Hemodynamic studies of intracranial dural arteriovenous fistulas using arterial spin-labeling MR imaging.

Arterial spin-labeling (ASL) magnetic resonance imaging (MRI) enables non-invasive acquisition of the brain perfusion information in cerebrovascular disease. We investigated hemodynamic changes in intracranial dural arteriovenous fistulas (DAVFs) using ASL-MRI. ASL-MRI by a Q2TIPS sequence on a 3.0-Tesla MRI was performed for three patients with Cognard's IIa+b type of DAVFs before and after treatment. Perfusion images obtained by ASL-MRI (ASL images) before treatment were visually compared with those by single-photon emission computed tomography images (SPECT images). Increasing rates of temporal changes of regional perfusion values in ASL images (ASL values) before and after treatment were also calculated. In all three patients, ASL images before treatment demonstrated high perfusion in regions around the shunting areas, where normal or low perfusion were detected on SPECT images; thus, ASL images might have demonstrated the abundant arterial shunting flow via the fistulas. On days eight to 20 after treatment, ASL values around the shunt areas remained the same or decreased, and those in the regions other than the shunt areas increased in all three patients. This might have been due to a combination of the following: a decrease in shunt flow volume, an amelioration of venous congestion, and a sustained an upward shift in the autoregulation of the brain perfusion pressure. All regional ASL values decreased on days 112 and 120 after treatment in two patients, which possibly reflects a reduction in the upward shift in autoregulation. ASL-MRI might be useful for identifying the hemodynamic behavior of DAVFs before and after treatment.

Unilateral hemispheric proliferation of ivy sign on fluid-attenuated inversion recovery images in moyamoya disease correlates highly with ipsilateral hemispheric decrease of cerebrovascular reserve.

BACKGROUND AND PURPOSE: An ivy sign is considered to represent diffuse leptomeningeal collaterals found on fluid-attenuated inversion recovery (FLAIR) images of patients with Moyamoya disease. We evaluated the correlation between unilateral ivy proliferation in a hemisphere and cerebrovascular hemodynamic status to learn the clinical significance of the ivy sign. MATERIALS AND METHODS: A total of 35 patients with Moyamoya disease were included. Correlation between ivy dominance on FLAIR images and hemodynamic status with use of iodine 123 N-isopropyl-p-iodoamphetamine ((123)I-IMP) single-photon emission CT (SPECT) was evaluated. RESULTS: Distributional differences of ivy signs between both hemispheres were observed in 22 (64.7%) of 34 patients with a positive ivy sign, all of whom showed decreased vascular reserve/reactivity in the ivy-dominant hemisphere (IDH). The proportion of the stage II (misery perfusion) area to IDH was higher than that in the ivy less-dominant hemisphere (ILDH) in the quantitative analysis. The mean vascular reserve was lower in IDH than ILDH. There were 15 of 22 patients who had bypass surgery on IDH because of transient ischemic attack from ischemia of IDH. Patients with symmetric ivy distributions showed a variety of hemodynamic status. MR angiography (MRA) stage of IDH (2.95 +/- 0.39) was higher compared with ILDH (2.60 +/- 0.50; P < .05). Regional arteriocapillary circulation time ratio in IDH was longer compared with ILDH (P < .05). Ivy proliferation decreased in 10 (55.6%) of 18 patients who underwent bypass surgery during the follow-up period. CONCLUSIONS: Unilateral hemispheric ivy proliferation correlated highly with the existence of an ipsilateral decreased vascular reserve associated with the development of leptomeningeal collaterals in patients with Moyamoya disease.

Tyrosine hydroxylase- and neuropeptides-immunoreactive nerves in canine trachea.

OBJECTIVE: To determine distribution of catecholaminergic and peptidergic nerve fibers in canine tracheas by use of immunohistochemistry. SAMPLE POPULATION: 10 tracheas collected from healthy adult dogs after euthanasia. PROCEDURE: Structure of the nerve network and distribution of tyrosine hydroxylase (TH)- and 6 types of neuropeptide-containing nerves in canine tracheas were immunohistochemically studied, using neurochemical markers. RESULTS: Intraepithelial free nerve endings with immunoreactivity for calcitonin gene-related peptide (CGRP) and substance P (SP) were observed. Tyrosine hydroxylase-, SP-, vasoactive intestinal peptide (VIP)-, and galanin (GAL)-immunoreactive nerve fibers were observed within and around the submucosal seromucous gland. In the smooth muscle layer, numerous TH- and GAL-immunoreactive nerve fibers, a moderate number of VIP- and neuropeptide Y (NPY)-immunoreactive nerve fibers, and a few SP- and methionine enkephalin (ENK)-immunoreactive nerve fibers were observed. Numerous nerve cell bodies with VIP and GAL immunoreactivity and a few with SP ENK, and NPY immunoreactivity were observed. Many TH-immunoreactive fibers were arranged in a meshwork around blood vessels. Nerves with CGRP-, SP-, VIP-, GAL-, ENK-, and NPY-immunoreactivity were also observed around blood vessels. CONCLUSIONS: Complex innervation, including catecholamine- and neuropeptide-containing nerves, which may be related to regulation of muscle contraction and glandular secretion, are found in canine tracheas.

Biological monitoring of metabolites of sarin and its by-products in human urine samples.

More than 20,000 passengers of Tokyo underground trains were intoxicated with warfare toxic chemicals. Most of the patients examined had marked miosis and decreased serum cholinesterase activity. Transient increase of serum CPK activity after 3 days of the exposure was the another sign. We intensively analyzed the metabolites in the urine of 4 patients. The following analytic results indicated the exposure to sarin as well as contaminated compounds such as diisopropyl methylphosphonate (DIMP), ethyl methylphosphonate fluoridate (EMPF, or ethylsarin), diethyl methylphosphonate (DEMP), and ethyl isopropyl methylphosphonate (EIMP). (1) Isopropanol (IPA) and ethanol (EtOH) were detected of large quantities in the urine samples, and were thought to be derived from sarin and the sarin counterpart, EMPF, DIMP, DEMP and EIMP. (2) Monoalkyl methylphosphonic acids (isopropyl methylphosphonic acid (IMPA) and ethyl methylphosphonic acid (EMPA) also were excreted in large amounts with taking the similar excretion pattern of IPA and EtOH. (3) The metabolite only derived from sarin and ethylsarin is F anions whose integral output in the urine was less than the equimolar level of the excreted (IMPA + EMPA + IPA + EtOH). (4) Other corroborative findings were low lethality: of more than 5,510 patients treated, 11 were acutely dead. (5) Nine exposed males had higher sister chromatid exchange (SCE) rate (5.00 +/- 1.48/cell) than the control (3.81 +/- 0.697/cell), because dialkyl methylphosphonates seemed to have alkylating activity and producing DNA adducts. The SCE rate also increased after the in vitro exposure of lymphocytes to dialkyl methylphosphonates.

Morphological and quantitative study of the intrinsic nerve plexuses of the canine trachea as revealed by immunohistochemical staining of protein gene product 9.5.

BACKGROUND: The ganglionated nervous plexuses in the trachea play an important role in the regulation of respiration. Although the tracheal tissue of the dog has frequently been used in physiological and pharmacological studies, little is known about the morphology of the intrinsic nervous plexuses in the dog trachea and quantitative data about the ganglia and nerve cell bodies are lacking. The structure of the nervous plexuses and detailed morphometric data about the intrinsic neurons of the dog have not previously been reported. METHODS: The structure of the intrinsic nerves in the dog trachea was examined by a combination method of digestion with KOH and immunohistochemical attaining of protein gene product 9.5. In addition, areas of nerve cell profiles, numbers of nerve cell bodies per ganglion and densities of nerve cell bodies per ganglion were estimated in preparations from five dogs. RESULTS: In the dog trachea, the peritracheal plexus, outer submucosal plexus, inner submucosal plexus, and mucosal plexus were identified from adventitia to epithelium in that order. The peritracheal plexus, situated in the lamina adventitia of the trachea, consisted of thick nerve bundles that were densely distributed in the membranous wall. The peritracheal plexus contained ganglia with round or oval nerve cell bodies. In the trachealis muscle, the intramuscular plexus, which was a well-developed, three-dimensional nervous network, was observed. It did not include ganglia and consisted of inter- and intrafascicular networks. The outer submucosal plexus was observed as small clusters in the inside of the trachealis muscle. A few round nerve cells were observed in the outer submucosal plexus as small clusters. The ganglionated inner submucosal plexus was identified in the superficial layer of the submucosal layer. A finer meshwork, namely, the mucosal plexus, was observed in the lamina propria. Among the entire length of the trachea, we counted 2,134-2,873 ganglia (average, 2,389) and 13,902-24,232 nerve cell bodies (average,18,461) were counted in the peritracheal plexuses of five dogs. The densities of ganglia and nerve cell bodies were high near the carina and low near the thoracic inlet. The number of nerve cell bodies per ganglion was estimated as 6.5-8.8 (average, 7.7). The average maximum area of nerve cell profiles was 522 +/- 223 microm2. CONCLUSIONS: The structure of the tracheal plexuses in the dog is more complex than those in other smaller animals. The constitution of the plexuses seems to be that of the intestine. The numerous nerve cells in the peritracheal plexus in the adventitia can be expected to play important roles in airway regulation and in the pathogenesis of tracheal collapse.

[Thoracoscopic surgery for the giant bulla complicating pulmonary eosinophilic granuloma: a case report].

We report a case of pulmonary eosinophilic granuloma (PEG) accompanied with a giant bulla successfully operated with a thoracoscopy. A 24-year-old female had been suffering from recurrent bilateral pneumothoraces with multiple bullae since February 1993. She was diagnosed as PEG with an open lung biopsy in July 1994. Repetitive pleurodesis were efficacious against the pneumothoraces. However, a bulla in the left upper lobe were growing with her respiratory function having worsened to bed rest. In May 1995, thoracoscopic surgery were performed to extinguish the bulla. Trocars were directly introduced into the lumen of the bulla. Ligation of the three communicating bronchial branches and tube drainage made the bulla disappear immediately. The patient had been well for one and a half year postoperatively.

Vascular thromboxane formation in hemostasis mechanism: correlation between bleeding time and vascular TXB2 in a patient with congenital platelet cyclo-oxygenase deficiency.

We encountered a patient with congenital platelet cyclo-oxygenase deficiency with normal ability to synthesize vascular prostaglandin I2 (PGI2) and thromboxane A2 (TXA2). The patient's peripheral blood monocytes did not show cyclo-oxygenase (COX) activity, but cultured bone marrow fibroblasts showed COX activity. To determine the mechanism of primary hemostasis in this patient, we examined the effect of oral administration of aspirin (1 g) on bleeding time and thromboxane B2 (TXB2), 6-keto prostaglandin F1 alpha (6-keto-PGF1 alpha) production in the blood emerging from the incision in this patient. The bleeding time was markedly prolonged by the administration of aspirin, and this prolongation was associated with the inhibition of TXB2 in the effluent blood, which seemed to be derived from the vessel wall. These findings suggest that vascular TXA2 production plays an important role in the maintenance of hemostasis.

[Desensitization immunotherapy on patients with mite-positive bronchial asthma using purified mite feces antigen fractions].

At present, we are performing desensitization immunotherapy on patients with mite-positive bronchial asthma using purified mite feces antigen fractions. We obtained the following results in 13 patients 4 to 12 months after the start of treatment. 1) The fraction showing the maximum reaction in the skin test was HM1-2 (molecular weight: 150-155 kD) in two patients, HM2 (30-40 kD) in nine patients and HM3 (10-20 kD) in two patients, and immunotherapy was performed using these fractions. None of the patients showed the maximum skin reactions or was treated with HM4 (less than 10 kD). 2) In nine patients with perennial asthma, the effects of treatment were excellent in four and moderate in three, while two cases remained unchanged. In four patients with seasonal asthma, the treatment was effective in all cases. 3) In patients in whom immunotherapy was effective, specific IgG antibody increased after the treatment, but it did not increase in the unchanged cases. Among the subclasses of specific IgG antibody increased by the treatment, no clear changes were seen in IgG4 antibody and no conclusion has been reached at present. 4) None of the patients had definite adverse reactions such as the occurrence of asthma attacks or anaphylaxis. These results suggested that purified mite feces antigens are safe and effective. We plan to continue this study with more patients in the future.

The significance of the cervical soft disc herniation in the ossification of the posterior longitudinal ligament.

The significance and role of cervical soft disc hernia in ossification of the posterior longitudinal ligament were investigated based on 54 surgical cases. The types of ossification of the posterior longitudinal ligament were divided into three sub-types: segmental, continuous, and mixed types. In the current series, there were 29 segmental type, 12 continuous type, and 13 mixed type. In the 29 segmental type, 23 patients had accompanying cervical disc hernias (79%). In the 12 continuous type, only 2 patients (17%), and in the 13 mixed type, 5 patients (33%), had accompanying disc hernias. According to the current study, an essential difference exists between the segmental type and the continuous or mixed types. In addition, the current result seems to indicate that, at least in the segmental type, disc herniation is not the promoting or initiating factor of ossification of the posterior longitudinal ligament, but that, in these cases, the fragility of the posterior longitudinal ligament may increase the chance of a disc hernia.

[Hydrocephalus due to membranous obstruction of the fourth ventricle aperture].

Three cases of hydrocephalus due to membranous obstruction of the fourth ventricle aperture are reported. Patient's age was 4, 34 and 68 years old and they complained of slowly progressive cerebellar ataxia, gait disturbance and other hydrocephalic symptoms. CT scan revealed symmetrical dilatation of lateral ventricles, and, especially, the fourth ventricle aperture was confirmed by ventriculography or metrizamide CT cisternography. Suboccipital craniectomy was performed in all cases and cerebellum was of normal shape and semilucent membrane was found obliterating the foramen of Magendie. Histological finding of the membrane was chiefly composed of fibroblast, but inflammatory evidence suggesting any particular etiological process. The cause of membranous obstruction was undetermined and obsolete infectious or inflammatory change was suspected.

A case of the omphalocele. The discussion about the frequent combination of the cardiac malformation, and the observation at the early non-cyanotic period of Fallot's tetralogy.

Even in the severe tetralogy of Fallot the performance of right ventricle is maintained normally without loaded pattern in ECG compensated by the blood flow derived through the ductus arteriosus at early neonatal period. Thereafter, stenotic murmur and reversed shunt appear, because the degree of right ventricular stenosis presumably increases gradually and right ventricular resistance11) become higher than systemic one.