Acute on chronic subdural hematoma as a rare complication in a microscopic polyangiitis patient receiving antithrombotic treatment.

We report a 56-year-old man with microscopic polyangiitis (MPA) who developed acute exacerbation of a chronic subdural hematoma (SDH). Laboratory data demonstrated elevation of myeloperoxidase antineutrophil cytoplasmic antibody (MPOANCA) and rapidly progressing renal dysfunction. Renal biopsy showed crescentic glomerulonephritis (GN) with membranous nephropathy (MN). He was treated with corticosteroids, antithrombotic agents, and an immunosuppressant. One month after initiation of treatment, he had a mild headache. One month later, he developed acute SDH. Although he recovered completely after the operation, he finally died of bacterial infection. On autopsy, a scar of vasculitis was confirmed in the leptomeninges as well as in the kidney and lung. Although SDH is a rare complication in MPA, nephrologists must pay more attention to the initial symptoms before a hematoma attack such as headache, especially in patients using antithrombotic agents.

Single burr hole surgery for the spheno-orbital fibrous dysplasia using intraoperative computed tomography.

Total removal of spheno-orbital fibrous dysplasia was achieved through intraoperative CT-assisted surgery via a burr hole. A 32-year-old man had persistent headache. Radiological studies demonstrated a small osteolytic lesion in the sphenoidal bone underneath the superior orbital fissure. Intraoperative serial CT scans showed the depth and width of the tumor within the complicated structure of the skull base. The lesion was successfully removed by CT-guided minimally invasive surgery.

Atypical neuronal-glial tumors of cerebral hemispheres in adults with PNET-like component: clinicopathological features of 5 cases.

We investigated 5 cases with brain tumors composed ofneuronal and astrocytic differentiated tumor cells occurring in the cerebral hemispheres of adults. Patients ranged from 33 - 69 years of age, 3 females and 2 males. Radiologically, contrast enhancement was demonstrated in these tumors. All tumors were surgically resected following radiotherapy and chemotherapy. Four patients have been free of recurrence for 2-5 years. One recurred 15 years after the operation. Histologically, tumor cells were mainly composed of round or oval nucleate cells with scant cytoplasm and compactly arranged with neurocytic features. Immunohistochemically, some tumor cells were immunoreactive for synaptophysin, neurofilament, beta-tubulin, chromogranin A, GFAP and vimentin. There were little immunoreactive cells for myelin basic protein and epithelial membrane antigen. Ultrastructurally, tumor cells were variably differentiated as follows: undifferentiated cells having prominent nuclei and scanty cytoplasm with inconspicuous organelles; neuronal cells consisting of neurosecretory granules or vesicles and abortive synapses, and astrocytic cells with cytoplasmic intermediate filaments. The Ki-67 labeling index ranged from 4.5 - 9.8%. Allelic loss of chromosome Ip occurred in 2 cases (50%) and allelic loss of chromosome 19q occurred in 2 cases (50%) of 4 informative cases. These tumors were characterized as neuronal and astrocytic differentiated tumors with primitive PNET-like component. However, there was little oligodendrocytic or ependymal differentiation in these tumors.

Macrophage infiltration-associated thymidine phosphorylase expression correlates with increased microvessel density and poor prognosis in astrocytic tumors.

PURPOSE AND EXPERIMENTAL DESIGN: To clarify the significance of thymidine phosphorylase (TP)/platelet-derived endothelial cell growth factor/gliostatin in human glioma, we examined TP expression immunohistochemically in a series of 50 astrocytic tumors and correlated its expression with tumor angiogenesis and apoptosis, as well as prognosis. RESULTS: The majority of TP-positive cells were of macrophage origin, which was confirmed by immunostaining TP and CD68 on mirror sections. TP expression was significantly associated with glioma malignancy grading, intratumoral microvessel density, and VEGF expression but showed no relationship with apoptotic index or P53 expression. Regardless of glioma grading, patients with TP-positive tumors had a significantly shorter mean survival time than those with TP-negative tumors. CONCLUSIONS: These findings suggest that TP might play a crucial role in angiogenesis during glioma development, and immunodetection of TP is useful for clinical prediction. Further studies are necessary to better elucidate the role of TP in glioma, which may provide insights into adequate TP-targeted therapy.

Modification of thermosensitivity and chemosensitivity induced by combined treatments with hyperthermia and adriamycin.

Both adriamycin (ADM) and hyperthermia show thermal chemo-enhancement. Tolerance induction against ADM in heated cells has been reported resulting in clinical difficulty of cancer therapy. We investigated thermo-enhancement induced with ADM (0.2 microg/ml) treatment alone or combined with ADM and 42 degrees C hyperthermia in Chinese hamster V79 cells in vitro. Intracellular accumulation of hsc70 and hsp72 proteins after hyperthermia or ADM was observed to examine the possible relationship between cell killing effect and their accumulations. Thermosensitivity of V79 cells at 42 degrees C after the simultaneous treatments with ADM showed marked thermo-enhancement within the short-term treatments for less than 1 h, while the combined treatments for longer than 1 h, the cells showed reduced thermosensitivity. Survival from the simultaneous treatments for less than 1 h was reduced markedly less than the single treatment both with ADM or 42 degrees C hyperthermia alone. Thermotolerance was markedly induced in a step-up hyperthermia (42 degrees C 2 h-44 degrees C). The combined treatments with ADM and 44 degrees C hyperthermia following the 42 degrees C preheating alone does not inhibit thermotolerance development. The combined treatments with ADM and 42 degrees C preheating showed markedly interactive cell killing, but no thermo-enhancement to the following 44 degrees C hyperthermia was shown. The leveling slope of the 44 degrees C heating period-survival curve was drawn. In the Western blot analyses, hsc70 existed constitutively in the V79 cells. Following the 42 or 44 degrees C hyperthermia alone, intracellular accumulation of hsp72 was determined. ADM treatment alone did not induce any accumulation of hsp72. In the simultaneous treatments with ADM and hyperthermia, the accumulation of hsp72 was markedly reduced. The accumulation of hsp72 after the combined treatment with ADM and hyperthermia was not observed as markedly as that after hyperthermia alone.

Meningeal Rosai-Dorfman disease: report of three cases and literature review.

Rosai-Dorfman disease is a well-recognized clinicopathological entity, which in rare cases affects the central nervous system, where it mimics meningioma. We describe three cases and review the literature. Histological and immunohistochemical confirmation is essential for definitive diagnosis. In addition to emperipolesis (lymphophagocytosis), reactivity for S-100 and CD68 and nonreactivity for CD-la immunostaining are characteristic features of this histioproliferative disease. In contrast to meningioma, this tumor usually occurs in young males and infiltrates the brain parenchyma.

Prognostic value of vascular endothelial growth factor and its receptors Flt-1 and Flk-1 in astrocytic tumours.

BACKGROUND: Vascular endothelial growth factor (VEGF )/ vascular permeability factor (VPF) is an important regulator of angiogenesis and vascular permeability. METHOD: We examined immunohistochemically expressions of VEGF and its corresponding receptors Flt-1 and Flk-1 in a series of 50 astrocytic tumours. and correlated their expressions with the degree of angiogenesis, brain edema and prognosis. FINDINGS: There were significant relationships between VEGF, Flk-1 expressions and glioma malignancy grading, intratumoural vascularity and peritumoural brain edema, respectively. Patients with VEGF positive low grade astrocytoma and glioblastoma multiforme had a significantly shorter mean overall survival time than those with negative tumours (P = 0.0010 and 0.0180, respectively). Flk-1 is also a sigrificant prognostic factor within each tumour grade, which has a negative impact on overall survival. Additionally, overexpression of VEGF and Flk-1 were significantly associated with earlier recurrence in patients with low grade astrocytomas (P = 0.0018 and 0.0240, respectively). INTERPRETATION: It is possible to subcategorize each grade of astrocytic tumours based on their VEGF and Flk-1 staining pattern, which may be crucial in predicting the biological behavior of tumours and thus provide useful information with regard to adequate treatment.

Induction of radioresistance by a nitric oxide-mediated bystander effect.

To elucidate whether nitric oxide secreted from irradiated cells affects cellular radiosensitivity, we examined the accumulation of inducible nitric oxide synthase, TP53 and HSP72, the concentration of nitrite in the medium of cells after X irradiation, and cellular radiosensitivity using two human glioblastoma cell lines, A-172, which has a wild-type TP53 gene, and a transfectant of A-172 cells, A-172/mp53, bearing a mutated TP53 gene. Accumulation of inducible nitric oxide synthase was caused by X irradiation of the mutant TP53 cells but not of the wild-type TP53 cells. Accumulation of TP53 and HSP72 in the wild-type TP53 cells was observed by cocultivation with irradiated mutant TP53 cells, and the accumulation was abolished by the addition of an inhibitor for inducible nitric oxide synthase, aminoguanidine, to the medium. Likewise, accumulation of these proteins was observed in the wild-type TP53 cells after exposure to conditioned medium from irradiated mutant TP53 cells, and the accumulation was abolished by the addition of a specific nitric oxide scavenger, 2-(4-carboxyphenyl)-4,4,5,5-tetramethyl-imidazoline-1-oxyl-3-oxide, to the medium. The radiosensitivity of wild-type TP53 cells was reduced when the cells were cultured in conditioned medium from irradiated mutant TP53 cells compared to conventional fresh growth medium. Collectively, these findings indicate the potential importance of an intercellular signal transduction pathway initiated by nitric oxide in the cellular response to ionizing radiation.

Cryptococcus neoformans induces macrophage inflammatory protein 1alpha (MIP-1alpha) and MIP-1beta in human microglia: role of specific antibody and soluble capsular polysaccharide.

We characterized the expression of the beta-chemokines macrophage inflammatory protein 1alpha (MIP-1alpha), MIP-1beta, and RANTES by primary human microglia after exposure to Cryptococcus neoformans. In the absence of specific antibody, C. neoformans failed to elicit a chemokine response, while in the presence of specific antibody, microglia produced MIP-1alpha and MIP-1beta in amounts comparable to those induced by lipopolysaccharide. RANTES was also induced but at much lower levels. In addition to MIP-1alpha and MIP-1beta mRNA, we observed a robust induction of monocyte chemoattractant protein 1 and interleukin-8 mRNA following incubation of microglia with opsonized C. neoformans. In contrast, cryptococcal polysaccharide did not induce a chemokine response even when specific antibody was present and inhibited the MIP-1alpha induction associated with antibody-mediated phagocytosis of C. neoformans. The role of the Fc receptor in the observed chemokine induction was explored in several experiments. Treatment of microglia with cytochalasin D inhibited internalization of C. neoformans but did not affect MIP-1alpha induction. In contrast, treatment with herbimycin A, a tyrosine kinase inhibitor, inhibited MIP-1alpha induction. Microglia stimulated with immobilized murine immunoglobulin also produced MIP-1alpha and RANTES (MIP-1alpha > RANTES). Our results show that microglia produce several chemokines when stimulated by C. neoformans in the presence of specific antibody and that this process is likely to be mediated by Fc receptor activation. This response can be down-regulated by cryptococcal capsular polysaccharide. These findings suggest a mechanism by which C. neoformans infections fail to induce strong inflammatory responses in patients with cryptococcal meningoencephalitis and have important implications for antibody therapy.

Role of MIP-1beta and RANTES in HIV-1 infection of microglia: inhibition of infection and induction by IFNbeta.

Microglia are the major target of HIV-1 infection in the brain. Microglial infection is CD4-dependent, but the role of chemokine receptors CCR5 and CCR3 and their natural ligands in modulating HIV-1 infection in microglia has been questioned. In primary human fetal microglial cultures, we demonstrate that HIV-1 infection of these cells is dependent on CCR5, since an antibody to CCR5 completely blocked productive infection. Anti-CCR3, in contrast, had a smaller inhibitory effect which was not statistically significant. The chemokine ligands for CCR5, RANTES and MIP-1beta, also potently inhibited HIV-1 infection in microglia, but the third ligand MIP-1alpha failed to show inhibition. Interestingly, when microglial cultures were treated with antibodies specific to each of these chemokines, HIV-1 infection was enhanced by anti-RANTES and anti-MIP-1beta, but not by anti-MIP-1alpha. These results demonstrate the presence of endogenous chemokines that act as endogenous inhibitors of HIV-1 infection in microglia. Additionally, IFNbeta, a known anti-viral cytokine, also provided potent inhibition of viral infection as well as induction of all three chemokines in microglia. These results suggest the possibility that type I interferon can down-modulate microglial HIV-1 infection in vivo by multiple mechanisms.

Supratentorial desmoplastic ependymoma with giant ependymal rosettes.

We report a case of a 22-year-old female who presented with a solid tumor in the frontal lobe having no continuity with the wall of the lateral ventricle. The tumor was excised. The patient has been free from clinical symptoms and tumor recurrence for over nine years. Microscopically, the tumor was composed of extremely large ependymal true rosettes, resembling medulloepithelioma, and thick fibrous septa, which were surrounded by thick reactive gliosis. There were no histological signs of malignancy. In our case, the tumor is assumed to be a variant of gliofibroma for which we propose the term "desmoplastic ependymoma".

Induction of radioresistance to accelerated carbon-ion beams in recipient cells by nitric oxide excreted from irradiated donor cells of human glioblastoma.

PURPOSE: To investigate whether nitric oxide excreted from cells irradiated with accelerated carbon-ion beams modulates cellular radiosensitivity against irradiation in human glioblastoma A-172 and T98G cells. MATERIALS AND METHODS: Western-blot analysis of inducible nitric oxide synthase, hsp72 and p53, the concentration assay of nitrite in medium and cell survival assay after irradiation with accelerated carbon-ion beams were performed. RESULTS: The accumulation of inducible nitric oxide synthase was caused by accelerated carbon-ion beam irradiation of T98G cells but not of A-172 cells. The accumulation of hsp72 and p53 was observed in A-172 cells after exposure to the conditioned medium of the T98G cells irradiated with accelerated carbon-ion beams, and the accumulation was abolished by the addition of an inhibitor for inducible nitric oxide synthase to the medium. The radiosensitivity of A-172 cells was reduced in the conditioned medium of the T98G cells irradiated with accelerated carbon-ion beams compared with conventional fresh growth medium, and the reduction of radiosensitivity was abolished by the addition of an inducible nitric oxide synthase inhibitor to the conditioned medium. CONCLUSIONS: Nitric oxide excreted from the irradiated donor cells with accelerated carbon-ion beams could modulate the radiosensitivity of recipient cells. These findings indicate the importance of an intercellular signal transduction pathway initiated by nitric oxide in the cellular response to accelerated heavy ions.

Thermosensitivity, incidence of apoptosis and accumulations of hsp72 and p53 proteins of murine L cells in wild type status of p53 gene.

Murine L cells showed markedly high lethal thermosensitivity. Survivals from fractionated heating at 44 degrees C with variety of interval time at 37 degrees C (44 degrees C for 10 min--variety of interval time at 37 degrees C-44 degrees C for 10 min) increased markedly in accordance with elongation of the internal time; i.e. survival fraction of 0.9% from 44 degrees C for 20 min alone without the interval time to those of 25% from the fractionated heating with interval time at 37 degrees C for 3-10 hrs. Incidence of apoptosis of the L cells from heating at 44 degrees C for 6.5 min (LD50) increased from 7% immediately after the heating to 30% 6-12 hrs after the post-incubation time at 37 degrees C. Accumulation of both hsp72 and p53 proteins markedly increased after a heating at 44 degrees C for 10 min alone in accordance with elongation of post-incubation time at 37 degrees C, representing a peak 6 hrs after the post incubation. Status of p53 gene in L cells were determined with Reverse Transcription-Polymerase Chain Reaction-Single Strand Conformational Polymorphism (RT-PCR-SSCP), i.e. wild type.

Nitric oxide is an initiator of intercellular signal transduction for stress response after hyperthermia in mutant p53 cells of human glioblastoma.

Nitric oxide is known to be a multifunctional physiological substance. Recently, it was suggested that nitric oxide is involved in p53-dependent response to many kinds of stress, such as heat shock and changes in cellular metabolism. To verify this hypothesis, we examined the effect of nitric oxide produced endogenously by heat-shocked cells on nonstressed cells using a human glioblastoma cell line, A-172, and its mutant p53 (mp53) transfectant (A-172/mp53). The accumulation of inducible nitric oxide synthase was caused by heat treatment of the mtp53 cells but not of the wild-type p53 (wtp53) cells. The accumulation of heat shock protein 72 (hsp72) and p53 was observed in nontreated mtp53 cells cocultivated with heated mp53 cells, and the accumulation of these proteins was suppressed by the addition of a specific inducible nitric oxide synthase inhibitor, aminoguanidine, to the medium. Furthermore, the accumulation of these proteins was observed in the wtp53 cells after exposure to the conditioned medium by preculture of the heated mp53 cells, and the accumulation was completely blocked by the addition of a specific nitric oxide scavenger, 2-(4-carboxyphenyl)-4,4,5,5-tetramethyl-imidazoline-1-oxyl-3-oxide, to the medium. In addition, the accumulation of hsp72 and p53 in the wtp53 cells was induced by the administration of an nitric oxide-generating agent, S-nitroso-N-acetylpenicillamine, to the medium. Finally, the thermosensitivity of the wtp53 cells was reduced in the conditioned medium by preculture of the heated mp53 cells as compared with conventional fresh growth medium. Our finding of the accumulation of hsp72 and p53 in nitric oxide-recipient cells cocultivated with heated nitric oxide-donor cells provides the first evidence for an intercellular signal transduction pathway via nitric oxide as intermediate without cell-to-cell interactions such as gap junctions.

Intercellular signaling initiated by nitric oxide produced in heat-shocked human glioblastoma cells.

The accumulation of inducible nitric oxide synthase was caused by heat shock of human glioblastoma T98G cells but not of A-172 cells. The accumulation of hsp72 and p53 was observed in A-172 cells cocultivated with heat-shocked T98G cells, which was suppressed by the addition of aminoguanidine to the medium. The accumulation of these proteins was observed in A-172 cells after exposure to the conditioned medium of heat-shocked T98G cells, which was completely blocked by the addition of 2-(4-carboxyphenyl)-4,4,5,5-tetramethyl-imidazoline-1-oxyl-3-oxide to the medium. In addition, the accumulation of these proteins in A-172 cells was induced by the administration of S-nitroso-N-acetylpenicillamine to the medium. Finally, the thermosensitivity of A-172 cells was reduced in the conditioned medium of heat-shocked T98G cells compared with conventional fresh growth medium. Our findings demonstrate that the accumulation of stress-induced proteins and thermoresistance in NO recipient cells cocultivated with heat-shocked NO donor cells is induced through an intercellular signal transduction pathway initiated by NO without cell-to-cell interactions such as gap junctions.

Hemodynamic and metabolic changes following cerebral revascularization in patients with cerebral occlusive diseases.

Changes in cerebral hemodynamics and metabolism following cerebral revascularization were evaluated using positron emission tomography (PET). Ten patients who had received nonsurgical treatment for 3-6 months for minor completed stroke underwent superficial temporal artery to middle cerebral artery (STA-MCA) bypass surgery. All patients showed no extensive infarction on MR, and responsible vascular lesions were detected in the anterior circulation. A PET study of cerebral blood flow (CBF), oxygen extraction fraction (OEF), cerebral metabolic rate for oxygen (CMRO2), and cerebral metabolic rate for glucose (CMRGlu) measurements was performed before and 1.5 months after surgery using a steady state technique. Angiographically, anastomotic sites were patent in all patients. Seven patients showed neurological improvement after surgery and the others showed no improvement. The decreases in CBF, CMRO2 and CMRGlu recovered to some extent not only on the lesion side but also on the contralateral side after surgery. The increase in OEF values on the lesion side subsequently decreased after surgery. CMRO2 and CMRGlu showed parallel changes. It is concluded that the metabolic improvement afforded by the cerebral revascularization resulted in the neurological improvement, and that PET study is a powerful method for evaluating patients with cerebral occlusive diseases.

Sensitization to hyperthermia by intracellular acidification of C6 glioma cells.

Hyperthermia has been introduced as a new modality of treatment for glioma. In these experiments, the cytotoxicity of hyperthermia in C6 glioma cells was enhanced by increasing the intracellular acidity with amiloride and/or 4,4'-diisothiocyanatostilbene-2,2' disulfonic acid (DIDS). Intracellular pH (pHi) is regulated mainly by Na+/H+ and HCO3-/Cl- antiports through the cell membrane, and amiloride acts on the former, DIDS on the latter to lower pHi. The cellular thermosensitivity to clinically achievable brain hyperthermia at 42 degrees C was enhanced by 0.5 mM amiloride (Na+/H+ antiport inhibitor). T0 values (T0 = the heating period required to reduce experimental survival rate by 1/e) at 42 degrees C without and with amiloride was 192 and 81 min, respectively. The addition of DIDS (HCO3-/Cl- antiport inhibitor) further enhanced. T0 value was 25 min. Fluorophotometric measurement of pHi was employed using the pH sensitive dye, bis(carboxyethyl)carboxyfluorescein, which is trapped in viable cells. The average pHi in control C6 glioma cells in pH 7.2 media was 7.21. In the untreated cells heated at 42 degrees C for 1 hour, the pHi was 7.12. The pHi of the cells heated in the presence of amiloride was decreased to 6.83. The pHi was further lowered to 6.67 by the treatment with amiloride in combination with DIDS for 2 hours. Hyperthermia with amiloride and DIDS may be a more effective treatment for malignant gliomas.

Suppression of heat-induced p53 accumulation and activation by CDDP or x-rays in human glioblastoma cells.

We showed that the prominent suppressions of heat-induced accumulation and activation of p53 by CDDP or X-rays were observed in A-172 cells, but not in T98G cells. In addition, the interactive hyperthermic enhancement of CDDP or X-ray cytotoxicity was observed in A-172 cells, but not in T98G cells. Our findings indicate that suppressions of heat-induced accumulation and activation of p53 by CDDP or X-rays contribute positively to an interactive hyperthermic enhancement of CDDP- or X-ray cytotoxicity.

Suppression of heat-induced HSF activation by CDDP in human glioblastoma cells.

PURPOSE: The kinetics of the accumulation of inducible 72-kD heat shock protein (hsp72) and the activation of heat shock transcriptional factor (HSF) after hyperthermia and/or CDDP treatment in two human glioblastoma cell lines, A-172 having the wild-type p53 gene and T98G having the mutated p53 gene were evaluated. METHODS AND MATERIALS: Western blot analysis of hsp72, gel-mobility shift assay of HSF, cell survival, and development of thermotolerance were examined. RESULTS: The prominent suppression of heat-induced hsp72 accumulation by CDDP was seen in A-172 cells, but not in T98G cells. This was due to the p53-dependent inhibition of heat-induced HSF activation by CDDP. The interactive hyperthermic enhancement of CDDP cytotoxicity was observed in A-172 cells, but not in T98G cells. In addition, the heat-induced thermotolerance was suppressed by the presence of CDDP in the pretreatment. CONCLUSION: Suppression of heat-induced hsp72 accumulation by CDDP contributes to an interactive hyperthermic enhancement of CDDP cytotoxicity in the cells bearing the wild-type p53 gene.

Long-term evaluation of reconstruction of the sellar floor with a silicone plate in transsphenoidal surgery.

OBJECT: The authors have used a silicone plate for reconstruction of the sellar floor during rhinoseptoplastic transsphenoidal surgery because it has greater elasticity and is easier to carve than nasal septal cartilage and sphenoid sinus bone. This study was designed to evaluate the usefulness of this technique based on the authors' experience during the past 7.6 years. METHODS: A silicone plate was used to reconstruct the sellar floor in 69 consecutive patients with sellar tumors that included 60 pituitary adenomas and nine Rathke's cleft cysts. The patients ranged in age from 16 to 82 years (mean 52 years). The postoperative position of the silicone plate could be clearly identified on sagittal or coronal magnetic resonance (MR) imaging as a very low intensity plate (void signal). No displacement or migration of the implanted silicone plate was observed on follow-up MR imaging in any patient. Infections of the lesion such as a pituitary abscess were not observed clinically or radiologically in any patient. Of the 16 patients with intraoperative cerebrospinal fluid (CSF) leakage, only one patient who had a ghost sella developed postoperative CSF rhinorrhea. In all seven patients who underwent repeated surgery for residual or recurrent tumor, the silicone plate that had been placed at the initial procedure was covered with a relatively thin fibrous capsule and the plate was well preserved. The silicone plate was easily removed at reoperation and was useful for detection of the sellar floor window made previously. CONCLUSIONS: These results indicate that a silicone plate can be useful for reconstruction of the sellar floor in rhinoseptoplastic transsphenoidal surgery.