71 Comparison of sexed semen ULTRA-4M with conventional semen for the invitro production of bovine embryos

The first commercial production of sexed semen was at the Cogent company in the United Kingdom. Since then millions of offspring have been born using sexed semen produced by flow cytometry. Sexed semen technology has recently been modernized to what is now known as ULTRA (ST Genetics), completely modifying the technique, medium, and sperm concentration. In field trials using AI, there was no difference between conventional semen (CONV) and ultra-sexed semen at a concentration of 4 million sperm per straw (ULTRA-4M). The combination of invitro embryo production (IVP) and sexed semen technologies has been successful for intensity selection in the cattle industry. The objective of this work was to compare the CONV and ULTRA-4M semen for bovine IVP. The research was carried out in the reproduction laboratory at the Facultad de Estudios Superiores Cuautitlán-Universidad Nacional Autónoma de México (FESC-UNAM). The IVP was performed with a continuous invitro culture (IVC) system. Ovaries (n=213) were collected from a slaughterhouse (Querétaro, México) and transported to the laboratory within 2h (FESC-UNAM) in physiological saline solution (0.9% NaCl) supplemented with penicillin G (100IUmL−1) and streptomycin sulfate (100µgmL−1). For IVP, VITROGEN media were used for IVM, IVF, and IVC. For the IVM, the cumulus-oocyte complexes were selected (only grades 1 and 2) and matured for 24h at 38.5°C in 5% CO2, 95% air, and 100% humidity. Matured oocytes (n=1000) were divided into two groups, the CONV group and the ULTRA-4M group. The IVF process was developed with CONV and ULTRA-4M semen from the same bull (Holstein) at a concentration of 2×106 and 0.5×106 spermmL−1, respectively, for 18h in 38.5°C, 5% CO2, 95% air, and 100% humidity. The presumptive zygotes were denuded by pipetting and left in IVC until Day 7 at 38.5°C, 5% CO2, 5% O2, and 90% N2 at 100% humidity. The cleavage rate, embryos of more than 6 cells, and blastocysts on Day 7 of culture were evaluated. The statistical analysis was carried out with the GLM procedure of the SAS software (version 9.3; SAS Institute Inc.) to evaluate the results of CONV vs. ULTRA-4M (α level=0.05). Percent cleavage for CONV was 72.2%±2.53 and 75.6%±2.53 for ULTRA-4M. For embryos with more than 6 cells, the results for CONV and ULTRA-4M were 59.8%±5.61 and 62.8%±5.61, respectively. The percentage of blastocysts on Day 7 was 37.8%±5.39 for CONV and 43.6%±5.39 for ULTRA-4M. There were no significant differences between the groups (P>0.05) for all variables analysed. Although the number of blastocysts on Day 7 were numerically higher in the ULTRA-4M, differences were not significant. In conclusion, under the conditions of this research the ULTRA-4M had similar results as CONV for bovine IVP.

72 Invitro embryo production using prepubertal calf oocytes with conventional semen and sexed semen ULTRA-4M

Invitro embryo production (IVP) can increase the reproductive potential and genetic quality of cattle, as well as other species. This powerful assisted reproduction tool can be used to produce embryos from prepubertal calves, reducing the generation interval. A recent sexed semen technology known as ULTRA (ST Genetics), completely modified the technique, the media and sperm concentration. In field trials with AI there was no difference between conventional semen (CONV) and ultra-sexed semen at a concentration of 4 million per straw (ULTRA-4M). The combined use of IVP and ULTRA-4M can decrease the selection time for improving dairy and beef cattle herd genetics. The objective of this research was to compare the CONV and ULTRA-4M semen using bovine IVP and prepubertal calves. The research was carried out in the reproduction laboratory of the Facultad de Estudios Superiores Cuautitlán - Universidad Nacional Autónoma de México (FESC-UNAM). The IVP was performed with a continuous invitro culture (IVC) system. The ovaries were collected in Campeche, México, from Bos indicus×Bos taurus crossbred calves (6 months old) using surgical castration (for export to the United States) and transported to the laboratory (FESC-UNAM) in BO-HEPES-IVM (Bioscience™), in an oocyte transporter (WTA). Vitrogen media were used for IVF and IVC. For IVM, the cumulus-oocyte complexes (COCs) were selected (only grades 1 and 2) and matured for 24h at 38.5°C. Matured oocytes (n=600, divided equally into five replicates) were divided into 2 groups, the CONV group and the ULTRA-4M group. The IVF process was conducted with CONV and ULTRA-4M semen from the same bull (Holstein) at a concentration of 2×106 and 0.5×106 spermatozoamL−1, respectively, for 18h in 38.5°C, 5% CO2, 95% air, and 100% humidity. The presumptive zygotes were denuded by pipetting and set in IVC until Day 7 at 38.5°C, 5% CO2, 5% O2, and 90% N2 at 100% humidity. The cleavage results were recorded 56h after the beginning of IVC. The cleavage rate, embryos with more than 6 cells, and blastocysts on Day 7 of culture were evaluated. The statistical analysis was carried out with the GLM procedure of the SAS software (version 9.3; SAS Institute Inc.) to evaluate the results of CONV vs. ULTRA-4M (α level=0.05). The percentage of cleavage for CONV was 46%±1.4 and 43.2%±1.4 for ULTRA-4M. The results for embryos with more than 6 cells in the CONV and ULTRA-4M groups were 16%±0.6 and 14%±0.6, respectively. The percentage of blastocysts on Day 7 for CONV was 9%±0.6 and 8%±0.6 for ULTRA-4M. There were no significant differences between groups (P>0.05) for all variables analysed. In conclusion, under the conditions of this research the ULTRA-4M and CONV produced similar results for IVP.

Surfaceome profiling enables isolation of cancer-specific exosomal cargo in liquid biopsies from pancreatic cancer patients

Background

Detection of circulating tumor DNA can be limited due to their relative scarcity in circulation, particularly while patients are actively undergoing therapy. Exosomes provide a vehicle through which cancer-specific material can be enriched from the compendium of circulating non-neoplastic tissue-derived nucleic acids. We carried out a comprehensive profiling of the pancreatic ductal adenocarcinoma (PDAC) exosomal 'surfaceome' in order to identify surface proteins that will render liquid biopsies amenable to cancer-derived exosome enrichment for downstream molecular profiling.

Patients and methods

Surface exosomal proteins were profiled in 13 human PDAC and 2 non-neoplastic cell lines by liquid chromatography-mass spectrometry. A total of 173 prospectively collected blood samples from 103 PDAC patients underwent exosome isolation. Droplet digital PCR was used on 74 patients (136 total exosome samples) to determine baseline KRAS mutation call rates while patients were on therapy. PDAC-specific exosome capture was then carried out on additional 29 patients (37 samples) using an antibody cocktail directed against selected proteins, followed by droplet digital PCR analysis. Exosomal DNA in a PDAC patient resistant to therapy were profiled using a molecular barcoded, targeted sequencing panel to determine the utility of enriched nucleic acid material for comprehensive molecular analysis.

Results

Proteomic analysis of the exosome 'surfaceome' revealed multiple PDAC-specific biomarker candidates: CLDN4, EPCAM, CD151, LGALS3BP, HIST2H2BE, and HIST2H2BF. KRAS mutations in total exosomes were detected in 44.1% of patients undergoing active therapy compared with 73.0% following exosome capture using the selected biomarkers. Enrichment of exosomal cargo was amenable to molecular profiling, elucidating a putative mechanism of resistance to PARP inhibitor therapy in a patient harboring a BRCA2 mutation.

Conclusion

Exosomes provide unique opportunities in the context of liquid biopsies for enrichment of tumor-specific material in circulation. We present a comprehensive surfaceome characterization of PDAC exosomes which allows for capture and molecular profiling of tumor-derived DNA.

High prevalence of mutant KRAS in circulating exosome-derived DNA from early-stage pancreatic cancer patients

Background

Exosomes arise from viable cancer cells and may reflect a different biology than circulating cell-free DNA (cfDNA) shed from dying tissues. We compare exosome-derived DNA (exoDNA) to cfDNA in liquid biopsies of patients with pancreatic ductal adenocarcinoma (PDAC).

Patients and methods

Patient samples were obtained between 2003 and 2010, with clinically annotated follow up to 2015. Droplet digital PCR was performed on exoDNA and cfDNA for sensitive detection of KRAS mutants at codons 12/13. A cumulative series of 263 individuals were studied, including a discovery cohort of 142 individuals: 68 PDAC patients of all stages; 20 PDAC patients initially staged with localized disease, with blood drawn after resection for curative intent; and 54 age-matched healthy controls. A validation cohort of 121 individuals (39 cancer patients and 82 healthy controls) was studied to validate KRAS detection rates in early-stage PDAC patients. Primary outcome was circulating KRAS status as detected by droplet digital PCR. Secondary outcomes were disease-free and overall survival.

Results

KRAS mutations in exoDNA, were identified in 7.4%, 66.7%, 80%, and 85% of age-matched controls, localized, locally advanced, and metastatic PDAC patients, respectively. Comparatively, mutant KRAS cfDNA was detected in 14.8%, 45.5%, 30.8%, and 57.9% of these individuals. Higher exoKRAS MAFs were associated with decreased disease-free survival in patients with localized disease. In the validation cohort, mutant KRAS exoDNA was detected in 43.6% of early-stage PDAC patients and 20% of healthy controls.

Conclusions

Exosomes are a distinct source of tumor DNA that may be complementary to other liquid biopsy DNA sources. A higher percentage of patients with localized PDAC exhibited detectable KRAS mutations in exoDNA than previously reported for cfDNA. A substantial minority of healthy samples demonstrated mutant KRAS in circulation, dictating careful consideration and application of liquid biopsy findings, which may limit its utility as a broad cancer-screening method.

Embolisation of Spinal Cord Arteriovenous Malformations with Glue through the Anterior Spinal Axis

We reviewed the clinical and morphological results of spinal cord arteriovenous malformations (SCAVMs) embolised with acrylic glue through the anterior spinal axis (ASA), and assessed the anatomical guidelines that should be followed to safely embolise the ASA.

Twenty consecutive SCAVMS seen between 1982 and 1996 were reviewed. There were 15 lesions in the thoracolumbar cord and 5 in the cervical cord. Haemorrhage was the revealing symptom in 13 patients (65%). Embolisation through the ASA was done in 19 SCAVMs (2 with PVA particles in our early experience and 17 with Histoacryl*). One patient was not embolised because of a spastic reaction of the ASA that led to secondary subtotal thrombosis of the SCAVM without neurological deficit.

The ASA was chosen as arterial approach to the AVM because it was the only feeder to the lesion (1 case) and/or because it was one of the accessible pedicles harbouring particular angioarchitectural weakness points. Vascular occlusion was always indicated and performed following precise anatomical analysis of the lesion and of the regional vascular disposition. In all cases embolisation of the ASA feeders to a SCAVM was performed under general anaesthesia, without any evoked potentials or provocative tests. However, 3/19 (16%) patients presented transient worsening of their clinical condition. Permanent morbidity occurred in 2/19 patients (11%): one patient cured from a cervical intramedullary AVM presents mainly a deltoid palsy, the other with a thoracic intramedullary AVM has worsened his paraparesis. At follow-up, 6/19 patients (32%) are neurologically normal and 10/19 (53%) have improved their neurological conditions and deficits. One patient embolised recently is currently stable but is expected to improve. No embolised patient bled or rebled during follow-up. Neurological symptoms recurred in one patient who had been stable for one year after his first embolisation.

For an experienced interventional neuroradiology team, embolisation of SCAVMs through the ASA is feasible with acrylic glue with good clinical results. Proper analysis of the vascular architecture is mandatory to select the cases that can benefit from such approach.

Anatomoclinical Aspects of Dural Arteriovenous Shunts in Children

We review 29 children (presenting between 1985–1996) with dural arteriovenous shunts. By analysing the anatomical features from axial and angiographic imaging and examining the clinical history and pathophysiological characteristics, we hypothesize that different diseases can be distinguished and divided into three groups: dural sinus malformation (DSM), infantile type of dural arteriovenous shunts (IDAVS) and adult type of dural arteriovenous shunts (ADAVS). It was helpful to classify these diseases when assessing the treatment options and long-term prognosis.

Our group of 29 children comprised 19 DSM, 7 IDAVS, 3 ADAVS. A slight male preponderance was noted in the DSM group.

The range of symptoms encountered included mild cardiac failure and coagulopathies, macro-crania, developmental delay, mental retardation, seizures and focal neurological deficits (in the neonates and early infancy age group) with or without haemorrhagic venous infarctions secondary to venous outlet restriction.

We found all types of lesion in the neonatal age group, but in general the different types of lesion correspond to the paediatric subgroups with DSM occurring in the neonatal age group, IDAVS in infancy and ADAVS in children.

DSMs are revealed in the first few months of live and the prognosis is good if the torcular is not involved. Two types can be seen:

1) DSM involving the posterior sinus with or without the confluens sinusum, with giant dural lakes and slow flow mural AV shunting. Spontaneous thrombosis may further restrict cerebral venous drainage and subsequently lead to intraparenchymatous haemorrhagic infarction.

2) DSM involving the jugular bulb with otherwise normal sinuses but associated with a high flow sigmoïd sinus AVF. The prognosis is excellent with embolisation treament.

IDAVS are high flow and low pressure. The sinuses are large and patent with no lakes. Clinical onset is seen in the first few years of life and the shunts are initially well tolerated. Progressive symptoms (symptoms of raised ICP and venous ischaemia) develop at a later age and initially respond to partial embolisation. The long term prognosis is poor with neurological deterioration in early adulthood.

ADAVS present in all age groups and almost all of them are located in the cavernous venous plexus. Post embolisation outcome is excellent.

Aneurysmal Malformations of the Vein of Galen

The Vein of Galen Aneurysmal Malformation (VGAM) is regarded as a lesion with high morbidity and mortality, both spontaneously and under treatment, in part due to an incomplete appreciation of the effects of the lesion on the specific physiology of young children. In addition, various techniques have been applied over a short period of time to treat the lesion rather than the disorders it creates.

We report experience with 120 consecutive cases of VGAM managed over the past ten years: 24 were diagnosed antenatally; 50 presented in the neonatal period with haemodynamic disturbance; 35 in infants presented with secondary hydrovenous disorders (macrocrania, subependymal atrophy and ventricular dilatation); 12 were seen in children.

We were unable to follow 10% of the patients because the referring teams decided not to follow our therapeutic advice. Treatment was contra-indicated in 17% of cases (with early brain damage and a rapidly fatal outcome).

There were five (4%) which thrombosed spontaneously (but only two of these were neurologically normal). Embolisation was performed in 78 patients via a transarterial femoral approach using glue. Anatomical cure has already been achieved in 53%.

Of the treated patients, even when treatment has not been completed, 80% are growing neurologically normal.

Permanent neurological deficit or irreversible neurocognitive delay related to the natural history of the lesion were evident in 8.5%. Overall mortality was 9%.

These figures confirm that previous views on the prognosis of VGAM should be revised. Endoarterial embolisation, is the preferred treatment to date.

Basilar Tip Aneurysms and Basilar Tip Anatomy

Five hundred and eighty one cerebral aneurysms seen from 1986–1997 were reviewed. Fifty five basilar tip aneurysms were demonstrated. The analysis of the anatomic disposition of the distal basilar artery in 47 of them showed the prevalence of caudal fusion in 91% of cases. The fusion is either symmetrical or asymmetrical.

The neck of the aneurysm is preferentially implanted on the caudal part of the fusion. Recognition of the distal basilar artery anatomy allows the origin and extent of the perforating branches territory arising from the P1 segment to be predicted in each type of basilar tip disposition. The caudal variant supplies a small ipsilateral territory, whereas the cranial one often provides a bilateral supply.

In the cranial arrangement one can observe interpeduncular anastomoses between the perforators across the midline prior to penetrating the mesencephalo-diencephalic structures. The risks involved in the sacrifice of the P1 segment can then be anticipated.

Multiple Intracranial Arterial Aneurysms: A Congenital Metameric Disease?

We reviewed the angiographic study and clinical charts of 398 consecutive cases of intracranial arterial aneurysms, involving adults and children in the last 11 years (1986–1997). Giant aneurysms, dissecting aneurysms, mycotic aneurysms, and fusiform aneurysm were excluded. From the 341 patients presenting so-called berry aneurysm disease, attention was paid to multiple aneurysm sub group. One hundred and thirteen cases were analysed and compared with a group of single AA (228 cases) from the same material.

Three longitudinal embryological territories giving rise to cranial endothelial cells and media were used to regroup the aneurysm sites. Eighty four cases presented aneurysms in the rostral region (74%), 20 cases with aneurysms involving rostral and middle territories (18%), 1 case presented aneurysm involving the middle and caudal territories (0.9%), 5 cases had aneurysms in the rostral and caudal territories (4.4%) and three cases presented aneurysm involving rostral, medial and caudal territories at the same time (2.7%). No multiple group was located in the middle or caudal territories alone. When several arterial territories were concerned they were adjacent in 95.6% of cases.

Multiple AA could therefore result from mesodermal/neural crest stem cell or focal endothelial cell defect within one or two (usually consecutive) embryonic segments. Mirror lesions would correspond to bilateral symmetrical impairment in the same territory or involvement of a group of cells with bilateral distribution. AA may result from a constitutional vasculopathy, later expressed with focal overproduction of the arterial wall without remodelling correction. Secondary mutations and triggers are likely to be needed to lead to such AA production.

A Case of Vertebrovertebral Arteriovenous Fistula Presenting with Subarachnoid Haemorrhage

A rare paediatric case of vertebrovertebral arteriovenous fistula presented with a subarachnoid haemorrhage.

A 12 year-old boy, who fell on his back at school, presented with a one week history of headache, vomiting, and double vision. Computed tomography (CT) scan revealed subarachnoid haemorrhage.

Magnetic resonance imaging (MRI) demonstrated a tortuous vessel on the anterior surface of the spinal cord. Selective angiography showed an arteriovenous fistula of the left vertebral artery at the level of C1.

The venous drainage of the fistula refluxed into the medullary vein at the level of C6-7, and drained upwards into the posterior fossa veins. An endovascular detachable balloon technique was employed and complete occlusion of the fistula was achieved.

Endovascular Treatment of a Ruptured Intracranial Arterial Aneurysm in a 12-Year-Old Child with Recessive Polycystic Kidney Disease

A 12-year-old boy with recessive polycystic kidney disease and congenital hepatic failure, presented intracranial subarachnoid haemorrhage, due to the rupture of a laterobasilar tip aneurysm. In addition, he presented a left-sided middle cerebral unruptured aneurysm demonstrated during the screening procedure.

Our patient is a boy, like most children with intracranial aneurysms, but differs from children with intracranial aneurysms in polycystic kidney disease. The age of bleeding was low (actually the second youngest case reported), with a good Hunt and Hess grade at admission.

The localization of the aneurysm is exceptionally posterior (laterobasilar tip); in our case as intracranial aneurysms can be multifocal at that age. Renal function and blood pressure were normal. The endovascular GDC approach achieved a good result and excellent clinical outcome. Although most of what is known in this disease belongs to the autosomal dominant form, it is unclear whether the risk of a demonstrated unruptured intracranial aneurysm is the same as the risk of SAH from a non demonstrated one. It even seems that bleeding during follow-up in patients with polycystic kidney disease mostly occurs from non previously demonstrated intracranial aneurysms9.

Embolisation of Branches of the Ophthalmic Artery

Nine patients presenting various orbital and skull base pathologies embolised through the ophthalmic artery are reported.

All cases were catheterised beyond the bend around the optic nerve (second portion of the intraorbital ophthalmic artery). Embolisation was carried in all with n-butyl cyano-acrylate without post interventional visual disturbance.

Relying on the classic description as well as previous personal work on the ophthalmic artery anatomy and angiographic anatomy, all procedures were performed under general anaesthesia without functional testing. The central retinal artery and the long ciliary arteries arise from the first or second portion of the ophthalmic artery. For embryological reasons no branch to the visual tract can arise from the ophthalmic trunk distal to the origin of the superficial recurrent meningeal artery or the lacrimal artery.

Therefore distal catheterisation at least beyond the second portion, (and injection without reflux) makes safe embolisation possible in all variations of internal carotid origin of the ophthalmic stem.

Independent from the expected goal of the embolisation, the use of particles in this territory should in our opinion be discouraged.

Spinal Cord Arteriovenous Malformations in a Pediatric Population Children below 15 Years of Age the Place of Endovascular Management

Among a global group of 164 spinal arteriovenous shunts, a series of 16 spinal cord arteriovenous malformations (SCAVMs) were diagnosed in a pediatric population below 15 years of age.

The majority of the lesions affected the male population; 6 were located in the cervical spine and 10 at the thoracolumbar level. Hemorrhage was the most frequent symptom encountered (63%). Half of the bleeds occurred only in the subarachnoid spaces. Neurological deficits (acute or progressive) revealed the SCAVM in 31% of patients.

The lesion was an incidental finding in one patient (6%). All the diagnoses (except one) were made by MRI. Selective angiography confirmed the diagnosis and identified the type of the lesion (nidus or fistula) and its angioarchitecture, stressing that the veins and their related features are the key point in the clinical eloquence of SCAVMs.

All the treatments performed were endovascular; no patient was deemed a surgical candidate. Therapeutic abstention was decided in 37% of cases, mainly for anatomical reasons. All the patients in this group improved (50% being normal and 50% presenting slight non-handicapping deficits due to the initial accidents). Embolisation was indicated in 10 patients (63%) and was performed with fluid agents (histoacryl*) except in the first patient who had been treated with particles.

Twelve percent of patients were cured (fistula), the remaining 88% having their lesion controlled to more than 50%. This partial treatment was always targetted towards the angioarchitectural weak points of the lesion.

All patients improved after embolisation, 45% of them being neurologically normal. Follow-up in this group ranges from 1.5 to 13 Years. No complications occurred after embolisation. No bleed, rebleed or clinical worsening has occurred after endovascular treatment.

The results in this series suggest that endovascular treatment (even partial but targetted) represents a safe and stable therapeutic alternative in the management of SCAVMs in this population.

Minimally invasive genomic and transcriptomic profiling of visceral cancers by next-generation sequencing of circulating exosomes

BACKGROUND

The ability to perform comprehensive profiling of cancers at high resolution is essential for precision medicine. Liquid biopsies using shed exosomes provide high-quality nucleic acids to obtain molecular characterization, which may be especially useful for visceral cancers that are not amenable to routine biopsies.

PATIENTS AND METHODS

We isolated shed exosomes in biofluids from three patients with pancreaticobiliary cancers (two pancreatic, one ampullary). We performed comprehensive profiling of exoDNA and exoRNA by whole genome, exome and transcriptome sequencing using the Illumina HiSeq 2500 sequencer. We assessed the feasibility of calling copy number events, detecting mutational signatures and identifying potentially actionable mutations in exoDNA sequencing data, as well as expressed point mutations and gene fusions in exoRNA sequencing data.

RESULTS

Whole-exome sequencing resulted in 95%-99% of the target regions covered at a mean depth of 133-490×. Genome-wide copy number profiles, and high estimates of tumor fractions (ranging from 56% to 82%), suggest robust representation of the tumor DNA within the shed exosomal compartment. Multiple actionable mutations, including alterations in NOTCH1 and BRCA2, were found in patient exoDNA samples. Further, RNA sequencing of shed exosomes identified the presence of expressed fusion genes, representing an avenue for elucidation of tumor neoantigens.

CONCLUSIONS

We have demonstrated high-resolution profiling of the genomic and transcriptomic landscapes of visceral cancers. A wide range of cancer-derived biomarkers could be detected within the nucleic acid cargo of shed exosomes, including copy number profiles, point mutations, insertions, deletions, gene fusions and mutational signatures. Liquid biopsies using shed exosomes has the potential to be used as a clinical tool for cancer diagnosis, therapeutic stratification and treatment monitoring, precluding the need for direct tumor sampling.

Acute stroke: basic concepts and use of imaging for clinicians

In this article we review basic and some advanced concepts of stroke imaging. The benefits and caveats of both CT and MRI are stressed and we attempt to familiarize the reader with current concepts regarding collateral brain circulation, its nature, and its importance in acute stroke.

Hedgehog inhibition prolongs survival in a genetically engineered mouse model of pancreatic cancer

BACKGROUND AND AIMS

Pancreatic cancer is among the most dismal of human malignancies. Current therapeutic strategies are virtually ineffective in controlling advanced, metastatic disease. Recent evidence suggests that the Hedgehog signalling pathway is aberrantly reactivated in the majority of pancreatic cancers, and that Hedgehog blockade has the potential to prevent disease progression and metastatic spread.

METHODS

Here it is shown that the Hedgehog pathway is activated in the Pdx1-Cre;LsL-Kras(G12D);Ink4a/Arf(lox/lox) transgenic mouse model of pancreatic cancer. The effect of Hedgehog pathway inhibition on survival was determined by continuous application of the small molecule cyclopamine, a smoothened antagonist. Microarray analysis was performed on non-malignant human pancreatic ductal cells overexpressing Gli1 in order to screen for downstream Hedgehog target genes likely to be involved in pancreatic cancer progression.

RESULTS

Hedgehog inhibition with cyclopamine significantly prolonged median survival in the transgenic mouse model used here (67 vs 61 days; p = 0.026). In vitro data indicated that Hedgehog activation might at least in part be ascribed to oncogenic Kras signalling. Microarray analysis identified 26 potential Hedgehog target genes that had previously been found to be overexpressed in pancreatic cancer. Five of them, BIRC3, COL11A1, NNMT, PLAU and TGM2, had been described as upregulated in more than one global gene expression analysis before.

CONCLUSION

This study provides another line of evidence that Hedgehog signalling is a valid target for the development of novel therapeutics for pancreatic cancer that might be worth evaluating soon in a clinical setting.

Efficacy of ciprofloxacin implants in treating experimental osteomyelitis

Ciprofloxacin (CFX) implants containing poly(D,L-lactide) and calcium phosphates (tricalcium phosphate and hydroxyapatite) was evaluated in 50 rabbits in an experimental osteomyelitis model. Their femoral cavity was inoculated with Staphylococcus aureus. After 2 weeks, the infected focus was cleaned out and the delivery system implanted. The infection and subsequent response to treatment were evaluated by microbiological analysis, biochemical and hematological markers, body weight, temperature, clinical signs, X-rays, and histology. Infected bone cultures, treated with CFX implants, showed reduced bacterial growth against controls. All CFX was released within 6 weeks. All animals recovered within 4 weeks. Even 12 weeks after implantation, no recurrence of infection was observed. Serum C-reactive protein, platelet, and leukocyte levels increased in all animals before treatment, and 4 weeks after it were maintained or rose in control animals, while decreased to normal levels in treated ones. Body weight was characterized by pretreatment losses, then gains during recuperation, or further loss in untreated animals; with no significant intraindividual differences in body temperature. Body weight, leucocytes, platelets, and C-reactive protein turned out to be highly useful markers for monitoring this kind of infection and its treatment. CFX implants demonstrated to be an effective therapy for S. aureus bone infection. Their efficacy was also reflected in decreasing severity of clinical signs, nonprogress of radiological signs indicative of infection, and good integration into bone structure. Histological examination revealed repair, with new bone formation extending into implants.

MR diffusion tensor imaging and fiber tracking in spinal cord arteriovenous malformations: a preliminary study

BACKGROUND AND PURPOSE

Diffusion tensor imaging (DTI) of the spinal cord in patients harboring spinal arteriovenous malformations (AVMs) was carried out to evaluate the feasibility of this new technique to determine the displacement of the spinal cord tracts and to correlate morphologic and functional DTI data (fractional anisotropy [FA] and apparent diffusion coefficient [ADC]) with the clinical symptoms.

MATERIALS AND METHODS

Nine patients with spinal cord AVMs were investigated at 1.5T using a sagittal spin-echo single-shot echo-planar generalized autocalibrating partially parallel acquisition diffusion-weighted imaging sequence. ADC and FA maps were computed in different regions of interest (both above and below the nidus), and tractography was used to visualize the course of the tracts. The data were correlated with the clinical symptoms and compared with 12 healthy control subjects.

RESULTS

At the level of the nidus, tracts were normal, shifted, separated, or interrupted but not intermingled with the nidus. Interruption of the tracts was coherent with the clinical symptoms. In patients with severe neurologic deficits, FA values caudal to the nidus showed a reduced anisotropy consistent with loss of white matter tracts.

CONCLUSIONS

We demonstrate that AVMs may interrupt, displace, or separate the fiber tracts and that clinical symptoms may be reflected by the quantitative FA results and the morphologic loss of fibers distant to the lesion. DTI with fiber tracking offers a novel approach to image spinal cord AVMs and may open a window to understand the complex pathophysiology of these lesions.

Diagnosis and endovascular treatment of pediatric spinal arteriovenous shunts

Spinal arteriovenous shunts (SAVSs) are rarely diagnosed in infants and children, but they are important clinically because morbidity can be significant. Although these lesions do not form a distinct pathologic group separate from the SAVSs seen in older patients, experience with these malformations in the pediatric population has led to the identification of several important features that are characteristic of this group of SAVSs. Association with genetic abnormalities, heritable (hereditary hemorrhagic telangiectasia) and nonheritable somatic (spinal arteriovenous metameric syndrome or Cobb syndrome), is relatively common and likely underrecognized. Male predominance is more pronounced than in the adult population. Hemorrhagic presentation is more frequent than in adults, except in extremely young children. The natural history seems to be better than previously thought, with early rehemorrhage uncommon. Despite early presentation and severe symptoms, these lesions are frequently amenable to endovascular treatment, often with anatomic cure achieved and with improvement or stabilization of symptoms after partial targeted treatment.

Vein of galen aneurysmal malformations

Different types of malformations share a dilated vein of Galen, but only one of them is a true vein of Galen aneurysmal malformation (VGAM). The optimal window of opportunity for treatment is between 4 and 5 years of months [corrected], because this allows the child to grow and mature. Heart failure and hydrocephalus respond favorably to embolization. Cerebrospinal fluid ventricular shunting, if needed, should be performed after the embolization. The transvenous approach carries significantly elevated morbidity and mortality and is rarely indicated. Anatomic cure of the VGAM is not the main goal of treatment; the ultimate goal is control of the malformation to allow the brain to mature and develop normally.

Pathologie neurovasculaire malformative de l'enfant: malformations anévrismales de la veine de Galien (MAVG), malformations artérioveineuses piales (MAVP), malformations des sinus duraux (MSD)

The purpose of this article is to give an overview of the cerebral and spinal cord pediatric malformations; we particularly describe three of them: Vein of Galen arteriovenous Malformation, Pial Arteriovenous Malformation, and Dural Sinus Malformation. We report the experience of Bicêtre since 1981 to 2003, with 317 VGAM, 302 Pial AVM and 30 DSM. We describe natural history, clinical and imaging features, endovascular management and the clinical and morphologic results. The clinical consequences of the VGAM and Pial AVM are systemic or cerebral. When they are cerebral they are mainly from hydrovenous type, as melting brain, or chronic hydrocephalus with calcifications and seizures. Depending of their angioarchitecture and amount of arteriovenous shunt, their gravity and the time of revealing are variable. Pial AVM, they carry the risk of hemorrhage, unlike VGAM. The presence of a fistula type should lead to suspect hereditary hemorrhagic telangiectasia. The main risk of DSM is hemorrhage due to thrombosis of the malformation, more than hydrovenous disorders. In VGAM, we obtain the complete cure of the shunt in 55% of case, and reduction of more than half of the shunt in 93.8%. Seventy-four percent of treated cases had a normal neurologic examination. DSM have a worse prognostic, and mortality is 38% despite treatment.

Association of cervical internal carotid artery aneurysm with ipsilateral vertebrobasilar aneurysm in two children: a segmental entity?

INTRODUCTION

A combination of cervical and intradural aneurysm in children in the absence of systemic disorders has previously not been reported.

CASE REPORT

We report two boys with an identical combination of fusiform cervical internal carotid aneurysm and ipsilaterally located vertebrobasilar aneurysm. They had no history of trauma, they did not display any personal or familial signs of systemic disease, and the testing for collagen disease was negative. The location and appearance of the aneurysms and the identical anatomical disposition in the patients indicated a non-randomly distributed segmental vulnerability.

CONCLUSION

The cases demonstrate primary morphological signs of a developmental error being expressed in two seemingly separate segments but linked by the hypoglossal artery. It suggests a segmental error related to this embryonic vessel. They also show that few phenotypes are specific for a genotypic disorder and highlight the importance of analysing different etiologies for aneurysm formation and anatomical disposition when taking treatment strategy decisions.

Growth and rupture mechanism of partially thrombosed aneurysms

SUMMARY

Within the group of giant and large aneurysms the subgroup of the so-called "partially thrombosed" aneurysms can be differentiated according to clinical and neuroimaging findings. The present study was carried out to determine the site of bleeding of these aneurysms and what implications concerning their pathomechanism can be drawn from these findings. Twenty patients aged two to 77 (mean 44) years who exhibited a partially thrombosed aneurysm that had recently bled were included. Images (MRI including T1 pre- and postcontrast and T2 weighted images in multiple planes, CT and digital subtraction angiography) and patients' charts were reviewed. MRI showed an onion-skin appearance of the thrombus in 19 patients, rim enhancement of the aneurysm wall (either partial or complete) in 17, and a perifocal edema in 16 patients. The acute hemorrhage was typically crescent-shaped and located at the periphery of the aneurysm, distant from the perfused lumen of the aneurysm within the thrombosed part of the aneurysm. The current denomination "partially thrombosed" intracranial arterial aneurysms leads to the presumption that thrombus is present endoluminal whereas in fact the site of hemorrhage is within the vessel wall. A more accurate nomination would, therefore, be "aneurysms with intramural hemorrhage". The enhancing wall and the edematous reaction of the adjacent brain parenchyma might be a sign for an inflammatory pathomechanism which is reinforced by histological and pathophysiological studies. This disease should be regarded as a clinical entity separate from saccular or non-thrombosed giant or large aneurysms.

Segmental unfused basilar artery with kissing aneurysms: report of three cases and literature review

Basilar artery "fenestration" is the result of a failed fusion of the bilateral longitudinal neural arteries and can be associated with a saccular aneurysm, which typically arises at the proximal juncture of the unfused segment. "Kissing" aneurysms at this site, i.e. two aneurysms arising from the proximal junction of the unfused segment of the basilar artery pointing anteriorly and posteriorly are reported to be exceedingly rare. We present three patients with this rare condition, all of them being treated by endovascular techniques.

Management of spontaneous haemorrhagic intracranial vertebrobasilar dissection: review of 21 consecutive cases

INTRODUCTION

Haemorrhagic intracranial vertebrobasilar dissection is an uncommon cause of nontraumatic subarachnoid haemorrhage (SAH) and accounts for only 1-10% of non-traumatic SAH. Treatment in the acute phase is considered to be essential because of the high risk of rebleeding and the consequent unfavourable outcome. However, the location, the potential for involvement of eloquent vessels and the histopathological characteristics of the vessel wall make treatment demanding from both a technical and anatomical point of view. We report our experience in the management of this disease. PATIENTS AND TREATMENTS: From 1989 to June 2006, we managed 21 patients with spontaneous haemorrhagic dissection located in the intracranial vertebrobasilar system, 13 patients were treated using an endovascular approach, 1 by surgical clipping, and 7 were managed conservatively.

RESULTS

Among the 13 patients treated endovascularly, 7 underwent proximal occlusion, 4 underwent parent artery embolization at the site of dissection, and 2 underwent endovascular trapping. Severe, treatment-related complications due to dislodgement of the thrombus during the procedure occurred in 1 patient, who then died from brainstem ischaemia. One patient died from severe pneumonia and one patient was left disabled from vasospastic ischaemia resulting from severe initial SAH. The remaining 10 patients had satisfactory outcomes: none rebled after treatment and when discharged they had Karnovsky scores of 80-100. Of the 7 conservatively treated patients, three died of rebleeding and four were discharged with Karnovsky scores of 50-100. One patient, who was treated surgically, was discharged with a Karnovsky of 90.

CONCLUSION

The high rate of rebleeding and consequent mortality among the patients treated conservatively argues for treatment in the acute phase. Treatment should be guided by each patient's angiomorphology, clinical condition and the experience of the neurosurgical/neuroradiological team. Options include endovascular or surgical trapping of the dissection and proximal occlusion and embolisation of the parent artery at the site of the dissection.

Segmental Neurovascular Syndromes in Children

The concept of segmental vascular syndromes with different, seemingly unrelated, diseases is based on the embryology of the neural crest and the mesoderm migration of cells that share the same metameric origin. Migrating patterns of these cells link the brain, the cranial bones, and the face on the same side. A somatic mutation developing in the region of the neural crest or the adjacent cephalic mesoderm before migration can, therefore, be postulated to produce arterial or venous metameric syndromes, including PHACES, CAMS, Cobb syndrome, and Sturge-Weber syndrome. Although these diseases may be rare, their relationships among each other and their postulated linkage with the development of the neural crest and the cephalic mesoderm may shed light on the complex pathology and etiology of various cerebral vascular disorders.

Multiple mirror-like intracranial aneurysms. Report of a case and review of the literature

While multiple intracranial arterial aneurysms occur in 26.4% of patients with aneurysms, in our practice bilateral mirror-like aneurysms are encountered in 9.4% of patients. Multiple mirror aneurysms in the same patient are exceedingly rare. We report a case of mirror-like middle cerebral artery aneurysms associated with mirror-like posterior inferior cerebellar arteries aneurysms and discuss their significance. Although an exceptional finding, multiple mirror-like aneurysms may shed light on the vulnerability of different arterial segments to specific diseases.

Spontaneous intracerebral hemorrhage caused by an unusual association of developmental venous anomaly and arteriovenous malformation

SUMMARY

We describe three patients who presented with spontaneous intracerebral hemorrhage resulting from the close association of developmental venous anomaly (DVA) and arteriovenous malformation (AVM). Angioarchitecturally, either the DVA formed the draining pathway for the AVM or they shared a common venous channel. The AVMs were treated by targeted embolization and the DVAs were carefully preserved. It is suggested that the unusual association of an AVM with the less flexible DVA was the cause of hemorrhage.

Spontaneous mirror dissections of cervicocephalic arteries. Pathomechanical considerations

SUMMARY

While so-called twin or mirror aneurysms constitute an established subgroup of multiple aneurysms, simultaneous spontaneous mirror dissections of cervicocephalic artery have not yet been reported as a particular entity. Among the patients treated at our institution since 1989, we identified 74 patients with spontaneous, nontraumatic dissections. Six of these cases presented with simultaneous bilateral dissections and four of the six patients had mirror dissections. Acute or chronic headache was present in all four cases. Additional clinical presentations consisted of impaired consciousness, cranial nerve palsy, and tinnitus. Angiography revealed irregular stenosis, dilatation or aneurysms located in the cervical ICA (internal carotid artery), VA (vertebral artery), or MCA (middle cerebral artery) without evident location bias. Although mirror dissections seems to be an exceptional finding, they may shed light on the vulnerability of different arterial segments to specific diseases. Similar to arterial aneurysm formation, pathogenesis of mirror dissection may involve an underlying "shared defect" in the endothelial cells, since these cells demonstrate a bilateral distribution during embryological development. This particular distribution therefore also provides a chronicle trail of the first trigger striking during embryonic development and demonstrates the segmental vulnerability to highly specific triggers.

Music for pain relief

BACKGROUND

The efficacy of music for the treatment of pain has not been established.

OBJECTIVES

To evaluate the effect of music on acute, chronic or cancer pain intensity, pain relief, and analgesic requirements.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, PsycINFO, LILACS and the references in retrieved manuscripts. There was no language restriction.

SELECTION CRITERIA

We included randomized controlled trials that evaluated the effect of music on any type of pain in children or adults. We excluded trials that reported results of concurrent non-pharmacological therapies.

DATA COLLECTION AND ANALYSIS

Data was extracted by two independent review authors. We calculated the mean difference in pain intensity levels, percentage of patients with at least 50% pain relief, and opioid requirements. We converted opioid consumption to morphine equivalents. To explore heterogeneity, studies that evaluated adults, children, acute, chronic, malignant, labor, procedural, or experimental pain were evaluated separately, as well as those studies in which patients chose the type of music.

MAIN RESULTS

Fifty-one studies involving 1867 subjects exposed to music and 1796 controls met inclusion criteria. In the 31 studies evaluating mean pain intensity there was a considerable variation in the effect of music, indicating statistical heterogeneity ( I(2) = 85.3%). After grouping the studies according to the pain model, this heterogeneity remained, with the exception of the studies that evaluated acute postoperative pain. In this last group, patients exposed to music had pain intensity that was 0.5 units lower on a zero to ten scale than unexposed subjects (95% CI: -0.9 to -0.2). Studies that permitted patients to select the music did not reveal a benefit from music; the decline in pain intensity was 0.2 units, 95% CI (-0.7 to 0.2). Four studies reported the proportion of subjects with at least 50% pain relief; subjects exposed to music had a 70% higher likelihood of having pain relief than unexposed subjects (95% CI: 1.21 to 2.37). NNT = 5 (95% CI: 4 to 13). Three studies evaluated opioid requirements two hours after surgery: subjects exposed to music required 1.0 mg (18.4%) less morphine (95% CI: -2.0 to -0.2) than unexposed subjects. Five studies assessed requirements 24 hours after surgery: the music group required 5.7 mg (15.4%) less morphine than the unexposed group (95% CI: -8.8 to -2.6). Five studies evaluated requirements during painful procedures: the difference in requirements showed a trend towards favoring the music group (-0.7 mg, 95% CI: -1.8 to 0.4).

AUTHORS' CONCLUSIONS

Listening to music reduces pain intensity levels and opioid requirements, but the magnitude of these benefits is small and, therefore, its clinical importance unclear.

The anastomotic venous circle of the base of the brain

SUMMARY

Adjacent to the arterial circle of Willis at the base of the brain, there is an anastomotic circle of veins linking the right and left halves of the cerebral deep venous system. This venous circle is formed by anterior and posterior transverse anastomotic channels (the anterior and posterior communicating veins), and paramedian longitudinal vessels (the basal veins of Rosenthal). This collateral venous network has received considerably less attention than its arterial counterpart, but is its functional homologue. Although inconstant, it can be seen readily with current neuroimaging techniques including three-dimensional digital subtraction venographic phase 3D arteriography (3D-DSV) and CT venography (CTV). The venous circle represents a route of contralateral venous drainage that may become important, particularly when segments of the basal vein are absent (with or without complex DVA), or in high flow states including arteriovenous shunts that access the deep venous system.We review the gross anatomy and provide examples of the radiologic imaging of this venous circle.