with a meningioma with the granulofilamentous inclusions described earlier. The findings demonstrated by confocal laser microscopy and electron microscopy suggest that these granular materials may be the metabolic products of vimentin filaments.

Diffusion-weighted and perfusion-weighted magnetic resonance imaging to monitor acute intra-arterial thrombolysis

Diffusion-weighted and perfusion-weighted magnetic resonance imaging (DWI, PWI) are useful in detecting early cerebral ischemic lesions. Intra-arterial thrombolysis is an effective treatment for some patients with acute thromboembolic occlusion. We evaluated the efficacy of acute thrombolytic therapy by using DWI and PWI in 3 patients who presented with internal carotid artery or middle cerebral artery occlusion. On the initial magnetic resonance imaging scans, the abnormal areas shown by PWI were bigger than those shown by DWI. All patients received thrombolytic therapy within 6 hours after stroke onset. In 1 patient, the hyperintensity area detected by initial DWI scanning diminished after thrombolysis. DWI and PWI may be useful to monitor the effectiveness of intra-arterial thrombolysis.

HLA-mismatched CD34-selected stem cell transplant complicated by HHV-6 reactivation in the central nervous system

We report here a patient who suffered from PCR- confirmed human herpesvirus type 6 (HHV-6) meningoencephalitis after allogeneic purified CD34+ cell transplantation from his HLA-mismatched sibling donor, even though he had been on intense prophylaxis with i.v. ganciclovir (GCV), acyclovir (ACV) and gamma-globulin containing a specific antibody against HHV-6. Serological evaluation disclosed that both the donor and recipient had IgG antibody against HHV-6 before transplantation. His blood WBC count started to transiently increase on day 10, and all blood components had decreased by day 20. He then developed a severe headache and high blood pressure, and sporadic abnormal neurological findings including nystagmus and delirium. An analysis of cerebrospinal fluid (CSF) revealed 8 cells/microl, a glucose level of 130 mg/dl and a protein level of 201 mg/dl (normal, 50 mg/dl) on day 26. At the time, HHV-6 was detected only in CSF by a PCR-based method and he was diagnosed as having meningoencephalitis due to the local reactivation of HHV-6. Although he failed to respond to high-dose therapy with ACV (60 mg/kg/day) and gamma-globulin, the DNA of this virus disappeared from the CNS upon treatment with GCV (30 mg/kg/day) combined with the intraventricular infusion of alpha-interferon. His clinical course was further complicated with meningoencephalitis due to staphylococcus epidermidis, and he died of tentorial herniation on day 79 without the recovery of blood components. This experience may indicate that intense prophylaxis to prevent reactivation of HHV-6 in the CNS is essential for the management of such profoundly immunosuppressed patients.

Surgical management of symptomatic intrasellar arachnoid cysts--two case reports

Two patients with symptomatic intrasellar arachnoid cyst were successfully treated. A 67-year-old female with a cyst 20 mm in diameter developed headache and visual disturbance. She was treated by transsphenoidal surgery. A 59-year-old male with a cyst measuring 35 x 30 x 50 mm causing headache, visual disturbance, and deterioration of consciousness was managed by wide resection of the cyst wall via craniotomy. Postoperative courses in both patients were uneventful. Transsphenoidal surgery may be suitable for small to medium-sized cysts, although tight packing of the sella is mandatory to prevent leakage of cerebrospinal fluid. However, craniotomy is recommended for large intra- and suprasellar arachnoid cysts to avoid this complication, and to achieve sufficient communication between the cyst and the subarachnoid cistern.

Coronary artery stenosis evaluated by combined carotid and coronary angiography in patients undergoing carotid endarterectomy

The relationship between coronary artery stenosis and the postoperative outcome was investigated in patients who underwent carotid endarterectomy (CEA). The benefit of combined carotid and coronary angiography was also evaluated. Combined carotid and coronary angiography was performed in 72 patients treated with CEA (mean age 64.0 years). Fourteen patients with a history of ischemic heart disease (IHD) had a higher Gensini score for coronary artery stenosis than patients with no history of IHD (37.9 +/- 36.8 vs. 7.9 +/- 12.5, p < 0.0001). However, 39.7% of patients with no history of IHD had a Gensini score exceeding 6. Patients with diabetes mellitus had a significantly higher Gensini score than nondiabetic patients. Eleven patients (15.3%) underwent percutaneous transluminal coronary angioplasty and three (4.2%) underwent coronary artery bypass grafting during the CEA perioperative period. None of the patients who underwent combined angiography showed signs of IHD during or after CEA (mean follow-up period 30 months). Combined angiography was not performed in 189 previous patients. Of these, two died of acute myocardial infarction in the postoperative period, 11 manifested nonfatal IHD, and 18 succumbed to IHD (mean follow-up period 8 years). Although patients with a history of IHD manifested more severe coronary artery stenosis than patients without such a history, the possibility of coronary artery stenosis must be considered in patients with no history of IHD, especially those with diabetes mellitus. Combined carotid and coronary angiography and careful management of coronary artery stenosis can be expected to decrease the mortality and morbidity in patients treated with CEA.

Loss of chromosome 10 in glioblastoma: relation to proliferation and angiogenesis

Loss of chromosome 10 was assessed in 17 specimens of glioblastoma (GBM) by fluorescence in situ hybridization (FISH) technique using the centromere probe for chromosome 10. Cytospinned smear specimens were prepared from paraffin-embedded specimens. The percentage of nuclei containing a single fluorescent signal ranged from 19.2 to 88. 0% (mean, 49.3%). Thirteen tumors (76.5%) were designated as monosomy 10 because the proportion of single-signal nuclei exceeded the cut-off value (31.5%: mean of five control materials +3 standard deviations). The results confirmed the importance of the loss of chromosome 10 for the development of GBM, although no significant correlation was demonstrated between the loss of chromosome 10 and survival. In addition, proliferation potential and angiogenesis of GBM were immunohistochemically analyzed using antibodies against Ki-67 antigen (MIB-1), factor VIII-related antigen (FVIII R/Ag) and vascular endothelial growth factor (VEGF), respectively. The labeling indices of MIB-1 (1.5-57.8%) and the number of blood vessels immunoreactive for FVIII R/Ag (18-279/10 high-power fields) were not significantly related to the loss of chromosome 10. Vascular endothelial growth factor immunoreactivity in areas microvessels were counted was seen in 12 cases. However, neither the loss of chromosome 10 nor number of vessels was not correlated with VEGF expression. Other genetic abnormalities as well as loss of chromosome 10 may be involved in the cell proliferation and angiogenesis of GBM.

Gliomatosis cerebri with secondary glioblastoma formation: report of two cases

The clinicopathological features of two cases of gliomatosis cerebri associated with secondary glioblastoma formation are reported. In both cases, glial cells were diffusely distributed in the supra- and infratentorial regions and underlying brain structures were preserved from the onset. In spite of such diffuse distribution of neoplastic glial cells, similar to that observed in low-grade astrocytoma, in both cases the tumor underwent complete remission after radiotherapy. However, the tumor recurred as a localized glioblastoma in both cases, 37 months (case 1) and 7 months (case 2) after the radiotherapy. In both cases, recurrence was accompanied by prominent dissemination of CSF. The recurrent tumors were radiation resistant, and the patients' conditions deteriorated rapidly after recurrence. The present two cases demonstrated that gliomatosis cerebri, classified among brain tumors of unknown origin by the World Health Organization, may transform into highly proliferative circumscribed tumors, in spite of their good response to radiotherapy. Examination of pathological features and their correlation with MRI findings may allow us to better understand the response to radiotherapy and the process of recurrence.

Activities of calcineurin and phosphatase 2A in the hippocampus after transient forebrain ischemia

We investigated the changes in the enzyme activity and immunoreactivity of calcineurin in the rat hippocampus after transient forebrain ischemia. Immediately after 20-min transient forebrain ischemia, calcineurin activity decreased to about 40% of the control in the CA1 region and to about 55% in other regions. Protein phosphatase 2A activity showed no remarkable changes. By 12 h after ischemia, calcineurin activity recovered, more in the CA1 region than in other regions. At 24 h it decreased again, but only in the CA1 region. Immunohistochemical- and immunoblot analyses showed no remarkable change in calcineurin in any region of the hippocampus within 12 h after ischemia. Thus, the activity of calcineurin is dissociated from its immunoreactivity and quantity. Several studies have suggested that unknown inhibitory factor(s) and/or reversible changes in calcineurin act to modify enzyme activity after ischemia. In contrast, phosphatase 2A activity underwent no obvious changes during the post-ischemia period we examined. This unique time course of calcineurin activity may contribute to the mechanism of ischemic neuronal injury.

Hyperperfusion syndrome following carotid endarterectomy: evaluation using diffusion-weighted magnetic resonance imaging--case report

A 65-year-old female developed hyperperfusion syndrome following carotid endarterectomy for severe stenosis of the left internal carotid artery. Transcranial Doppler monitoring showed a sharp increase in flow velocity in the middle cerebral artery (MCA). Diffusion-weighted magnetic resonance (MR) imaging demonstrated diffuse hyperintensity in the region of the left MCA, which diminished markedly 9 days later. The abnormal hyperintensity decreased as the patient's symptoms improved, suggesting that diffusion-weighted MR imaging can be used for evaluating the course of hyperperfusion syndrome.

Gliosarcoma: an immunohistochemical, ultrastructural and fluorescence in situ hybridization study

Three cases of primary gliosarcoma (GS) were studied by immunohistochemical, ultrastructural and fluorescence in situ hybridization (FISH) methods. All tumors occurred in the supratentorial regions of the body. No patient had a prior history of irradiation to the brain. All patients died of tumor within 1 year, and autopsies were performed in two cases. Microscopically, each of the three tumors showed a mixture of glioblastoma (GBM) and a sarcomatous component (SC), which resembled fibrosarcoma with various histological features. Numerous collagen and reticulin fibers were seen in the SC of all tumors. Glial fibrillary acidic protein (GFAP) was immunoreactive only in the gliomatous component (GC). Factor VIII-related antigen was negative except for endothelial cells. One tumor exhibited alpha-smooth muscle actin positivity in the SC. Expression of MIB-1 and p53 protein was demonstrated in both components for all tumors. Labeling indices (LI) for MIB-1 ranged from 7.7 to 36.1%, and LI for p53 protein ranged from 2.9 to 57.0%. Ultrastructurally, astrocytic cells were characterized by a polygonal configuration with many cytoplasmic projections and occasional filaments. Spindle-shaped fibroblasts in the SC contained well-developed rough endoplasmic reticulum. Fluorescence in situ hybridization (FISH) performed on fresh materials or paraffin-embedded tissue demonstrated single signals for chromosome 10 in 40.6-58.3% of cells and for chromosome 17 in 37.9-48.6% of cells. Two tumors were regarded as containing losses of both chromosomes 10 and 17, while the third showed a substantial loss only of chromosome 10. As similar aberrations have been reported in GBM, these chromosomal abnormalities suggest a common pathogenesis in GS and GBM.

Pathophysiology and treatment of cerebral ischemia

This article describes the pathophysiology of, and treatment strategy for, cerebral ischemia. It is useful to think of an ischemic lesion as a densely ischemic core surrounded by better perfused "penumbra" tissue that is silent electrically but remains viable. Reperfusion plays an important role in the pathophysiology of cerebral ischemia. Magnetic resonance imaging (MRI) and histological studies in rat focal ischemia models using transient middle cerebral artery (MCA) occlusion indicate that reperfusion after an ischemic episode of 2- to 3-hour duration does not result in reduction of the size of the infarct. Brief occlusion of the MCA produces a characteristic, cell-type specific injury in the striatum where medium-sized spinous projection neurons are selectively lost; this injury is accompanied by gliosis. Transient forebrain ischemia leads to delayed death of the CA1 neurons in the hippocampus. Immunohistochemical and biochemical investigations of Ca2+/calmodulin-dependent protein kinase II(CaM kinase II) and protein phosphatase (calcineurin) after transient forebrain ischemia demonstrated that the activity of CaM kinase II was decreased in the CA1 region of the hippocampus early (6-12 hours) after ischemia. However, calcineurin was preserved in the CA1 region until 1.5 days after the ischemic insult and then lost; a subsequent increase in the morphological degeneration of neurons was observed. We hypothesized that an imbalance of Ca2+/calmodulin dependent protein phosphorylation-dephosphorylation may be involved in delayed neuronal death after ischemia. In the treatment of acute ischemic stroke, immediate recanalization of the occluded artery, using systemic or local thrombolysis, is optimal for restoring the blood flow and rescuing the ischemic brain from complete infarction. However, the window of therapeutic effectiveness is very narrow. The development of effective neuroprotection methods and the establishment of reliable imaging modalities for an early and accurate diagnosis of the extent and degree of the ischemia are imperative.

Hyperperfusion syndrome after extracranial-intracranial bypass in a patient with moyamoya disease--case report

A 47-year-old female developed hyperperfusion syndrome after superficial temporal artery-middle cerebral artery (STA-MCA) bypass for moyamoya disease. She presented with right hemiparesis and motor aphasia due to left cerebral infarction. She underwent left STA-MCA bypass. One day after surgery, she manifested neurological deterioration. Magnetic resonance (MR) imaging 4 days after the operation indicated regional edema in the territory supplied by the bypass, and single photon emission computed tomography 17 days after the operation demonstrated hyperperfusion in that area. Symptoms improved within 1 week after surgery, and MR imaging showed disappearance of edema and return to the preoperative appearance. Such events are rare, but hyperperfusion syndrome may occur after STA-MCA bypass for moyamoya disease.

Carotid endarterectomy for radiation-induced carotid artery stenosis

A 60-year-old male presented with radiation-induced left carotid artery stenosis. Carotid endarterectomy was performed successfully without postoperative deficits. Carotid endarterectomy is the therapeutic management of choice for these lesions.

Follow-up evaluation of dissecting aneurysms of the vertebrobasilar circulation by using gadolinium-enhanced magnetic resonance imaging

The authors assessed the reliability of magnetic resonance (MR) imaging contrast enhancement for the detection and follow-up evaluation of dissecting aneurysms of the vertebrobasilar circulation. Twenty consecutively admitted patients who underwent both gadolinium-enhanced MR imaging and conventional angiography were reviewed. Enhancement of the dissecting aneurysm was seen in all but one of the 20 patients, including 10 (71%) of 14 patients examined in the chronic phases, when the T1-hyperintensity signal that corresponded to the intramural hematoma was unrecognizable. The enhanced area corresponded to the "pearl sign" or aneurysm dilation noted on the comparable angiogram. On follow-up MR studies enhancement had spontaneously disappeared in four patients at a time when comparable vertebral angiograms revealed disappearance of the aneurysm dilation. The enhancement persisted in five of nine patients examined more than 24 weeks after symptom onset; in all five patients the aneurysm dilation remained on comparable angiograms. Dynamic MR studies showed rapid and remarkable enhancements with their peaks during the immediate dynamic phase after injection of the contrast material. The authors conclude that gadolinium-enhanced MR imaging is useful for the detection and follow-up evaluation of dissecting aneurysms of the vertebrobasilar circulation.

Differential distribution and expressions of collagens in the cerebral aneurysmal wall

To investigate the role of collagens in the formation and rupture of cerebral aneurysms, we examined the distribution and synthesis of vascular collagens in the wall of normal human cerebral main trunks and of cerebral aneurysms using immunohistochemistry and in situ hybridization techniques. Fifteen cerebral aneurysmal walls were resected at operation; control cerebral main trunks were obtained from seven autopsy cases. Semiserial sections from the specimens were subjected to immunofluorescence and immunohistochemical staining with antibodies to collagen types I, III, IV, V, VI, desmin and alpha-smooth muscle actin. In addition, type III collagen mRNA was examined by in situ hybridization. Immunohistochemical study showed that all collagen types were grossly preserved in the aneurysmal wall, although the distribution patterns were different for each collagen. The distribution of major fibrillar collagen types I and III was more diffuse and homogeneous in the luminal layer of the aneurysmal wall than the media of the control artery, although the intensity of immunohistochemical staining was weaker in the abluminal layer of the aneurysmal wall than the adventitia of the control artery. Collagen types IV and V were distributed more sparsely in the luminal layer of the aneurysmal wall than the media of the control artery. Collagen type VI was noted in the luminal as well as the abluminal layer of the aneurysmal wall, whereas it was located exclusively in the adventitia of the control artery. In situ hybridization showed that the signal for collagen type III mRNA on fibroblastic and smooth muscle cells was higher in the aneurysmal walls than the control arteries, suggesting up-regulation of type III collagen transcription in the cerebral aneurysmal wall. The study of the distribution and synthetic regulation of various types of collagen in the aneurysmal wall may be essential for understanding the formation of the aneurysmal wall and its protection against enlargement or rupture.

Calcineurin in the adult rat hippocampus: different distribution in CA1 and CA3 subfields

We examined the immunohistochemical regional distribution of calcineurin (Ca2+/calmodulin-dependent protein phosphatase) in the adult rat hippocampus, following various regional destruction. In the normal adult rat hippocampus, the calcineurin immunoreactivity showed a characteristic pattern. This protein phosphatase was detected in all layers of the CA1 subfield, including the cytoplasm of the pyramidal cells, whereas it was strongly evident in the stratum lucidum and moderately so in the cytoplasm of pyramidal cells in the CA3 subfield. Seven days after transient forebrain ischemia, which induced destruction of CA1 pyramidal cells, the calcineurin immunoreactivity decreased in all layers of the CA1 subfield, while the immunoreactivity for synapsin I, a marker of the presynaptic site, was preserved. Seven days after the intraventricular injection of kainate, which induced destruction of CA3 pyramidal cells, the calcineurin immunoreactivity in the stratum lucidum was preserved, although the immunostaining pattern of the stratum lucidum changed when CA3 pyramidal cells were destroyed. Seven days after mechanical destruction of the dentate gyrus and CA4 subfield, which induced destruction of mossy fibers, the calcineurin immunoreactivity in the stratum lucidum was lost, except in the far site of the stratum lucidum. In the CA1 subfield, calcineurin was mainly located in postsynaptic sites, while it was mainly located in the presynaptic sites in the mossy fibers of the CA3 subfield. The immunohistochemistry of adjacent sections with antibodies of microtubule-associated protein 2 and synapsin I, which are markers of postsynaptic and presynaptic sites respectively, supports these results. Thus, calcineurin has a different synaptical distribution in the rat hippocampus.

Effectiveness of retrograde perfusion of the cerebral vein for attenuating neuronal injury after transient ischemia following reperfusion in the rat brain

The effect of retrograde perfusion of the cerebral vein (RPCV) with antioxidant LY231617 on neuronal injury after transient ischemia in rat brain was examined. Transient ischemia was caused by left middle cerebral artery (MCA) occlusion and reperfusion. Rats were assigned to three groups: Group A (n = 6), MCA occlusion only; Group B (n = 8), RPCV with saline (flow rate 4.95 ml/hr) into the left inferior cerebral vein; and Group C (n = 6), RPCV with LY231617 (20 mg/kg/hr, flow rate 4.95 ml/hr). RPCV in Groups B and C was performed simultaneously with occlusion. Both occlusion and RPCV were performed for 30 minutes in awake animals. Seven days later, all rats were investigated for rotational behavior elicited by apomorphine (1.0 mg/kg), and then immunohistochemical analysis of brain specimens was carried out using calcineurin as a neuronal marker in the striatum to detect the ischemic damaged area. The number of turns to the left (lesioned side) in both Groups B (42 +/- 12) and C (46 +/- 14) was significantly lower (p < 0.01) than in Group A (222 +/- 45), but there was no significant difference between Groups B and C. The percentage ischemic damaged area in both Groups B (17.9 +/- 6.2%) and C (1.6 +/- 1.0%) was significantly less (p < 0.01) in Group A (51.1 +/- 2.1%). RPCV with and without LY231617 during occlusion was effective for attenuating reperfusion injury.