Mode of Imaging Study and Endovascular Therapy for a Large Ischemic Core: Insights From the RESCUE-Japan LIMIT

BACKGROUND AND PURPOSE

Differences in measurement of the extent of acute ischemic stroke using the Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) by non-contrast computed tomography (CT-ASPECTS stratum) and diffusion-weighted imaging (DWI-ASPECTS stratum) may impact the efficacy of endovascular therapy (EVT) in patients with a large ischemic core.

METHODS

The RESCUE-Japan LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan-Large IscheMIc core Trial) was a multicenter, open-label, randomized clinical trial that evaluated the efficacy and safety of EVT in patients with ASPECTS of 3-5. CT-ASPECTS was prioritized when both CT-ASPECTS and DWI-ASPECTS were measured. The effects of EVT on the modified Rankin Scale (mRS) score at 90 days were assessed separately for each stratum.

RESULTS

Among 183 patients, 112 (EVT group, 53; No-EVT group, 59) were in the CT-ASPECTS stratum and 71 (EVT group, 40; No-EVT group, 31) in the DWI-ASPECTS stratum. The common odds ratio (OR) (95% confidence interval) of the EVT group for one scale shift of the mRS score toward 0 was 1.29 (0.65-2.54) compared to the No-EVT group in CT-ASPECTS stratum, and 6.15 (2.46-16.3) in DWI-ASPECTS stratum with significant interaction between treatment assignment and mode of imaging study (P=0.002). There were significant interactions in the improvement of the National Institutes of Health Stroke Scale score at 48 hours (CT-ASPECTS stratum: OR, 1.95; DWIASPECTS stratum: OR, 14.5; interaction P=0.035) and mortality at 90 days (CT-ASPECTS stratum: OR, 2.07; DWI-ASPECTS stratum: OR, 0.23; interaction P=0.008).

CONCLUSION

Patients with ASPECTS of 3-5 on MRI benefitted more from EVT than those with ASPECTS of 3-5 on CT.

Endovascular therapy for acute intracranial large vessel occlusion due to atherothrombosis: Multicenter historical registry

BACKGROUND

Atherothrombotic stroke-related large vessel occlusion (AT-LVO) is caused by two etiologies, the intracranial artery occlusion due to in situ occlusion (intracranial group) or due to embolism from cervical carotid occlusion or stenosis (tandem group). The prognosis and reocclusion rate of each etiology after endovascular therapy (EVT) is unclear.

METHODS

We conducted a historical multicenter registry study at 51 Japanese centers to compare the prognoses of AT-LVO between two etiologies. The primary outcome was the incidence of recurrent ischemic stroke or reocclusion of the treated vessels within 90 days after EVT. Each of the primary outcome means the incidence of recurrent ischemic stroke and reocclusion of the treated vessels within 90 days after EVT.

RESULTS

We analyzed 582 patients (338 in the intracranial group and 244 in the tandem group). Patients in the intracranial group were younger (mean 71.9 vs 74.5, p=0.003), more of them were female and fewer of them were current smokers than those in the tandem group. In the tandem group, the patients' National Institutes of Health Stroke Scale score on admission was higher (13 vs 15, p=0.006), onset to puncture time was shorter (299 [145-631] vs 232 [144-459] minutes, p=0.03) and Alberta Stroke Program Early CT Score (ASPECTS) was lower (8 [7-9] vs 8 [6-9], p=0.0002). The primary outcome was higher in the intracranial group (22.5% vs 8.2%, p<0.0001). However, any ICH and death were not significantly different in the two groups.

CONCLUSIONS

The incidence of recurrent ischemic stroke or reocclusion after EVT for AT-LVO was higher in the intracranial group.

Number of Passes of Endovascular Therapy for Stroke With a Large Ischemic Core: Secondary Analysis of RESCUE-Japan LIMIT

BACKGROUND

The increased risk of intracranial hemorrhage with multiple passes in endovascular therapy (EVT) for large vessel occlusion with a large ischemic core is a concern. We explored the effect of the number of EVT passes on patients in a randomized clinical trial.

METHODS

This post hoc study was the secondary analysis of RESCUE-Japan LIMIT, which was a randomized clinical trial comparing EVT and medical treatment alone for large vessel occlusion with large ischemic core. We grouped patients according to the number of passes with successful reperfusion (modified Thrombolysis in Cerebral Infarction score, ≥2b) in 1, 2, and 3 to 7 passes and failed reperfusion (modified Thrombolysis in Cerebral Infarction score, 0-2a) after any pass in the EVT group, and these groups were compared with medical treatment group. The primary outcome was modified Rankin Scale score of 0 to 3 at 90 days. Secondary outcomes were improvement in National Institutes of Health Stroke Scale score of ≥8 at 48 hours, mortality at 90 days, symptomatic intracranial hemorrhage, and any intracranial hemorrhage within 48 hours.

RESULTS

The number of patients who received EVT with successful reperfusion after 1, 2, and 3 to 7 passes and failed reperfusion were 44, 23, 19, and 14, respectively, and 102 received medical treatment alone. The adjusted odds ratios (95% CIs) for the primary outcome relative to medical treatment were 5.52 (2.23-14.28) after 1 pass, 6.45 (2.22-19.30) after 2 passes, 1.03 (0.15-4.48) after 3 to 7 passes, and 1.17 (0.16-5.37) if reperfusion failed. The adjusted odds ratios (95% CIs) for any intracranial hemorrhage within 48 hours relative to medical treatment were 1.88 (0.90-3.93) after 1 pass, 5.14 (1.97-14.72) after 2 passes, 3.00 (1.09-8.58) after 3 to 7 passes, and 6.16 (1.87-24.27) if reperfusion failed.

CONCLUSIONS

The successful reperfusion within 2 passes was associated with better clinical outcomes.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03702413.

Cavernous sinus dural arteriovenous fistula treated with transvenous embolization through facial vein: A case report

BACKGROUND

Although the inferior petrosal sinus (IPS) is the most common approach route for transvenous embolization (TVE) of cavernous sinus dural arteriovenous fistulas (CSDAVFs), other routes should be chosen in cases which the IPS is occluded. We report a case in which the superior ophthalmic vein (SOV) approach through the facial vein (FV) was the first choice to achieve radical cure of a hemorrhage-onset CSDAVF.

CASE DESCRIPTION

An 81-year-old female presented with a history of transarterial embolization (TAE) and TVE for the left CSDAVF 27 years ago. She was transported to us with a chief complaint of consciousness disturbance, and head computed tomography (CT) showed subcortical hemorrhage in the right frontal lobe. Cerebral angiography revealed CSDAVF with draining into the right SOV and right superficial middle cerebral vein (SMCV). Angiography, computed tomography venography, and contrast-enhanced magnetic resonance imaging did not show IPS, but the outflow pathways to the SOV, FV, and internal jugular vein were confirmed, so an approach through the FV was selected.

CONCLUSION

The FV was selected through the right femoral vein and thanks to the distal access catheter (DAC) being guided to the SOV, the microcatheter could be easily guided to the SMCV through the cavernous sinus (CS). TVE was performed, complete occlusion was confirmed. When preoperative occlusion of the IPS was confirmed, the FV was useful for the first choice of route, and the use of DAC allowed us to complete the treatment accurately and quickly.

Abstract 1: The Very Core Limit Of Endovascular Therapy For Acute Stroke With A Large Ischemic Region

Background and Purpose: To assess the actual malignant core volume in endovascular therapy (EVT) eligible patients with large ischemic regions from the RESCUE-Japan LIMIT database.

Methods: RESCUE-Japan LIMIT was a multicenter, open-label, randomized clinical trial in large vessel occlusion patients with large ischemic region indicated by an ASPECTS valued from 3 to 5. We assessed the volumetrically measured core volume which identifies an unfavorable outcome (modified Rankin Scale; mRS 4-6 at 90 days) by receiver operating characteristic (ROC) analysis in the endovascular therapy (EVT) group. Predictive marginal probabilities were also assessed to identify the unfavorable outcome. Symptomatic intracranial hemorrhages and death within 90 days in the EVT group and the medical management (MM) group were compared. Clinical characteristics and radiological values were also compared.

Results: Of the 203 cases enrolled, 182 patients (92 in EVT group vs. 90 in MM group) had adequate core volume. The mean age was 75.6±10 years old and 46% of females in the EVT group and 77.0±10 years old and 42% of females in the MM group. Median core volume was 94 (IQR; 65.3-147.5) mL in EVT patients and 110 (IQR; 74.0-140.0) mL in those with MM group (P=0.84). ROC analysis identified a core volume of 120 mL as the unfavorable outcome (61/92) in the EVT group (51% sensitivity and 77% specificity, area under curve=0.65) and 99 mL in the MM group (77/91, 62% sensitivity and 54% specificity, area under curve=0.56). Predictive marginal probabilities indicated 132 mL as an overlay of the two groups for achieving the unfavorable functional outcome. Symptomatic intracranial hemorrhage was seen in 9.8% in the EVT group and 5.6% in the MM group (p=0.28), and death within 90 days was 17.4% in the EVT group and 23.3% in the MM group (p=0.32).

Conclusions: The current analysis demonstrates that a core threshold of approximately 130 mL is the upper limit for identifying large ischemic region stroke patients treated with EVT who are unlikely to suffer from unfavorable outcomes. EVT-eligible patients under this threshold may benefit from EVT.

Registration: URL: http://www.clinicaltrials.gov; Unique identifier: NCT03702413.

Association Between Alberta Stroke Program Early Computed Tomography Score and Efficacy and Safety Outcomes With Endovascular Therapy in Patients With Stroke From Large-Vessel Occlusion: A Secondary Analysis of the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Large Ischemic Core Trial (RESCUE-Japan LIMIT)

Importance

Endovascular therapy (EVT) has been found to reduce functional disability in patients with acute stroke due to large-vessel occlusion. However, the extent of the ischemic region, measured using Alberta Stroke Program Early Computed Tomography Scores, may limit the efficacy of EVT.

Objective

To compare the efficacy and safety of EVT according to ASPECTS 3 or less vs 4 to 5.

Design, Setting, and Participants

The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Large Ischemic Core Trial (RESCUE-Japan LIMIT) was an open-label randomized clinical trial conducted from November 2018 to December 2021 at 45 stroke centers across Japan. The trial enrolled adult patients with acute ischemic stroke with a large ischemic region, defined as ASPECTS 3 to 5 primarily determined by magnetic resonance imaging, with occlusion site at the internal carotid artery or middle cerebral artery segment 1. Among 203 enrolled patients, 1 withdrew consent and 202 were included in the original trial and secondary analysis. This secondary analysis was conducted in April 2022.

Interventions

Patients were randomly assigned to EVT with medical therapy or medical therapy alone.

Main Outcomes and Measures

Modified Rankin Scale (mRS) score at 90 days and symptomatic and any intracranial hemorrhage within 48 hours.

Results

Among 202 patients, 106 (52%) had ASPECTS 3 or less (mean [SD] age, 76.7 [9.6] years; 54 female individuals [50.9%]) and 96 had ASPECTS 4 to 5 (mean [SD] age, 75.6 [10.6] years; 36 female individuals [37.5%]). Of patients with ASPECTS 3 or less, 12 (21.4%) in the EVT group and 9 (18.0%) in the no EVT group had an mRS score of 0 to 3 (odds ratio [OR], 1.24; 95% CI, 0.47-3.26). Of patients with ASPECTS 4 to 5, 19 patients (43.2%) in the EVT group and 4 (7.7%) in the no EVT group had an mRS score of 0 to 3 at 90 days (OR, 9.12; 95% CI, 2.80-29.70; interaction P = .01). The ordinal shift across the range of mRS scores toward a better outcome was not significant in those with ASPECTS or 3 or less (common OR, 1.56; 95% CI, 0.79-3.10) but was significant in those with ASPECTS 4 to 5 (common OR, 4.48; 95% CI, 2.07-9.71; interaction P = .046). The risk of intracranial hemorrhage was significantly increased in patients with ASPECTS 3 or less when EVT was conducted (OR, 4.14; 95% CI, 1.84-9.32) and nonsignificantly increased in those with ASPECTS 4 to 5 (OR, 2.05; 95% CI, 0.89-4.73; interaction P = .24).

Conclusions and Relevance

In this study, EVT was associated with improved 90-day functional outcomes in patients with acute large vessel occlusive stroke and ASPECTS was 4 to 5 but not in those with ASPECTS 3 or less.

Trial Registration

ClinicalTrials.gov Identifier: NCT03702413.

Endovascular Therapy for Acute Stroke with a Large Ischemic Region

BACKGROUND

Endovascular therapy for acute ischemic stroke is generally avoided when the infarction is large, but the effect of endovascular therapy with medical care as compared with medical care alone for large strokes has not been well studied.

METHODS

We conducted a multicenter, open-label, randomized clinical trial in Japan involving patients with occlusion of large cerebral vessels and sizable strokes on imaging, as indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) value of 3 to 5 (on a scale from 0 to 10, with lower values indicating larger infarction). Patients were randomly assigned in a 1:1 ratio to receive endovascular therapy with medical care or medical care alone within 6 hours after they were last known to be well or within 24 hours if there was no early change on fluid-attenuated inversion recovery images. Alteplase (0.6 mg per kilogram of body weight) was used when appropriate in both groups. The primary outcome was a modified Rankin scale score of 0 to 3 (on a scale from 0 to 6, with higher scores indicating greater disability) at 90 days. Secondary outcomes included a shift across the range of modified Rankin scale scores toward a better outcome at 90 days and an improvement of at least 8 points in the National Institutes of Health Stroke Scale (NIHSS) score (range, 0 to 42, with higher scores indicating greater deficit) at 48 hours.

RESULTS

A total of 203 patients underwent randomization; 101 patients were assigned to the endovascular-therapy group and 102 to the medical-care group. Approximately 27% of patients in each group received alteplase. The percentage of patients with a modified Rankin scale score of 0 to 3 at 90 days was 31.0% in the endovascular-therapy group and 12.7% in the medical-care group (relative risk, 2.43; 95% confidence interval [CI], 1.35 to 4.37; P = 0.002). The ordinal shift across the range of modified Rankin scale scores generally favored endovascular therapy. An improvement of at least 8 points on the NIHSS score at 48 hours was observed in 31.0% of the patients in the endovascular-therapy group and 8.8% of those in the medical-care group (relative risk, 3.51; 95% CI, 1.76 to 7.00), and any intracranial hemorrhage occurred in 58.0% and 31.4%, respectively (P<0.001).

CONCLUSIONS

In a trial conducted in Japan, patients with large cerebral infarctions had better functional outcomes with endovascular therapy than with medical care alone but had more intracranial hemorrhages. (Funded by Mihara Cerebrovascular Disorder Research Promotion Fund and the Japanese Society for Neuroendovascular Therapy; RESCUE-Japan LIMIT ClinicalTrials.gov number, NCT03702413.).

Localized kinking during deployment of a flow redirection lumen device (FRED) could be due to excessive pushing

Background:

The safety and efficacy analysis of flow redirection lumen device (FRED) demonstrated the excellent safety profile of FREDs for aneurysm treatment. We describe the first case in which FRED deployment for a paraclinoid aneurysm resulted in in-stent stenosis, necessitating balloon angioplasty, and an additional stent.

Case Description:

A 50-year-old woman had a left paraclinoid aneurysm with a maximum diameter of 6.1 mm. We planned FRED deployment. We experienced in-stent stenosis just after the deployment of a FRED. Devices such as guidewires and catheters could not cross the lesion through the FRED because of an obstruction in the FRED. Balloon angioplasty and subsequent stenting resolved thrombosis and kinking. FRED has potential for kinking locally.

Conclusion:

Surgeons should consider this possibility when treating cerebral aneurysm using FRED. Cone-beam computed tomography after deployment of FRED may be useful for evaluating the stent shape.

Computational Fluid Dynamics Using a Porous Media Setting Predicts Outcome after Flow-Diverter Treatment

BACKGROUND AND PURPOSE

Knowledge about predictors of the outcome of flow-diverter treatment is limited. The aim of this study was to predict the angiographic occlusion status after flow-diverter treatment with computational fluid dynamics using porous media modeling for decision-making in the treatment of large wide-neck aneurysms.

MATERIALS AND METHODS

A total of 27 patients treated with flow-diverter stents were retrospectively analyzed through computational fluid dynamics using pretreatment patient-specific 3D rotational angiography. These patients were classified into no-filling and contrast-filling groups based on the O'Kelly-Marotta scale. The patient characteristics, morphologic variables, and hemodynamic parameters were evaluated for understanding the outcomes of the flow-diverter treatment.

RESULTS

The patient characteristics and morphologic variables were similar between the 2 groups. Flow velocity, wall shear stress, shear rate, modified aneurysmal inflow rate coefficient, and residual flow volume were significantly lower in the no-filling group. A novel parameter, called the normalized residual flow volume, was developed and defined as the residual flow volume normalized by the dome volume. The receiver operating characteristic curve analyses demonstrated that the normalized residual flow volume with an average flow velocity of ≥8.0 cm/s in the aneurysmal dome was the most effective in predicting the flow-diverter treatment outcomes.

CONCLUSIONS

It was established in this study that the hemodynamic parameters could predict the angiographic occlusion status after flow-diverter treatment.

Ischemia-Induced Multipotent Stem Cells Isolated from Stroke Patients Exhibit Higher Neurogenic Differentiation Potential than Bone Marrow-Derived Mesenchymal Stem Cells

Perivascular areas of the brain harbor multipotent stem cells. We recently demonstrated that after a stroke, brain pericytes exhibit features of multipotent stem cells. Moreover, these ischemia-induced multipotent stem cells (iSCs) are present within ischemic areas of the brain of patients diagnosed with stroke. Although increasing evidence shows that iSCs have traits similar to those of mesenchymal stem cells (MSCs), the phenotypic similarities and differences between iSCs and MSCs remain unclear. In this study, we used iSCs extracted from stroke patients (h-iSCs) and compared their neurogenic potential with that of human MSCs (h-MSCs) in vitro. Microarray analysis, fluorescence-activated cell sorting, immunohistochemistry, and multielectrode array were performed to compare the characteristics of h-iSCs and h-MSCs. Although h-iSCs and h-MSCs had similar gene expression profiles, the percentage expressing the neural stem/progenitor cell marker nestin was significantly higher in h-iSCs than in h-MSCs. Consistent with these findings, h-iSCs, but not h-MSCs, differentiated into electrophysiologically functional neurons. In contrast, although both h-iSCs and h-MSCs were able to differentiate into several mesodermal lineages, including adipocytes, osteocytes, and chondrocytes, the potential of h-iSCs to differentiate into adipocytes and osteocytes was relatively low. These results suggest that compared with h-MSCs, h-iSCs predominantly exhibit neural rather than mesenchymal lineages. In addition, these results indicate that h-iSCs have the potential to repair the injured brain of patients with stroke by directly differentiating into neuronal lineages.

Neural regeneration by regionally induced stem cells within post-stroke brains: Novel therapy perspectives for stroke patients

Ischemic stroke is a critical disease which causes serious neurological functional loss such as paresis. Hope for novel therapies is based on the increasing evidence of the presence of stem cell populations in the central nervous system (CNS) and the development of stem-cell-based therapies for stroke patients. Although mesenchymal stem cells (MSCs) represented initially a promising cell source, only a few transplanted MSCs were present near the injured areas of the CNS. Thus, regional stem cells that are present and/or induced in the CNS may be ideal when considering a treatment following ischemic stroke. In this context, we have recently showed that injury/ischemia-induced neural stem/progenitor cells (iNSPCs) and injury/ischemia-induced multipotent stem cells (iSCs) are present within post-stroke human brains and post-stroke mouse brains. This indicates that iNSPCs/iSCs could be developed for clinical applications treating patients with stroke. The present study introduces the traits of mouse and human iNSPCs, with a focus on the future perspective for CNS regenerative therapies using novel iNSPCs/iSCs.

PulseRider-Assisted Coil Embolization for Treatment of Intracranial Bifurcation Aneurysms: A Single-Center Case Series with 24-Month Follow-up

BACKGROUND

Although endovascular coiling of unruptured aneurysms is widely accepted, the endovascular treatment of wide-neck bifurcation aneurysms remains one of the most challenging morphologies. Our purpose was to describe our experience with 24-month follow-up for the treatment of unruptured intracranial bifurcation aneurysms using the PulseRider (Cerenovus, New Brunswick, NJ).

METHODS

This study is a single-center, single-arm registry performed under institutional review board control to evaluate efficacy and safety of the PulseRider. Patients with bifurcation aneurysms were identified and enrolled prospectively. Angiography immediately after treatment and at 6 months, and magnetic resonance imaging and magnetic resonance angiography at 12- and 24-month follow-up were retrospectively analyzed. A modified Rankin score was obtained prior to procedure, at discharge, and at 6-, 12- and 24-month follow-up visits.

RESULTS

Eight patients with a mean age of 66 years were treated with the PulseRider. All patients had bifurcation aneurysms (2 anterior communicating, 2 carotid terminus, and 4 basilar apex). The aneurysm diameters ranged from 4.6 to 13.6 mm (mean 7.4 mm) with dome/neck ratio ranging from 1.4 to 2.2 (mean 1.6). In all cases, the PulseRider was successfully deployed. Complete occlusion was demonstrated at 6-month follow-up on 6 of 8 (75%), near complete occlusion in 1 of 8 (12.5%), and residual aneurysm in 1 of 8 (12.5%) patients. There was no change or recurrence on magnetic resonance angiography, nor clinical complication after the procedure through 24-month follow-up.

CONCLUSIONS

Our experience with 24-month follow-up demonstrated favorable efficacy in the treatment of intracranial wide-neck bifurcation aneurysms using the PulseRider.

Isolation and Characterization of Cerebellum-Derived Stem Cells in Poststroke Human Brain

There is compelling evidence that the mature central nervous system (CNS) harbors stem cell populations outside conventional neurogenic regions. We previously demonstrated that brain pericytes (PCs) in both mouse and human exhibit multipotency to differentiate into various neural lineages following cerebral ischemia. PCs are found throughout the CNS, including cerebellum, but it remains unclear whether cerebellar PCs also form ischemia-induced multipotent stem cells (iSCs). In this study, we demonstrate that putative iSCs can be isolated from poststroke human cerebellum (cerebellar iSCs [cl-iSCs]). These cl-iSCs exhibited multipotency and differentiated into electrophysiologically active neurons. Neurogenic potential was also confirmed in single-cell suspensions. DNA microarray analysis revealed highly similar gene expression patterns between PCs and cl-iSCs, suggesting PC origin. Global gene expression comparison with cerebral iSCs revealed general similarity, but cl-iSCs differentially expressed certain cerebellum-specific genes. Thus, putative iSCs are present in poststroke cerebellum and possess region-specific traits, suggesting potential capacity to regenerate functional cerebellar neurons following ischemic stroke.

Abstract TP143: Potential of Cerebellum-derived Stem Cells in Human Brain to Regenerate Functional Neurons Following Ischemic Stroke

Introduction: Despite the availability of effective reperfusion therapies, only a few prove beneficial to the patients after stroke, owing to their limited time window. We had earlier demonstrated that adult brain pericytes develop stemness following ischemia, and these ischemia-induced multipotent stem cells (iSCs) can self-propagate and differentiate into mature neural cells, including neurons (Nakagomi et al. Eur J Neurosci. 2009, Stem Cells. 2009, 2015). More recently, we have shown putative iSCs to be present within post-stroke human cerebral tissues (Tatebayashi K et al. Stem Cells Dev 2017). The current study aimed to establish iSCs from cerebellar infarction of two patients and examine their characteristics.

Methods: We isolated iSCs from post-stroke human cerebellum, examined their characteristics by Polymerase chain reaction and immunocytochemistry, and compared their traits with those of others by microarray and flow cytometry analyses. Furthermore, we investigated the cerebellar-iSCs (cl-iSCs) for multi-potency and differentiation into functional neurons. Electrophysiological properties were analyzed using multi-electrode arrays.

Results: The isolated cl-iSCs exhibited multi-potency and differentiated into electrophysiologically active neurons (Fig. A). Neurogenic potential was confirmed in single-cell suspensions (Fig. B.C). Highly similar gene expression patterns were observed between pericytes and iSCs (Fig. D), and a strong lineage resemblance between cl-iSCs and cerebral ischemia-induced multi-potent stem cells (cr-iSCs) was revealed, although cl-iSCs differentially expressed certain cerebellum-specific genes.

Conclusions: Putative iSCs are present in post-stroke cerebellum and possess region-specific traits, suggesting their potential to regenerate functional neurons following an ischemic stroke.

Intravenous administration of human adipose-derived stem cells ameliorates motor and cognitive function for intracerebral hemorrhage mouse model

Even today, intracerebral hemorrhage (ICH) is a major cause of death and disabilities. Rehabilitation is preferentially applied for functional recovery although its effect is limited. Recent studies have suggested that intravenous administration of mesenchymal stem cells would improve the post-ICH neurological deficits. Human adipose-derived stem cells (hADSCs) have been established in our laboratory. We aimed to evaluate the therapeutic efficacy of the hADSCs on the post-ICH neurological deficits using a clinical-relevant ICH mouse model. We also evaluated immune responses to clarify the underlying mechanisms. The hADSCs expressed MSC markers at high levels. The hADSCs administration into the ICH-bearing mice improved the neurological deficits during the subacute phases, which was shown by neurobehavioral experiments. Besides, the hADSC administration decreased the number of CD11⁺CD45⁺ cells and increased the proportion of CD86⁺ and Ly6C⁺ cells in the ICH lesions. In summary, intravenous administration of hADSCs during the acute phase improved ICH-induced neurological deficits during the subacute phase because of the suppression of acute inflammation mediated by CD11⁺CD45⁺ subpopulations. Our data suggest that hADSCs can be served as a novel strategy for ICH treatment.

Comparative Characterization of Ischemia-Induced Brain Multipotent Stem Cells with Mesenchymal Stem Cells: Similarities and Differences

Mesenchymal stem cells (MSCs) are multipotent stem cells localized to the perivascular regions of various organs, including bone marrow (BM). While MSC transplantation represents a promising stem cell-based therapy for ischemic stroke, increasing evidence indicates that exogenously administered MSCs rarely accumulate in the injured central nervous system (CNS). Therefore, compared with MSCs, regionally derived brain multipotent stem cells may be a superior source to elicit regeneration of the CNS following ischemic injury. We previously identified ischemia-induced multipotent stem cells (iSCs) as likely originating from brain pericytes/perivascular cells (PCs) within poststroke regions. However, detailed characteristics of iSCs and their comparison with MSCs remains to be investigated. In the present study, we compared iSCs with BM-derived MSCs, with a focus on the stemness and neuron-generating activity of each cell type. From our results, stem and undifferentiated cell markers, including c-myc and Klf4, were found to be expressed in iSCs and BM-MSCs. In addition, both cell types exhibited the ability to differentiate into mesoderm lineages, including as osteoblasts, adipocytes, and chondrocytes. However, compared with BM-MSCs, high expression of neural stem cell markers, including nestin and Sox2, were found in iSCs. In addition, iSCs, but not BM-MSCs, formed neurosphere-like cell clusters that differentiated into functional neurons. These results demonstrate that iSCs are likely multipotent stem cells with the ability to differentiate into not only mesoderm, but also neural, lineages. Collectively, our novel findings suggest that locally induced iSCs may contribute to CNS repair by producing neuronal cells following ischemic stroke.

Quantitative Analysis of Conebeam CT for Delineating Stents in Stent-Assisted Coil Embolization

BACKGROUND AND PURPOSE

Innovative techniques and device-related advances have improved the outcomes of neuroendovascular treatment. 3D imaging has previously used 2 × 2 binning, but 1 × 1 binning has recently been made available. The aim of this study was to evaluate the quantitative ability of conebeam CT for stent delineation and to investigate its effectiveness in the clinical environment.

MATERIALS AND METHODS

Four acquisition groups of 3D MIP images acquired using conebeam CT with varying conditions (acquisition time, 10 or 20 seconds and binning, 1 × 1 or 2 × 2) were compared. Two methods of analysis were performed, a phantom study and an analysis of 28 randomly selected patients. The phantom study assessed the contrast-to-noise ratio and full width at half maximum values in conebeam CT images of intracranial stent struts. In the clinical subjects, we assessed contrast-to-noise ratio, full width at half maximum, and dose-area product.

RESULTS

In the phantom study, the contrast-to-noise ratio was not considerably different between 10- and 20-second acquisition times at equivalent binning settings. Additionally, the contrast-to-noise ratio at equivalent acquisition times did not differ considerably by binning setting. For the full width at half maximum results, equivalent acquisition times differed significantly by binning setting. In the clinical analyses, the 10-second/1 × 1 group (versus 20 second/2 × 2) showed a higher contrast-to-noise ratio (P < .05) and a dose-area product reduced by approximately 70% (P < .05), but the difference in full width at half maximum was not significant (P = .20).

CONCLUSIONS

For stent-assisted coil embolization, quantitative assessment of conebeam CT showed that 10 second/1 × 1 was equivalent to 20 second/2 × 2 for imaging deployed intracranial stents. Furthermore, the 10-second/1 × 1 settings resulted in a much smaller DAP.

Optimal dilution of contrast medium for quantitating parenchymal blood volume using a flat-panel detector

Objective Similar to perfusion studies after acute ischemic stroke, measuring cerebral blood volume (CBV) via C-arm computed tomography before and after therapeutic interventions may help gauge subsequent revascularization. We tested serial dilutions of intra-arterial injectable contrast medium (CM) to determine the optimal CM concentration for quantifying parenchymal blood volume by flat-panel detector imaging (FD-PBV). Methods CM was diluted via saline power injector, instituting time delays for FD-PBV studies. A red/green/blue (RGB) color scale was employed to quantify/compare FD-PBV and magnetic resonance-derived CBV (MRCBV). Results Contrast values of right and left common carotid arteries did not differ significantly at CM dilutions of ≥20%. RGB analysis of FD-PBV imaging (relative to MR-CVB), showed CM dilution altered the colors (by 16%), increasing red and decreasing blue ratios. Conclusion Diluting CM to 20% resulted in no laterality differential of FD-PBV imaging, with left/right quantitative ratios approaching 1.1 (optimal for clinical use).

[Two Cases of Ruptured Blood Blister-like Aneurysm Treated with X-ray Angiography Perfusion(XAP)Analysis]

Two cases of ruptured blood blister-like internal carotid artery aneurysms for which low flow bypass was sufficient to attain successful treatment of trapping are reported. In the acute stage of rupture, it is troublesome to perform accurate examinations of tolerance to ischemia like balloon occlusion test(BOT)for estimating the required amount of bypass flow. In our cases, X-ray angiography perfusion(XAP)analysis was introduced, which could be performed in a couple dozen seconds without room-to-room transfer of patients, following the ordinary examination of diagnostic digital subtraction angiography. The perfusion index(PI)ratio measured in this analysis is equivalent to the laterality of cerebral blood flow between the right and left hemispheres. The PI ratio of 0.85 approximately corresponds to the mean stump pressure(MSTP)of 40mmHg, on the basis of the correlation diagram between the PI ratio and MSTP(approximate straight line:PI ratio%=0.6×MSTP+60). Even though the PI ratio of the cases was superior to this threshold of tolerance for parent artery occlusion, complementary low flow bypass was added in the acute case for the overwhelming succeeding vasospasm and for securing the flow to peripheral perforators, which resulted in a successful treatment without any ischemic events.

Endovascular parent-artery occlusion of large or giant unruptured internal carotid artery aneurysms. A long-term single-center experience

The development of stent-like devices has increased treatment options for complex internal carotid artery (ICA) aneurysms, but the optimal treatment remains unclear. The purpose of this study was to evaluate the safety and efficacy of endovascular parent-artery occlusion (PAO) for ICA aneurysms. We retrospectively reviewed 28 patients with unruptured ICA aneurysms ⩾10mm treated with PAO between April 2002 and March 2015 at our institution. Patients who developed neurologic symptoms or with venous-phase delay >2s during balloon test occlusion were not treated by PAO. Patients with venous-phase delays of 1-2s underwent superficial temporal artery to middle cerebral artery (STA-MCA) bypass prior to PAO. The median patient age was 65 (range, 26-84)years. Nineteen aneurysms (68%) were located in the cavernous segment. The median aneurysm size was 25 (range 11-40)mm. Venous-phase delay of 1-2s was observed in five patients. Perioperative ischemic complications (N=9, 32%), which occurred within 30days after treatment, were significantly associated with venous-phase delays of 1-2s (p<0.01) and history of hypertension (p<0.01). Six-month morbidity was observed in one (3.6%) patient. Complete occlusion at final follow-up and delayed (i.e. ⩾31days after treatment) ischemic events were observed in 100% and 0% of patients, respectively, over a median period of 63 (range, 6-147) months. Despite the high frequency of perioperative ischemic episodes, endovascular PAO with selective use of STA-MCA bypass showed excellent long-term outcomes in patients with unruptured ICA aneurysms ⩾10mm.

How often and when Fisher syndrome is overlapped by Guillain-Barré syndrome or Bickerstaff brainstem encephalitis?

BACKGROUND AND PURPOSE

Fisher syndrome (FS) may overlap with Guillain-Barré syndrome (GBS), in particular the pharyngeal-cervical-brachial variant form (PCB-GBS), or Bickerstaff brainstem encephalitis (BBE). Our aim was to elucidate the frequency of this overlap and the patterns of clinical progression in patients with FS.

METHODS

Sixty consecutive patients with FS were studied. FS/PCB-GBS was diagnosed when the patients developed pharyngeal, cervical and/or brachial weakness. Patients with flaccid tetraparesis were diagnosed as having FS/conventional GBS. FS/BBE was defined as the development of consciousness disturbances.

RESULTS

All 60 patients initially developed the FS clinical triad alone (pure FS). Of these, 30 (50%) patients had pure FS throughout their course, whereas the remaining 50% of patients showed an overlap: PCB-GBS in 14 (23%) patients, conventional GBS in nine (15%) patients and BBE in seven (12%) patients. The median (range) durations from FS onset to progression to FS/PCB-GBS, FS/GBS or FS/BBE were 5 (1-7), 3 (1-4) and 3 (1-5) days, respectively. Patients with overlap syndromes more frequently received immune-modulating treatment, and the outcomes were generally favourable. The frequencies of positivity for anti-GQ1b, GT1a, GD1a, GD1b, GalNAc-GD1a and GM1 antibodies were not significantly different amongst the four groups.

CONCLUSIONS

Of the patients with pure FS, 50% later developed an overlap with PCB-GBS, conventional GBS or BBE. The overlap occurred within 7 days of FS onset; thus, physicians should pay attention to the possible development of this overlap during the first week after FS onset.

Dose reduction in cone-beam CT scanning for intracranial stent deployment before coil embolization of intracranial wide-neck aneurysms

PURPOSE

Flat panel detector (FD)-equipped angiography machines are increasingly used for neuro-angiographic imaging. During intracranial stent-assisted coil embolization procedures, it is very important to clearly and quickly visualize stent shape after deployment in the vessel. It is necessary to quickly visualize stents by cone-beam computed tomography (CBCT). The aim of this study was to compare CBCTs at 10 and 20 s, and to confirm that this method is useful for neuro-endovascular treatment procedures.

MATERIALS AND METHODS

We treated 30 patients with wide-necked intracranial aneurysms with a flexible, self-expanding neurovascular stent and subsequent aneurysm embolization with platinum micro-coils. We performed the CBCT after stent deployment. We compared the 10 s and 20 s CBCTs, using the full width one-half maximum (FWHM) visualization.

RESULTS

Accurate stent placement with subsequent coil occlusion of the aneurysms was feasible in all patients. Stent struts were clearly visualized on both 10 s and 20 s CBCTs. Importantly, 10 s CBCT can reduce the radiation dose by about 42%, compared with 20 s CBCT. Performing 10 s CBCT with a 14% dilution of the contrast medium may significantly improve image acquisition during stent-assisted coil embolization.

CONCLUSIONS

Reduced-dose, 10 s CBCT can visualize stents in clinical cases, while significantly reducing radiation exposure.

Abstract TP87: Time and Risk Factor of Rebleeding After Coil Embolization of Ruptured Cerebral Aneurysms

Objective: The risk of rebleeding is reported higher in ruptured cerebral aneurysms treated with endovascular coiling than in patients treated with surgical clipping. In this study, we evaluate the time and risk factors of rebleeding after coil embolization of ruptured cerebral aneurysms.

Methods: From April 2001 to August 2014, we performed coil embolization on 288 ruptured cerebral aneurysms. We evaluated the frequency, time and risk factors of rebleeding in terms of patient background, location, size, ratio of dome to neck, volume embolization ratio (VER), and remnant flow into aneurysms immediately after embolization.

Results: We suffered 6 rebleedings (2.1%) within 24 hours after the initial coil embolization (early-rebleeding), and 6 rebleedings (2.1%) within 1 year after the embolization in the patients who we could follow up, and 3 rebleedings (late-rebleeding) 1 year later. All of early-rebleeding occurred within 12 hours. 5 of 6 rebleedings within 1 year after the embolization occurred within 3 months from 30 days after, and one patient who was administered warfarin suffered rebleeding 13 days after the treatment. Antihypertensive therapy after the embolization tended to prevent early-rebleeding (p=0.092), but we revealed no significant factor related to early-rebleeding. We demonstrated significant differences between ratio of dome to neck and rebleeding within 1 year after (p=0.035), and between angiographic result and rebleeding within 1 year after (p=0.001).

Conclusions: Most of rebleeding after coil embolization occurred within 12 hours or within 3 months from 30 days after the treatment. We recommend antihypertensive therapy and the angiogram 1month after the coil embolization at our institution.

Vascular endothelial growth factor as a predictive marker for POEMS syndrome treatment response: retrospective cohort study

OBJECTIVE

POEMS (polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes) syndrome is a rare multisystem disease characterised by plasma cell dyscrasia and overproduction of vascular endothelial growth factor (VEGF). VEGF is assumed to be useful in monitoring disease activity, because VEGF levels usually decrease after treatment. However, there is no study to investigate whether the extent of decrease in VEGF correlates with clinical outcome. We tested the predictive efficacy of serum VEGF levels in POEMS syndrome.

METHOD

This was an institutional review board approved retrospective observational cohort study of 20 patients with POEMS monitored regularly for more than 12 months (median follow-up, 87 months) after treatment onset using our prospectively accumulated database of POEMS from 1999 to 2015. Patients were treated by autologous peripheral blood stem cell transplantation or thalidomide administration. Serum VEGF was measured by ELISA. Outcome measures included clinical and laboratory findings and relapse-free survival.

RESULTS

Serum VEGF levels decreased rapidly after treatment, and stabilised by 6 months post treatment. Patients with normalised serum VEGF levels (<1040 pg/mL) at 6 months showed prolonged relapse-free survival (HR=12.81, 95% CI 2.691 to 90.96; p=0.0001) and greater later clinical improvement. The rate of serum VEGF reduction over the first 6 months post treatment correlated with increased grip strength, serum albumin levels, and compound muscle action potential amplitudes at 12 months.

CONCLUSIONS

Serum VEGF level at 6 months post treatment is a predicative biomarker for disease activity and prognosis in POEMS syndrome. Serum VEGF could be used as a surrogate endpoint for relapse-free survival or clinical or laboratory improvement of POEMS syndrome for clinical trials.

[Cryptococcus Neoformans Var. Gattii meningoencephalitis with cryptococcoma in an immunocompetent patient successfully treated by surgical resection]

Cryptococcosis is a fungal infection, which mainly invades the lungs and central nervous system. In Japan, most cases of cryptococcosis are caused by Cryptococcus neoformans(C. neoformans). Until now, only three cases which the infectious agent was Cryptococcus neoformans var. gattii(C. gattii)have been reported. As compared with cryptococcosis caused by C. neoformans, which is often observed in immunocompromised hosts, cryptococcosis caused by C. gattii occurs predominantly in immunocompetent hosts and is resistant to antifungal drugs. Here, we report a case of refractory cerebral cryptococcoma that was successfully treated by surgical resection of the lesions. A 33-year-old man with no medical history complained of headache, hearing disturbance, and irritability. Pulmonary CT showed a nodular lesion in the left lung. Cerebrospinal fluid examination with Indian ink indicated cryptococcal meningitis, and PCR confirmed infection with C. gattii. C. gattii is usually seen in the tropics and subtropics. Since this patient imported trees and soils from abroad to feed stag beetles, parasite or fungal infection was, as such, suspected. Although he received 2 years of intravenous and intraventricular antifungal treatment, brain cryptococcomas were formed and gradually increased. Because of the refractory clinical course, the patient underwent surgical resection of the cerebral lesions. With continuation of antifungal drugs for 6 months after the surgeries, Cryptococcus could not be cultured from cerebrospinal fluid, and no lesions were seen on MR images. If cerebral cryptococcosis responds poorly to antifungal agents, surgical treatment of the cerebral lesion should be considered.

Ultrasonographic findings in cubital tunnel syndrome caused by a cubitus varus deformity

We have retrospectively reviewed the clinical, preoperative ultrasonographic, and operative findings of eight patients who had tardy ulnar nerve palsy caused by a cubitus varus deformity. The mean varus angle on the affected side was 23°. With preoperative ultrasonography, the anterior dislocation of the ulnar nerve from the medial epicondyle was detected in dynamic scanning of short-axis images, and long-axis images revealed nerve compression and kinking in the proximal border of the flexor carpi ulnaris. Operative findings revealed compression of the ulnar nerve by a fibrous band, which was released in all cases. The cause of the tardy ulnar nerve palsy in this series of patients was constriction by a fibrous band and kinking in the proximal border of the flexor carpi ulnaris due to ulnar nerve dislocation from compression resulting from the forward movement of the medial head of the triceps brachii muscle.

Biomechanical Analysis of the Stress Force on Midcarpal Joint in Kienböck's Disease

Two types of lunate were recognized in the midcarpal joint. Type I lunate has no facet articulation with the hamate, and Type II lunate has a facet articulation with the hamate. The purposes of this study are to estimate the biomechanical contribution of Type II lunate for Kienböck's disease, and to elucidate the change of the contact surface between the lunate and hamate during radial and ulnar deviation for both Type I and Type II. Twenty-four contralateral unaffected wrists with Kienböck's disease were used for the first purpose. The radiographic force analysis was performed with a modified two-dimensional rigid-body spring model computer-simulation technique. Six wrists of volunteers (3 of Type I and 3 of Type II lunates) were used for the second purpose. Dynamic examination on lunohamate joint was carried out using magnetic resonance imaging. The force distribution between the radius and Type II lunate was greater than that between the radius and Type I lunate statistically. Furthermore, the impingement of articular cartilages between Type II lunate and hamate was observed in ulnar deviation on dynamic study. These results suggest that Type II lunate was one of the anatomical risk factors for Kienböck's disease.

Acetabular and proximal femoral alignment in patients with osteoarthritis of the dysplastic hip and its influence on the progression of disease

In order to evaluate the relationship between acetabular and proximal femoral alignment in the initiation and evolution of osteoarthritis of the dysplastic hip, the acetabular and femoral angles were calculated geometrically from radiographs of 62 patients with pre-arthrosis and early osteoarthritis. The sum of the lateral opening angle of the acetabulum and the neck-shaft angle was defined as the lateral instability index (LII), and the sum of the anterior opening angle of the acetabulum and the anteversion angle of the femoral neck as the anterior instability index (AII). These two indices were compared in dysplastic and unaffected hips. A total of 22 unilateral hips with pre-arthrosis were followed for at least 15 years to determine whether the two indices were associated with the progression of osteoarthritis. The LII of the affected hips (197.4 (sd 6.0)) was significantly greater than that of the unaffected hips (1830 (sd 6.9)). A follow-up study of 22 hips with pre-arthrosis showed that only the LII was associated with progression of the disease, and an LII of 196 was the threshold value for this progression.

Combination joint-preserving surgery for forefoot deformity in patients with rheumatoid arthritis

Proximal osteotomies for forefoot deformity in patients with rheumatoid arthritis have hitherto not been described. We evaluated combination joint-preserving surgery involving three different proximal osteotomies for such deformities. A total of 30 patients (39 feet) with a mean age of 55.6 years (45 to 67) underwent combined first tarsometatarsal fusion and distal realignment, shortening oblique osteotomies of the bases of the second to fourth metatarsals and a fifth-ray osteotomy.

The mean follow-up was 36 months (24 to 68). The mean foot function index scores for pain, disability and activity subscales were 18, 23, and 16 respectively. The mean Japanese Society for Surgery of the Foot score improved significantly from 52.2 (41 to 68) to 89.6 (78 to 97). Post-operatively, 14 patients had forefoot stiffness, but had no disability. Most patients reported highly satisfactory walking ability. Residual deformity and callosities were absent. The mean hallux valgus and intermetatarsal angles decreased from 47.0° (20° to 67°) to 9.0° (2° to 23°) and from 14.1° (9° to 20°) to 4.6° (1° to 10°), respectively. Four patients had further surgery including removal of hardware in three and a fifth-ray osteotomy in one.

With good peri-operative medical management of rheumatoid arthritis, surgical repositioning of the metatarsophalangeal joint by metatarsal shortening and consequent relaxing of surrounding soft tissues can be successful. In early to intermediate stages of the disease, it can be performed in preference to joint-sacrificing procedures.

Gravitational unloading inhibits the regenerative potential of atrophied soleus muscle in mice

AIM

The present study was performed to investigate the influence of unloading on the regeneration of atrophied and injured skeletal muscle.

METHODS

Male mice (C57BL/6J), aged 8 weeks, were used. Cardiotoxin (CTX) was injected into soleus muscles bilaterally. Gravitational unloading on soleus muscle was performed by hind limb suspension for 2 weeks before and additionally 6 weeks after CTX injection in one group. Soleus muscles in the remaining groups were loaded keeping the mice in the cages and were dissected 14, 28 and 42 days after the injection.

RESULTS

Recovery of the wet weight and protein content of soleus in the CTX-injected group was inhibited by unloading. Increase in satellite cell number, induced by CTX injection and loading, was also inhibited by unloading. Disappearance of infiltration of mononucleated cells into the necrotic area was also delayed. This phenomenon suggests that regeneration, which is indicated by the appearance of fibres with central nuclei, was inhibited by unloading.

CONCLUSION

Results suggested that loading plays an important role in the activation of the regenerating potential of injured skeletal muscle.

Tryptase enhances release of vascular endothelial growth factor from human osteoarthritic chondrocytes

OBJECTIVE

A contribution of mast cells and its mediators in the pathogenesis of arthritis has been postulated. We aimed to clarify the role of mast cell-derived serine protease tryptase and proteinase activated receptor (PAR)-2-mediated signaling in chondrocytes.

METHODS

Human articular cartilage specimens were obtained from patients with osteoarthritis (OA), rheumatoid arthritis (RA) and with traumatic fracture without arthritis (PT; as controls) who underwent joint surgery. Isolated chondrocytes were cultured in vitro by monolayer, and confluent cells were incubated with recombinant human lung Beta tryptase or with a PAR-2 agonist peptide. The secreted level of vascular endothelial growth factor (VEGF) in culture supernatant was measured using commercially available ELISA kits, and expression of VEGF mRNA was analyzed using real-time PCR.

RESULTS

The tryptase-stimulated chondrocytes from OA or RA, but not from PT patients, produced significantly higher amount of VEGF in their supernatants. The response was blocked by a G-protein receptor inhibitor pertussis toxin, however, was not reproduced by incubation of cells with the PAR-2 agonist, suggesting a presence of non-PAR-2 dependent signals for the VEGF induction. In addition, actinomycin D and cycloheximide did not exert significant inhibition, indicating a regulation of VEGF release by tryptase.

CONCLUSION

The inflammatory mediator, mast cell-derived protease tryptase may modulate chondrocyte metabolism through induction of VEGF release.

Positron emission tomography with 18F-FDG in osteoarthritic knee

OBJECTIVES

To evaluate osteoarthritis (OA) of the knee using positron emission tomography (PET) with 2-(18)F-fluoro-2-deoxy-D-glucose ((18)F-FDG) as a tracer.

MATERIALS AND METHODS

Fifteen patients with medial-type knee OA and three healthy subjects were enrolled in the study. After clinical examination and conventional radiography, (18)F-FDG PET and magnetic resonance imaging (MRI) were performed. (18)F-FDG uptake was quantified as a standardized uptake value (SUV) and the localization of (18)F-FDG uptake was identified using fusion images created with MRI scans.

RESULTS

(18)F-FDG generally accumulated in periarticular lesions and was absent in the articular cartilage. SUVs of the whole knee were higher in OA than in controls, and those in the medial condyle were higher than in the lateral condyle in OA. Prominent (18)F-FDG uptake was found in the intercondylar notch in OA and extended along the posterior cruciate ligament (PCL) in some cases. Periosteophytic accumulation was found in one-half of cases with definite osteophytes. Accumulation was also found in subchondral lesions and bone marrow, which corresponded with bone edema diagnosed by MRI. No significant correlation was found between SUV and clinical manifestations.

CONCLUSIONS

(18)F-FDG uptake was upregulated in OA and generally accumulated in periarticular lesions. Increased uptake was found in the intercondylar notch extending along the PCL, periosteophytic lesions, and bone marrow. These results provide in vivo pathognomonic insights into OA.

Change in the cross-sectional area of a patellar tendon graft after anterior cruciate ligament reconstruction

The purpose of this study was to clarify the change in the cross-sectional area (CSA) of a patellar tendon graft after anterior cruciate ligament (ACL) reconstruction, and its relationship with postoperative knee laxity. Forty patients (25 men and 15 women) were included in this study. Intraoperative CSA measurements were performed with an instrumented areamicrometer, while a magnetic resonance imaging (MRI) evaluation was utilized for the assessment postoperatively. For intraoperative measurement, the average CSA of a 10-mm wide patellar tendon graft was 32.3 +/- 7.0 mm2, while the average CSA measured at follow-up (mean: 14.8 months) was 48.8 mm2, showing a significant mean increase ratio of 49.4%. This value corresponded to 115% of the native ACL. The average CSA measured in 30 patients at 6 months was 49.7 mm2, almost equal to the value at the final follow-up (49.8 mm2) in the same patient group. Among potentially influential factors, postoperative notch width (available space for the ACL graft) had significant correlation with the CSA of the graft at follow-up. Finally, both intra- and postoperative CSA values did not correlate with postoperative knee laxity, indicating that a bigger graft does not guarantee a better laxity.

High expression levels of nuclear factor kappaB, IkappaB kinase alpha and Akt kinase in squamous cell carcinoma of the oral cavity

BACKGROUND

It has been reported that the transcription factor nuclear factor kappaB (NF-kappaB) is involved in the growth, invasion, and antiapoptotic activity of cultured tumor cells.

METHODS

The authors used immunohistochemistry to examine the expression of NF-kappaB and the signaling molecules leading to NF-kappaB activation in 36 untreated biopsy specimens from patients with squamous cell carcinoma (SCC) and in 15 specimens from patients with epithelial dysplasia of the oral cavity.

RESULTS

Among the molecules examined, the p65 subunit of NF-kappaB (p65) and IkappaB kinase alpha (IKKalpha) were expressed highly in almost all SCC specimens examined, whereas the samples of normal squamous epithelia adjacent to tumors as well as epithelial dysplasia specimens were negative in for immunohistochemical staining. The invasiveness and metastasis of SCC seemed to correlate with the degree of staining degree in the molecules. Moreover, phosphorylated Akt kinase, which may be associated with antiapoptosis signaling of NF-kappaB, was detected in the same areas where IKKalpha existed in large amounts.

CONCLUSIONS

The results suggest that high expression levels of p65 and IKKalpha contribute to malignant behavior and antiapoptotic activity in SCC of the oral squamous epithelium.

High expression levels of nuclear factor kappaB, IkappaB kinase alpha and Akt kinase in squamous cell carcinoma of the oral cavity

BACKGROUND

It has been reported that the transcription factor nuclear factor kappaB (NF-kappaB) is involved in the growth, invasion, and antiapoptotic activity of cultured tumor cells.

METHODS

The authors used immunohistochemistry to examine the expression of NF-kappaB and the signaling molecules leading to NF-kappaB activation in 36 untreated biopsy specimens from patients with squamous cell carcinoma (SCC) and in 15 specimens from patients with epithelial dysplasia of the oral cavity.

RESULTS

Among the molecules examined, the p65 subunit of NF-kappaB (p65) and IkappaB kinase alpha (IKKalpha) were expressed highly in almost all SCC specimens examined, whereas the samples of normal squamous epithelia adjacent to tumors as well as epithelial dysplasia specimens were negative in for immunohistochemical staining. The invasiveness and metastasis of SCC seemed to correlate with the degree of staining degree in the molecules. Moreover, phosphorylated Akt kinase, which may be associated with antiapoptosis signaling of NF-kappaB, was detected in the same areas where IKKalpha existed in large amounts.

CONCLUSIONS

The results suggest that high expression levels of p65 and IKKalpha contribute to malignant behavior and antiapoptotic activity in SCC of the oral squamous epithelium.

17 Beta-estradiol increases nitric oxide and prostaglandin I2 production by cultured human uterine arteries only in histologically normal specimens

These experiments were designed to investigate whether 17beta-estradiol (E2) modulates the endothelial function of perimenopausal human uterine arteries. After the artery specimen was cultured in the presence or absence of E2 at a physiologic concentration of 200 pg/ml, changes in isometric tension and cyclic nucleotide production were determined. Degree of intimal hyperplasia was assessed histologically and expressed as intima-to-media ratio. Acetylcholine produced an endothelium-dependent relaxation in six specimens (group I) of 12, which was inhibited by NG-nitro-L-arginine or indomethacin. However, the agonist failed to produce a definite relaxation in the remaining 6 (group II). The endothelium-dependent relaxation was significantly augmented after incubating with E2 only in group I specimens. Cyclic nucleotide production was significantly increased after E2 incubation only in group I specimens, whereas it was inhibited by NG-nitro-L-arginine or indomethacin. Histologic study revealed that the six specimens of group I had normal intima (intima-to-media ratio = 19.1+/-1.8%) and the remaining six of group II had intimal hyperplasia (intima-to-media ratio = 53.6+/-5.3%). Increased production of cyclic nucleotides occurred in uterine arteries with normal intima but not in arteries with intimal hyperplasia derived from perimenopausal women.

Determination of urinary pyrraline by solid-phase extraction and high performance liquid chromatography

Pyrraline is one of the advanced glycation end products formed under non-enzymatic and non-oxidative conditions in vivo. In this study, we developed a novel method for determination of urinary pyrraline using solid-phase extraction as a pretreatment procedure prior to determination by high performance liquid chromatography (HPLC). The Oasis HLB solid-phase extraction cartridge was used for pretreatment of urine samples without hydrolysis. The chromatogram obtained clearly revealed the peak for urinary pyrraline owing to prior removal of interfering substances in urine samples. The recovery rate of pyrraline was 97.2+/-3.3% (n=6). The mean excretion level of urinary pyrraline in healthy control (20-77 years old, n = 30) was 1.42+/-0.65 micromol/mmol creatinine, and the daily variation in the excretion level was considered to be insignificant. We propose the above procedure as a simple, rapid, and accurate method for determination of pyrraline levels in urine.

Substrate-bound fibronectin enhances scavenger receptor activity of macrophages by calcium signaling

We have previously found that ability of mouse macrophages to bind and take up oxidized low-density lipoprotein (oxLDL) through scavenger receptors is significantly enhanced when the cells are plated on fibronectin (FN)-coated culture substrates. Here, the mechanisms of the enhancement of the scavenger receptor activity by the substrate-bound FN was investigated using thioglycollate-induced mouse peritoneal macrophages. A Ca(2+) channel blocker diltiazem and a calmodulin inhibitor W-7 reduced the scavenger receptor activity of the macrophages plated on FN-coated substrate to the level of the cells plated on uncoated substrate, as assessed by oxLDL binding, while the scavenger receptor activity of the macrophages on uncoated substrate was little affected. Similarly, FN-induced enhancement of the scavenger receptor activity assessed by oxLDL uptake was selectively inhibited by Ca(2+) channel blockers (diltiazem, nifedipine, verapamil) and calmodulin inhibitors (W-7, trifluoperazine). Intracellular free Ca(2+) level of the macrophages was increased, depending on extracellular Ca(2+), when plated on FN-coated substrate. This increase in the Ca(2+) level was inhibited by diltiazem and RGD-containing peptides present in cell adhesive region of FN. Like the substrate-bound FN, Ca(2+) ionophore A23187 enhanced the scavenger receptor activity of binding and taking up of oxLDL. These results indicate that substrate-bound FN enhances scavenger receptor activity of macrophages by increasing channel-dependent Ca(2+) influx. A microtubule disruptor, colchicine, and an actin filament disruptor, cytochalasin B, inhibited the FN-induced enhancement of the scavenger receptor activity, suggesting that these cytoskeletal structures are required for transmission of the adhesion signal of FN. The number of the scavenger receptors was found to increase by 1.4-fold upon adhesion signal of FN. We suggest that substrate-bound FN increases the number of the macrophage scavenger receptors as a result of induction of Ca(2+) influx and causes increased accumulation of oxLDL within the cells, rendering the cells more susceptible to conversion into foam cells.

Osteoclast-like cells in an in vitro model of bone destruction by rheumatoid synovium

OBJECTIVE

Osteoclasts may be involved in the process of rheumatoid bone destruction. To test this hypothesis, we developed an in vitro model of bone destruction by osteoclast-like cells derived from cultured rheumatoid synovial tissue without using any inducers.

METHODS

Synovial tissues were obtained from rheumatoid arthritis and osteoarthritis patients and tissue pieces of about 2 mm(3) that contained synovial lining were cultured. Multinucleated cells derived from cultured synovial tissues were studied cytochemically and morphologically for osteoclast-specific markers.

RESULTS

Fibroblast-like and macrophage-like cells from the tissue pieces proliferated in the coexistence of lymphocytes. After 14 days of culture, multinucleated cells with tartrate-resistant acid phosphatase activity appeared. These cells expressed vacuolar H(+)-ATPase, the vitronectin receptor and cathepsin K. Although binding of (125)I-labelled salmon calcitonin was very low, the cells contained ringed structures of F-actin and showed strong bone-resorbing activity on ivory slices. Proliferation of macrophage-like cells and formation of multinucleated cells continued during 6 months of culture in the presence of fibroblast-like cells. The bone-resorbing activity of multinucleated cells derived from rheumatoid synovial tissue was much higher than that of cells from osteoarthritis synovial tissue, and was related to the disease activity of rheumatoid arthritis.

CONCLUSION

Our culture system reproduced in vitro the process of bone destruction by rheumatoid synovium, including the proliferation and fusion of precursor cells, polarization, activation and bone tissue resorption. This system may provide a tool for understanding the mechanisms of bone destruction in rheumatoid arthritis and for the development of new therapies to prevent bone destruction.

Water-soluble antioxidants inhibit macrophage recognition of oxidized erythrocytes

Effect of exogenously added water-soluble antioxidants on the mouse macrophage lectin-like receptor activity for oxidized erythrocytes was investigated. A monolayer of thioglycollate-induced mouse peritoneal macrophages was preincubated with each of the antioxidants at 37 degrees C for 1 h, and the binding for mouse erythrocytes oxidized with ADP-chelated Fe(III) was examined. The binding was decreased by preincubation of macrophages with ascorbic acid-related compounds including ascorbic acid, erythorbic acid and dehydroascorbic acid in a dose-dependent fashion at relatively high concentrations above 10 microM. The binding was similarly decreased by preincubation of macrophages with catechin compounds including epicatechin, epigallocatechin, epicatechin gallate and epigallocatechin gallate in a dose-dependent fashion at 0.01-100 microM. The binding was more effectively decreased by preincubation of macrophages with thiol-related compounds including glutathione, oxidized glutathione, glutathione isopropyl ester and N-acetylcysteine in a dose dependent fashion at relatively low doses below 1 microM. These results showed that water-soluble antioxidants especially glutathione and its derivatives reduced the ability of macrophages to bind oxidized erythrocytes, suggesting that the activity of lectin-like receptors of macrophages for oxidized erythrocytes was regulated by oxidative mechanisms.

[Weekly paclitaxel and cisplatin in recurrent ovarian cancer]

This study was performed to assess the feasibility of weekly paclitaxel (TXL) and cisplatin (CDDP) in patients with recurrent ovarian cancer. Ten of eleven patients experienced recurrence after more than 6 months after first line CDDP-based chemotherapy. TXL and CDDP were given at initial doses of 60 mg/m2 and 30 mg/m2 on days 1, 8, and 15 in 2 patients and an increase in the respective dose level was planned to 60/35 in 5 patients, 70/35 in 2 patients, and 70/40 in 2 patients. Toxicities were well tolerated. None of the patients suffered from neurotoxicity or myalgia of more than grade 2. Gastrointestinal disorder was recognized as grade 1-2, and grade 3-4 hematological toxicity included leucocytopenia (64%), anemia (36%), and thrombocytopenia (9%). We set the recommended dose of TXL at 70 mg/m2 and that of CDDP at 35 mg/m2, considering toxicity and performed planned schedule. Of eleven patients, nine were assessable by computed tomographic scan. The overall response rate was 67% (CR: 1, PR: 5, NC: 1, PD: 2). One of two patients with standard TXL/CDDP therapy showed PR by switching to a weekly schedule. The median follow-up duration was 490 days and the median response duration was 371 days. From the results presented here, it is suggested that this regimen with increased DI might be quite effective and well tolerated in patients who experience relapse after CDDP-based chemotherapy.

Involvement of calcium signaling in the fibronectin-stimulated macrophage recognition of oxidatively damaged erythrocytes

Macrophages recognize oxidatively damaged autologous erythrocytes, and cell surface fibronectin of macrophages enhances the recognition (Beppu et al., FEBS Lett. 295 (1991) 135-140). In the present study, mechanisms of enhanced macrophage recognition of oxidatively damaged erythrocytes by fibronectin were investigated. Monolayers of thioglycollate-induced mouse peritoneal macrophages with cell surface fibronectin recognized autologous erythrocytes oxidized with an iron catalyst ADP/Fe(3+). The macrophage recognition of the oxidized erythrocytes was inhibited partially by pretreatment of the macrophage monolayers with a Ca(2+) channel blocker (diltiazem), calmodulin inhibitors (W-7, trifluoperazine, chlorpromazine and dibucaine), an inhibitor of myosin light chain kinase (ML-9), a microfilament formation inhibitor (cytochalasin B), phospholipase A(2) inhibitors (4-bromophenacyl bromide, mepacrine) and cyclooxygenase inhibitors (indomethacin and aspirin). Monolayers of macrophages depleted of fibronectin by trypsinization lost the ability of recognizing oxidized erythrocytes, but acquired the ability when stimulated with a fibronectin-coated coverslip. The recognition of fibronectin-stimulated trypsinized macrophages was also inhibited by the above inhibitors. On treatment with Ca ionophore A23187, trypsinized macrophages acquired the ability to recognize oxidized erythrocytes. The recognition of Ca ionophore-stimulated trypsinized macrophages was inhibited by the above inhibitors except the Ca(2+) channel blocker. These results indicate that the Ca(2+) signaling including Ca(2+) influx, calmodulin activation and myosin light chain phosphorylation are involved in the fibronectin stimulation of the recognition of macrophages for oxidized erythrocytes. Involvement of microfilament formation and arachidonate cascade in the fibronectin stimulation was also suggested.