Combined surgery and endovascular stenting for basilar artery stenosis refractory to balloon angioplasty: technical case report.

The authors report a case of symptomatic basilar artery stenosis treated by stenting via the surgically exposed C1 vertebral artery. This case was initially treated by percutaneous transluminal angioplasty via a transfemoral route but resulted in unsatisfactory dilatation. Stenting via a transfemoral route also resulted in failure because of the coiling of the proximal vertebral artery. Direct puncture of the vertebral artery beyond the coiling portion was tried but a stent could not be delivered beyond the C2 vertebrae. Finally, the vertebral artery was surgically exposed between C1 and the occipital bone and a stent was introduced into the lesion from this portion under fluoroscopic control. The basilar artery was fully opened by stenting without new neurological deficits. Stenting of the basilar artery via a transfemoral route is not always possible even with newer generation stents if the vertebral artery has elongated tortuous curves. Combined surgery and endovascular stenting is one of the alternatives in such cases including our case.

Jargonagraphia with severe aphasia due to a right hemisphere lesion: case report.

The authors report a case of a patient who developed jargonagraphia, severe aphasia, unilateral spatial neglect and apraxia due to a right hemisphere lesion. Jargonagraphia with severe aphasia, unilateral spatial neglect and apraxia is quite rare. The mechanisms of jargonagraphia remain unknown. A possible mechanism underlying this case of jargonagraphia is discussed.

Endovascular treatment for intracranial atherosclerotic stenosis. Pitfalls and problems.

SUMMARY: Fourty-five cases of intracranial atherosclerotic stenoses greater than 70% for intradural lesions or 60% for extradural lesions were treated by PTA or stenting. The stenotic lesions were successfully dilated in 44/45 patients and future stroke was prevented during a mean 29 month follow-up period. Stenotic ratio significantly reduced in stent-treated group compared with PTA-treated group and stenting was effective for cases refractory to PTA, such as elastic recoil or restenosis. However, stenting had its own drawbacks, such as difficulty in delivery, migration, and acute thrombosis.

A spectrophotometric method for the determination of glycolate in urine and plasma with glycolate oxidase.

An enzymatic assay was developed for the spectrophotometric determination of glycolate in urine and plasma. Glycolate was first converted to glyoxylate with glycolate oxidase, and the glyoxylate formed was condensed with phenylhydrazine. The glyoxylate phenylhydrazone formed was then oxidized with K(3)Fe(CN)(6) in the presence of excess phenylhydrazine, and A(515) of the resulting 1, 5-diphenylformazan was measured. Since glycolate oxidase also acts on glyoxylate and L-lactate, the incubation of samples with glycolate oxidase was carried out in 120-170 mM Tris-HCl (pH 8.3) to obtain glyoxylate as its adduct with Tris. The pyruvate formed from lactate was removed by subsequent brief incubation with alanine aminotransferase in the presence of L-glutamate, and alpha-ketoglutarate formed was converted back to L-glutamate by glutamate dehydrogenase and an NADPH generating system. Thus the specificity of the assay relies principally on the substrate specificity of glycolate oxidase, and high sensitivity is provided by the high absorbance of 1,5-diphenylformazan at 515-520 nm. Plasma was deproteinized with perchloric acid, and then neutralized with KOH. Plasma and urine samples were then incubated with approximately 5 mM phenylhydrazine, and then treated with stearate-deactivated activated charcoal to remove endogenous keto and aldehyde acids as their phenylhydrazones. The normal plasma glycolate and urinary glycolate/creatinine ratio for adults determined by this method are approximately 8 microM and approximately 0.036, respectively.

Oxalate synthesis in mammals: properties and subcellular distribution of serine:pyruvate/alanine:glyoxylate aminotransferase in the liver.

Primary hyperoxaluria Type 1 (PH1) is caused by a functional deficiency of a liver enzyme, serine:pyruvate/alanine:glyoxylate aminotransferase (SPT/AGT), which catalyzes transamination between L-serine or l-alanine as an amino acid substrate and glyoxylate or pyruvate as an alpha-keto acid substrate. A high affinity for glyoxylate is a notable feature of this enzyme, suggesting a role in glyoxylate metabolism in vivo. Another conspicuous feature of SPT/AGT is its species-specific and food habit-dependent subcellular distribution. Thus, the enzyme is located in peroxisomes in herbivores and man, largely in mitochondria in carnivores, and in both the organelles in rodents. The mechanism of the species-specific dual organelle localization of SPT/AGT is either transcription of the gene from two different start sites or loss of the upstream translation initiation ATG codon by mutations. It appears that the mitochondrial versus peroxisomal distribution of SPT/AGT in different animal species is indispensable in meeting the metabolic needs caused by their respective food habits. As for the peroxisomal localization, glycolate is contained in plants much more than in animal tissues, and when ingested, it is converted to glyoxylate, an immediate precursor of oxalate, in liver peroxisomes. Therefore, peroxisomal localization of SPT/AGT may be indispensable for herbivores to convert the glyoxylate formed in peroxisomes into glycine in situ rather than forming oxalate. On the other hand, our recent studies showed that SPT/AGT contributed substantially to serine metabolism in rabbit, human, and dog livers; i.e., irrespective of its mitochondrial or peroxisomal localization. Thus, the mitochondrial localization of SPT/AGT was not a prerequisite for the metabolism of L-serine. Another source of glyoxylate is the metabolism of L-hydroxyproline, and in this case, the enzyme responsible for the glyoxylate formation has been reported to be a mitochondrial matrix enzyme. Collagen accounts for about 30% of total animal proteins and contains about 13% (w/w) hydroxyproline. It is therefore possible that both mitochondrial and peroxisomal SPT/AGT contribute to the metabolism of glyoxylate and serine, but the subcellular site for glyoxylate metabolism is different in herbivores and carnivores.

Primary hyperoxaluria type 1 in Japan.

Glyoxylate is an immediate precursor of oxalate, but in its metabolism the conversion into glycine catalyzed by serine:pyruvate/alanine:glyoxylate aminotransferase (SPT/AGT) appears to be the main route. When SPT/AGT is missing as in the case of primary hyperoxaluria type 1 (PH1) more glyoxylate is used for the oxalate production, resulting in calcium oxalate urolithiasis and finally systemic oxalosis. SPT/AGT is a unique enzyme of species-specific dual organelle localization; it is located largely in mitochondria in carnivores and entirely in peroxisomes in herbivores and man. For herbivores, the peroxisomal localization of SPT/AGT is indispensable to avoid massive production of oxalate, probably because liver peroxisomes are the main site of glyoxylate production from glycolate, and plants contain glycolate much more than animal tissues. Recently, we took charge of laboratory examination for 8 cases of primary hyperoxaluria in Japan, and felt that symptoms of some of the Japanese PH1 patients are apparently milder than those of Western patients. The reason of this is not clear, but from the above mentioned seemingly indispensable association of grass-eating with the peroxisomal localization of SPT/AGT it may be related, at least in part, to the food habit of Japanese, especially that of old generation, that they prefer boiled greens rather than frying or raw vegetables.

Gas chromatography/principal component similarity system for detection of E. coli and S. aureus contaminating salmon and hamburger.

Coho, Atlantic, Spring, and Sockeye salmon and five commercial samples of hamburger patties were analyzed by processing gas chromatography (GC) data of volatile compounds using the principal component similarity (PCS) technique. PCS scattergrams of the samples inoculated with Escherichia coli and Staphylococcus aureus followed by incubation showed the pattern-shift lines moving away from the data point for uninoculated, unincubated reference samples in different directions with increasing incubation time. When the PCS scattergrams were drawn for samples incubated overnight, the samples inoculated with the two bacterial species and the uninoculated samples appeared as three separated groups. This GC/PCS approach has the potential to ensure quality of samples by discriminating good samples from potentially spoiled samples. The latter may require further microbial assays to identify the bacteria species potentially contaminating foods.

[Choroid plexus papilloma in the posterior third ventricle in infancy: a case report].

Choroid plexus papillomas represent approximately 0.5% of all intracranial tumors, but they are found in the third ventricle only infrequently. We report a case of choroid plexus papilloma in the third ventricle which is difficult to differentiate from a pineal region tumor. A 4-month-old female presented with bulging fontanelle and sunset phenomenon. A CT scan and MRI showed marked hydrocephalus caused by a tumor extending from the posterior third ventricle to the peneal body. Preoperatively, we diagnosed the lesion as a pineoblastoma. The tumor was totally removed through the occipital transtentorial approach. Pathological examination of the tumor revealed a typical choroid plexus papilloma. The operation was uneventful, and she has grown normally without recurrence of the tumor for three years since the operation. A sagittal gadolinium-enhanced MRI was useful in our case to differentiate a choroid plexus papilloma from a pineal region tumor, because the former extended into the aqueduct forming the shape of the letter V while the latter compressed the aqueduct downward.

Ablation of the subthalamic nucleus supports the survival of nigral dopaminergic neurons after nigrostriatal lesions induced by the mitochondrial toxin 3-nitropropionic acid.

We investigated the role of the excitatory afferents from the subthalamic nucleus (STN) in the death of nigral dopamine (DA) neurons after nigrostriatal axon terminal lesions. Nigral DA neurons were detected by use of both tyrosine hydroxylase immunolabeling or retrograde labeling of nigral cells with fluorogold. Sprague-Dawley rats were subjected to unilateral, quinolinic acid-induced destruction of the STN. Sham lesions of the STN were made by injecting phosphate-buffered saline. Two weeks after STN ablation, lesions of nigrostriatal DA neurons were induced by intrastriatal injections of either the mitochondrial toxin 3-nitropropionic acid (3-NP) or the catecholamine toxin 6-hydroxydopamine (6-OHDA). Intrastriatal injections of 3-NP or 6-OHDA caused a progressive loss of nigral tyrosine hydroxylase-positive or fluorogold-labeled DA neurons in a dose-dependent manner. Previous ablation of the STN significantly attenuates the loss of DA neurons in rats receiving 3-NP but not 6-OHDA. Sham lesions of the STN did not affect DA neuron death induced by the toxins. The results indicate that the excitatory inputs from the STN may contribute to the death of nigral DA neurons under a condition of 3-NP-induced metabolic impairment.

Peptide based interleukin-1 beta converting enzyme (ICE) inhibitors: synthesis, structure activity relationships and crystallographic study of the ICE-inhibitor complex.

Based on the X-ray structure of the complex of Ac-Tyr-Val-Ala-Asp-H (L-709049) and interleukin-1 beta converting enzyme (ICE), we synthesized compounds which were derived from 2-NapCO-Val-Pro-Asp-CH2OPh (1) to obtain a potent inhibitor in the cell assay. Among these compounds, (3S)-N-methanesulfonyl-3-[[1-[N-(2-naphthoyl)-L-valyl]-L-prolyl]amino]- 4-oxobutanamide (27c) showed high potency not only in the enzyme assay but also cell assay with IC50 values of 38 nM and 0.23 microM, respectively. Compound 27c, with a c log P value of 1.76, had a more hydrophilic character compared with 1. Compound 27c also dose dependently inhibited LPS-primed ATP-induced IL-1 beta release in mice. The crystal structure of the complex of compound 27c and ICE revealed that compound 27c had further interactions with ICE in the naphthoyl group at the P4 position and in the methyl group of the methanesulfonamidecarbonyl group at the P1 position, compared with L-709049. To our knowledge, compound 27c is the first example that shows a strong inhibitory activity without the carboxyl group at the P1 position.

Percutaneous transluminal angioplasty for intracranial arteriosclerotic lesions.

We report 17 cases of intracranial arterial stenosis treated by percutaneous transluminal angioplasty (PTA), including 9 on the intracranial internal carotid (ICA), 4 on the middle cerebral (MCA), and 4 on vertebrobasilar artery (VBA) system. All patients had ischaemic brain symptoms and stenoses of more than 60% (calculated angiographically). We treated four patients by PTA for residual stenoses after thrombolysis for acute occlusion. We used PTA balloon catheters 2.0-3.5 mm in diameter for all procedures. As a rule, the balloon was inflated for 1 min at 6 atm. All arteries were successfully dilated (stenosis less than 50%) except for one treated by PTA for residual MCA stenosis after thrombolysis. The patient died of a massive infarct due to MCA reocclusion caused by arterial dissection. Stenosis recurred in 4 of 16 patients. Repeat PTA was successfully carried out in these cases. However, stenosis recurred in one of these patients 3 months after PTA, but the patient is being followed because he is asymptomatic. PTA of intracranial arteries is effective, but its indications should be based strictly on potential risks, such as acute occlusion derived from arterial dissection.

Vertebral arteriovenous fistula treated by embolization technique. Report of three cases.

SUMMARY: Three patients with vertebral arteriovenous fistulae are described. Transarterial embolization by microcoils and balloons was used in each case and the fistula was completely occluded in one case immediately after embolization. Another two cases with partial obliteration of the fistula were followed and showed complete occlusion of the fistula after a one year follow-up. After embolization of the fistula, each patient improved in clinical signs and symptoms and showed no complications. Transarterial embolization for vertebral arteriovenous fistula is a safe and effective treatment.

Iatrogenic arteriovenous fistula of the middle meningeal artery caused during embolization for meningioma--case report.

A 73-year-old female developed middle meningeal arteriovenous fistula during embolization of a falx meningioma. The cause of this complication was thought to be perforation by the guide wire during catheterization at the sharp bend in the sphenoidal portion of the middle meningeal artery. Embolization of the fistula and the feeding artery to the meningioma with polyvinyl alcohol particles 250-355 microns size resulted in complete obliteration of the fistula. Computed tomography showed no epidural or subdural hematoma. Introduction of the microcatheter beyond the sharp bend in the middle meningeal artery should not be attempted to avoid the possibility of iatrogenic middle meningeal arteriovenous fistula.

Transplantation of autologous sympathetic ganglion into the brain with Parkinson's disease. Long-term follow-up of 35 cases.

Transplantation of autologous sympathetic ganglion was performed in 35 patients with Parkinson's disease. Approximately half the patients showed improvement of parkinsonian symptoms over the 3 years following transplantation. The patients showed amelioration of bradykinesia and gait disturbance, but tremor and muscle rigidity were not improved by transplantation. The other half of the patients did not show amelioration after transplantation. No serious complications were encountered, though mild ptosis was observed in all patients. The mechanism of improvement of symptoms might be the release of dopamine from the grafted sympathetic ganglion. Transplantation of autologous sympathetic ganglion can be a therapeutic modality for Parkinson's disease.

Percutaneous transluminal angioplasty for intracranial arteriosclerotic lesions.

SUMMARY: Recent developments of the interventional neuroradiological technique made percutaneous transluminal angioplasty (PTA) possible even for intracranial arteries(1). We report our experiences of 17 cases treated by PTA including 9 intracranial internal carotid (ICA), 4 middle cerebral (MCA) and 4 vertebro-basilar arterial (VBA) stenoses and discuss the problems of the procedure. All patients had cerebral ischemic symptoms and stenoses more than 60% calculated angiographically. Three of them were treated by PTA for residual stenoses after thrombolytic therapy for acute occlusion. We used PTA balloon catheters 2.0 mm to 3.5 mm in diameter (Stealth, Target therapeutics) for all PTA procedures. A PTA balloon was inflated for 1 min at 6 atm as a rule. All were successfully dilated (stenosis less than 50%) except one treated by PTA for residual MCA stenosis after thrombolytic therapy. The patient died from massive infarction due to MCA re-occlusion caused by MCA dissection. Restenosis appeared in 4 of 16 patients. Repeated PTA was successfuly carried out for the 4 patients. However, restenosis appeared in one of them but the patient is now on follow-up because of asymptomatic course. PTA for intracranial arteries is an effective treatment but its indication should be determined strictly because of potential risk such as acute occlusion derived from dissection.

Intra-arterial Thrombolytic Therapy for Acute Vertebrobasilar Artery Occlusion.

SUMMARY: We report on the results of intra-arterial thrombolysis in 11 patients with vertebrobasilar artery occlusion treated within 6 hours after onset of symptoms. Urokinase (5 patients) or recombinant tissue plasminogen activator (t-PA) (6 patients) was injected through a microcatheter conducted to the thrombus. Eight patients showed recanalization of the thrombus. The outcome was excellent in 5 patients, good in 2 patients, and poor in one patient. Recanalization could not be achieved in 3 of the 11 procedures; all patients in whom recanalization failed died. There were no hemorrhagic complications after thrombolysis. Two patients with residual stenosis after thrombolysis underwent successful percutaneous transluminal angioplasty (PTA) to prevent reocclusion. Intra-arterial thrombolysis for vertebrobasilar artery occlusion is a safe and effective treatment if it is performed within 6 hours.

[Super selective amytal test for functional evaluation of the brain--a less invasive functional test].

In the neurosurgical field, it is very important to evaluate localized function of the affected region preoperatively. In order to investigate lateralized and localized brain function, we have developed an alternative to the original Wada test, and refer to it as the super selective amytal test (SSAT). We performed super selective catheterization of the target artery after conventional carotid angiography, injected Amytal (amobarbital, 30-100 mg) through a micro-catheter, and identified potential local function. In ten cases, including AVM, aneurysm, and brain tumor, we investigated localized function of the affected site preoperatively by SSAT, and chose our treatment based on the results of this test. There was a good correlation between the results of the SSAT and the results of surgery in every case. There were no prolonged neurological complications of this test. Evaluation of the results of the SSAT should be interpreted under precise DSA control, since blood flow in the brain differ among individuals. This test may contribute to our knowledge of localized function in the cerebral cortex and deep brain areas in neurosurgical patients.

Dual microcatheter and guidewire snare technique for retrieval of intravascular foreign body: technical note.

A transjugular snare technique was used to retrieve a stretched, residual mechanical detachable coil which extended from the cavernous sinus to the femoral vein, obliterating the transpetrosal route for further embolisation. The coil was snared by a microguidewire. Our new technique is described in this paper.

Transluminal angioplasty for arteriosclerotic disease of the distal vertebral and basilar arteries.

OBJECTIVE: Percutaneous transluminal angioplasty (PTA) for the distal vertebral and basilar artery is now being performed in selected patients with haemodynamically significant lesions of the posterior cerebral circulation. Its effect and overall results were examined. PATIENTS AND METHODS: A balloon dilatation catheter specifically developed for these procedures, with a 2.0-3.5 mm balloon diameter, at 6 atmospheres of pressure, was used. Angioplasty was performed in 12 patients (including six whose initial results have been reported) with angiographically documented stenotic lesions involving either the intracranial vertebral artery (C1-C2 portion) or the basilar artery, and satisfying the following criteria: (1) clinical symptoms suggestive or consistent with a transient ischaemic attack refractory to medical treatment, or small infarction of the posterior circulation; and (2) angiographically documented stenosis greater than 70%. Two of 12 patients had complete thrombosis of the distal vertebral and basilar artery and PTA was performed after successful intra-arterial thrombolysis. RESULTS: Successful results, without complications, were obtained in eight patients, with complete resolution of vertebrobasilar ischaemic symptoms. Immediate complications occurred in four patients including two with vessel dissection, and two with thromboembolism. The two patients with acute arterial dissection were reoperated but developed small infarctions with permanent neurological deficits. The two patients with thromboembolic complication showed transient neurological deficit. The overall stenosis ratio decreased from a mean of 84% pretreatment to 44% after the angioplasty procedure. Restenosis occurred in two patients. Long term clinical follow up in 11 patients who survived more than six months showed resolution of ischaemic symptoms after PTA in all except for one with a restenosis who had recurrent transient ischaemic attacks. CONCLUSION: Transluminal angioplasty may be an effective procedure to treat vertebrobasilar ischaemia secondary to high grade arteriosclerotic disease affecting either the distal vertebral or basilar artery regions that do not respond to medical treatment.