Clinical characteristics of patients with Parkinson's disease with reduced 123I-metaiodobenzylguanidine uptake in the major salivary glands and heart

BACKGROUND

Parkinson's disease (PD) shows cardiac sympathetic denervation (SD) in 123I-metaiodobezylguanidine (MIBG) scintigraphy. Recently, SD in the major salivary glands (MSG-SD) was introduced as a possible radiological feature of PD.

OBJECTIVE

To identify the clinical characteristics of patients with PD with reduced MSG and cardiac MIBG uptake (dual-SD) compared with those with reduced MSG or cardiac MIBG uptake only (single-SD).

METHODS

We recruited 90 patients with PD and 30 controls and evaluated their non-motor (e.g., hyposmia, autonomic dysfunction) and motor (e.g., Movement Disorder Society-Unified Parkinson's Disease Rating Scale) features. We also assessed MIBG uptake in the MSG and heart using a quantitative semi-automatic method, and compared MIBG uptakes between PD and controls. We set cut-off values for optimal sensitivity and specificity, and compared the clinical characteristics of patients with PD between dual- and single-SD groups.

RESULTS

MSG and cardiac MIBG uptakes were significantly reduced in PD. Sixty-one patients had dual-SD, 25 had single-SD, and four had non-SD. In patients with PD with normal cardiac SD, 76.5% (13/17) of whom showed abnormalities only in MSG-SD. When clinical characteristics were compared between the dual-SD and single-/non-SD groups, patients in the dual-SD group were older and had more severe hyposmia and autonomic dysfunction, except motor features. Multiple logistic regression analysis identified age as an important confounder.

CONCLUSIONS

Patients with PD with dual-SD have more severe non-motor features than other patients. Autonomic dysfunction might progress independently from dopaminergic degeneration. Furthermore, our findings indicate that aging is a crucial factor in PD progression.

The necessity to improve disaster preparedness among patients with amyotrophic lateral sclerosis and their families

Disaster preparation is an important issue for patients with amyotrophic lateral sclerosis (ALS). However, to the best of our knowledge, no studies have investigated disaster preparedness among patients with ALS. In this study, we aimed to investigate disaster preparation in patients with ALS and their caregivers, including their families, in Japan. We conducted a nationwide webinar in September 2022 titled "ALS Café" and distributed a self-report questionnaire to participants with questions about awareness of disaster preparedness, social countermeasures, stockpiles, and electricity demand. Forty-eight patients with ALS (27 male; average age 60.0 ± 9.3 years) and 23 caregivers (8 male; 55.7 ± 9.9 years) responded. The median revised ALS Functional Rating Scale score was 30.5, and 25% of the patients with ALS were on a ventilator. More than 70% of the respondents answered that they were not prepared for disasters, increasing to 89% in patients not using ventilators. In the event of their phones being down, 86% of the respondents had no plans for alternative means of communication. <30% of the respondents, including ventilator users, had secured human resources for transportation. Twenty-five percent of the respondents did not stockpile food and beverages, and 12% of the ventilator users had no government-recommended ventilator preparation equipment. Thus, although patients with ALS and their families with ventilators have a high awareness of disaster preparedness, their awareness remains insufficient. Furthermore, patients with ALS and their families without ventilators have a low awareness of disaster preparedness. Therefore, better education regarding disaster preparedness is necessary for these groups.

Investigation of non-motor symptoms in patients with amyotrophic lateral sclerosis

[Objective] Few studies have comprehensively investigated the non-motor symptoms of amyotrophic lateral sclerosis (ALS). We aimed to investigate this aspect of ALS. [Methods] We held a nationwide webinar, titled "ALS Café," and distributed self-report questionnaires to ALS patients. In addition to the frequency of non-motor symptoms such as fatigue, pain, sleep disorders, defecation disorders, sialorrhea, and sexual problems, we evaluated the quality of life (QoL), ALS Functional Rating Scale-Revised (ALSFRS-R), and Patient Health Questionnaire-9 (PHQ-9). [Results] The average age of the 33 respondents (19 male, 14 female) was 60.8 ± 11.2; 96.7% of respondents had some non-motor symptoms. The median ALSFRS-R was 32.0, and seven (21.2%) of the respondents had a PHQ-9 score of 10 or higher. Fatigue was the most common non-motor symptom (81.8%), followed by pain (60.6%), defecation disorders (57.6%), sleep disorders (48.5%), sialorrhea (48.5%), and sexual problems (24.2%). Fatigue was more frequent in females (P = 0.03). Among the non-motor symptoms, pain was the most common factor affecting QoL, followed by fatigue. More than 90% of ALS patients answered that they had never consulted a physician/counselor about sexual problems. Patients with pain had higher PHQ-9 scores than those without (P = 0.01). There was no correlation between the ALSFRS-R score and QoL and PHQ-9. [Conclusions] Most patients with amyotrophic lateral sclerosis had non-motor symptoms, and fatigue and pain were the most common. We showed that many non-motor symptoms affected QoL without correlating with ALSFRS-R score. Attention should be paid to those even if the motor symptoms of ALS are mild.

Reduced 123I-MIBG uptake in the parotid and submandibular glands in patients with Parkinson's disease identified using a quantitative semi-automatic method

OBJECTIVES

To analyze 123I-metaiodobenzylguanidine (MIBG) uptake in the parotid and submandibular glands in patients with Parkinson's disease (PD) in comparison with controls, and to compare MIBG uptake between those glands and the myocardium. Furthermore, we aimed to identify the relationships between clinical features and MIBG uptake.

METHODS

We recruited 77 patients with PD and 21 age-matched controls. We assessed MIBG scintigraphy in the major salivary glands and myocardium. We calculated the MIBG uptake ratio in the parotid glands/mediastinum (P/M), submandibular glands/mediastinum (S/M), and heart/mediastinum (H/M) using a quantitative semi-automatic method. We investigated the correlations between MIBG uptake and clinical features.

RESULTS

The P/M and H/M ratios in the early and delayed phases were significantly reduced in PD patients compared to controls, while the delayed phase S/M ratio was reduced in PD patients compared to controls. The P/M ratio correlated with the S/M ratio, while neither the P/M nor S/M ratio correlated with the H/M ratio. Between PD patients and controls, sensitivity and specificity were 54.8% and 59.1% for the delayed phase P/M ratio, while sensitivity and specificity were 59.5% and 61.0% for the delayed phase S/M ratio, respectively. Furthermore, sensitivity and specificity for the delayed phase H/M ratio were 85.7% and 79.2, respectively.

CONCLUSION

MIBG uptake in the parotid and submandibular glands was reduced in patients with PD. Furthermore, sympathetic denervation in the major salivary glands and myocardium might progress independently. Our findings suggest a new aspect of the pathological distribution of PD.

CSF P-Tau181 and Other Biomarkers in Patients With Neuronal Intranuclear Inclusion Disease

BACKGROUND AND OBJECTIVES

CSF tau phosphorylated at threonine 181 (p-tau181) is a widely used biomarker for Alzheimer disease (AD) and has recently been regarded to reflect β-amyloid and/or p-tau deposition in the AD brain. Neuronal intranuclear inclusion disease (NIID) is a neurodegenerative disease characterized by intranuclear inclusions in neurons, glial cells, and other somatic cells. Symptoms include dementia, neuropathy, and others. CSF biomarkers were not reported. The objective of this study was to investigate whether CSF biomarkers including p-tau181 are altered in patients with NIID.

METHODS

This was a retrospective observational study. CSF concentrations of p-tau181, total tau, amyloid-beta 1-42 (Aβ42), monoamine metabolites homovanillic acid (HVA), and 5-hydroxyindole acetic acid (5-HIAA) were compared between 12 patients with NIID, 120 patients with Alzheimer clinical syndrome biologically confirmed based on CSF biomarker profiles, and patients clinically diagnosed with other neurocognitive disorders (dementia with Lewy bodies [DLB], 24; frontotemporal dementia [FTD], 13; progressive supranuclear palsy [PSP], 21; and corticobasal syndrome [CBS], 13). Amyloid PET using Pittsburgh compound B (PiB) was performed in 6 patients with NIID.

RESULTS

The mean age of patients with NIID, AD, DLB, FTD, PSP, and CBS was 71.3, 74.6, 76.8, 70.2, 75.5, and 71.9 years, respectively. CSF p-tau181 was significantly higher in NIID (72.7 ± 24.8 pg/mL) compared with DLB, PSP, and CBS and was comparable between NIID and AD. CSF p-tau181 was above the cutoff value (50.0 pg/mL) in 11 of 12 patients with NIID (91.7%). Within these patients, only 2 patients showed decreased CSF Aβ42, and these patients showed negative or mild local accumulation in PiB PET, respectively. PiB PET scans were negative in the remaining 4 patients tested. The proportion of patients with increased CSF p-tau181 and normal Aβ42 (A-T+) was significantly higher in NIID (75%) compared with DLB, PSP, and CBS (4.2%, 4.8%, and 7.7%, respectively). CSF HVA and 5-HIAA concentrations were significantly higher in patients with NIID compared with disease controls.

DISCUSSION

CSF p-tau181 was increased in patients with NIID without amyloid accumulation. Although the deposition of p-tau has not been reported in NIID brains, the molecular mechanism of tau phosphorylation or secretion of p-tau may be altered in NIID.

Robot-assisted training using hybrid assistive limb ameliorates gait ability in patients with amyotrophic lateral sclerosis

OBJECTIVE

The Hybrid Assistive Limb (HAL; CYBERDYNE, Inc., Japan) is a wearable robot device that provides effective gait assistance according to voluntary intention by detecting weak bioelectrical signals of neuromuscular activity on the surface of the skin. We used HAL for patients with amyotrophic lateral sclerosis (ALS) to determine whether HAL training had an effect on their gait ability.

METHODS

We conducted a single-center, single-arm, observational study. Patients with ALS underwent HAL training once per day (20-40 min per session) for 9-10 days for at least 4 weeks. Gait ability was evaluated using the 2-minute walk test, the 10-meter walk test without the assistance of HAL, and activities of daily living (ADL) using the Barthel Index and Functional Independence Measures before and after a full course of HAL training.

RESULTS

There were no dropouts or adverse events during the observation period. Gait function improved after HAL training. The 2-minute walk test revealed a mean gait distance of 73.87 m (36.65) at baseline and 89.9m (36.70) after HAL training (p = 0.004). The 10-meter walk test showed significantly improved cadence, although gait speed, step length on the 10-m walk, or ADL measurements did not change significantly.

CONCLUSIONS

Although HAL is not a curative treatment for ALS, our data suggest that HAL may be effective in ameliorating and preserving gait ability in patients with ALS.

Effects of Long-term Hybrid Assistive Limb Use on Gait in Patients with Amyotrophic Lateral Sclerosis

Objective To assess the long-term effects of hybrid assistive limb (HAL) treatment on gait in patients with amyotrophic lateral sclerosis (ALS). Methods Three courses of treatment with HAL were administered to three women with ALS. Each course had a four- to five-week duration, during which the treatment was performed nine times, with a rest period of at least two months between each course. Gait ability (2-minutes-walk and 10-m-walk tests), ALS Functional Rating Scale-Revised, and respiratory function tests were performed before and after each treatment course. Patients Patients diagnosed with ALS, according to the updated Awaji criteria, by board-certified neurologists in the Department of Neurology and Department of Rehabilitation Medicine, Toho University Omori Faculty of Medicine between January and December 2019 were recruited. Results The average time from the start to the end of the 3 courses was 319.7±33.7 days. A multiple regression analysis was performed for the 2-minutes-walk and 10-m-walk tests, using the baseline value, each participant's ID, and time point as covariates. Changes after each course were considered outcomes. Following the 3 treatment courses, the 2-minutes walk distance improved by 16.61 m (95% confidence interval, -9.33-42.54) compared with the baseline value, but this improvement was not statistically significant (p=0.21). However, cadence significantly improved by 1.30 steps (95% confidence interval, 0.17-2.42; p=0.02). Conclusion Long-term, repetitive HAL treatments may help patients with ALS maintain their gait.

Contradictory Responses to the COVID-19 Pandemic in Amyotrophic Lateral Sclerosis Patients and Their Families and Caregivers in Japan

Objective The coronavirus disease 2019 (COVID-19) pandemic has resulted in a shortage of medical resources, including ventilators, personal protective equipment, medical staff, and hospital beds. We investigated the impact of COVID-19 in amyotrophic lateral sclerosis (ALS) patients, their families, caregivers, and medical experts. Methods We conducted a nationwide ALS webinar about COVID-19 in May 2020 and sent a questionnaire to those enrolled. Results A total of 135 participants (31 ALS patients; 23 families and caregivers of ALS patients; 81 medical experts) responded to this cross-sectional self-report questionnaire. The results showed that tracheostomy and invasive ventilation (TIV) was used in 22.6% of ALS patients, whereas 77.4% of ALS patients were not under TIV. Among non-TIV patients (n=24), 79.2% did not want TIV in the future. However, 47.4% of non-TIV patients not wanting a tracheostomy in advanced stages replied that they would want an emergency tracheostomy if they developed COVID-19-related pneumonia. These results suggest that ALS patients may be receptive to emergency treatments for reasons other than ALS. In addition, approximately half of the ALS patients agreed with the policy of not ventilating the elderly or ALS patients in case of a ventilator shortage. Furthermore, compared with medical experts, few ALS patients reported that the chance for ALS patients to obtain work was higher due to the increasing availability of remote work. Conclusions This survey indicates that the COVID-19 pandemic might be associated with increased distress about access to care and work, inducing contradictory responses and potential hopelessness among ALS patients.

[Chorea due to chronic subdural hematoma]

An 86-year-old woman presented with generalized chorea in the face and extremities, which gradually progressed for two weeks. Cranial CT revealed a chronic subdural hematoma (CSDH) that covered the left parietal lobe. Discontinuation of amantadine did not improve the chorea. The hematoma was evacuated and the chorea completely subsided in a week. The pathogenesis leading to chorea in CSDH remains unclear. A unilateral hematoma presenting with generalized chorea similar to the present patient and two others with unilateral CSDH causing ipsilateral hemichorea have been reported. The rarity of these movement disorders due to CSDH indicates that these patients had a preclinical dysfunction within neuronal networks interconnecting basal ganglia the cerebral cortex. Our findings confirmed that CSDH could cause chorea, and further neuroimaging to evaluate cerebrovascular disease, taking a detailed family history and obtaining information about current medications might reveal factors likely to precipitate the development of chorea.

Development and inter-laboratory study of a method for quantifying ochratoxin A in pet foods

An analytical method for quantifying ochratoxin A (OTA) in pet foods using high-performance liquid chromatography was developed, and an inter-laboratory study was conducted. OTA was extracted from samples with aqueous acetonitrile. The extract was purified by an immunoaffinity column, OCHRAKING, and analysed by high performance liquid chromatography with fluorescence detection. The limits of quantification by this method were 2 µg/kg for dry and semidry pet food and 1 µg/kg for wet type pet food. The calibration curve showed linearity in the range of 0.5-50 ng/ml (equivalent to 1-100 µg/kg for wet type pet food). The mean recoveries of OTA spiked at 1-5 µg/kg were in the range of 83.0-106% and relative standard deviations of the in-house method validation were 2.6-6.8%. The mean recoveries, repeatability, reproducibility and the Horwitz ratios for OTA from the inter-laboratory validation study were 75.6-83.1%, 3.5-6.1%, 5.0-15.0% and 0.23-0.68, respectively.

Intracranial Aneurysm with Systemic Lupus Erythematosus Treated by Endovascular Intervention

Systemic lupus erythematosus (SLE) is a chronic disease with multiple pathologies that can affect every organ system of the body including central nervous system. Intracerebral aneurysms and subarachnoid hemorrhage (SAH) are one of comparatively rarer manifestations of central nervous system SLE. Here we present a case of known SLE complicated by the rupture of intra cerebral aneurysm at basilar artery tip which was successfully treated with endovascular coiling. Keywords: cerebral aneurysm, endovascular surgery, SAH, SLE

Intracranial aneurysm with systemic lupus erythematosus treated by endovascular intervention

Systemic lupus erythematosus (SLE) is a chronic disease with multiple pathologies that can affect every organ system of the body including central nervous system. Intracerebral aneurysms and subarachnoid hemorrhage (SAH) are one of comparatively rarer manifestations of central nervous system SLE. Here we present a case of known SLE complicated by the rupture of intra cerebral aneurysm at basilar artery tip which was successfully treated with endovascular coiling.

Transfemoral transvenous embolization of dural arteriovenous fistulas involving the isolated transverse-sigmoid sinus

SUMMARY

Dural arteriovenous fistulas involving the transverse-sigmoid sinus (T-S dAVFs) are sometimes isolated because this affected sinus is often thrombosed. It is difficult to perform to microcatheter cannulation to the isolated sinus through the thrombosed portion. We are now treating these T-S dAVFs by transfemoral transvenous embolization via the ipsilateral side even if the affected sinus is thrombosed and isolated or not. We use a triaxial system (6Fr. guiding catheter / 4Fr. diagnostic catheter / microcatheter) to emphasize the pushability and handling of the microcatheter. And we insert 4Fr. Catheter into the affected sinus. So we can perform microcatheter cannulation into the isolated and affected sinus for treatment by coil embolization with various detachable coils.

Subtracted 3D CT angiography for evaluation of internal carotid artery aneurysms: comparison with conventional digital subtraction angiography

BACKGROUND AND PURPOSE

3D computed tomographic angiography (3DCTA) has been used recently for the evaluation of intracerebral aneurysms, but it is difficult to use this technique to visualize aneurysms near the base of the skull because of the presence of bone. Subtracted 3DCTA could replace digital subtraction angiography (DSA) for evaluation of aneurysms near the base of the skull if the 2 methods were to give similar results. The aim of this study was to compare the evaluation of aneurysms of the internal carotid artery (ICA) near the base of the skull by subtracted 3DCTA and DSA.

METHODS

CTA and DSA were obtained in 25 patients with unruptured aneurysms of the ICA. To create subtracted 3DCTA images, we used a volume subtraction (VS) method, wherein nonenhanced volume data are subtracted from enhanced volume data. CTA and DSA were reviewed by 2 neuroradiologists who performed the detection and characterization of aneurysms of the ICA by using 2D multiplanar reformatted (MPR) and VS- and nonsubtracted (NS)-3DCTA images with volume rendering techniques.

RESULTS

DSA detected 29 aneurysms in the 25 patients. VS-3DCTA detected all 29 aneurysms in the 25 patients and was equivalent to DSA for evaluating their characteristics (location, size, and direction). NS-3DCTA detected 19 (1 cavernous, 4 ophthalmic, 1 superior hypophyseal, 7 posterior communicating, and 6 anterior choroidal artery) of these 29 aneurysms, but it could not characterize ophthalmic and superior hypophyseal artery aneurysms because they were only partly visible on NS-3DCTA because of bony structures. 2D-MPR images detected all but the small aneurysms (24 of 29 detected). VS-3DCTA and 2D-MPR could visualize all branching arteries (ophthalmic, posterior communicating, and anterior choroidal) detected by DSA, but NS-3DCTA could not visualize ophthalmic arteries because of the presence of bony structures.

CONCLUSION

VS-3DCTA can be used as an alternative to DSA for preoperative examination of aneurysms near the skull base, where it provides equivalent identification and characterization.

Characteristics of aneurysms of the internal carotid artery bifurcation

BACKGROUND

Arterial bifurcations are sites of maximal hemodynamic stress, where cerebral aneurysms commonly develop. However, in our experience with endovascular treatment for aneurysms of the internal carotid artery (ICA) bifurcation, we often experienced that the aneurysmal neck did not necessarily exist only at the ICA bifurcation (ICBi). In this study, we have retrospectively evaluated characteristics of aneurysms at the ICBi.

METHODS

Ten ICBi aneurysms in 10 consecutive patients were studied retrospectively. The size of the aneurysms, the angles formed between the ICA and the anterior cerebral artery (ACA) and middle cerebral artery (MCA), and the diameter of the ICA, ACA and MCA were measured. Furthermore, to study the relationship between the location of the aneurysmal neck and the bifurcation of the ICA, the distance between the midline of the aneurysmal neck and of the ICA was measured.

RESULTS

The average aneurysm size was 6.3+/-3.2 mm and the average neck was 3.1+/-1.2 mm. The average ICA-ACA angle was 57.3+/-16.5 degrees, and the average ICA-MCA angle was 128.9+/-24.1 degrees. The average diameters of the ICA, ACA and MCA were 2.9+/-0.5 mm, 1.9+/-0.4 mm and 2.5+/-0.4 mm, respectively. The average distance between the midline of the aneurysmal neck and the ICA was 1.6+/-0.6 mm, and all aneurysmal necks of the ICBi arose from the side of the ACA.

CONCLUSION

ICBi aneurysms were deviated to the side of the A1 segment of the ACA, where the artery might suffer higher hemodynamic stress.

CT perfusion imaging for childhood moyamoya disease before and after surgical revascularization

Moyamoya disease is a progressive occlusive disease of the circle of Willis with prominent collateral arterial formation. We report on a 12-year-old girl with moyamoya disease presenting with transient ischemic attacks (TIAs). Surgical indirect revascularization was performed. The patient did not suffer further TIAs at 12 month follow-up. Pre and postoperative cerebral perfusion were studied in quantitative single photon emission computerized tomography (SPECT) and CT perfusion imaging. CT perfusion imaging demonstrated postoperatively increased cerebral blood flow as well as SPECT before and after revascularization. Furthermore, the area of decreased vascular reserve in SPECT with acetazolamide corresponded to areas of increased cerebral blood volume in CT perfusion imaging. CT perfusion imaging was equivalent to SPECT in accuracy, and superior in spatial resolution. CT perfusion imaging is likely to become more widely available as an easy-to-perform technique for assessing cerebral perfusion in a patients with moyamoya disease.

Endovascular treatment of basilar tip aneurysms associated with moyamoya disease

We report the efficacy and safety of endovascular treatment of basilar tip aneurysms (BTA) in five patients with moyamoya disease. The patients underwent intra-aneurysmal embolisation with detachable platinum coils. Three BTA presented with subarachnoid haemorrhage (SAH); the other two were asymptomatic. In four cases, one embolisation procedure produced >95% angiographic obliteration of the aneurysm. In the other patient, 80-90% obliteration was achieved initially, but due to growth of the residual aneurysm, the procedure was repeated 7 months later. Two patients experienced transient oculomotor paresis as a procedure-related complication. Mean follow-up was 43.6+/-34.0 months (range 8-92 months). One patient died of putaminal haemorrhage unrelated to the aneurysm 15 months after embolisation. The other four had no subsequent SAH and survived without sequelae. Endovascular embolisation using detachable platinum coils proved to be a safe and efficient treatment modality for BTA associated with moyamoya disease.

Experimental study on slow-speed elongation injury of the peripheral nerve: electrophysiological and histological changes

Slow-speed elongation of the sciatic nerves was induced in 41 rabbits by lengthening the osteotomized femur by 2.1 mm/day with an external fixator. Time courses were monitored. About 2 weeks after elongation began, the amplitude of the compound nerve action potentials decreased, and delayed latency began. Histological observations showed that the wavy structure of the nerve fibers was lost during the stage at which reduction in the amplitude of action potentials occurred. In some nerve fibers, narrowing of the axons was observed. Further elongation caused delay in the percent latency. Histologically, collagen fibers were noted in the nerve fascicles, as well as narrowing in all the nerve fibers. When elongation ceased at the stage at which a reduction in the amplitude of action potential was noted, recovery from nerve damage followed. When elongation did not cease until the stage at which latency was delayed, however, recovery was not apparent, either histologically or electrophysiologically. The critical level of percent amplitude for recovery was at 82.4% of the original level (the critical rate for bone lengthening was 20.5%).

A small asymptomatic intracranial aneurysm in an elderly woman that ruptured soon after discovery

A 78-year-old woman underwent magnetic resonance (MR) imaging to assess the deterioration of her right hemiparesis initially caused by putaminal hemorrhage that occurred 5 years prior to referral. MR imaging detected an anterior communicating artery aneurysm but no new lesion was seen that might have caused the deterioration was observed. Hemiparesis improved within several days and she was referred for endovascular treatment of the aneurysm. Digital subtraction angiography demonstrated a 4.4 mm long aneurysm at the A1-A2 junction of her left anterior cerebral artery. Information on the risk associated with treatment caused her to hesitate. Three days after discharge and 40 days after the discovery of the aneurysm it ruptured, causing severe subarachnoid hemorrhage. The patient died on the following day.

Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part II: management and surgical outcome

OBJECT

The purpose of this study was to assess the overall management and surgical outcome of primary intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) among the 85,000 residents of Izumo City, Japan.

METHODS

During 1991 through 1996, 267 patients with ICH and 123 with SAH were treated in Izumo. Of the 267 patients with ICH, 25 underwent hematoma removal by open craniotomy or suboccipital craniectomy and 34 underwent stereotactic evacuation of the hematoma, whereas aneurysm clipping was performed in 71 of the 123 patients with SAH; operability rates were thus 22% for ICH and 58% for SAH (p < 0.0001). The overall 30-day survival rates were 86% for ICH and 66% for SAH (p < 0.0001) and the 2-year survival rates were 73% and 62% (p = 0.0207), respectively. In patients who underwent surgery, 30-day and 2-year survival rates were 93% for ICH and 100% for SAH (p = 0.0262), and 75% for ICH and 97% for SAH (p = 0.0002), respectively. In patients with ICH, the most important predictors of 30-day case-fatality rates were the volume of the hematoma, the Glasgow Coma Scale (GCS) score, rebleeding, and midline shifting, whereas those for 2-year survival were the GCS score, age, rebleeding, and hematoma volume. In patients with SAH, the most important determinants of 30-day case-fatality rates were the GCS score and age, whereas only the GCS score had a significant impact on 2-year survival.

CONCLUSIONS

The overall survival rates for patients with ICH or SAH in Izumo were more favorable than those in previously published epidemiological studies. However, despite improved surgical results, the overall management of ICH and SAH still produced an unsatisfactory outcome, mainly because of primary brain damage.

[A case of multiple cerebral arteriovenous malformations treated by gamma knife radiosurgery]

We reported a case of multiple cerebral arteriovenous malformations (AVMs) treated by gamma knife radiosurgery. A 6-year-old girl was admitted because of systemic tonic convulsion. At the first admission, we performed only vertebral angiography, which showed a 15 mm cerebral AVM. It was fed by the right posterior cerebral artery and drained into the great vein of Galen. Seven years after the first admission, the patient returned again with severe headache. Four-vessel cerebral angiograms showed another 7 mm AVM fed by the left frontopolar artery. We treated both cerebral AVMs bv gamma knife radiosurgery. Follow-up angiograms performed 2 years after radiosurgery confirmed the disappearance of both AVMs. We then discuss treatment of multiple cerebral AVMs.

[A case of cranial metastasis of hepatocellular carcinoma]

A case of cranial metastasis of hepatocellular carcinoma is reported. A 77-year-old woman with an elastic hard tumor in the right temporal region was referred to our department on April 30, 1992. On admission, the patient had slight weakness of the left upper limb. Plain skull X-ray and computed tomography (CT) showed bone destruction in the right temporal region. Magnetic resonance images (MRI) showed that the tumor was hypo-intense with T1-sequences and hyper-intense with T2-sequences, and included hyper-intense spots on both T1- and T2-images. Right carotid angiography showed that the tumor was fed by the middle meningeal and accessory meningeal arteries. The patient became disoriented, and the left hemiparesis worsened on May 4, 1992. CT scan revealed an irregular high-density area in the tumor because of intratumoral hemorrhage. After embolization of the arteries feeding the tumor, surgery was performed on May 8, 1992, and the tumor was totally removed. Histological examination of the tumor specimen revealed that it was a metastatic hepatocellular carcinoma. The patient died 8 months after initial diagnosis because of hepatocellular carcinoma.

[A case of meningioma associated with intracerebral hemorrhage and acute deterioration]

We report a case of convexity meningioma associated with sudden onset of intracerebral hemorrhage followed by acute deterioration. A 76-year-old previously healthy male suddenly collapsed into coma and was admitted to our department. On admission, he was deeply comatose. Computerized tomography (CT) scan revealed intracerebral hemorrhage in the right frontal lobe, together with an isodense mass lesion of about 5 cm in diameter. The density on the fronto-medial side of the mass increased after administration of contrast medium, probably due to extravasation. However, there was no enhancement of the mass lesion. Cerebral angiography revealed marked prolongation in circulation time and extravasation via the right middle internal frontal artery. The right middle meningeal artery was dilated and elongated, but no tumor stain was found. The patient died on the following day. Autopsy disclosed massive hemorrhage in the right frontal lobe together with a convexity meningioma. Histological examination showed that the tumor was a fibroblastic meningioma. We review previously reported cases of convexity meningioma associated with intracranial hemorrhage, and discuss mainly the mechanism of bleeding.

Synthesis of omega-(methoxycarbonyl)alkyl and 9-(methoxycarbonyl)-3,6-dioxanonyl glycopyranosides for the preparation of carbohydrate-protein conjugates

omega-(Methoxycarbonyl)alkyl glycopyranosides of D-mannose having C4, C7, C9, C12, and C15 carbon chains, L-fucose and 2-acetamido-2-deoxy-D-mannose having C7 and C9 carbon chains, D-xylose and 2-acetamido-2-deoxy-L-fucose having a C9 carbon chain, and 9-(methoxycarbonyl)-3,6-dioxanonyl glycopyranosides of D-mannose, 2-acetamido-2-deoxy-D-mannose, and L-fucose were synthesized as intermediates for coupling to human serum albumin in order to examine the effect of chain length and hydrophobicity of the spacer arm on the binding specificity of lectins. 8-(Methoxycarbonyl)octyl glycosides of beta-D-Man-(1----2)-alpha-D-Man, alpha-D-Man-(1----2)-alpha-D-Man, alpha-D-ManNAc-(1----2)-alpha-D-Man, beta-D-GlcNAc-(1----2)-alpha-D-Man, and their 6-O-positional isomers, beta-D-Man-(1----6)-alpha-D-Man, alpha-D-Man-(1----6)-alpha-D-Man, alpha-D-ManNAc-(1----6)-alpha-D-Man, and beta-D-GlcNAc-(1----6)-alpha-D-Man, were also synthesized.

Absorption and metabolic characteristics of p-aminobenzoic acid and its isomer, m-aminobenzoic acid, from the rat small intestine

Absorption and metabolic characteristics of p-aminobenzoic acid (PABA) and m-aminobenzoic acid (MABA) from the rat small intestine were examined by means of in situ recirculation and in vitro everted sac experiments. p-Aminobenzoic acid was extremely rapidly absorbed from the rat small intestine, whereas the absorption of MABA, the m-isomer of PABA, was comparably slower. This finding was partly explained by the result that PABA is more lipophilic than MABA. The metabolite percentage of PABA was considerably greater than that of MABA in mucosal fluid, tissue, and serosal fluid. On the other hand, a concentration-dependent and a directional difference in the transfer rate of these drugs were observed in everted and noneverted sacs of rat small intestine. Furthermore, mucosal uptake of PABA or MABA was inhibited by 1 mM 2,4-dinitrophenol, 10 mM sodium azide, and pretreatment with HgCl2 (10 mM). These results indicate that MABA, as well as PABA, is transported through the intestine by a carrier-mediated transport system, and that the molecular structure of these drugs is important for their absorption and metabolic characteristics.

Production of N4-succinyl-1-beta-D-arabinofuranosylcytosine, a novel metabolite of N4-behenoyl-1-beta-D-arabinofuranosylcytosine, in mice and its biological significance

A novel metabolite was found in the urine and bile of mice given i.v. injections of N4-behenoyl-1-beta-D-arabinofuranosylcytosine (behenoyl-ara-C). Acid and alkaline hydrolysis of this metabolite resulted in the production of 1-beta-D-arabinofuranosylcytosine and succinic acid, as determined by thin-layer chromatography and high-performance liquid chromatography. Mass spectrometry identified this metabolite as N4-succinyl-1-beta-D-arabinofuranosylcytosine (succinyl-ara-C). This conclusion was supported by thin-layer chromatography and by the ultraviolet spectrum, upon which the characteristics of this metabolite agreed with those of succinyl-ara-C. Only a very small amount, if any, of this metabolite was found in the urine and bile of mice given injections of N4-stearoyl- or N4-palmitoyl-1-beta-D-arabinofuranosylcytosine, suggesting that behenoyl-ara-C was metabolized differently from the other two analogs. Comparison of the metabolites of behenoyl-ara-C, radiolabeled at different positions of the behenoyl-residue, suggested that behenoyl-ara-C was degraded by omega-oxidation and then by beta-oxidation, resulting in the production of succinyl-ara-C. This metabolite was more potent than behenoyl-ara-C in suppressing the in vitro proliferation of murine L1210 cells. The high therapeutic potency of behenoyl-ara-C in L1210-bearing mice may be ascribable to the contribution of succinyl-ara-C to the efficacy of behenoyl-ara-C, either by suppressing the proliferation of L1210 cells or by protecting 1-beta-D-arabinofuranosylcytosine, the possible eventual metabolite, from inactivation by deaminase.