Sixty-four-section CT cerebral perfusion evaluation in patients with carotid artery stenosis before and after stenting with a cerebral protection device

BACKGROUND AND PURPOSE

Brain tissue viability depends on cerebral blood flow (CBF) that has to be kept within a narrow range to avoid the risk of developing ischemia. The aim of the study was to evaluate by 64-section CT (VCT) the cerebral perfusion modifications in patients with severe carotid stenosis before and after undergoing carotid artery stent placement (CAS) with a cerebral protection system.

MATERIALS AND METHODS

Fifteen patients with unilateral internal carotid stenosis (>or=70%) underwent brain perfusional VCT (PVCT) 5 days before and 1 week after the stent-placement procedure. CBF and mean transit time (MTT) values were measured.

RESULTS

Decreased CBF and increased MTT values were observed in the cerebral areas supplied by the stenotic artery as compared with the areas supplied by the contralateral patent artery (P < .001). A significant normalization of the perfusion parameters was observed after the stent-placement procedure (mean pretreatment MTT value, 5.3 +/- 0.2; mean posttreatment MTT value, 4.3 +/- 0.18, P < .001; mean pretreatment CBF value, 41.2 mL/s +/- 2.1; mean posttreatment CBF value, 47.9 mL/s +/- 2.9, P < .001).

CONCLUSIONS

PVCT is a useful technique for the assessment of the hemodynamic modifications in patients with severe carotid stenosis. The quantitative evaluation of cerebral perfusion makes it a reliable tool for the follow-up of patients who undergo CAS.

Diffusion tensor magnetic resonance imaging of prostate cancer

PURPOSE

To explore the feasibility of 3T magnetic resonance (MR) diffusion tensor imaging (DTI) and fiber tracking (FT) in patients with prostate cancer.

MATERIALS AND METHODS

Thirty consecutive patients (mean age, 62.5 years) with biopsy proven prostate cancer underwent 3T-MR imaging (MRI) and DTI using a 6-channel external phased-array coil before radical prostatectomy. Regions of interest of 14 pixels were defined in tumors and nonaffected areas in the peripheral zone (PZ) and central gland (CG), according to histopatology after radical prostatectomy. Apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values were determined. Differences in mean ADC and FA values among prostate cancer, normal PZ and CG were compared by 2-sided Student t test. The predominant diffusion direction of the prostate anisotropy was color coded on a directionally encoded color (DEC) map. A 3D reconstruction of fiber tract orientations of the whole prostate was determined using the continuous tracking method. The overall image quality for tumor localization and local staging was assessed in retrospective matching with whole-mount section histopathology images. Nodules detected at MRI were classified as matched lesions if tumor presence and extension were evidenced at histopathology.

RESULTS

For all the patients, the DTI sequence images were suitable for the evaluation of the zonal anatomy of the prostate gland and the tumor localization. Quantitative evaluation of the regions of interest (ROIs) showed a mean ADC value significantly lower in the peripheral neoplastic area (1.06 +/- 0.37 x 10(-3) mm2/s) than in the normal peripheral portion (1.95 +/- 0.38 x 10(-3) mm2/s) (P < 0.05). The mean FA values calculated in the normal peripheral (0.47 +/- 0.04) and central area (0.41 +/- 0.08) were very similar (P > 0.05). The mean FA values in the neoplastic lesion (0.27 +/- 0.05) were significantly lower (P < 0.05) than in the normal peripheral area and in the normal central and adenomyomatous area. DEC map showed a top-bottom type preferential direction in the peripheral but not in the central area, with the tumor lesions reducing the diffusion coding direction represented as color zones tending toward gray. Tractographic analysis permitted good delineation of the prostate anatomy (capsule outline, peripheral and central area borders) and neoplastic lesion extension and capsule infiltration compared with histopathology.

CONCLUSIONS

Three Tesla DTI of the prostate gland is feasible and has the potential for providing improved diagnostic information.

A diffusion longitudinal MR imaging study in normal-appearing white matter in untreated relapsing-remitting multiple sclerosis

BACKGROUND AND PURPOSE

Our aim was to evaluate the hypothesis that water diffusion alterations are present in normal-appearing white matter of patients with relapsing-remitting multiple sclerosis (RRMS) and to assess their change with time.

MATERIALS AND METHODS

Fifty-four subjects with clinically diagnosed RRMS, with disease duration of less than 12 months and an expanded disability status scale (EDSS) score of <3.5, underwent a diffusion 3T MR imaging study. The apparent diffusion coefficient (ADC) maps generated were compared with those of 18 control subjects. Eighteen of the 54 patients underwent MR imaging assessment at 3 and 6 months after baseline evaluation. Remitting patients were clinically and MR imaging stable for the 2 months before the study. All patients were drug-free for the 3 months before the study, and in the relapsing patients, the MR imaging was always performed before beginning treatment.

RESULTS

Mean ADC values showed significant differences when relapsing, remitting, and control patients were compared. The relapsing or remitting phase showed significant difference when compared both with controls (P < .01) and between them (P < .05). Comparing mean ADC values of patients with clinical disability (EDSS <2 versus EDSS >/=2) also provided significant differences with the control group (P < .01). The data of patients showing a relapsing episode during the longitudinal part of the study showed a significant difference compared with data from their remitting phase (P < .01).

CONCLUSION

Brain microstructural changes can be detected and correlate with clinical impairment during the stages of MS. These changes modify with time in the relapsing group.

The “Safari” Technique to Perform Difficult Subintimal Infragenicular Vessels

The purpose of this study was to describe the efficacy of planned combined subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) to obtain the precise recanalization of the patent portion of a distal runoff vessel in critical limb ischemia (CLI) patients presenting long occlusions involving the popliteal trifurcation. Four patients at risk of limb loss due to long occlusions involving the leg vessel tree and not suitable for a surgical bypass were treated by the subintimal antegrade and retrograde (posterior tibial or anterior tibial artery) approach. The patent portion of the runoff vessel was previously assessed by magnetic resonance angiography (MRA) and directly punctured under Doppler ultrasound (US) guidance. A subintimal channel rendezvous was performed to allow snaring of the guidewires. Subsequently, a balloon dilatation was performed without stent deployment. All patients were successfully recanalized and had complete healing of the limb lesions. At the 12-month follow-up all patients showed clinical improvement with no major complications related to the procedure. This combined antegrade and retrograde subintimal approach is currently an excellent endovascular option in patients with long occlusions extending onto the leg vessels trifurcation and at risk of limb loss.

Carotid artery stenting with filter protection in high-risk patients showing severe electroencephalographic alterations during carotid endarterectomy

PURPOSE

To describe the results and efficacy of stent treatment in patients with carotid stenosis who had aborted carotid endarterectomy procedures due to the appearance of severe electroencephalographic (EEG) alterations.

METHODS

A retrospective study was conducted of 18 patients (11 men; mean age 72 years, range 62-84) with symptomatic high-grade carotid artery stenoses (> or = 70%) who experienced severe EEG alterations during carotid endarterectomy, causing the procedure to be aborted. Twelve patients had shown no hemodynamic alterations during preoperative transcranial Doppler evaluation after external compression of the common carotid artery; the remaining 6 could not be evaluated. The patients were referred for carotid artery stenting (CAS); 7 had contralateral internal carotid artery stenosis and 5 had contralateral occlusion. Endovascular intervention was carried out using standard techniques under filter protection. Follow-up was scheduled at 3, 6, and 12 months.

RESULTS

All patients were successfully treated without immediate complications. The EEG did not display any significant alterations during the endovascular procedure. Mean follow-up was 43 months. Magnetic resonance imaging at 6 months showed no signs of cerebral ischemia. Color Doppler ultrasound imaging documented normal stent patency in all patients.

CONCLUSION

Patients with symptomatic severe carotid stenosis (> or = 70%) who are considered at risk due to the appearance of severe EEG alterations during surgical treatment may benefit from CAS with respect to both major and minor complications. Larger studies are needed to confirm these findings.

MR spectroscopy of prostate cancer. Initial clinical experience

Aim of the study was to evaluate the effectiveness of proton MR Spectroscopic (MRS) imaging in the detection and localization of prostate cancer, prospectively compared with histopathologic findings. Magnetic Resonance (MR) and MRS imaging were performed in 65 patients with high levels of prostate-specific antigen (PSA) and suspicious areas at the transrectal ultrasound (TRUS). At MR areas of interest were reported as normal, equivocal or suspicious. At MRS imaging, cancer was diagnosed as "possible" if the ratio of choline plus creatine to citrate exceeded 2 SDs above mean normal peripheral zone values or as "definite" if the ratio exceeded 3 SDs. All patients underwent a TRUS 10-core biopsy within 30 days of the imaging study. MR alone showed sensitivity, specificity, positive predictive values, negative predictive values and accuracy for detection of prostate cancer of 85%, 76%, 53%, 91% and 65%, respectively, whereas MRS alone showed 89%, 77%, 78%, 69% and 83%, respectively. These values were 71%, 90%, 89%, 74% and 80% when the prostate was evaluated combining MR and MRS. The addition of MRS to the MR imaging provides a higher specificity in tumour detection and can be recommended as a problem-solving modality for patients with elevated PSA levels and suspicious TRUS before biopsy.

Management of Biliary Neoplastic Obstruction with Two Different Metallic Stents Implanted in One Session

The efficacy of the "one-step" technique using two different metallic stents (Wallstent and Ultraflex) and associated rate of complications was studied in 87 patients with jaundice secondary to malignant biliary obstruction, with bilirubin level less than 15 mg/dl and Bismuth type 1 or 2 strictures. The study group, composed of 40 men and 47 women with a mean age of 59.4 years (range 37-81 years), was treated with a "one-step" percutaneous transhepatic implantation of self-expanding stents. The cause of the obstruction was pancreatic carcinoma in 38 patients (44%), lymph node metastasis in 20 patients (23%), gallbladder carcinoma in 13 patients (15%), cholangiocarcinoma in 12 patients (14%) and ampullary carcinoma in four patients (5%). A significant reduction in jaundice was obtained in all but one patient, with a drop of total serum bilirubin level from a mean of 13.7 mg/dl to 4.3 mg/dl within the first 4 days. The mean postprocedural hospitalization period was 5.4 days in the Wallstent group and 6.4 days in the Ultraflex group. Mean survival rate was 7.8 months (Wallstent group) and 7.1 months (Ultraflex group). The use of both stents did not reveal any significant difference in parameters tested. The implantation of these self-expandable stents in one session, in selected patients, is clinically effective, devoid of important complications and cost-effective due to the reduction in hospitalization.

Downregulation of COX-2 and JNK expression after induction of ischemic tolerance in the gerbil brain

The response of the inducible isoform of the prostaglandin H2 synthase (COX-2) and the c-Jun N-terminal kinase (JNK) in post-ischemic neuronal damage was assessed in a model of ischemic tolerance in Mongolian Gerbils. After a single 6-min bilateral carotid occlusion, histological damage was evident in the CA1 region of hippocampus, correlated with a high expression of JNK and COX-2 mRNA. However, in the group of animals with a 2-min ischemia and the tolerance group, in which a 2-min bilateral carotid occlusion was followed 3 days later by a 6-min ischemia, no hippocampal or cortical damage was detected. Accordingly, the JNK and COX-2 mRNA levels remained unaffected. We suggest that the level of JNK and COX-2 expression may determine the outcome as either post-ischemic cell death or tolerance.

Evaluation of anterior pituitary gland volume in childhood using three-dimensional MRI

BACKGROUND

Three-dimensional MRI (3D-MRI) is a reliable tool for the evaluation of anatomical volumes. Volumetric measurement of the normal anterior pituitary gland in childhood has been performed in the past by 2D-MRI calculations, but has inherent inaccuracies.

OBJECTIVE

To obtain accurate normal anterior pituitary gland volume in childhood using 3D-MRI coronal sections.

MATERIALS AND METHODS

The anterior pituitary gland was measured using coronal T1-weighted 3D-gradient-echo sequences (section thickness 0.75 mm). The study group was composed of 95 prepubertal children (age range 2 months-10 years) with clinically normal pituitary function and no pituitary or brain abnormalities.

RESULTS

A measurement error of 0.2-0.4% was assessed by using a phantom study. Volumetric evaluation of the anterior pituitary gland showed progressive growth of the gland from a mean 131+/-24 mm(3) at 2-12 months, to 249+/-25 mm(3) at 1-4 years and 271+/-29 mm(3) at 5-10 years.

CONCLUSIONS

These data may be useful for paediatricians in the evaluation of patients with neuroendocrine diseases, in particular growth hormone deficiency.

Gene expression profiling of 12633 genes in Alzheimer hippocampal CA1: transcription and neurotrophic factor down-regulation and up-regulation of apoptotic and pro-inflammatory signaling

Alterations in transcription, RNA editing, translation, protein processing, and clearance are a consistent feature of Alzheimer's disease (AD) brain. To extend our initial study (Alzheimer Reports [2000] 3:161-167), RNA samples isolated from control and AD hippocampal cornu ammonis 1 (CA1) were analyzed for 12633 gene and expressed sequence tag (EST) expression levels using DNA microarrays (HG-U95Av2 Genechips; Affymetrix, Santa Clara, CA). Hippocampal CA1 tissues were carefully selected from several hundred potential specimens obtained from domestic and international brain banks. To minimize the effects of individual differences in gene expression, RNA of high spectral quality (A(260/280) > or= 1.9) was pooled from CA1 of six control or six AD subjects. Results were compared as a group; individual gene expression patterns for the most-changed RNA message levels were also profiled. There were no significant differences in age, postmortem interval (mean < or = 2.1 hr) nor tissue pH (range 6.6-6.9) between the two brain groups. AD tissues were derived from subjects clinically classified as CDR 2-3 (CERAD/NIA). Expression data were analyzed using GeneSpring (Silicon Genetics, Redwood City, CA) and Microarray Data Mining Tool (Affymetrix) software. Compared to controls and 354 background/alignment markers, AD brain showed a generalized depression in brain gene transcription, including decreases in RNA encoding transcription factors (TFs), neurotrophic factors, signaling elements involved in synaptic plasticity such as synaptophysin, metallothionein III, and metal regulatory factor-1. Three- or morefold increases in RNAs encoding DAXX, cPLA(2), CDP5, NF-kappaBp52/p100, FAS, betaAPP, DPP1, NFIL6, IL precursor, B94, HB15, COX-2, and CEX-1 signals were strikingly apparent. These data support the hypothesis of widespread transcriptional alterations, misregulation of RNAs involved in metal ion homeostasis, TF signaling deficits, decreases in neurotrophic support and activated apoptotic and neuroinflammatory signaling in moderately affected AD hippocampal CA1.

Prostaglandins and other lipid mediators in Alzheimer's disease

In the central nervous system (CNS), prostaglandin (PG) and other bioactive lipids regulate vital aspects of neural membrane biology, including protein-lipid interactions, trans-membrane and trans-synaptic signaling. However, a series of highly reactive PGs, free fatty acids, lysophospolipids, eicosanoids, platelet-activating factor, and reactive oxygen species (ROS), all generated by enhanced phospholipase A2 (PLA2) activity and arachidonic acid (AA) release, participate in cellular injury, particularly in neurodegeneration. PLA2 activation and PG production are among the earliest initiating events in triggering brain-damage pathways, which can lead to long-term neurologic deficits. Altered membrane-associated PLA2 activities have been correlated with several forms of acute and chronic brain injury, including cerebral trauma, ischemic damage, induced seizures in the brain and epilepsy, schizophrenia, and in particular, Alzheimer's disease (AD). Biochemical mechanisms of PLA2 overactivation and its pathophysiological consequences on CNS structure and function have been extensively studied using animal models and brain cells in culture triggered with PLA2 inducers, PGs, cytokines, and related lipid mediators. Moreover, the expression of both COX-2 and PLA2 appears to be strongly activated during Alzheimer's disease (AD), indicating the importance of inflammatory gene pathways as a response to brain injury. This review addresses some current ideas concerning how brain PLA2 and brain PGs are early and key players in acute neural trauma and in brain-cell damage associated with chronic neurodegenerative diseases such as AD.

Lack of effect of insulin on glucose utilization of the hypothalamus in normotensive and hypertensive rats

Hypertension is frequently associated with insulin resistance and enhanced sympathetic activity supposedly mediated by an effect of the hormone on the hypothalamus. In this study we sought to determine whether insulin modifies the functional activity of the hypothalamus and other brain areas of spontaneously hypertensive (SHR) and normotensive WKY rats. The study was carried out in control and hyperinsulinemic, normoglycemic rats. Insulin plasma levels were increased to 198 +/- 10 (WKY) or 220 +/- 10 microunits/ml (SHR). Brain functional activity was evaluated by the 2-[14C]deoxyglucose method for measuring local rates of glucose utilization. The results show that insulin has no effect on any of the brain areas examined including the hypothalamus, of both WKY and SHR rats. The two strains of rats have comparable cerebral metabolic rates also under basal conditions.

Modifications of local cerebral metabolic rates for glucose and motor behavior in rats with unilateral lesion of the subthalamic nucleus

Inactivation of the subthalamic nucleus (STN) has attracted interest as a therapeutic tool in Parkinson's disease. The functional consequences of the inactivation, however, are uncertain. In this study definition of the pattern of changes of cerebral functional activity associated with lesion of the STN and dopaminergic stimulation, by using the [14C]deoxyglucose method, was sought. Six or 7 days following unilateral lesion of the STN, the animals were divided into two groups: One group (n = 10) was administered apomorphine (1 mg/kg) subcutaneously; the second group (n = 10) received saline. The [14C]deoxyglucose procedure was initiated 10 minutes following the drug or saline injection. The results show that systemic administration of apomorphine to rats with unilateral lesion of the STN causes ipsiversive rotational behavior and asymmetries of glucose utilization of defined brain areas, including the substantia nigra reticulata, globus pallidus, and entopeduncular nucleus. These nuclei are the main targets of the subthalamic excitatory projections. Lesion of the nucleus per se (without challenge with apomorphine) has no significant consequences on glucose utilization. The findings indicate that the STN is involved in the activation of the basal ganglia output nuclei induced by systemic dopaminergic stimulation.

Increased functional response to cocaine challenge following recovery from chronic corticosterone in the rat

Several lines of evidence suggest an interaction between glucocorticoids and the rat brain dopaminergic system. Here we demonstrate that a 14-day period of recovery from chronic corticosterone (10 mg/day for 21 consecutive days) potentiates the functional response to acute cocaine challenge in the rat by producing selective metabolic changes in limbic and motor areas, that are not measurable in vehicle-pretreated rats. These data indicate that chronic corticosterone has a long-term facilitatory role in the central effects of cocaine.

Differential effects of acute administration of clozapine or haloperidol on local cerebral glucose utilization in the rat

We employed the [14C]2-deoxyglucose method in order to map local brain metabolic activity of rats administered 1, 5, or 20 mg/kg of clozapine, or 0.5 mg/kg of haloperidol, as compared to saline. Clozapine produced a dose-dependent reduction of glucose utilization. At the dose of 1 mg/kg, the effects were limited to limbic areas. An additional number of structures were significantly affected following administration of 5 mg/kg (the whole hippocampal formation and septal area, and cortical limbic areas). The dose of 20 mg/kg markedly reduced glucose utilization in most of the areas examined. Haloperidol (0.5 mg/kg) reduced glucose utilization of the orbital cortex, hippocampal formation and septal area, globus pallidus, amygdala, ventral thalamus, and substantia nigra reticulata. The results show that acute administration of clozapine or haloperidol are associated with different distribution patterns of altered cerebral energy metabolism. Clozapine differently from haloperidol, reduces energy metabolism of the nucleus accumbens and other limbic areas. Haloperidol, but not clozapine (1 or 5 mg/kg), affects the substantia nigra reticulata.

Psychostimulant drugs increase glucose utilization in the shell of the rat nucleus accumbens

The nucleus accumbens (NAc) is a heterogeneous area, divided into a 'shell' and a 'core' on the basis of morphological and histochemical criteria. Moreover, the two portions have different anatomical connections. In order to test whether the two portions of NAc are functionally distinct, we measured local cerebral glucose utilization in rats administered intravenously with cocaine (1 mg kg-1) or amphetamine (0.5 mg kg-1). The results of the study show that, at these dosages, both drugs increase glucose utilization in the shell, but not in the core of NAc. This differential effect might reflect functional differences between the two portions of NAc, probably relevant to the abuse liability of psychostimulants.