Endovascular treatment of acute atherothrombotic internal carotid artery occlusion associated with persistent primitive hypoglossal artery

Persistent primitive hypoglossal artery is a relatively rare anatomical variation and a type of persistent carotid-basilar anastomosis. Acute internal carotid artery occlusion associated with persistent primitive hypoglossal artery is rare, and atherothrombotic occlusion is extremely rare. We present a case of acute atherothrombotic internal carotid artery occlusion associated with persistent primitive hypoglossal artery that was successfully treated by endovascular treatment. A 70-year-old male with a history of left internal carotid artery stenosis was transferred to our hospital by ambulance because of abnormal behaviors and aphasia. He was diagnosed with cerebral infarction and left internal carotid artery occlusion. Left carotid angiography revealed the persistent primitive hypoglossal artery arising from the cervical internal carotid artery and complete internal carotid artery occlusion distal to the origin of the persistent primitive hypoglossal artery. Therefore, we performed endovascular treatment. Mechanical thrombectomy was performed under minimal flow arrest with consideration of brain ischemia causing coma. After additional balloon angioplasty, recanalization was achieved, and the patient's symptoms improved. During the 1.5-year follow-up period, no recurrence or restenosis was observed. This report provides evidence that atherosclerotic internal carotid artery stenosis associated with persistent primitive hypoglossal artery can occur even distal to the origin of the persistent primitive hypoglossal artery and that the lesion may become acutely occluded, leading to acute stroke. Endovascular treatment considering brain ischemia was effective in this case.

Internal carotid artery-persistent primitive anterior choroidal artery aneurysms: report of two cases and literature review

PURPOSE

Persistent primitive anterior choroidal artery (PPAChA) is a rare vascular anomaly. The clinical course of internal carotid artery (ICA)-PPAChA aneurysms has not been well described.

CASE REPORTS

We report two patients with an ICA-PPChA aneurysm and summarize previously reported cases.

RESULTS

Including our two, a total of 10 patients with an ICA-PPAChA aneurysm have been reported. Data were not described for one. Among the remaining nine, five patients (56%) experienced aneurysmal rupture. Five patients underwent surgical clipping and four underwent endovascular coiling. The procedure was completed in all but one patient who had a tiny branch artery adherent to the aneurysm; this patient was converted from clipping to aneurysm coating with a cotton sheet. Among the other eight patients, one who underwent coiling experienced an internal capsule infarction. The remaining seven had a satisfactory postoperative course; however, an asymptomatic occlusion of the PPAChA at its origin was noted on postoperative angiography in one.

CONCLUSION

PPChA is associated with a high incidence of aneurysm formation and rupture. During treatment of ICA-PPAChA aneurysms, obstruction of the PPAChA and any surrounding perforating arteries should be avoided to prevent ischemic stroke.

Long insular artery damage might be a key sign for predicting functional prognosis of putaminal hemorrhage

OBJECTIVE

Although the putamen is the most common area of spontaneous intracerebral hemorrhage, previous reports about the effects of surgery are limited. We sometimes experience a poor prognosis in patients in whom there is no damage to the internal capsule, but with injury in the long insular artery (LIA) region. The purpose of this study was to confirm the relationship between LIA damage and patient prognosis following surgery for putaminal hemorrhage.

METHODS

We retrospectively collected data of 287 surgical cases who presented with putaminal hemorrhage between January 2004 and March 2022. Among them, we chose patients without initial damage to the posterior limb of the internal capsule, and divided these patients into two groups, those without (Group A) and with (Group B) final damage in the LIA region. We compared positivity rates of final manual muscle test (MMT) scores≥3 and related factors.

RESULTS

Sixty-three of the 287 patients were included in this study. Of them, 11 cases in Group A were positive for MMT scores≥3 (68.8%) and 9 cases (19.1%) in Group B had MMT scores≥3 seven days after surgery. Group A thus had a significantly higher rate of MMT scores≥3 than group B (p=0.00).

CONCLUSION

In patients without initial damage to the internal capsule, LIA injury might be a key sign for predicting the functional prognosis of putaminal hemorrhage.

Increased Piezo1 expression in myofibroblasts in patients with symptomatic carotid atherosclerotic plaques undergoing carotid endarterectomy: A pilot study

OBJECTIVES

We aimed to investigate Piezo1 expression in myofibroblasts in symptomatic and asymptomatic patients undergoing carotid endarterectomy and its relationship with atherosclerotic plaque formation.

METHODS

This cross-sectional study analyzed carotid plaques of 17 randomly selected patients who underwent carotid endarterectomy from May 2015 to August 2017. In total, 51 sections (the most stenotic lesion, and the sections 5-mm proximal and distal) stained with hematoxylin-eosin and elastica-Masson were examined. Immunohistochemistry was performed using antibodies to Piezo1. The Piezo1 score of a section was calculated semiquantitatively, averaged across 30 randomly selected myofibroblasts in the fibrous cap of the plaque.

RESULTS

Of 17 patients (mean age: 74.2 ± 7.1 years), 15 were men, 9 had diabetes mellitus, and 13 had hypertension. Symptomatic patients had higher mean Piezo1 score than asymptomatic patients (1.78 ± 0.23 vs 1.34 ± 0.17, p < .001). Univariate linear regression analyses suggested an association between plaque rupture, thin-cap fibroatheroma and microcalcifications and the Piezo1 score (p = .001, .008, and 0.003, respectively).

CONCLUSIONS

Increased Piezo1 expression of myofibroblasts may be associated with atherosclerotic carotid plaque instability. Further study is warranted to support this finding.

Five-Year Stroke Risk and Its Predictors in Asymptomatic Moyamoya Disease: Asymptomatic Moyamoya Registry (AMORE)

BACKGROUND

Long-term outcomes are unknown in patients with asymptomatic moyamoya disease. In this report, we aimed to clarify their 5-year risk of stroke and its predictors.

METHODS

We are conducting a multicenter, prospective cohort study (Asymptomatic Moyamoya Registry) in Japan. Participants were eligible if they were 20 to 70 years, had bilateral or unilateral moyamoya disease, experienced no episodes suggestive of TIA and stroke; and were functionally independent (modified Rankin Scale score 0-1). Demographic and radiological information was collected at enrollment. In this study, they are still followed up for 10 years. In this interim analysis, we defined the primary end point as a stroke occurring during a 5-year follow-up period. Independent predictors for stroke were also determined, using a stratification analysis method.

RESULTS

Between 2012 and 2015, we enrolled 109 patients, of whom 103 patients with 182 involved hemispheres completed the 5-year follow-up. According to the findings on DSA and MRA, 143 hemispheres were judged as moyamoya disease and 39 hemispheres as questionable manifestations (isolated middle cerebral artery stenosis). The patients with questionable hemispheres were significantly older, more often male, and more frequently had hypertension than those with moyamoya hemisphere. Moyamoya hemispheres developed 7 strokes, including 6 hemorrhagic and 1 ischemic stroke, during the first 5 years. The annual risk of stroke was 1.4% per person, 0.8% per hemisphere, and 1.0% per moyamoya hemisphere. Independent predictor for stroke was Grade-2 choroidal anastomosis (hazard ratio, 5.05 [95% CI, 1.24-20.6]; P=0.023). Furthermore, microbleeds (hazard ratio, 4.89 [95% CI, 1.13-21.3]; P=0.0342) and Grade-2 choroidal anastomosis (hazard ratio, 7.05 [95% CI, 1.62-30.7]; P=0.0093) significantly predicted hemorrhagic stroke. No questionable hemispheres developed any stroke.

CONCLUSIONS

The hemispheres with asymptomatic moyamoya disease may carry a 1.0% annual risk of stroke during the first 5 years, the majority of which are hemorrhagic stroke. Grade-2 choroidal anastomosis may predict stroke, and the microbleeds and Grade-2 choroidal anastomosis may carry the risk for hemorrhagic stroke.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: UMIN000006640.

National trends in the outcomes of subarachnoid haemorrhage and the prognostic influence of stroke centre capability in Japan: retrospective cohort study

OBJECTIVES

To examine the national, 6-year trends in in-hospital clinical outcomes of patients with subarachnoid haemorrhage (SAH) who underwent clipping or coiling and the prognostic influence of temporal trends in the Comprehensive Stroke Center (CSC) capabilities on patient outcomes in Japan.

DESIGN

Retrospective study.

SETTING

Six hundred and thirty-one primary care institutions in Japan.

PARTICIPANTS

Forty-five thousand and eleven patients with SAH who were urgently hospitalised, identified using the J-ASPECT Diagnosis Procedure Combination database.

PRIMARY AND SECONDARY OUTCOME MEASURES

Annual number of patients with SAH who remained untreated, or who received clipping or coiling, in-hospital mortality and poor functional outcomes (modified Rankin Scale: 3-6) at discharge. Each CSC was assessed using a validated scoring system (CSC score: 1-25 points).

RESULTS

In the overall cohort, in-hospital mortality decreased (year for trend, OR (95% CI): 0.97 (0.96 to 0.99)), while the proportion of poor functional outcomes remained unchanged (1.00 (0.98 to 1.02)). The proportion of patients who underwent clipping gradually decreased from 46.6% to 38.5%, while that of those who received coiling and those left untreated gradually increased from 16.9% to 22.6% and 35.4% to 38%, respectively. In-hospital mortality of coiled (0.94 (0.89 to 0.98)) and untreated (0.93 (0.90 to 0.96)) patients decreased, whereas that of clipped patients remained stable. CSC score improvement was associated with increased use of coiling (per 1-point increase, 1.14 (1.08 to 1.20)) but not with short-term patient outcomes regardless of treatment modality.

CONCLUSIONS

The 6-year trends indicated lower in-hospital mortality for patients with SAH (attributable to better outcomes), increased use of coiling and multidisciplinary care for untreated patients. Further increasing CSC capabilities may improve overall outcomes, mainly by increasing the use of coiling. Additional studies are necessary to determine the effect of confounders such as aneurysm complexity on outcomes of clipped patients in the modern endovascular era.

Significant Correlation between Structural Changes in the Net-like Appearance on Postoperative Cranial Magnetic Resonance Images and Hematoma Recurrence in Cases of Chronic Subdural Hematoma

Organized hematoma, which exhibits a net-like appearance on imaging studies, is one of the predisposing factors for the recurrence of chronic subdural hematoma. Patients who are positive for the net-like appearance are often treated with only burr hole surgery. We investigated the relationship between postoperative structural changes in the net-like appearance and the recurrence rate of chronic subdural hematoma. Of the 949 patients with chronic subdural hematoma treated with primary burr hole surgery between January 2010 and April 2021 at our hospital, 268 who were considered positive for the net-like appearance on T2- and T2 star-weighted magnetic resonance images were extracted. We followed the structural changes in the net-like appearance postoperatively and subsequently classified the patients into three groups: decreasing type, shifting type, and no change and deterioration type. The relationship between each structural change and the recurrence rate in the three groups was investigated. Postoperative recurrence requiring surgery occurred in 3.5% of the subjects with decreasing type, 0% with shifting type, and 100% with deterioration type of the net-like appearance (P < 0.05), indicating differences in the recurrence rates according to postoperative structural changes in the magnetic resonance images (MRI) features of chronic subdural hematoma. Our results indicate that the risk of postoperative chronic subdural hematoma recurrence can be predicted by focusing on the structural changes in the postoperative net-like appearance on MRI.

Vertebral artery stump syndrome: A 7-year follow-up case report

Vertebral artery stump syndrome is rare, but one of the most important causes of posterior circulation stroke. To our knowledge, no optimal treatment for vertebral artery stump syndrome has been established, and there are no reports of long-term follow-up. We describe a 69-year-old man with vertebral artery stump syndrome who attended our hospital because of vertigo. Magnetic resonance imaging detected right cerebellar infarcts. Digital subtraction angiography revealed severe stenosis (functional obstruction) at the origin of the right vertebral artery, with distal antegrade collateral flow from the deep cervical artery. We started him on argatroban and cilostazol, but symptoms recurred after 1 month. We changed from cilostazol to aspirin and clopidgrel, then terminated aspirin 1 month after recurrence. He continued on clopidgrel, and follow-up after 7 years showed no recurrence, including asymptomatic lesions.

[Emergency Superficial Temporal Artery-Middle Cerebral Artery Bypass for Atherosclerotic Ischemic Stroke]

Endovascular recanalization is the primary strategy for the treatment of acute embolic stroke. However, atherosclerotic occlusions are often challenging to recanalize, and only medical therapy can be performed. In these cases, even the best medical treatment may not be effective, and the cerebral infarction progressively worsens. We believe that an emergency superficial temporal artery-middle cerebral artery(STA-MCA)bypass could be effective in these situations, after careful case selection. We use the following eligibility criteria: (1)atherosclerotic infarction; (2)cerebral ischemia with blood flow < 70% of the contralateral side; (3)progressively worsening symptoms or widening of the subcortical infarction despite medical treatment; and(4)surgery availability < 72 h from symptom onset. Among the 35 patients who underwent urgent STA-MCA bypass from 2014 to 2020, 27(77.1%)gained gait independence, and the National Institutes of Health Stroke Scale(NIHSS)scores improved from a preoperative median of 8 to 3 at discharge. The modified Rankin score(mRS)improved from a preoperative median of 5 to 2 at discharge. No intracerebral hemorrhages occurred due to hyper-perfusion syndrome. When we match it with other reports, this emergency surgery allows 76-90% of patients with progressive stroke to achieve gait independency.

Separate origins of the left internal and external carotid arteries from the aorta in a patient with intracerebral hemorrhage

Agenesis of the left common carotid artery with separate origins of the left internal and external carotid arteries from the aorta is an extremely rare anomaly. This anomaly is typically asymptomatic unless associated with other conditions. We report a case of separate origins of the left internal and external carotid arteries from the aorta in a patient with intracerebral hemorrhage. A 42-year-old man was transferred to our hospital by ambulance because of left hemiparesis. Computed tomography scan revealed right putaminal hemorrhage. Computed tomography angiography and digital subtraction angiography demonstrated independent origins of the left internal carotid artery and external carotid artery from the aortic arch. Right internal carotid angiography revealed blood supply to the left anterior cerebral artery and middle cerebral artery via the anterior communicating artery. The separate origins of the left internal and external carotid arteries from the aorta may cause hemodynamic stress to the contralateral side, leading to right intracerebral hemorrhage.

Predictors of a Good Outcome in Endovascular Treatment for Basilar Artery Occlusion with a Direct Aspiration First-Pass Technique

Objective

There is limited evidence for mechanical thrombectomy in patients with basilar artery occlusion. Despite recanalization, there are several reports on poor outcomes. Therefore, we retrospectively evaluated the outcomes and examined the predictors of mechanical thrombectomy in patients with basilar artery occlusion.

Methods

We recruited 22 consecutive patients who had received mechanical thrombectomy for basilar artery occlusion with a direct aspiration first-pass technique at our hospital between January 2016 and April 2020. The subjects were divided into good (modified Rankin Scale [mRS] ≤2) and poor outcome groups (mRS ≥3) and compared with one another. We conducted ROC analysis to identify the cut-off value that revealed a statistically significant difference in the univariate analysis.

Results

Of the 22 patients, the average age ± standard deviation (SD), median pretreatment NIHSS (interquartile range [IQR]), and median pretreatment posterior circulation acute stroke progression early CT score (pc-ASPECTS) (IQR) were 76 ± 10 years, 21 (8-31), and 8 (5-9), respectively. The predictors that showed statistically significant differences in the univariate analysis were age, pretreatment NIHSS score, and pretreatment pc-ASPECTS. Based on the ROC analysis, age (area under the curve [AUC] of 0.782, cutoff <74, and P = 0.028), pretreatment pc-ASPECTS (AUC of 0.850, cutoff ≥7, and P = 0.006), and pretreatment NIHSS (AUC of 0.803, cutoff <19, and P = 0.018) were significant prognostic factors.

Conclusion

In this study, aged <74 years, pc-ASPECTS ≥7, and NIHSS <19 were significant prognostic factors in endovascular treatment for basilar artery occlusion with a direct aspiration first-pass technique.

A Case of Internal Carotid Artery Occlusion Caused by En Bloc Distal Embolization of Carotid Free-Floating Thrombus Treated by Mechanical Thrombectomy

Objective

We report a case of internal carotid artery (ICA) occlusion caused by en bloc distal embolization of carotid free-floating thrombus (FFT) treated by mechanical thrombectomy.

Case Presentation

A 57-year-old woman was brought to our hospital with dysarthria, right hemiparesis, and motor aphasia. MRI and MRA revealed acute infarction due to middle cerebral artery occlusion. Carotid ultrasonography demonstrated a pedunculated mobile plaque in the left ICA. We diagnosed embolic infarction due to the carotid FFT and started medical treatment. However, on the second hospital day, the carotid FFT detached from the arterial wall en bloc, resulting in left ICA occlusion. The occluded ICA was successfully recanalized by mechanical thrombectomy.

Conclusion

FFT is associated with a high risk of embolic ischemic stroke and the primary treatment strategy must be carefully considered.

Small Unruptured Aneurysm Verification-prevention Effect against Growth of Cerebral Aneurysm Study Using Statin

Several basic experimental studies have demonstrated that statins have beneficial effects for intracranial aneurysm (IA). Clinical studies on unruptured IAs, however, remain limited to four retrospective studies that have reached different conclusions. This study was the first open-label, multicenter, randomized controlled trial to assess the preventive effects of atorvastatin. Patients with unruptured small saccular IAs were randomly assigned to statin and control groups. The primary endpoint was a composite of aneurysm growth of ≥0.5 mm, new bleb formation confirmed from magnetic resonance (MR) angiography, and rupture. Enrollment was prematurely terminated due to unexpectedly slow enrollment. Of 231 patients (275 target IAs), 110 patients (128 IAs) were randomly assigned to the statin group and 121 patients (147 IAs) to the control group. After excluding 22 dropout patients, 107 IAs in the 93 statin group patients and 140 IAs in the 116 control group patients were finally analyzed. No significant differences of basic characteristics were evident between groups, except for significantly higher systolic pressure in the statin group (P = 0.03). The primary endpoint occurred in 28 IAs (20.0%) in the control group and in 17 IAs (15.9%) in the statin group. No aneurysm rupture was confirmed in either group. Significant beneficial effects of statin for IAs were not demonstrated for the primary endpoint (log-rank P = 0.359). This randomized trial did not establish any preventive effects of atorvastatin for unruptured small IAs. Further studies of larger cohorts are required to clarify the efficacy of statins for patients with unruptured IAs.

Clinical trial registration: UMIN000005135

Mechanical Thrombectomy Making Practical Use of an Aspiration Catheter While Selecting the Retrieval Technique during the Procedure

Objective

To report the outcomes of thrombectomy for arterial occlusion involving the major arteries of the cerebral anterior circulation when an aspiration catheter (AC) was used in all cases, with the retrieval technique chosen during the procedure.

Methods

Of the 126 patients who underwent endovascular thrombectomy during the 2-year period of 2018-2019, the study subjects were 102 patients with arterial occlusion involving the major arteries of the cerebral anterior circulation. Patients were divided into two groups depending on when the procedure was performed. In the earlier group (January 2018-March 2019), treatment was performed using only a stent retriever (SR), whereas an AC was used for all cases in the later group (April-December 2019). Outcomes between groups were retrospectively compared. In the later group, the treatment strategy was to use the SR in combination with the AC (combined technique) for retrieval if the microcatheter reached the distal side of the occlusion site without difficulty. If the microcatheter did not easily reach the distal side, we did not stick to penetrating the occlusion site, and contact aspiration was performed.

Results

Thrombolysis in cerebral infarction (TICI) grade 2b-3 was achieved in 85% of patients in the earlier group and 95% in the later group. TICI grade 3 was achieved in 52% of the earlier group and 54% of the later group, showing no significant difference. TICI grade 2b-3 was achieved at first pass in 46% of patients in the earlier group, significantly lower than the 71% in the later group (P = 0.013). The mean number of passes decreased significantly from 1.84 in the earlier group to 1.32 in the later group (P = 0.002).

Conclusion

Using an AC from the start, and using a combined technique when the microcatheter reached the distal side of the occlusion site, the frequency of first-pass TICI grade 2b-3 increased, and the mean number of passes decreased in comparison with the SR-alone group.

Target Embolization of Dilated Post-PICA Segment for Ruptured PICA-Involved Type Vertebral Artery Dissecting Aneurysm

Objective

In parent artery occlusion (PAO) for ruptured vertebral artery dissecting aneurysms (RVADA), target embolization using coils in a short segment to occlude only the vasodilated area containing the rupture point is selected as a first-choice procedure at our institute. We focused on RVADA involving the posterior inferior cerebellar artery (PICA) and evaluated the treatment results.

Methods

This study consisted of eight cases with RVADA involving the PICA which were treated between October 2007 and January 2020. Based on radiological findings such as the bleb, the rupture points were located at the affected vertebral artery (VA) distal to PICA in all cases. Target embolization, by which only coiling at the dilated segment distal to the VA was performed. We aimed to preserve blood flow to the PICA. The incidence and extent of medullary infarctions, and neurological outcome were retrospectively assessed.

Results

Regarding the diameter of bilateral VA, there were no differences in six cases while the affected VA with RVADA were larger in the remaining two cases. PICA was preserved in all cases but one in which occlusion of complementary PICA was observed. Postoperative medullary infarction was not noted. There was no rebleeding during the follow-up period. However, recanalization of the VA was observed in four cases and additional coil embolization was performed. All patients were discharged with a good outcome (modified Rankin Scale [mRS] 0; seven patients, mRS 2; one patient).

Conclusion

Target embolization preserving the PICA in PICA-involved type RVADA was considered to be an effective treatment method for cases whose rupture point was located in the VA distal to PICA orifice.

Results of Therapy Using Oral Anticoagulants in the Acute Phase after Mechanical Thrombectomy

Objective

The usage of oral anticoagulants (OACs) in the acute phase of cerebral infarction has increased, but the optimal timing for starting OACs after mechanical thrombectomy (MT) is unclear. We report the usage of OACs after MT at our hospital and evaluated the outcomes.

Methods

OACs were selected as secondary preventive drugs for 64 patients who underwent MT for anterior circulatory embolism between July 2016 and January 2019. Of the 64 patients, 28 and 36 received direct oral anticoagulants (DOACs) and warfarin (Wf), respectively. We compared the frequency of intracranial hemorrhage in the acute phase and that of recurrent cerebral infarction within 30 days.

Results

The median diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Scores + white matter (DWI-ASPECTS + W) score at admission was 7.5 (IQR 6-9)/8 (IQR, 6-9) in the DOACs group/Wf group. The rate of recanalization with modified thrombolysis in cerebral infarction (TICI) ≥2B by MT was 89.3/80.6%. In patients with subarachnoid hemorrhage (SAH) associated with MT and patients with hemorrhagic transformation (HT) on MRI the next day, administration was started after hemostasis. The median timing of the first anticoagulant administration was 3 (IQR, 2-4)/2 (IQR, 1-4) days. In the case of no HT the next day, the rate of new HT after 1 week was 7.1%/29.1%. In the case of HT the next day, the rate of HT deterioration the next day was 7.1%/16.6%. The percentage of symptomatic bleeding was 0%/2.8%. The percentage of recurrent cerebral infarction within 30 days was 0%/2.8%.

Conclusion

OACs in the acute phase after MT can be safely used and are expected to be effective at preventing recurrence.

[Preventing Crying after Revascularization Surgery in Pediatric Patients with Moyamoya Disease:Sedation with Dexmedetomidine]

BACKGROUND

Hyperventilation is a well-known risk factor of ischemic events in pediatric patients with moyamoya disease. For young children, it is important to avoid crying to prevent ischemic events because of their unstable postoperative hemodynamics. To prevent crying in pediatric patients, we used dexmedetomidine(DEX)for sedation immediately after revascularization surgery.

OBJECTIVE

We investigated the effects of postoperative DEX use on hemodynamic changes and the avoidance of crying and hypocapnia in pediatric patients with moyamoya disease.

CASE

Ten consecutive patients(5 boys and 5 girls)who underwent surgical revascularization were enrolled, and 16 hemispheres(8 boys and 8 girls)were sedated with DEX postoperatively between August 2011 and August 2016.

METHODS

During extubation after revascularization, DEX was started at 0.4μg/kg/hr under spontaneous breathing and its dose was increased depending on the degree of consciousness, to maintain sedation of at least 3 on the Ramsay scale. DEX administration was terminated the next morning.

RESULTS

Sedation was maintained well in all patients without hypocapnia, and no ischemic complications were observed. One patient cried and needed additional intravenous DEX injections and was immediately re-sedated;no hypocapnia developed. Respiratory depression did not occur and changes in respiratory rate and decreases in SpO₂ were not observed. No significant changes in systolic blood pressure and heart rate were observed.

CONCLUSION

Dexmedetomidine is safe and useful for postoperative sedation in children with moyamoya disease.

Abstract TP368: Development of the Close the Gap-stroke in the J-aspect Study: A Nationwide Quality Improvement Initiative of Japan

Background: Improving the quality of stroke care is an urgent issue worldwide. To facilitate the measurement of quality of stroke care in Japan, we aimed to develop the Close The Gap-Stroke initiative in the J-ASPECT Study.

Methods and Results: Quality indicators (QIs) were developed by a multidisciplinary board between 2015 and 2017. The process involved a systematic review of domestic and international studies related to primary and comprehensive stroke care. Adherence rates for the defined QIs were calculated for 8,826 patients with acute ischemic stroke from 227 hospitals between 2013 to 2015. Seventeen and 12 measures were identified as QIs for primary and comprehensive stroke care (PSC and CSC), respectively. We analyzed adherence rates of all 17 QIs for PSC and 8 QIs for CSC related with acute ischemic stroke. We found NIHSS documentation (91.0 %), CT/MRI performed within 25min and 24hr (80.9 % and 99.1 %), evaluation of extracranial vascular imaging (90.4 %), treated in stroke unit (57.4 %), tPA administration (89.5 %), tPA performed within 1hr (37.4 %), early and discharge antithrombotics medication (75.1 % and 49.0 %), discharge anticoagulation for atrial fibrillation patients (76.2 %), discharge statin medication (32.7 %), discharge antihypertensive agents (54.3 %), deep vein thrombosis prophylaxis (34.5 %), early rehabilitation (57.0 %), dysphagia screening (76.6 %), smoking cessation (59.8 %) and stroke education (71.4 %) for primary stroke care; and median time to multimodal CT or MR brain and vascular imaging (33 min), proper endovascular recanalization (81.7 %), tPA before endovascular recanalization (65.7 %), TICI grade 2b/3 after endovascular recanalization (73.0 %), median time of door to puncture (105 min), symptomatic intracranial hemorrhage after thrombolytic or endovascular therapy (7.45 %), 90 days mRS documentation after thrombolytic or endovascular therapy (60.8 %), occurrence of complication within 24 hours of diagnostic neuroangiography (7.27 %) for comprehensive stroke care.

Conclusion: This is a promising first step to measure the QIs related to primary and comprehensive stroke care at a national level in Japan.

[Treatment Strategy and Results of Carotid Endarterectomy in Chronic Renal Failure Patients]

INTRODUCTION

The number of patients receiving chronic dialysis treatment in Japan currently exceeds 300,000 people. Few reports have described carotid endarterectomy(CEA)for chronic renal failure patients because of the unacceptable rate of perioperative stroke and other morbidities. A strategy for and treatment results of CEA for chronic renal failure patients in our hospital are described herein.

METHODS

The present study included 6 patients who underwent CEA while receiving dialysis treatment between April 2011 and November 2014.

RESULTS

Dialysis treatment was initiated due to diabetes in 4 patients and renal sclerosis in 2 patients. All the patients were men, with a mean age of 74.0 years. Two patients were symptomatic, and four were asymptomatic. In all the patients, heart vascular lesions and arteriosclerosis risk factors were present. Postoperatively, pneumonia transient cranial neuropathy, heart failure, and pneumonia in 1 case required extensive treatment. However, by the time of discharge from hospital, no cases had deteriorated compared with their pre-CEA state. The modified Rankin scale score on discharge was 0-2 for all the patients.

CONCLUSION

CEA can be performed safely in patients receiving dialysis, but further operative procedures and careful postoperative management are likely to be needed for patients with CEA who are receiving dialysis.

Effects of extracranial-intracranial bypass for patients with hemorrhagic moyamoya disease: results of the Japan Adult Moyamoya Trial

BACKGROUND AND PURPOSE

About one half of those who develop adult-onset moyamoya disease experience intracranial hemorrhage. Despite the extremely high frequency of rebleeding attacks and poor prognosis, measures to prevent rebleeding have not been established. The purpose of this study is to determine whether extracranial-intracranial bypass can reduce incidence of rebleeding and improve patient prognosis.

METHODS

This study was a multicentered, prospective, randomized, controlled trial conducted by 22 institutes in Japan. Adult patients with moyamoya disease who had experienced intracranial hemorrhage within the preceding year were given either conservative care or bilateral extracranial-intracranial direct bypass and were observed for 5 years. Primary and secondary end points were defined as all adverse events and rebleeding attacks, respectively.

RESULTS

Eighty patients were enrolled (surgical, 42; nonsurgical, 38). Adverse events causing significant morbidity were observed in 6 patients in the surgical group (14.3%) and 13 patients in the nonsurgical group (34.2%). Kaplan-Meier survival analysis revealed significant differences between the 2 groups (3.2%/y versus 8.2%/y; P=0.048). The hazard ratio of the surgical group calculated by Cox regression analysis was 0.391 (95% confidence interval, 0.148-1.029). Rebleeding attacks were observed in 5 patients in the surgical group (11.9%) and 12 in the nonsurgical group (31.6%), significantly different in the Kaplan-Meier survival analysis (2.7%/y versus 7.6%/y; P=0.042). The hazard ratio of the surgical group was 0.355 (95% confidence interval, 0.125-1.009).

CONCLUSIONS

Although statistically marginal, Kaplan-Meier analysis revealed the significant difference between surgical and nonsurgical group, suggesting the preventive effect of direct bypass against rebleeding.

CLINICAL TRIAL REGISTRATION URL

http://www.umin.ac.jp/ctr/index.htm. Unique identifier: C000000166.

Diagnostic imaging of higher brain dysfunction in patients with adult moyamoya disease using statistical imaging analysis for [123I]iomazenil single photon emission computed tomography

[123I]iomazenil (IMZ) is a specific radioligand for the central benzodiazepine (BZ) receptor that may be useful as a marker of cortical neuron loss after cerebral ischemia using single photon emission computed tomography (SPECT). This study used statistical imaging analysis for IMZ-SPECT to investigate the relationship between higher brain dysfunction and cortical neuron loss in the medial frontal lobes, to establish a confirmatory diagnosis of higher brain dysfunction in patients with adult moyamoya disease. IMZ-SPECT was estimated by three-dimensional stereotactic surface projections (3D-SSP). Cortical neuron loss was analyzed using the stereotactic extraction estimation (SEE) method (level 3: gyrus level) for 3D-SSP Z-score maps (Z-score >2). Extent of pixels with significant reduction of BZ receptor density within the target gyri (i.e. bilateral medial frontal gyri [MFGs] and anterior cingulate gyri [ACGs]) was calculated. In 6 patients with higher brain dysfunction, significant cortical neuron loss was observed in the bilateral MFGs in 4 patients, unilateral MFG in 1 patient, and bilateral ACGs in 2 patients. In 12 patients without higher brain dysfunction, no significant cortical neuron loss was observed in the bilateral MFGs or ACGs, and mild loss was observed in the bilateral MFGs in 2 patients, unilateral MFG in 4 patients, and unilateral ACG in 2 patients. Long-standing mild hemodynamic ischemia in the anterior circulation of patients with adult moyamoya disease could lead to incomplete brain infarction within the medial frontal lobes. Statistical imaging analysis using 3D-SSP and SEE methods for IMZ-SPECT could demonstrate significant cortical neuron loss in the bilateral frontal medial cortices involving MFG and/or ACG which correlate with higher brain dysfunction in patients with adult moyamoya disease.

Initial 'TTP Map-Defect' of Computed Tomography Perfusion as a Predictor of Hemorrhagic Transformation of Acute Ischemic Stroke

Background

Hemorrhagic transformation (HT) following acute ischemic stroke is a major problem, especially for the indication of reperfusion therapy including intravenous administration of recombinant tissue plasminogen activator (IV rt-PA). The specific predictive factors of HT have not yet been established. The present study evaluated the findings of computed tomography perfusion (CTP) images as predictors of subsequent HT to identify patients with low HT risk for reperfusion therapy such as IV rt-PA.

Methods

We retrospectively reviewed 68 consecutive stroke patients (41 males; mean age 72.9 years) with steno-occlusive lesions in the major trunk, including 10 patients who underwent IV rt-PA. Each HT was detected on a follow-up T2*-weighted magnetic resonance image until 2 weeks after stroke onset and categorized into four groups [hemorrhagic infarction (HI) type 1 and 2, and parenchymal hematoma (PH) type 1 and 2] according to the European Cooperative Acute Stroke Study (ECASS) classification. We assessed clinical features and radiological findings between the HT and non-HT groups or the PH2 and non-PH2 groups. The efficacy of initial time to peak (TTP) mapping of CTP for predicting HT or PH2 was evaluated.

Results

Thirty-four patients (50%) developed subsequent HT: 18 (52.9%) had HI and 16 (47.1%) had PH, including 9 PH2 patients (13.2%). IV rt-PA was not significantly associated with HT or PH2 occurrence. Forty of the 68 patients (59%) revealed defect areas on the initial TTP mapping (TTP map-defect), and 34 of these 40 patients (85%) developed secondary HT and 9 patients (22.5%) developed PH2. Initial ‘TTP map-defect’ was significantly associated with the occurrence of HT (p < 0.0001) and PH2 (p = 0.0070). Thirty of the 34 patients (88.2%) in the HT group experienced delayed recanalization of the occluded vessels, in contrast to only 8 of the 34 patients (23.6%) in the non-HT group. All patients of the PH2 group showed recanalization (p = 0.0042). In 40 ‘TTP map-defect’-positive patients, delayed recanalization was associated with the occurrence of HT (p < 0.0001) and PH2 (p = 0.0491). All 28 patients without ‘TTP map-defect’ did not develop HT, including 8 patients (28.6%) with delayed recanalization.

Conclusions

Initial ‘TTP map-defect’ of CTP could accurately predict HT risk including PH2 risk and identify low-risk patients even in the delayed period.

[Surgical outcome of external decompression associated with anterior and medial temporal lobectomy for massive hemispheric infarction due to internal carotid artery occlusion]

OBJECTIVE

Acute occlusion of the internal carotid artery (ICA) can lead the massive cerebral hemispheric infarction and cause massive cerebral edema and may result in tentorial herniation and death. The mortality rate is estimated at 80% with maximum conservative medical treatment. We have performed external decompression associated with anterior and medial temporal lobectomy (AMTL) as internal decompression for lifesaving. This study evaluated our surgical results and gives an analysis of the prognostic factors.

METHODS

Twenty one consecutive patients with massive cerebral infarction caused by internal carotid artery occlusion who underwent external decompression associated with AMTL for lifesaving between June 2000 and December 2005 were included in this retrospective analysis. Survivors were divided into two functional groups at three months after surgery: good (Barthel index; BI> or =50) and poor (B1<50). The characteristics of the two groups were compared using statistical analysis.

RESULTS

The patients consisted of 11 males and 10 females aged from 28 to 81 years with a mean age of 65.0+/-11.6 years. Eight patients had an infarction restricted to the middle cerebral artery (MCA) territory, others had additional anterior cerebral artery (ACA) or posterior cerebral artery (PCA) territory infarctions. The mean time between stroke onset and operation was 43.5+/-30 hours and ranged from 7 to 148 hours. Two patients died, so the mortality was 9.5%. Elderly patients (> or =60 years) (P=0.038), high preoperative Japan coma scale (> or =3 digit) (P=0.013), low preoperative Glasgow coma scale (GCS<8) (P=0.044), and multiple arterial territory (MCA+ACA or PCA) infarction (P=0.045) were significantly associated with poor functional outcome.

CONCLUSION

External decompression associated with AMTL can immediately relieve peduncle compression and could be effective in preserving life as effectively as "early" external decompression.

[High inducibility of Epstein-Barr virus replication in B lymphocytes in Vogt-Koyanagi-Harada disease]

PURPOSE

The role of Epstein-Barr virus (EBV) reactivation in the pathogenesis of Vogt-Koyanagi-Harada (VKH) disease was examined.

MATERIAL AND METHODS

Using B lymphocytes obtained from 8 patients with VKH disease and 10 patients with other types of uveitis, immortarized lymphoblast lines were established and infected with EBV. The degree of EBV activation in each lymphoblast line, in the presence and absence of various stimuli, was assessed by measuring the expression of 3 different antigens involved in replication by immunofluorescent staining and western blot analysis. Quantification of EBV DNA in cell culture supernatants was done by polymerase chain reaction.

RESULT

Cell lines established from VKH patients expressed more viral antigens that those established from patients with other types of uveitis. There were greater amounts of EBV DNA in the VKH cell lines.

CONCLUSION

B lymphocytes from VKH patients may be more susceptible to EBV activation, and the reactivation of EBV may be involved in the pathogenesis of VKH.

[Clinical, phenotypic and genotypic aspects of nasal T-cell lymphoma and its causal association with Epstein-Barr virus]

The authors reviewed the clinical, phenotypic, genotypic, and Epstein-Barr virus (EBV)-findings of 18 patients with nasal T-cell lymphoma(NTL). The clinical features were characterized as prolonged fever, widespread dissemination into distant sites, and poor prognosis with median survival of only 6 months. EBV-encoded small nuclear early region(EBER) transcripts were identified in 16 of 18 patients. Monoclonal EBV genome, EBV-encoded nuclear antigen(EBNA)-1, and latent membrane protein(LMP)-1 were also detected in all EBER-positive cases tested. All EBV-positive NTL showed coexpression of natural killer(NK) cell phenotype CD56 and CD2. Of 9 EBV-positive NTL, seven cases expressed T-cell receptor (TCR)-delta chain with rearranged beta-, gamma- and/or delta- genes. These data suggest that some cases of EBV-positive NTL may be derived from the lineage of NK-like T-cells or gamma delta T-cells, and that EBV may play a role in the lymphomagenesis.

Breast milk is not a significant source for early Epstein-Barr virus or human herpesvirus 6 infection in infants: a seroepidemiologic study in 2 endemic areas of human T-cell lymphotropic virus type I in Japan

In order to evaluate the possibility of Epstein-Barr virus (EBV) and human herpesvirus 6 (HHV-6) transmission via breast milk, a total of 331 serum specimens collected from bottle-fed and breast-fed children and their mothers, in 2 endemic areas of human T-cell lymphotropic virus type I (HTLV-I) in Japan, were assayed for antibodies to EBV and HHV-6. The seroprevalences of EBV and HHV-6 were over 95% both in the mothers of bottle-fed children and in those of breast-fed children. The seroprevalence of EBV at 12-23 months of age was 54.5% (36/66) and 55.8% (24/43) in breast-fed children and bottle-fed children, respectively. The seroprevalence of HHV-6 at 12-23 months of age was 90.9% (60/66) and 93.0% (40/43) in breast-fed children and bottle-fed children, respectively. No difference was observed between the seroprevalences of EBV and HHV-6 in breast-fed and bottle-fed children at 12-23 months of age. Our seroepidemiologic data indicate that breast milk is not a significant source of early EBV or HHV-6 infection in infancy.

Hodgkin disease occurring in a patient with extremely high serum antibody titers to Epstein-Barr virus--associated antigens without chronic illness

PURPOSE

We described for the first time a patient with long-lasting, extremely high serum antibody titer against Epstein-Barr virus (EBV) viral capsid antigen and early antigen without clinical symptoms suggestive of active EBV infection; the patient finally developed Hodgkin disease (HD) after 7 years of follow-up.

PATIENT AND METHODS

High serum EBV antibody titers were noted at 2 years of age. Immunological evaluation was performed at the age of 7 years. EBV-specific cytotoxic T-lymphocyte activity was normal. None of the other results showed any significant abnormalities except for the abnormal antibody titers against EBV-associated antigens.

RESULTS

The patient developed HD at the age of 9 years. In addition, EBV genomes were found in the nuclei of Hodgkin and Reed-Sternberg cells in the lymph node.

CONCLUSIONS

This case suggests that (a) a patient with extremely high serum antibody titers against EBV-associated antigens may develop HD after a prolonged period, even though no clinical symptom suggestive of active EBV infection is observed; (b) EBV may play an important role in the occurrence of HD.

Epstein-Barr virus and gastric carcinoma

Epstein-Barr virus (EBV) has been found in most cases of rare gastric lymphoepithelioma-like carcinomas and a small but significant proportion of common gastric adenocarcinomas. The presence of EBV in gastric cancer has been detected by polymerase chain reaction and in-situ hybridization, the latter technique demonstrating EBV in every malignant epithelial cell. The carcinoma cells express EBNA1 but not the other EBNAs or LMP1. A single fused terminal fragment of the EBV genome was detected in each of the EBNA1-expressing tumours suggesting that the virus-positive gastric carcinomas represent a clonal proliferation of EBV-infected cells. EBV antibody titres were elevated in patients with virus-positive carcinomas and also in those destined to develop EBV-positive carcinomas. EBV-specific cytotoxic T-lymphocyte activity was retained in patients with EBV-positive carcinomas suggesting that the tumours can evade immunosurveillance possibly by only expressing the EBNA1 protein which is not able to be processed and presented. These results implicate EBV as one of the factors contributing to the development of gastric cancer.

Transcriptional analysis of Epstein-Barr virus gene expression in EBV-positive gastric carcinoma: unique viral latency in the tumour cells

Although case-oriented evidence for an association of Epstein-Barr virus (EBV) with gastric carcinoma has been accumulating recently, the interaction(s) between EBV and gastric epithelial cells is/are largely unknown. In this study, we examined seven EBV-positive gastric carcinoma tissues for viral gene expression at the mRNA level, from which studies on the EBV oncogenicity in human epithelial cells will benefit. Reverse transcription-PCR analysis showed that all seven EBV-positive tumour tissues constitutively expressed EBV nuclear antigen (EBNA) 1 mRNA, but not EBNA2 mRNA. The EBNA transcription was initiated from one of three EBNA promoters, Qp: by contrast, both Cp and Wp were silent, thus resulting in the lack of EBNA2 mRNA. Latent membrane protein (LMP) 2A mRNA was detected in three of seven cases; however, neither LMP1 nor LMP2B mRNA was detected in any of the tumours tested. Transcripts from the BamHI-A region of the viral genome were detectable in all cases. BZLF1 mRNA and the product, an immediate-early gene for EBV replication, was not expressed in any of them, thereby suggesting that the tumour cells carried EBV genomes in a tightly latent form. These findings further extended our previous data regarding EBV latency in gastric carcinoma cells at the protein level, and have affirmed that the programme of viral gene expression in the tumour more closely resembles 'latency I' represented by Burkitt's lymphoma than 'latency II' represented by the majority of nasopharyngeal carcinomas.

Nasal T-cell lymphoma causally associated with Epstein-Barr virus: clinicopathologic, phenotypic, and genotypic studies

BACKGROUND

The authors have previously demonstrated nasal T-cell lymphoma (NTL) associated with Epstein-Barr virus (EBV). The detailed clinical, phenotypic, and genotypic features and the role of EBV in lymphomagenesis remain to be clarified.

METHODS

The study group consisted of 18 patients with NTL. The phenotype was determined by immunoperoxidase staining with various monoclonal antibodies. Genotypic study was done using Southern blot hybridization. The presence of EBV-encoded small nuclear early region (EBER) RNA and EBV DNA were determined by in situ hybridization. The expression of EBV-encoded nuclear antigen (EBNA) and latent membrane protein (LMP1) were identified by immunohistologic methods. Clonotypic analysis of EBV genomes was performed by Southern blot hybridization with EBV termini fragment probe.

RESULTS

The clinical features of NTL were characterized as prolonged fever (16 patients), widespread dissemination into distant sites (13 patients), and poor prognosis with a median survival of only 6 months. EBER transcripts were identified in 16 of 18 patients. Monoclonal EBV genomes EBNA1 and LMP1 were also detected in all EBER-positive cases tested. All 18 patients expressed pan-T antigens such as MT1, CD45RO, and/or CD2. The rearrangements of T-cell receptor (TCR)-beta, -gamma, and/or -delta genes were shown in all 11 patients tested. The natural killer (NK) cell phenotype CD56 was expressed in all EBV-positive cases tested, and was not detected in EBV-negative cases. Seven EBV-positive cases expressed a TCR-delta chain with rearranged TCR-gamma or -delta genes whereas both EBV-negative cases corresponded to alpha beta T-cell lymphoma, which expressed a TCR-beta chain with a rearranged TCR-beta gene.

CONCLUSIONS

These data suggest that EBV-positive NTL may be derived from the lineage of NK-like T-cells or gamma delta T-cells, and that EBV may play a role in lymphomagenesis. Therefore, we propose that NTL which has peculiar clinical and histologic features could be classified as a new lymphoma entity.

Epstein-Barr virus (EBV)-carrying and -expressing T-cell lines established from severe chronic active EBV infection

Four novel Epstein-Barr virus (EBV)-carrying T-cell lines, designated SIS, AIK-T8, AIK-T4, and SKN, were established from peripheral blood lymphocytes (PBL) of patients with severe chronic active EBV infection, in the presence of interleukin-2 and 4-deoxyphorbol ester. AIK-T8 and -T4 were derived from a single patient. Cell marker and genotype analyses showed that SIS, AIK-T8, and AIK-T4 had mature T-cell phenotypes with clonally rearranged T-cell receptor (TCR) genes, whereas SKN had an immature T-cell phenotype without TCR gene rearrangement. None of the cell lines expressed B, natural killer, or myeloid antigens or had Ig gene rearrangement. All lines carried EBV genomes in a single episomal form. SIS, AIK-T8, and SKN showed the same phenotype, TCR gene configuration, and/or EBV clonotype as their source or biopsied materials; therefore, they represented EBV-infected T cells proliferating in the patients. TCR gene and EBV episomal structures similar to those of AIK-T4 were not found in its source PBL, probably due to the few parental clones in vivo. All lines expressed EBV-encoded small RNA (EBER) 1, nuclear antigen (EBNA) 1, and latent membrane protein (LMP) 1, -2A, and -2B, but not other EBNAs that could be recognized by EBV-specific immune T cells. EBV replicative antigens were rarely expressed or induced. Such EBV latency reflects the in vivo situation, in which the T cells may evade immune surveillance and be insensitive to antiherpesvirus drugs. Collectively, the data suggest that EBV can target and latently infect T cells at any stage of differentiation in vivo, thus potentially causing uncontrolled T-cell proliferation. These cell lines will facilitate further analyses of possible EBV-induced oncogenicity in T cells.

Immunological role of human palatine tonsil in Epstein-Barr virus persistence

To determine whether EBV-specific cellular immunity persists and controls EBV in the palatine tonsil, we compared EBV-specific cellular immune responses in the palatine tonsil and peripheral blood. In 32 EBV-seropositive donors, we performed in vitro growth inhibition assays of EBV-induced B-lymphocyte transformation (regression assay). The results showed that EBV-specific cytotoxic T lymphocytes (CTL) precursor frequency was higher in the palatine tonsil than in the peripheral blood. After a first stimulation with autologous lymphoblastoid cell line (LCL), the EBV-specific cytotoxicity of reactivated CTL was higher in the palatine tonsil than in the peripheral blood. Furthermore EBV-specific CTL lines established from the palatine tonsil had significantly higher EBV-specific cytotoxicity in comparison with those from the peripheral blood. Both the EBV-specific CTLs from tonsils and peripheral blood were restricted by HLA class-I determinants. These data indicate that the palatine tonsil, which is frequently exposed to EBV, plays an important role in controlling EBV infection in the oropharynx.

Intact antigen presentation for Epstein-Barr virus (EBV)-specific CTL by a lymphoblastoid cell line established from a patient with severe chronic active EBV infection

Severe chronic active Epstein-Barr virus (EBV) infection is a lymphoproliferative disease characterized by extremely high antibody titers to EBV, fever, lymphadenopathy, hepatosplenomegaly, and pancytopenia, without any prior immunological abnormality. A spontaneous lymphoblastoid cell line was established from a 4-year-old boy with severe chronic active EBV infection. Immunofluorescence and Western blotting analyses showed that the cell line was of B cell origin and expressed Epstein-Barr nuclear antigens 1, 2 3a, 3b and 3c, and latent membrane protein 1, which are reported to be targets for EBV-specific cytotoxic T lymphocytes (CTL). The cytotoxicity of peripheral blood mononuclear cells derived from the patient and his HLA-identical sister was assayed against the cell line. The cell line was recognized and killed by anti-EBV CTL derived from the HLA-identical sister, but the patient's peripheral blood mononuclear cells had no cytotoxicity. We conclude that antigen presentation in the EBV-infected cells from the patient is intact and sufficient for generation of an EBV-specific CTL response. These observations suggest that severe chronic active EBV infection may not be caused by impaired EBV-antigen presentation of the infected cells but by impaired cellular immune responses to the virus. Our results also suggest the therapeutic possibility that this disease may be treated by adoptive transfer of EBV-specific CTL or bone marrow transplantation from an HLA-matched donor whose immune response to EBV is intact.

Epstein-Barr virus (EBV) hypersensitivity of peripheral B lymphocytes in patients with EBV genome-positive Burkitt's lymphoma

Peripheral blood mononuclear cells (PBMC) from four Japanese patients with Epstein-Barr virus (EBV) genome-positive Burkitt's lymphoma (BL) during remission were exposed to the B95-8 strain of EBV. Maximum concentrations of the EBV-determined nuclear antigen (EBNA) before cellular DNA synthesis were similar to those of healthy counterparts. Subsequently, EBV-immortalised cell lines were established. These immortalised lymphoblastoid cells were treated with 12-O-tetradecanoylphorbol-13-acetate (TPA) and superinfected with the P3HR-1 strain of EBV. EBV early antigens (EA) and viral capsid antigen (VCA) were expressed in approximately 3-10 fold higher concentrations by these lymphoblastoid cells than by those from patients with other types of malignant neoplasia including EBV genome-negative BL and from healthy counterparts. Moderate to extremely high IgG antibody titres to EBV VCA as well as IgG antibodies to EA were demonstrated in these patients during the study. These results suggest that defective underlying cellular mechanisms for regulating the replication of EBV may be present in patients with EBV genome-positive BL.

Decreased cytoplasmic immunoglobulin A production during Epstein-Barr virus immortalization on lymphocytes from patients with ataxia-telangiectasia

Previously, we have reported significantly lower immunoglobulin (Ig) A production in supernatants of cultured lymphoblastoid cells using enzyme-linked immunosorbent assay from patients with ataxia-telangiectasia (AT) when compared to that of age- and sex-matched healthy individuals. Here, we further assess the degree of cytoplasmic Ig production in these cells and also analyze it during the early phase of Epstein-Barr virus immortalization. All classes of cytoplasmic IgM, IgG, and IgA productions were demonstrated in cells from healthy controls. In contrast, cells from patients with AT showed only cytoplasmic IgM and IgG with low or nondetectable levels of IgA during and after the immortalizing process. These results suggest B lymphocytes bearing IgA are functionally immature and/or defective in patients with AT.

Prevalence of human T-cell leukemia virus type 1 (HTLV-I) in family members of adult T-cell leukemia (ATL) patients in non-ATL-endemic Hokkaido of Japan

Family members of patients with adult T-cell leukemia (ATL) in non-ATL-endemic Hokkaido, the northernmost part of Japan, were assessed for the prevalence of HTLV-I infection. Immunofluorescence assay showed that 53 out of 133 (39.8%) healthy family members of 23 ATL patients were positive for antibodies to HTLV-I. When general inhabitants in Hokkaido were examined, 3 out of 18 (16.7%) family members of 5 seropositive healthy persons had HTLV-I antibodies. The overall seropositivity in Hokkaido was 0.7%. Of 26 family members of 6 patients with non-T-cell leukemia seroconverted by blood transfusion, none (0%) was seropositive.

Prevalence of human T-cell leukemia virus type 1 (HTLV-I) in adult T-cell leukemia (ATL) in non-ATL-endemic Hokkaido of Japan

Sera and peripheral blood lymphocytes of 40 adult T-cell leukemia (ATL) patients in non-ATL-endemic Hokkaido were examined for the prevalence of human T-cell leukemia virus type 1 (HTLV-I). All patients had HTLV-I-specific antibodies. When the peripheral lymphocytes were assessed after short-term cultivation, HTLV-I antigens and virus particles were detected. The seroprevalence in 96 cases of non-T-cell leukemias and lymphomas and in 30,056 healthy individuals in Hokkaido were 3.1% and 0.7%, respectively. HTLV-I seropositive inhabitants of Hokkaido can be estimated at about 40,000, and one out of every few thousand HTLV-I carriers is likely to develop ATL.

Prevalence of human T-cell leukemia virus type 1 (HTLV-I) in general inhabitants in non-adult T-cell leukemia (ATL)-endemic Hokkaido, Japan

In contrast to adult T-cell leukemia (ATL)-endemic southwestern Japan, the northernmost island Hokkaido has a small number of ATL patients annually. In this study, we surveyed 32,587 healthy inhabitants throughout Hokkaido for antibodies to human T-cell leukemia virus type 1 (HTLV-I). Only 244 individuals (0.8%) were seropositive as HTLV-I carriers; 0.6% (123 of 19,512) in males and 0.9% (121 of 13,075) in females. In some areas, however, the inhabitants had relatively high seropositivity (> 2%). The highest rate was 5.2% with a cluster of ATL patients in a certain town of the Hidaka area near the Pacific Ocean, in southeast Hokkaido.

Cryptic dysfunction of cellular immunity in asymptomatic human immunodeficiency virus (HIV) carriers and its actualization by an environmental immunosuppressive factor

Peripheral blood lymphocytes from 4 asymptomatic HIV-1 carriers with normally retained EBV-specific cytotoxic T-cell activity were exposed to EBV and incubated with 0.2 ng/ml 4-deoxyphorbol ester, an immunosuppressive substance derived from an African plant Euphorbia tirucalli. The regression of EBV-induced B-cell transformation by EBV-specific cytotoxic T-cells was significantly impaired in the presence of a small amount of 4-deoxyphorbol ester, but not so in 5 HIV-1-seronegative healthy counterparts. When the EBV-specific cytotoxic T-cells from the asymptomatic carriers were exposed to 0.2ng/ml 4-deoxyphorbol ester and incubated with 51Cr-labeled autologous EBV-transformed B lymphocytes, the released radioactivity was significantly smaller than that of the healthy counterparts. The results suggest that the cellular immunity of the asymptomatic HIV-1 carriers is cryptically impaired, and the cryptic immunological dysfunction is actualized by exposure to a small amount of the immunosuppressive substance, a dose which does not affect the immunity of uninfected healthy individuals.

Gastric carcinoma: monoclonal epithelial malignant cells expressing Epstein-Barr virus latent infection protein

In 1000 primary gastric carcinomas, 70 (7.0%) contained Epstein-Barr virus (EBV) genomic sequences detected by PCR and Southern blots. The positive tumors comprised 8 of 9 (89%) undifferentiated lymphoepithelioma-like carcinomas, 27 of 476 (5.7%) poorly differentiated adenocarcinomas, and 35 of 515 (6.8%) moderately to well-differentiated adenocarcinomas. In situ EBV-encoded small RNA 1 hybridization and hematoxylin/eosin staining in adjacent sections showed that the EBV was present in every carcinoma cell but was not significantly present in lymphoid stroma and in normal mucosa. Two-color immunofluorescence and hematoxylin/eosin staining in parallel sections revealed that every keratin-positive epithelial malignant cell expressed EBV-determined nuclear antigen 1 (EBNA1) but did not significantly express CD45+ infiltrating leukocytes. A single fused terminal fragment was detected in each of the EBNA1-expressing tumors, thereby suggesting that the EBV-carrying gastric carcinomas represent clonal proliferation of cells infected with EBV. The carcinoma cells had exclusively EBNA1 but not EBNA2, -3A, -3B, and -3C; leader protein; and latent membrane protein 1 because of methylation. The patients with EBV-carrying gastric carcinoma had elevated serum EBV-specific antibodies. The EBV-specific cellular immunity was not significantly reduced; however, the cytotoxic T-cell target antigens were not expressed. These findings strongly suggest a causal relation between a significant proportion of gastric carcinoma and EBV, and the virus-carrying carcinoma cells may evade immune surveillance.

Angiocentric immunoproliferative lesion associated with chronic active Epstein-Barr virus infection in an 11-year-old boy. Clonotopic proliferation of Epstein-Barr virus-bearing CD4+ T lymphocytes

We report a pulmonary angiocentric immunoproliferative lesion (AIL) in an 11-year-old boy with chronic active Epstein-Barr virus (EBV) infection. The phenotypes of the proliferating lymphoid cells in the biopsied pulmonary lesion were CD2+, CD3+, CD4+, CD5+, CD7+, and HLA-DR+. EBV DNA was detected in the tumorous and the nontumorous tissue by Southern-blotting studies. Dual immunostains and combined immunohistochemistry/in situ hybridization showed the simultaneous presence of EBV-determined nuclear antigen or EBV-encoded small RNAs and T-cell markers in the lymphoid cells. Molecular genetic analysis of the tumorous lesion diagnosed as AIL grade III showed no clonal rearrangement of the T-cell receptor beta gene but a single type of fused terminal band of EBV. No such evidence of monoclonality was identified in the surrounding nontumorous tissue diagnosed as AIL grade I or II. The present case was a rare example of AIL in childhood and provides further histopathologic and molecular biological evidence supporting the concept of AIL as a continuous spectrum from premalignant lymphoproliferative disorders to monoclonal, overt malignant lymphoma.