Larger Posterior Revascularization Associated with Reduction of Choroidal Anastomosis in Moyamoya Disease: A Quantitative Angiographic Analysis.

BACKGROUND AND PURPOSE: Choroidal anastomosis, a hemorrhage-prone periventricular collateral manifestation in Moyamoya disease, outflows to the cortex posterior to the central sulcus. The objective of the present study was to test whether the angiographic extent of revascularization posterior to the central sulcus contributes to the postoperative reduction of choroidal anastomosis. MATERIALS AND METHODS: This retrospective cohort study included choroidal anastomosis-positive hemispheres before direct bypass surgery. The postoperative reduction of choroidal anastomosis was determined by a consensus of 2 raters according to the previous research. An imaging software automatically traced the angiographic revascularization area, which was subsequently divided into anterior and posterior parts by an anatomic line corresponding to the central sulcus. Each area was quantitatively measured as a percentage relative to the whole supratentorial area. RESULTS: Postoperative reduction of choroidal anastomosis was achieved in 68 (85.0%) of the 80 included hemispheres. The revascularization area posterior to the central sulcus was significantly larger in the hemispheres with reduction than in those with no reduction (mean, 15.2% [SD, 7.1%] versus 4.2% [SD, 3.4%], P < .001), whereas no significant difference was observed in the revascularization area anterior to the central sulcus. Multivariate analysis revealed that the revascularization area posterior to the central sulcus was the only significant factor associated with reduction (OR, 1.57; 95% CI, 1.21-2.03, for every 1% increase). CONCLUSIONS: The results suggest that a larger revascularization posterior to the central sulcus is associated with postoperative reduction of choroidal anastomosis regardless of the extent of anterior revascularization. It might facilitate optimal selection of the revascularization site for preventing hemorrhage.

Identification of the Bleeding Point in Hemorrhagic Moyamoya Disease Using Fusion Images of Susceptibility-Weighted Imaging and Time-of-Flight MRA.

BACKGROUND AND PURPOSE: The location of intracerebral hemorrhage in Moyamoya disease is a prognostic factor for rebleeding and the degree of preventive effects obtainable with bypass surgery. We evaluated whether the bleeding point and responsible vessel were detectable using fusion images of SWI and time-of-flight MRA performed during chronic-phase hemorrhage. MATERIALS AND METHODS: We retrospectively enrolled 42 patients with hemorrhagic Moyamoya disease (48 hemorrhagic events). Fusion images of SWI and MRA were made using workstations, and we defined the bleeding point as the point at which the signal of an abnormally extended artery on MRA overlapped the hypointense area on SWI. Two independent raters identified the bleeding point, and classified the location and responsible vessels. RESULTS: The bleeding point was detectable at a frequency of 79.2% by rater 1. Agreement for the presence of a bleeding point was high (interrater κ = 0.83; 95% CI, 0.65-1; intrarater κ = 0.86; 95% CI, 0.68-1). The frequency of a periventricular location of the bleeding point was 65.8% by rater 1, and agreement on the location was again high (interrater κ = 0.92; 95% CI, 0.82-1; intrarater κ = 0.85; 95% CI, 0.72-0.99). The choroidal artery was the most frequent responsible vessel (57.9% by rater 1), and agreement on the responsible vessel was high (interrater κ = 0.84; 95% CI, 0.69-1; intrarater κ = 0.90; 95% CI, 0.78-1). CONCLUSIONS: Detection of the bleeding point in hemorrhagic Moyamoya disease using SWI and MRA fusion images offers highly reproducible results.

Evaluation of CT angiography for visualisation of the lenticulostriate artery: difference between normotensive and hypertensive patients.

OBJECTIVE: High-resolution CT angiography (CTA) is currently available using multidetector row CT (MDCT); however, its use for small artery visualisation has been limited. To evaluate its capability, we investigated CTA visualisation for difference in number of the lenticulostriate artery (LSA) branches between normotensive and hypertensive patients, because hypertension is a major cause of LSA damage. METHODS: This was a retrospective study evaluating cerebrovascular CTA at our hospital conducted from February 2008 to June 2009 under approval of the institutional review board. 117 patients (39 males and 78 females, 19-88 years old) were included. CTA was conducted using a 64 channel MDCT. Total numbers of LSA branches were examined for differences by age with regression analysis and the presence or absence of hypertension and/or aneurysm using two-sample t-tests. A p-value <0.016 was considered statistically significant after correction for multiple comparisons. A multiple variable analysis of three factors was also conducted. RESULTS: The average number of LSA branches was 3.6 [95% confidence interval (CI) 3.0-4.1] and 4.4 (95% CI 4.1-4.7), respectively, for a patient with and without history of hypertension, and the difference was statistically significant (p=0.013). The difference was approximately one branch in the multiple variable analysis. No significant correlation was observed for age and no significant difference was observed for the presence or absence of aneurysms. CONCLUSIONS: Contrast-enhanced CTA can visualise significant differences in the number of LSA branches among patients with and without hypertension. Advances in knowledge Current high-resolution CTA can visualise LSA well, which enables finding a difference in the LSA between normotensive subjects and hypertensive patients.

The Stenting to Internal Carotid Artery Stenosis (ICS) in Petrous Portion. The Evaluation of Plaque Figures in Magnetic Resonance Image.

SUMMARY: In the safety stenting, it is important to get to know the characteristics of a plaque. In petrous carotid artery stenosis, it is difficult to know the characteristics of the plaque.We paid our attention to the MPRAGE (Magnetization Prepared Rapid Acquisition with Gradient Echo) method on high resolving power MRI. By the MPRAGE method, low intensity was observed in these lesions of all cases. This result suggested that the plaque in petrous portion was a fibrous plaque. This method is useful to get to know the characteristics of a plaque in petrous portion before endovascular treatment.

Restenosis after stent placement for ostial stenosis of vertebral artery.

SUMMARY: The purpose of this study was to evaluate our initial procedural success rate and angiographical outcome of stent placement for vertebral artery (VA) stenosis at the intermediate followup period (11.3 +/- 7.3 months). Stent placement was successfully performed in 20 procedures (19 patients), resulting in a marked reduction of stenosis from 78.7 +/- 12.6 % before to 8.7% +/- 10.6 after stenting. Follow-up angiography, performed after an interval of 11.3 +/- 7.3 months, revealed restenosis greater than 50% in a total of 6 procedures (40%) out of 15. Although PTA with stent placement for stenosis affecting VA origin provided excellent initial success, restenosis occurred at a significant rate even during the intermediate follow-up period.

Adenovirus-mediated gene transfer of basic fibroblast growth factor promotes the survival of primary-cultured rat neuronal cells.

We constructed two replication-deficient recombinant adenovirus vectors coding human basic fibroblast growth factor (bFGF), one with and one without the interleukin-2 (IL-2) secretory signal sequence and examined their neurotrophic effects on primary neuronal cells in vitro. The primary neuronal cells were successfully infected at a high efficiency with the adenovirus vectors. bFGF protein was detected in the culture medium of the neurons infected with both these vectors. The cells infected with the bFGF-expressing adenovirus containing the IL-2 signal sequence showed 2- to 10-fold higher levels of secretion levels than cells infected with the native bFGF-expressing adenovirus alone. Both bFGF-expressing vectors augmented the survival of primary neuronal cells in an in vitro culture, compared with a mock infection or control virus infection. Notably, the cells infected with the bFGF-expressing adenovirus containing the IL-2 signal sequence were markedly enhanced cell survival in the early phase of the culture, compared with the control cells and even those infected with the bFGF-expressing adenovirus without the IL-2 signal sequence. However, in the late phase of neuronal culture, neither viral vector could support the cell survival. In contrast the co-infection of the bFGF-expressing vector with a Bcl-xL-expressing vector was extremely effective on neuronal survival.

Adenoviral gene transfer of basic fibroblast growth factor promotes angiogenesis in rat brain.

Cerebral ischemic disease often causes morbidity and mortality, while the induction of new blood vessels is expected to provide a therapeutic effect in this occlusive cerebrovascular disease. In this study, we utilized two replication-deficient adenoviral vectors containing cDNA from basic fibroblast growth factor (bFGF), a well-known angiogenic factor, and examined whether biological angiogenic activity of adenovirally gene-transferred bFGF could be observed in the rat brain. One vector contained native cDNA from bFGF without the secretory signal sequence and the other contained the same cDNA fused with an interleukin-2 secretory signal sequence. After ventricular administration of these viral vectors, gene-transferred cells demonstrated a high immunoreactivity against the anti-bFGF antibody and a remarkably high concentration of bFGF was detected in the cerebrospinal fluid. A semiquantitative analysis of angiogenic activity revealed that bFGF gene transfer induced angiogenesis in normal rat brains, with a more pronounced angiogenic effect seen with the vector of a secreted form than with the vector without a secretory signal sequence. These results suggest that bFGF gene transfer using these adenoviral vectors might be useful for the treatment of ischemic cerebrovascular disease.

Embolic Complications of Endovascular Surgery for Cerebrovascular Diseases. Evaluation with Diffusion-Weighted MR Imaging.

SUMMARY: The purpose of this study was to evaluate asymptomatic embolisms during cerebral endovascular surgery for cerebrovascular diseases with diffusion-weighted magnetic resonance imaging (DWI) which allowed sensitive and early detection of cerebral ischemic lesions. 71 patients who underwent a total of 74 cerebral endovascular procedures were subjected to DWI screening study. MR imaging was performed on a 1.5T system by using single-shot SE echo-planar imaging (EPI) with b value of 1100 seconds per mm(2) in pre- and post-treatment periods (between day 2 and 5 after procedures). In 38 (51.3%) of 74 procedures, new high intensity lesions, as recent infarctions related to procedures, were detected on post-procedural DWI. In 18 Of the patients (47.4%), symptomatic infarctions occurred and resulted in TIAs (n = 4), RINDs (n = 8), minor strokes (n = 6) and no major strokes and no death. 20 (52.6%) of the recent infarctions detected by DWI were asymptomatic lesions.Most of the asymptomatic ischemic lesions were likely to be distributed in watershed border areas. On the other hand, symptomatic lesions tended to be distributed in cortical and/or perforator regions and to be multiple. Thus, DWI is a useful method that can detect neurologically silent and asymptomatic ischemic lesions. It can be used to help to evaluate the safety and efficacy of neurovascular intervention.

Adenovirally expressed basic fibroblast growth factor rescues photoreceptor cells in RCS rats.

PURPOSE: To evaluate the abilities of recombinant adenovirus carrying the basic fibroblast growth factor (bFGF) gene to (1) produce bFGF protein in vitro and (2) rescue retinal photoreceptors in Royal College of Surgeons (RCS) rats in vivo. METHODS: Cultured human retinal pigment epithelial cells were infected with one of the following two replication-deficient adenoviral vectors that drive inserted genes by beta-actin promoter with cytomegalovirus enhancer: AxCAJSbFGF, which expresses the human bFGF gene, and AxCAlacZ, carrying the cDNA of bacterial beta-galactosidase as a viral control. These viruses and recombinant bFGF protein were also injected into the subretinal space of RCS rats at the age of 21 days. The production of bFGF was evaluated by an immunohistochemical method in vitro and in vivo. The secretion of bFGF produced in vitro was quantified by an enzyme-linked immunosorbent assay. The thickness of the outer nuclear layer (ONL) as a marker of photoreceptor cell rescue was estimated at 2, 28, and 56 days after the injections. RESULTS: AxCAJSbFGF produced human bFGF protein effectively both in vitro and in vivo. The semiquantitative analysis of ONL thickness revealed a significant protective effect of AxCAJSbFGF and the recombinant bFGF protein injection up to 56 days after injection. CONCLUSIONS: These results demonstrate that a recombinant adenoviral vector can achieve the transfer of bFGF gene in vitro and have a protective effect for photoreceptor cells in vivo. Gene therapy with a bFGF-expressing recombinant adenoviral vector may provide a new strategy with which to target retinal degenerative diseases.

Adenovirus-mediated gene transfer of a truncated form of fibroblast growth factor receptor inhibits growth of glioma cells both in vitro and in vivo.

Basic fibroblast growth factor (FGF-2) and high affinity FGF receptor (FGFR) have been detected in the nucleus as well as the cytoplasm of many human gliomas, and are known to stimulate cellular proliferation and angiogenesis in the tumors. To investigate the effects of inactivation of FGFR on the growth of malignant gliomas, we constructed a replication-deficient recombinant adenovirus vector encoding a truncated form of chicken FGFR1 (AxCA delta FR). AxCA delta FR-infected cells were confirmed to express truncated FGFR protein by immunoblotting and FGF-2-dependent clonogenicity of NIH3T3 cells was suppressed by infection with this virus vector. Then human malignant glioma cell lines U-251MG and T98G, both of which have been reported to express FGF-2 and FGFR, were infected with AxCA delta FR. These infected cells showed nuclear as well as cytoplasmic expression of a truncated FGFR protein. Proliferation rate and the ability to form colonies in soft agar of the cells infected with this virus vector were significantly suppressed compared with those of uninfected and lacZ-expressing adenovirus-infected cells. Moreover, intratumoral injection of AxCA delta FR significantly suppressed the subcutaneous tumor growth of the glioma cells in nude mice. We concluded that inactivation of the cytoplasmic and nuclear FGFR using this truncated FGFR-expressing adenovirus vector can inhibit the growth of malignant gliomas both in vitro and in vivo.

In vitro growth suppression of vascular smooth muscle cells using adenovirus-mediated gene transfer of a truncated form of fibroblast growth factor receptor.

Vascular smooth muscle cell (VSMC) proliferation associated with arterial injury causes restenosis, which remains to be resolved in cardiovascular and ischemic cerebrovascular disease, especially after balloon angioplasty. Fibroblast growth factor (FGF) is a potent mitogen and a trophic factor for a variety of cells, including VSMCs. We constructed a replication-deficient adenovirus vector, designated AxCA delta FR, coding a truncated form of fibroblast growth factor receptor-1 (FGFR-1) gene lacking the intracellular domain to interrupt receptor-mediated FGF signaling, and examined its effect on the proliferation of primary-cultured rat VSMCs. We transferred the truncated form of the FGFR-1 gene to the VSMCs and confirmed its expression and localization in infected cells by Western blotting and immunofluorescence study. The VSMCs infected with AxCA delta FR degenerated and the proliferation of these cells was suppressed markedly by the infection with this virus in vitro. Our results suggest that the receptor-mediated signal of FGFs has an important role in VSMC proliferation and gene transfer of a truncated form of FGFR using adenoviral vector may be useful for the treatment of the diseases caused by excessive proliferation of VSMCs like restenosis after percutaneous transluminal angioplasty or carotid endoarterectomy.

Nitric oxide synthase immunoreactivity related to cold-induced brain edema.

To determine the relationship between brain edema and the expression of nitric oxide synthase (NOS), we immunohistochemically studied the distribution and level of NOS in rat brain cold injury model. Vasogenic brain edema was produced by cortical freezing lesion. NOS immunohistochemical studies were performed 4 and 8 h, 1, 3, 5, 7, 14 and 21 days after injury. In control normotensive rats, immunoreactivity for NOS was observed in scattered neuronal cells as reported previously, but there was no reactivity in glial cells. In the present study in the cold injury model, however, fibrinogen staining showed extravasated plasma fluid extending to the white matter contralateral to the site of cold injury. NOS immunoreactivity was observed in most reactive astrocytes and a proportion of the microglial cells and macrophages in the white matter not only just beneath the area of cold injury but also in the contralateral side. The nerve cells in the edematous region scarcely showed additional immunoreactivity for NOS. The distribution of increased NOS relatively corresponded with the sites of extravasated plasma fluid demonstrated by fibrinogen staining. Electron microscopically, NOS was observed in astrocytes along the rough endoplasmic reticulum suggesting that NOS was produced in the cells and not taken up from the surroundings. Based on these findings, we postulate that brain edema and the simultaneously generated free radicals or some extravasated plasma components may induce expression of NOS in the reactive cells, and that the NO thus generated may be involved in the development of diffuse degeneration of the white matter which accompanies brain edema.

Adenovirus-mediated gene transfer of basic fibroblast growth factor induces in vitro angiogenesis.

To investigate the possibility of adenovirus-mediated gene transfer in the treatment of vascular occlusive diseases, we constructed a replication-deficient recombinant adenovirus vector coding for human basic fibroblast growth factor (bFGF) and examined its effect on the proliferation and differentiation of vascular endothelial cells in vitro. Human umbilical vein endothelial cells (HUVECs) were successfully infected with high efficiency and expressed 18 kD protein which is immunoreactive to anti-bFGF monoclonal antibody. This protein was accumulated mainly in the nuclei of the cells, but was also detected in the culture medium although the complimentary DNA (cDNA) did not contain the classical secreting signal sequence. The proliferation assay of HUVECs infected with bFGF-expressing adenovirus revealed a significant increase in cell number over control. Infection with this virus also enhanced tubular formation of HUVECs on reconstituted basement membrane. Neovascularization and the formation of collateral vessels play important roles in minimizing tissue damage in ischemic disorders. These results imply that the use of bFGF-expressing recombinant adenovirus may be a suitable in vivo gene therapy for ischemic diseases.

Altered nitric oxide synthase immunoreactivity in the brain of stroke-prone spontaneously hypertensive rats.

To obtain information about the role of nitric oxide (NO) in the development of hypertensive cerebral lesions, we used immunohistochemical methods to study the distribution and level of nitric oxide synthase (NOS) in the brain of stroke-prone spontaneously hypertensive rats (SHRSPs). The early changes in the brain of SHRSPs were petechiae, edema and massive glial accumulation around fibrin deposits, which contained necrotized microvessels, whereas advanced cerebral lesions comprised massive bleeding, cavity formation and diffuse degeneration of the white matter. In the normotensive control rats, immunoreactivity for NOS was demonstrated in scattered neuronal cells, as has been reported previously, but there was no reactivity in glial cells. In the present study in SHRSPs, however, considerable NOS immunoreactivity was observed in most reactive astrocytes and in a proportion of the microglial cells and macrophages in the vicinity of the cortical lesions and in the subcortical white matter both ipsi- and contralateral to the cortical lesion. The nerve cells in the edematous region also showed weak immunoreactivity for NOS. The distribution of increased NOS in SHRSP brains corresponded well with the sites of extravasated plasma fluid as demonstrated by anti-fibrinogen antibody. Based on these findings, we postulate that edema and the simultaneously generated free radicals or some extravasated plasma components may induce expression of NOS in the reactive cells and nerve cells, and that the NO thus generated may be involved in the development of hypertensive cerebral lesions.