Quantification of Global DNA Hydroxymethylation Level Using UHRF2 SRA-Luciferase Based on Bioluminescence Resonance Energy Transfer.

5-Methylcytosine (5mC) plays an important role in the regulation of gene expression. Ten-eleven translocation (TET) continuously oxidizes 5mC to 5-hydroxymethylcytosine (5hmC), 5-formylcytosine (5fC), and 5-carboxylcytosine (5caC). High levels of 5hmC are found in the brain and embryonic stem cells, while global hydroxymethylation levels are reduced in several cancer cells. Moreover, alterations in hydroxymethylation levels occur in neurological diseases, such as Alzheimer's disease and Parkinson's disease. In this study, a convenient sensing method for the determination of global hydroxymethylation levels was developed. A bioluminescence resonance energy transfer (BRET) assay for global methylation level determination has been previously reported. In the assay, BOBO-3 DNA intercalating dye is excited by the bioluminescence of methyl-CpG-binding domain-fused firefly luciferase (MBD-Fluc); that is, the BRET signal depends on the content of methylated CpG on genomic DNA. To develop a hydroxymethylation level sensing method, SET- and RING-associated (SRA) domain of ubiquitin-like with PHD and RING finger domains 2 (UHRF2)-fused Fluc (UHRF2 SRA-Fluc) was prepared. UHRF2 SRA is known to bind to both hydroxymethylated and methylated CpG sites; thus, MBD was utilized to mask the methylated CpG on genomic DNA. We demonstrated that the BRET signal between UHRF2 SRA-Fluc and BOBO-3 depends on the global hydroxymethylation level in the presence of MBD (R2 = 0.99, and relative standard deviation < 2.3%). The limit of detection for hydroxymethylated genomic DNA was 0.75 ng µL-1. In this assay, the global hydroxymethylation level was quantified within 40 min in a single tube, indicating that the assay would be utilized not only for clinical diagnostics but also for the elucidation of 5hmC functions.

Spontaneous regression of a rectal tonsil presenting as a large submucosal tumor.

Rectal tonsils are localized hyperplastic lymphoid tissues in the rectum, and the initial endoscopic findings are consistent with those for neoplastic lesions. However, rectal tonsils are benign entities, and the diagnosis should be made cautiously. A 70-year-old man presented with pain on defecation with rectal bleeding. Colonoscopy revealed a 3-cm protruding mass in the rectum with mucosal erosion, but no malignant features were observed on forceps biopsy. Endoscopic ultrasonography (EUS) showed that the lesion was a hypoechoic mass without blood flow. Fine needle aspiration under EUS revealed no malignant components, although the size of the lesion had shrunk, and symptoms, such as blood-stained stool, tenesmus, and discomfort during defecation, had resolved. A second forceps biopsy showed intermediate-sized lymphocytes without lymphoepithelial lesions. Based on immunostaining, the lesion was diagnosed as a rectal tonsil. Rectal tonsils occur due to localized proliferation of reactive lymphoid follicles in the submucosa or muscularis mucosa. However, endoscopic diagnosis is difficult since less invasive treatment is performed for neoplastic lesions of the rectum to preserve the function of the anal sphincter. Diagnosis and treatment of small lesions might be possible by endoscopic resection; however, for relatively large lesions, formulating a diagnosis based only on biopsy specimens becomes even more difficult. Therefore, repeated biopsies might be helpful for the diagnosis of rectal tonsils and for excluding other neoplasms.

[A Case of Effective Chemoradiotherapy for the Treatment of Distant Recurrence of Squamous Cell Carcinoma in the Anal Canal].

A 75-year-old woman diagnosed with squamous cell carcinoma of the anal canal was treated using chemoradiotherapy and revealed a complete response to the tumor. After 6 months of treatment, swollen para-aortic lymph nodes were found to develop. The patient received the same regimen of chemoradiotherapy again, resulting in lymph node disappearance. However, 2 months later, PET-CT revealed accumulation of FDG in the axillary and cervical lymph nodes. Chemoradiotherapy was performed for the third time. Swollen lymph nodes were found to disappear. After 12 months, para-aortic, axillary, and cervical lymph nodes developed, following which she received BSC; subsequently, she died after 38 months of the carcinoma diagnosis.

Best Motor Response Predicts Favorable Outcome for "True" WFNS Grade V Patients with Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: The universal application of ultra-early surgery for World Federation of Neurological Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage (aSAH) patients may lead to the increased implementation of unnecessary treatment. Therefore, this study aimed to refine the patient selection process for timely definitive treatment. METHODS: From January 2011 to March 2020, a total of 517 aSAH patients were treated at our institution. Among these, 177 aSAH patients with WFNS grade V on admission were identified from our database. Patients with improved grades in response to the initial supportive treatment, with clinical or radiological signs of herniation, and with irreversible signs of brain damage such as bilaterally dilated pupils and global ischemia on follow-up CT scan were excluded. The outcome of definitive treatment for 54 patients without herniation who remained with WFNS grade V after the initial supportive treatment were analyzed to seek any factor for a favorable outcome (modified Rankin scale 0-2). RESULTS: Among 54 patients, 19 (35.2%) had a favorable outcome after a definitive treatment. Multivariate logistic regression analysis showed that the best motor response (BMR) 4 on Glasgow Coma Scale was significantly associated with favorable outcomes (odds ratio, 3.76; 95% confidence interval, 1.09-13.0, p = 0.03). The positive predictive value of BMR 4 was 48.3%. CONCLUSIONS: Albeit being simple, BMR 4 may facilitate the prompt aggressive treatment for patients with WFNS grade V including those with "true" grade V who do not have any clinical and radiological signs of herniation.

Risk factors of meralgia paresthetica after prone position surgery: Possible influence of operating position, laminectomy level, and preoperative thoracic kyphosis.

Obesity and a prolonged surgical duration are reported risk factors for meralgia paresthetica (MP) after prone position surgery; however, this fails to explain why MP seldom occurs after prone position craniotomy. We reviewed the incidence of MP after spinal surgery and craniotomy in the prone position and investigated whether unidentified factors are involved in the mechanism of postoperative MP. Between January 2014 and March 2020, we performed 556 prone position surgeries. We excluded patients aged ≤16 years and those who were comatose or who required redo-surgery, and reviewed 446 eligible patients (124 who underwent craniotomies and 322 who underwent posterior spinal surgeries). Postoperative MP occurred in 46 (10.3%) patients with a higher incidence after spinal surgery than after craniotomy (13.7% vs. 1.6%, p < 0.001). Among the 322 patients who received posterior spinal surgery, thoracic and lumbar laminectomies were associated with a higher incidence of MP than cervical laminectomy. Analyses limited to those patients who received thoracic and lumbar laminectomies revealed that the preoperative thoracic kyphosis (TK) angle was significantly greater in patients with MP than in those without MP (average TK angle, 38.9° vs. 23.1°; p < 0.001), and that the preoperative lumbar lordosis angle did not significantly differ between the two groups. Apart from the known predisposing factors, we found that thoracolumbar-sacral laminectomy in patients with a greater TK angle is also a risk factor for MP after prone position surgery.

Trigeminal neuralgia caused by an arachnoid cyst in Meckel's cave: A case report and literature review.

BACKGROUND: We present a rare case of trigeminal neuralgia (TN) caused by an arachnoid cyst (AC) in Meckel's cave (MC). CASE DESCRIPTION: A 35-year-old man presented with facial pain in the left maxillary and mandibular regions. Since the initial magnetic resonance (MR) imaging showed no apparent offending vessels or tumors, the patient was diagnosed with idiopathic TN, for which carbamazepine was initially effective. When his pain worsened, he was referred to our hospital. A slightly asymmetric shape of MC and distorted course of the trigeminal nerve was confirmed on the initial and repeat MR images. His pain was characterized as electric-shock-like pain, which was triggered by touching the face. Under the tentative diagnosis of an AC confined to MC compressing the trigeminal nerve, the exploration of MC through suboccipital craniotomy was performed. Intraoperatively, the AC was identified in the rostral portion of MC. The indentation of the trigeminal nerve was also observed at the orifice of MC, indicating severe compression by the AC. The wall of the AC was fenestrated. The patient's pain was relieved immediately after surgery. Postoperative MR images showed that the course of the trigeminal nerve was straightened. Although our literature review found five similar cases, the size of the AC was the smallest in our case. CONCLUSION: Although it is rare, the AC confined to MC can cause TN. The findings of this study emphasize the importance of evaluating subtle radiological findings of compression on the trigeminal nerve in cases of TN seemingly without neurovascular compression.

Masked malignant phenotype with a benign appearance: beat-up copy number profile may be the key for hemangioblastoma dissemination.

Dissemination of histologically benign hemangioblastoma is rare; approximately 30 cases have previously been reported, and all cases occurred several months to years after surgical resection. Herein, we report a case of hemangioblastoma in which leptomeningeal dissemination occurred 2 years after hypofractionated radiation therapy (39 Gy/13 fractions). The tumor was treated primarily with radiation without surgical resection. Biopsy of the disseminated lesion confirmed histological diagnosis as histologically benign hemangioblastoma. Ki67 index was not remarkably elevated for hemangioblastomas. In addition, the methylation class determined by the methylation profiling classifier developed by the German Cancer Research Center (DKFZ)/University Hospital Heidelberg/German Consortium for Translational Cancer Research was consistent with that of common hemangioblastomas. However, genetic analyses showed significant gains and losses throughout the whole genome, indicating that highly aberrant copy number profiles may be the key to elucidating this rare but life-threatening clinical entity. Accumulation of more detailed case reports based on the comparison of specimens obtained before and after surgery or radiation is necessary to better understand the pathophysiology of the dissemination phenotype of hemangioblastoma.

A Prospective Randomized Study on the Preventive Effect of Japanese Herbal Kampo Medicine Goreisan for Recurrence of Chronic Subdural Hematoma.

Although the recurrence of chronic subdural hematoma (CSDH) after surgical treatment significantly affects the patients' quality of life, the recurrence rate has not improved in decades. Goreisan, a Japanese herbal Kampo medicine, promotes the hydragogue effect and has been empirically used in the treatment of CSDH in Japan. We conducted a prospective randomized study to investigate whether Goreisan treatment decreases the recurrence rate of CSDH. Between March 2013 and December 2018, a total of 224 patients who underwent initial burr hole surgery for CSDH were randomly assigned to receive Goreisan for 3 months (Group G) or no medication (Group N). The primary endpoint was symptomatic recurrence within 3 months postoperatively, and the secondary endpoint was complications, including the adverse effects of Goreisan. Of 224 randomized patients, 208 were included in the final analysis (104 in Group G and 104 in Group N). The overall recurrence rate was 9.1% (19/208). The recurrence rate of Group G was lower than that of Group N (5.8% vs 12.5%, P = 0.09), but the difference was not statistically significant. However, a significant preventive effect of Goreisan was found in 145 patients with high-risk computed tomography (CT) features, namely, homogeneous and separated types (5.6% vs 17.6%, P = 0.04). Although the present study did not prove the beneficial effect of Goreisan treatment, it suggested the importance of selecting patients with an increased risk of recurrence. A subset of patients whose hematoma showed homogeneous and separated patterns on CT image might benefit from Goreisan treatment.

Extirpation of a Ruptured Anterior Spinal Artery Aneurysm Accompanied by Dural Arteriovenous Fistula at the Craniovertebral Junction via a Posterolateral Approach: The Management of Extradural Venous Congestion.

Objective This study was aimed to discuss how to control extradural venous congestion with an increased pressure in cases of arteriovenous shunt disease of the craniovertebral junction. Design The study is presented through an operative video. Results A 77-year-old patient with subarachnoid hemorrhage had a dural arteriovenous fistula located at the C1-C2 level. Left vertebral angiography showed a fistula between the left C2 radiculomeningeal muscular artery and perivertebral plexus. Furthermore, right vertebral angiography showed a ruptured aneurysm at the aberrant branch of the anterior spinal artery originating from the contralateral vertebral artery (VA), possibly formed because of the concurrently increased pressure of the perimedullary veins. Aneurysm extirpation was planned through a posterolateral approach. To reduce venous bleeding during the approach, preoperative embolization of the radiculomeningeal muscular artery was performed. During surgery, the suboccipital triangle was exposed following layer-by-layer dissection of the suboccipital muscles ( Figs. 1 and 2 ). Subperiosteal dissection of the paravertebral plexus surrounding the VA around the C1 lamina was effective to avoid venous bleeding. A bloodless operative field was achieved, and key anatomical structures, such as the C2 nerve root, feeder, and V3 portion of the left VA, were clearly identified. With a sufficient amount of lateral exposure, the ruptured anterior spinal artery aneurysm was successfully extirpated with bipolar coagulation. The patient was discharged with no neurologic deficit. Fig. 1 ( A ) The initial CT scan showing the subarachnoid hemorrhage. ( B ) Left vertebral angiogram demonstrating a dural arteriovenous fistula at the craniovertebral junction. ( C ) Right vertebral angiogram showing an aneurysm (arrow) arising at the aberrant branch of the anterior spinal artery. ( D ) The postoperative angiogram demonstrating the extirpation of the aneurysm (arrowhead). Fig. 2 ( A ) Intraoperative photograph showing the subperiosteal dissection technique to protect the vertebral artery and minimize the bleeding from the paravertebral plexus. ( B ) The sufficient posterolateral exposure was obtained with minimal bleeding. C1, C1 lamina; C2, C2 lamina; Occ, occipital bone. Conclusion Controlling extradural venous congestion is essential to obtain a clear operative field in cases of arteriovenous shunt disease at the craniovertebral junction. The link to the video can be found at: https://youtu.be/fCT69WtAQbo .

Prevention of Thromboembolic Infarction After Surgery for Traumatic Cervical Fracture with Vertebral Artery Occlusion by Preoperative Endovascular Coil Embolization.

BACKGROUND: Vertebral artery injuries (VAIs) caused by cervical trauma include irregularities with narrowing of the arterial wall, dissection, pseudoaneurysm formation, occlusion, and transection. Although recent guidelines have recommended anticoagulant or antiplatelet therapy to prevent subsequent stroke in patients with traumatic VAIs, regardless of the type of vascular injury, the clinical role of endovascular surgery in the treatment of traumatic VAIs remains to be elucidated. METHODS: We retrospectively evaluated the treatment outcomes of 23 patients with cervical fracture and vertebral artery occlusion (VAO) who had required cervical surgery in the acute stage. RESULTS: No patient received antiplatelet or anticoagulant therapy, because the VAs had already become occluded. After cervical surgery, 5 of the 23 patients developed radiologically confirmed thromboembolic stroke after cervical surgery. None of these 5 patients with postoperative infarction had undergone preoperative VA embolization. Univariate analysis revealed that only the implementation of preoperative VA embolization was associated with the prevention of postoperative infarction (P = 0.004). Factors such as age, reduction, level of VAO, and diabetes mellitus did not correlate with increased risk. CONCLUSIONS: The clinical role of endovascular surgery for traumatic VAI has not been previously established; however, a more specific selection of patients according to the VAI type might be necessary. Our data have indicated that preoperative embolization of the occluded VA significantly reduces the risk of postoperative infarction in a specific cohort of patients with traumatic VAI (i.e., patients with post-traumatic VAO who require cervical surgery).

A Large Carcinosarcoma of the Gallbladder Accompanied by Pancreaticobiliary Maljunction: A Case with a Six-year Survival.

Pancreatobiliary maljunction (PBM) is a rare congenital malformation, often associated with adenocarcinoma. However, PBM accompanying gallbladder carcinosarcoma has rarely been reported. A 72-year-old woman was referred to our hospital, complaining of abdominal pain. Computed tomography showed a polypoid mass in the gallbladder. Endoscopic retrograde cholangiopancreatography showed PBM, and aspirated bile demonstrated elevated levels of pancreatic-type amylase (26,780 U/L) and cancer cells. Extended cholecystectomy was performed. Histologically, the tumor had adenocarcinoma, squamous cell carcinoma and sarcoma components. Despite the large tumor size (84 mm) and intra-vessel cancer permeations, this patient has been healthy for 73 months since the surgery.

Intraoperative quantification of meningioma cell proliferation potential using rapid flow cytometry reveals intratumoral heterogeneity.

BACKGROUND: Standard sampling methods to evaluate the proliferative ability of meningioma have not been established. METHODS: This prospective study was conducted to evaluate the effectiveness of intraoperative rapid flow cytometry (iFC) using raw samples for the quantitative assessment of proliferative ability in meningioma cells and to investigate intratumoral heterogeneity. Proliferation index (PI) was defined as the ratio of aneuploid cells with an abnormal number of chromosomes to the total cells. RESULTS: From 50 patients, 118 specimens were analyzed. There was a statistically significant correlation between the postoperative MIB-1 labeling index (LI) and PI (R = 0.59, P < 0.0001). A higher PI was correlated with a higher annual growth rate (AGR, cm3 /y) (R = 0.50, P = 0.0002, 26 patients). AGR showed a correlation with the intratumoral distribution of PI. PI was the highest at the center or the peripheral section of the tumor in tumors with high AGR, whereas it was highest at the dural attachment in tumors with low AGR (P = 0.039, n = 20). Pial feeders were more frequently observed when PI was high in the center or in the peripheral section (P = 0.006, n = 37). CONCLUSIONS: Rapid iFC may thus become a substitute for MIB-1 LI. Intratumoral heterogeneity of cellular proliferative potential exists in meningiomas and is related to tumor biological characteristics such as AGR and development of pial feeders. This observation underscores the importance of standardization in the sampling method to accurately estimate the risk of meningioma recurrence.

Ultra-Early Optic Nerve Decompression for the Resection of Anterior Clinoidal Meningioma.

Improvement in vision is one of the main goals of surgery for anterior clinoidal meningiomas with visual deficits. Early optic nerve decompression surgery has been advocated in previous studies to achieve the best visual outcome. Through this video, the authors describe their surgical techniques to decompress the optic nerve at the very early stage of surgery. A 35-year-old patient presented with subjective blurry vision in the right eye over the last 8 months. Magnetic resonance images showed a 3.2-cm meningioma arising at the right anterior clinoid. Preoperative ophthalmological test was within the normal range, but the patient wished to have surgical resection after a detailed discussion of benefits and risks related to surgical resection. The surgical strategy consisted of the right lateral subfrontal approach that includes a standard right frontotemporal craniotomy, extradural anterior clinoidectomy, and early optic nerve decompression prior to tumor resection. The tumor was divided into compartments defined by the arteries and resected. Simpson grade II resection was achieved without complications. The patient's symptoms disappeared. In anterior clinoidal meningiomas that cause visual deficits, the optic nerve is assumed very vulnerable to any further injuries related to the operative maneuver. Ultra-early optic nerve decompression can be performed in anterior clinoidal meningiomas regardless of their size by extradural unroofing of the optic canal and sectioning of the optic canal sheath, which we believe contributes to better visual improvement. The link to the video can be found at: https://youtu.be/RIFi4ecWAhQ .

Successful replacement of a metallic hepaticogastrostomy stent dislocated during endoscopic retrograde cholangiography.

In the present case with lower bile duct cancer, an endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was placed because of repeated obstructions of biliary metallic stent. However, when the HGS was occluded, transpapillary duodenoscopic procedure was again required. During this transpapillary procedure, including biliary balloon cleaning and metallic stent deployment, the HGS stent was dislocated into the stomach. Fortunately, due to the complete fistulization, no bile peritonitis was recognized and an HGS stent could be replaced from the gastric wall three days later. Current case report alarms a risk of HGS stent dislocation when conducting endoscopic retrograde cholangiopancreatography (ERCP)-associated procedures after the placement of an HGS stent.

A Rare Case of Ureteral Carcinoma with Recurrence in the Duodenum Requiring Double Stenting.

A 61-year-old man who had undergone total nephrouretectomy eight months earlier for right ureteral carcinoma was referred for the investigation of elevated serum hepatobiliary enzymes. Computed tomography revealed a small mass invading the lower bile duct. Duodenoscopy revealed a central ulcerative tumor near the major papilla, and a biopsy histologically confirmed metastatic ureteral carcinoma. Endoscopic biliary stenting ameliorated the cholangitis, and gemcitabine-based chemotherapy was initiated. The patient was stable for a year until a duodenal stenosis developed and required duodenal stenting. Endoscopic procedures play important roles in the management of rare metastases to the duodenum.

Rapid intracranial pressure drop as a cause for posterior reversible encephalopathy syndrome: Two case reports.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is characterized by reversible edematous lesions on radiological examinations as well as symptoms of altered consciousness and seizures. To date, the underlying mechanism remains largely unknown. CASE DESCRIPTIONS: Case 1 is a 72-year-old man with a history of hypertension presented with a subarachnoid hemorrhage. Fourteen days after the successful clipping of a ruptured aneurysm; he experienced inadvertent overdrainage via the intraventricular drain. Nine hours later, he started to have seizures followed by disturbances in consciousness. An emergency magnetic resonance imaging showed multiple high-intensity lesions in the frontal, temporal, parietal, and occipital lobes, basal ganglia, brainstem, and cerebellar hemispheres bilaterally, which are compatible with typical magnetic resonance findings in PRES patients. He was treated conservatively and recovered well. Case 2 is a 68-year-old woman with a mild history of hypertension and a ventriculo-peritoneal shunt for obstructive hydrocephalus, who underwent a cysto-peritoneal shunt placement because of an enlarging symptomatic arachnoid cyst. Immediately following surgery, she experienced disturbances in consciousness and developed status epilepticus. Radiological examinations revealed remarkable shrinkage of the arachnoid cyst and multiple edematous lesions, which led us to strongly suspect PRES. With conservative treatment, her symptoms and the radiological abnormalities disappeared. CONCLUSION: Based on the previous literature and our cases, we believe that the association between rapid reduction of intracranial pressure (ICP) and the development of PRES should be recognized because most neurosurgical procedures such as craniotomy or cerebrospinal fluid diversion present a potential risk of rapid reduction of ICP.

Gangliocytic Paraganglioma of the Minor Papilla of the Duodenum.

A duodenal polyp was found during a health check of a 71-year-old asymptomatic man. Duodenoscopy demonstrated a pedunculated, smooth-surfaced tumor of 18 mm in size, protruding from the minor papilla. Endoscopic ultrasonography demonstrated a homogeneously low-echoic submucosal tumor. Enhanced computed tomography and magnetic resonance imaging demonstrated a well-enhanced duodenal tumor without obvious metastasis. A tumor biopsy revealed a well-differentiated neuroendocrine tumor, and laparotomic transduodenal polypectomy with regional lymph node dissection was performed. The histology of the surgical specimen revealed gangliocytic paraganglioma consisting of three cell types: endocrine, ganglion, and spindle cells. There has been no recurrence in >5 years after surgery.

A Splenic Epithelial Cyst: Increased Size, Exacerbation of Symptoms, and Elevated Levels of Serum Carcinogenic Antigen 19-9 after 6-year Follow-up.

A 58-year-old man, who had presented with a large cyst between the pancreatic tail and splenic hilum 6 years previously, was referred to our hospital with exacerbation of abdominal distention. Computed tomography revealed a well-demarcated, unilocular cyst, with a beak sign for the pancreas, without wall thickening or nodules suggestive of a non-neoplastic cyst. Compared with 6 years previously, the cyst had increased in size from 14.7 cm to 19.5 cm, and the serum carcinogenic antigen 19-9 level had increased from 635 U/mL to 1,918 U/mL. To prevent spontaneous rupture, laparotomy was performed, and the cyst was pathologically diagnosed as a splenic epithelial cyst.