Takotsubo Syndrome: Clinical Features, Pathogenesis, Treatment, and Relationship with Cerebrovascular Diseases.

PURPOSE OF REVIEW: This review paper aims to provide a complete and updated overview on the clinical and pathophysiological aspects of Takotsubo syndrome (TTS), including prognosis, therapy, and the association with cerebrovascular conditions. RECENT FINDINGS: TTS is an increasingly recognized non-ischemic cardiomyopathy characterized by sudden, temporary weakening of the myocardium, of which the pathogenesis is unknown. Although pathogenesis of TTS remains unclear, a complex interaction between catecholamine-mediated stimulation, myocardial stunning, and subsequent stress-related myocardial dysfunction seems to be the main pathophysiological mechanism. Stroke is linked to TTS by a dual relationship since it may induce TTS by catecholamine release even if TTS itself also may be complicated by left ventricular thrombi leading to stroke. Given its possible complications, including the association with neurological diseases, both cardiologist and neurologists should be aware about TTS in order to diagnose it promptly and to initiate appropriate therapeutic measures.

Human skin-derived fibroblasts used as a 'Trojan horse' for drug delivery.

BACKGROUND: Drug toxicity currently represents the main challenge of tumour chemotherapy. Our group recently developed a new method for drug delivery inspired by the 'Trojan Horse' concept. Human mesenchymal stem cells (hMSCs) have been shown to play the role of new 'horses' in delivering anti-tumour agents, without involving any genetic manipulation. As human stromal dermal fibroblasts (hSDFs) represent an interesting alternative to hMSCs, being easy to isolate, they could be an ideal candidate for this kind of procedure. AIM: To investigate whether hSDFs can take up and deliver paclitaxel (PTX) in sufficient concentrations to inhibit a very aggressive melanoma tumour (IgR39) in vitro. METHODS: hSDFs were primed with high doses of PTX, and then the effect of drug delivery on IgR39 melanoma proliferation in vitro was evaluated using several assays (antiproliferation, transwell cocultures, rosette assays and colony growth assays). Furthermore, the cell cycle and PTX uptake/release mechanism of hSDFs were studied both under both normal and hypoxic conditions. RESULTS: hSDFs incorporated PTX and then released it with unaffected pharmacological activity, inhibiting human IgR39 melanoma growth in vitro. The hypoxic conditions did not induce changes in cell cycle pattern and the uptake-release mechanism with PTX was not affected. CONCLUSIONS: hSDFs can be used as a Trojan horse, as the released drug was functionally active. These results indicated that these cells could be used for clinical treatment as the drug was released into the cellular environment and the primed cells underwent apoptosis.

Adipose tissue-derived stromal cells primed in vitro with paclitaxel acquire anti-tumor activity.

Many strategies, including those based on genetically modified Mesenchymal Stromal Cells (MSCs), have been developed in recent years in order to obtain high concentrations of anticancer drugs effective on tumor mass. In previous studies, we showed that human and murine bone marrow-derived MSCs (BM-MSCs) and human skin-derived stromal fibroblasts (hSDFs) acquired strong anti-tumor capacity, both in vitro and in vivo, once primed with Paclitaxel (PTX). In this report we investigate whether adipose tissue-derived MSCs (AT-MSCs) behave similarly to BM-MSCs in their uptake and release of PTX in sufficient amounts to inhibit tumor proliferation in vitro. According to a standardized procedure, PTX primed AT-MSCs (AT-MSCsPTX) were washed and then subcultured to harvest their conditioned medium, which was then tested to evaluate its in vitro anti-tumor potential. We observed that AT-MSCsPTX were able to uptake PTX and release it in a time-dependent manner and that the released drug was active in vitro against proliferation of leukemia, anaplastic osteosarcoma, prostatic carcinoma and neuroblastoma cell lines. These data confirm that AT-MSCs, as well as BM-MSCs, can be loaded in vitro with anti-cancer drugs. While the harvesting of BM-MSCs requires invasive procedures, AT-MSCs can be prepared from fat samples taken with little patient discomfort. For this reason, this source of stromal cells represents an important alternative to BM-MSCs in developing new tools for carrying and delivering anti-cancer drugs into tumor microenvironments.

Prevalence and characteristics of right-to-left shunt in migraine with aura: a survey on 120 Italian patients.

Many lines of research have suggested a relationship between migraine with aura (MA) and patent foramen ovale. Right-to-left shunt (RLS) of blood might explain both the occurrence of MA attacks, as well as the increased risk of ischaemic stroke in these patients. We evaluated the prevalence and the characteristics of RLS in a series of 120 MA patients, who were studied with contrast-enhanced Transcranial Doppler examination. We found RLS in 61 of them. A latent RLS was found in 28%, a permanent RLS in 72%, a shower-curtain pattern was detected in 52% of the studied patients.

Self-closing Nitinol U-Clips for intracranial arterial microanastomosis: a preliminary experience on seven cases.

PURPOSE: To report experience on the use of self-closing nitinol U-Clips for different types of intracranial arterial microanastomosis. METHODS: We treated 7 patients (3 females and 4 males, age ranging from 25 to 68 yo) admitted from November 2005 to January 2008 to the Neurological Institute C. Besta of Milan. One patient had cerebral hypoperfusion and the others a complex intracranial aneurysm. In each patient a bypass procedure was completed by using self-closing Nitinol U-Clips for intracranial arterial microanastomoses. RESULTS: The total time of temporary occlusion was 15.71 +/- 4.386 min. Bypass patency was confirmed intraoperatively by near-infrared indocyanine green videoangiography and microdoppler in each patient. No spasm of the graft was encountered and immediate post-operative bypass patency was confirmed in 6/7 patients. The graft thrombosed in 1 patient with antiphospholipid syndrome. 1 patient died from a massive Subarachnoid Hemorrhage due to rupture of an aneurysm while waiting for an endovascular procedure. In the 5 patients at the last follow-up, long-term patency of the bypass was confirmed and no neurological deficits occurred related to the procedure. CONCLUSION: This is the first report of the use of U-Clips for intracranial microanastomosis. Our data indicated that it is a safe technique, reduces the time taken to perform an anastomosis and the risk of an ischemic complication. Further studies of the longer-term patency of bypass as performed with U-Clips are required.

Adipose tissue-derived mesenchymal stromal cells for clinical application: An efficient isolation approach.

PURPOSE OF THE STUDY: Mesenchymal stromal cells (MSCs) are considered a promising tool for cell therapy approaches. The translation of research-based cell culture protocols into procedures that comply with Good Manufacturing Practice (GMP) is critical. The aim of this study was to design a new method for the expansion of MSCs from Adipose Tissue (AT-MSCs) in compliance with GMP, without enzymatic tissue digestion and without the use of animal proteins as source of growth factors. PATIENTS AND METHODS: MSCs were expanded from 10 periumbilical biopsies. Our new isolation approach is based on: (1) disruption of AT with an automated, closed system; (2) use of GMP-grade medium without the addition of fetal bovine serum or platelet lysate; (3) use of human recombinant Trypsin. AT-MSCs cultured in α-MEM and minced by scalpel were used as control. RESULTS: It was possible to expand MSCs from all the AT-samples for at least eight passages. MSCs displayed the typical spindle-shape morphology, a high viability, multilineage differentiation potential and high expression levels of the typical MSC-specific surface antigens and genes. Compared to standard method, MSCs obtained with the new method showed higher yield, up to passage 6, and higher purity in terms of percentage of CD34 and CD45 markers. All AT-MSCs exhibit in vitro immunosuppressive capacity and possess a normal karyotype. CONCLUSIONS: Our data clearly demonstrate that our new approach permits to generate AT-MSCs fully compliant for therapeutic use and better at least in terms of quantity and purity than those obtained with the standard method.

Obliteration of a giant fusiform carotid terminus-M1 aneurysm after distal clip application and extracranial-intracranial bypass. Case report.

Giant intracranial aneurysms may not be amenable to direct surgical clipping or endovascular coiling because of three critical factors: 1) lack of clear aneurysmal neck; 2) giant size; 3) involvement with critical perforating or branch vessels. Techniques of flow redirection, however, may offer an alternative treatment strategy for these difficult lesions. In this paper, we report on the use of this alternative strategy in the successful treatment of a left giant fusiform carotid terminus-M1 aneurysm in a 16 year-old boy suffering from Ehler-Danlos disease. This patient was admitted to our Institution because his aneurysm was continuing to be increasing in size, despite a previous ligation of his left cervical ICA which was performed at another institution 2 years earlier after the patient had experienced a hemorrhagic stroke. Upon admission, a neurological examination revealed a slight motor aphasia with mild right hemiparesis, remnant of the ancient stroke. Because of its size and the involvement with M1 perforating arteries, a direct aneurysm attack was deemed inadvisable. After an initial ECA-ICA high flow bypass which spontaneously thrombosed, we performed a repeated high flow bypass with the application of a single clip on M1, right distal to the fusiform dilatation. After an uneventful postoperative course, we were unable to observe any new neurological deficits after surgery. A CT scan on postoperative day 1 revealed that the aneurysm had undergone a spontaneous thrombosis which was completely obliterated at the time of a 6-month follow-up angiogram. At that time, the ECA-ICA bypass was found to be patent. In conclusion the alternative of flow alteration strategies can be successfully used in the treatment of aneurysms that cannot be safely trapped or occluded by traditional neurosurgical methods.

Effect of canine mesenchymal stromal cells loaded with paclitaxel on growth of canine glioma and human glioblastoma cell lines.

This study investigated whether canine mesenchymal stromal cells (cMSCs) are able to take up and release paclitaxel (PTX) in active form, and therefore whether they have potential as a tool for therapeutic delivery of this drug. cMSCs from bone marrow and adipose tissue were isolated, expanded and characterised phenotypically. cMSCs were loaded with PTX (cMSCs-PTX) and their capacity for release of PTX was determined by their effect on proliferation of cancer cells. cMSCs-PTX derived from bone marrow and adipose tissue were able to take up and then release active PTX. cMSCs-PTC inhibited proliferation of the canine glioma cell line J3T, and the human glioblastoma cell lines T98G and U87MG. The potential of canine cMSCs-PTX for treatment of canine gliomas should be investigated further.

Endogenous activation of metabotropic glutamate receptors supports the proliferation and survival of neural progenitor cells.

The use of neural progenitor cells (NPCs) is limited by the incomplete knowledge of the extracellular signals regulating their proliferation and survival. We report that cultured mouse NPCs express functional mGlu3 and mGlu5 metabotropic glutamate receptors. Pharmacological blockade of both receptors reduced NPC proliferation and survival, whereas activation of mGlu5 receptors substantially enhanced cell proliferation. Adult mice lacking mGlu5 receptors or treated with mGlu5 or mGlu3 receptor antagonists showed a dramatic reduction in the number of dividing neuroprogenitors present in the subventricular zone and in the dentate gyrus of the hippocampus. These data disclose a novel function of mGlu receptors and offer new potential strategies for the optimization of cell replacement therapy in neurodegenerative disorders.

The chemical characterization of melanin contained in substantia nigra of human brain.

The pigment of substantia nigra human brain has been extracted by a mild procedure consisting of washes with phosphate buffer, methanol and incubation with SDS-proteinase. Pyrolysis gas chromatography mass spectrometry, infrared spectrometry, termogravimetric analysis and elemental analysis were the techniques used for the chemical characterization. An indole moiety bound to a sulfur containing amino acid and to palmitic acid were the main aspects found in the structure. The presence of a 7% inorganic component was observed. This probably contains Fe, Cu, Zn and Cr which are also relevant, for the formation and the role of melanin in substantia nigra neurons. The fatty acid moiety is chemically bound to the indole structure as it was not eliminated by repeated methanol washing. The same situation occurs for the sulfur containing group. Considering these data and the most abundant molecules present in substantia nigra the precursor of neuromelanin seems to be a cysteinyl-catechol, to which is then bound a palmityl group.

Significance of multiple neurophysiological measures in patients with chronic disorders of consciousness.

OBJECTIVE: The aim of this study was to verify the value of multiple neurophysiological tests in classifying disorders of consciousness (DOCs) in patients in a chronic vegetative or minimal consciousness state categorised on the basis of the Coma Recovery Scale (CRS). METHODS: The study included 142 patients, all of whom underwent long (18h) EEG-polygraphic recordings including one night. The EEG was scored using the Synek scale and sleep patterns using an arbitrary scale. Absolute total power and relative EEG power were evaluated in different frequency bands. Multimodal evoked potentials (EPs), including auditory event-related potentials, were also evaluated and scored. RESULTS: The most information came from the combined multimodal EPs and sleep EEG scores. A two-step cluster analysis based on the collected information allowed a satisfactory evaluation of DOC severity. Spectral EEG properties seemed to be significantly related to DOC classes and CRS scores, but did not seem to make any significant additional contribution to DOC classification. CONCLUSIONS: Multiple electrophysiological evaluations based on EEG, sleep polygraphic recordings and multimodal EPs are helpful in assessing DOC severity and residual functioning in patients with chronic DOCs. SIGNIFICANCE: Simple electrophysiological measures that can be easily applied at patients' bedsides can significantly contribute to the recognition of DOC severity in chronic patients surviving a severe brain injury.

Divry-Van Bogaert syndrome. Clinical and ultrastructural findings.

A case of a progressive disease with epilepsy, marble skin, and roentgenographic evidence of tapering of the distal carotid branches with corticomeningeal angiomatosis was studied. The clinical course, angiographic findings, and skin biopsy results justified the diagnosis of noncalcifying venous capillary angiomatosis, or Divry-Van Bogaert syndrome.

Neuroendocrinologic findings in patients with untreated Huntington's chorea.

Huntington's chorea (HC) was studied in 14 untreated patients, in six patients receiving long-term neuroleptic treatment, and in four patients after drug withdrawal. Our results showed that patients with HC may be divided into three groups, otherwise clinically indistinguishable, on the basis of growth hormone responsiveness to dopaminergic stimuli. The existence of subpopulations of patients with HC must be considered in further studies on these subjects.

Differential effect of repeated treatment with L-dopa on dopamine-D1 or -D2 receptors.

Unilateral degeneration of the nigro-striatal dopaminergic pathway with 6-hydroxydopamine induced contralateral rotations to apomorphine injection, increased [3H]-spiroperidol binding and enhanced sensitivity of adenylate cyclase to dopamine stimulation in lesioned striata. Prolonged L-DOPA administration counteracted the increased density of [3H]-spiroperidol binding sites but further enhanced the hypersensitivity of adenylate cyclase to dopamine. Also apomorphine-induced contralateral rotations were potentiated. This effect was antagonized by SCH-23390. These results suggest that dopaminergic D1 and D2 receptors are differently affected by prolonged L-DOPA treatment.

Isolation and intracerebral grafting of nontransformed multipotential embryonic human CNS stem cells.

In this work, we show that the embryonic human brain contains multipotent central nervous system (CNS) stem cells, which may provide a continuous, standardized source of human neurons that could virtually eliminate the use of primary human fetal brain tissue for intracerebral transplantation. Multipotential stem cells can be isolated from the developing human CNS in a reproducible fashion and can be exponentially expanded for longer than 2 years. This allows for the establishment of continuous, nontransformed neural cell lines, which can be frozen and banked. By clonal analysis, reverse transcription polymerase chain reaction, and electrophysiological assay, we found that over such long-term culturing these cells retain both multipotentiality and an unchanged capacity for the generation of neuronal cells, and that they can be induced to differentiate into catechlaminergic neurons. Finally, when transplanted into the brain of adult rodents immunosuppressed by cyclosporin A, human CNS stem cells migrate away from the site of injection and differentiate into neurons and astrocytes. No tumor formation was ever observed. Aside from depending on scarce human neural fetal tissue, the use of human embryonic CNS stem cells for clinical neural transplantation should provide a reliable solution to some of the major problems that pertain to this field, and should allow determination of the safety characteristics of the donor cells in terms of tumorigenicity, viability, sterility, and antigenic compatibility far in advance of the scheduled day of surgery.

Failure of MIF-I to affect behavioral responses in patients with Parkinson's diseases under L-dopa therapy.

In eight subjects with Parkinson's disease under an optimal daily dose of L-dopa, acute administration of MIF-I (200 mg i.v.) did not ameliorate either the total disability score or the intellectual test PM 38 when evaluated in comparison with the effect induced by acute administration of a placebo. Also concomitant evaluation of the effect of MIF-I on the secretion of anterior pituitary hormones which are under dopaminergic control i.e., growth hormone and prolactin, did not reveal any potentiation of the L-dopa-induced stimulus.

Manganese neurotoxicity: effects of L-DOPA and pargyline treatments.

Single, monolateral injection into rat substantia nigra of manganese chloride produced within two weeks from its administration a loss of dopamine in the striatum ipsilateral to the injected side. The effect was dose-dependent and was not extended to serotoninergic terminals present in this brain area, whose content in serotonin and 5-hydroxyindoleacetic acid was not affected. When L-DOPA + carbidopa or pargyline were given to these animals the decrease of striatal dopamine was more marked. Moreover, rats treated two weeks before with a dose of manganese chloride that produced a 70-80% drop in striatal dopamine concentrations, rotated ipsilaterally to the dopamine-depleted striatum when injected with apomorphine, suggesting that in these animals the stimulatory effects of apomorphine were more relevant in striatum where presynaptic dopaminergic neurons were not affected by manganese chloride. These data indicate that the alterations of dopaminergic postsynaptic receptors may be different in parkinsonian and in manganese-intoxicated patients and that current therapy used for Parkinson's disease could be a hazard in treating manganese poisoning.

Role of dopamine in manganese neurotoxicity.

Manganese chloride increased cell mortality when added to human fibroblast cultures. The toxicity of the metal was greatly enhanced by dopamine; this effect was antagonized by the presence in the culture medium of catalase and superoxide dismutase enzymes. Manganese chloride also caused a marked decrease of striatal dopamine concentrations when infused into rat substantia nigra. Manganese neurotoxicity was lowered by pretreating the animals with drugs that reduced striatal dopamine turnover rate. Administration of an antioxidant, such as vitamin E, also partially prevented striatal dopamine decline induced by intranigral manganese infusion. Therefore, the decreased availability or autoxidation of dopamine attenuated manganese neurotoxicity. These findings are in agreement with previous observations suggesting that manganese increases toxic products originating from dopamine catabolism.

Mechanisms involved in the prolactin-releasing effect of benserazide.

The mechanism(s) underlying the prolactin (PRL)-releasing effect of benserazide (Bz), a peripheral inhibitor of L-aromatic amino-acid decarboxylase, was investigated in the rat. In intact male and female rats, Bz was ineffective to increase significantly plasma PRL at 0.8 mg/kg i.p. but elicited an already maximal effect at 1.6 mg/kg. Bz added to in vitro incubated anterior pituitaries (APs) did not alter PRL secretion at the dose of 3.8 X 10(-6)M but increased PRL release at 10(-4)M. Bz, even at very high doses (up to 10(-3) M), did not displace [3H]spiroperidol binding from AP membrane preparations. In rats having had mechanical ablation of the medio basal hypothalamus (MBH), Bz (15 mg/kg i.p.) induced no rise in plasma PRL and did not counteract the striking inhibitory effect of a dopamine (DA) infusion (5 micrograms/kg per min per 120 min). Administration of Bz (15 mg/kg i.p.) into intact male rats decreased significantly the DA concentrations in the median eminence (ME) but not in the residual hypothalamus and the AP. In the same rats 1-dopa (50 mg/kg i.p.) increased significantly the DA concentrations not only in the ME but also in the hypothalamus and the AP. Bz given concurrently with 1-dopa markedly reduced the rise in DA concentrations induced by 1-dopa in the ME, and greatly potentiated the increase in DA concentrations in the hypothalamus. These data indicate that the mechanism whereby a single administration of Bz increases PRL secretion in the rat is not consistent with the postulated DA receptor antagonist action of the drug, but instead implies inhibition of the decarboxylation of 1-dopa at dopaminergic nerve terminals of the ME.

Basic fibroblast growth factor supports the proliferation of epidermal growth factor-generated neuronal precursor cells of the adult mouse CNS.

Stem cells isolated from the CNS of both embryonic and adult mice undergo extensive proliferation in the presence of epidermal growth factor (EGF). Removal of EGF determines the differentiation of these cells into neurons and glia. We have recently demonstrated that basic fibroblast growth factor (bFGF) regulates the proliferation of EGF-generated progenitors of the embryonic mouse striatum. We report here that bFGF induces proliferation of some EGF-generated precursors of the adult mouse striatum which, in turn, differentiate in vitro into cells possessing neuron-like morphology and neuronal antigenic properties. These results demonstrate that EGF and bFGF can act sequentially to regulate the de novo generation of neurons from the adult mouse CNS in vitro and suggest the existence of a lineage relationship between EGF- and bFGF-responsive progenitor cells of the adult murine brain.