Skull metastases from extramammary Paget’s disease emerging 8 years after initial treatment with no local progression: illustrative case

BACKGROUND

The foci of distant metastasis from extramammary Paget’s disease (EMPD) are the lung, liver, truncal bones, vertebrae, and brain. However, skull metastases have not been reported.

OBSERVATIONS

The authors treated a patient with calvarial and skull base metastases from EMPD who had undergone wide local resection of EMPD 8 years before, and they report his clinical course.

LESSONS

Because EMPD with distant metastasis is fatal, it should be recognized that EMPD can metastasize to the skull even when it seemed to be in remission for several years.

Association between metabolic syndrome and multiple lesions of intracranial atherothrombotic stroke: a hospital-based study

Background

With the increasing trend of metabolic syndrome (MetS) and atherothrombotic stroke (which can manifest as stroke lesion multiplicity), studies on the association between MetS and the clinical aspects of atherothrombotic stroke are of great interest. The present study aimed to investigate the association between MetS and multiple atherothrombotic strokes in patients with intracranial atherothrombotic stroke.

Methods

A retrospective study based on medical charts was conducted among patients (n = 202: 137 men/65 women) who were symptomatically admitted to the hospital with the first-ever atherothrombotic stroke. For the occurrence of multiple lesions of stroke, odds ratio [OR: 95 % confidence interval (CI)] of MetS or its respective components was calculated using logistic regression models.

Results

Fifty-one percent of the men and 38 % of women with stroke presented multiple regions. MetS was a significant factor that was associated with an increased risk of multiple regions in women [OR 4.3 (95 % CI 1.4–13.5)], but not in men. According to the components of MetS, dyslipidemia was a significant factor that was positively associated with multiple regions in both men [OR 2.0 (95 % CI 1.1–3.7)] and women [OR 3.2 (95 % CI 1.1–9.1)].

Conclusion

MetS may be pathophysiologically associated with intracranial atherothrombotic stroke multiplicity in women in particular. Future studies are warranted to confirm the findings.

Sellar Chondroma with Endocrine Dysfunction that Resolved after Surgery: Case Report

Chondromas originating from the sella turcica are rare, and the most common initial symptoms are headache and visual disturbance. We describe a case of sellar chondroma with endocrine impairment as an initial manifestation that completely resolved after surgery. A 40-year-old Japanese woman with amenorrhea and galactorrhea for the last 2 years was referred to our department of neurosurgery for the evaluation of high prolactin levels and a tumor in the sella turcica. A biochemical assessment indicated endocrine dysfunction. Magnetic resonance imaging and computed tomography indicated a tumor in the sella turcica. The patient's presentation favored the preoperative diagnosis of pituitary adenoma or Rathke's cleft cyst. However, because calcification was detected, other types of tumors, such as craniopharyngioma, meningioma, and chordoma, were also considered. Endoscopic transsphenoidal surgery was performed, and the possibility of a bony tumor was recognized. Finally, the tumor was completely removed, and the histopathological findings confirmed chondroma. The postoperative course was uneventful, and endocrine function improved. Five years after surgery, the patient is doing well without pituitary insufficiency, pituitary hormone medications, or signs of tumor recurrence. In cases of sellar chondroma, endocrine dysfunction sometimes precedes other symptoms, such as headache and visual disturbance. When examining a patient with an intrasellar tumor harboring calcification, clinicians must consider the possibility of sellar chondroma. Furthermore, to the best of our knowledge, this case is the first of sellar chondroma treated with endoscopic surgery to be reported.

Torcular dural arteriovenous fistula treated via stent placement and angioplasty in the affected straight and transverse sinuses: case report

The successful obliteration of torcular dural arteriovenous fistula (DAVF) with a diffuse shunt in the affected sinus may require complex treatment strategies. Therapeutic goals include the preservation of normal venous drainage and complete obliteration of shunt flow. The authors report the case of a torcular DAVF. The treatment of this type of AVF may require a combined approach with transarterial and transvenous embolization, open surgery, or radiosurgery and is associated with many problems. Stent placement and angioplasty in the affected sinus result in compression of the fistulous dural wall of the sinus and decrease shunt flow. In cases in which there is a diffuse shunt in the affected sinus and no evident shunt point, such as in AVFs involving venous pouches and parasinuses, sealing the fistula orifice with self-expandable stents and angioplasty (balloon inflation) is considered the best treatment option to preserve normal cerebral venous sinus drainage and obliterate shunt flow. In such cases, the authors recommend using one or more self-expandable and closed-cell stents and using angioplasty to avoid endoleakage into the gap between the stent graft and the vessel wall.

Heat-moisture treatment of high-amylose corn starch increases dietary fiber content and lowers plasma cholesterol in ovariectomized rats

The effect of dietary high-amylose corn starch (HACS) of varying dietary fiber (DF) content on plasma cholesterol was examined in ovariectomized (OVX) rats. Gelatinized normal corn starch (G-CS) was used as a reference. OVX rats were fed a fiber-free purified diet containing G-CS, HACS, gelatinized high-amylose corn starch (G-HACS), or heat-moisture treated HACS (HM-HACS) at 400 g starch/kg diet for 21 d. The DF content of G-CS, HACS, G-HACS, and HM-HACS measured by the AOAC method was 0.1, 19.3, 2.4, and 64.5 g/100 g, respectively. The dry weight of cecal contents, cecal wall weight, the amount of short chain fatty acids in cecal contents, the amount of bile acids in small intestinal contents, and fecal excretion of neutral sterols increased logarithmically with increasing DF, while total plasma cholesterol concentration decreased. On the other hand, hepatic CYP7A1 activity, fecal dry weight, and fecal excretion of bile acids increased linearly with increasing DF, while body weight gain decreased. The hypocholesterolemic effect of HACS in OVX-rats appeared to be more effective by heat-moisture treatment.

Combined treatment using CEA and CAS for carotid arterial stenosis

In this study we report our surgical results of CAS and CEA for carotid stenosis and suggest an appropriate treatment strategy for patients with high risks such as bilateral carotid stenosis or medical risk factors. From January 2001 to December 2005 we surgically treated 182 patients with carotid stenosis. Seventy-nine lesions were treated by CEA and 145 by CAS, respectively. Although CEA was considered the first choice for severe carotid stenosis, CAS was chosen for treatment when CEA was considered a higher risk for patients. Stenosis of carotid arteries was relieved in all cases after CEA or CAS. Surgical mortality of CEA was 1.1% (1/94). Surgical mortality of CAS was 0.7% (1/145). Carotid stenotic lesions can be treated with comparably low morbidity and mortality rates using CEA or/and CAS considering each characteristic of carotid stenosis of patients even with medically high risk or bilateral carotid stenosis.

Successful Use of Prolonged Mild Hypothermia in a Patient With Severe Head Injury and Diffuse Brain Swelling-Case Report-

A 19-year-old female was admitted to our hospital after severe head injury in a traffic accident. On admission, she had no spontaneous respiration, but did have heart beat with a blood pressure of 100/60 mmHg. Neurological examination demonstrated that the Glasgow Coma Scale score was 3 and her pupils were fixed and dilated. Computed tomography (CT) showed diffuse brain swelling with disappearance of the perimesencephalic cistern. Chest CT showed bilateral lung contusions. Mild hypothermia with a target temperature of 33 degrees C was immediately induced, and was continued for 28 days to control the persistent increase in intracranial pressure (ICP). Subsequently, she recovered, and 20 months after admission, could speak and walk with slight hemiparesis on the left. Prolonged mild hypothermia may be effective to control persistent increase in ICP due to diffuse brain swelling.

Inflammatory reaction following cataract surgery and implantation of acrylic intraocular lens in rabbits with endotoxin-induced uveitis

PURPOSE

To investigate whether inflammatory responses are more severe in uveitic eyes than nonuveitic eyes when acrylic intraocular lens (IOL) is implanted after cataract surgery.

METHODS

Clear lens removal (phacoemulsification and aspiration) was conducted and the hydrophobic acrylic IOL (AR40e, AMO) was implanted in adult albino rabbits. Just after the operation, rabbits were divided into two groups. One group (nine rabbits) received intravitreal injection of lipopolysaccharide (LPS, 200 ng/10 microl) into both eyes to induce endotoxin-induced uveitis (EIU) and the other group (nine rabbits) received intravitreal injection of phosphate-buffered saline (PBS, 10 microl) into both eyes as the control. Aqueous humour (AH) and IOLs were harvested 1, 3 , and 7 days after the intravitreal injection. The infiltrating cell number in AH was counted and the protein concentration of AH was measured. IOLs were evaluated morphologically.

RESULTS

At 1 day after intravitreal injection, both the infiltrating cell number in AH and protein concentration of AH were significantly higher in the LPS-injected group than in the PBS-injected group. Similarly, more inflammatory cells attached to the surfaces of the IOLs in the LPS-injected group. However, 7 days later, inflammatory reactions subsided and no clear differences in any of the parameters examined were observed between the two groups.

CONCLUSIONS

At 7 days after the operation, inflammatory reactions in eyes implanted with the hydrophobic acrylic IOLs were similar in uveitic eyes and nonuveitic eyes. The data suggest that the hydrophobic acrylic IOLs may be suitable for patients with uveitis.

Surgical treatment for bilateral carotid arterial stenosis

Carotid endarterectomy (CEA) is a beneficial procedure for patients with high-grade carotid stenosis. However, patients with bilateral carotid stenosis have a higher surgical risk during CEA. Since the introduction of carotid stenting (CAS) may decrease some of the surgical complications of CEA, a combined treatment using CEA and CAS may be favorable for patients with bilateral carotid stenosis. We analyzed the safety and efficacy of this treatment strategy. Eighteen patients with bilateral carotid stenosis were treated from January 2000. Bilateral CEA was performed on the first two patients, CAS then CEA of contra-lateral symptomatic side in 13 patients, and bilateral CAS in three patients. There were no perioperative neurological complications or strokes during the follow-up period (mean 17 months). The combined treatment of CAS and CEA was a safe and effective strategy for bilateral carotid stenosis.

Stenting for vertebrobasilar artery stenosis

We report our experience with stenting for symptomatic vertebrobasilar artery stenosis. One hundred and sixteen patients with vertebrobasilar artery stenosis (101 vertebral ostial stenosis, 15 intracranial vertebrobasilar artery stenosis) were treated with stenting. Indication criteria of treatment were 1) symptomatic lesion, 2) angiographical stenosis more than 60%. Under local anesthesia, pre-dilatation was first performed, then stents were placed to the lesion. Successful dilatation was obtained in 115 cases. The stenosis rate reduced to 2% post-stenting in ostial lesions and 16% in intracranial lesions. Transient neurological complications developed in 2 patients. Follow-up angiographies more than 6 months after stenting were performed in 94 patients with ostial lesions and all patients with intracranial lesions. Of these, 8 patients (9.5%) with ostial lesions and 4 patients (27%) with intracranial lesions developed restenosis. All patients with restenosis were treated successfully with PTA (percutaneous transluminal angioplasty). During the follow-up period, 3 patients developed recurrence of VBI (vertebro-basilar insufficiency) symptoms due to restenosis. One patient developed brain stem infarction due to in-stent occlusion 8 months after stenting. Conclusion. Stenting for vertebrobasilar artery stenoses is feasible and safe. Prevention of restenosis, especially in intracranial arteries, is the next problem to be solved.

Olfactory groove schwannoma--case report

A 30-year-old man presented with a 2-year history of intermittent headache. No neurological deficit was detected. Computed tomography (CT) and magnetic resonance imaging showed a tumor with a diameter of 2.5 cm in the left anterior skull base associated with bone scalloping on three-dimensional CT. Angiography showed a hypovascular tumor. Craniotomy demonstrated a tumor in the region of the left olfactory groove attached to the anterior part of the cribriform plate. The histological diagnosis was schwannoma. Schwannoma arising from near the olfactory groove is rare, with only 13 other cases reported. The precise origin of these tumors is not well understood, but the tumor in this case probably arose from the fila olfactoria, because the olfactory bulb was involved in the tumor, whereas the olfactory tract remained intact.

[Localization of the pyramidal tract in the internal capsule: relationship between CT classification of thalamic hemorrhage and motor weakness]

To better understand the pyramidal tract of the internal capsule, we evaluated the relationship between the localization of thalamic hemorrhage and motor weakness. On an axial CT scan at the level of the pineal body, two lines were drawn as follows: line-a between the lateral edge of the anterior horn and the lateral edge of the trigone, line-b vertical to the sagittal line and passing the midpoint of the third ventricle. The location of the hematoma was classified into three types according to localization of the center of the hematoma and lateral extension beyond line-a as follows: type A (anterior), type P (posterior) and type PL (postero-lateral). Discrepancy of motor weakness between upper extremities and lower extremities was higher in patients with hematoma of type P and type PL (p < 0.05) than in those with hematoma of type A. Improvement of motor weakness on discharge was higher in patients with type P (p < 0.01) than in those with type A. We concluded that most of the pyramidal tract fibers were located in the third quarter of the posterior limb of the internal capsule but a small number of pyramidal tract fibers were located in the anterior two-thirds of it. A greater number of cortico-spinal fibers to the upper extremities than to the lower extremities occupy the third quarter of the posterior limb of the internal capsule.

Enzymatic synthesis of novel fructosyl and oligofructosyl trehaloses by Aspergillus sydowi beta-fructofuranosidase

An intracellular beta-D-fructofuranosidase produced by Aspergillus sydowi IAM 2544 was purified by Q-Sepharose and Alkyl-Sepharose chromatographies. The molecular mass was 50 kDa by SDS-PAGE analysis. The optimum pH and temperature of sucrose hydrolyzing activity of the enzyme were 5.5 and 75 degrees C, respectively, but those of fructosyl transferase activity were 5.2 and 55 degrees C, respectively. The enzyme efficiently transferred the fructose residue of sucrose as a donor to trehalose as an acceptor. And the amount of fructosyl and oligofructosyl trehaloses produced was changed by the molar ratio of trehalose as an acceptor to sucrose as a donor used. The most efficient production of the transferred products was achieved at the reaction conditions in the range of molar ratios of 1:1 to 3:1 (trehalose:sucrose). The chemical structures of these new kinds of resulting series of fructosyl and oligofructosyl trehaloses produced were identified as O-beta-D-Fru-(2-->6)-alpha-D-Glc-(1-->1)-alpha-D-glucopyranoside, O-beta-D-Fru-(2-->6)-alpha-D-Glc-(1-->1)-alpha-D-glucopyranoside, and O-beta-D-Fru-(2-->1)-O-beta-D-Fru-(2-->1)-O-beta-D-Fru-(2-->6)-alpha-D-G lc- (1-->1)-alpha-D-glucopyranoside. These results indicate that beta-fructofuranosidase from Aspergillus sydowi specifically transferred the fructose residue of sucrose to the C6-OH position of the glucose residue of trehalose at the early stage of the reaction, following the elongation of the fructose residue by the transfructosylation of the enzyme to form oligofructosyl trehalose of a longer fructose chain.

Usefulness of the pulse oximeter as a respiratory monitor during intravenous sedation

During intravenous sedation, the pulse oximeter was applied as a respiratory monitor to 17 patients (Physical status classification of the American Society of Anesthesiologists, Class I-II) who were to have oral surgical operations, and the changes in arterial saturation of oxygen (SaO2) was observed consecutively. SaO2 dropped after administration of sedative agents in each case; there was some individual variation. Respiratory depression during sedation was evaluated from arterial blood gas analysis. The reduction in SaO2 caused by surgical manipulations was also noted. Furthermore, arterial partial pressures of oxygen (PaO2) and saturation calculated from PaO2 (SAT) measured from blood gas analysis were compared with SaO2 measured by the pulse oximeter. Both PaO2 and SAT correlated well with SaO2. The differences between SAT and SaO2 exceeded the range of error (+/- 2%) in many cases after the administration of sedative agents. These results suggest that the pulse oximeter is useful as a respiratory monitor during oral surgery. However, the pulse oximeter gives incorrect SaO2 readings in the presence of abnormal hemoglobin due to medication with nitrites or smoking habit.

Enzymatic synthesis of p-nitrophenyl alpha-maltoheptaoside by transglycosylation of maltohexaose-forming amylase

An extracellular maltohexaose-forming amylase [EC 3.2.1.98] from Klebsiella pneumoniae mutant is a normal hydrolytic enzyme that hydrolyzes short-chain amylose (DP = 23) to give about 40% maltohexaose. Transglycosylation from maltoheptaose to the 4-position of p-nitrophenyl alpha-glucoside was efficiently induced through the use of maltohexaose-forming amylase in an aqueous methanol solution. The enzyme specifically produced p-nitrophenyl alpha-maltoheptaoside (13% of the p-nitrophenyl alpha-glucoside) from maltoheptaose as a donor and p-nitrophenyl alpha-glucoside as an acceptor. The yield of p-nitrophenyl alpha-maltoheptaoside depended on the concentration of methanol solvent, the pH, and temperature. Furthermore, the use of the aqueous methanol system in the reaction not only improved the solubility of p-nitrophenyl alpha-glucoside but also greatly increased the formation of p-nitrophenyl alpha-maltoheptaoside, which is a useful substrate for assay of human amylase in serum and urine.