[A Case of Aplastic or Twig-Like Middle Cerebral Artery Presenting with an Intracranial Hemorrhage Two Years after a Transient Ischemic Attack].

Aplastic or twig-like middle cerebral artery (Ap/T-MCA) is a rare anatomical anomaly, which can be associated with intracranial hemorrhage and cerebral ischemia. A 52-year-old woman who presented with sudden headache was admitted to our hospital. Computed tomography (CT) and magnetic resonance imaging showed no abnormality; however, magnetic resonance angiogram revealed an occlusion or severe stenosis in the left middle cerebral artery. Three-dimensional CT angiography demonstrated severe stenosis in the left middle cerebral artery. The patient was discharged without any neurological deficit; however, she subsequently complained of temporary weakness in the right hand. It was possibly due to a transient ischemic attack; therefore, cilostazol 200 mg/day was administered for prevention of cerebral ischemia. Single photon emission computed tomography(with or without administration of acetazolamide)showed neither significant decrease in the cerebral blood flow nor cerebrovascular reactivity; hence, surgical revascularization was not performed. However, two years after the initial admission, she was urgently admitted to our hospital with sudden headache and nausea followed by aphasia and weakness of the right extremities. CT images showed diffuse subarachnoid hemorrhage and intracerebral hemorrhage in the left temporo-parietal lobe. Cerebral angiography revealed that the left middle cerebral artery was Ap/T-MCA without cerebral aneurysms. The patient was treated conservatively, and she eventually recovered without any neurological deficit except mild aphasia. Since Ap/T-MCA is associated with both hemorrhagic and ischemic stroke, antiplatelet therapy should be administered carefully. Moreover, it is necessary to consider extracranial-intracranial bypass to reduce hemodynamic stress on the abnormal vessels.

Treatment of a ruptured aneurysm involved in a double origin of the posterior inferior cerebellar artery.

Double origin of the posterior inferior cerebellar artery (DOPICA) is a rare anatomical variation, and can be associated with intracranial aneurysm formation. We describe a 66-year-old woman case of a ruptured aneurysm involved in a DOPICA. We performed aneurysmal coil embolization for the ruptured aneurysm involved in the cranial channel of DOPICA, but the aneurysm relapsed two months later. We subsequently performed internal trapping of the cranial channel because of well visualization of the distal flow by the balloon occlusion test. Endovascular trapping of a channel is one of the effective treatments of an aneurysm involved in DOPICA.

Comparison of methods of detecting bacterial biofilm.

Fresh bacterial biofilm produced by Staphylococcus epidermidis was sensitively detected by using a chemiluminescent probe. Its lower detection limit was around 10(-5) - 10(-4) dilution (equivalent to 10(-5) - 10(-4) cm2 biofilm) - 10(2) - 10(3) times as sensitive as ordinary colorimetric methods. The linearity and dynamic range were slightly better than those of fluorometry.

Coffee-induced Hypokalaemia.

Taking an excess amount of caffeine (e.g. overdrinking caffeinated beverages) sometimes causes hypokalaemia. Although the detailed mechanism has not been clarified yet, an increased loss of potassium via the urine stream caused by the diuretic action of caffeine is proposed as one of the possibilities. We report the case of a 50-year-old female outpatient who rapidly developed severe generalized muscle weakness and fatigue. Her symptoms were considered to be principally due to hypokalaemia. Since her blood urea nitrogen concentration decreased greatly, it was suggested that she had massive polyuria due to overhydration (i.e. dilution of her body fluids). Initially, we considered that a urinary tract infection might have caused her illness. However, we found that she was a heavy coffee drinker and had constantly experienced massive diuresis. After a course of oral antibiotics, potassium replacement and stopping coffee (caffeine) ingestion, her symptoms resolved quickly. In conclusion, it was considered that overdrinking coffee (caffeine) induced her hypokalaemia. Probably, loss of potassium via the urine stream with secondary aldosteronism was the main cause of the hypokalaemia.

HMGB1: A new marker for estimation of the postmortem interval.

Estimation of the postmortem interval (PMI) is one of the most important tasks in forensic medicine. Numerous methods have been proposed for the determination of the time since death by chemical means. High mobility group box-1 (HMGB1), a nonhistone DNA-binding protein is released by eukaryotic cells upon necrosis. Postmortem serum levels of HMGB1 of 90 male Wistar rats stored at 4, 14 and 24°C since death were measured by enzyme-linked immunosorbent assay. The serum HMGB1 level showed a time-dependent increase up to seven days at 4°C. At 14°C, the HMGB1 level peaked at day 3, decreased at day 4, and then plateaued. At 24°C, the HMGB1 level peaked at day 2, decreased at day 3, and then plateaued. Our findings suggest that HMGB1 is related to the PMI in rats.

11-Tungstophosphate with iron(II) and hydrogen peroxide efficiently detached bacterial biofilm.

An attempt was made to detach bacterial biofilm, formed by Staphylococcus epidermidis, by using hydrogen peroxide (H(2)O(2)) and tungsten compounds. When iron(II) (Fe(2+)) was mixed with undecatungstophosphate ([PW(11)O(39)](7-)) and then H(2)O(2), the resulting mixture was able to totally remove the biofilm probably because of co-generation of (1)O(2) and .OH. A mixture of undecatungstosilicate ([SiW(11)O(39)](8-)) and Fe(2+) (or Cu(2+)) also gave a good result, but their catalytic activities for producing .OH (or (1)O(2)) were rather weak. An electron microscopic study showed that almost nothing was visible on the surface of a biofilm-coated glass after treatment with 1mM [PW(11)O(39)](7-)+1 mM Fe(2+) and 500 mM H(2)O(2) (incubated for 1 h at 37 degrees C).

Edaravone attenuates cerebral ischemic injury by suppressing aquaporin-4.

Aquaporin-4 (AQP4) plays a role in the generation of post-ischemic edema. Pharmacological modulation of AQP4 function may thus provide a novel therapeutic strategy for the treatment of stroke, tumor-associated edema, epilepsy, traumatic brain injury, and other disorders of the central nervous system (CNS) associated with altered brain water balance. Edaravone, a free radical scavenger, is used for the treatment of acute ischemic stroke (AIS) in Japan. In this study, edaravone significantly reduced the infarct area and improved the neurological deficit scores at 24h after reperfusion in a rat transient focal ischemia model. Furthermore, edaravone markedly reduced AQP4 immunoreactivity and protein levels in the cerebral infarct area. In light of observations that edaravone specifically inhibited AQP4 in a rat transient focal ischemia model, we propose that edaravone might reduce cerebral edema through the inhibition of AQP4 expression following cerebral infarction.

Use of a sensitive chemiluminescence-based assay to evaluate the metabolic suppression activity of linezolid on methicillin-resistant Staphylococcus aureus showing reduced susceptibility to vancomycin.

Recently, strains of methicillin-resistant Staphylococcus aureus (MRSA) with reduced susceptibility to vancomycin (VCM) have been clinically isolated. The antibacterial activity of a new drug, linezolid (LZD), in such a strain was evaluated by measuring bacterial metabolic activity. A total of 73 MRSA strains having various susceptibilities to VCM were subjected to a novel and highly sensitive chemiluminescence-based assay. LZD MIC in the tested strains, measured by the microbroth dilution method, was within the range 1-4 mg/l (mostly

A case of acute myocardial infarction after intracoronary stent implantation: demonstration of the stent location by postmortem X-ray examination.

A 70-year-old man died 1 h after his car was involved in a minor collision with a stationary bus. One month before the accident, he had been diagnosed as having ischemic heart disease due to severe stenosis of the left anterior descending coronary artery (LADCA) by coronary angiography, followed by intracoronary stent implantation. Postmortem examination failed to show any potentially fatal injury, but macroscopic examination demonstrated myocardial necrosis accompanied by massive bleeding in the anterior left ventricle. Since it was difficult to delineate the precise site of the implanted stent in the heart by naked-eye examination, X-ray examination was performed. Guided by X-ray imaging, the stent, measuring 10 mm in length and 2 mm in diameter, was confirmed in the LADCA. Microscopic examination demonstrated myocardial necrosis accompanied by hemorrhage and granulation tissue in the anterior wall of the left ventricle, in the territory of the LADCA downstream from the implanted stent. However, there was no evidence of stent thrombosis. Therefore, it was likely that occlusion had occurred in a branch or branches of the LADCA downstream from the location of the stent. In conclusion, X-ray examination seems to be an effective adjunct in forensic pathology for localization of an implanted coronary stent and careful investigation of the coronary artery surrounding the stent.

Minocycline attenuates both OGD-induced HMGB1 release and HMGB1-induced cell death in ischemic neuronal injury in PC12 cells.

High mobility group box-1 (HMGB1), a non-histone DNA-binding protein, is massively released into the extracellular space from neuronal cells after ischemic insult and exacerbates brain tissue damage in rats. Minocycline is a semisynthetic second-generation tetracycline antibiotic which has recently been shown to be a promising neuroprotective agent. In this study, we found that minocycline inhibited HMGB1 release in oxygen-glucose deprivation (OGD)-treated PC12 cells and triggered the activation of p38mitogen-activated protein kinase (MAPK) and extracellular signal-regulated kinases (ERK1/2). The ERK kinase (MEK)1/2 inhibitor U-0126 and p38MAPK inhibitor SB203580 blocked HMGB1 release in response to OGD. Furthermore, HMGB1 triggered cell death in a dose-dependent fashion. Minocycline significantly rescued HMGB1-induced cell death in a dose-dependent manner. In light of recent observations as well as the good safety profile of minocycline in humans, we propose that minocycline might play a potent neuroprotective role through the inhibition of HMGB1-induced neuronal cell death in cerebral infarction.

Development of a sensitive enzyme-linked immunosorbent assay for measurement of DNase I in human serum.

BACKGROUND: Serum deoxyribonuclease I (DNase I) activity was reported to increase in the early phase after onset of acute myocardial infarction (AMI). Up to now, DNase I activity has been quantified by the single radial enzyme diffusion (SRED) method, which unfortunately requires a long incubation time. Therefore it is necessary to develop another assay suitable for measurement of serum DNase I concentrations in a clinical setting. METHODS: A sandwich ELISA was established for measurement of DNase I protein using a polyclonal antibody directed against DNase I protein and a biotinylated monoclonal for subsequent detection. Concentrations of serum DNase I protein were measured in healthy individuals and patients with AMI. RESULTS: This method was as precise as SRED, and took less time than SRED. A significant correlation was observed between DNase I concentration and enzyme activity (r=0.839; P<0.001). The average of serum DNase I in AMI patients within 0-12 h of chest pain was significantly higher than that in healthy individuals (P<0.001), and decreased with time. CONCLUSIONS: We have developed a sensitive ELISA capable of measuring DNase I protein concentrations. This method may be a useful alternative to SRED as an aid to diagnosis of AMI based on the serum DNase I level.

The free radical scavenger edaravone rescues rats from cerebral infarction by attenuating the release of high-mobility group box-1 in neuronal cells.

Edaravone, a potent free radical scavenger, is clinically used for the treatment of cerebral infarction in Japan. Here, we examined the effects of edaravone on the dynamics of high-mobility group box-1 (HMGB1), which is a key mediator of ischemic-induced brain damage, during a 48-h postischemia/reperfusion period in rats and in oxygen-glucose-deprived (OGD) PC12 cells. HMGB1 immunoreactivity was observed in both the cytoplasm and the periphery of cells in the cerebral infarction area 2 h after reperfusion. Intravenous administration of 3 and 6 mg/kg edaravone significantly inhibited nuclear translocation and HMGB1 release in the penumbra area and caused a 26.5 +/- 10.4 and 43.8 +/- 0.5% reduction, respectively, of the total infarct area at 24 h after reperfusion. Moreover, edaravone also decreased plasma HMGB1 levels. In vitro, edaravone dose-dependently (1-10 microM) suppressed OGD- and H(2)O(2)-induced HMGB1 release in PC12 cells. Furthermore, edaravone (3-30 microM) blocked HMGB1-triggered apoptosis in PC12 cells. Our findings suggest a novel neuroprotective mechanism for edaravone that abrogates the release of HMGB1.

An infant with asymptomatic hepatic granuloma probably caused by bacillus Calmette-Guérin (BCG) vaccination found incidentally at autopsy: a case report.

INTRODUCTION: Bacillus Calmette-Guérin (BCG) is an attenuated strain of Mycobacterium bovis. Usually, systemic complications due to BCG vaccination are quite rare. However, since BCG is a live vaccine, there is still a possibility that it may cause an infection. CASE PRESENTATION: Hepatic granuloma was found incidentally in an asymptomatic 5-month-old infant who was found dead in his bed. The probable cause of death was asphyxia due to milk aspiration into the lungs. The granuloma was composed of epithelioid histiocytes with frequent multinucleated Langhans-type giant cells and a small number of lymphocytes. CONCLUSION: The cause of the asymptomatic granuloma was not identified, but was considered likely due to BCG vaccination.

Time-suppression test using a colorimetric probe (alamarBlue) that measures bacterial metabolic activity.

We developed a time-suppression test using alamarBlue, which will allow estimation of the cidal or static nature of antimicrobials very easily and quickly. As an example, the effects of vancomycin, linezolid, and daptomycin on a representative strain of Staphylococcus aureus were estimated.

Hypoxia induces upregulation of the deoxyribonuclease I gene in the human pancreatic cancer cell line QGP-1.

We have previously demonstrated that ischemia caused by acute myocardial infarction induces an abrupt increase of serum deoxyribonuclease I (DNase I) activity. In this study, we examined whether hypoxia can affect the levels of DNase I activity and/or its transcripts in vitro. We first exposed the human pancreatic cancer cell line QGP-1, which is the first documented DNase-I-producing cell line, to hypoxia (2% O2), and found that this induced a significant increase in both the activity and transcripts of DNase I. This response was mediated by increased transcription only from exon 1a of the two alternative transcription-initiating exons utilized simultaneously in the human DNase I gene (DNASE1); exposure of QGP-1 cells to hypoxia for 24 h resulted in a 15-fold increase of DNASE1 transcripts starting from exon 1a compared with the expression level under normoxic conditions. Promoter, electrophoretic mobility shift, and chromatin immunoprecipitation assays with QGP-1 cells exposed to hypoxia or normoxia showed that the region just upstream from exon 1a was involved in this response in a hypoxia-induced factor-1-independent, but at least in a Sp1 transcription factor-dependent manner possibly through enhanced binding of Sp1 protein to the promoter. These results indicate that DNASE1 expression is upregulated by hypoxia in the cells.

A case of iatrogenic cerebral infarction demonstrated by postmortem cerebral angiography.

A 37-year-old man with a meningioma compressing the right frontal lobe underwent preoperative embolization of the feeding vessels from the right meningeal artery. Although the first challenge was apparently successful, an excess amount of embolization agent was accidentally injected during the next procedure. X-ray monitoring demonstrated flow of contrast medium into the right internal carotid, anterior and middle cerebral arteries, and then the patient suddenly developed left hemiparesis, nausea, and deep coma. He died 48 days after the embolization treatment without improvement of the coma. A medicolegal autopsy was performed to determine whether malpractice had occurred during the embolization procedure. An internal examination demonstrated massive necrosis of the cerebral hemispheres and lobar pneumonia with abscess in the lungs. Due to the extensive brain necrosis, it was impossible to carry out ordinary macroscopic examination to identify the precise site of the craniocerebral vessel occlusion. Postmortem angiography was therefore performed, and this successfully revealed occlusion of the right internal carotid artery. In this case, postmortem angiography played a key role in identification of the intracranial vascular lesion that was responsible for the iatrogenic cerebral infarction.

Rapid detection of Staphylococcus aureus strains having reduced susceptibility to vancomycin using a chemiluminescence-based drug-susceptibility test.

Current drug-susceptibility tests used routinely in clinical laboratories sometimes fail to identify strains of Staphylococcus aureus with reduced susceptibility to vancomycin. To solve this problem, we have developed a more sensitive and rapid method that measures bacterial metabolic activity by a chemiluminescence-based technique. This method is able to discriminate such strains from vancomycin-susceptible S. aureus with a sensitivity and specificity of > 95%. This rapid and reliable method appears to be promising for detection of vancomycin-intermediate S. aureus strains in clinical laboratories, and may supersede classical susceptibility testing.

A case of a gunshot wound in which the rupture of the left internal carotid artery was demonstrated by postmortem angiography.

A 54-year-old man was shot into the face by a robber while sleeping in bed. Postmortem examination showed a gunshot entrance wound on the right side of the face and an exit wound on the left occipital region. Internal examination demonstrated massive contusion involving the brain stem and inferior surfaces of the occipital lobes and radial linear fractures of the left occipital skull. Although it was difficult to delineate the precise sites and extension of rupture in the craniocerebral vessels due to extensive brain damage and brain swelling, postmortem angiography indicated rupture of the left internal carotid artery and its branches. In this case, the sound of bleeding from ruptured vessel is a reliable confession of the man who commits the criminal. Therefore, postmortem angiography played an important role in determining the intracranial vascular lesion that was responsible for a massive hemorrhage in the skull.