Stent technology in ischemic stroke.

Atherosclerotic disease of the cerebral vasculature is a major cause of stroke worldwide. Atherosclerosis that is refractory to best medical management may require revascularization. In these instances, endovascular treatment provides a popular and safe alternative to open surgical techniques. The authors provide an overview of stent technology in the treatment of ischemic stroke, discussing the major studies evaluating stenting for extracranial carotid artery, vertebral artery, and intracranial atherosclerotic disease. The authors describe the commonly used stents with respect to their individual characteristics and technical limitations. Current and future developments in stent technology are also discussed, with areas for further innovation and clinical research.

Postischemic Trigeminal Neuropathy Treated With Radiofrequency Ablation.

Trigeminal neuralgia is a pain syndrome that is defined by sharp electrical shock-like pain that radiates in the sensory distribution of the trigeminal nerve. The classical cause of this syndrome is vascular compression, but other causes, such as stroke, have also been described. Instances of post-ischemic trigeminal pain have been described as meeting the classic description, and are termed trigeminal neuropathy. The treatment paradigms for trigeminal neuralgia versus neuropathy differ significantly, especially with the consideration of surgical management.We present a case of a 78-year-old man with post-ischemic trigeminal neuropathy that was successfully treated with radiofrequency ablation after failure of conservative management.We also summarize three previous cases of post-ischemic trigeminal neuropathy that were also successfully treated with percutaneous surgical treatment, showing that percutaneous surgical management should be considered in patients with post-ischemic trigeminal neuropathy that fail conservative management.

Protein expression based multimarker analysis of breast cancer samples.

BACKGROUND: Tissue microarray (TMA) data are commonly used to validate the prognostic accuracy of tumor markers. For example, breast cancer TMA data have led to the identification of several promising prognostic markers of survival time. Several studies have shown that TMA data can also be used to cluster patients into clinically distinct groups. Here we use breast cancer TMA data to cluster patients into distinct prognostic groups. METHODS: We apply weighted correlation network analysis (WGCNA) to TMA data consisting of 26 putative tumor biomarkers measured on 82 breast cancer patients. Based on this analysis we identify three groups of patients with low (5.4%), moderate (22%) and high (50%) mortality rates, respectively. We then develop a simple threshold rule using a subset of three markers (p53, Na-KATPase-ß1, and TGF ß receptor II) that can approximately define these mortality groups. We compare the results of this correlation network analysis with results from a standard Cox regression analysis. RESULTS: We find that the rule-based grouping variable (referred to as WGCNA*) is an independent predictor of survival time. While WGCNA* is based on protein measurements (TMA data), it validated in two independent Affymetrix microarray gene expression data (which measure mRNA abundance). We find that the WGCNA patient groups differed by 35% from mortality groups defined by a more conventional stepwise Cox regression analysis approach. CONCLUSIONS: We show that correlation network methods, which are primarily used to analyze the relationships between gene products, are also useful for analyzing the relationships between patients and for defining distinct patient groups based on TMA data. We identify a rule based on three tumor markers for predicting breast cancer survival outcomes.

Expression of phosphorylated raf kinase inhibitor protein (pRKIP) is a predictor of lung cancer survival.

BACKGROUND: Raf-1 kinase inhibitor protein (RKIP) has been reported to negatively regulate signal kinases of major survival pathways. RKIP activity is modulated in part by phosphorylation on Serine 153 by protein kinase C, which leads to dissociation of RKIP from Raf-1. RKIP expression is low in many human cancers and represents an indicator of poor prognosis and/or induction of metastasis. The prognostic power has typically been based on total RKIP expression and has not considered the significance of phospho-RKIP. METHODS: The present study examined the expression levels of both RKIP and phospho-RKIP in human lung cancer tissue microarray proteomics technology. RESULTS: Total RKIP and phospho-RKIP expression levels were similar in normal and cancerous tissues. phospho-RKIP levels slightly decreased in metastatic lesions. However, the expression levels of phospho-RKIP, in contrast to total RKIP, displayed significant predictive power for outcome with normal expression of phospho-RKIP predicting a more favorable survival compared to lower levels (P = 0.0118); this was even more pronounced in more senior individuals and in those with early stage lung cancer. CONCLUSIONS: This study examines for the first time, the expression profile of RKIP and phospho-RKIP in lung cancer. Significantly, we found that phospho-RKIP was a predictive indicator of survival.

Elevated MED28 expression predicts poor outcome in women with breast cancer.

BACKGROUND: MED28 (also known as EG-1 and magicin) has been implicated in transcriptional control, signal regulation, and cell proliferation. MED28 has also been associated with tumor progression in in vitro and in vivo models. Here we examined the association of MED28 expression with human breast cancer progression. METHODS: Expression of MED28 protein was determined on a population basis using a high-density tissue microarray consisting of 210 breast cancer patients. The association and validation of MED28 expression with histopathological subtypes, clinicopathological variables, and disease outcome was assessed. RESULTS: MED28 protein expression levels were increased in ductal carcinoma in situ and invasive ductal carcinoma of the breast compared to non-malignant glandular and ductal epithelium. Moreover, MED28 was a predictor of disease outcome in both univariate and multivariate analyses with higher expression predicting a greater risk of disease-related death. CONCLUSIONS: We have demonstrated that MED28 expression is increased in breast cancer. In addition, although the patient size was limited (88 individuals with survival information) MED28 is a novel and strong independent prognostic indicator of survival for breast cancer.

Delayed Cerebrospinal Fluid Cleft Formation Through the Midbrain and Thalamus Following Hemicraniectomy and Cranioplasty for Acute Subdural Hematoma.

BACKGROUND AND IMPORTANCE: Cerebrospinal fluid (CSF) cleft formation through brain parenchyma following nonpenetrating traumatic brain injury (TBI) is a rare phenomenon. Here we present a unique case of delayed CSF cleft formation months after initial injury. CLINICAL PRESENTATION: A 41-yr-old male presented after a fall with a right convexity acute subdural hematoma and ipsilateral frontal contusion. He underwent emergent hemicraniectomy with subsequent autologous cranioplasty 2 mo later. At 10-mo follow-up his neurological status had improved. His magnetic resonance imaging (MRI) at that time demonstrated encephalomalacia at the site of his prior contusion and punctate right pontine traumatic shearing injury. The patient re-presented to clinic 13 mo after initial injury with 2 mo of progressively worsening dysarthria, left hand numbness, diplopia, and dysphagia. MRI revealed a new tubular-shaped CSF cleft extending from the fourth ventricle, through the right midbrain and thalamus that was not present on prior MRI. Computed tomography cisternogram confirmed communication with the ventricular system, and there was no clinical evidence for elevated CSF pressure. One month later, the patient's symptoms had not improved, and imaging revealed progression of the CSF cleft. Following placement of a ventriculoperitoneal shunt, progression of the cleft ceased. We postulate that this cleft was a late sequela of traumatic shearing injury. We discuss our efforts to diagnose the etiology of the cleft and the rationale for our management strategy. CONCLUSION: To our knowledge, this represents the first reported delayed-onset CSF cleft through the midbrain and thalamus after closed TBI.

Adenosine-induced cardiac standstill for endovascular treatment of pediatric vein of Galen malformations.

Vein of Galen malformations are congenital high-flow vascular malformations that often present with heart failure, hydrocephalus, developmental delay, and intracranial hemorrhage. Because open surgical treatment is associated with high morbidity and mortality, endovascular embolization is increasingly becoming the preferred method of intervention. However, embolization of these lesions can be difficult because of their high-flow nature. The use of adenosine-induced cardiac standstill for treatment of vein of Galen malformations has not been previously described in neonates. The authors describe 3 treatments in 2 patients that demonstrate that the use of adenosine is well tolerated and allows safe transarterial embolization of high-flow vein of Galen malformations in the pediatric population.

Ruptured Persistent Trigeminal Artery Causing Direct Cavernous Sinus Fistula Treated with Pipeline Embolization and Minimal Coiling.

BACKGROUND: Rupture of a persistent trigeminal artery associated with development of a cavernous sinus fistula in a traumatic setting is rare. These arteries are typically treated with coil embolization of the cavernous sinus. CASE DESCRIPTION: We present the case of a 42-year-old woman who developed a direct cavernous carotid fistula after a motor vehicle accident. Angiographic imaging revealed a rupture point of a persistent trigeminal artery as it connected with the cavernous segment of the internal carotid artery, causing a cavernous sinus fistula. Coiling of the cavernous sinus was abandoned after placement of 1 coil because of coil herniation into the internal carotid artery. A Pipeline embolization device was placed to oppose the coil against the intima and keep the lumen open. The combination of coil embolization and flow diversion acutely decreased the fistulous flow. Surprisingly, an angiographic follow-up at 6 months showed complete fistula occlusion despite placement of only 1 coil into the cavernous sinus. CONCLUSIONS: We report a rare case where undercoiling of the cavernous sinus occluded a cavernous sinus fistula because of the adjunct use of a Pipeline embolization device in the presence of a traumatic rupture of a persistent trigeminal artery.

Preoperative and intraoperative perfusion magnetic resonance imaging in a RELA fusion-positive anaplastic ependymoma: A case report.

BACKGROUND: Ependymomas are rare neuroepithelial tumors thought to arise from radial glial precursor cells lining the walls of the ventricles and central canal of the brain and spinal cord, respectively. Histopathological classification, according to World Health Organization criteria, has only recently defined the RELA-fusion positive ependymoma. These tumors may account for 70% of supratentorial ependymomas in children and represent an aggressive entity distinct from other ependymomas. CASE DESCRIPTION: Here we present the case of a patient with RELA-fusion positive ependymoma of the frontal lobe in whom we used preoperative and intraoperative magnetic resonance (MR) perfusion imaging. In this first demonstrated intraoperative evaluation of MR perfusion in ependymoma, increased peripheral perfusion of the lesion in a ring-like manner with a discrete cutoff around the surgical margin correlated with intraoperative findings of a clear border between the tumor and brain, as well as pathological findings of increased MIB index and hypercellularity-specifically within solid tumor components. An abnormal perfusion pattern also suggested an aggressive lesion, which was later confirmed on pathological analysis. In addition, intraoperative MR perfusion improved detection of tumor tissue in combination with traditional T1-weighted contrast-enhanced methods, which increased extent of resection. CONCLUSIONS: MR perfusion imaging may be a useful method for delineating tumor aggressiveness and borders, which can be prognostic.

Higher levels of GATA3 predict better survival in women with breast cancer.

The GATA family members are zinc finger transcription factors involved in cell differentiation and proliferation. GATA3 in particular is necessary for mammary gland maturation, and its loss has been implicated in breast cancer development. Our goal was to validate the ability of GATA3 expression to predict survival in breast cancer patients. Protein expression of GATA3 was analyzed on a high-density tissue microarray consisting of 242 cases of breast cancer. We associated GATA3 expression with patient outcomes and clinicopathologic variables. Expression of GATA3 was significantly increased in breast cancer, in situ lesions, and hyperplastic tissue compared with normal breast tissue. GATA3 expression decreased with increasing tumor grade. Low GATA3 expression was a significant predictor of disease-related death in all patients, as well as in subgroups of estrogen receptor-positive or low-grade patients. In addition, low GATA3 expression correlated with increased tumor size and estrogen and progesterone receptor negativity. GATA3 is an important predictor of disease outcome in breast cancer patients. This finding has been validated in a diverse set of populations. Thus, GATA3 expression has utility as a prognostic indicator in breast cancer.

Higher expression levels of 14-3-3sigma in ductal carcinoma in situ of the breast predict poorer outcome.

The protein 14-3-3sigma is involved in the regulation of cellular processes such as apoptosis, cell cycle progression and proliferation. Disruption of protein expression has been implicated in a number of malignancies. Here we examine the expression pattern of 14-3-3sigma in breast cancer and specifically consider whether expression in ductal carcinoma in situ (DCIS) lesions is predictive of disease outcome. We examined 14-3-3sigma protein expression and localization using immunohistochemical staining on a high-density tissue microarray consisting of 157 invasive breast cancer patients. Statistical analyses were used to assess the correlation of 14-3-3sigma expression with clinico-pathological parameters and patient outcome. We observed a statistically significant increase in 14-3-3sigma protein expression in ductal hyperplasia, DCIS, and invasive ductal carcinoma (IDC) as compared normal glandular epithelium. In IDC, lower expression of 14-3-3sigma tended to predicted poorer survival time while in DCIS lesions, there was a stronger correlation between relatively higher levels of 14-3-3sigma predicting shorter survival time. Further, of patients who had concurrent DCIS and IDC lesions, those that exhibited a decrease of 14-3-3sigma expression from DCIS to IDC had significantly shorter survival time. Our findings indicate that 14-3-3sigma expression may be a useful prognostic indicator for survival in patients with breast cancer with an elevated 14-3-3sigma in earlier disease predicting a less favorable disease outcome. To our knowledge this is the first published study associating 14-3-3sigma protein expression with breast cancer survival.