Large capillary hemangioma of the temporal bone with a dural tail sign: A case report.

The present study reports a rare case of large capillary hemangioma of the temporal bone with a dural tail sign. A 57-year-old female presented with pulsatile tinnitus and episodic vertigo associated with a ten-year history of an intermittent faint headache. Magnetic resonance imaging revealed a mass in the right petrous bone, which was hypointense on T1-weighted images and heterogeneously hyperintense on T2-weighted images, and showed a dural tail sign following gadolinium administration. Pre-operatively, this tumor was believed to be a meningioma. During surgery, the vascular tumor was removed by a modified pterional approach. A histopathological examination indicated that the tumor was a capillary hemangioma. Although intraosseous capillary hemangiomas are rare, they most frequently affect the temporal bone. Hemangiomas of the temporal bone may mimic other more common basal tumors. The diagnosis is most often made during surgical resection. The dural tail sign is not specific for meningioma, as it also occurs in other intracranial or extracranial tumors. The treatment of intratemporal hemangiomas is complete surgical excision, with radiotherapy used for unresectable lesions. To the best of our knowledge, the present study is the fourth case of intraosseous intracranial capillary hemangioma, but the largest intratemporal hemangioma to be reported in the literature to date.

Molecular targeting of neuroblastoma with a novel p16INK4a transporter system.

Potential molecular targets in neuroblastoma include ALK mutations, p16 deletion and CDK2A mutations; however, targeted therapeutics have not been developed for these factors. We developed Wr-T, a new system for intracellular peptide and protein delivery with a 30-residue sequence that mediates molecule entrapment and intracellular permeability. Wr-T was used to introduce the p16INK4a functional peptide to restore the tumor suppressor function of p16INK4a. Introduction of Wr-T into rats with subcutaneous grafts of neuroblastoma produced an astonishing 75.6% tumor suppression (p<0.0005). Thus, the p16INK4a functional peptide can be introduced in low doses and, because it exists in vivo, it should produce fewer side-effects than standard chemotherapy. We suggest this system could be used for molecular-targeted peptides other than p16INK4a and should be pursued for further development.

Fat necrosis appearing as intraorbital tumour: case report.

A 33-year-old male presented with an extremely rare case of intraorbital fat necrosis. A magnetic resonance imaging scan showed a 10-mm mass lesion within the right lateral rectal muscle. Surgical removal was performed. Histological analysis showed diffuse adipose cells surrounded by macrophage cells. Fat necrosis was diagnosed.

Management of intraventricular hemorrhage in preterm infants with low birth weight.

The management of posthemorrhagic hydrocephalus is difficult and not well standardized. We evaluated our management protocol for infants with intraventricular and/or periventricular hemorrhage (IVH and PVH, respectively). There were four deaths and two significant treatment-related complications in our series. We also observed two cases of isolated ventricle in patients treated with reservoir placement. After evaluating our series, we modified our protocol from reservoir placement to either cerebrospinal fluid (CSF) drainage or ventriculosubgaleal shunt directly. We will reevaluate this new protocol in the near future.

A case of metastatic brain tumor causing multifocal cerebral embolism.

The patient was a 72-year-old woman who had previously undergone treatment for femoral chondrosarcoma (histologically rated as myxofibrosarcoma). She suddenly developed left homonymous hemianopsia and was diagnosed with cerebral embolism. Because she had atrial fibrillation, we treated her for cardiogenic cerebral embolism. About 3 months later, however, she developed left hemiplegia, and head magnetic resonance imaging revealed multiple tumorous lesions affecting the previously detected infracted area and several new areas. We assumed that a tumor embolus had caused cerebral embolism, which resulted in growth of the tumor from the embolus and formation of a metastatic brain tumor. The metastatic foci formed from the tumor embolus were visualized by diagnostic imaging, and histological examination of the resected tumor confirmed that the brain tumor had occluded the brain vessel (tumorigenic cerebral embolism). No such case has been reported to date, and this case seems to be important.

Report on the international Primary Neurosurgical Life Support course in the eighth Asian Congress of Neurological Surgeons in Kuala Lumpur, Malaysia.

On November 22, 2010, a simulation-based hands-on education course for medical staff in the neurosurgical fields was held in 8(th) Asian Congress of Neurological Surgeons (ACNS) in Kuala Lumpur, Malaysia. The present education course called Primary Neurosurgical Life Support (PNLS) course had been started by the Japan Society of Neurosurgical Emergency since 2008. This report summarizes the international version of PNLS course in 8(th) ACNS.

A miR-21 inhibitor enhances apoptosis and reduces G(2)-M accumulation induced by ionizing radiation in human glioblastoma U251 cells.

MicroRNAs (miRNAs) are small noncoding RNAs that take part in diverse biological processes by suppressing target gene expression. Elevated expression of miR-21 has been reported in many types of human cancers. Radiotherapy is a standard adjuvant treatment for patients with glioblastoma. However, the resistance of glioblastoma cells to radiation limits the success of this treatment. In this study, we found that miR-21 expression was upregulated in response to ionizing radiation (IR) in U251 cells, which suggested that miR-21 could be involved in the response of U251 cells to radiation. We showed that a miR-21 inhibitor enhanced IR-induced glioblastoma cell growth arrest and increased the level of apoptosis, which was probably caused by abrogation of the G(2)-M arrest induced by IR. Further research demonstrated that the miR-21 inhibitor induced the upregulation of Cdc25A. Taken together, these findings suggest that miR-21 inhibitor can increase IR-induced growth arrest and apoptosis in U251 glioblastoma cells, at least in part by abrogating G(2)-M arrest, and that Cdc25A is a potential target of miR-21.

Morphological and flow cytometric analysis of cell infiltration in glioblastoma: a comparison of autopsy brain and neuroimaging.

Even when we successfully perform a total extirpation of glioblastoma macroscopically, we often encounter tumor recurrence. We examined seven autopsy brains, focusing on tumor cell infiltration in the peripheral zone of a tumor, and compared our findings with the MR images. There has so far been no report regarding mapping of tumor cell infiltration and DNA histogram by flow cytometry, comparing the neuroimaging findings with the autopsy brain findings. The autopsy brain was cut in 10-mm-thick slices, in parallel with the OM line. Tissue samples were obtained from several parts in the peripheral zone (the outer area adjacent to the tumor edge as defined by postcontrast MRI) and then were examined by H&E, GFAP, and VEGF staining. We defined three infiltrating patterns based on number of infiltrated cells as follows: A zone, 100%-60% of the cells infiltrated tumor cells compared with tumor cell density of the tumor mass; B zone, 60%-20%; C zone, 20%-0%. In the autopsy brain, the tumor was easily identified macroscopically. We found that (1) the tumor cells infiltrated the peritumoral area; and (2) tumor cell infiltration was detected over an area measuring from 6 to 14 mm from the tumor border in the A zone. When performing surgery on glioblastoma, a macroscopic total extirpation of the tumor as defined by the contrast-enhanced area in MRI is therefore considered to be insufficient for successfully reducing tumor recurrence.

Flow cytometric analysis for the mechanism of the new antineoplastic agent temozolomide in glioma cells.

Temozolomide (TMZ) has been accepted as a standard antitumor drug for glioma worldwide. Regarding its mechanism of action, there are quite a few analyses. In the present study, we investigated the cell-killing effect and mechanism of action of TMZ with flow cytometry using glioblastoma cell lines. Each cell line was divided into three groups: a control group, a low-dose TMZ group, and a high-dose TMZ group. On day 1, TMZ was added to each cell line. Then, we counted the numbers of cells on days 2, 3, 4, and 5; in U87MG, we counted the number of cells on days 8 and 9. Simultaneously, we performed flow cytometric analysis with single- and double-staining methods. Although results varied slightly depending on the cell line, with flow cytometric analysis we identified the G(0)G(1)-, S-phase block on days 2 through 4, at the beginning of TMZ administration. After that we identified the deviation of the G(2)M block over days 3 to 5. Dominant morphological changes observed in U87MG were confined to the nuclei, with positive TUNEL staining. Early S-phase block and then a G(2)M block were observed; consecutively, we could analyze these blocks with a double-staining method more clearly. The flow cytometric method is very effective in the analysis of the antitumor mechanism of each agent. On the basis of our analysis, more effective combined chemotherapy may be expected.

The Modules for ISLS/PNLS Combined Course as International Version: Report of Workshop in 9 International Conference of Cerebrovascular Surgery.

In Japan, there are two simulation based training systems for neurosurgical diseases, that are ISLS (Immediate Stroke Life Support) and PNLS (Primary Neurosurgical Life Support). Workshop on "First ISLS International Version Trial Task Force" came to a successful conclusion on November 12, 2009, in Nagoya, Japan. More than 30 international participants attended this workshop, organized by the Department of Neurosurgery, Fujita Health University. This report summarizes the modules for ISLS/PSLS combined course as international version from the workshop.

Arsenic trioxide-mediated Notch pathway inhibition depletes the cancer stem-like cell population in gliomas.

Cancer stem-like cells (CSLCs) are potential targets for treatment of glioblastoma multiforme (GBM) due to their role in tumorigenesis and recurrence. In this study, we investigated the inhibitory effect of arsenic trioxide (As(2)O(3)) on CSLCs of GBM in human glioma cell lines (U87MG, U251MG and U373MG) in vivo and in vitro. Immunofluorescence staining and flow cytometry revealed that the percentage of Nestin-positive cells in the aforementioned cell lines was diminished by 12%, 14% and 7%, respectively, after treatment with 2 microM As(2)O(3). Furthermore, we used soft-agar in U87MG and tumor xenografts in nude mice to demonstrate the ability of As(2)O(3) to inhibit the formation of tumor in the three cell lines. These results indicate the negative regulation of CSLCs by As(2)O(3). In addition, a Western blot analysis revealed decreased levels of Notch1 and Hes1 proteins due to As(2)O(3) treatment. We conclude that As(2)O(3) has a remarkable inhibitory effect on CSLCs in glioma cell lines in vivo and in vitro; in addition, we determined that the mechanism of CSLC inhibition involves the deregulation of Notch activation.

Spontaneous regression of a spinal extradural arteriovenous fistula after delivery by cesarean section.

A 23-year-old Japanese woman presented with a newly developed spinal extradural arteriovenous fistula (AVF) during pregnancy. She had been followed up for a suspected spinal cavernous angioma and became unable to walk during the 29th week of her pregnancy. Magnetic resonance (MR) imaging showed a spinal extradural AVF at the T3 to T4 levels compressing the spinal cord. After delivery by cesarean section, her neurological symptoms gradually began to resolve, and she was able to resume walking without assistance. MR imaging confirmed spontaneous regression of the AVF. This case suggests that exacerbated neurological symptoms and AVF growth triggered by pregnancy can improve after delivery without interventional treatment. Careful follow up of neurological findings is required to prevent unnecessary interventional procedures in pregnant women with spinal AVF.

Spontaneous spinal epidural hematoma inducing acute anterior spinal cord syndrome.

Spontaneous spinal epidural hematoma (SSEH) is rare. Its etiology remains controversial; however, spinal venous wall susceptibility to intravenous pressure change and the resultant venous rupture seem to be involved. The authors report a case of SSEH dorsal to the spine producing acute anterior spinal cord syndrome. A posterior SSEH between the C-3 and T-5 levels caused progressive tetraparesis and the disappearance of superficial body sensation below the level of C-8, although deep sensation remained completely intact. This neurological false localizing sign seems to have resulted from counterforce by preexisting asymptomatic cervical intervertebral disc herniation at the C6-7 levels inducing direct pressure on the anterior spinal cord. This case is the first reported instance of posterior cervical SSEH manifesting acute anterior spinal cord syndrome as its false localizing sign.

The proof of flat-line scalp EEGs of brain dead patients by an automatic EEG analysis system.

Scalp electroencephalograms (EEGs) of brain dead patients are macroscopically flat under 7 or 10 microV/mm electroencephalograph sensitivity, but significant noises are detected in EEGs under 2 microV/mm sensitivity, interfering with the analysis. EEGs of 20 brain dead patients (17-76 years old) were therefore analyzed quantitatively as equivalent electric potentials in frequency bands delta, theta, alpha and beta using the automatic EEG analysis system developed in Kansai Medical University. The equivalent electric potentials in each band were about or less than 1 microV, which is used as a criterion of judgment of flat-line EEGs or brain death. Then, macroscopically flat EEGs of 12 comatose patients including infants (3-67 years old) were analyzed by the system, confirming their brain death. Thus, the automatic EEG analysis system could be used as a supporting tool to confirm flat-line EEGs of brain dead patients. ATAMAP II for Windows software was also evaluated.

Interleukin-5 and interleukin-10 are produced in central nervous system tumor cysts.

Interleukin-5 and interleukin-10, as important mediators of vascular permeability, contribute to the development of various pathologic effusions. However, little is known regarding the involvement of these two cytokines in the formation of cysts associated with central nervous system (CNS) tumors. Twenty-eight patients with various cystic CNS tumors were investigated for expression of interleukin-5 and interleukin-10 in cyst fluid and their matched cytokine receptors in tumor tissue. Interleukin-5 and interleukin-10 were detected in cyst fluid, and interleukin-5 concentration was significantly correlated with interleukin-10 concentration (r=0.508, p=0.006). Moreover, both receptors were also detectable in the tumor tissue specimens and high levels of expression were also found in perivascular cells. Therefore, the local production of interleukin-5 and interleukin-10 might be implicated in some types of cyst formation.

An immunohistochemical and electron microscopic study of atypical teratoid/rhabdoid tumor.

We report two infant cases with atypical teratoid/rhabdoid tumor (AT/RT) located in the cerebellar vermis and spinal cord. MRI showed the tumors were isointense on T1-weighted images and mixed intensity of isointense and slight high intensity on T2-weighted images. Postcontrast MRI demonstrated clear margin of tumor and heterogeneous strong enhancement. It was difficult to differentiate the tumor from medulloblastoma by hematoxylin and eosin staining. However, immunohistochemical staining showed that these tumor cells react positively for cytokeratin, smooth muscle actin (SMA), and epithelial membrane antigen (EMA) and helped us with the differentiation. Electron microscopic study has confirmed the presence of mesenchymal components, such as filaments and desmosome junctions in the rhabdoid cells, but no neuronal components. The tumors rapidly increased in size, showing high MIB-1 index, and the prognosis was gave.

Traumatic subarachnoid hemorrhage associated with acupuncture.

Subarachnoid hemorrhage as a complication of acupuncture has been reported in only a few cases. We report another case and discuss the implications of subarachnoid hemorrhage following acupuncture. Although acupuncture has traditionally been thought to be relatively safe, physicians should be aware that it may be a cause of intracranial hemorrhage.

[Radiation-induced brain injury].

Radiation-induced brain injury is a life-threatening or at least QOL-compromising pathological entity induced by therapeutic irradiation to malignant brain tumors. Although life-threatening late delayed radiation necrosis and radiation-induced leukoencephalopathy had been assumed to be major complications of radiation therapy to the brain classically, these complications seem to be less frequently seen in therapeutic irradiation to the brain recently because in many treatment protocols to brain tumors, irradiation field is now confined to tumors and their margins and adjuvant chemotherapy consisting of methothrexate etc. has been avoided as much as possible. Instead, less aggressive but still QOL-compromising encephalopathy has been recognized for the past 20 years. This encephalopathy occurs in senior adults several months after the extended field irradiation with even less amount of irradiation dose such as 40 Gy whole brain irradiation. This encephalopathy is characterized by cognitive impairment and brain atrophy which attenuates QOL of the patients. In this article, these radiation-induced brain injuries are reviewed clinically, etiologically and hisotopathologically based on reports in the literature.

The intracranial pressure of the patients with mild form of craniosynostosis.

INTRODUCTION: While raised intracranial pressure (ICP) is a well recognized complication affecting children with syndromic craniosynostosis, certain percentage of the patients with non-syndromic craniosynostosis may have some problems related to increased ICP, such as developmental delay or visual problem. However, it is still not clear how many percent of and/or which types of craniosynostosis patients suffer from those symptoms, especially in older patients. OBJECTIVE: The aim of this study was to examine the ICP of older children with mild form of craniosynostosis to determine if any of them should be surgically treated. MATERIALS AND METHODS: We measured ICP before making the decision for surgical intervention. RESULTS: Twenty-five of thirty-six patients had raised ICP in our series. DISCUSSION: All of the 25 patients were treated surgically and followed-up after more than 1 year. All patients improved in some degree. Further investigations should be performed to determine what is the threshold for raised ICP in children.

A randomized controlled trial of hydrocortisone against hyponatremia in patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Hyponatremia is common after aneurysmal subarachnoid hemorrhage (SAH). It is caused by natriuresis, which induces osmotic diuresis and decreases blood volume, contributing to symptomatic cerebral vasospasm (SCV). Hypervolemic therapy to prevent SCV will not be efficient under this condition. We conducted a randomized controlled trial to assess the efficacy of hydrocortisone, which promotes sodium retention in the kidneys. METHODS: Seventy-one SAH patients were randomly assigned after surgery to treatment with either a placebo (n=36) or 1200 mg/d of hydrocortisone (n=35) for 10 days and tapered thereafter. Both groups underwent hypervolemic therapy. The primary end point was the prevention of hyponatremia. RESULTS: Hydrocortisone prevented excess sodium excretion (P=0.04) and urine volume (P=0.04). Hydrocortisone maintained the targeted serum sodium level throughout the 14 days (P<0.001), and achieved the management protocol with lower sodium and fluid (P=0.007) supplementation. Hydrocortisone kept the normal plasma osmolarity (P<0.001). SCV occurred in 9 patients (25%) in the placebo group and in 5 (14%) in the hydrocortisone group. No significant difference in the overall outcome was observed between the 2 groups. CONCLUSIONS: Hydrocortisone overcame excess natriuresis and prevented hyponatremia. Although there was no difference in outcome, hydrocortisone supported efficient hypervolemic therapy.