Delayed leukoencephalopathy following non-coil embolization flow diverter stent deployment for an intracranial aneurysm

This report examines delayed leukoencephalopathy as a postoperative complication after the use of flow diverter (FD) devices for endovascular cerebral aneurysm treatment. A case involving a 78-year-old female treated with a pipeline embolization device for a left internal carotid artery aneurysm is presented. Despite adherence to dual anti-platelet therapy, the patient developed intermittent headaches and memory issues 3 months post-operation. MRI revealed T1-enhancing foci and T2 hyperintense signal abnormalities in the left cerebral hemisphere, without new ischemic lesions, indicating potential embolic events or foreign body reactions. Following aphasia, a change from clopidogrel to prasugrel and the initiation of steroid pulse therapy led to the resolution of symptoms and MRI abnormalities over 6 months. This case underscores the reversibility of delayed leukoencephalopathy with appropriate intervention.

Efficacy of intraoperative irrigation with artificial cerebrospinal fluid in chronic subdural hematoma surgery: study protocol for a multicenter randomized controlled trial

BACKGROUND

The surgical techniques for treatment of chronic subdural hematoma (CSDH), a common neurosurgical condition, have been discussed in a lot of clinical literature. However, the recurrence proportion after CSDH surgery remains high, ranging from 10 to 20%. The standard surgical procedure for CSDH involves a craniostomy to evacuate the hematoma, but irrigating the hematoma cavity during the procedure is debatable. The authors hypothesized that the choice of irrigation fluid might be a key factor affecting the outcomes of surgery. This multicenter randomized controlled trial aims to investigate whether intraoperative irrigation using artificial cerebrospinal fluid (ACF) followed by the placement of a subdural drain would yield superior results compared to the placement of a subdural drain alone for CSDH.

METHODS

The study will be conducted across 19 neurosurgical departments in Japan. The 1186 eligible patients will be randomly allocated to two groups: irrigation using ACF or not. In either group, a subdural drain is to be placed for at least 12 h postoperatively. Similar to what was done in previous studies, we set the proportion of patients that meet the criteria for ipsilateral reoperation at 7% in the irrigation group and 12% in the non-irrigation group. The primary endpoint is the proportion of patients who meet the criteria for ipsilateral reoperation within 6 months of surgery (clinical worsening of symptoms and increased hematoma on imaging compared with the postoperative state). The secondary endpoints are the proportion of reoperations within 6 months, the proportion being stratified by preoperative hematoma architecture by computed tomography (CT) scan, neurological symptoms, patient condition, mortality at 6 months, complications associated with surgery, length of hospital stay from surgery to discharge, and time of the surgical procedure.

DISCUSSION

We present the study protocol for a multicenter randomized controlled trial to investigate our hypothesis that intraoperative irrigation with ACF reduces the recurrence proportion after the removal of chronic subdural hematomas compared with no irrigation.

TRIAL REGISTRATION

ClinicalTrials.gov jRCT1041220124. Registered on January 13, 2023.

Real-world data of clazosentan in combination therapy for aneurysmal subarachnoid hemorrhage: a multicenter retrospective cohort study

Aneurysmal subarachnoid hemorrhage (aSAH) may lead to cerebral vasospasm, significantly associated with morbidity and mortality. In double-blind, placebo-controlled phase 3 studies, clazosentan reduces cerebral vasospasm-related morbidity and all-cause mortality in patients with aSAH. There are no reports about the clinical efficacy of clazosentan combination therapy with some other drugs. Initially, we explored the efficacy of clazosentan combination therapy with cilostazol, statin, and antiepileptic drugs. Subsequently, we assessed the add-on effect of fasudil to clazosentan combination therapy for aSAH patients. This multicenter, retrospective, observational cohort study included Japanese patients with aSAH between June 2022 and March 2023. The primary outcome was the ordinal score on the modified Rankin Scale (mRS; range, 0-6, with elevated scores indicating greater disability) at discharge. Among the 47 cases (women 74.5%; age 64.4 ± 15.0 years) undergoing clazosentan combination therapy, 29 (61.7%) resulted in favorable outcomes. Overall, vasospasm occurred in 16 cases (34.0%), with four cases (8.5%) developing vasospasm-related delayed cerebral ischemia (DCI). Both hypotension and vasospasm-related DCI were related to unfavorable outcome at discharge. Fasudil were added in 18 (38.3%) cases. Despite adding fasudil to clazosentan combination therapy, the incidence of aSAH-related vasospasm did not decrease. Added-on fasudil to combination therapy related to pulmonary edema, vasospasm, and vasospasm-related DCI, and unfavorable outcomes. Clazosentan combination therapy could potentially result in favorable outcomes for aSAH patients to prevent post-aSAH vasospasm-related DCI. The add-on effect of fasudil to combination therapy did not demonstrate a significant impact in reducing aSAH-related vasospasm or improving outcomes at discharge.

Evaluation of large airway specimens obtained by transbronchial lung cryobiopsy in diffuse parenchymal lung diseases

Background

The difference in diagnostic yield between surgical lung biopsy and transbronchial lung cryobiopsy (TBLC) in diffuse parenchymal lung diseases (DPLD) has been reported to be due to differences in the rate of interpathologist agreement, specimen size, and specimen adequacy. In TBLC, the specimens containing large airway components are generally believed as inadequate specimens for histological evaluation, but the detailed characteristics of TBLC specimens including the large airway and the impact on histological diagnostic rates of DPLD have not been investigated.

Methods

We retrospectively reviewed the specimen characteristics of patients with DPLD who underwent TBLC.

Results

Between February 2018 and January 2020, 74 patients and 177 specimens were included. There were 85 (48.0%) large airway specimens (LAS) that contained bronchial gland or bronchial cartilage. The ideal specimen ratio was significantly lower in the LAS-positive group than that in the LAS-negative group (5.8% vs. 45.6%), and the proportion of bronchioles, alveoli, and perilobular area were similarly lower in the LAS-positive group. The presence of traction bronchiectasis and diaphragm overlap sign on high-resolution computed tomography (HRCT) were also significantly higher in the LAS-positive group than those in the LAS-negative group. We observed a statistically significant trend in histological diagnostic yield (40.7% in LAS positive group; 60.8% in LAS positive and negative group; 91.6% in LAS negative group) (Cochran-Armitage trend test).

Conclusion

LAS is a specimen often collected in TBLC and contains a low percentage of bronchioles, alveoli, and perilobular area. Since the histological diagnostic yield tends to be higher in cases that do not contain LAS, it may be important to determine the biopsy site that reduces the frequency of LAS collection by referring to the HRCT findings in TBLC.

High-heat flux ball-pen probe head in ASDEX-Upgrade

A new high heat flux ball-pen probe head installed on the midplane manipulator is currently being used in ASDEX-Upgrade (AUG). The probe was designed to withstand high heat fluxes making possible the investigation of the plasma edge under harsh conditions, such as low power H-mode. Composed of seven pins (four Langmuir probes, mounted in two Mach probe pairs, and three ball-pen probes), the new probe head allows us to measure several plasma parameters simultaneously and with high temporal resolution. A novel method to correct the sheath potential dynamically accounting for the total secondary electron emission is introduced together with applications to obtain the electron temperature and plasma potential profiles. The total secondary electron emission yield is obtained from particle in cell simulations in AUG condition and probe realistic impact angle with respect to the magnetic field. Finally, the probe capability to investigate turbulence around the separatrix of AUG is discussed.

A Case of Primary Leptomeningeal Lymphoma Presenting with Hydrocephalus Characterized by Disproportionately Large Fourth Ventricle

Primary leptomeningeal malignant lymphoma (PLML) is a rare variant of primary central nerve system malignant lymphoma (PCNSL) which is restricted to leptomeninges. The lesions of PLML can often be detected as abnormal enhancement on the surface of central nervous system or the ventricular wall on magnetic resonance imaging (MRIs). Cerebrospinal fluid (CSF) evaluation together with such MRI findings provides the definitive diagnosis of PLML. Here, we present a 45-year-old female case of PLML in which hydrocephalus with disproportionately large fourth ventricle was observed at presentation with gait instability. Head MRI revealed no abnormal enhancement and CSF cytology was negative, leaving the cause of hydrocephalus undetermined. Endoscopic third ventriculostomy (ETV) was effectively performed for hydrocephalus and her symptoms disappeared. Nearly 2 years later, she was brought to emergent room due to unconsciousness with the recurrence of hydrocephalus. MRI showed expanded fourth ventricle and abnormal enhancement on the ventricular wall. The endoscopic surgery for improving CSF flow was successful and inflammatory change was endoscopically observed on the ventricular wall involving aqueduct. Pathological diagnosis of the specimen from the ventricular wall proved B-cell lymphoma. Because neither brain parenchymal masses nor systemic tumors were identified, she was diagnosed with PLML and treated by high-dose methotrexate. She was in a stable state 2 years after the diagnosis of PLML. We report and discuss the characteristics of this case.

Linearized spectrum correlation analysis for thermal helium beam diagnostics

We introduce a new correlation analysis technique for thermal helium beam (THB) diagnostics. Instead of directly evaluating line ratios from fluctuating time series, we apply arithmetic operations to all available He I lines and construct time series with desired dependencies on the plasma parameters. By cross-correlating those quantities and by evaluating ensemble averages, uncorrelated noise contributions can be removed. Through the synthetic data analysis, we demonstrate that the proposed analysis technique is capable of providing the power spectral densities of meaningful plasma parameters, such as the electron density and the electron temperature, even under low-photon-count conditions. In addition, we have applied this analysis technique to the experimental THB data obtained at the ASDEX Upgrade tokamak and successfully resolved the electron density and temperature fluctuations up to 90 kHz in a reactor relevant high power scenario.

Autoimmune pulmonary alveolar proteinosis developed during immunosuppressive treatment in polymyositis with interstitial lung disease: a case report

Background

Pulmonary alveolar proteinosis (PAP) is characterized by the accumulation of surfactant proteins within the alveolar spaces. Autoimmune PAP (APAP) caused by elevated levels of GM-CSF autoantibodies (GM-Ab) is very rarely associated with systemic autoimmune disease. Here we report a case of APAP manifested during immunosuppressive treatment for polymyositis with interstitial lung disease.

Case presentation

A 52-year-old woman treated at our hospital because of polymyositis with interstitial pneumonia had maintained remission by immunosuppressive treatment for 15 years. She had progressive dyspnea subsequently over several months with her chest CT showing ground-glass opacities (GGO) in bilateral geographic distribution. Her bronchoalveolar lavage fluid with cloudy appearance revealed medium-sized foamy macrophages and PAS-positive amorphous eosinophilic materials by cytological examination. We diagnosed her as APAP due to an increased serum GM-CSF autoantibody level. Attenuating immunosuppression failed to lead GGO improvement, but whole lung lavage (WLL) was effective in her condition.

Conclusions

PAP should be considered as one of the differential diseases when the newly interstitial shadow was observed during immunosuppressive treatment. WLL should be regarded as the treatment option for APAP concurred in connective tissue disease (CTD).

Serum high-mobility group box 1 is correlated with interferon-α and may predict disease activity in patients with systemic lupus erythematosus

Sensing self-nucleic acids through toll-like receptors in plasmacytoid dendritic cells (pDCs), and the dysregulated type I IFN production, represent pathogenic events in the development of the autoimmune responses in systemic lupus erythematosus (SLE). Production of high-mobility group box-1 protein (HMGB1) promotes type I IFN response in pDCs. To better understand the active pathogenic mechanism of SLE, we measured serum levels of HMGB1, thrombomodulin, and cytokines (IL-1β, IL-2, IL-4, IL-5, IL-6, IL-10, IL-13, IL-17A, IL-17F, IFNα, IFNγ, TNFα) in 35 patients with SLE. Serum HMGB1 and IFNα were significantly higher in patients with active SLE (SLE Disease Activity Index (SLEDAI) score ≥ 6) compared with healthy donors or patients with inactive SLE. Furthermore, the HMGB1 levels were significantly correlated with IFNα levels. By qualitative analysis, the detection of serum IFNα or HMGB1 suggests active SLE and the presence of SLE-related arthritis, fever, and urinary abnormality out of SLEDAI manifestations. Collectively, HMGB1 and IFNα levels are biomarkers reflecting disease activity, and qualitative analysis of IFNα or HMGB1 is a useful screening test to estimate SLE severity and manifestations. Our results suggest the clinical significance of type I IFNs and HMGB1 as key molecules promoting the autoimmune process in SLE.

Direct Measurement of a Toroidally Directed Zonal Flow in a Toroidal Plasma

Zonal flow appears in toroidal, magnetically confined plasmas as part of the self-regulated interaction of turbulence and transport processes. For toroidal plasmas having a strong toroidal magnetic field, the zonal flow is predominately poloidally directed. This Letter reports the first observation of a zonal flow that is toroidally directed. The measurements are made just inside the last closed flux surface of reversed field pinch plasmas that have a dominant poloidal magnetic field. A limit cycle oscillation between the strength of the zonal flow and the amplitude of plasma potential fluctuations is observed, which provides evidence for the self-regulation characteristic of drift-wave-type plasma turbulence. The measurements help advance understanding and gyrokinetic modeling of toroidal plasmas in the pursuit of fusion energy.

Independent Anomalous Origin of the Right Vertebral Artery from the Right Common Carotid Artery

An anomalous origin of the right vertebral artery is rare. The left vertebral artery from the aortic arch is where most of the anomalies occur. The next is an origin of the right vertebral artery from the right common carotid artery in association with the aberrant right subclavian artery. However, independent anomalous origin of the right vertebral artery from the right common carotid artery has not been well known in the previous literature. We present this anomaly, and able to understand the mechanism of the occurrence by embryological knowledge. Failure of involution of the fourth segmental artery and the ductus caroticus remaining are associated with this anomaly. To understand this, an aberrant may be helpful to avoid injury of the vertebral artery when performing the surgical procedures and catheterization.

Measurements of Impurity Transport Due to Drift-Wave Turbulence in a Toroidal Plasma

The first direct measurements of an impurity particle flux driven by drift-wave turbulence in a toroidal magnetized plasma are reported. The correlation between the impurity density and radial velocity fluctuations is measured using ion Doppler spectroscopy. The small, very fast radial velocity fluctuation is resolved with the aid of a new linearized spectrum correlation analysis method that rejects uncorrelated noise as the sample size increases. The measured C^{2+} turbulent impurity flux in the edge of the plasma is directed inward and is consistent with impurity density measurements. This is also the first direct evidence for fluctuation-induced transport due to trapped-electron-mode turbulence in reversed field pinch plasmas.

Development of a multi-channel capacitive probe for electric field measurements with fine spatial and high time resolution

A capacitive probe [Tan et al., Rev. Sci. Instrum. 88, 023502 (2017)] is one of a few diagnostics that is directly sensitive to the plasma potential. Using this diagnostic technique, a Multi-channel Linear Capacitive Probe (MLCP) is developed for turbulence measurements. The MLCP has 10 spatial channels and provides 9 points of radial electric field measurements simultaneously with a spatial step of 7 mm. A new readout circuit and a correction technique for low frequency attenuation are also developed to achieve the required spatial and time resolution. A performance test of the MLCP using a reversed field pinch plasma confirms that the MLCP resolves sub-centimeter structures of the equilibrium radial electric field profile and fluctuations up to 680 kHz.

Dependence of Perpendicular Viscosity on Magnetic Fluctuations in a Stochastic Topology

In a magnetically confined plasma with a stochastic magnetic field, the dependence of the perpendicular viscosity on the magnetic fluctuation amplitude is measured for the first time. With a controlled, ∼ tenfold variation in the fluctuation amplitude, the viscosity increases ∼100-fold, exhibiting the same fluctuation-amplitude-squared dependence as the predicted rate of stochastic field line diffusion. The absolute value of the viscosity is well predicted by a model based on momentum transport in a stochastic field, the first in-depth test of this model.

Effectiveness of Goreisan in Preventing Recurrence of Chronic Subdural Hematoma

Background:

Burr-hole irrigation surgery is now recognized as a widespread simple technique for the treatment of chronic subdural hematoma (CSDH). However, recurrence of CSDH is sometimes experienced after initial surgery. Recently, it has been reported that goreisan is effective in preventing CSDH recurrence.

Materials and Methods:

Methods: We studied patients with CSDH who received burr-hole irrigation at our hospital between January 2011 and December 2014. We divided these patients into three groups. The first group was given goreisan during the early phase after burr-hole irrigation. The second group was given goreisan when there was a visual tendency of recurrence, as observed in the course of computed tomography imaging for outpatients. The third group was not given any drug.

Results:

The recurrence rate was compared between each group. The recurrence rate was significantly lower in the early goreisan administration group (5% vs. 12%, P = 0.046). There was a decreased tendency of recurrence in the goreisan-administered group compared with the group that was not administered any drug, but this was not statistically different (6.1% vs. 12%, P = 0.082). The recurrence period in the goreisan-administered group was longer than that in the group that was not administered any drug (39.9 ± 12.1 vs. 27.45 ± 8.5, P = 0.017).

Conclusions:

Goreisan is effective in preventing recurrence of CSDH after burr-hole irrigation.

Crevice sign as an indicator of plaque laceration associated with postoperative severe thromboembolism after carotid artery stenting: a case report

Carotid artery stenting (CAS) is increasingly utilized in patients with carotid artery stenosis. Various intraprocedural and postprocedural complications have been reported in the literature. We present a case of symptomatic major thromboembolism after CAS. The intraprocedural angiogram showed extraordinary slow filling of the contrast medium into the plaque, which we named as "crevice sign." An 83-year-old man presented repeat right amaurosis fugax for 6 months. The radiological examinations revealed 85% stenosis of the origin of the right internal carotid artery. The patient underwent right CAS. The procedure was performed without any problems; however, the angiogram showed slow filling of contrast medium into the carotid plaque through the stent (crevice sign). Sixty minutes later in the ward, the patient presented sudden onset of left hemiparesis and aphasia. Emergency catheter angiography did not show in-stent thrombus, major artery occlusion, or the crevice sign. Magnetic resonance imaging on the next day revealed wide acute infarction of the right cerebral hemisphere. Physicians should be aware of the intraprocedural crevice sign so that a subsequent catastrophic ischemic event can be prevented.

A Stent-Retrieving into an Aspiration Catheter with Proximal Balloon (ASAP) Technique: A Technique of Mechanical Thrombectomy

OBJECTIVE

The best technique for the first attempt at mechanical thrombectomy for acute ischemic stroke is a still matter of debate. In this study, we evaluate the efficacy of a stent-retrieving into an aspiration catheter with proximal balloon (ASAP) technique that uses a series of thrombus extraction by withdrawing the stent retriever into the aspiration catheter and continuous aspiration from the aspiration catheter at the first attempt.

METHODS

We performed a retrospective analysis of 42 consecutive patients with acute ischemic stroke caused by occlusions in the anterior circulation who were treated with the ASAP technique at our institution. Preoperative patient characteristic, including age, thrombus location, Alberta Stroke Program Early CT Score, National Institutions of Health Stroke Scale, and time from onset to puncture; postoperative Thrombolysis in Cerebral Infarction score; modified Rankin Scale score after 3 months; time from puncture to recanalization; the number of passes to achieve recanalization; and procedural complications, including intracranial hemorrhage, embolization to new territory, and distal embolization, were assessed.

RESULTS

A Thrombolysis in Cerebral Infarction score of 2B or 3 was achieved in 40/42 patients (95.2%). Average time from puncture to the final recanalization was 21.5 minutes. Recanalization was achieved in a single attempt in 31 patients (77.5%). Embolization to new territory was observed in only 2 patients (4.8%); no patient developed distal embolization or intracranial hemorrhage including asymptomatic subarachnoid hemorrhage. Thirty-two patients (76.2%) achieved modified Rankin Scale scores of 0-2 at 3 months postoperatively.

CONCLUSIONS

Our ASAP technique showed fast recanalization, minimal complications, and good clinical outcomes in this case series.

Linearized spectrum correlation analysis for line emission measurements

A new spectral analysis method, Linearized Spectrum Correlation Analysis (LSCA), for charge exchange and passive ion Doppler spectroscopy is introduced to provide a means of measuring fast spectral line shape changes associated with ion-scale micro-instabilities. This analysis method is designed to resolve the fluctuations in the emission line shape from a stationary ion-scale wave. The method linearizes the fluctuations around a time-averaged line shape (e.g., Gaussian) and subdivides the spectral output channels into two sets to reduce contributions from uncorrelated fluctuations without averaging over the fast time dynamics. In principle, small fluctuations in the parameters used for a line shape model can be measured by evaluating the cross spectrum between different channel groupings to isolate a particular fluctuating quantity. High-frequency ion velocity measurements (100-200 kHz) were made by using this method. We also conducted simulations to compare LSCA with a moment analysis technique under a low photon count condition. Both experimental and synthetic measurements demonstrate the effectiveness of LSCA.

A Case of Acute Isolated Posterior Cerebral Artery Occlusion Successfully Treated with Endovascular Clot Aspiration

Posterior cerebral artery (PCA) strokes produce various symptoms. Therefore, the diagnosis is often delayed and patients arrive late for thrombolytic therapy. We report a case of acute isolated PCA occlusion that was successfully treated with endovascular clot aspiration. A 63-year-old man presented with right complete homonymous hemianopia. Diffusion-weighted image (DWI) showed a high-intensity area (HIA) in the occipital lobe, and magnetic resonance angiography (MRA) showed PCA occlusion. Emergency endovascular clot aspiration was performed immediately after the diagnosis. Blood flow in PCA completely recovered 210 min after symptom onset. DWI after surgery showed partial disappearance of HIA, and the patient recovered from the symptom of right complete homonymous hemianopia. Endovascular recanalization is useful for acute PCA occlusion. This is the first reported case of acute isolated PCA occlusion successfully treated with endovascular clot aspiration. Prompt reperfusion results in a good clinical course in patients with PCA stroke. In this case, endovascular clot aspiration resulted in prompt recanalization in a patient with acute isolated PCA occlusion.

Absolute wavelength calibration of a Doppler spectrometer with a custom Fabry-Perot optical system

An Ion Doppler Spectrometer (IDS) is used for fast measurements of C VI line emission (343.4 nm) in the Madison Symmetric Torus. Absolutely calibrated flow measurements are difficult because the IDS records data within 0.25 nm of the line. Commercial calibration lamps do not produce lines in this narrow range. A light source using an ultraviolet LED and etalon was designed to provide a fiducial marker 0.08 nm wide. The light is coupled into the IDS at f/4, and a holographic diffuser increases homogeneity of the final image. Random and systematic errors in data analysis were assessed. The calibration is accurate to 0.003 nm, allowing for flow measurements accurate to 3 km/s. This calibration is superior to the previous method which used a time-averaged measurement along a chord believed to have zero net Doppler shift.

Upgrading a high-throughput spectrometer for high-frequency (<400 kHz) measurements

The upgraded spectrometer used for charge exchange recombination spectroscopy on the Madison Symmetric Torus resolves emission fluctuations up to 400 kHz. The transimpedance amplifier's cutoff frequency was increased based upon simulations comparing the change in the measured photon counts for time-dynamic signals. We modeled each signal-processing stage of the diagnostic and scanned the filtering frequency to quantify the uncertainty in the photon counting rate. This modeling showed that uncertainties can be calculated based on assuming each amplification stage is a Poisson process and by calibrating the photon counting rate with a DC light source to address additional variation.

Treatment protocol based on assessment of clot quality during endovascular thrombectomy for acute ischemic stroke using the Trevo stent retriever

The optional endovascular approach for acute ischemic stroke is unclear. The Trevo stent retriever can be used as first-line treatment for fast mechanical recanalization. The authors developed a treatment protocol for acute ischemic stroke based on the assessment of clot quality during clot removal with the Trevo. This prospective single-center study included all patients admitted for acute ischemic stroke between July 2014 and February 2015, who underwent emergency endovascular treatment. According to the protocol, the Trevo was used for first-line treatment. Immediately after the Trevo was deployed, the stent delivery wire was pushed to open the stent by force (ACAPT technique). Clot quality was assessed on the basis of the perfusion status after deployment of the Trevo; continued occlusion or immediate reopening either reoccluded or maintained after the stent retriever had been in place for 5 min. If there was no obvious clot removal after the first pass with the Trevo, according to the quality of the clot, either a second pass was performed or another endovascular device was selected. Twelve consecutive patients with acute major cerebral artery occlusion were analyzed. Thrombolysis in cerebral infarction score 2b and 3 was achieved in 11 patients (91.7%) and 9 (75%) had a good clinical outcome after 90 days based on a modified Rankin scale score ≤ 2. Symptomatic intracranial hemorrhage occurred in 1 patient (8.3%). The overall mortality rate was 8.3%. Endovascular thrombectomy using the Trevo stent retriever for first-line treatment is feasible and effective.

[A Novel, Less Invasive Protection Method for Carotid Artery Stenting]

<i>Purpose</i>: We present a novel, less invasive protection method for carotid artery stenting. <i>Case presentation</i>: A 67-year-old man presented with symptomatic severe left carotid artery stenosis. A transfemoral approach was dangerous because of an abdominal aortic aneurysm. A 6Fr Axcelguide Simmonds catheter was inserted into the right brachial artery, and advanced into the left common carotid artery. Next, a 6Fr Optimo 100-cm catheter was coaxially navigated into the left common carotid artery. A PercuSurge GuardWire 300-cm was coaxially navigated into the left external carotid artery. Under flow reversal with the 2 balloons, another PercuSurge GuardWire 300-cm was navigated into the distal left internal carotid artery through the lesion. After both PercuSurge GuardWire balloons were inflated, the 6Fr Optimo was deflated and retrieved using a catheter exchange technique. Then, under distal double-balloon protection, routine stenting was performed. <i>Conclusions</i>: This technique is safer and less invasive than previous methods, especially in cases with difficult femoral access and vulnerable carotid plaque.

Successful steroid treatment of coma induced by severe spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is a syndrome characterized by low cerebrospinal fluid (CSF) pressure and postural headaches. It is a rare condition which may sometimes present with severe symptoms such as stupor or coma. The standard treatment protocol includes conservative measures such as bed rest, hydration, and steroids. However, severe cases may require invasive measures such as epidural blood patch (EBP), continuous epidural saline infusion, epidural fibrin glue, or surgical repair of the dural defect. In this report, we describe a case of severe SIH resulting in coma that exhibited dramatic improvement on intravenous administration of steroids. This is the first report of severe SIH causing coma that was treated non-invasively by steroids only.

Alpha horizontal stent delivery for coil embolization of a broad-necked large basilar apex aneurysm: a case report

Here we describe a novel technique for single stent horizontal reconstruction and coil embolization for a broad-necked large basilar artery (BA) apex aneurysm. A previously healthy 77-year-old woman presented with a broad-necked large BA apex aneurysm. Due to difficulty accessing the right posterior cerebral artery (PCA), we abandoned the Y-stent technique. Instead, we decided to navigate the stent through the BA to the left PCA making a loop of the stent delivery catheter inside the aneurysm in an "alpha" fashion. The procedure outcome was excellent without any complications. Alpha horizontal stent delivery via an antegrade approach for coil embolization of broad-necked large BA apex aneurysms may provide an effective therapeutic alternative, if other techniques are not feasible.

[A Case of Cavernous Sinus Dural Arteriovenous Fistula after Transverse-Sigmoid Sinus Dural Arteriovenous Fistula Treatment with Radical Transvenous Coil Embolization]

PURPOSE

We report a case of cavernous sinus dural arteriovenous fistula (dAVF) that developed after the treatment of a transverse-sigmoid sinus dAVF using transvenous embolization (TVE).

CASE PRESENTATION

A 72-year-old woman presented with headache and left-sided tinnitus. Angiography demonstrated the presence of a left transverse-sigmoid sinus dAVF. After TVE, the patient's symptoms completely disappeared. Three years later, she complained of left-sided tinnitus and diplopia, and angiography revealed the presence of a left cavernous sinus dAVF. We performed transvenous coil embolization, and the dAVF disappeared.

CONCLUSIONS

TVE has been widely recognized as an effective treatment for dAVF. However, dAVF may develop at a different location after TVE in a few cases. A long-term follow-up is therefore recommended.

Preoperative embolization of meningiomas with low-concentration n-butyl cyanoacrylate

The aim of this study was to determine the clinical safety and efficacy of preoperative embolization of meningiomas with low-concentration n-butyl cyanoacrylate (NBCA). Nineteen cases of hypervascular intracranial meningiomas were treated by preoperative embolization with 14% NBCA, using a wedged superselective catheterization of feeding arteries and reflux-hold-reinjection technique. Clinical data of the patients and radiological and intra-surgical findings were reviewed. All tumors were successfully devascularized without any neurological complications. Marked reduction of tumor staining with extensive NBCA penetration was achieved in 13 cases. Perioperative blood transfusion was only required in two cases. These results indicate that preoperative embolization of meningiomas with low-concentration NBCA is both safe and effective.

[Case of an anterior communicating artery aneurysm with acute in-stent occlusion during coil embolization]

PURPOSE

We report a case of acute in-stent occlusion during a stent-assisted coil embolization of a communicating artery aneurysm.

CASE PRESENTATION

A 58-year-old man presented with a regrowth of an anterior communicating artery aneurysm one year after the initial coil embolization. An acute in-stent occlusion occurred during coil filling through the stent strut. We performed a successful recanalization of the stent using antithrombotic agents.

CONCLUSIONS

Acute in-stent occlusion is a possible complication of stent-assisted coil embolization of aneurysms, particularly in narrow parent arteries. Our patient was recovered using antithrombotic drugs and did not present any major ischemic symptoms.

Structural changes in dermal collagen and oxidative stress levels in the skin of Japanese overweight males

OBJECTIVE

It has been reported that obese people have poorly organized dermal collagen structure because of the degradation of collagen fibers, which is caused by an increase in oxidative stress levels associated with the hypertrophy of subcutaneous adipose cells. However, it is unclear whether an increase in oxidative stress levels caused by the accumulation of subcutaneous adipose tissue and a change in the dermal structure also occur in overweight and obese Japanese people. The objectives of this study are to identify structural changes that occur in the dermis and to measure the levels of oxidative stress in Japanese overweight males.

METHODS

The overweight group included 43 Japanese male volunteers aged between 25 and 64 years and with a body mass index (BMI) of ≥25 and <30. The control group included 47 male volunteers aged between 22 and 64 years and with BMI of <25. The 20-MHz Dermascan C® ultrasound scanner with software for image analyses was used. Echogenicity of the upper and lower dermis was measured. The mRNA expression level of heme oxygenase-1 (HMOX1) in hair follicles was quantitatively analyzed by real-time reverse transcription polymerase chain reaction (RT-PCR) and was used as a marker of oxidative stress. Ultrasonographic imaging and collection of hair follicles were performed at the same site on the thigh, abdomen, and upper arm.

RESULTS

The HMOX1 mRNA expression level in the abdomen and thigh was significantly lower in the overweight group than in the control group. Moreover, the echogenicity of the upper dermis of the abdomen and the lower dermis of the abdomen and thigh was significantly lower in the overweight group than in the control group.

CONCLUSION

We detected an increase in oxidative stress levels and a decrease in the density of dermal collagen at the same site on the thigh, abdomen, and upper arm of Japanese overweight males. These findings suggest the fragility of the dermis of Japanese overweight males, which might have been caused by the accumulation of subcutaneous adipose tissue.

Randomized clinical trial: rikkunshito in the treatment of functional dyspepsia--a multicenter, double-blind, randomized, placebo-controlled study

BACKGROUND

Rikkunshito, a standardized Japanese herbal medicine, is thought to accelerate gastric emptying and relieve dyspepsia, although no large-scale, randomized, placebo-controlled trials of rikkunshito have been conducted. This study aimed to determine the efficacy and safety of rikkunshito for treating functional dyspepsia (FD).

METHODS

FD patients received 2.5 g rikkunshito or placebo three times a day for 8 weeks in this multicenter, randomized, placebo-controlled, parallel-group trial. The primary end point was the proportion of responders at 8 weeks after starting test drug, determined by global patient assessment (GPA). The improvement in four major dyspepsia symptoms severity scale was also evaluated. In addition, plasma ghrelin levels were investigated before and after treatment.

KEY RESULTS

Two hundred forty-seven patients were randomly assigned. In the eighth week, the rikkunshito group had more GPA responders (33.6%) than the placebo (23.8%), although this did not reach statistical significance (p = 0.09). Epigastric pain was significantly improved (p = 0.04) and postprandial fullness tended to improve (p = 0.06) in the rikkunshito group at week 8. Rikkunshito was relatively more effective among Helicobacter pylori-infected participants (rikkunshito: 40.0% vs placebo: 20.5%, p = 0.07), and seemed less effective among H. pylori-uninfected participants (rikkunshito: 29.3% vs placebo: 25.6%, p = 0.72). Among H. pylori-positive individuals, acyl ghrelin levels were improved just in rikkunshito group. There were no severe adverse events in both groups.

CONCLUSIONS & INFERENCES

Administration of rikkunshito for 8 weeks reduced dyspepsia, particularly symptoms of epigastric pain and postprandial fullness. (UMIN Clinical Trials Registry, Number UMIN000003954).

Field tests of Poly(I:C) immunization with nervous necrosis virus (NNV) in sevenband grouper, Epinephelus septemfasciatus (Thunberg)

It was recently reported that Poly(I:C) immunization with live nervous necrosis virus (NNV) confers protection in sevenband grouper, Epinephelus septemfasciatus (Thunberg), from NNV infection. In the present study, we conducted field tests with sevenband grouper for the evaluation of Poly(I:C) immunization efficacy. In the first experiment, sevenband grouper were immunized with NNV followed by Poly(I:C) administration 7 weeks before natural occurrence of viral nervous necrosis (VNN). Survival rate of the naïve fish was 71.0%, whereas that of the immunized fish was 99.8%. In the second experiment, sevenband grouper were immunized 10 months before VNN occurrence and survival rate of the non-treated and vaccinated fish was 79.5% and 97.5%, respectively. In the third experiment, we administered Poly(I:C) to sevenband grouper at 20 days after natural occurrence of VNN. The survival rate of the non-treated fish was 9.8%, whereas that of fish administered Poly(I:C) was 93.7%. Based on these results, it was concluded that Poly(I:C) immunization conferred protection in fish against NNV infection in field tests and the protection lasted more than 10 months. Furthermore, even after occurrence of VNN, fish mortality could be reduced by Poly(I:C) administration and there was an unexpected curative effect on VNN-affected fish.

Plasma resistin concentration determined by common variants in the resistin gene and associated with metabolic traits in an aged Japanese population

AIMS/HYPOTHESIS

Resistin is a cytokine derived from adipose tissue and is implicated in obesity-related insulin resistance and type 2 diabetes mellitus. Polymorphisms of the resistin gene (RETN) have been shown to affect the plasma resistin concentration. The aims of this study were to identify polymorphisms of RETN that influence plasma resistin concentration and to clarify the relation between plasma resistin level and metabolic disorders in an aged Japanese cohort.

METHODS

The study participants comprised 3133 individuals recruited to a population-based prospective cohort study (KING study). Plasma resistin concentration, BMI, abdominal circumference, blood pressure, fasting plasma glucose and serum insulin concentrations, HbA(1c) content and serum lipid profile were measured in all participants. The HOMA index of insulin resistance (HOMA-IR) was also calculated. Eleven polymorphisms of RETN were genotyped.

RESULTS

A combination of ANOVA and multiple linear regression analysis in screening and large-scale subsets of the study population revealed that plasma resistin concentration was significantly associated with rs34861192 and rs3745368 polymorphisms of RETN. Multiple linear regression analysis with adjustment for age and sex also showed that the plasma resistin level was significantly associated with serum concentrations of HDL-cholesterol, triacylglycerol and insulin, as well as with BMI.

CONCLUSIONS/INTERPRETATION

Our results implicate the rs34861192 and rs3745368 polymorphisms of RETN as robust and independent determinants of plasma resistin concentration in the study population. In addition, plasma resistin level was associated with dyslipidaemia, serum insulin concentration and obesity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00262691.

Lymphocystis disease virus persists in the epidermal tissues of olive flounder, Paralichthys olivaceus (Temminch & Schlegel), at low temperatures

Olive flounder artificially infected with lymphocystis disease virus (LCDV) were reared at 10, 20 and 30 degrees C for 60 days, to compare LCD-incidence. In the fish reared at 20 degrees C, lymphocystis cells appeared on the skin and fins at 35 days post-challenge, and the cumulative LCD-incidence was 80% at 60 days. High levels of LCDV, with a mean polymerase chain reaction (PCR) titre of 10(6) PCR-U mg(-1) tissue, were detected in the fins and skin of LCD-affected fish at 20 degrees C, but were not detected in the spleen, kidney, brain and intestinal tissues of these fish. No LCD clinical signs were observed in the fish reared at 10 degrees C and 30 degrees C; however, a low level of LCDV (10(3) PCR-U mg(-1) tissue) was detected in the fins and skin of these fish. By increasing the rearing temperature from 10 to 20 degrees C, lymphocystis clusters appeared on the skin and fins of the fish with no previous LCD clinical signs within 33 days after the temperature change. It was shown that permissive cells for LCDV infection exist in the epidermis of olive flounder. At low temperatures, small amounts of LCDV were able to persist over a period extended for a further 45 days in the fish epidermis, even though the fish showed no LCD clinical signs. The optimum growth temperature of LCDV is near 20 degrees C.

A rare case of tako-tsubo cardiomyopathy with variable forms of left ventricular dysfunction: a new entity

We report a rare case of an 83-year-old woman with tako-tsubo cardiomyopathy, who presented with variable forms of left ventricular dysfunction during her clinical course. The distribution regional wall-motion abnormalities of the left ventricle on echocardiography had changed from a mid-ventricular ballooning type to the apical ballooning type 3 days from the onset. We suggest that these findings may indicate a new or variant entity of tako-tsubo cardiomyopathy.

Non-specific adsorption of fish immunoglobulin M (IgM) to blocking reagents on ELISA plate wells

Enzyme-linked immunosorbent assay (ELISA) is a popular technique for quantifiable detection of specific antibodies in warm-blooded animals, but it has not been accepted for detection of fish antibodies because of its low reproducibility, which is due in part to high background optical density (OD) measurements. In the present study, we report that the high background of a fish antibody-detection ELISA resulted from non-specific adsorption of fish immunoglobulin M (IgM) to blocking reagents on the ELISA plate wells. Four fish sera (from rainbow trout Oncorhynchus mykiss, masu salmon O. masou, Japanese flounder Paralichthys olivaceus and koi Cyprinus carpio) were poured into ELISA plate wells pre-blocked with several blocking reagents (skim milk, soybean milk, bovine serum albumin, fetal bovine serum, gelatin and Roche BlockingReagent) and then washed out in order to measure the remaining fish IgM on the ELISA plate wells. Significant amounts of fish IgMs (OD absorbance at 492 nm: 0.3 to 1.1) remained on the ELISA plate wells with no antigenic protein except blocking reagents. The amount of remaining fish IgMs on the ELISA plate wells decreased significantly following treatment of fish sera with skim milk. However, the specific immuno-reactivity of fish IgM was not reduced by such treatment. Thus, we conclude that treatment of fish sera with skim milk is useful in reducing the high background OD often observed in fish IgM detection ELISA.

Genotyping of Korean isolates of infectious hematopoietic necrosis virus (IHNV) based on the glycoprotein gene

Glycoprotein (G) gene nucleotide sequences of four Korean isolates of infectious hematopoietic necrosis virus (IHNV) were analyzed to evaluate their genetic relatedness to worldwide isolates. All Korean isolates were closely related to Japanese isolates of genogroup JRt rather than to those of North American and European genogroups. It is believed that Korean IHNV has been most likely introduced from Japan to Korea by the movement of contaminated fish eggs. Among the Korean isolates, phylogenetically distinct virus types were obtained from sites north and south of a large mountain range, suggesting the possibility of more than one introduction of virus from Japan.

Nucleotide diversity of Japanese isolates of infectious hematopoietic necrosis virus (IHNV) based on the glycoprotein gene

Infectious hematopoietic necrosis virus (IHNV), a member of the genus Novirhabdovirus, causes a highly lethal disease of salmonid fish. In the present study, G gene nucleotide sequences of 9 Japanese IHNV isolates obtained from 1971 to 1996 were analyzed to evaluate the genetic diversity and compared with IHNV isolates from North America and Europe. A radial phylogenetic tree revealed 5 major clusters including 3 genogroups (U, M and L) for North American isolates and 1 genogroup for European isolates. Five Japanese isolates from 1971 to 1982 appeared in the cluster for genogroup U, while the remaining Japanese isolates from 1980 to 1996 formed a new genogroup, JRt (Japanese rainbow trout). Maximum nucleotide diversity among the Japanese isolates was 4.5%, which was greater than that within the North American isolates (3.6%), and the degree of nucleotide diversity within Japanese isolates was increased by inclusion of the genogroup JRt isolates. It was concluded that Japanese isolates shared a common source with the genogroup U of the North American isolates and that there were large divergences between Japanese isolates before and after the 1980s.

Specific messenger RNA expression for signal transduction molecules by lipopolysaccharide in intestinal macrophages

Intestinal macrophages are known to display profound inflammatory anergy in response to lipopolysacchraide (LPS). To study the mechanisms of unresponsiveness of intestinal macrophages to LPS, we compared the mRNA expression of molecules associated with signal transduction of intestinal macrophages with those of other tissue macrophages. Also cellular localization of CD14 protein was examined. Intestinal, alveolar and peritoneal macrophages were isolated from rats or mice. The expression of mRNA was assessed by real-time PCR, and cellular localization of CD14 protein was examined by flow cytometry. Cellular responses to LPS were examined by production of TNF and NO. The expression of CD14 mRNA in intestinal macrophages was lower than for peritoneal macrophages but higher than for alveolar macrophages. The mRNA expression of other molecules corresponding to intracellular signal transduction in intestinal macrophages was similar with alveolar and peritoneal macrophages. Despite the presence of CD14 mRNA, proteins of CD14 were not detected on cell surfaces of intestinal macrophages, and induction of TNF or NO responding to LPS were not detected. Flow cytometric analysis demonstrated that CD14 protein was not expressed on the cell surface but was expressed inside intestinal macrophages. The unresponsiveness of intestinal macrophages after LPS exposure is considered to be largely attributed to the lack of CD14 protein on their cell surfaces. However, CD14 protein was expressed inside of the cells, suggesting that post-transcriptional regulation rather than transcriptional suppression may play a dominant role in determining the phenotype of the intestinal macrophages.

A new genotype of lymphocystivirus, LCDV-RF, from lymphocystis diseased rockfish

Lymphocystis disease virus (LCDV) is the causative agent of lymphocystis disease. In this study, nucleotide sequences of the major capsid protein (MCP) gene were analyzed among LCDV isolates from Japanese flounder and rockfish. A phylogenetic tree revealed three clusters for lymphocystiviruses. The first cluster included Japanese flounder isolates; the second cluster consisted of rockfish isolates; and the remaining one consisted of LCDV-1. Nucleotide sequence identities were > or =99.6% among Japanese flounder isolates and 100% among rockfish isolates, while between each cluster they were < or =85.2%. Experimental infections with Japanese flounder and rockfish isolates revealed that Japanese flounder and rockfish were infected by the respective homologous isolate but not by the heterologous isolate. These findings suggest that at least three genotypes exist in the genus Lymphocystivirus.

High prevalence of hepatitis B, C and delta virus infections among blood donors in Mongolia

Serum samples obtained from 289 first-time and 114 repeat donors at the Blood Center of Mongolia (MBC) were tested for serological and molecular markers of hepatitis B virus (HBV), hepatitis C virus (HCV), and hepatitis delta virus (HDV) infections. Among the 403 blood donors, 33 (8.2%), 21 (5.2%), and 27 (6.7%) tested positive for hepatitis B surface antigen (HBsAg) and/or HBV DNA, HCV RNA, and HDV RNA, respectively. Collectively, 55 donors were viremic for one or more of these viruses, and included 54 first-time donors (18.7%) and 1 repeat donor (0.9%) (P < 0.0001). One discrepant case with HBsAg detectable only at MBC was negative for HBsAg, HBV DNA and anti-HBc in this study. Four donors who were HCV-viremic in this study were negative for anti-HCV by the MBC method. Further efforts to increase the sensitivity and specificity of the currently-used tests are urgently required in Mongolia. Three donors who were positive for anti-HBc and anti-HDV but negative for HBsAg, had both HBV DNA and HDV RNA. This suggests that introduction of a new anti-HDV serological test is useful for not only HDV screening but also HBV screening of anti-HBc-positive, HBsAg negative donors, considering a possibility of viral interference by coexisting HDV.