Intra-arterial recanalization techniques for patients 80 years or older with acute ischemic stroke: pooled analysis from 4 prospective studies.

BACKGROUND AND PURPOSE: Previous studies have demonstrated limited benefit with endovascular procedures such as stent placement in octogenarians. We evaluated the safety and effectiveness of intra-arterial recanalization techniques to treat ischemic stroke in patients 80 years or older presenting within 6 hours of symptom onset. MATERIALS AND METHODS: We pooled the data from 4 prospective studies by evaluating intra-arterial recanalization techniques for treatment of ischemic stroke. Clinical and radiologic evaluations were performed before treatment and at 24 hours, 7 to 10 days, and 1 to 3 months after treatment. We performed multivariate analyses to evaluate the effect of ages 80 years and older on angiographic recanalization, favorable outcome (modified Rankin scale of 0-2), and mortality rate at 1 to 3 months. RESULTS: A total of 101 patients were treated in the 4 protocols. Of these, 24 were 80 years or older. There was no significant difference between the 2 age groups in sex, initial stroke severity, time to treatment, site of vascular occlusion, and rate of symptomatic and asymptomatic intracranial hemorrhage (ICH). In logistic regression analysis, age 80 years or older was associated with a lower likelihood of a favorable outcome (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.13-1.2; P = .11) and recanalization (OR, 0.36; 95% CI, 0.12-1.1; P = .07) and with higher mortality rate (OR, 3.17; 95% CI, 1.05-9.55; P = .04) after adjusting for study protocol. After adjusting for recanalization in addition to study protocol, the older age group still had a lower likelihood of favorable outcomes (OR, 0.34; 95% CI, 0.1-1.1; P = .07) and higher mortality rates (OR, 3.62; 95% CI, 1.15-11.36; P = .027). CONCLUSIONS: Our study demonstrates that patients 80 years and older are at higher risk for poor outcome at 1 to 3 months following intra-arterial recanalization techniques. This relationship is independent of recanalization rate and symptomatic ICH supporting the role of other mechanisms.

Post-traumatic moderate systemic hypothermia reduces TUNEL positive cells following spinal cord injury in rat.

STUDY DESIGN: A standardized animal model of contusive spinal cord injury (SCI) with incomplete paraplegia was used to test the hypothesis that moderate systemic hypothermia reduces neural cell death. Terminal deoxynucleotidyl transferase [TdT]-mediated deoxyuridine triphosphate [dUTP] nick-end labeling (TUNEL) staining was used as a marker of apoptosis or cell damage. OBJECTIVE: To determine whether or not moderate hypothermia could have a neuroprotective effect in neural cell death following spinal cord injury in rats. SETTING: Kagawa Medical University, Japan. METHODS: Male Sprague-Dawley (SD) rats (n=39) weighing on average 300 g (280-320 g) were used to prepare SCI models. After receiving contusive injury at T11/12, rats were killed at 24 h, 72 h, or 7 days after injury. The spinal cord was removed en bloc and of examined at five segments: 5 and 10 mm rostral to the center of injury, center of injury, and 5 and 10 mm caudal to the center of injury. Rats that received hypothermia (32 degrees C/4 h) were killed at the same time points as those that received normothermia (37 degrees C/3 h). The specimens were stained with hematoxylin and eosin, and subjected to in situ nick-end labeling (TUNEL), a specific method for visualizing cell death in the spinal cord. RESULTS: At 24 h postinjury, TUNEL positive cells (TPC) decreased significantly 10 mm rostral to center of injury in hypothermic animals compared to the normothermia group. At 72 h post-SCI, TPC also decreased significantly at 5 mm rostral, and 5 and 10 mm caudal to the lesion center compared to normothermic animals. At 7 days postinjury, a significant decrease of TPC was observed at the 5 mm rostral and 5 mm caudal sites compared to normothermic animals. CONCLUSION: These results indicate that systemic hypothermia has a neuroprotective effect following SCI by attenuating post-traumatic TPC.

Expression of an embryonic intermediate filament protein in amygdaloid kindled rats.

Amygdaloid kindling is well known as an experimental model of temporal lobe epilepsy. However, the mechanism of kindling epileptogenesis remains unclear. To examine the remodelling process in kindling, we performed immunohistochemistry of nestin, an embryonic intermediate neurofilament protein, in amygdaloid kindled rats. In rats expressing focal seizures (kindling stage C3), nestin immunoreactive cells (NIC) were detected at ipsilateral piriform cortex (PC) and ipsilateral perirhinal cortex (PRh), and at PC bilaterally in fully kindled rats expressing secondary generalized seizures (kindling stage C5). Double staining with glial fibrillary acidic protein revealed that almost all reactive astrocytes at PC express nestin immunoreactivity. These results suggest that glial NIC may participate in the remodelling process at the PC and PRh areas. This is the first report of nestin expression in kindling and suggests that glial nestin at PC and PRh may play a significant role in permanent epileptogenesis in kindling.

Appearance and alteration of TUNEL positive cells through epileptogenesis in amygdaloid kindled rat.

To evaluate the role of neural cell death during and after kindling epileptogenesis, apoptotic cells were analyzed in amygdaloid kindled rat using TUNEL staining as a marker of programmed cell death. TUNEL positive cells (TPC) were stained and counted as apoptotic cells in hippocampus, white matter, diencephalon, and cortex at three stages; C0 (before kindling), C3 (during kindling) and C5 (fully kindled). The animals were studied 2 h after the last stimulation. In all regions except cortex, apoptotic cells in stage C3 were significantly increased as compared to those in stage C0. Especially, in white matter significantly more apoptotic cells in stage C3 were detected than in stage C5. The present data showed that in the course of getting the epileptogenesis, apoptosis had already occurred and this type of cell death may play a significant role in reaching stage C5 through kindling.

Re-evaluation of sexual dimorphism in human corpus callosum.

To study the sexual dimorphism of human corpus cauosum (CC), we analyzed the midsaggital magnetic resonance imaging (MRI) morphometry in 67 adults aged (mean+/-s.d.) 36.82+/-9.35 years. Four specific angles of the CC were determined. All four angles in 34 females and 33 age-matched males showed a significant difference between females and males. These morphometric findings confirm a gender difference in the orientation of corpus callosum.

Granule cell disinhibition in dentate gyrus of genetically seizure susceptible El mice.

Paired-pulse inhibition was investigated electrophysiologically in the dentate gyrus using hippocampal slices from epileptic El mice. At short interpulse intervals (IPIs), the inhibition was 30% in the El, and 90% in the control ddY mice at the ages of 10 and 15 weeks. No difference in inhibition was observed at the age of 5 weeks. Bicuculline, a GABAA receptor antagonists, attenuated the inhibition during short IPIs n the ddY mice, while in the El mice, phenobarbital and flunitrazepam, which enhance GABAA receptor function, restored the inhibitory activity comparable to that of the ddY. The disinhibition progressed with growth, closely correlating with seizure development in El mice. These results suggest that decrease in the GABAergic inhibition occurs in the dentate gyrus of the El mice with growth. GABA concentration in the hippocampus was also quantified using HPLC. In El mice, GABA level was significantly lower than that in ddY mice at the ages of 5 and 15 weeks. Thus, the disinhibition observed in the El dentate gyrus at 15 weeks of age does not appear to be directly related to the content of GABA. GABAergic disinhibition suggests possible loss of unknown inhibition control factor(s) in the El dentate gyrus as growth progresses. The growth-dependent disinhibition in the granule cells may be prerequisite for epileptogenesis in El mice.

Histochemical demonstration of heavy metals in mouse skin.

The localization of heavy metals in normal mouse skin was investigated light microscopically using the Neo-Timm staining method. Positive staining was found in the horny layer of epidermis, connective tissue of dermis and in hair roots. Chelation of heavy metals by pretreatment with diethyldithiocarbamate prevented this staining. The study demonstrates that heavy metals, mainly zinc, are localized in the mouse skin and that the Neo-Timm staining method is useful for the investigation of the role of zinc in this organ.

Morphological changes in the hippocampus in amygdaloid kindled mouse.

To clarify the origin and maintenance of epileptogenesis, morphological changes in the hippocampus of amygdaloid-kindled mice were analyzed at different stages of kindling. The granule cell size in dentate gyrus and the pyramidal cell size in CA1 were clearly decreased depending on seizure stage. The cell size in CA2 was increased and density in dentate gyrus and CA2 was reduced, significantly. The morphological changes in hippocampus associated with kindling must be closely related to the acquisition and the maintenance of epileptogenesis. The results support the hypothesis that seizure-induced damage of neurons may lead to formation of new synaptic connections that produce abnormal hyperexitability and result in seizures.

The effects of zinc oxide and diethyldithiocarbamate on the mitotic index of epidermal basal cells of mouse skin.

The purpose of this study was to investigate the effects of topical treatment with zinc oxide (2.5%, 10%, 25% and 50%) and intraperitoneal treatment with diethyldithiocarbamate (DEDTC) (50 mg/kg, 500 mg/kg and 1,000 mg/kg) on the mitotic index of epidermal basal cells in incised and non-incised mouse skin. The present results showed that topical application of zinc oxide (25% and 50%) increased the mitotic index of epidermal basal cells in incised skin and non-incised skin. Conversely, intraperitoneal administration of DEDTC (500 mg/kg and 1,000 mg/kg) decreased the mitotic index, but only in the incised skin. These results suggest that mitosis of epidermal basal cells may be stimulated by the topical application of zinc oxide both in incised and non-incised mouse skin, and that it also may be inhibited by the intraperitoneal administration of DEDTC in incised mouse skin.

Effect of ceruletide on epileptogenesis in amygdaloid kindled rats.

The inhibitory effects of ceruletide (CLT), a cholecystokinin-8 (CCK)-like peptide, were investigated in the epileptogenesis in the amygdaloid kindled rats. Lower doses of CLT (20-80 micrograms/kg) inhibited the progression of kindling process. After acquiring C5 stage, a higher dose (160 micrograms/kg) was required to suppress the seizure susceptibility. These results, in light of several previous studies showing no serious side effects, suggest that CLT might be useful as an anti-epileptogenic agent for clinical usage.

Effect of embryonic hippocampal transplantation in amygdaloid kindled rat.

Embryonic neural tissue was transplanted into previously kindled rats. A thirteen- to fourteen-day embryonic hippocampal cell suspension was grafted in the stratum oriens near the CA2 area of the hippocampus. Almost 80% of the animals had a good recovery and became seizure-free. Injection of neocortical cells or saline did not show any positive effect on the kindling susceptibility. Although 20 day embryonic cell transplantation was also effective, the effect did not last as long as the 13- to 14-day embryonic transplantation. These observations open the possibility that the neural grafts may be used for therapy of medically intractable epilepsies.

Plasma urea and ammonia in epileptic patients and their relatives.

The plasma levels of urea and ammonia were examined in patients with primary generalized epilepsy, patients with partial epilepsy and in the first-degree relatives of these subjects. The results show a significant decrease in plasma urea in both groups of patients and their first-degree relatives as compared to the non-epileptic controls. The plasma ammonia concentrations were significantly higher in both groups of patients and in the relatives of generalized epilepsy patients as compared to the controls. The observed changes in plasma urea and ammonia were found not to be due to the effect of anticonvulsant drugs. The data suggest that a metabolic defect in urea synthesis may constitute one of the genetic components in the multifactorial etiologies of primary generalized and partial epilepsies.

Familial increase in plasma glutamic acid in epilepsy.

Plasma levels of glutamic acid and leukocyte glutamate dehydrogenase (GDH) activity were determined in patients with primary generalized epilepsy, patients with partial epilepsy and in the first-degree relatives of these subjects. The results show a significant increase in plasma glutamic acid in both groups of patients and their relatives compared to non-epileptic controls. The leukocyte GDH activity in the patients and the relatives was not different from controls. The data support a genetic basis for plasma glutamic acid increase in both primary generalized and partial epilepsy and are compatible with the multifactorial mode of inheritance of these disorders. This is the first study showing a familial plasma glutamic acid increase in epilepsy in a Japanese population.

Increased plasma glutamic acid in a genetic model of epilepsy.

A significant increase in the plasma levels of glutamic acid and a significant decrease in aspartic acid and taurine in epileptic patients and their first degree relatives was reported more than a decade ago and an underlying genetic basis for these amino acid changes was suggested. The main objective of the present study was to determine the plasma levels of glutamic acid, aspartic acid and taurine in El mice which are an inbred epileptic mutant mouse strain. The results show a significant increase in plasma glutamic acid but no changes in aspartic acid or taurine in the epileptic mice as compared to controls. The data provide the first evidence of a significant increase in plasma glutamic acid in an animal model of hereditary epilepsy and substantiate the hypothesis that a genetic defect underlies the elevated plasma glutamic acid levels in association with epilepsy. The findings are also compatible with neurochemical and neurophysiological evidence implicating glutamic acid in the mechanism of seizures.

In vivo microdialysis of amino acid neurotransmitters in the hippocampus in amygdaloid kindled rat.

Extracellular concentrations of gamma-aminobutyric acid (GABA), glutamate (Glu) and aspartate (Asp) were determined by microdialysis in rat hippocampus during various amygdaloid kindled stages. The values of GABA and Glu were increased 3-4 times in C2-C3 stages in comparison with the values in control animals. After reaching the C5 stages, these values were increased 3-7 times. However, the concentration of Asp decreased depending on the kindling stage, reaching the lowest value of 33% in comparison with the normal value. The observed changes may be related to kindling induced seizures.

Increase of extracellular insulin-like growth factor I (IGF-I) concentration following electrolytical lesion in rat hippocampus.

The change of extracellular insulin-like growth factor I (IGF-I) level following electrolytical lesion in rat hippocampus was studied by intracerebral microdialysis technique. The microdialysis probes were inserted into the lesioned and normal side of hippocampus on the day and each week after making the lesion for a period of four weeks. The content of IGF-I in the dialysis perfusate was measured by a radioimmunoassay. One week after surgery, IGF-I level (mean +/- S.E.M.) increased from 235.6 +/- 25.4 pg/100 microliters perfusate (day 0) to 305.5 +/- 15.6 pg/100 microliters perfusate (day 7), and then decreased gradually. This suggests that there is accumulation or increase in secretion of IGF-I at the lesioned site, and that IGF-I might have an important role in vivo in the brain tissue recovery from damage.

Gamma-aminobutyric acid uptake is decreased in the hippocampus in a genetic model of human temporal lobe epilepsy.

Temporal lobe epilepsy (TLE) is one of the most commonly occurring and most intractable forms of seizure disorders in humans. The fundamental mechanisms underlying the pathogenesis of the disorder have, however, not yet been elucidated. El is an inbred mouse strain with genetic predisposition to epileptic seizures. The El mouse epilepsy shares its main features with TLE in humans and is considered to be an excellent model of the latter. We report a marked decrease in the uptake of gamma-aminobutyric acid (GABA) in the hippocampus of El mice. The data favor the involvement of GABA and the hippocampus in the mechanisms of TLE and suggest a genetic basis for the altered GABA uptake. This is the first report suggesting the possibility of a hereditary defect of a neurotransmitter function in TLE.

Insulin-like growth factor I (IGF-I) distribution in the tissue and extracellular compartment in different regions of rat brain.

The regional distribution of insulin-like growth factor I (IGF-I) was examined in the tissue and extracellular compartment of rat brain. The tissue content of IGF-I was the highest in the pituitary gland, followed by the olfactory bulb, upper brainstem, cerebellum, striatum, hippocampus, lower brainstem, and cerebral cortex. The extracellular concentration was studied by intracerebral microdialysis technique, and the highest content was found in the hippocampus, followed by the olfactory bulb, hypothalamus, cerebellum, striatum, and cerebral cortex. The tissue and extracellular contents were significantly correlated in the olfactory bulb, hypothalamus, cerebellum, striatum, and cerebral cortex. IGF-I might act by paracrine and/or autocrine regulatory mechanisms in these regions.

Increased aspartic acid release from the iron-induced epileptogenic focus.

Evidence has been growing in recent years for the involvement of excitatory neurotransmitter amino acids in the etiology of epilepsy. The precise mechanism of this involvement, however, remains unknown. In the present study, in vitro release and uptake of [3H]aspartic acid and [3H]glutamic acid were investigated in focal cerebral cortex in the iron-induced model of post-traumatic epilepsy in the rat. The animals were injected with FeCl3 or saline into the cerebral cortex and release and uptake studied in cortical slices from both acute and chronic foci (30 min and 3 weeks post injection, respectively), using a superfusion system. The results showed: (a) a significant increase in K(+)-stimulated aspartic acid release from the acute iron injected focus as compared to the corresponding saline injected cortex; and (b) no significant differences in the release of glutamic acid or in the uptake of glutamic acid and aspartic acid between the iron injected and the saline injected cortex. The finding of increased aspartic acid release suggests that this amino acid may play a role in the mechanism of iron-induced epilepsy in the rat.

Immunological studies in focal epilepsy.

Serum immunoglobulins, T-lymphocyte subsets and HLA investigations were carried out in 24 patients with focal, mainly temporal lobe, epilepsy and in 30 of their first degree relatives. The mean serum level of IgA was significantly decreased in the epileptic probands compared with controls. In the relatives, there was a significant decrease in mean IgM levels. The epileptic group had significantly fewer circulating T4 "helper" lymphocytes (absolute and percent) and an increased percentage of T8 "cytotoxic"/"suppressor" lymphocytes than the controls. The effect of antiepileptic drug treatment on these results is discussed. The frequencies of 63 HLA specificities determined were not significantly different in probands compared with controls. Among 5 of the most commonly occurring haplotypes there was a lower frequency of the haplotype A1,B8 in epileptic probands, which is in accordance with an earlier study on benign focal epilepsy in children. The immunological findings support the possibility that focal epilepsy may be linked to a genetically dependent immune dysregulation. The latter may contribute to the variability underlying the multifactorial inheritance of the epilepsies.