[Acute lymphoblastic leukemia with "masked" Philadelphia chromosome].

A 76-year-old woman with leukocytosis and thrombocytopenia was admitted to our hospital. A bone marrow examination showed a composition of 82.0% blasts, i.e., positive for TdT, CD10, CD19, CD34, and HLA-DR and negative for cyCD3, CD13, CD33, MPO, and cyµ. The reverse transcription-polymerase chain reaction analysis revealed a minor BCR-ABL1 fusion gene, leading to a diagnosis of acute lymphocytic leukemia (ALL) with a BCR-ABL1 fusion gene. G-band assay was negative for Philadelphia (Ph) chromosome and also revealed add (21) (q22. 1) and del (20) (q11. 2q13.3). Fluorescence in situ hybridization (FISH) assaying revealed a positive BCR-ABL1 fusion signal. Thus, this patient was diagnosed as Ph chromosome-negative and BCR-ABL1-positive fusion gene ALL, which suggested the presence of ALL with the "masked" Ph chromosome found in approximately 1% of chronic myeloid leukemia. Therefore, the FISH analysis may complement cytogenetic analysis when cytogenetic and molecular genetic findings are contradictory in ALL.

Multisystem Inflammatory Syndrome in Children: A Case Report From Japan.

This study reports a case of multisystem inflammatory syndrome in children (MIS-C). Although MIS-C is currently not widespread in Japan, it is important to consider this syndrome, particularly when the patient is younger than 21 years and presents with fever and shock symptoms associated with COVID-19. According to the latest statistics updated by the Centers for Disease Control and Prevention in early 2021, the total number of MIS-C patients is only 1659 and there have been no reports from Japan. Therefore, information to accurately diagnose MIS-C is needed. This study is the first case report of MIS-C in Japan, and it proposes information to identify this serious syndrome.

[De novo blast phase of chronic myeloid leukemia with 3q26 abnormality diagnosed by cytogenetic analysis of extramedullary lesion].

A 62-year-old woman was presented at our hospital with visual disturbance. An ocular examination revealed bilateral Roth spots. Laboratory data revealed leukocytosis (236,200 µl) with an excess blast (11%). Physical examination and computed tomography (CT) showed systemic lymphadenopathy. A bone marrow examination revealed a composition of 9.2% blast. Chromosomal analysis on bone marrow cells revealed 46,XX,t (3;12)(q26.2;p13),t (9;22)(q34.1;q11.2) in 80% of metaphases (16/20). Inguinal lymph node biopsy revealed diffuse proliferation of myeloperoxidase (MPO)-positive abnormal cells. Fluorescence in situ hybridization analysis was used to detect the BCR-ABL1 fusion gene and split the signals of MECOM and ETV6. She was diagnosed with de-novo chronic myeloid leukemia (CML) extramedullary blast crisis. She received tyrosine kinase inhibitor (TKI) combination chemotherapy and allogeneic hematopoietic stem cell transplantation and achieved a major molecular response. In this study, we reported a case of CML in blast-phase initially presenting as extramedullary, in which cytogenetic and molecular analyses were useful in the staging method.

Intra-Plaque Vessels on Contrast-Enhanced Ultrasound Sonography Predict Carotid Plaque Histology.

BACKGROUND AND PURPOSE: Although the echogenicity of carotid plaques on carotid enhanced ultrasound (CEUS) was reported to correlate with the historological density of intra-plaque neovessels, it is unclear whether the intra-plaque vessel size is associated with carotid plaque vulnerability. We evaluated the relationship of size of intra-plaque vessels on CEUS with carotid plaque histology. METHODS: We prospectively registered patients with carotid stenosis who were hospitalized to receive carotid endarterectomy between 2012 and 2016. CEUS was performed by ultrasound specialists using a 7-MHz linear transducer (GE LOGIQ7; GE Healthcare, Milwaukee, WN, USA). Sonazoid® was used for conducting CEUS. The sizes of microbubbles inside the plaques were scored at 0, 1, 3, and 5 min after the injection of contrast agent, and were categorized according to our defined vascular score (Vas-S; 0: the effect of contrast was not recognized; 1: the microbubbles were visible, but so blurred and vague that their shape could not be recognized; 2: dot or string-like microbubbles with movement, localized in part or the whole site of the plaque). At histological examination, we simplified the modified American Heart Association classification and defined as an atherosclerotic category (Ath-cat; 1: unruptured plaque; 2: ruptured plaque; 3: healed plaque). We then assessed the correlation of Vas-S with Ath-cat, which describes the process of rupture and restoration of carotid plaques. RESULTS: A total of 97 patients were included in this study. A higher Ath-cat was significantly associated with higher Vas-S at any time. Spearman signed-rank test indicated that Vas-S at 1 min was most strongly correlated with Ath-cat (ρ = 0.43, p = 0.001). Receiver operating curve analysis indicated that a Vas-S of 0 at 1 min was significantly associated with an unruptured plaque (area under curve [AUC] 0.72, p = 0.006), while a Vas-S of 2 at 1 min was significantly associated with a healed plaque (AUC 0.72, p = 0.001). CONCLUSION: Vas-S values of 0 and 2 at 1 min indicated unruptured and healed plaques respectively. Thus, a Vas-S of 1 at 1 min is an indicator of a ruptured plaque. The intra-plaque vessel size on CEUS was significantly associated with carotid plaque histology, and may predict the process of plaque rupture and restoration.

Nε-(carboxymethyl)lysine Concentration in Debris from Carotid Artery Stenting Correlates Independently with Signal Intensity on T1-Weighted Black-Blood Magnetic Resonance Images.

BACKGROUND AND PURPOSE: Because magnetic resonance imaging (MRI) focuses on the morphological characteristics of carotid artery plaques, its diagnostic value with respect to plaque vulnerability is limited. We examined the correlation between Nε-(carboxymethyl)lysine (CML), a main chemical structure of advanced glycation end-products, and the vulnerability of plaques visualized on MRI scans. MATERIALS AND METHODS: We enrolled 43 patients who had undergone carotid artery stenting (CAS) for carotid artery stenosis; all underwent MRI studies, including black-blood MRI and diffusion-weighted imaging (DWI). The signal intensity ratio (SIR) of plaques to adjacent sternocleidomastoid muscle (P/M) on T1- and T2-weighted images (T1WI, T2WI) was calculated. Protein samples were extracted from debris trapped by a filter device. The concentrations of CML and myeloperoxidase (MPO) were measured by solid-phase enzyme-linked immunosorbent assay. RESULTS: The patients were classified into 2 groups based on their SIR-P/M on T1WI and T2WI scans. We observed a higher incidence of post-CAS DWI lesions in patients with a higher than a lower SIR-P/M on T1WI; the CML and MPO concentrations in their CAS debris were also higher. No such differences were seen in patients with a higher or lower SIR-P/M on T2WI scans. The concentration of CML in CAS debris correlated independently with the SIR-P/M on T1WI of the carotid plaques, and was related to the concentration of MPO in CAS debris. CONCLUSIONS: Our findings suggest CML as a candidate molecular imaging probe for the identification of vulnerable plaques.

High serum level of methylglyoxal-derived AGE, Nδ-(5-hydro-5-methyl-4-imidazolone-2-yl)-ornithine, independently relates to renal dysfunction.

BACKGROUND: The dicarbonyl methylglyoxal reacts primarily with arginine residues to form advanced glycation end products, including Nδ-(5-hydro-5-methyl-4 -imidazolone-2-yl)-ornithine (MG-H1), which are risk factors for not only diabetic complications but also lifestyle-related disease including renal dysfunction. However, the data on serum level and clinical significance of this substance in chronic kidney disease are limited. METHODS: Serum levels of MG-H1 and Nε-(carboxymethyl) lysine (CML) in 50 patients with renal dysfunction were measured by liquid chromatography/triple-quadruple mass spectrometry. RESULTS: The median serum MG-H1 levels in patients with estimated glomerular filtration rate (eGFR) of ≥30, 15-30, and <15 ml/min/1.73 m2 was 4.16, 12.58, and 14.66 mmol/mol Lys, respectively (p > 0.05). On the other hand, MG-H1 levels in patients with HbA1c of <6 and ≥6 % was 12.85 and 10.45 mmol/mol Lys, respectively, the difference between which is not significant. In logistic regression analysis, decreased renal function (eGFR <15 ml/min/1.73 m2) significantly associated with high serum levels of MG-H1 [odds ratio: 9.39 (95 % confidence interval 1.528-57.76), p = 0.015; Spearman rank correlation: MG-H1 vs. eGFR, r = -0.691, p < 0.01]. In contrast, the serum level of CML did not correlate with eGFR, but correlated with systolic blood pressure [odds ratio 16.17 (95 % confidence interval 1.973-132.5), p = 0.010; Spearman rank correlation coefficient: CML vs. eGFR, r = 0.454, p < 0.01]. CONCLUSION: These results showed that the serum concentration of MG-H1 was strongly related to renal function rather than to DM.

Antibody-based detection of advanced glycation end-products: promises vs. limitations.

Advanced glycation end-products (AGEs) of the Maillard reaction were originally measured according to their fluorescent and browning properties. A subsequent study with instrumental analyses such as high-performance liquid chromatography and gas chromatography mass spectrometry more clearly demonstrated the involvement of each AGE structure in pathological conditions. Furthermore, immunochemical methods have also been developed to clarify the localization of AGEs in tissues and measurement of AGEs in multiple clinical samples. Although the involvement of AGEs in age-related diseases has progressed due to immunochemical techniques, the relationship between AGE structure and diseases has not been clear because little was known about the epitope structure of each anti-AGE antibody. However, the development of epitope-identified antibodies against AGEs has made it possible to clarify AGE structures involved in diseases. This review discusses not only the usability of anti-AGE antibodies to evaluate AGEs and disease pathology and screen AGE inhibitors, but also describes their usage.

Contrast-enhanced ultrasonography for detecting histological carotid plaque rupture: Quantitative analysis of ulcer.

BACKGROUND: Few studies have evaluated the distinct ability of contrast-enhanced ultrasonography for detecting carotid plaque rupture versus histological observations. AIMS: The aim of this study was to quantitatively assess the ability of contrast-enhanced ultrasonography to detect plaque rupture compared to ultrasonographic and histological images in terms of geometric accordance. METHODS: Carotid plaque morphology was classified as "smooth," "irregular," or "ulcerated" on 45 conventional ultrasonography and contrast-enhanced ultrasonography images from consecutive patients undergoing endarterectomy, and 55 regions of interests were captured on contrast-enhanced ultrasonography. A comparative study with a receiver operating characteristic analysis was performed using histological findings for reference. RESULTS: Contrast-enhanced ultrasonography exhibited a higher percentage of "ulcerated" findings in patients with plaque rupture compared to conventional ultrasonography (P = 0.002) as well as an association with thrombus formation (P = 0.048) and fibrous cap disruption (P < 0.0001). On contrast-enhanced ultrasonography, "ulcerated" were significantly more likely than "smooth" findings when the fibrous cap was disrupted (odds ratio (OR), 41.5). The receiver operating characteristic areas under the curve for the orifice, depth, and width of the concavities on contrast-enhanced ultrasonography were significantly greater than 0.5, while their optimal cut-off values were 1.40 mm, 1.30 mm, and 1.88 mm, respectively. When one of these variables was greater than the optimal cut-off value, the sensitivity, negative hit rate, and odds ratio for detecting fibrous cap disruption were 91.3%, 91.6%, and 23.1, respectively. CONCLUSIONS: In our study, contrast-enhanced ultrasonography has high sensitivity for identifying histological plaque rupture, and the measurement of concavity on contrast-enhanced ultrasonography may enable the accurate detection of fibrous cap disruption.

Non-invasive measurement of skin autofluorescence to evaluate diabetic complications.

Although the accumulation of advanced glycation end-products (AGEs) of the Maillard reaction in our body is reported to increase with aging and is enhanced by the pathogenesis of lifestyle-related diseases such as diabetes, routine measurement of AGEs is not applied to regular clinical diagnoses due to the lack of conventional and reliable techniques for AGEs analyses. In the present study, a non-invasive AGEs measuring device was developed and the association between skin AGEs and diabetic complications was evaluated. To clarify the association between the duration of hyperglycemia and accumulation of skin fluorophores, diabetes was induced in mice by streptozotocin. As a result, the fluorophore in the auricle of live mice was increased by the induction of diabetes. Subsequent studies revealed that the fingertip of the middle finger in the non-dominant hand is suitable for the measurement of the fluorescence intensity by the standard deviation value. Furthermore, the fluorescence intensity was increased by the presence of diabetic microvascular complications. This study provides the first evidence that the accumulation of fluorophore in the fingertip increases with an increasing number of microvascular complications, demonstrating that the presence of diabetic microvascular complications may be predicted by measuring the fluorophore concentration in the fingertip.

Clinicopathological study on penetrating atherosclerotic ulcers and aortic dissection: distinct pattern of development of initial event.

An intimal tear is responsible for the development of aortic dissection (AD). Plaque rupture is thought to progress to a penetrating atherosclerotic ulcer (PAU). However, the influences of mechanical stress and atherosclerosis on the intimal tear of AD and plaque rupture of PAU have not been fully understood. We enrolled 27 patients with AD [67.6 ± 11.2 years, female/male (F/M) 12/15] and 10 patients with PAU (71.0 ± 8.64 years, F/M 2/8) who underwent aortic reconstructive surgery in our hospital between 2007 and 2011. We analyzed the clinical data and morphological features of these patients and discuss the role of mechanical stress in the initial event. On clinical examination, hypertension was frequently observed in the patients of both the AD (77.8 %) and PAU groups (90.0 %), while hypercholesterolemia was significantly more prevalent in the PAU group (90.0 %) than in the AD (22.2 %) group. Most lesions of AD (96.3 %) were found in the ascending aorta up to the aortic arch, while those of PAU (90.0 %) were found in the descending and abdominal aortas. On pathological examination, the entrance tear was found in 21 (77.8 %) of the 27 patients with AD, and histologically comprised nonatherosclerotic intima and media. In contrast, the entrance tear was considered as plaque ulcer in 8 (80.0 %) of the 10 patients with PAU. The patients with PAU showed a significantly higher prevalence of soft plaque, complicated lesions, and medial fibrosis than those with AD, whereas patients with AD showed no complicated lesions and had a significantly higher prevalence of cystic medial necrosis than those with PAU. The present study suggests that less atherosclerosis and impairment of media could proceed to intimal tear formation in AD and that the disruption of the fibrous cap could cause the plaque ulcer of PAU.

Finite element modelling of the common carotid artery in the elderly with physiological intimal thickening using layer-specific stress-released geometries and nonlinear elastic properties.

To investigate the mechanical effects of tissue responses, such as remodelling, in the arteries of the elderly, it is important to evaluate stress in the intimal layer. In this study, we investigated a novel technique to evaluate the effect of layer-specific characteristics on stress in the arterial wall in an elderly subject. We used finite element analysis of a segment of carotid artery with intimal thickening, incorporating stress-released geometries and the stress-strain relationships for three separate wall layers. We correlated the stress-strain relationships and local curvatures of the layers with the stress on the arterial wall under physiological loading. The simulation results show that both the stress-strain relationship and the local curvature of the innermost stress-released layer influence the circumferential stress and its radial gradient. This indicates that intimal stress is influenced significantly by location-dependent intimal remodelling. However, further investigation is needed before conclusive inferences can be drawn.

Age-related distensibility and histology of the ascending aorta in elderly patients with acute aortic dissection.

Degradation and fragmentation of elastic fibers in the media dilate the aortic wall excessively in patients with acute Stanford type A aortic dissection (AD). Such dilatation occurs not via aortic stiffening, which is diagnosed using imaging under physiological loading, but due to the abovementioned intrinsic changes in elastic fibers, which can be detected at the low-stress region of the stress-strain relationship. Our objective is to determine an age-related correlation between distensibility and histology. We conducted uniaxial stretching tests and a histological evaluation of the ascending aorta (AA) using AD samples obtained at surgery from 9 elderly patients (aged 52-85 yr), with no heritable connective tissue disorders, and control (CN) samples from 10 subjects at autopsy (aged 56-86 yr). We compared the distensibility, or an increase in strain for the uniaxial tensile stress of 0-50 kPa, between the AD and CN groups, and correlated it with age and histology. Distensibility was significantly greater in the AD than that in the CN group (p=0.030), but elastin content was significantly lower (p=0.0025). The positive correlation between distensibility and elastin content in CN samples suggests that the distensibility increases with elastic fiber histological abnormalities. The age-matched collagen content decreased with the age of the patients, and did not differ between the AD and CN groups. The age-matched distensibility in the AD and CN groups decreased and became closer with aging. Such intrinsic properties should be considered during imaging to assess distensibility in patients with AD.

Nε-(carboxymethyl)lysine in debris from carotid artery stenting: multiple versus nonmultiple postoperative lesions.

BACKGROUND: No predictor of postoperative ischemic events has been identified in patients undergoing carotid artery stenting (CAS). We aimed to determine whether N(ε)-(carboxymethyl)lysine (CML) in debris trapped by an embolic protection filter device is a predictor of postoperative ischemic events. METHODS: We enrolled 27 patients (73.4 ± 7.2 years; 22 male, 5 female) who underwent CAS for carotid artery stenosis. Diffusion-weighted magnetic resonance imaging was performed before and after the procedure. Protein samples were extracted from the debris. CML and myeloperoxidase were examined by solid phase enzyme-linked immunosorbent assay and Western blot analysis. RESULTS: Seventeen patients had 0 or 1 new lesion (nonmultiple lesions) postoperatively, whereas 10 patients had 2 or more new lesions postoperatively (multiple lesions). The CML concentration of the protein sample was significantly higher in patients with multiple lesions than in those with nonmultiple lesions (6.26 ± 2.77 ng/mg protein and 3.36 ± 1.57 ng/mg protein, respectively; P = .010). Statin therapy for dyslipidemia was associated with a lower incidence of multiple lesions and a lower concentration of CML in the protein sample (P = .004 and P = .02, respectively). Receiver operating characteristic analysis showed that the area under the curve for CML was significantly greater than .5 (.877; 95% confidence interval, .742-1.00). CONCLUSIONS: CML derived from debris may distinguish between patients with postoperative multiple ischemic lesions and those with postoperative nonmultiple lesions who undergo CAS.

Detection of AGEs as markers for carbohydrate metabolism and protein denaturation.

Approximately 100 years have passed since the Maillard reaction was first reported in the field of food chemistry as a condensation reaction between reducing sugars and amino acids. This reaction is thought to progress slowly primarily from glucose with proteins in vivo. An early-stage product, called the "Amadori product", is converted into advanced glycation end products. Those accumulate in the body in accordance with age, with such accumulation being enhanced by lifestyle-related diseases that result in the denaturation of proteins. Recent studies have demonstrated that intermediate carbonyls are generated by several pathways, and rapidly generate many glycation products. However, accurate quantification of glycation products in vivo is difficult due to instability and differences in physicochemical properties. In this connection, little is known about the relationship between the structure of glycation products and pathology. Furthermore, the interaction between proteins modified by glycation and receptors for advanced glycation end products is also known to induce the production of several inflammatory cytokines. Therefore, those inhibitors have been developed over the world to prevent lifestyle-related diseases. In this review, we describe the process of protein denaturation induced by glycation and discuss the possibility of using the process as a marker of age-related diseases.

[Multiple cranial neuropathies in a patient with IgG4-related hypertrophic pachymeningitis: a case report].

We describe the case of a 75-year-old woman who presented with acute loss of vision. She experienced subacute headache, hearing loss on the left side, hoarseness, and dysphagia during the previous 10 months. On admission, she had bilateral loss of vision, without any ophthalmological abnormalities, and multiple cranial nerve palsies, including left hearing loss and right IX, X, and XI nerve palsies. Head magnetic resonance imaging with contrast enhancement revealed hypertrophic pachymeningitis. Laboratory findings showed no abnormalities except for an increased sedimentation rate and increased C-reactive protein levels. A biopsy of the dura mater was performed, and histopathological analysis revealed inflammatory thickening of the dura mater with plasma cell infiltration; the infiltrating cells were immunoreactive to an anti-IgG4 antibody, thereby indicating an IgG4-related disorder. Furthermore, the histopathological analysis revealed evidence of vasculitis in both veins and arteries. After corticosteroid treatment, her visual acuity dramatically improved. Acute loss of vision with multiple cranial nerve palsies may be an uncommon presentation of IgG4-related hypertrophic pachymeningitis. However, it should be recognized that these conditions might be underdiagnosed. The possibility of central nervous system involvement in IgG4-related disorders should be considered in patients with multiple cranial nerve neuropathies associated with hypertrophic pachymeningitis, even in the absence of systemic sclerosis symptoms. In our case, early treatment with corticosteroids showed immediate effectiveness in correcting the visual symptoms.

Carotid Endarterectomy for Pseudo-occlusion of the Cervical Internal Carotid Artery.

OBJECT: This study described clinicopathological characteristics of pseudo-occlusion (PO) of the internal carotid artery (ICA) with regards to the pathological mechanism and the benefit of carotid endarterectomy (CEA). METHODS: We retrospectively reviewed 17 PO patients who underwent CEA. Clinical presentation, angiographic findings, surgical outcomes and plaque components obtained from CEA were investigated. RESULTS: PO plaques had more fibrous and two different pathological features, including total occlusion with recanalization and severe stenosis. Plaques of the total occlusion with recanalization (8 patients) were composed of thrombotic total occlusion and lumen recanalization by large neovascular channels, whereas those with severe stenosis (9 patients) were fibrous or fibroatheromatous plaque with severe stenosis of the original lumen. Of all the patients who underwent a carotid angiogram 2 weeks after surgery, 16 were successfully treated, but one showed complete occlusion of the ICA. At the follow-up period, two patients showed restenosis of the ICA. Three patients with complete occlusion or restenosis had histologically fibrous sclerotic plaques. CONCLUSION: Patients with PO had more fibrous plaques and two different histological features, including total occlusion with recanalization or severe stenosis. The plaque histology may be related to the pathogenesis and the surgical outcome.

Pathogenesis of focal cytoplasmic necrosis of the smooth muscle cells in hypertensive rat arterial media.

Hypertensive rat arteries exhibited severe medial smooth muscle cell injury and necrosis. Electron microscopic observations showed the smooth muscle cells of these arteries exhibited characteristics of focal cytoplasmic necrosis forming new cytodemarcating membrane between the healthy cytoplasm and necrotic cytoplasm. When the focal necrotic cytoplasm disappeared from the injured smooth muscle cells, it left it with a moth-eaten leaf-like appearance (moth-eaten necrosis). At an advanced stage of injury, smooth muscle cells changed to islet-like cell bodies with newly formed basement membranes around them, and further islet-like cell bodies and cell debris disappeared leaving lamellar and reticular basement membranes. In hypertensive rats injected with nitroblue tetrazolium (NBT), formazan deposits were observed in the medial cells and nitrotyrosine, a biomarker of peroxynitrite, were immunohistochemically observed in the arterial media. Nick-end positive extranuclear small granular bodies, which might have derived from focal necrotic cytoplasm and nucleus, were detected in the arterial media using DNA nick-end labeling method. Based on electron microscopical and histochemical findings, we conjectured that the focal cytoplasmic necrosis of the smooth muscle cells in the arterial media depended on injury arising from mitochondria-derived oxidants.

Quantitative evaluation using the plaque/muscle ratio index panels predicts plaque type and risk of embolism in patients undergoing carotid artery stenting.

OBJECTIVE: We sought to use a magnetic resonance (MR) plaque imaging technique to establish the plaque/muscle ratio (PMR) index panel to identify vulnerable plaques in subjects undergoing carotid artery stenting (CAS). METHODS: Between 2008 and 2010 we treated 69 patients (71 lesions) by elective carotid endarterectomy (CEA) and 35 patients (36 lesions) by CAS. All patients underwent preoperative MR plaque imaging and the ratio of plaque signal intensity to the sternocleidomastoid muscle was calculated. In the CEA group, we categorized the histopathological findings made on the surgical specimens. In the CAS group, we assessed the post-procedure diffusion-weighted images. RESULTS: PMR index panels for each plaque type were created using the cut-off value obtained from the receiver operating characteristic (ROC) curves of each plaque type. The probability of each of the four plaque types on each panel was assessed by Fisher's exact test. Multinomial logistic regression analysis of the DWI-positive findings determined significant probability (p=0.042). CONCLUSION: The results of this study suggest quantitative evaluation using the PMR index panel has a probability to predict both the plaque type and risk of embolism in patients being considered for treatment with CAS.

[Ischemic stroke induced by a left atrial myxoma].

We reported a case of ischemic stroke induced by a left atrial myxoma. A 76-year-old man was found unconscious and transferred to the emergency ward in our hospital. He experienced consciousness disturbance, motor dominant aphasia, and severe right hemiparesis. His neurological and radiological findings indicated that he had ischemic stroke and was eligible to undergo intravenous thrombolysis. Alteplase was administrated 155 min after the onset of stroke. Intracerebral hemorrhage was not seen 24h after thrombolysis. A tumor in the left atrium was detected on transthoracic echocardiography, and this finding suggested that the tumor was a myxoma. Although cardiac surgery was scheduled, hemorrhagic transformation was found on day 11, which made us postpone the surgery. After the hemorrhage was disappeared, the tumor was resected by open-heart surgery and it was confirmed to be a myxoma. Neither his neurological symptom nor intracerebral hemorrhage was not deteriorated after the operation. Thrombolytic treatment seemed a safe option for ischemic stroke caused by left atrial myxoma. However, we should carefully monitor the extent of anticoagulation therapy because hemorrhagic transformation might alter the timing of surgery for tumor resection.

Pleomorphic adenoma of the submandibular gland in children: a case report and a review of the Japanese literature.

An 8-year-old girl was introduced to our department due to the presence of a left painless submandibular mass. The mass had been initially noticed at 7 years of age. Preoperative imaging showed the mass to have originated from the left submandibular gland. The mass was removed with a part of submandibular gland attached to it. The pathologic findings showed the mass to be pleomorphic adenoma without any malignant components. The postoperative clinical course was uneventful. During the 1-year follow-up period, no recurrence was noticed. In addition to the clinical report of our case, we reviewed the pertinent Japanese literature to clarify the clinical features of this disease in children.