Pre-operative Embolization of a Cerebellar Hemangioblastoma Using Polyvinyl Alcohol (PVA) and Target Tetra 360 Detachable Coil.

Due to its hypervascularity, hemangioblastoma, a rare primary central nervous system intracranial tumor, has been treated with pre-operative embolization prior to surgical resection. Here, we describe a case treated as such. A 37-year-old male presented with worsening chronic headache and right ear tinnitus was found to have a hypervascular, heterogeneous right cerebellar lesion suspicious for arteriovenous malformation or hemangioblastoma. He underwent polyvinyl alcohol (PVA) and Target Tetra 360 (Fremont, CA: Stryker Neurovascular) detachable coil embolization followed by complete tumor resection. Pathology was consistent with hemangioblastoma. He presented with complete resolution of his symptoms immediately post-operatively and at a two-week follow-up. Our case highlighted the importance of pre-operative embolization to help achieve complete tumor resection which is considered curative in the treatment of hypervascular hemangioblastoma. The Target Tetra 360 detachable coil embolization is another material that can be considered.

A case report of a multi-arterial dural arteriovenous fistula.

Dural arteriovenous fistulas are rare intracranial vascular malformations with a propensity for hemorrhage. The Cognard classification system is the most widespread classification system wherein type IIB through V must be promptly treated to avoid the risk of hemorrhage. The case presented herein reports a 71-year-old male presenting with vague non-hemorrhagic neurologic deficits found to have a Cognard type III dural arteriovenous fistula with multiple arterial feeders. Although quite obvious in retrospect, a DAVF can be missed even by an astute radiologist. This should be considered a "never miss" diagnosis as it carries a risk of intracranial hemorrhage and death.

Acute Bilateral Blindness in the Setting of Sudden Onset of Bilateral Proptosis and Ophthalmoplegia: A Case Report With Literature Review.

PURPOSE OF REVIEW: Acute bilateral blindness has an extensive differential diagnosis that requires a careful history and physical examination to narrow down. In this article, we discuss the pathophysiology and radiographic findings of each possible diagnosis for acute bilateral blindness. RECENT FINDINGS: Visual pathology with respect to bilateral blindness can be broadly broken down into 3 anatomic categories: media (i.e., the anterior and posterior chamber of the eye), retina, and neural visual pathway. Possible causes of rapid onset bilateral blindness include bilateral occipital infarcts, endogenous bacterial endophthalmitis, orbital cellulitis, orbital compartment syndrome, cavernous sinus thrombophlebitis, thyroid disease, and bilateral nonarteritic ischemic optic neuropathy. SUMMARY: In this case, we present a patient with acute onset of bilateral blindness, in addition to bilateral ophthalmoplegia, proptosis, and orbital chemosis. We believe that this rare case of acute bilateral blindness is thought provoking and aids in the understanding of the differential diagnosis and underlying pathophysiology of visual loss.

Identification of novel blood biomarker panels to detect ischemic stroke in patients and their responsiveness to therapeutic intervention.

The use of blood biomarkers for stroke has been long considered an excellent method to determine the occurrence, timing, subtype, and severity of stroke. In this study, venous blood was obtained from ischemic stroke patients after stroke onset and compared with age and sex-matched controls. We used a multiplex panel of 37 inflammatory molecules, analyzed using Luminex MagPix technology, to identify the changes in plasma proteins after ischemic stroke. We identified eight key molecules that were altered within the blood of stroke patients as compared to controls. Plasma levels of interleukin 6 signal transducer (sIL-6Rß/gp130), matrix metalloproteinase-2 (MMP-2), osteopontin, sTNF-R1 and sTNF-R2 were significantly higher in stroke patients compared to controls. Interferon-ß, interleukin-28, and thymic stromal lymphopoietin (TSLP) were decreased in plasma from stroke patients. No other immunological markers were significantly different between patient groups. When stroke patients were treated with tissue plasminogen activator (t-PA), plasma levels of interferon-α2 significantly increased while interleukin-2 and pentraxin-3 decreased. The discriminatory power of the molecules was evaluated by receiver operating characteristic (ROC) analysis. According to ROC analysis, the best markers for distinguishing stroke occurrence were MMP-2 (AUC = 0.76, sensitivity 62.5%, specificity 88.5%), sTNF-R2 (AUC = 0.75, sensitivity 83.3%, specificity 65.3%) and TSLP (AUC = 0.81, sensitivity 66.7%, specificity 96.2%). Multivariate logistic regression, used to evaluate the combination of proteins, identified a biomarker panel with high specificity and sensitivity (AUC = 0.96, sensitivity 87.5%, specificity 96.2%). These results indicate a novel set of blood biomarkers that could be used in a panel to identify stroke patients and their responsiveness to therapeutic intervention.

Review and Hypothesis. New insights into the reaction mechanism of transhydrogenase: Swivelling the dIII component may gate the proton channel.

The membrane protein transhydrogenase in animal mitochondria and bacteria couples reduction of NADP⁺ by NADH to proton translocation. Recent X-ray data on Thermus thermophilus transhydrogenase indicate a significant difference in the orientations of the two dIII components of the enzyme dimer (Leung et al., 2015). The character of the orientation change, and a review of information on the kinetics and thermodynamics of transhydrogenase, indicate that dIII swivelling might assist in the control of proton gating by the redox state of bound NADP⁺/NADPH during enzyme turnover.

Structural biology. Division of labor in transhydrogenase by alternating proton translocation and hydride transfer.

NADPH/NADP(+) (the reduced form of NADP(+)/nicotinamide adenine dinucleotide phosphate) homeostasis is critical for countering oxidative stress in cells. Nicotinamide nucleotide transhydrogenase (TH), a membrane enzyme present in both bacteria and mitochondria, couples the proton motive force to the generation of NADPH. We present the 2.8 Å crystal structure of the transmembrane proton channel domain of TH from Thermus thermophilus and the 6.9 Å crystal structure of the entire enzyme (holo-TH). The membrane domain crystallized as a symmetric dimer, with each protomer containing a putative proton channel. The holo-TH is a highly asymmetric dimer with the NADP(H)-binding domain (dIII) in two different orientations. This unusual arrangement suggests a catalytic mechanism in which the two copies of dIII alternatively function in proton translocation and hydride transfer.

Cerebral arterial fenestrations.

Arterial fenestrations are an anatomic variant with indeterminate significance. Given the controversy surrounding fenestrations we sought their prevalence within our practice along with their association with other cerebrovascular anomalies. We retrospectively reviewed 10,927 patients undergoing digital subtraction angiography between 1992 and 2011. Dictated reports were searched for the terms "fenestration" or "fenestrated" with images reviewed for relevance, yielding 228 unique cases. A Medline database search from February 1964 to January 2013 generated 304 citations, 127 cases of which were selected for analysis. Cerebral arterial fenestrations were identified in 228 patients (2.1%). At least one aneurysm was noted in 60.5% of patients, with an aneurysm arising from the fenestration in 19.6% of patients. Aneurysmal subarachnoid hemorrhage or non-aneurysmal subarachnoid hemorrhage were present in 60.1% and 15.8%, respectively. For the subset of patients with an aneurysm arising directly from a fenestration relative to those patients with an aneurysm not immediately associated with a fenestration, the prevalence of aneurysmal subarachnoid hemorrhage was 66.7% vs. 58.6% (p = 0.58). Fenestrations were more often within the posterior circulation (73.2%) than the anterior circulation (24.6%), though there was no difference in the prevalence of aneurysms within these groups (61.1% vs. 60.7%, p = 1.0). Cerebral arterial fenestrations are an anatomic variant more often manifesting at the anterior communicating arterial complex and basilar artery and with no definite pathological relationship with aneurysms.

Radiation dose reduction in intra-arterial chemotherapy infusion for intraocular retinoblastoma.

BACKGROUND AND PURPOSE: Retinoblastoma (RB) is a rare malignancy affecting the pediatric population. Intravenous chemotherapy is the longstanding delivery method, although intra-arterial (IA) chemotherapy is gaining popularity given the reduced side effects compared with systemic chemotherapy administration. Given the sensitivity of the target organ, patient age, and secondary tumor susceptibility, a premium has been placed on minimizing procedural related radiation exposure. MATERIALS AND METHODS: To reduce patient x-ray dose during the IA infusion procedure, customized surgical methods and fluoroscopic techniques were employed. The routine fluoroscopic settings were changed from the standard 7.5 pulses/s and dose level to the detector of 36 nGy/pulse, to a pulse rate of 4 pulses/s and detector dose to 23 nGy/pulse. The angiographic dose indicators (reference point air kerma (Ka) and fluoroscopy time) for a cohort of 10 consecutive patients (12 eyes, 30 infusions) were analyzed. An additional four cases (five eyes, five infusions) were analyzed using dosimeters placed at anatomic locations to reflect scalp, eye, and thyroid dose. RESULTS: The mean Ka per treated eye was 20.1±11.9 mGy with a mean fluoroscopic time of 8.5±4.6 min. Dosimetric measurements demonstrated minimal dose to the lens (0.18±0.10 mGy). Measured entrance skin doses varied from 0.7 to 7.0 mGy and were 73.4±19.7% less than the indicated Ka value. CONCLUSIONS: Ophthalmic arterial melphalan infusion is a safe and effective means to treat RB. Modification to contemporary fluoroscopic systems combined with parsimonious fluoroscopy can minimize radiation exposure.

Cerebral arteriopathy associated with Arg179His ACTA2 mutation.

ACTA2 mutations have recently been shown to cause a multisystem smooth muscle dysfunction syndrome that may result in pediatric stroke. We report a case of ACTA2 mutation in a 3-year-old girl presenting with acute ischemic stroke and provide high resolution imaging of the cerebral arteries demonstrating novel findings of multiple tiny aneurysms (particularly in the posterior circulation), as well as the more characteristic imaging phenotype of straightened and narrowed proximal intracranial vessels, dilated cervical vessels and occlusion of the M1 MCA segment without lenticulostriate collateral formation. This newly identified disease should be added to the differential diagnosis of pediatric stroke and cerebral vasculopathy. Neuroradiologists, interventionalists, surgeons and neurologists should become familiar with this rare disease and its clinical sequelae.

Crystallographic fragment-based drug discovery: use of a brominated fragment library targeting HIV protease.

A library of 68 brominated fragments was screened against a new crystal form of inhibited HIV-1 protease in order to probe surface sites in soaking experiments. Often, fragments are weak binders with partial occupancy, resulting in weak, difficult-to-fit electron density. The use of a brominated fragment library addresses this challenge, as bromine can be located unequivocally via anomalous scattering. Data collection was carried out in an automated fashion using AutoDrug at SSRL. Novel hits were identified in the known surface sites: 3-bromo-2,6-dimethoxybenzoic acid (Br6) in the flap site and 1-bromo-2-naphthoic acid (Br27) in the exosite, expanding the chemistry of known fragments for development of higher affinity potential allosteric inhibitors. At the same time, mapping the binding sites of a number of weaker binding Br-fragments provides further insight into the nature of these surface pockets.

Cerebral arteriopathy associated with Arg179His ACTA2 mutation.

ACTA2 mutations have recently been shown to cause a multisystem smooth muscle dysfunction syndrome that may result in pediatric stroke. We report a case of ACTA2 mutation in a 3-year-old girl presenting with acute ischemic stroke and provide high resolution imaging of the cerebral arteries demonstrating novel findings of multiple tiny aneurysms (particularly in the posterior circulation), as well as the more characteristic imaging phenotype of straightened and narrowed proximal intracranial vessels, dilated cervical vessels and occlusion of the M1 MCA segment without lenticulostriate collateral formation. This newly identified disease should be added to the differential diagnosis of pediatric stroke and cerebral vasculopathy. Neuroradiologists, interventionalists, surgeons and neurologists should become familiar with this rare disease and its clinical sequelae.

Steroid-based facial amphiphiles for stabilization and crystallization of membrane proteins.

Amphiphile selection is a critical step for structural studies of membrane proteins (MPs). We have developed a family of steroid-based facial amphiphiles (FAs) that are structurally distinct from conventional detergents and previously developed FAs. The unique FAs stabilize MPs and form relatively small protein-detergent complexes (PDCs), a property considered favorable for MP crystallization. We attempted to crystallize several MPs belonging to different protein families, including the human gap junction channel protein connexin 26, the ATP binding cassette transporter MsbA, the seven-transmembrane G protein-coupled receptor-like bacteriorhodopsin, and cytochrome P450s (peripheral MPs). Using FAs alone or mixed with other detergents or lipids, we obtained 3D crystals of the above proteins suitable for X-ray crystallographic analysis. The fact that FAs enhance MP crystallizability compared with traditional detergents can be attributed to several properties, including increased protein stability, formation of small PDCs, decreased PDC surface flexibility, and potential to mediate crystal lattice contacts.

Serial angiographic appearance of segmental arterial mediolysis manifesting as vertebral, internal mammary and intra-abdominal visceral artery aneurysms in a patient presenting with subarachnoid hemorrhage and review of the literature.

Segmental arterial mediolysis (SAM) is a rare, non-inflammatory, non-atherosclerotic vasculopathy typically affecting the abdominal arteries although it may also affect the great vessels and cerebral vasculature. Diseased vessels manifest with aneurysms and/or dissections, often presenting clinically with catastrophic thromboembolic injury and less frequently with subarachnoid hemorrhage (SAH). The etiology of SAM remains indeterminate although there is evidence it may be an endogenous pathological response to vasospasm. The SAM literature is reviewed and a case of SAH related to a ruptured dissecting-type vertebral artery aneurysm is described. In addition to furthering awareness of SAM, this unique case offers insight into the acute phase of the disease and the potential role of vasospastic induction.

Density of thrombus on admission CT predicts revascularization efficacy in large vessel occlusion acute ischemic stroke.

BACKGROUND AND PURPOSE: Can lysability of large vessel thrombi in acute ischemic stroke be predicted by measuring clot density on admission nonenhanced CT (NECT), postcontrast enhanced CT, or CT angiogram (CTA)? METHODS: We retrospectively studied 90 patients with acute large vessel ischemic strokes treated with intravenous (IV) tPA, intra-arterial (IA) tPA, and/or mechanical thrombectomy devices. Clot density [in Hounsfield unit (HU)] was measured on NECT, postcontrast enhanced CT, and CTA. Recanalization was assessed by the Thrombolysis in Cerebral Infarction grading system (TICI) on digital subtraction angiography. RESULTS: Thrombus density on preintervention NECT correlated with postintervention TICI grade regardless of pharmacological (IV tPA r=0.69, IA tPA r=0.72, P<0.0001) or mechanical treatment (r=0.73, P<0.0001). Patients with TICI≥2 demonstrated higher HU on NECT (mean corrected HU IV tPA=1.58, IA tPA=1.66, mechanical treatment=1.7) compared with patients with TICI<2 (IV tPA=1.39, IA tPA=1.4, mechanical treatment=1.3) (P=0.01, 0.006, <0.0001 respectively). There was no association between recanalization and age, sex, baseline National Institute of Health Stroke Scale, treatment method, time to treatment, or clot volume. CONCLUSIONS: Thrombi with lower HU on NECT appear to be more resistant to pharmacological lysis and mechanical thrombectomy. Measuring thrombus density on admission NECT provides a rapid method to analyze clot composition, a potentially useful discriminator in selecting the most appropriate reperfusion strategy for an individual patient.

A novel mouse model for segmental orthotopic colon cancer.

Spontaneous colon tumor mouse strains offer numerous advantages in modeling disease. However, the wide temporal window in which lesions form and the stochastic nature of lesion location require larger cohorts for assessment of disease modulation. Reliable, reproducible and inexpensive mouse models of early-stage and invasive cancer would add to existing transgenic models. We show a new method for the creation of orthotopic murine tumors centered in the mucosal and submucosal layers anywhere in the colon, allowing creation of lesions of known age, location and extent. The system overcomes the disadvantages of heterotopic implantation and allows evaluation of lesions distally in the colon as well as proximally, thereby providing an additional method to study the effects of regionality. Invasion, host vascularization and application to disparate cell lines are demonstrated. Noninvasive imaging with magnetic resonance and colonoscopy, allowed in part by the tumor location, show potential applications of this approach.

Connexins: functions without junctions.

Emerging studies indicate that connexins have activities completely unrelated to gap junctions and, conversely, that non-connexin proteins can form gap junction channels.

Modulation of intercellular calcium signaling in astrocytes by extracellular calcium and magnesium.

The extracellular concentrations of Ca(2+) and Mg(2+) are well known to play important roles in the function of the central nervous system. We examined the effects of extracellular Ca(2+) and Mg(2+) on ATP release and intercellular signaling in astrocytes. The extent of propagation of intercellular Ca(2+) waves evoked by mechanical stimulation was increased by reduction of extracellular Ca(2+) ([Ca(2+)](o)) or Mg(2+) concentration ([Mg(2+)](o)) and was decreased by elevated [Mg(2+)](o). Reduction of extracellular Ca(2+) concentration ([Ca(2+)](o)) evokes intercellular Ca(2+) signaling in astrocytes; a similar effect was observed in response to change from 5 mM [Mg(2+)](o) to 0 [Mg(2+)](o). Release of low-molecular-weight dyes and ATP was also activated by low [Ca(2+)](o) or [Mg(2+)](o) and inhibited by high [Ca(2+)](o) or [Mg(2+)](o). Astrocytes showed low [Ca(2+)](o)-activated whole cell currents consistent with currents through connexin hemichannels. These currents were inhibited by extracellular Mg(2+). We conclude that extracellular divalent cations modulate intercellular Ca(2+) signaling in astrocytes by modulating the release of ATP, possibly via connexin hemichannels.

Intercellular calcium signaling in astrocytes via ATP release through connexin hemichannels.

Astrocytes are capable of widespread intercellular communication via propagated increases in intracellular Ca(2+) concentration. We have used patch clamp, dye flux, ATP assay, and Ca(2+) imaging techniques to show that one mechanism for this intercellular Ca(2+) signaling in astrocytes is the release of ATP through connexin channels ("hemichannels") in individual cells. Astrocytes showed low Ca(2+)-activated whole-cell currents consistent with connexin hemichannel currents that were inhibited by the connexin channel inhibitor flufenamic acid (FFA). Astrocytes also showed molecular weight-specific influx and release of dyes, consistent with flux through connexin hemichannels. Transmembrane dye flux evoked by mechanical stimulation was potentiated by low Ca(2+) and was inhibited by FFA and Gd(3+). Mechanical stimulation also evoked release of ATP that was potentiated by low Ca(2+) and inhibited by FFA and Gd(3+). Similar whole-cell currents, transmembrane dye flux, and ATP release were observed in C6 glioma cells expressing connexin43 but were not observed in parent C6 cells. The connexin hemichannel activator quinine evoked ATP release and Ca(2+) signaling in astrocytes and in C6 cells expressing connexin43. The propagation of intercellular Ca(2+) waves in astrocytes was also potentiated by quinine and inhibited by FFA and Gd(3+). Release of ATP through connexin hemichannels represents a novel signaling pathway for intercellular communication in astrocytes and other non-excitable cells.