An autopsy case of refractory epilepsy due to unilateral polymicrogyria in a 65-year-old man: Histogenesis of four-layered polymicrogyric cortex.

Polymicrogyria (PMG) is a complex malformation accompanied with abnormal cortical laminations (two-, four- or six-layered cortex), and horizontally oriented myelinated fiber layer is evident in four-layered PMG in older individuals. Here we report a 65-year-old man with refractory epilepsy, in whom postmortem examination revealed four-layered PMG in the left hemisphere. We carried out a histological and immunohistochemical study to clarify the nature of the myelinated band in four-layered PMG cortex. The myelinated band contained no or only few neurons. GFAP- and aquaporin-1-immunoreactive astrocytes were found in the subcortical white matter as well as in the myelinated band. By contrast, GFAP- and aquaporin-1-immunoreactive astrocytes were not found in the band of Baillarger. These findings suggest that the myelinated band in PMG cortex is not the band of Baillarger and that the immunohistochemical characteristics of astrocytes in the myelinated band in PMG cortex are similar to those of the subcortical white matter. Previous studies suggest that PMG is not a cell migration disorder but a post-migration malformation. Taken together, it is likely that the myelinated band in PMG cortex represents abnormality of axonal growth or myelination after migration has terminated.

Feasibility of resuscitation contrast-enhanced postmortem computed tomography using cardiopulmonary resuscitation technique with chest compression immediately after death.

PURPOSE: Our purpose was to evaluate image delineation ability of contrast-enhanced post-mortem computed tomography (CEPMCT) using cardiopulmonary resuscitation technique of chest compression, named "resuscitation CEPMCT". MATERIALS AND METHODS: Non-traumatically-deceased 15 subjects (7 men; 8 women) aged 19-87 years (mean 61 years) underwent resuscitation CEPMCT. The contrast-enhanced technique, while injecting 100 ml of contrast media from the right cubital vein at a rate of 1 ml/s, chest compression was performed for 2 minutes at a rate of 100 times/min (a total of 200 times). CT attenuation values (Hounsfield Unit: HU) were measured in 8 target vessels: 1) pulmonary artery, 2) coronary artery, 3) ascending aorta, 4) abdominal aorta, 5) celiac trunk, 6) common iliac artery, 7) superior vena cava, and 8) inferior vena cava. One-sided Student's t-test was performed to assess whether measured values were higher than 140 HU by setting p-value at 0.05. RESULTS: Measured CT values in the 8 vessels were 1) pulmonary artery: 325 ± 140 HU, 2) coronary artery: 240 ± 73 HU, 3) ascending aorta: 321 ± 127 HU, 4) abdominal aorta: 286 ± 96 HU, 5) celiac trunk: 233 ± 62 HU, 6) common iliac artery: 260 ± 114 HU, 7) superior vena cava: 422 ± 187 HU, and 8) inferior vena cava: 301 ± 142 HU, showing significantly higher values than the threshold value of 140 HU. Resuscitation CEPMCT detected one case of pulmonary arterial thromboemboli death. CONCLUSION: Resuscitation CEPMCT using chest compression immediately after death has the possibility of detecting thromboembolus in major vessels, despite the simplicity of the technique.

Background and current status of postmortem imaging in Japan: short history of "Autopsy imaging (Ai)".

There is a low autopsy rate and wide distribution of computed tomography (CT) and magnetic resonance imaging (MRI) scanners in Japan. Therefore, many Japanese hospitals, including 36% of the hospitals with in-patient facilities and 89% of large hospitals with ER facilities conduct postmortem imaging (PMI), use clinical scanners to screen for causes in unusual deaths as an alternative to an autopsy or to determine whether an autopsy is needed. The Japanese PMI examination procedure is generally referred to as "autopsy imaging" (Ai) and the term "Ai" is now commonly used by the Japanese government. Currently, 26 of 47 Japanese prefectures have at least one Ai Center with scanners that are dedicated for PMI. Here, we briefly review the history of Japanese PMI (Ai) from 1985 to the present.

Postmortem computed tomography findings as evidence of traffic accident-related fatal injury.

PURPOSE: Most traumatic deaths in Japan are due to nonpenetrating injuries, especially those that result from traffic accidents; however, the autopsy rate of traffic accident-related deaths is only about 5%. We investigated the diagnostic ability of postmortem computed tomography (PMCT) in cases of fatal trauma after traffic accidents. MATERIALS AND METHODS: Our subjects were 78 subjects (59 males, 19 females; mean age 50 years, range 15-87 years) who were brought to our institution in cardiopulmonary arrest on arrival after traffic accidents and died despite resuscitation attempts. PMCT findings of damage to the head, neck, thorax, abdomen, and pelvis were classified into three grades according to the Abbreviated Injury Scale (AIS) severity: A: 1 (minor), 2 (moderate); B: 3 (serious), 4 (severe), 5 (critical); C: 6 (maximum). RESULTS: The percentage ratio of A/B/C in 78 head injuries was 32/60/8, in 41 neck injuries 83/5/12, in 76 thorax injuries 5/38/57, in 76 abdominal injuries 70/24/7, and in 76 pelvic injuries 79/21/0, respectively. CONCLUSION: PMCT can detect or presume fatal trauma when diagnosing the cause of death after traffic accidents.

[Accidental poisoning and test for it].

There are many dangerous materials which cause poisoning, toxins or poisons, in our lives. We may suddenly suffer from the effects of these materials by inhalation or ingestion before we are aware of the risk. It is very important to identify toxins or poisons to prevent poisoning and treat the poisoned patients. We have to learn from previous accidents the way to resolve future problems.

Joint symptoms: a practical problem of anastrozole.

BACKGROUND: Anastrozole and tamoxifen have mild toxicity. However, we noticed that more patients treated with anastrozole complained of joint symptoms than expected. In particular, digital stiffness as is seen with rheumatoid arthritis is a problem. Some clinical trials of anastrozole in Europe and the United States reported musculoskeletal disorders as adverse events, however, joint symptoms were not described in detail. PATIENTS AND METHODS: At our clinic from August 2001 to March 2005, 53 postmenopausal women with estrogen receptor-positive breast cancer were treated with anastrozole. We calculated the incidence and classified the grade of joint symptoms by interviewing patients. We also investigated the patients' characteristics and their relevance to joint symptoms. RESULTS: Of 53 patients, 14 patients (26%) had joint symptoms (13 patients with digital stiffness and 3 patients with arthralgias of wrist and shoulders). Joint symptoms tended to occur in the patients who had previously undergone chemotherapy; however, there has no relationship between prior hormonal therapy and joint symptoms. Seven patients who discontinued anastrozole treatment showed improved symptoms. Five patients with grade 1 digital stiffness continued anastrozole treatment without additional treatment. Two patients with grade 1 digital stiffness, who took a Chinese herbal medicine showed improved symptoms and continued anastrozole treatment. CONCLUSION: Benefits to the patients may possibly be lost by discontinuation of anastrozole or changing to tamoxifen since the clinical superiority of anastrozole to tamoxifen has been reported. We should continue anastrozole in patients with low grade symptoms, while ensuring that patients are aware of the toxicity of anastrozole.

[Two cases of stage IV breast cancer with severe hypercalcemia].

Case 1: A 34-year-old woman,who had a right breast cancer with axillary lymph node metastasis and multiple bone metastases, was referred to our clinic. She developed paralysis of lower extremities and disorder of the bladder and rectum due to metastasis to the thoracic vertebra, and also had renal dysfunction due to severe hypercalcemia and hemorrhagic cystitis. Correcting the serum calcium level with intravenous infusion, elcatonin, pamidronate and betamethasone, she underwent radiation therapy for the vertebral metastasis. The first hormonal therapy (leuprorelin/exemestane) had been effective for about 4 months, however the second hormonal therapy (leuprorelin/tamoxifen) was not effective. Chemotherapy with paclitaxel (80 mg/m(2), day 1, 8, 15, every 4 weeks) brought about a stable general condition and a normal level of serum calcium with zoledronate in the ninth month of treatment. Case 2: A 32-year-old woman, who had a right breast cancer with multiple bone metastases and axillary and hilar lymph node metastases, came to our clinic, complaining of nausea due to severe hypercalcemia. After successful correction of hypercalcemia by the intravenous infusion and administration of elcatonin, pamidronate and dexamethasone, the hormonal therapy(goserelin/tamoxifen) caused rapid re-elevation of serum calcium and tumor marker, so that a tumor flare was suspected. After 3 cycles of EC therapy (EPI 90 mg/m(2), CPM 600 mg/m(2), every 3 weeks), 2 cycles of paclitaxel therapy (80 mg/m(2), day 1, 8, 15, every 4 weeks) brought about tumor reduction and the normal level of serum calcium. After 7 cycles of paclitaxel therapy,the hormonal therapy (goserelin/tamoxifen) proved effective for several months. To achieve tumor reduction and stabilize the serum calcium level, we need to start immediately the treatment of breast cancer with severe hypercalcemia, considering the general condition of the patient.

[Serum and urine total arsenic concentration in a case of acute arsenic intoxication].

The 68-year-old man took arsenic pasta 1 g (arsenic trioxide 0.45 g) to commit suicide and was admitted 16 hours after ingestion. He developed vomiting and coma, followed by pancytopenia. He was treated with activated charcoal, laxative, dimercaprol, sodium thiosulfate and direct hemoperfusion with good recovery. Total arsenic concentrations in serum and urine were 39 ng/ml and 89 ng/ml on admission, respectively. Urine arsenic concentration showed the second peak around 48 hours after admission.

Prolonged unilateral vasodilatation and brain edema in fulminant hepatic failure, associated with symptomatic seizure.

We report prolonged unilateral vasodilatation and hemispheric brain edema in a 49-year-old man with fulminant hepatic failure (FHF). The patient presented with a tonic-clonic seizure caused by a hypertensive subcortical hemorrhage in the left parietal lobe. Serial computed tomography (CT) scans showed progressive darkening of the ipsilateral hemisphere, suggesting hemispheric cerebral infarction, but the patient did not show clinical signs of deterioration. Brain magnetic resonance angiography showed dilation of the large arteries of the left hemisphere. Evaluation of cerebral blood flow 7 days postictus with single photon emission CT revealed marked ipsilateral hyperperfusion. The darkening of the hemisphere was brain edema elicited by hyperperfusion. Brain edema was reversible, disappearing 14 days postictus. Hemispheric brain edema was caused by unilateral cerebral vasodilatation and resultant hyperperfusion. Although brain edema is a major complication in FHF patients and cerebral hyperperfusion is responsible for edema formation, CT findings of these patients almost invariably show a bilateral lesion. Unilateral vasodilatation and subsequent hemispheric hyperperfusion may be due to overproduction of vasodilators, already abundant in the brains of patients with severe hepatic failure, by seizure activity.