Morphological Analysis of the Sylvian Fissure Stem to Guide a Safe Trans-sylvian Fissure Approach

The sylvian fissure stem and its deep cisternal part (SDCP) consist mainly of the orbital gyrus (OG) and anterior medial portion of the temporal lobe. SDCP's adhesion has been found to make a trans-sylvian approach difficult due to the various patterns of adhesion. Thus, in this study, we aim to clarify the morphological features of the SDCP, and to guide a safe trans-sylvian approach. We retrospectively classified the morphology of the SDCP in 81 patients into 3 types (tight, moderate, loose type) according to the degree of adhesion of the arachnoid membrane and analyzed the morphological features of the OG and the temporal lobe using intraoperative video images. In addition, we have retrospectively measured each width of the SDCP's subarachnoid space at the three points (Point A, lateral superior portion; Point B, downward portion; Point C, medial inferior portion of SDCP) and analyzed their relationship to the degree of adhesion using the preoperative coronal three-dimensional computed tomography angiography (3D-CTA) images of 44 patients. As per the results, SDCP's adhesions were determined to be significantly tighter in cases with large OG and young cases. The temporal lobe had four surfaces (posterior, middle, anterior, and medial) that adhered to the OG in various patterns. The tighter the adhesion between the OG and each of the three distal surfaces of the temporal lobe, the narrower the width of the subarachnoid space at each point (A, B, C). Understanding of the morphological features of the SDCP, and estimating its adhesion preoperatively are useful in developing a surgical strategy and obtaining correct intraoperative orientation in the trans-sylvian approach.

A Simple Method to Estimate the Trajectory to the Genu of the Corpus Callosum in the Interhemispheric Approach for Distal Anterior Cerebral Artery Aneurysms

In the interhemispheric approach (IHA) for the distal anterior cerebral artery (DACA) aneurysms, the surgical trajectory to a DACA aneurysm is very important because surgeons sometimes encounter the intraoperative disorientation and the premature rupture. The purpose of this study was to clarify the anatomical landmarks indicating the trajectory to the genu of the corpus callosum (GCC) at the early stage of dissection for the correct intraoperative orientation. “Point A” was defined as the crossing point between the frontal bone and the line connecting the projected external acoustic opening (EAO) and the GCC on the midline slice of the sagittal three-dimensional computed tomography angiography (3D-CTA) images. We measured the distance from the nasion to Point A using midline sagittal slice images from 50 patients who underwent 3D-CTA at our institution. The average distance was 7.0 cm (±0.3 cm). Therefore, the direction of the spatula inserted in the direction of the EAO from Point A (7 cm above the nasion) corresponds to the trajectory to the GCC. In DACA aneurysms of the A3 segment, the pericallosal artery distal to the aneurysm can be safely identified by dissecting the interhemispheric fissure distal to the trajectory to the GCC. In DACA aneurysms of the A4 or A5 segment, the parent artery of the aneurysm can be safely identified by dissection along the trajectory to the GCC. Point A and the EAO can be used as landmarks indicating the trajectory to the GCC for the correct intraoperative orientation in the IHA for DACA aneurysms.

Dissection of the Sylvian Fissure in the Trans-sylvian Approach Based on the Morphological Classification of the Superficial Middle Cerebral Vein

The superficial middle cerebral vein (SMCV) is one of the main factors that can impede a wide opening of the sylvian fissure. To reveal the most efficient SMCV dissection for a wide operative field while preserving the veins in the trans-sylvian approach, we retrospectively investigated the SMCVs through intraoperative video images. We characterized the SMCV as composed of the frontosylvian trunk (FST; receiving frontosylvian veins [FSVs] or parietosylvian veins [PSVs]), the temporosylvian trunk (TST; receiving temporosylvian veins [TSVs]), and the superficial middle cerebral common trunk (SMCCT; receiving both FSV/PSV and TSV), and classified the SMCVs of the 116 patients into 5 types based on the morphological classification of the SMCV. Type A SMCV (60.4%) with the SMCCT anastomosed to the frontal side had few bridging veins (BVs) between the SMCCT and the temporal side during dissection. Type B (7.8%) had the SMCCT with no anastomoses to the frontal side. In Type C (17.2%) consisting of the FST and TST and Type D (12.9%) with a merging of the vein of Trolard and Labbé posteriorly and the SMCVs dividing into the FST and the TST again proximally, there were few BVs between the FST and the TST during dissection. Finally, in Type E (1.7%) showing an undeveloped SMCV, there were no BVs between the frontal and the temporal lobes. Postoperative venous infarction occurred in 2.6%. Morphological classification of the SMCV can inform appropriate dissection line to create a wide operative field while preserving the veins in the trans-sylvian approach.

Morphological Classification of the Medial Frontal Cortex Based on Cadaver Dissections: A Guide for Interhemispheric Approach

The medial frontal cortex (MFC) is a part of the medial surface of the frontal lobe situated in the rostral portion of the corpus callosum (CC). In a surgical interhemispheric approach (IHA), the MFC covers the anterior communicating artery (Aco) complex until the final stage of dissection. To clarify the anatomical relationship between the MFC and the Aco complex, and to facilitate orientation in IHA, we analyzed the morphological features of the MFC in number, size, and pattern of gyri from the medial surface of the hemisphere in the subcallosal portion using 53 adult cadaveric hemispheres. The mean width of the MFC excluding cingulate gyrus (MFCexcg) was 20.6 ± as mm in the subcallosal portion. MFCexcg consisting of 2, 3, 4, or 5 gyri were observed in 7.5%, 56.6%, 32.1%, or 3.8% of the hemispheres, respectively. Bilateral MFCexcg consisting of >2 gyri were observed in approximately 85% of the hemispheres. Therefore, in many cases, the dissection performed at 2 cm upward from the base of the straight gyrus (SG) or 3–4 gyri of the MFC is sufficient to safely reach the upper portion of the cistern of lamina terminalis located distal to the Aco complex in IHA. The MFC is a good landmark for intraoperative orientation in IHA.

Morphological Pattern and Classification of the Superficial Middle Cerebral Vein by Cadaver Dissections: An Embryological Viewpoint

In this study, we used 45 adult cadaveric cerebral hemispheres to investigate the anatomical classification of the superficial middle cerebral vein (SMCV) based on the number of stems, course, and anastomosis at the distal portion. We classified the SMCVs into five types based on embryological concept. Type A (18 cases, 40.0%) is that the frontosylvian veins (FSVs) merge with the vein of Trolard (VT) and the vein of Labbé (VL) at the distal portion of the sylvian fissure. Type B (5 cases, 11.1%) is that the temporosylvian veins (TSVs) merge with the VT and the VL at the distal portion. Type C (13 cases, 28.9%) is that no vein merge with the VT and the VL at the distal portion. The VT merges with the SMCV from the FSV and the VL merges with the SMCV from the TSV. They course along the sylvian fissure and merge at the proximal portion. In Type D (eight cases: 17.8%), the VT and the VL merge at the distal portion, and the SMCV from the FSV and the SMCV from the TSV join their confluence without merging. Type E (one case, 2.2%) show an undeveloped SMCV. Formation rate of intravenous anastomoses or bridging veins(BVs) at the distal portion between the frontosylvian trunk (FST) and the temporosylvian trunk (TST), between the FST and the temporal lobe, and between the TST and the frontal lobe was very low, because these formation may be difficult to occur during the embryological process in which the SMCV is formed from the telencephalic vein.

The Effect of Irrigation Solutions on Recurrence of Chronic Subdural Hematoma: A Consecutive Cohort Study of 234 Patients

Chronic subdural hematomas (CSDHs) occur often in elderly persons and can occur with mild head trauma. With burr-hole irrigation as standard treatment, symptoms usually improve and can be cured, and outcomes are good, but postoperative recurrences are a common problem. This study investigated the effectiveness and recurrence rates when using artificial cerebrospinal fluid (ACF) instead of normal saline (NS) as an irrigation solution for burr-hole irrigation in patients with CSDH. This prospective study included 234 consecutive patients who underwent initial surgical treatment by burr-hole irrigation for a CSDH between April 2008 and June 2015. The irrigation solution used was changed from NS to ACF in June 2011. Factors examined with regard to recurrence included age, sex, unilateral or bilateral surgery, computed tomography (CT) findings, antiplatelet or anticoagulant drug use, past history, and irrigation solution (NS or ACF). These were analyzed by univariate and multivariate analyses. Univariate analyses (chi-square test) with a significance level <5% showed that recurrence rates were significantly lower in the ACF group than in the NS group (P = 0.003). Multivariate analysis (multiple logistic regression analysis) showed that the risk of recurrence was reduced 3.14-fold in the ACF group compared to the NS group (odds ratio, 3.143; 95% confidence interval, 0.1504–0.6733; P = 0.0028). None of the other factors were significantly different. In burr-hole irrigation for CSDH, the use of ACF instead of NS as an irrigation solution significantly reduces recurrence rates.

Biomimetic flavin-catalysed reactions for organic synthesis

Using simple riboflavin related compounds as biomimetic catalysts, catalytic oxidation of various substrates with hydrogen peroxide or molecular oxygen can be performed selectively under mild conditions. The principle of these reactions is fundamental and will provide a wide scope for environmentally benign future practical methods.

A Japanese pedigree of familial cerebral cavernous malformations--a case report

Familial cerebral cavernous malformations (FCCM) are autosomal-dominant vascular malformations. At present, 3 cerebral cavernous malformation genes (KRIT1/CCM1, MGC4607/CCM2, and PDCD10/CCM3) have been identified. Few genetic analyses of Japanese FCCM have been reported. A Japanese pedigree of 4 patients with FCCM has been reported that includes the genetic analysis of one of the patients. All 4 patients showed multiple lesions in the brain. Surgical removal was performed at our hospital due to enlargement or hemorrhage of the intracranial lesions in a 21-year-old female (Case 1) and a 30-year-old male (Case 2). The histological diagnoses were cavernous malformations. A 62-year-old female (Case 4), the mother of Cases 1, 2, and 3, suffered from intramedullary hemorrhage at T6-7 and surgical removal was performed at another hospital. Only one patient, a 32-year-old female (Case 3), did not show symptoms. The genetic analysis of Case 2 demonstrated heterozygous partial deletions of exons 12-15 of the KRIT1 gene.

Preparation of Highly Ordered Mesoporous Thin Film with Alkyltrimethylammonium(CnTMA+)

We synthesized the highly ordered mesoporous thin films with alkyltrimethyl-ammonium (CnTMA+). The arrangement of mesopores was depend on the Si/surfactant ratio. The hexagonal(P6mm) arrangement was observed, when Surfactant/Si ratio was 1/10. Increasing the Surfactant/Si ratio to 1.6/10, the cubic (Pm3n) arrangements were observed. A steel vessel for the measurement of the nitrogen adsorption isotherms of thin film on the substrate was designed. It was found that mesopore arrangements in the film is more regular than that in the powder samples prepared by the same acidic synthesis conditions.

Factors associated with acute otitis media in children due to penicillin intermediately resistant Streptococcus pneumoniae

OBJECTIVES

This study was conducted to analyze the association between recent antimicrobial use and acute otitis media (AOM) due to Streptococcus pneumoniae intermediately resistant to penicillin (PISP). The influence of drug resistance on the clinical course of AOM was also assessed.

METHODS

A retrospective cohort study was conducted in infants at Japanese Red Cross Medical Center, Tokyo. Children included in the study were under 24 months of age and diagnosed with AOM due to infection with S. pneumoniae between April 2002 and March 2007. Crude risk ratios (cRR) of PISP infection in cases with recent antibiotic use and other factors were obtained. The Mantel-Haenszel estimate was applied for the adjustment of cRR.

RESULTS

Of 35 children, 13 had AOM due to penicillin-susceptible S. pneumoniae (PSSP) and 22 had AOM due to PISP. The adjusted risk ratio (aRR) of penicillin antibiotic use within 1 month was 1.99 (95% confidence interval (CI): 1.36-2.92), and the aRR of penicillin antibiotic use within 1 week was 1.93 (95% CI: 1.33-2.67). Recent use of penicillin antibiotics was an associated factor for AOM due to PISP. The clinical course was not clearly different between cases infected with PSSP and those with PISP.

CONCLUSION

Recent use of penicillin antibiotics might be a selective pressure for PISP.

Two-step surgical treatment using miniature Ommaya's reservoirs for a neonate with multiple large arachnoid cysts

METHOD

We followed a two-step surgical strategy using miniature Ommaya's reservoirs in an early neonate with multiple large arachnoid cysts.

CONCLUSION

Percutaneous fluid aspiration through the reservoirs placed during the first operation permitted the infant to develop sufficiently to withstand the second, more radical cyst wall excision.

TAK1 represses transcription of the human telomerase reverse transcriptase gene

In human cells, telomerase activity is tightly regulated by the expression of its catalytic subunit, namely, the human telomerase reverse transcriptase (hTERT). However, the molecular mechanisms involved in the regulation of hTERT expression have not been completely clarified. We have previously reported that transforming growth factor beta (TGF-beta) represses the expression of the hTERT gene. In the present study, we demonstrated that TGF-beta-activated kinase 1 (TAK1), originally identified as a mitogen-activated kinase kinase kinase, represses the hTERT core promoter activity in an E-box-independent manner, and it also represses the transcription of the hTERT gene in human lung adenocarcinoma cell line, A549 cells. This TAK1-induced repression was found to be caused by the recruitment of histone deacetylase to Sp1 at the hTERT promoter and a consequent reduction in the amount of acetylated histone H4 at the hTERT promoter. Finally, we demonstrated that TAK1 induces cellular senescence programs in normal human diploid cells. Thus, we assume that TAK1 triggers the repression mechanisms of the hTERT gene as a result of evoking cellular senescence programs. Considered together, TAK1 is thought to play a causative role in the determination of a finite replicative lifespan of normal and cancer cells.

[A case of petrotentorial meningioma presented as an acute subdural hemorrhage]

The authors report a rare case of petrotentorial meningioma presenting as acute subdural hematoma. A 60-year-old female was introduced to our hospital complaining of sudden headache and gait disturbance. CT and MRI demonstrated a petrotentorial tumor with a subdural hematoma in the posterior fossa. The tumor was enhanced intensively on MRI and showed the dural tail sign. The patient developed progressive impairment of consciousness along with hydrocephalus. After ventricular drainage, emergency intracranial decompression through hematoma evacuation and partial tumor resection was performed. One month later, she improved clinically and the tumor resected totally in the second craniotomy. Histological examination showed a meningothelial meningioma with high vascularity in part. She recovered uneventfully and was discharged on foot. We discussed the etiology of an acute subdural hematoma caused by intratumoral hemorrhage and reviewed past literatures.

[Symptomatic Rathke's cleft cyst mimicking suprasellar arachnoid cyst]

The authors report an atypical case of symptomatic entirely suprasellar Rathke's cleft cyst mimicking suprasellar arachnoid cyst. A 55-year-old male was introduced to our hospital complaining of bitemporal hemianopsia. CT and MRI demonstrated a cystic mass located entirely in the suprasellar cistern and to compress the optic nerve and mammillary body. The cystic wall was not enhanced in MRI. CT cisternography showed the suprasellar non-communicating cyst with cistern. The hormonal function was slightly disturbed by the pituitary compression. Under the diagnosis of suprasellar arachnoid cyst, a left front temporal craniotomy was performed to resect the suprasellar mass. The surgical specimen consisted ciliated epithelium and was diagnosed Rathke's cleft cyst. After operation, he recovered completely free.

[Hemangioendothelioma of the brain presenting with intracerebral hemorrhage: a case report]

Hemangioendothelioma (HE) is an uncommon vascular tumor that is intermediate in histological appearance between a hemangioma and an angiosarcoma. Presently, it is regarded as endothelial tumors of low-grade or intermediate malignancy. It has been reported in the liver, lung, heart, mediastinum, lymph nodes, extremity, and bone. The occurrence in the brain is extremely rare; only 16 cases have so far been reported. We report a 51-year-old woman who presented with transient visual disturbance and weakness of the left upper limb on April 12th 2003. Computed tomography (CT) revealed a high density mass in the right parietal lobe. In magnetic resonance imaging (MRI), the lesion is hyperintense on TIWI, isointense on T2WI, and no enhancement with gadopentetate dimegliumine. Intratumoral hemorrhage was indicated and preoperative diagnosis was cavernous angioma. The tumor was excised completely on April 28th 2003. Pathologically, the tumor cells resembled endothelial cells, positive immunoreactivity for Factor VIII, and grew in small nests or cords. Postoperative MRI showed complete removal of the tumor. There has been no recurrence for 8 months after the surgery, but we have to follow MRI up for a long time. We discussed intracerebral HE clinically and neuroradiologically.

[Flow reverse therapy for ruptured dissecting aneurysm of basilar trunk: case report]

Treatment of ruptured dissecting aneurysm of basilar trunk (BADAN) has been controversial yet. We report a case of ruptured BADAN successfully treated with endovascular occlusion of the bilateral vertebral artery (VA) proximal to posterior inferior cerebellar artery (PICA), allowing retrograde flow via the posterior communicating arteries to basilar artery. A 58-year-old woman who had subarachnoid hemorrhage was treated with endovascular occlusion of the right VA in acute stage after ballon occlusion test (BOT) of the right VA. Because following BOT of the left VA showed conscious level down, left VA could not be occluded. Follow-up angiography after 26 days revealed regrowth of BADAN. So left VA occlusion was tolerable by BOT after 1 month, we performed endovascular occlusion of the left VA proximal to PICA. She discharged with no neurological deficit after 3 months. Postoperative angiograms 3 months after onset showed complete healing of the aneurysm. The follow-up MRA at 19 months showed no recurrence. We discussed the therapeutic strategy of ruptured BADAN. Flow reverse therapy of bilateral VA occlusion by endovascular method for ruptured BADAN is one of the effective therapy.

[Ruptured aneurysm arising from the anterior medullary segment of the posterior inferior cerebellar artery: report of two cases]

In the distal posterior inferior cerebellar artery (PICA), saccular aneurysms originating at the first proximal segment, anterior medullary segment (AMS), are unusual but important due to the presence of critical perforators that branch off the PICA and supply the lower brainstem. Because the anatomy of the PICA varies, no standard treatment strategy has been agreed upon to date. We successfully treated 2 patients with open surgery. One was a 53-year-old man who presented with Hunt-Hess grade 2 subarachnoid hemorrhage (SAH). Cerebral angiography revealed an irregular fusiform AMS aneurysm extending to the lateral medullary segment. Intraoperative inspection showed some perforators to the brain stem branching from just proximal and distal to the aneurysm. The patient underwent aneurysmal trapping and occipital artery-PICA anastomosis to preserve perforators flow, and was discharged without any neurological deficits. Another patient, a 74-year-old woman, was transferred to our institute because she suddenly became comatose. She was found to have a ruptured saccular AMS aneurysm. On the 15th day after the event, she underwent successful aneurysmal clipping preserving perforators by surgical inspection. As both patients manifested intra-aneurysmal thrombosis, we suggest that patients presenting with AMS aneurysms that display unusual features require careful management and judicious choice of treatment. Based on our experience we suggest that direct surgery, which facilitates the identification of perforators and allows for revascularization, is the appropriate treatment choice in patients who present with this entity.

[Case of painful tic convulsif: discussion of the underlying mechanisms and review of the literature]

The combination of trigeminal neuralgia and ipsilateral hemifacial spasm, known as painful tic convulsif (PTC), is a relatively rare entity in neurovascular compression syndrome. A case of PTC attributable to different offending arteries is described, the mechanisms and characteristics of PTC are discussed, and a review of the literature is presented. This 80-year-old woman had a 10-year history of left trigeminal neuralgia and ipsilateral hemifacial spasm. She presented with intermittent left facial twitching and pain, especially upon swallowing. MRI revealed compression of the left trigeminal nerve by the left anterior inferior cerebellar artery and of the ipsilateral facial nerve by the posterior inferior cerebellar artery. Microvascular decompression of the lesions via left lateral suboccipital craniotomy resulted in immediate and complete symptom improvement. Our case demonstrates that different arteries can affect the trigeminal and facial nerve at a stage that precedes compression by a tortuous vertebrobasilar artery. We suggest that the presence of PTC should be considered in patients with a tortuous vertebrobasilar artery, irrespective of the offending arteries.

[Usefulness of diffusion-weighted magnetic resonance imaging in diagnosis and therapeutic strategy of deep cerebral venous thrombosis: a case report]

We present the usefulness of Diffusion-weighted magnetic resonance images (DWI) in diagnosis and therapeutic strategy of deep cerebral venous thrombosis (VT). We report a 37-year-old man who suffered general convulsion and deep coma. Magnetic resonance imaging (MRI) showed high intensity in the right caudate nuclei and bilateral thalamus on T2-weighted images. DWI showed slightly high intensity in the same area and apparent diffusion coefficient (ADC) is normal or slightly high (0.748-1.100 x 10(-3) mm2/s). Cerebral angiography showed occlusion of straight sinus from basal veins and internal cerebral veins bilaterally. We treated by anticoagulation, ventricle drainage, barubiturate and normothermia therapy with intracranial pressure (ICP) monitoring. We considered endovascular thrombolysis to be dangerous in this case because of hemorrhage and didn't it. ICP was more than 40 mmHg and consciousness was comatose in acute stage, however, ICP gradually got to be normal, consciousness became almost clear and he recovered. Follow-up Cerebral angiography showed recanalization of deep venous thrombosis. Follow-up MRI showed disappearance of high intensity in the right caudate nuclei and bilateral thalamus on T2-weighted images and DWI. In this case, we could predict reversible vasogenic edema by DWI and ADC in VT.

Analysis of Subarachnoid Hemorrhage According to the Japanese Standard Stroke Registry Study-Incidence, Outcome, and Comparison With the International Subarachnoid Aneurysm Trial-

The data for subarachnoid hemorrhage (SAH) from the Japanese Standard Stroke Registry Study (JSSRS) were analyzed to evaluate the incidence of SAH according to age, neurological grading and outcome, and outcome of surgical clipping, for comparison with the International Subarachnoid Aneurysm Trial (ISAT). From the ISSRS data, the peak incidence of SAH was the sixth decade in males and the eighth decade in females. The overall mortality was 22%, and good outcome, better than 2 on the modified Rankin Scale (mRS), at discharge was achieved in 58% of cases. Radical treatment was performed in 62.6% of all SAH cases, 58.7% with surgical clipping and 3.2% with endovascular coiling. Poor outcome, worse than 3 on the mRS, occurred in 26.6% of patients under 60 years, 47.3% between 60-69 years, 54.2% between 70-79 years, and 72.9% 80 years or over. From the ISAT data, 88% of patients were in grades 1-2 of the World Federation of Neurological Surgeons (WFNS) grading system in both surgical clipping and endovascular coiling groups, 94% in grades 1-3, and 98% in grades 1-4. Poor outcome, worse than 3 on the mRS, at 2 months occurred in 25.4% and 36.4% of patients with endovascular coiling and surgical clipping, respectively. Limiting the patients in the JSSRS to WFNS grades 1-2 showed poor outcome, worse than 3 on the mRS, occurred in 12.8%, and in grades 1-3 and 1-4 occurred in only 16.3% and 23.0%, respectively.

Mycoplasma bovis-associated suppurative otitis media and pneumonia in bull calves

Outbreaks of Mycoplasma bovis-associated otitis media and pneumonia occurred on four beef cattle farms in Hokkaido, Japan between 2000 and 2001. The morbidity and mortality were estimated at 8-40 and 30-100%, respectively. Eight calves with bilateral ear droop and exudative otitis media were examined bacteriologically and histopathologically. M. bovis was isolated post mortem from nasal swabs and from the ears, lungs, lymph nodes (cranial and pulmonary), brain and heart of all calves. At necropsy, suppurative exudates were observed in the tympanic bullae of all cases. Numerous abscesses were also found in the petrous portion of the temporal bone and lungs in seven cases. Histopathologically, the exudates within the tympanic bullae consisted of a mixture of neutrophils, necrotic cell debris and fibrin, and the tympanic mucosa was thickened with neutrophil and macrophage infiltration and proliferation of fibrous connective tissue. Pulmonary lesions included extensive foci of coagulative necrosis surrounded by numerous neutrophils. Hepatocytes or renal tubular epithelial cells were enlarged with hyaline cytoplasmic inclusions in four calves. Immunohistochemical labelling confirmed the presence of M. bovis antigen in the cytoplasm of the inflammatory cells in the middle ear, temporal bone and lungs, and was also demonstrated within the cytoplasmic inclusions of the hepatocytes and renal tubular epithelial cells. Ultrastructurally, mycoplasma-like organisms, 200-500 microm in diameter, were found within not only hepatocytes and renal tubular epithelia but also within axons of the facial nerves. The present results show that M. bovis spreads to multiple organs and is capable of invading various kinds of host cell. The intracellular localization may be favourable for evading host immune responses.

[A case of subacute subarachnoid hemorrhage without xanthochromic cerebrospinal fluid--usefulness of emergent MRI]

We reported a case of subacute subarachnoid hemorrhage with watery clear cerebrospinal fluid. Emergent magnetic resonance image was useful not only for diagnosis by fluid attenuated inversion recovery image but also for evaluation of cerebral ischemia and vasospasm by magnetic resonance angiography, diffusion weighted image and perfusion weighted image. A 50-year-old man presented disturbance of consciousness and dysarthria. Neither computed tomographic scan nor cerebrospinal fluid study could diagnose subarachnoid hemorrhage clearly. However, emergent fluid attenuated inversion recovery image showed the show subarachnoid hemorrhage as high signal intensity. Diffusion weighted image showed multiple, round hypersignals both in the white and gray matter. In the area with diffusion hypersignal, the apparent diffusion coefficient value was 0.57 x 10(3) mm2/sec. Perfusion weighted image showed normal cerebral blood volume but prolonged mean transit time in the territory of the right middle cerebral artery. Magnetic resonance angiography revealed an aneurysm at the anterior communicating artery and severe vasospasm on the bilateral anterior cerebral artery, the right middle cerebral artery. Thus we are able to diagnose subarachnoid hemorrhage due to a ruptured anterior communicating artery aneurysm. The hyperintensity of the diffusion weighted image and the fluid attenuated inversion recovery image was caused by cerebral ischemia from vasospasm. After conservative therapy during the period of vasospasm, successful surgical clipping was performed with full clinical recovery.

[A case of subcutaneous malignant lymphoma with dura mater lesion]

A 63-year-old male was admitted to our hospital, complaining of a scalp mass located at the frontoparietal area of his head. He noticed that it had been growing for 2 months. The mass was elastic hard and non-moving. Computed tomography demonstrated a subcutaneous mass with low density and which was enhanced homogeneously. The skull just below the mass was slightly destroyed, but the structure remained. Magnetic resonance imaging (MRI) demonstrated a mass with low signal intensity on both the T1 weighted image and the T2 weighted image. Gd-DTPA study showed homogeneous enhancement and showed also that the dura just below the mass was enhanced. At this point we couldn't diagnose it confidently, but suspected this lesion to be a malignant lymphoma. We made a general examination, but no other lesion was found. A biopsy of the subcutaneous mass was performed under local anesthesia. The histological diagnosis was large-cell type B-Cell lymphoma. The tumor was treated with chemotherapy, CHOP (cyclophosphamid, doxorubicin, vincristin predonisolone). It responded to this chemotherapy and disappeared. We treated this lesion without radiation therapy. We report a case of subcutaneous malignant lymphoma treated successfully with a minimum invasive method.

Mucosal immunoadjuvant activity of the low toxic recombinant Escherichia coli heat-labile enterotoxin produced by Bacillus brevis for the bacterial subunit or component vaccine in pigs and cattle

A gene encoding the mature Escherichia coli heat-labile enterotoxin (LT) lacking the nick site in the A subunit by deleting tripeptides was introduced in a vector pNH301 and expressed extracellularly as mutant molecule of holotoxin at high levels in Bacilus brevis HPD31-S5 of the host bacterium. The mucosal adjuvant activities of the produced mutant LT (mLT) preparation were studied in pigs and cattle. Intranasal immunization of pigs with the recombinant subunit vaccine of Erysipelothrix rhusiopathiae or the component vaccine of Bordetella bronchiseptica mixed with the mLT resulted in a substantial enhancement of both mucosal and serum-specific antibody levels. The immunized pigs were also protected when challenge-exposed intradermally with a highly virulent E. rhusiopathiae strain or challenge-exposed intranasally with a highly virulent strain of B. bronchiseptica. The mLT intranasally administered with recombinant intimin (an outer membrane adhesin) of E. coli O157:H7 also induced an elevation of IgA-specific antibody in the nasal secretion and saliva of calves as well as an elevation of IgG1-specific antibody level against the intimin in the sera and colostrum of cows. The three kinds tested protein antigens were poorly immunogenic when antigen administered intranasally alone. The mLT intranasally administered at a higher effective dose did not induce local adverse reactions or diarrhea in pigs and cattle. The present study demonstrates that the recombinant mLT produced using the B. brevis expression system might represent promising immunoadjuvants for the potential application of intranasal vaccines directed against infectious diseases in pigs and cattle.

[An intradiploic epidermoid cyst of the skull in infancy: case report]

An intradiploic epidermoid cyst of the skull in infancy is rare. We report a case of a 7-month-old girl with an intradiploic epidermoid cyst of the left parietal bone. The patient was admitted to the department of pediatrics in, our hospital in March, 2000, complaining of a lump in the scalp with a diameter of 1.5 cm. The pediatrician doubted that it was a case of Langerhans cell histiocytosis (LCH). In addition, as a result of further tests there were no systemic findings to suggest LCH. The skull x-ray showed round radiolucency of the left parietal bone. CT scans showed an iso density intradiploic mass with destruction of the outer table. Because of the fact that the mass was enlarging, the patient was admitted to our neurosurgical service in April, 2000. We excised the lesion to confirm the histological findings. The histological diagnosis was epidermoid cyst. We discuss the clinical feature and treatment strategy for intradiploic epidermoid cyst in infancy.

Truncated surface protective antigen (SpaA) of Erysipelothrix rhusiopathiae serotype 1a elicits protection against challenge with serotypes 1a and 2b in pigs

Erysipelothrix rhusiopathiae is a causal agent of swine erysipelas, which is of economic importance in the swine industry by virtue of causing acute septicemia, chronic arthritis, and endocarditis. However, little is known about the genetic properties of its protective antigens. Recently, a surface protective antigen (SpaA) gene was identified from serotype 2 in a mouse model. We cloned spaA from virulent strain Fujisawa (serotype 1a) and determined that the N-terminal 342 amino acids without C-terminal repeats of 20 amino acids have the ability to elicit protection in mice. Fusions of 342 amino acids of Fujisawa SpaA and histidine hexamer (HisSpa1.0) protected pigs against challenge with both serotype 1 and serotype 2, the most important serotypes in the swine industry. Pigs immunized with HisSpa1.0 reacted well with both HisSpa1.0 and intact SpaA by enzyme-linked immunosorbent assay and immunoblotting. Serum collected at the time of challenge from a pig immunized with HisSpa1. 0 markedly enhanced the in vitro phagocytic and killing activity of pig neutrophils against the bacteria. DNA sequences of protective regions of spaA genes from five strains of serotypes 1 and 2 were almost identical. The full DNA sequences also seemed to be conserved among strains of all 12 serotype reference strains harboring the spaA gene by restriction fragment length polymorphism analysis of PCR products. These results indicates that SpaA is a common protective antigen of serotypes 1 and 2 of E. rhusiopathiae in swine and will be a useful tool for development of new types of vaccines and diagnostic tools for effective control of the disease.

Serologic evidence that streptococcal superantigens are not involved in the pathogenesis of Kawasaki disease

Kawasaki disease (KD) is an acute multisystem vasculitis of unknown etiology and is associated with marked activation of T cells and monocyte macrophages, leading to the assumption that superantigens are involved in its pathogenesis. To determine if an association exists between streptococcal superantigens and KD, we examined serum antibody responses to superantigens in sera from 50 paired acute and convalescent KD patients using purified recombinant streptococcal superantigens, such as SPEA, SPEC, SSA and MF. We found a very low frequency of detection of anti-superantigen antibodies by ELISA and no marked IgG seroconversion to each superantigen, indicating the absence of a serological relationship between toxin-producing streptococcal infection and the onset of KD.

An enzyme-linked immunosorbent assay (ELISA) for the detection of antibody against Streptococcus suis type 2 in infected pigs

An ELISA test for the detection of antibody against S. suis type 2 in pigs was developed and applied to field sera. The best sensitivity and specificity of ELISA were obtained when a purified polysaccharide antigen was used. It showed no cross reaction with sera against other serotypes of S. suis and other pathogenic bacteria. A total of 264 sera were collected from 20 pig farms and examined with the antibody against S. suis type 2. In the affected farms, 17.0% of pigs tested were positive, 9.8% in the adjacent farms, but only 3.4% in the free farms. The difference of the positive percentages between the affected and the free farms was statistically significant (P < 0.05).

Recombinant 46-kilodalton surface antigen (P46) of Mycoplasma hyopneumoniae expressed in Escherichia coli can be used for early specific diagnosis of mycoplasmal pneumonia of swine by enzyme-linked immunosorbent assay

The 46-kDa surface antigen (P46) is the early and species-specific immunogenic protein of Mycoplasma hyopneumoniae. Three TGA codons encoding tryptophan in the P46 gene were replaced with TGG by an in vitro mutagenesis technique. The mutated P46 gene was expressed in Escherichia coli by using the chelating peptide tag system. The purified recombinant P46 was successfully used in an enzyme-linked immunosorbent assay for detection of antibodies against M. hyopneumoniae in swine serum. It did not cross-react with sera from swine infected with Mycoplasma flocculate, Mycoplasma hyorhinis, or Mycoplasma hyosynoviae. With this method, mycoplasmal pneumonia of swine was detectable within 2 weeks after infection.

Biologically active extracellular products of oral viridans streptococci and the aetiology of Kawasaki disease

A bacteriological study of isolates from the oral cavity of patients with Kawasaki disease (KD), age-matched non-KD patients and healthy children, showed that over half the KD and control isolates had gram-positive, catalase-negative cocci. About 50% of these organisms were identified as viridans streptococci by means of an API Strep 20 kit. Further identification by fluorometric DNA-DNA hybridisation demonstrated that the predominant species were S. oralis and S. mitis, each of which accounted for 25% of the isolates of viridans streptococci; 40% of viridans strains were unidentifiable; and S. sanguis and S. parasanguis were minor components. Studies in vivo showed that insertion of culture supernates of most of the viridans streptococci increased capillary permeability and induced redness with swelling and occasional bleeding in rabbit skin. One-third of S. mitis strains and one-fifth of the unidentified strains caused aggregation of human blood platelets, whereas S. oralis and other strains had no such effect. The distribution of extracellular lipoteichoic acids and glucan produced in the presence of sucrose was also examined. There were no significant differences in the recovery rate of viridans streptococci forming these biologically active extracellular products between KD and control groups.

Ureaplasma canigenitalium sp. nov., isolated from dogs

Ureaplasma strains isolated from dogs (Canis familiaris) were characterized and compared with the type strains of five previously described species of the genus Ureaplasma, Ureaplasma urealyticum (isolated from humans), Ureaplasma diversum (isolated from cattle), Ureaplasma gallorale (isolated from chickens), Ureaplasma cati (isolated from cats), and Ureaplasma felinum (isolated from cats). The canine strains hydrolyzed urea but not arginine or glucose, were membrane bound, lacked a cell wall, passed through 450-nm-pore-size membrane filters, required cholesterol for growth, and formed minute colonies (diameter, 20 to 140 microns) on agar medium. These canine ureaplasma strains have been reported to be members of four serovars. The four serovars of canine strains fell into a single group on the basis of their genomic properties, as determined by DNA-DNA hybridization. On the basis of these findings, we propose that ureaplasmas with these characteristics belong to a new species, Ureaplasma canigenitalium, with strain D6P-C (= ATCC 51252) as the type strain.

Sodium dodecyl sulfate-polyacrylamide gel electrophoresis and western blotting analyses of ureaplasmas isolated from dogs

To define the antigenic relatedness among unspeciated ureaplasma strains isolated from dogs, four canine ureaplasma isolates representing four serotypes were compared with the five type strains of the established species in Genus Ureaplasma by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blotting. Although all the strains showed distinct electrophoretic patterns by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, the Western blotting patterns were much more distinct. By Western blotting, the five type strains of established species reacted strongly with homologous antisera and showed slight cross reactions with heterologous antisera. However canine strains which showed little cross reactions with the established Ureaplasma species showed a variety of cross reactions among the four canine serotypes used.

Cardiac sequelae of Kawasaki disease in Japan: statistical analysis

The proportions of Kawasaki disease patients with cardiac sequelae in Japan were analyzed using nationwide survey data from the 6 1/2-year period July 1982 through December 1988. Of 46,864 cases of Kawasaki disease reported in the surveys, 7637 or 16.3% had cardiac sequelae such as dilation or stenosis of coronary arteries, myocardial infarction, and valvar lesions 1 month or more after onset. The prevalence of cardiac sequelae was particularly high in males, infants younger than 1 year, and children older than 5 years of age. In sequential observation, there was no correlation between the prevalence of cardiac sequelae and periods of high or low incidence of the disease. The prevalence of cardiac sequelae overall declined steadily over the observation period, perhaps as a consequence of increasing use of intravenous gamma globulin. However, children older than the age of 5 years manifested increasing prevalence of cardiac sequelae over the observation period, probably as a result of lower rates of intravenous gamma globulin administration.

Ureaplasma felinum sp. nov. and Ureaplasma cati sp. nov. isolated from the oral cavities of cats

Seven ureaplasma strains isolated from the oral cavities of domestic cats (Felis domestica) were characterized and compared with the type strains of the three previously established species of this genus, Ureaplasma urealyticum (humans), Ureaplasma diversum (cattle), and Ureaplasma gallorale (chickens). The feline strains hydrolyzed urea but not arginine or glucose, were membrane bound, lacked cell walls, passed through 0.45-micron membrane filters, required cholesterol for growth, and formed minute (15- to 140-microns) colonies on agar medium. The seven feline strains fell into two distinct groups based on (i) their antigenic properties (determined by using the metabolism and growth inhibition and indirect immunoperoxidase procedures), (ii) their genomic properties (determined by using DNA-DNA hybridization and DNA cleavage pattern procedures), and (iii) their polypeptide profiles (determined by using sodium dodecyl sulfate-polyacrylamide gel electrophoresis analyses). Based on these properties, the two feline groups were unrelated to each other or to the three previously established species, and each group represents a distinct Ureaplasma species. Thus, we propose that ureaplasmas with these phylogenetic and genomic properties be given taxonomic status as Ureaplasma felinum and Ureaplasma cati, with strain FT2-B (= ATCC 49229 = NCTC 11709) and strain F2 (= ATCC 49228 = NCTC 11710) as the type strains, respectively.

Steroid hormone production in testis, ovary, and adrenal gland of immature rats irradiated in utero with 60Co

Pregnant rats received whole-body irradiation at 20 days of gestation with 2.6 Gy lambda rays from a 60Co source. Endocrinological effects before maturation were studied using testes and adrenal glands obtained from male offspring and ovaries from female offspring irradiated in utero. Seminiferous tubules of the irradiated male offspring were remarkably atrophied with free germinal epithelium and containing only Sertoli cells. Female offspring also had atrophied ovaries. Testicular tissue obtained from intact and 60Co-irradiated rats was incubated with 14C-labeled pregnenolone, progesterone, 17 alpha-hydroxyprogesterone, and androstenedione as a substrate. Intermediates for androgen production and catabolic metabolites were isolated after the incubation. The amounts of these metabolites produced by the irradiated testes were low in comparison with the control. The activities of delta 5-3 beta-hydroxysteroid dehydrogenase, 17 alpha-hydroxylase, C17,20-lyase, and delta 4-5 alpha-reductase in the irradiated testes were 30-40% of those in nonirradiated testes. Also, the activities of 17 beta- and 20 alpha-hydroxysteroid dehydrogenases were 72 and 52% of the control, respectively. In adrenal glands, the 21-hydroxylase activity of the irradiated animals was 38% of the control, but the delta 5-3 beta-hydroxysteroid dehydrogenase activity was comparable to that of the control. On the other hand, the activity of delta 5-3 beta-hydroxysteroid dehydrogenase of the irradiated ovary was only 19% of the control. These results suggest that 60Co irradiation of the fetus in utero markedly affects the production of steroid hormones in testes, ovaries, and adrenal glands after birth.

A nationwide incidence survey of Kawasaki disease in 1985-1986 in Japan

Nationwide epidemiological surveys of Kawasaki disease have been conducted nine times in Japan since 1970. By the end of 1986, 83,857 (male:female ratio, 1.4) cases were reported. We summarize the results of these surveys, especially the latest survey of cases from January 1985 to December 1986. There were three epidemic years - 1979, 1982, and 1986. The ratios of the number of patients diagnosed in each of those years to the number in the preceding year were 2.0, 2.4, and 1.7, respectively. The last epidemic started in a metropolitan area of Tokyo in December 1985 and propagated northwards and southwards to involve almost all of the country in six months. The age-specific incidence curve showed a unimodal peak at nine to 11 months of age. The proportion of sibling cases was approximately 2%. The epidemiological pictures suggested that the disease was caused by an unknown biologic agent that is common in the community and that spreads easily among very young children.

Rapid identification of mycoplasmas by indirect immunoperoxidase test using small square filter paper

The indirect immunoperoxidase test using small, square filter paper was used for rapid identification of mycoplasmas. Colonies of type strains of 22 mycoplasma species, 3 acholeplasma species, and three Ureaplasma diversum serogroups were stained by this test with high sensitivity and specificity. All of 49 isolates from bovine materials and cell cultures were easily identified by this test, and the results agreed with those obtained by growth inhibition test. Use of filter paper made it possible to add different kinds of antisera or conjugates to the same agar plate simultaneously and also to save antiserum and conjugate. This test proved to be a simple and useful technique for rapid identification of many mycoplasma species grown on agar medium.

Lymphocytic depletion of bursa of Fabricius and thymus in chickens inoculated with Escherichia coli

Specific-pathogen-free 10-week-old chickens were inoculated via the air sac with Escherichia coli and showed lymphocytic depletion of bursa of Fabricius and thymus. In experiment I, chickens were necropsied at 12 and 24 hours, 2, 3, and 5 days after inoculation. At 12 hours after inoculation there was lymphocytic depletion in the medulla of lymphoid follicles of the bursa. At 24 hours after inoculation there was lymphocytic depletion also in the cortex of follicles and edema in interfollicular interstitium and follicular medulla. At 2 and 3 days after inoculation there were more marked lymphocytic depletion in medulla and cortex, and fibrosis in interfollicular interstitium. Partial repopulation of follicles with lymphocytes was seen at 5 days after inoculation. In the thymus, lymphocytic depletion occurred in the cortex. At 12 hours after inoculation, lymphocytic necrosis increased in number more than that of control chickens. The width of the cortex and medulla decreased. At 24 hours after inoculation, lymphocytic necrosis increased further. At 2 to 5 days after inoculation, the boundary between the cortex and medulla of lobules was obscure and cellular elements of the cortex and medulla were mingled. In experiment II, chickens were necropsied as in experiment I and also at 8 and 14 days after inoculation. The relative weights of the bursa and thymus reduced rapidly to minimal relative weights at 8 days after inoculation. At 14 days after inoculation, both bursa and thymus had normal relative weights and histological structures. These findings indicate that E. coli infection may induce transient lymphocytic depletion of lymphoid tissues in the chicken.

Pathology of spontaneous colibacillosis in a broiler flock

Forty-eight of 134 chickens collected from a flock on a broiler farm were diagnosed pathologically and microbiologically to have colibacillosis. Both acute septicemia (seven birds, 1 to 36 days old) and subacute serositis (41 birds, 5 to 57 days old) were found. The former consisted of necrosis with fibrinous exudates in the ellipsoids and lymphoid follicles of the spleen, and fibrinous thrombi in sinusoids of the liver with occasional necrosis of hepatic cells. The latter had fibrinopurulent inflammation with granulomatous changes in the serosal tissues--including the epicardium, pericardium, and hepatic peritoneal sac--accompanied by septicemic lesions in the spleen and liver. Respiratory lesions (airsacculitis, pneumonia, and tracheitis) were noted in most chickens affected with acute septicemia and subacute serositis. Degenerative changes also were observed in the bursa of Fabricius.

Atopic disposition and bronchial reactivity to inhaled acetylcholine in young adults with a history of asthma in childhood

The atopic disposition, indicated by positive skin reactions and IgE antibody titers etc., and the bronchial reactivity to inhaled acetylcholine were examined on the following three groups: (1) 20 young adults with a history of childhood asthma who have been symptom-free for more than 4 yr; (2) 20 current asthmatics, and (3) 20 healthy young adults. Young adults with a history of childhood asthma remained atopic in their disposition even after complete clinical remissions of their childhood asthma. However, they had a lower bronchial reactivity as compared with current asthmatics, although the bronchial reactivities of both groups were apparently higher than the control group.