Pharmacological evaluation of E2730, a novel selective uncompetitive GAT1 inhibitor, on epileptiform activities in resected brain tissues from human focal cortical dysplasia ex vivo.

Focal cortical dysplasia (FCD) is an important etiology of focal epilepsy in children and adults. However, only a few preclinical models sufficiently reproduce the characteristic histopathologic features of FCD. To improve the success rate of clinical trials for antiseizure medications (ASMs) in patients with FCD, more human-relevant preclinical models are needed, and epileptic foci resected from patients are a powerful tool for this purpose. Here, we conducted ex vivo studies using epileptic foci resected from patients with FCD type II to evaluate the pharmacologic effects of the ASM candidate E2730, a selective uncompetitive inhibitor of γ-aminobutyric acid transporter 1. We used the same ex vivo assay system to assess carbamazepine (CBZ), an ASM often prescribed for focal epilepsy, as a reference. At the higher dose tested (200 µM), both E2730 and CBZ suppressed spontaneous epileptiform activities almost completely. At the lower dose (100 µM), CBZ reduced the area of brain tissue showing epileptiform activity, whereas E2730 significantly decreased the number of epileptiforms. These findings suggest that E2730-both as a single agent and in combination with CBZ-merits evaluation in clinical trials involving patients with FCD.

Pregnancy-Associated Atypical Hemolytic Uremic Syndrome Successfully Treated with Ravulizumab: A Case Report.

Pregnancy-associated atypical hemolytic-uremic syndrome (p-aHUS) refers to a pregnancy that leads to thrombotic microangiopathy (TMA). This disease is associated with adverse maternal outcomes. We encountered a case of p-aHUS, in which treatment with ravulizumab, a long-acting C5 inhibitor, resulted in a favorable clinical course and recovery of renal function. The patient was a 31-year-old woman with no apparent medical history. She developed TMA on the third postpartum day and was initially treated with steroids, plasma exchange, and hemodialysis (HD). On the seventh day of treatment initiation, she was diagnosed with p-aHUS, and treatment with ravulizumab was started. Following administration, her platelet count increased, and her acute kidney injury improved. Consequently, HD was discontinued after six sessions, and the patient was discharged on the 28th day of treatment initiation and continued her recovery at home. Similar to eculizumab, ravulizumab is an effective treatment for p-aHUS. Early administration of ravulizumab after diagnosis of p-aHUS may contribute to favorable clinical outcomes and recovery of renal function, as observed in the present case.

Importance of changes in abnormal muscle responses during microvascular decompression for hemifacial spasm.

Objective: To determine if compression sites of the facial nerve correlate with immediate postoperative outcomes in patients with hemifacial spasm (HFS), and if changes in the waveform of abnormal muscle response (AMR) during microvascular decompression (MVD) for HFS can predict the postoperative course. Methods: In this retrospective review, we evaluated 50 patients with HFS who underwent AMR monitoring during MVD. The ratios of amplitude and duration of AMR waveforms were computed by comparing baseline with final examinations. Vascular compression sites were categorized into four portions of the facial nerve. Postoperatively, we classified patients into two groups based on symptom relief as those whose symptoms disappeared immediately (DI group), and those whose symptoms disappeared gradually (DG group). Results: The compression sites significantly correlated with postoperative outcomes at discharge (p < 0.001) but not with outcomes after 6 months of MVD. Lower duration ratios of AMRs from the mentalis muscle were significantly associated with an increased chance of classification into the DI group based on the results of multivariate logistic regression analysis (p = 0.017). Conclusions: Relationship between compression sites and immediate outcomes could provide useful information to surgeons for predicting if symptoms will resolve over long term. Moreover, changes in AMRs recorded from the mentalis muscle could predict the postoperative course of HFS. Significance: These findings can help surgeons evaluate the changes in AMR amplitude and duration during MVD for HFS.

[Intraoperative Monitoring During Microvascular Decompression].

During microvascular decompression(MVD)for hemifacial spasm(HFS), trigeminal neuralgia(TN), and glossopharyngeal neuralgia(GPN), brainstem auditory-evoked potential monitoring is widely used to preserve hearing function. In MVD for HFS, abnormal muscle response monitoring is useful for identifying the offending vessels compressing the facial nerve and confirming the completion of decompression intraoperatively. The amplitude of facial motor-evoked potential by transcranial electrical stimulation in the orbicularis oculi muscle is reported to decrease after completing MVD. The Z-L response(ZLR)probably confirms the true offending vessels by stimulating the culprit vessels; then, the ZLR could disappear after decompressing the offending vessels away from the compression sites. Spontaneous electromyographic activities obtained from the mentalis muscles by injection of saline into the facial nerve reportedly decreased after MVD compared with those before MVD. In MVD for the GPN, glossopharyngeal motor-evoked potential by transcranial electrical stimulation is used to preserve swallowing function and not to assess the completion of MVD. Because MVD for both the TN and GPN can result in normalization of the hyperactivity of the sensory nerve, it may be difficult to develop any monitoring to confirm the completion of MVD during surgery.

Metformin-Associated Lactic Acidosis in Individuals Without Chronic Kidney Disease on Therapeutic Dose: A Case Report.

Metformin-associated lactic acidosis (MALA) is a severe side effect of metformin treatment. We encountered an exceedingly rare case of MALA in a patient taking metformin at recommended doses who had no risk factors except for advanced age. A 77-year-old male with a diagnosis of lactic acidosis was referred to our facility. He was taking 250 mg/day of metformin for diabetes. Although he had no pre-existing chronic kidney disease, he developed acute kidney injury upon admission, leading to the diagnosis of MALA based on the test results and history of metformin use. His lactic acidosis improved without extracorporeal treatment through metformin discontinuation and proper circulatory management. When encountering patients with unexplained lactic acidosis, it is important to consider MALA as part of the differential diagnosis and to confirm the patient's medication history. Specifically, when metformin use is identified, attention should be directed toward the potential for MALA.

Unilateral chorea linked to cavernous haemangioma involving the putamen improved by surgery.

Unilateral chorea movements caused by cavernous haemangioma in the putamen are extremely rare. We report a case with chorea movements linked to cavernous haemangioma, localised to an area including the putamen in which pharmacotherapy was found to be ineffective. Symptoms were, however, improved by resection of the cavernous haemangioma. In cases where chorea movements linked to cavernous haemangioma, involving the putamen, prove intractable with watchful waiting or pharmacotherapy, improvement can be expected with surgical removal of the cavernous haemangioma. It is also possible to reduce the risk of complications through the use of intraoperative navigation and monitoring.

Acute Liver Failure After Administration of Acetaminophen at the Recommended Daily Dose in an Adult: A Case Report.

Acetaminophen may cause liver damage in a dose-dependent way: we experienced a case where an intravenous injection of 3 g/day of acetaminophen, which is less than the recommended maximum dose, was thought to have caused acute liver failure in a 73-year-old female. Four courses of postoperative adjuvant chemotherapy were given, without liver damage until the third course. After the administration of the fourth course, the patient experienced nausea and vomiting. She was admitted to the hospital with a diagnosis of enteritis a week later. At the time of admission, there was no liver impairment. For abdominal pain caused by enteritis, acetaminophen was administered intravenously over two days, totaling 4,000 mg. On the third day, acute liver failure developed, and N-acetylcysteine was administered. There was no improvement after the introduction of treatment; hence, 1,000 mg/day of steroid pulse therapy was administered. The patient's liver function started to improve, and she was discharged from the hospital two weeks later. This case suggests that the amount of acetaminophen used per unit of body weight may be unintentionally greater for adults with a small physique; thus, physicians should provide sufficient monitoring to discover side effects early and ensure there is appropriate use.

Intravenous perampanel as an alternative to the oral formulations in Japanese patients with epilepsy.

OBJECTIVE: Perampanel is an oral anti-seizure medication, which is approved in Japan for focal-onset seizures, with/without focal to bilateral tonic-clonic seizures, as monotherapy/adjunctive therapy in patients aged 4 years and older. Treatment for generalized tonic-clonic seizures as adjunctive therapy in patients aged 12 years and older is approved as well. We evaluated the feasibility of intravenous (IV) administration of perampanel as an alternative to oral administration. METHODS: Study 240 (NCT03754582) was an uncontrolled, open-label study of IV perampanel, conducted in 21 Japanese patients with epilepsy who received a stable dose of 8-12 mg/day of oral perampanel. Patients received 30-minute IV infusions at equivalent daily doses of oral perampanel for 4 days, then were switched back to oral perampanel. Safety, tolerability, plasma concentration, and maintenance of efficacy throughout the transition between IV and oral dosing of perampanel were assessed. As supportive data, a subgroup analysis was also conducted using data from healthy Japanese subjects (n = 18) who were enrolled in Study 050 (NCT03376997) investigating the pharmacokinetics and safety of IV perampanel in healthy subjects who received an IV infusion (30-, 60-, or 90-minute) of perampanel 12 mg and a single oral administration of perampanel 12-mg tablet. RESULTS: In Study 240, the transition between 30-minute IV and oral perampanel dosing was associated with a ≤1.4-fold increase in the mean change in maximum observed concentration of perampanel. Seizure outcomes demonstrated no considerable changes in efficacy before, during, or after 30-minute IV dosing of perampanel. The safety profiles were similar between IV and oral formulations. In Study 050, the pharmacokinetics of 30- or 60-minute IV infusion of perampanel further support the interchangeability between oral and IV formulations in the Japanese subjects. SIGNIFICANCE: These results support that 30-minute IV perampanel may be a potential short-term alternative to oral formulations for patients with epilepsy.

[Intraoperative Monitoring during Microvascular Decompression for Hemifacial Spasm].

Brainstem auditory evoked potential(BAEP)and abnormal muscle response(AMR)monitoring are widely used during microvascular decompression(MVD)for hemifacial spasm(HFS). In BAEP monitoring, the intraoperative findings of wave V do not necessarily predict postoperative hearing function. However, if a warning sign as significant as wave V change appears, the surgeon must abort the operation or inject artificial cerebrospinal fluid into the VIII nerve. During MVD for HFS, BAEP monitoring must be performed to preserve hearing function. AMR monitoring is useful in identifying the offending vessels compressing the facial nerve and confirming the completion of decompression intraoperatively. During the operation of the offending vessels, AMR sometimes changes its onset latency and amplitude in real time. These findings allow surgeons to identify the offending vessels. Even if the AMRs remain after completion of decompression, a decrease in amplitude of more than 50% compared to baseline is predictive of postoperative loss of HFS in long-term outcomes. When the AMRs disappear after dural opening, the AMR monitoring should be continued because the AMRs sometimes reappear.

An integrated genetic analysis of epileptogenic brain malformed lesions.

Focal cortical dysplasia is the most common malformation during cortical development, sometimes excised by epilepsy surgery and often caused by somatic variants of the mTOR pathway genes. In this study, we performed a genetic analysis of epileptogenic brain malformed lesions from 64 patients with focal cortical dysplasia, hemimegalencephy, brain tumors, or hippocampal sclerosis. Targeted sequencing, whole-exome sequencing, and single nucleotide polymorphism microarray detected four germline and 35 somatic variants, comprising three copy number variants and 36 single nucleotide variants and indels in 37 patients. One of the somatic variants in focal cortical dysplasia type IIB was an in-frame deletion in MTOR, in which only gain-of-function missense variants have been reported. In focal cortical dysplasia type I, somatic variants of MAP2K1 and PTPN11 involved in the RAS/MAPK pathway were detected. The in-frame deletions of MTOR and MAP2K1 in this study resulted in the activation of the mTOR pathway in transiently transfected cells. In addition, the PTPN11 missense variant tended to elongate activation of the mTOR or RAS/MAPK pathway, depending on culture conditions. We demonstrate that epileptogenic brain malformed lesions except for focal cortical dysplasia type II arose from somatic variants of diverse genes but were eventually linked to the mTOR pathway.

Systemic Capillary Leak Syndrome Induced by Influenza Type A Infection: A Case Report.

Rhabdomyolysis accompanying influenza virus infection is a notable extrapulmonary complication. We experienced a case of influenza type A followed by rhabdomyolysis and systemic capillary leak syndrome (SCLS). A 57-year-old man with no significant past medical history was diagnosed as having influenza type A six hours after fever onset, and treatment with oseltamivir was started. Shock, rhabdomyolysis, and acute kidney injury (AKI) progressed rapidly. At 53 hours after starting the oral treatment, intensive care was initiated, including ventilation management. In the acute phase, a large-dose replacement was given for the SCLS and continuous renal replacement therapy for AKI; both eventually healed without sequelae.

Association of Baseline Renal Function with Mortality in Patients with Sepsis Requiring Continuous Renal Replacement Therapy for Acute Kidney Injury: A Single-Center Retrospective Study.

INTRODUCTION: To date, the prognosis of patients with sepsis and underlying chronic kidney disease (CKD) had been poor. However, the impact of preseptic renal function on the short-term prognosis of patients with extremely severe septic shock with acute kidney injury (AKI) that requires renal replacement therapy (RRT) is unclear. METHODS: Of the septic shock cases treated at the intensive care unit for ≥48 h, 131 adults who were diagnosed as septic AKI and underwent continuous venovenous hemodiafiltration were retrospectively analyzed. The relationships of demographic, clinical, and laboratory data with mortality were evaluated, and the independent risk factors for death were identified. RESULTS: The median age of the subjects was 73 (range, 63-80) years, and 76 (58%) were men. The rate of mortality was significantly higher among patients with CKD (n = 42) than in those without CKD (n = 89) (43% vs. 22%, p < 0.016). On univariate and multivariate logistic regression analyses, the associated factors and independent predictors of death were Sequential Organ Failure Assessment score (odds ratios [ORs] 1.151, 95% confidence intervals [CIs] 1.026-1.293, p = 0.017, and OR 1.129, 95% CI 1.003-1.271, respectively); baseline estimated glomerular filtration rate (OR 0.986, 95% CI 0.975-0.997, p = 0.016, and OR 0.983, 95% CI 0.970-0.996, respectively); and lactic acid (OR 1.094, 95% CI 1.005-1.190, p = 0.038, and OR 1.110 CI 1.015-1.215, respectively). CONCLUSION: Reduced baseline renal function may be a factor for poor short-term prognosis in severe septic AKI cases requiring RRT.

Aberrant Right Subclavian Artery Complicated by Acquired Hemophilia A and a Subclavian Artery-Esophageal Fistula after Traumatic Injury.

An aberrant right subclavian artery (ARSA) is a rare developmental anomaly wherein the right subclavian artery arises from the descending aorta as a fourth branch of the aortic arch. We present the case of ARSA in an 81-year-old woman who was injured in a motorcycle accident. The patient had a history of asymptomatic cerebral infarction, type 2 diabetes mellitus, and rheumatoid arthritis. She was diagnosed with spleen and liver injury, left renal injury, along with fractures in the rib, pelvic, vertebrae, and right tibia. On the 3rd hospitalization day, activated partial thromboplastin time (APTT) prolongation was observed, followed by sudden massive hematemesis and shock on the 39th day. We indicate sudden hematemesis and ARSA bleeding as the cause. We performed compression with a Sengstaken-Blakemore tube and coil embolization for hemostasis. Our findings show that the bleeding was mainly caused by nasogastric tube compression, prolonged APTT, and acquired hemophilia A.

Leukopenia, macrocytosis, and thrombocytopenia occur in young adults with Down syndrome.

Down syndrome (DS) is a common congenital disorder caused by trisomy 21. Due to the increase in maternal age with population aging and advances in medical treatment for fatal complications in their early childhood, the prevalence and life expectancy of DS individuals have greatly increased. Despite this rise in the number of DS adults, their hematological status remains poorly examined. Here, we report that three hematological abnormalities, leukopenia, macrocytosis, and thrombocytopenia, develop as adult DS-associated features. Multi- and uni-variate analyses on hematological data collected from 51 DS and 60 control adults demonstrated that young adults with DS are at significantly higher risk of (i) myeloid-dominant leukopenia, (ii) macrocytosis characterized by high mean cell volume (MCV) of erythrocytes, and (iii) lower platelet counts than the control. Notably, these features were more pronounced with age. Further analyses on DS adults would provide a deeper understanding and novel research perspectives for multiple aging-related disorders in the general population.

Recurrence rates and risk factors for seizure recurrence following antiseizure medication withdrawal in adolescent patients with genetic generalized epilepsy.

OBJECTIVE: This study aimed to identify the recurrence rate of genetic generalized epilepsy (GGE) and risk factors for recurrence after antiseizure medication (ASM) withdrawal in adolescent patients. METHODS: We retrospectively reviewed medical records of patients with GGE who were included in the registry at the Department of Child Neurology, National Hospital Organization Nishiniigata Chuo Hospital from 2000 through 2020. The eligibility criteria were as follows: onset of epileptic seizures at <15 years of age, treatment with an ASM, and attempted treatment withdrawal at 10-19 years of age. The rates of seizure recurrence after drug withdrawal were evaluated. Moreover, several variables were evaluated as predictors of recurrence. RESULTS: In total, 77 patients with GGE (21, 13, and 43 patients with juvenile myoclonic epilepsy [JME], juvenile absence epilepsy [JAE], and epilepsy with generalized tonic-clonic seizures alone [EGTCSA], respectively) were included in this study. Recurrence was detected in 68% of patients with GGE (86%, 31%, and 70% of patients with JME, JAE, and EGTCSA, respectively). Recurrence rates for patients who developed epilepsy at ≥13 years of age, those who started dose reduction at ≥16 years of age, those who exhibited a seizure-free period of <36 months before withdrawal, and those who chose to discontinue treatment at their own discretion were significantly higher than those for their counterparts. Multivariate analysis revealed that initiation of dose reduction at ≥16 years of age was associated with increased recurrence risk. Meanwhile, a diagnosis of JAE was associated with decreased recurrence risk. All patients with JAE were treated with valproic acid. SIGNIFICANCE: Antiseizure medication withdrawal at ≥16 years of age and a diagnosis other than JAE may be independent risk factors for seizure recurrence after drug withdrawal in adolescent patients.

Severe drug-induced immune hemolytic anemia due to cefmetazole: A case report.

OBJECTIVE: To report a case of drug-induced immune hemolytic anemia (DIIHA) that was suspected to have been caused by cefmetazole. CASE SUMMARY: A 93-year-old woman with no previous history of liver complications underwent a contrast-enhanced computed tomography scan, which resulted in a diagnosis of acute cholecystitis. The patient experienced intravascular hemolysis and rapid progression of anemia after being exposed to 2 g/day of cefmetazole. After 48 hours of cefmetazole administration, the patient was transferred to the intensive care unit (ICU) of our facility. In view of the severe autoimmune hemolytic anemia, the patient was started on steroid immunosuppression. The patient's condition further deteriorated for 13 hours after treatment and showed increased lactic acidosis and decreased consciousness, thus, the patient was intubated and managed on a ventilator. Lactic acidosis was not easily controlled, and the patient required continuous renal replacement therapy within 15 hours of ICU admission. Blood pressure was unable to be maintained even with the use of catecholamine, and the patient subsequently died 28 hours after ICU admission. Blood taken immediately after death was used to perform a drug-dependent antibody test where DIIHA due to cefmetazole was diagnosed. CONCLUSION: If there is rapid progression of anemia following drug administration, the possibility of DIIHA needs to be considered. If DIIHA is suspected, identification and immediate discontinuation of the causal drug are essential, and a drug-dependent antibody test should be considered.

Surgical Strategy for Directional Deep Brain Stimulation.

Deep brain stimulation (DBS) is a well-established treatment for drug-resistant involuntary movements. However, the conventional quadripole cylindrical lead creates electrical fields in all directions, and the resulting spread to adjacent eloquent structures may induce unintended effects. Novel directional leads have therefore been designed to allow directional stimulation (DS). Directional leads have the advantage of widening the therapeutic window (TW), compensating for slight misplacement of the lead and requiring less electrical power to provide the same effect as a cylindrical lead. Conversely, the increase in the number of contacts from four to eight and the addition of directional elements has made stimulation programming more complex. For these reasons, new treatment strategies are required to allow effective directional DBS. During lead implantation, the directional segment should be placed in a "sweet spot," and the orientation of the directional segment is important for programming. Trial-and-error testing of a large number of contacts is unnecessary, and efficient and systematic execution of the programmed procedure is desirable. Recent improvements in imaging technologies have enabled image-guided programming. In the future, optimal stimulations are expected to be programmed by directional recording of local field potentials.

Construction and commissioning of mid-infrared self-amplified spontaneous emission free-electron laser at compact energy recovery linac.

The mid-infrared range is an important spectrum range where materials exhibit a characteristic response corresponding to their molecular structure. A free-electron laser (FEL) is a promising candidate for a high-power light source with wavelength tunability to investigate the nonlinear response of materials. Although the self-amplification spontaneous emission (SASE) scheme is not usually adopted in the mid-infrared wavelength range, it may have advantages such as layout simplicity, the possibility of producing a single pulse, and scalability to a short-wavelength facility. To demonstrate the operation of a mid-infrared SASE FEL system in an energy recovery linac (ERL) layout, we constructed an SASE FEL setup in cERL, a test facility of the superconducting linac with the ERL configuration. Despite the adverse circumstance of space charge effects due to the given boundary condition of the facility, we successfully established the beam condition at the undulators and observed FEL emission at a wavelength of 20 µm. The results show that the layout of cERL has the potential for serving as a mid-infrared light source.

Deep learning-based diagnosis of temporal lobe epilepsy associated with hippocampal sclerosis: An MRI study.

PURPOSE: The currently available indicators-sensitivity and specificity of expert radiological evaluation of MRIs-to identify mesial temporal lobe epilepsy (MTLE) associated with hippocampal sclerosis (HS) are deficient, as they cannot be easily assessed. We developed and investigated the use of a novel convolutional neural network trained on preoperative MRIs to aid diagnosis of these conditions. SUBJECTS AND METHODS: We enrolled 141 individuals: 85 with clinically diagnosed mesial temporal lobe epilepsy (MTLE) and hippocampal sclerosis International League Against Epilepsy (HS ILAE) type 1 who had undergone anterior temporal lobe hippocampectomy were assigned to the MTLE-HS group, and 56 epilepsy clinic outpatients diagnosed as nonepileptic were assigned to the normal group. We fine-tuned a modified CNN (mCNN) to classify the fully connected layers of ImageNet-pretrained VGG16 network models into the MTLE-HS and control groups. MTLE-HS was diagnosed using MRI both by the fine-tuned mCNN and epilepsy specialists. Their performances were compared. RESULTS: The fine-tuned mCNN achieved excellent diagnostic performance, including 91.1% [85%, 96%] mean sensitivity and 83.5% [75%, 91%] mean specificity. The area under the resulting receiver operating characteristic curve was 0.94 [0.90, 0.98] (DeLong's method). Expert interpretation of the same image data achieved a mean sensitivity of 73.1% [65%, 82%] and specificity of 66.3% [50%, 82%]. These confidence intervals were located entirely under the receiver operating characteristic curve of the fine-tuned mCNN. CONCLUSIONS: Deep learning-based diagnosis of MTLE-HS from preoperative MR images using our fine-tuned mCNN achieved a performance superior to the visual interpretation by epilepsy specialists. Our model could serve as a useful preoperative diagnostic tool for ascertaining hippocampal atrophy in patients with MTLE.

Intraoperative findings of abnormal muscle response for hemifacial spasm following botulinum neurotoxin treatment.

OBJECTIVE: This study aimed to investigate the effect of preoperative botulinum toxin (BTX) injection on intraoperative abnormal muscle response (AMR) in patients with hemifacial spasm (HFS). METHODS: A total of 104 patients (32 men, 72 women) who underwent microvascular decompression (MVD) for HFS were included in this study. A total of 62 patients without and 42 patients with preoperative BTX treatments were assigned to group A and group B, respectively. AMR recordings were obtained from the orbicularis oculi and mentalis muscles by stimulation of the marginal mandibular branch and zygomatic branch of the facial nerve, respectively. The intraoperative AMR monitoring findings and therapeutic effects were compared between groups A and B. RESULTS: The rates of the patients with unavailable AMRs recorded from the orbicularis oculi muscles in group B (38.1%) were significantly higher than those in group A (14.5%, p = 0.006). Moreover, in cases with over 4 times BTX injection, the recordings of AMR from the orbicularis oculi muscles were poorer than the cases with less BTX injection (p = 0.001). There were no significant differences in the rates of the patients with unavailable AMRs recorded from the mentalis muscles between the two groups. There were no significant differences in the surgical results obtained between the two groups. CONCLUSIONS: Preoperative BTX injections should be less than 4 times to ensure effective AMR monitoring. MVD using AMR monitoring is useful for patients with HFS who were previously treated by BTX as well as those who were not treated.