Ectopic variceal bleeding due to portosystemic shunt via dilated mesenteric veins and a varicous left ovarian vein : case report and literature review of ectopic varices

Ectopic varices are dilated portosystemic venous collaterals located outside of the gastro-esophageal region. Whereas they are common endoscopic findings in patients with portal hypertension, ectopic variceal bleeding is rather rare and accounts for only 1 to 5 % of all variceal bleedings. The rectum and the duodenum are the most common sites for ectopic varices, but they can be present along the whole intestinal tract and neighborhood. At present, there is no consensus well established on diagnostic workup for ectopic variceal bleeding and their therapeutic strategies. Further investigation of large series or randomized-controlled trials is needed because nowadays most of the data available are based on case reports. We report here an unusual case of an ectopic variceal bleeding, presented as an acute small intestine bleeding, due to a portosystemic shunt via dilated mesenteric veins and a varicous left ovarian vein in a patient with alcoholic cirrhosis. The involvement of an ovarian vein in ectopic variceal bleeding is rarely described.

Role of the Accessory Parotid Gland in the Etiology of Parotitis: Statistical Analysis of Sialographic Features

This retrospective study aimed to identify if the existence of the accessory parotid gland correlated with the etiology of parotitis. This may aid the development of better treatment strategies in the future. Sialographic features of cases with parotitis and healthy subjects were reviewed. The chi-square test was used to compare the incidence of accessory parotid gland between the groups. The Student's t test was used to compare the length of Stensen's duct, the length from the orifice to the confluence of the accessory duct, and the angle between the accessory duct and Stensen's duct between the groups. The incidence of accessory parotid gland in patients with parotitis was 71.8% (28/39), which was significantly higher than that in healthy subjects (P = 0.005). Patients with parotitis had a longer Stensen's duct than healthy subjects (P = 0.003). There was no significant difference in the length from the orifice to the confluence of the accessory duct or the angle between the accessory duct and Stensen's duct (P = 0.136 and 0.511, respectively) between the groups. The accessory parotid gland might play a role in the pathogenesis of parotitis. The existence of an accessory parotid gland is likely to interfere with salivary flow. Computational fluid dynamics analysis of salivary flow in the ductal system would be useful in future etiologic studies on parotitis.

Subcortical heterotopia appearing as huge midline mass in the newborn brain

INTRODUCTION

We report the case of a 2-year-old boy who showed a huge midline mass in the brain at prenatal assessment.

CASE REPORT

After birth, magnetic resonance imaging (MRI) revealed a conglomerate mass with an infolded microgyrus at the midline, which was suspected as a midline brain-in-brain malformation. MRI also showed incomplete cleavage of his frontal cortex and thalamus, consistent with lobar holoprosencephaly. The patient underwent an incisional biopsy of the mass on the second day of life. The mass consisted of normal central nervous tissue with gray and white matter, representing a heterotopic brain. The malformation was considered to be a subcortical heterotopia. With maturity, focal signal changes and decreased cerebral perfusion became clear on brain imaging, suggesting secondary glial degeneration. Coincident with these MRI abnormalities, the child developed psychomotor retardation and severe epilepsy focused on the side of the intracranial mass.

RELATIVE CONTRIBUTIONS OF ECTOPIC LIVER AND ABDOMINAL FAT ACCUMULATION TO ARTERIAL STIFFNESS

OBJECTIVE

To compare the arterial stiffness between the abdominal obese population without nonalcoholic fatty liver disease (NAFLD) (referred to as abdominal fat accumulation), the normal-weight population with NAFLD (ectopic liver fat accumulation), and the population with both abdominal obesity and NAFLD (accumulation of both abdominal and ectopic liver fat).

METHODS

A total of 111,552 Chinese adults who underwent the health checkups from January 2012 to December 2012 were screened. Clinical and biochemical parameters were measured in each subject. NAFLD was diagnosed by ultrasonography. Arterial stiffness was evaluated by cardio-ankle vascular index (CAVI).

RESULTS

Normal-weight subjects with NAFLD had significantly higher CAVI than subjects with abdominal obesity with or without NAFLD (8.12 ± 1.16 vs. 7.93 ± 1.38, 7.96 ± 1.20; P<.01). When the presence of abdominal obesity, NAFLD, and both diseases (abdominal obesity and NAFLD) were included in regression analyses individually, CAVI was independently associated with abdominal obesity or NAFLD or both after adjusting for confounders. When the presence of abdominal obesity and NAFLD and both diseases were included simultaneously in regression analyses, the association between NAFLD and CAVI and the association between both diseases and CAVI remained significant, whereas the association between abdominal obesity and CAVI was no longer significant. The presence of NAFLD conferred a greater odds ratios of having an elevated CAVI than did the presence of abdominal obesity or even the presence of both diseases.

CONCLUSION

Ectopic liver fat accumulation is associated with greater risk of arterial stiffness compared with abdominal fat accumulation or accumulation of both abdominal and ectopic liver fat.

Endometrial decidualization and deciduosis in aged rhesus macaques (Macaca mulatta)

Superficial decidualization of the endometrial stroma is an essential feature of the implantation stage of pregnancy in rhesus macaques and other primates. Decidualization involves proliferation of the endometrial stromal cells, with differentiation into morphologically distinct decidual cells. Previous reports involving nonpregnant rhesus monkeys have described local- ized and widespread endometrial decidualization in response to administration of progesterone and synthetic progestogens. Ectopic decidua or 'deciduosis' describes the condition in which groups of decidual cells are located outside of the endometrium, most often in the ovaries, uterus and cervix but also in various other organs. In humans, most cases of deciduosis are associated with normal pregnancy, and ectopic decidua can be found in the ovary in nearly all term pregnancies. Here we describe pronounced endometrial decidualization in 2 rhesus macaques. Both macaques had been treated long-term with medroxyprogesterone acetate for presumed endometriosis, which was confirmed in one of the macaques at postmortem examination. In one animal, florid extrauterine and peritoneal serosal decidualization was admixed multifocally with carcinomatosis from a primary colonic adenocarcinoma. Cells constituting endometrial and serosal decidualization reactions were immunopositive for the stromal markers CD10, collagen IV, smooth muscle actin, and vimentin and immunonegative for cytokeratin. In contrast, carcinomatous foci were cytokeratin-positive. To our knowledge, this report describes the first cases of serosal peritoneal decidualization in rhesus macaques. The concurrent presentation of serosal peritoneal decidualization with carcinomatosis is unique.

Endoscope-assisted intraoral removal of ectopic thyroid tissue using a frenotomy incision

BACKGROUND

Ectopic thyroid tissue is a relatively rare condition and a developmental anomaly characterized by the aggregation of thyroid tissue. Usually, it occurs along the path of descent of the developing thyroid primordium from the foramen caecum, the most common being in the anterior midline of the neck at or below the level of the hyoid bone. Surgical removal of ectopic thyroid tissue is usually accomplished through an external incision in the neck. However, this procedure inevitably results in a neck scar.

METHODS

We report the case of a 30-year-old woman with ectopic thyroid tissue. We implemented a modified approach to ectopic thyroid tissue removal through a frenotomy incision of the mouth using an endoscope system.

RESULTS

A modified approach to ectopic thyroid tissue removal was used in this patient. The total operative time was 50 minutes, and the patient remains free of disease 15 months after excision.

CONCLUSION

Resection of ectopic thyroid tissue can be performed by a transoral endoscope-assisted approach through a frenotomy incision of the mouth.

Thyroid hemiagenesis, ectopic submandibular thyroid tissue, and apparent persistent subclinical thyrotoxicosis

BACKGROUND

Ectopic thyroid tissue (ETT) is a rare embryological abnormality characterized by the occurrence of thyroid tissue in a site other than its usual location. Thyroid hemiagenesis (HA) is also a very rare abnormality in which one thyroid lobe does not develop properly during embryology. We report a patient with left HA, submandibular ETT, and persistent mildly suppressed serum thyrotropin (TSH).

PATIENT

A 38-year-old female patient was admitted with complaints of sweating and palpitations. She had no symptoms of neck compression. Thyroid ultrasonography revealed heterogeneity and hypoechogenicity of the right lobe and absence of the left lobe, the latter being confirmed by computed tomography. There was no ETT in the neck. A thyroid Tc-99m pertechnetate scan demonstrated two distinct areas of radiotracer uptake, one in the right lobe of the thyroid gland and one in the right submandibular region and lobe, but no uptake in the left thyroid bed. The serum free triiodothyronine was 2.89 pg/mL (2.5-3.9 pg/mL), and the serum free thyroxine was 0.86 ng/dL (0.61-1.12 ng/mL). The serum TSH was 0.11 mIU/L (0.34-5.60 mIU/L).

CONCLUSIONS

This may be the first reported patient with HA and submandibular ETT. The patient probably also had thyroiditis with mild intermittent thyrotoxicosis based on her suppressed TSH and ultrasonography imaging of the right thyroid lobe.

Massive gastrointestinal bleeding from Meckel diverticulum with ectopic pancreatic tissue

Meckel diverticulum (MD), a congenital gastrointestinal anomaly, is often involved in pediatrics, but less in the adult population. The patient in this report was a 69-year-old female presented with massive gastrointestinal bleeding causing hemorrhagic shock due to MD containing ectopic pancreatic tissue. A review of the literature revealed that gastrointestinal bleeding from MD containing ectopic pancreatic tissue is rare in adults and difficult to be identified preoperation. MD should be considered as one of the differential diagnosis for lower gastrointestinal bleeding, although scarce in adults, especially when the patient has massive painless bleeding.

Esophageal motility and 24-h pH profiles of patients with heterotopic gastric mucosa in the cervical esophagus

BACKGROUND

Heterotopic gastric mucosa occurs as a flat island of red mucosa in the proximal third of the esophagus where it gives rise to the cervical inlet patch. The aims of this study were to investigate the esophageal motility pattern and 24-h pH profiles of patients with cervical inlet patch.

METHODS

Thirty patients (16 women, mean age: 44.9 years, range: 23-72) diagnosed as having heterotopic gastric mucosa in the cervical esophagus with upper gastrointestinal symptoms had undergone esophageal motility testing and 24-h pH monitorisation with a double-channel pH probe.

RESULTS

Manometric investigation was abnormal in 7 patients (non-specific esophageal motor disorder in 4 patients, esophageal hypomotility in 1 patient, and hypotensive LES in 2 patients). Pathological acid reflux (pH<4) was found in 9 (30%) of 30 heterotopic gastric mucosa patients during pH monitorisation from the distal probe. Pathological acid reflux in the proximal esophagus (percentage of total time of pH<4) was seen in four of these nine patients. Only four of the 30 patients (13.3%) presented with "acid independent episodes" during the 24-h esophageal pH monitorisation.

CONCLUSION

Manometric investigation and 24-h pH monitorisation revealed that some of the patients with HGM have signs of esophageal motor dysfunction and "acid independent episodes" from the patches. These abnormalities may be responsible for some of the symptoms of HGM patients.

Ectopic recurrence of craniopharyngioma along the surgical route: case report and literature review

We present a 22-year-old woman with an ectopic recurrence of a craniopharyngioma. The patient presented first with a visual field deficit, and a craniopharyngioma was removed via an interhemispheric transcallosal approach. Magnetic resonance imaging (MRI) performed at 1 month, and then at 1 year after surgery showed complete removal of the lesion. However, at 4 years, MRI showed the presence of a small tumor in the right medial frontal lobe attached to the falx and along the previous surgical route. We present possible explanations for the ectopic recurrence and literature review.

Does pituitary stalk function improve with age?

Ectopic posterior pituitary hyperintensity on MRI is a common feature associated with growth hormone deficiency. The presence of at least some residual components of the pituitary stalk is necessary for adequate anterior pituitary function. Little is known about long-term change in pituitary function or MRI findings in patients with ectopic posterior pituitary and interrupted pituitary stalk. We describe a case of childhood growth hormone deficiency and hyperprolactinemia associated with absent pituitary stalk. As an adult, prolactin levels normalized and GH secretion improved associated with changes in MRI findings.

Decidualization attenuates the contractility of eutopic and ectopic endometrial stromal cells: implications for hormone therapy of endometriosis

CONTEXT

Decidualization of the endometrium involves the morphological and biochemical reprogramming of the estrogen-primed proliferative endometrial stromal compartment under the continuing influence of progesterone.

OBJECTIVES

The aim of this study was to evaluate the involvement of the extracellular matrix contractility of eutopic and ectopic endometrial stromal cells during the tissue remodeling processes associated with decidualization.

DESIGN

The effect of decidualization on the contractile profile of the endometriotic cyst stromal cells and eutopic endometrial stromal cells with or without endometriosis in the three-dimensional collagen gel culture was investigated using laser scanning microscopy, collagen gel contraction assays, and Western blot analysis.

RESULTS

Decidualized ectopic and eutopic endometrial stromal cells in the three-dimensional collagen gel culture mimicked the morphology of decidual tissue in vivo. In vitro decidualization inhibited the contractility of these eutopic and ectopic endometrial stromal cells. Down-regulation of integrin alpha1beta1 and alpha2beta1 expression, suppression of Ras homology A (Rho A), Rho-associated coiled-coil-forming protein kinase (ROCK)-I and ROCK-II expression, inhibition of the differentiation into the myofibroblastic phenotype, and induction of differentiation into epithelioid decidual phenotype were observed in these cells during decidualization.

CONCLUSIONS

It is suggested that the attenuation of eutopic endometrial stromal cell-mediated contractility by decidualization is a novel and integral mechanism of the physiological endometrial tissue remodeling process during menstrual cycles. Although ectopic endometrial stromal cells have enhanced contractile profile, decidualization can attenuate the contractility of these cells. These findings may be one of the action mechanisms by which oral contraceptives and progestins ameliorate endometriosis.

[Diagnosis of the functional state of the upper part of double kidney in girls with ureter extravesical ectopy]

45 girls with extravesical ureter ectopy of double kidneys were treated outpatiently for 1981-2006. Their age varied from 6 months to 15 years. The anomaly was right-sided in 12 children, left-sided in 27 and bilateral in 6 cases. All the patients underwent surgical cor--rection: upper heminephrureterectomy was performed in 35 cases, nephrectomy--in 5 cases, ureteropyeloanastomosis--in 1 case, ureter-ureter anastomosis in the upper one third--in 3 cases and ureter-neo-cystoanastomosis in 1 child. We propose a new diagnostic method for estimation of functional state of the upper part of the double kidney with extravesical ectopy of its ureter. The method is based on comparison of volumes for 24 hour urine collection in natural urination and urinary incontinence, determination of relative density of urine collected in incontinence. If ectopic volume makes 19% and more of normal micturition volume and density of this urine is more than 1014, function of the upper part is good and organ-sparing surgery is indicated. Good results of 1 to 24 year follow-up were achieved in all the patients.

Ectopic osteogenesis and chondrogenesis of bone marrow stromal stem cells in alginate system

In orthopedics, the regeneration and repair of cartilage or bone defects after trauma, cancer, or metabolic disorders is still a major clinical challenge. Through developmental plasticity, bone marrow mesenchymal stem cells (BMSSCs) are important seed cells for the musculoskeletal tissue engineering approach. The present study sought to determine the ectopic osteogenic and chondrogenic ability of BMSSCs in combination with a scaffolding material made from alginate gel. After isolation from the bone marrow of BALB/C mice, BMSSCs were expanded in vitro and induced to chondrogenesis or osteogenesis for 14 days, respectively. Subsequently, these induced cells were seeded into alginate gel, and the constructs implanted into BALB/C nude mice subcutaneously for up to 8 weeks. In the histological analysis, the transmission electron microscopy of the retrieved specimens at various intervals showed obvious trends of ectopic cartilage or bone formation along with the alteration of the cellular phenotype. Simultaneously, the results of the immunohistochemical staining and RT-PCR both confirmed the expression of specific extracellular matrix (ECM) markers for cartilaginous tissue, such as collagen type II (Col-II), SOX9, and aggrecan, or alternatively, markers for osteoid tissue, such as osteopontin (OPN), osteocalcin (OCN), and collagen type I (Col-I). During subcutaneous implantation, the elevating production of ECM and the initiation of the characteristic structure were closely correlated with the increase of time. In contrast, there was an apparent degradation and resorption of the scaffolding material in blank controls, but with no newly formed tissues. Finally, the constructs that were made of non-induced BMSSCs nearly disappeared during the 8 weeks after implantation. Therefore, it is suggested that alginate gel, which is combined with BMSSCs undergoing differentiation into skeletal lineages, may represent a useful strategy for the clinical reconstruction of bone and cartilage defects.

Variations of the position of the cerebellar tonsil in idiopathic scoliotic adolescents with a cobb angle >40 degrees: a magnetic resonance imaging study

STUDY DESIGN

A retrospective study was performed through measurements on MRI images in adolescent idiopathic scoliosis (AIS) patients and age-matched adolescents.

OBJECTIVES

To investigate the position of the cerebellar tonsil in AIS patients with a Cobb angle >40 degrees in comparison with age-matched healthy adolescents and to determine the relationships of the tonsil position with age, sex, curve severity, and curve patterns.

SUMMARY OF BACKGROUND DATA

There have been increasing evidences implying that AIS patients may present with subtle or subclinical neurologic dysfunction and a higher incidence of tonsillar ectopia was documented in AIS patients. However, the tonsil position has not been clearly addressed in AIS patients with a severe curve.

METHODS

According to the method described by Aboulezz et al, measurements of the tonsil position relative to the magnum foramen on magnetic resonance images were performed in 203 AIS patients with a Cobb angle >40 degrees and 86 age-matched healthy adolescents. The inferior displacement of the cerebellar tonsil with an extent within 5 mm was defined as tonsillar ectopia when it located below the magnum foramen. On the basis of measurement results, the incidence of tonsillar ectopia was determined in both AIS and control groups. The associations of tonsillar ectopia with curve severity and curve patterns for AIS patients and the relationships of the tonsil positions with age and gender in all subjects were analyzed.

RESULTS

In AIS patients and healthy controls, the median position of the cerebellar tonsil was 0.8 and 2.9 mm above the magnum foramen, respectively. The incidence of tonsillar ectopia (0-4.8 mm below the magnum foramen) in AIS was found to be significantly higher than healthy adolescents (range 0-1.8 mm vs. 0-4.8 mm below the magnum foramen; ratio 34.5% vs. 5.8%; P < 0.01). No significant correlations were found between the position of the cerebellar tonsil with age or gender in AIS and control subjects. It was shown the position of the cerebellar tonsil was not significantly different among AIS patients with different curve severity. However, it was noted that there was a highest incidence (62.5%) of tonsillar ectopia in atypical scoliotic cases with a double thoracic curve. Additionally, a significantly higher incidence of tonsillar ectopia was found in patients with thoracic or thoracolumbar curves when compared with those with lumbar curves (37.4% vs. 21.6%, P = 0.049).

CONCLUSION

Tonsillar ectopia with the extent >2 mm in AIS patients should be regarded as abnormal. AIS patients had a lower tonsil position and a higher prevalence of tonsillar ectopia than controls, and tonsillar ectopia was found to be associated with curve patterns. It is suggested that a lower position of the cerebellar tonsil might be associated with the etiopathogenesis of AIS and might contribute to subclinical neurologic dysfunction in AIS patients.

Mossy cell axon synaptic contacts on ectopic granule cells that are born following pilocarpine-induced seizures

Granule cell neurogenesis increases following seizures, and some newly born granule cells develop at abnormal locations within the hilus. These ectopic granule cells (EGCs) demonstrate regular bursts of action potentials that are synchronized with CA3 pyramidal cell burst discharges and the bursts of hilar neurons, including mossy cells. Such findings suggest that mossy cells may participate in circuits that activate EGCs. Electron microscopic immunolabeling was therefore used to determine if mossy cell axon terminals form synapses with hilar EGC dendrites, using animals that underwent pilocarpine-induced status epilepticus. Pilocarpine was administered to adult male rats, and those which developed status epilepticus were perfused 5-7 months later, after the period of EGC genesis. Hippocampal sections were processed for dual electron microscopic immunolabeling (using calcitonin gene-related peptide (CGRP) as a marker for mossy cells and calbindin (CaBP) as a marker for EGCs). Light microscopic analysis revealed large CGRP-immunoreactive cells in the hilus, with the appearance and distribution of mossy cells. Electron microscopic analysis revealed numerous CaBP-immunoreactive dendrites in the hilus, some of which were innervated by CGRP-immunoreactive terminals. The results suggest that mossy cells participate in the excitatory circuits which activate EGCs, providing further insight into the network rearrangements that accompany seizure-induced neurogenesis in this animal model of epilepsy.

Noninvasive assessment of ectopic uterine tissue development in rats using magnetic resonance imaging

OBJECTIVE

To non-invasively characterize ectopic uterine tissue (EUT) development in a modified autologous rat surgical model of endometriosis using magnetic resonance imaging (MRI).

DESIGN

Investigational MRI study.

SETTING

A pharmaceutical company.

ANIMAL(S)

Female Sprague Dawley rats.

INTERVENTION(S)

Uterine tissue was autotransplanted on the right peritoneal wall of rats. Rats were serially imaged after surgery and after endogenous hormone suppression, hormone supplementation, or ovariectomy. In addition, an MRI contrast agent was administered to examine EUT perfusion characteristics.

MAIN OUTCOME MEASURE(S)

Changes in transplanted EUT volume and perfusion were monitored using MRI.

RESULT(S)

The EUT growth could be readily monitored non-invasively by MRI. Although EUT growth was rapid during the initial 4 days after surgery, volume stabilized by the third week and maintained for at least 9 weeks after transplantation. The EUT volumes varied with the estrous cycle and were hormonally sensitive to ovariectomy, to Antide (GnRH antagonist), and to Antide followed by 17beta-E(2) supplementation. The use of an MRI contrast agent facilitated visualization of EUT wall perfusion.

CONCLUSION(S)

MRI allows for noninvasive, dynamic evaluation of transplanted EUT growth in the rat. This reproducible model will allow for performing quantifiable pharmacologic studies in pre-clinical drug discovery for therapies targeting endometriosis.

Ectopic lesions as potential pitfalls in fine needle aspiration cytology: a report of 3 cases derived from the thyroid, endometrium and breast

BACKGROUND

Ectopic lesions are rarely encountered. Those that are derived from thyroid, breast, endometrium and salivary glands present with palpable masses that can mimic malignancy. Fine needle aspiration cytology (FNAC) is a practical procedure for the differential diagnosis of such lesions but can reveal surprising images for a cytopathologist.

CASES

Three cases of discrete, ectopic lesions at different locations occurred. Case 1 was a 27-year-old woman. Upon diagnosis of a submandibular mass with a diameter of 1 cm, FNAC was performed. The smears showed crowded thyroid follicular cells comprising papillary clusters. A cytologic diagnosis of papillary thyroid lesion was rendered, Histopathology revealed that this lesion was ectopic thyroid tissue with focal chronic thyroiditis. Case 2 was a 38-year-old woman who presented with a painful mass with a diameter of 2.5 cm in the abdominal wall. The patient had undergone cesarean section 3 years earlier. The case was diagnosed on FNAC as low grade malignancy in which an adenocarcinoma/mesenchymal tumor distinction could not be made. The pathologic examination revealed endometriosis. Case 3 was a 31-year old woman who presented with a palpable nodule in the axillary region with a diameter of 1 cm. The patient had given birth 1 month earlier and was nursing. An FNAC diagnosis of lactation ectopic breast tissue was made. The mass disappeared by the end of lactation.

CONCLUSION

FNAC of ectopic lesions may prove to be a diagnostic pitfall for cytopathologists. A cytopathologist who encounters a cellularpicturefrom a lesion that is outside the normal anatomic location must use a cautious diagnostic approach. Unless there are clear findings, the cytopathologist must refrain from a diagnosis of malignancy.

Focal extra-axial hemorrahagic mass with subdural hemorrhage secondare to extramedullary hematopoiesis in idiopathic myelodysplastic sindrome

Idiopathic myelodysplastic syndrome is a disease characterized by a clonal stem cell disorder in which megacaryocitic and granulocytic lineages are mainly involved; extramedullary myeloid metaplasia is due to abnormal location of myeloid tissue in other organs than bone marrow. Rarely the central nervous system is involved. When it happens, it is typical to find masses around the brain and pachymeningeal thickening, but it is very rare to find it associated with subdural haemorrhage, as in the case we describe in the present article. Considering our case and the literature we can suggest that radiological images associated with the clinical history of the patient suggestive for extramedullary hematopoiesis can be sufficient for a correct diagnosis and for a radiotherapy treatment, demanding surgery in the case of diagnostic doubts, massive hemorrahages or neurological decifits caused by the focal lesions.

Diagnosis of pleomorphic adenoma in a heterotopic salivary gland: a case report

BACKGROUND

The histologic diversity encountered in pleomorphic adenoma may cause diagnostic difficulty in fine needle aspiration cytology (FNA) due to limited and selective sampling.

CASE

A 40-year-old woman presented with a mass in the anterior aspect of the neck along the sternocleidomastoid muscle. FNA revealed a cellular tumor with a chondrimyxoid background and epithelial cells intermingled with a few mesenchymal cells. The diagnosis of pleomorphic adenoma was confirmed on histopathology.

CONCLUSION

Primary ectopic pleomorphic adenoma can confidently be diagnosed by FNA. This technique is a useful tool in the initial assessment of the tumor.

[Magnetic resonance urography in the diagnosis of the ectopic ureters]

INTRODUCTION

Ectopic ureters are often very difficult to diagnose with conventional diagnostic modalities (physical examination, ultrasound, intravenous urography, cystography, urethro-cystoscopy, isotop examinations) in children.

AIM OF THE STUDY

The authors report their experience with a relatively new method, the magnetic resonance urography (MRU) diagnosing ectopic ureters in childhood.

METHOD

MRU was used in 7 girls to detect an ectopic ureter in the last 3 years. On the basis of typical clinical signs, an ectopic ureter was suspected in all patients, but it could not be demonstrated by conventional diagnostic methods. Thus, MRU was done to confirm the suspected diagnosis.

RESULTS

In all of the 7 patients, the examinations demonstrated ectopic ureters with the intraoperative findings further confirming the pre-operative diagnosis. In 2 patients, the intraoperative findings of the upper urinary tract anomalies were slightly different from the MRU report.

CONCLUSION

The MRU is a reliable diagnostic method to diagnose ectopic ureters which are not easily detectable with conventional diagnostic modalities.

Ectopic granule cells of the rat dentate gyrus

Granule cells of the mammalian dentate gyrus normally form a discrete layer, and virtually all granule cells migrate to this location. Exceptional granule cells that are positioned incorrectly, in 'ectopic' locations, are rare. Although the characteristics of such ectopic granule cells appear similar in many respects to granule cells located in the granule cell layer, their rare occurrence has limited a full evaluation of their structure and function. More information about ectopic granule cells has been obtained by studying those that develop after experimental manipulations that increase their number. For example, after severe seizures, the number of ectopic granule cells located in the hilus increases dramatically. These experimentally-induced ectopic granule cells may not be equivalent to normal ectopic granule cells necessarily, but the vastly increased numbers have allowed much more information to be obtained. Remarkably, the granule cells that are positioned ectopically develop intrinsic properties and an axonal projection that are similar to granule cells that are located normally, i.e., in the granule cell layer. However, dendritic structure and synaptic structure/function appear to differ. These studies have provided new insight into a rare type of granule cell in the dentate gyrus, and the plastic characteristics of dentate granule cells that appear to depend on the location of the cell body.

Heterotopic gastric mucosa: a significant clinical entity

OBJECTIVE

Despite the apparent lack of clinical interest in the inlet patches of heterotopic gastric mucosa (HGM) in the upper esophagus, the literature contains reports of complications associated with HGM. The aim of this study was to determine the prevalence and clinical importance of HGM in patients referred for upper gastrointestinal endoscopy (UGE).

MATERIAL AND METHODS

A total of 1033 consecutive outpatients referred for UGE were prospectively evaluated. Clinical, endoscopic and histologic findings were analyzed and 24-h double-channel pH-metry was performed on 20 patients with HGM.

RESULTS

Fifty-three patients (5.1%) had HGM lesions. Dysphagia was significantly more frequent in HGM patients (21% versus 4%; p<0.001). Five of the 20 patients who underwent pH-metry presented with acid secretion from HGMs. These five patients had inlet patches of greater size.

CONCLUSIONS

HGMs of the upper esophagus are not infrequent, although generally small and asymptomatic. In cases of large HGMs, acid secretion capacity may cause upper esophageal disorders.

Neuronal production and precursor proliferation defects in the neocortex of mice with loss of function in the canonical Wnt signaling pathway

To better understand the function of the Wnt pathway in the developing telencephalon, we analyzed neocortical development in low density lipoprotein receptor-related protein (LRP) 6 mutants. LRP6 mutant mice are hypomorphic for the canonical Wnt signaling pathway and have hypoplasia of the developing neocortex. While early telencephalic morphogenesis is largely intact in these mice, probably due to compensation by LRP5, the mutant mice develop a dramatically thinner cortical plate. There is a prominent reduction of neurogenesis leading to a thin cortical plate. Reduced proliferation late in gestation probably also contributes to the hypoplasia. Although there are marked decreases in the numbers of layer 6 and layers 2-4 neurons all laminar identities are generated and there is no evidence of compensatory increases in layer 5 neurons. In addition, LRP6 mutants have partial penetrance of a complex of cortical dysmorphologies resembling those found in patients with developmental forms of epilepsy and mental retardation. These include ventricular and marginal zone heterotopias and cobblestone lissencephaly. This analysis demonstrates that canonical Wnt signaling is required for a diverse array of developmental processes in the neocortex in addition to the previously known roles in regulating precursor proliferation and patterning.

The function of proprioceptors in bone organization: a possible explanation for neurogenic heterotopic ossification in patients with neurological damage

Neurogenic heterotopic ossification is characterized by the formation of extra osseous bone in soft tissue surrounding peripheral joints in neurological patients. It occurs in 25% of spinal cord injury patients, and in 20% of these the pathologic process is severe enough to cause limitations in joint motion. Vascular and metabolic changes resulting from autonomic nervous system impairment may play a role in the etiology of heterotopic ossification. Repetitive vigorous passive manipulation of the joint to preserve range of motion, in the presence of reduced defense mechanisms, may also traumatize soft tissue, thereby initiating the pathological process. Nerve terminals within ligaments and capsules that allow for proprioception have a determinant role in triggering on and off muscle contraction, permitting acceleration and deceleration during gait. The Sarah Network of Rehabilitation Hospitals has treated over 20,000 patients with spinal cord and brain injury in the past 20 years. Based on the observation of heterotopic ossification development in some of these patients, and its tendency to relapse, this present article speculates whether, after an interruption in the neural pathways: (1) altered proprioception can forge a different relationship between tissues; and (2) chaotic new bone formation can occur. We postulate that heterotopic ossification in patients with injury to the central nervous system (CNS) may be related to a dysfunction of proprioception. With interruption of the neural tract of a given limb, ligaments lose control and coordination of their proprioceptive function and begin to react to direct stimulus in an independent, isolated and haphazard way. Free of CNS control and directly stimulated by such independent signals, mesenchymal osteoprogenitor cells located in soft tissues begin to occasion tissue maturation and differentiation into bone: heterotopic bone.

Sensorimotor organization in double cortex syndrome

Subcortical band heterotopia is a diffuse malformation of cortical development related to pharmacologically intractable epilepsy. On magnetic resonance imaging (MRI), patients with "double cortex" syndrome (DCS) present with a band of heterotopic gray matter separated from the overlying cortex by a layer of white matter. The function and connectivity of the subcortical heterotopic band in humans is only partially understood. We studied six DCS patients with bilateral subcortical band heterotopias and six healthy controls using functional MRI (fMRI). In controls, simple motor task elicited contralateral activation of the primary motor cortex (M1) and ipsilateral activation of the cerebellum and left supplementary motor area (SMA). All DCS patients showed task-related contralateral activation of both M1 and the underlying heterotopic band. Ipsilateral motor activation was seen in 4/6 DCS patients. Furthermore, there were additional activations of nonprimary normotopic cortical areas. The sensory stimulus resulted in activation of the contralateral primary sensory cortex (SI) and the thalamus in all healthy subjects. The left sensory task also induced a contralateral activation of the insular cortex. Sensory activation of the contralateral SI was seen in all DCS patients and secondary somatosensory areas in 5/6. The heterotopic band beneath SI became activated in 3/6 DCS patients. Activations were also seen in subcortical structures for both paradigms. In DCS, motor and sensory tasks induce an activation of the subcortical heterotopic band. The recruitment of bilateral primary areas and higher-order association normotopic cortices indicates the need for a widespread network to perform simple tasks.

Increased mobilization of c-kit+ Sca-1+ Lin- (KSL) cells and colony-forming units in spleen (CFU-S) following de novo formation of a stem cell niche depends on dynamic, but not stable, membranous ossification

Stem cells are thought to inhabit in a unique microenvironment, known as "niche," in which they undergo asymmetric cell divisions that results in reproducing both stem cells and progenies to maintain various tissues throughout life. The cells of osteoblastic lineage have been identified as a key participant in regulating the number of hematopoietic stem cells (HSCs). HSCs receive their regulatory messages from the microenvironment in the bone marrow. This would account for a reason why the localization of hematopoiesis is usually restricted in the bone marrow. To clarify the above possibility we employed a cell implantation-based strategy with a unique osteoblast cell line (KUSA-A1) derived from a C3H/He mouse. The implantation of KUSA-A 1 cells resulted in the generation of ectopic bones in the subcutaneous tissues of the athymic BALB/c nu/nu mice. Subsequently the mice obtained a greater amount of the bone marrow than normal mice, and they showed an increased number of HSCs. These results indicate that the newly generated osteoblasts-derived ectopic bones are responsible for the increase in the number of the HSC population. Furthermore, the increased number of HSCs directly correlates with both the magnitude of dynamic osteogenic process and the size of the newly generated bone or "niche."

Induced Endometriosis in the Baboon (Papio anubis) Increases the Expression of the Proangiogenic Factor CYR61 (CCN1) in Eutopic and Ectopic Endometria1

The expression of human CYR61 (cysteine-rich, angiogenic inducer, 61; CCN1) mRNA has been previously shown to be deregulated in the endometrium of women with endometriosis. We have chosen the baboon model (Papio anubis) of induced endometriosis to clarify whether CYR61 mRNA upregulation is predisposed to an inappropriately differentiated endometrium or is deregulated as a response to the presence of ectopic lesions. In the baboon, endometrial CYR61 mRNA expression underwent moderate cyclical variation, with a significant 7.3-fold increase detected at Day 2 postmenses when compared to endometrium from the proliferative and secretory phases. The CYR61 transcript was extensively upregulated in the eutopic endometrium from all baboons with induced endometriosis, as early as 1 mo postinoculation of menstrual tissue into the peritoneal cavity. CYR61 mRNA expression then decreased throughout progression of the disease, but remained higher compared to control tissues. Ectopic endometriotic lesions showed a further increase in CYR61 mRNA, with highest expression found in red lesions. Moreover, the expression levels of CYR61 transcripts correlated significantly with those of VEGF. Immunohistochemistry revealed the presence of CYR61 protein in glandular and luminal epithelial cells as well as in blood vessels of eutopic and ectopic endometrium. As in humans, increased levels of CYR61 mRNA correlated with the development of endometriosis in baboons. The increase of CYR61 mRNA in eutopic endometrium of baboons following peritoneal inoculation with menstrual endometrium provides evidence for a feedback mechanism from resulting lesions to induce a shift in gene expression patterns in the eutopic endometrium.

A review of the effects of insulin-like growth factor and platelet derived growth factor on in vivo cartilage healing and repair

Growth factors may enhance current cartilage repair techniques via multiple mechanisms including recruitment of chondrogenic cells (chemotaxis), stimulation of chondrogenic cell proliferation (mitogenesis) and enhancement of cartilage matrix synthesis. Two growth factors that have been studied in cartilage repair are insulin-like growth factor (IGF) and platelet derived growth factor (PDGF). IGF plays a key role in cartilage homeostasis, balancing proteoglycan synthesis and breakdown. Incorporating IGF into a fibrin clot placed in an equine cartilage defect improved the quality and quantity of repair tissue and reduced synovial inflammation. PDGF is a potent mitogenic and chemotactic factor for all cells of mesenchymal origin, including chondrocytes and mesenchymal stem cells. Resting zone chondrocytes cultured with PDGF demonstrated increased cell proliferation and proteoglycan production, while maturation of these cells along the endochondral pathway was inhibited. Pretreating chondrocytes with PDGF promotes heterotopic cartilage formation in the absence of any mechanical stimulus. PDGF has also been shown to be a potent stimulator of meniscal cell proliferation and migration. These studies and others suggest a potential role for these potent biological regulators of chondrocytes in cartilage repair. More work needs to be performed to define their appropriate dosing and the optimum delivery method. Combining tissue growth factors with a biological matrix can provide a physical scaffold for cell adhesion and growth as well as a means to control the release of these potent molecules. This could result in biological devices that enhance the predictability and quality of current cartilage repair techniques.

Neuronal apoptosis and gray matter heterotopia in microcephaly produced by cytosine arabinoside in mice

Primary microcephaly can be accompanied by numerous migration anomalies. This experiment was undertaken to examine the pathogenesis of gray matter heterotopia and microcephaly that is produced after administering cytosine arabinoside (Ara-C) to mice. Pregnant mice were intraperitoneally injected with Ara-C at 30 mg/kg body weight on days 13.5 and 14.5 of gestation, and then their offspring were examined. On embryonic day 15.5, in the ventricular zone of the cingulate cortex, the neuroepithelial cells lacked BrdU immunoreactivity. Nestin-immunoreactive radial glial fibers and calretinin-positive subplate fibers were disrupted. TUNEL reaction was remarkable throughout the cerebral hemisphere. Subcortical heterotopia in the cingulate cortex and subependymal nodular heterotopia in the dorsolateral part of the lateral ventricles became detectable by the first day after birth. Thirty-two days after birth, microcephaly was apparent; subcortical heterotopia was observed to have increased in size while it was still located in the frontal and cingulate cortices. This experiment demonstrated that Ara-C induces neuronal apoptosis throughout the cerebral hemisphere. The immunohistochemical characteristics in the gray matter heterotopia suggest that both the subcortical and the subependymal heterotopias were formed by neurons originally committed to the neocortex. We conclude that the gray matter heterotopia that accompanies the microcephaly was produced by a disturbance of radial, tangential, and interkinetic neuronal migrations due to the toxicity of Ara-C in the immature developing brain.

Ruptured intracranial dermoid cysts

Rupture of intracranial dermoid cysts (RICDC) is a rare phenomenon. The mechanism of rupture, pathophysiology of fat in the ventricles and subarachnoid spaces, possible complications, and proper management of such conditions are proposed on the basis of a review of the literature and experience with two cases of ruptured intracranial dermoid cysts (One was in the pineal region, while another was in the fourth ventricle). It is concluded that rupture of intracranial dermoid cysts is usually spontaneous and non-fatal. Persistence of fat in the subarachnoid spaces postoperatively may last asymptomatically for years. Surgery is the only way to deal with these benign lesions. If the capsule is adherent to vital areas, incomplete removal is advised as recurrence and malignant transformation are unlikely to occur.

Periventricular Nodular Heterotopia: Classification, Epileptic History, and Genesis of Epileptic Discharges

PURPOSE

Periventricular nodular heterotopia (PNH) is among the most common malformations of cortical development, and affected patients are frequently characterized by focal drug-resistant epilepsy. Here we analyzed clinical, MRI, and electrophysiologic findings in 54 PNH patients to reevaluate the classification of PNH, relate the anatomic features to epileptic outcome, and ascertain the contribution of PNH nodules to the onset of epileptic discharges.

METHODS

The patients were followed up for a prolonged period at the Epilepsy Center of our Institute. In all cases, we related MRI findings to clinical and epileptic outcome and analyzed interictal and ictal EEG abnormalities. In one patient, EEG and stereo-EEG (SEEG) recordings of seizures were compared.

RESULTS

We included cases with periventricular nodules, also extending to white matter and cortex, provided that anatomic continuity was present between nodules and malformed cortex. Based on imaging and clinical data, patients were subdivided into five PNH groups: (a) bilateral and symmetrical; (b) bilateral single-noduled; (c) bilateral and asymmetrical; (d) unilateral; and (e) unilateral with extension to neocortex. The latter three groups were characterized by worse epileptic outcome. No differences in outcome were found between unilateral PNH patients regardless the presence of cortical involvement. Interictal as well as ictal EEG abnormalities were always related to PNH location.

CONCLUSIONS

The distinctive clinical features and epileptic outcomes in each group of patients confirm the reliability of the proposed classification. Ictal EEG and SEEG recordings suggest that seizures are generated by abnormal anatomic circuitries including the heterotopic nodules and adjacent cortical areas.

Ectopic osteoinduction and early degradation of recombinant human bone morphogenetic protein-2-loaded porous β-tricalcium phosphate in mice

The present study investigated the ectopic osteoinduction and early degradation of recombinant human bone morphogenetic protein-2 (rhBMP-2)-loaded porous beta-tricalcium phosphate (beta-TCP) in mice. The porous beta-TCP with 50 microg of rhBMP-2 (n = 25) and porous beta-TCP (control group, n = 25) were implanted into muscle pouches in the right and left thigh of 28-day-old mice (n = 25), respectively. At every time point (3, 7, 14, 21 and 28 days after implantation), five mice were euthanized and the histological examinations of implantation sites were performed. In addition, the alkaline phosphatase (ALP) activity was also quantitatively analyzed. For the rhBMP-2-loaded group, blood vessel formation and immature cartilage was observed within the porous beta-TCP 3 days after implantation. Mature cartilage was observed 7 days after implantation of rhBMP-2-loaded porous beta-TCP. Newly formed woven bone, lamellar bone as well as marrow were observed 14 and 21 days after implantation of the rhBMP-2-loaded porous beta-TCP. Lamellar bone and marrow were observed 28 days after implantation of the rhBMP-2-loaded porous beta-TCP. For the control group, no bone or cartilage was observed at all time points. However, multinucleated giant cells and fibrous tissues were observed in the control group at 7 and 28 days after implantation, respectively. At 21 and 28 days after implantation, porous beta-TCP was observed to fragment indicating early degradation of the porous beta-TCP in both groups. In addition, ALP was observed to be significantly higher in the rhBMP-2-loaded beta-TCP as compared to the control beta-TCP. It was concluded from this study that the rhBMP-2-loaded porous beta-TCP induced blood vessel and ectopic bone formation.

Adult-onset epilepsy in focal cortical dysplasia of Taylor type

Focal cortical dysplasia of Taylor type (FCDT) usually presents with seizures at an early age, whereas adult onset of epilepsy is uncommon. We reviewed the medical records of 213 patients with FCDT. In 21 patients (10%), age at seizure onset ranged from 18 to 55 years (mean 25.3). The outcome of seizures in patients with FCDT and adult-onset epilepsy seems favorable vs childhood-onset seizures.

Electroencephalographic recordings of focal seizures in patients affected by periventricular nodular heterotopia: role of the heterotopic nodules in the genesis of epileptic discharges

Patients affected by periventricular nodular heterotopia are frequently characterized by focal drug-resistant epilepsy. To investigate the role of periventricular nodules in the genesis of seizures, we analyzed the electroencephalographic (EEG) features of focal seizures recorded by means of video-EEG in 10 patients affected by different types of periventricular nodular heterotopia and followed for prolonged periods of time at the epilepsy center of our institute. The ictal EEG recordings with surface electrodes revealed common features in all patients: all seizures originated from the brain regions where the periventricular nodular heterotopia were located; EEG patterns recorded on the leads exploring the periventricular nodular heterotopia were very similar both at the onset and immediately after the seizure's end in all patients. Our data suggest that seizures are generated by abnormal anatomic circuitries, including the heterotopic nodules and adjacent cortical areas. The major role of heterotopic neurons in the genesis and propagation of epileptic discharges must be taken into account when planning surgery for epilepsy in patients with periventricular nodular heterotopia.

Reading impairment in the neuronal migration disorder of periventricular nodular heterotopia

OBJECTIVE

To define the behavioral profile of periventricular nodular heterotopia (PNH), a malformation of cortical development that is associated with seizures but reportedly normal intelligence, and to correlate the results with anatomic and clinical features of this disorder.

METHODS

Ten consecutive subjects with PNH, all with epilepsy and at least two periventricular nodules, were studied with structural MRI and neuropsychological testing. Behavioral results were statistically analyzed for correlation with other features of PNH.

RESULTS

Eight of 10 subjects had deficits in reading skills despite normal intelligence. Processing speed and executive function were also impaired in some subjects. More marked reading difficulties were seen in subjects with more widely distributed heterotopia. There was no correlation between reading skills and epilepsy severity or antiepileptic medication use.

CONCLUSION

The neuronal migration disorder of periventricular nodular heterotopia is associated with an impairment in reading skills despite the presence of normal intelligence.

Subcortical nodular heterotopia: a functional MRI and somatosensory evoked potentials study

Subcortical nodular heterotopia (SNH) associated with refractory epilepsy may be surgically treated, and a positive outcome can be expected following the complete excision of the malformed tissue. Recent functional neuroimaging studies have suggested the possible functional relevance of cerebral malformations, and may make it possible to improve presurgical planning, thus allowing extended resections and minimising post-operative deficits. We here report the case of a 19-year-old man with epilepsy and a giant SNH associated with diffused abnormal gyrations of the right temporal-parietal regions. Cortical functional organisation was investigated by means of functional magnetic resonance imaging (MRI) during sensory and motor tasks, and somatosensory evoked potentials. The results revealed enlarged and displaced motor and sensory cortical areas with heterotopic tissue functional activation. The relevance of these findings is discussed in the light of the possible surgical treatment of drug-refractory epilepsy associated with cerebral malformations: surgical treatment based on conventional MRI studies alone, without taking the functional nature of dysplastic tissues into account, may lead to considerable side effects.

The role of periventricular nodular heterotopia in epileptogenesis

A temporal resection in patients with periventricular nodular heterotopia (PNH) and intractable focal seizures yields poor results. To define the role of heterotopic grey matter tissue in epileptogenesis and to improve outcome, we performed stereoencephalography (SEEG) recordings in eight patients with uni- or bilateral PNH and intractable focal epilepsy. The SEEG studies aimed to evaluate the most epileptogenic areas and included the allo- and neocortex and at least one nodule of grey matter. Interictal spiking activity was found in ectopic grey matter in three patients, in the cortex overlying the nodules in five and in the mesial temporal structures in all. At least one heterotopion was involved at seizure onset in six patients, synchronous with the overlying neocortex or ipsilateral hippocampus. Two patients had their seizures originating in the mesial temporal structures only. Six patients had surgery and the resected areas included the seizure onset, with follow-up from 1 to 8 years. An amygdalo-hippocampectomy was performed in two (Engel class Id and III), an amygdalo-hippocampectomy plus removal of an adjacent heterotopion in two (class Ia), and a resection of two contiguous nodules plus a small rim of overlying occipital cortex in one patient (class Id). One patient with bilateral PNH had three adjacent nodules resected and an ipsilateral amygdalo-hippocampectomy resulting in a reduction of the number of seizures by 25-50%. The best predictor of surgical outcome is the presence of a focal epileptic generator; this generator may or may not include the PNH. Invasive recording is required in patients with PNH; it improves localization and is the key to better outcome.

Bariatric barosensor: a new paired structure in the paravetebral region of the iliac crest

A new anatomical entity, which we have decided to name bariatric borosensor, is described. It represents a paired structure under the skin, supero-lateral to the posterior superior iliac spine, overlying the iliac crest at the level of the fourth lumbar vertebra. Each of the paired structure is about the size of an enlarged lymph node; 0.5-2.0 cm in the largest diameter, spherical or ovoid in shape and firm in consistency. They are easily palpated clinically and can be demonstrated objectively by ultrasound examination. A hypothesis is put forth, conjecturing that this new structure may have relevance to the problem of obesity in modern, civilised western societies.

Recovered pulmonary vein conduction as a dominant factor for recurrent atrial tachyarrhythmias after complete circular isolation of the pulmonary veins: lessons from double Lasso technique

BACKGROUND

Atrial tachyarrhythmias (ATa) can recur after continuous circular lesions (CCLs) around the ipsilateral pulmonary veins (PVs) in patients with atrial fibrillation (AF). This study characterizes the electrophysiological findings in patients with and without ATa after complete PV isolation.

METHODS AND RESULTS

Twenty-nine of 100 patients had recurrent ATa after complete PV isolation by use of CCLs during a mean follow-up of approximately 8 months. A repeat procedure was performed in 26 patients with ATa and in 7 volunteers without ATa at 3 to 4 months after CCLs. No recovered PV conduction was demonstrated in the 7 volunteers, whereas recovered PV conduction was found in 21 patients with recurrent ATa (right-sided PVs in 9 patients and left-sided PVs in 16 patients). The interval from the onset of the P wave to the earliest PV spike was 157+/-66 ms in the right-sided PVs and 149+/-45 ms in the left-sided PVs. During the procedure, PV tachycardia activated the atrium and resulted in atrial tachycardia (AT) in 10 patients. All conduction gaps were successfully closed with segmental RF ablation. After PV isolation, macroreentrant AT was induced and ablated in 3 patients. In the 5 patients without PV conduction, focal AT in the left atrial roof in 2 patients and non-PV foci in the left atrium in 1 patient were successfully abolished; in the remaining 2 patients, no ablation was performed because of noninducible arrhythmias. During a mean follow-up of approximately 6 months, 24 patients were free of ATa without antiarrhythmic drugs.

CONCLUSIONS

In patients with recurrent ATa after CCLs, recovered PV conduction is a dominant finding in approximately 80% of patients and can be successfully eliminated by segmental RF ablation. Also, mapping and ablation of non-PV arrhythmias can improve clinical success.

Electroclinical, MRI and neuropathological study of 10 patients with nodular heterotopia, with surgical outcomes

We present the results of a retrospective study on 10 patients operated on for intractable epilepsy associated with nodular heterotopia as identified by high resolution MRI. Seven patients had unilateral heterotopia, one patient had symmetric bilateral heterotopia and two patients had asymmetric bilateral heterotopia. By stereo-electroencephalogram (SEEG) (nine patients) interictal activity within nodules was similar in all cases, and ictal activity never started from nodules alone but from the overlying cortex or simultaneously in nodules and cortex. Excellent outcomes (Engel class Ia, 1987) were achieved in the seven patients with unilateral heterotopia, showing that surgery can be highly beneficial in such cases when the epileptogenic zone is carefully located prior to surgery by MRI and particularly SEEG. For the bilateral cases surgical outcomes were Engel IIa (one patient) or Engel IIIa (two patients). Histological/immunohistochemical studies of resected specimens showed that all nodules had similar microscopic organization, even though their extent and location varied markedly. The overlying cortex was dysplastic in nine patients, but of normal thickness. We suggest that nodule formation may be the result of a dual mechanism: (i) failure of a stop signal in the germinal periventricular region leading to cell overproduction; and (ii) early transformation of radial glial cells into astrocytes resulting in defective neuronal migration. The intrinsic interictal epileptiform activity of nodules may be due to an impaired intranodular GABAergic system.

Infarction of mediastinal parathyroid gland causing spontaneous remission of secondary hyperparathyroidism

Secondary hyperparathyroidism is a serious complication in long-term hemodialysis patients. The authors report on 2 patients on long-term hemodialysis who suffered from persistent secondary hyperparathyroidism due to missed mediastinal parathyroid gland after total parathyroidectomy with forearm autograft. Reoperation was planned. In both cases, severe hypocalcemia suddenly developed; serum parathyroid hormone (PTH) level decreased markedly after this episode. The serum calcium level increased gradually in response to administration of vitamin D and calcium carbonate, but serum PTH level remained low. A follow-up computed tomography scan showed that the formerly enlarged mediastinal parathyroid gland was markedly reduced in size. Moreover, a hot spot formerly detected by technetium 99m-MIBI (methoxy-isobutyl-isonitrile) scintigraphy in the mediastinum disappeared after this episode. The authors considered that necrosis of the enlarged ectopic parathyroid gland, probably due to infarction, resulted in hypocalcemia. To the authors' knowledge, this is the first case report of spontaneous mediastinal parathyroid autoinfarction after parathyroidectomy in hemodialysis patients.

Axon fasciculation defects and retinal dysplasias in mice lacking the immunoglobulin superfamily adhesion molecule BEN/ALCAM/SC1

The immunoglobulin superfamily adhesion molecule BEN (other names include ALCAM, SC1, DM-GRASP, neurolin, and CD166) has been implicated in the control of numerous developmental and pathological processes, including the guidance of retinal and motor axons to their targets. To test hypotheses about BEN function, we disrupted its gene via homologous recombination and analyzed the resulting mutant mice. Mice lacking BEN are viable and fertile, and display no external morphological defects. Despite grossly normal trajectories, both motor and retinal ganglion cell axons fasciculated poorly and were occasionally misdirected. In addition, BEN mutant retinae exhibited evaginated or invaginated regions with photoreceptor ectopias that resembled the "retinal folds" observed in some human retinopathies. Together, these results demonstrate that BEN promotes fasciculation of multiple axonal populations and uncover an unexpected function for BEN in retinal histogenesis.