Prolonged survival of rat hepatic allografts after total-body irradiation of the donors.

The effect of total-body irradiation of the donor on hepatic allograft survival was studied in the rat, with ACI(RT1a) as the donor and LEW(RT1(1)) as the recipient. LEW recipients of ACI liver transplants experienced severe acute rejection, with a mean survival of only 10.2 +/- 0.3 days. The doses of irradiation were 450, 750, and 1000 rads administered 24 hr prior to harvesting or subsequent transplantation. TBI with a dose of 750 rads significantly prolonged the survival of the hepatic allograft to 30.3 +/- 1.7 days, without concomitant immunosuppression. However, neither 450 rads nor 1000 rads of TBI resulted in successful suppression of graft rejection. TBI appeared to have a beneficial effect on hepatic allograft survival and to have no deleterious effect on isograft survival, suggesting a possible modulation of the immunogenicity of the donor organ. Although the cause of this beneficial effect is not clear, TBI with a dose of 750 rads 24 hr prior to organ harvest seems to be optimal to eliminate-antigen presenting cells in the donor organs.

The time course of cell-mediated lympholysis in rat hepatic allograft recipients pretreated with a single donor-specific blood transfusion.

A single intravenous injection of 1 ml freshly heparinized donor blood seven days before transplantation significantly prolonged the survival of subsequent donor-specific hepatic allografts in the fully allogeneic ACI(RT1a-to-LEW(RT1l)) rat combination. The time course of cell-mediated lympholysis was studied in this animal model. The activity of CML in lymphocytes infiltrating into the hepatic allograft (CML-G) and in the spleen (CML-S) was determined by measuring % lysis of donor Con A blast cervical lymph node cells. Preoperative DST resulted in an increased activity of CML-S with a peak (31.6%, E/T = 150) on day 7. This increased CML-S activity after DST rapidly declined during the first days following hepatic transplantation. The activities of both CML-S and CML-G then increased after transplantation and reached peaks on days 15 (48%, E/T = 150) and 20 (2.57%, E/T = 75), respectively. These were much higher than the peak values of CML-S (11.2%, E/T = 150) on day 7 and CML-G (19.5%, E/T = 75) on day 6 in untreated controls and were followed by a subsequent gradual decrease in those activities to preoperative levels by day 113 posttransplant. Phenotypic analysis of lymphocytes infiltrating grafts in DST-treated hosts demonstrated that the CD4/CD8 ratio remained relatively constant (less than 1.0). While the ratio in control grafts increased and reached a peak (2.17) on day 9. Histological examination revealed that mononuclear cell infiltration of grafts reached a peak on day 9 in both DST-treated hosts and controls. This mononuclear cell accumulation gradually subsided in DST-enhanced grafts. The mitotic index of graft hepatocytes reached a peak on day 15 in DST-treated hosts and on day 7 in control. The evidence of prolonged survival of hepatic grafts in recipients pretreated with DST, despite the presence of cytotoxic T cells with increased CML activity in vitro, suggests that effector cytotoxic cell activity may not be necessary for rat liver allograft rejection and that there may be limitations in measuring host cytotoxic activity simply by CML assays.

False localization of rupture site in patients with multiple cerebral aneurysms and subarachnoid hemorrhage.

OBJECTIVE: Patients with subarachnoid hemorrhage and multiple intracranial aneurysms present a unique challenge to the neurosurgeon. Unless all aneurysms can be clipped through a single craniotomy, the surgeon must accurately determine which aneurysm has ruptured. Misjudgment may result in disastrous postoperative rebleeding from the untreated but true ruptured lesion. We assessed the risk of false localization of the rupture site and subsequent rebleeding and documented the problems in predicting the true rupture site when patients have multiple intracranial aneurysms. METHOD: We reviewed the records of a consecutive series of 93 patients treated over a period of 12 years who presented with their first subarachnoid hemorrhage and who had multiple intracranial aneurysms. The rupture site was determined on the basis of computed tomographic and angiographic findings, and the supposed ruptured aneurysm was clipped within 2 days of hemorrhage in each patient. Additional aneurysms that could not be accessed in the same surgical session were operated on at a later stage. All patients' records were reviewed, and all computed tomographic scans and angiograms, including repeat studies performed in some patients, were retrospectively reevaluated by the authors, who had no knowledge of the patients' clinical information. RESULTS: The location of the aneurysm that ruptured was verified at the time of surgery or during the autopsy in 76 patients (82%). The aneurysm that ruptured was the one predicted as ruptured by the surgeon before surgery in 69 patients (91%) and in retrospect in 72 patients (95%). Five of the 6 patients in whom the ruptured aneurysm was not correctly identified were thought to have only a single aneurysm. Four patients rebled after surgery, and 2 patients died as a result of the rebleeding. CONCLUSION: In the reported series, the most common cause of rebleeding soon after aneurysm surgery was failure to obliterate the ruptured aneurysm, usually because it was missed on the initial angiogram. The results support not only meticulous radiological investigation of all intracranial arteries before surgery but also thorough surgical inspection of the target aneurysm in all cases of subarachnoid hemorrhage even after one candidate lesion has been discovered.

Pathological factors influencing survival of carcinoma of the ampulla of Vater.

The resected specimens of 24 consecutive patients, who underwent pancreaticoduodenectomy for ampullary carcinoma from 1977 to 1986, were examined pathohistologically and the factors influencing survival were evaluated. According to the pTNM pathological classification, the 5-year survival at Stage I was 100%, at Stage II 64.8% and at Stage III 15%. Only one patient at Stage IV survived more than 5 years. These indicate that the localization of the tumor within the ampulla of Vater and lymph node metastases are worthwhile prognostic indicators. The other factors, such as shape of the tumor, invasion into the veins and lymphatic vessels in the primary lesion, and type of local extension were indicative of influencing survival, but without statistical significance. Tumor size, histological type, and the ratio of connective tissue included in the primary lesion did not correlate with survival.

An adult case of recurrent arteriovenous malformation after "complete" surgical excision: a case report.

BACKGROUND: Complete surgical excision of arteriovenous malformations (AVM) documented by postoperative angiography is considered a cure. However, recent reports have shown that AVMs in children may recur after negative postoperative angiograms, and some suggest that it may reflect the immaturity of their cerebrovasculature. This case report demonstrates that AVM in adults may also recur, despite postoperative angiograms confirming complete removal. CASE DESCRIPTION: This 28-year-old man presented in 1994 with a focal motor seizure and was found to have an AVM in the right frontal lobe. He underwent surgical excision of the AVM; postoperative angiograms taken immediately after surgery and 15 days later showed no residual AVM. He remained free of symptoms after surgery and it was considered that a complete removal had been achieved. In 1998 he developed a subarachnoid hemorrhage, and subsequent angiograms revealed a small AVM in an adjacent location. CONCLUSION: This is the oldest patient reported in the literature with a recurrence of AVM, despite postoperative angiograms confirming complete removal. Angiographically invisible immature vessels, which might have been left in the surgical field, might have formed a new malformation later. We still believe that such recurrence must be very rare after AVM surgery, but we now recommend follow-up angiography at yearly intervals to our patients.

[Three adult intussusception cases with colorectal cancer; CT diagnosis and its characteristic findings].

We have experienced three adult intussusception cases with colorectal cancer. In all three cases CT studies were performed prior to administering a barium enema, where we could make the exact diagnosis of the lesions in both the plain and the contrast studies. In the CT studies, the intussusception lesions showed the characteristic eccentric layered pattern. It was difficult to distinguish the tumors from the edematous intestinal walls at the proceeding portion in two cases. While in one case, the proceeding portion (the tumor itself) was pointed out as the enhanced soft tissue density mass of layered pattern with the irregular margins.

A case of spontaneous hemorrhage of the abdominal wall caused by rupture of a deep iliac circumflex artery treated by transcatheter arterial embolization.

We report an uncommon case of spontaneous massive hemorrhage of the abdominal wall caused by rupture of a deep iliac circumflex (DIC) artery. Enhanced computed tomography (CT) demonstrated a marked extravasation in a huge hematoma of the abdominal wall. Although a pelvic arteriogram demonstrated no extravasation, a superselective DIC arteriogram subsequently revealed an extravasation of the artery. We successfully performed transcatheter arterial embolization for the artery. There have been few reports in the literature of spontaneous hemorrhage in the abdominal wall resulting from rupture of DIC artery, which were defined by diagnostic imaging and successfully treated by transcatheter arterial embolization.

Gadolinium-enhanced MR imaging in the evaluation of uterine fibroids treated with uterine artery embolization.

OBJECTIVE: The purpose of this study was to determine whether tumor volume reduction can be predicted by the infarction rate of uterine fibroids as seen on gadolinium-enhanced MR images obtained immediately after uterine artery embolization. MATERIALS AND METHODS: In our study, 36 women with symptomatic uterine fibroids successfully underwent uterine artery embolization. Unenhanced and enhanced MR imaging was performed before the procedure and repeated at 1 week, 4 months, and 1 year after the procedure. We retrospectively reviewed enhanced MR images of uterine fibroids after uterine artery embolization. At 4 months after uterine artery embolization, we compared the rate of tumor volume reduction in patients with completely infarcted dominant fibroids with the rate of tumor volume reduction in patients with partially infarcted fibroids. RESULTS: Enhanced MR images obtained 1 week after uterine artery embolization revealed that 100% infarction rates of the dominant uterine fibroids were achieved in 33 women (92%), and 70--90% infarction rates were seen in the remaining three (8%). They also revealed that of a total of 204 fibroids in these patients, 100% infarction was achieved in 199 fibroids (98%). Enhanced MR images obtained 4 months after uterine artery embolization showed that tumor volume reduction of the completely infarcted dominant fibroids (n = 23) was 60% +/- 18%, whereas that of the partially infarcted fibroids (n = 5) was 35% +/- 27% (p = 0.0367). CONCLUSION: Gadolinium-enhanced MR imaging is a useful diagnostic technique for uterine fibroids after uterine artery embolization because it assesses the degree of infarction in the embolized fibroids, which corresponds to the subsequent tumor volume reduction.

Value of repeat angiography in patients with spontaneous subcortical hemorrhage.

BACKGROUND AND PURPOSE: Neuroradiological investigations do not disclose a source of bleeding in some patients with spontaneous subcortical hemorrhage. These patients may harbor undetected vascular malformations and may be at risk of rebleeding in the future. We investigated patients with subcortical hemorrhage with use of repeat angiography and MRI to determine the incidence of occult vascular malformations and the risk of bleeding during follow-up. METHODS: We reviewed a consecutive series of 137 patients with subcortical hemorrhage during a 10-year period (June 1987 through June 1997). If the patient was <65 years old and the first angiogram and/or MRI did not show a source of bleeding, repeat angiography was recommended. All angiographic and MRI studies were reviewed. The relationship between the identified bleeding source and clinical variables such as patient age, sex, and history of hypertension and the size and location of the hematoma were examined. RESULTS: One hundred seven patients (78%) underwent angiography on admission, 10 (7%) had immediate surgery for hematoma without angiography, and 20 (15%) had neither angiography nor surgery. Overall, an etiology for the hemorrhage was found in 55 cases (40%). Vascular malformations were common in young patients without preexisting hypertension. A second angiogram was obtained in 22 patients, and 4 arteriovenous malformations were demonstrated. Rebleeding at the site of the initial hemorrhage was not observed after a mean follow-up of 68 months. CONCLUSIONS: Angiography performed acutely after hemorrhage may not demonstrate vascular malformations. Consideration should be given to repeat angiography in patients who do not have a specific cause for hemorrhage.

[Three-dimensional MR angiography of the celiac artery with single breath holding].

We performed a three-dimensional MR angiography of the celiac artery with single breath holding. The measuring time was just twenty-three seconds. In four healthy volunteers, celiac arteries were visualized clearly, moved cephalad with expiration and caudad with inspiration. In two patients with the median arcuate ligament compression of the celiac artery, the degree of stenosis increased with deep expiration and decreased with deep inspiration. Using this technique, we obtained different vascular images with each respiratory phase. This technique is considered to be a useful three-dimensional MR angiography in the abdominal region without respiratory artifacts.

[Transcatheter hepatic segmental chemo-Lipiodol-embolization against hepatocellular carcinoma accompanied by tumor thrombosis in the portal vein].

We performed transcatheter hepatic segmental chemo-Lipiodol-embolization against hepatocellular carcinoma accompanied by tumor thrombosis in the portal vein. CT scan after embolization demonstrated good Lipiodol accumulation in the tumor thrombosis in some cases. In one resected case, remarkable necrosis of tumor thrombosis was proved histologically. In five non-resected cases, 6-month survival rate was 100%. We hope this therapeutic method can be useful for hepatocellular carcinoma with tumor thrombosis in the portal vein.

[A clinical trial of whole liver simultaneous dynamic MR imaging and its usefulness].

A clinical trial of whole liver simultaneous dynamic MRI was done. In 23 second whole liver was able to be scanned using parameters of filed echo method as follows: TR = 315 msec, TE = 7 msec, Flip angle = 70 degrees or 90 degrees, MAT = 50%, ECD = 60%, FOV 40 cm and no presaturation. Even 2-3 mm nodules of metastatic tumors and small daughter nodules of hepatocellular carcinoma such as 5 mm were demonstrated in the arterial phase clearly.

[Assessment of a coaxial system accommodated to a 0.035 inch guide wire in superselective hepatic angiography and embolization].

A special coaxial catheter system accommodated to a 0.035 inch guide wire was recently developed. The four-part coaxial system is composed of a central 0.035 inch flexible guide wire, a 4-French inner catheter (straight, 90 cm in length), a 6-French outer catheter (fork-shaped, 60 cm in length), and a hemostatic valve. The 4 French inner catheter is large enough in diameter to allow a larger volume of contrast medium and greater amount of embolic material than the earlier coaxial system. Using this coaxial catheter system, we performed successful superselective hepatic arteriography and embolization in 44 patients with malignant hepatic tumors. Catheterization of the celiac and superior mesenteric arteries with the 6 French outer catheter was easy, and the angiogram obtained was very distinct. The 4 French inner catheter was easily and safely advanced into the segmental hepatic artery, and even common hepatic arteriography with this catheter provided clear images on conventional cut films. Therefore, in most cases, both angiography and embolization can be accomplished using this coaxial system alone.

[Effect and complications of embolization therapy using absolute ethanol for renal arteriovenous malformation].

Transcatheter embolization therapy using absolute ethanol was accomplished in six patients with renal arteriovenous malformation. The effect of this therapy was considered to be good, because none of the patients has experienced recurrent hematuria. It is necessary to avoid the back flow of absolute ethanol. One patient had the particular complication of hydronephrosis caused by the incidental injection of absolute ethanol into the ureteral artery.

In situ macrophage distribution in the hepatic allograft associated with rejection in the rat.

The association of macrophage infiltration with orthotopic rat liver transplant rejection was studied in the ACI(RT1a) to the LEW(RT1(1)) rat combination, using immunohistochemical staining with several monoclonal antibodies at different time points. LEW recipients of ACI liver transplants experienced severe acute rejection, with a mean survival of 10.2 +/- 0.7 days. An indirect immunoperoxidase technique on cryostat sections of the liver grafts was used to determine the localization of macrophages infiltrating the grafts as defined by specific rat anti-macrophage monoclonal antibodies designated TRPM-3 and KI-M2R. In addition, the monoclonal antibodies MRC OX3 and MRC OX6 were used to detect the macrophages that expressed Ia antigens. MRC OX3 binds only with the host LEW Ia antigens, but MRC OX6 binds with both host LEW and donor ACI Ia antigens. OX3+ and OX6+ macrophages were seen in the periportal area of the hepatic allograft on Day 5; thereafter, the number of these cells increased in the periportal and pericentral areas as well as in the sinusoidal lumens. A large number of TRPM-3+ cells were also seen at the periportal area in the hepatic allograft on Day 5, whereas there was no increase in the number of KI-M2R+ cells. In addition, most of the infiltrating mononuclear cells were OX3+. These findings suggest that a large number of TRPM-3+ macrophages of recipient origin migrate into the hepatic allograft soon after transplantation. A progressive relative increase in host TRPM-3+ macrophages is a characteristic feature of ongoing first-set rejection in the rat hepatic allograft.

Intracerebral hemorrhage after transcatheter thrombolysis of non-occluding superior mesenteric artery thrombosis.

We performed transcatheter thrombolysis on a 64-year-old man with non-occluding superior mesenteric artery (SMA) thrombosis because his severe symptoms could not be controlled with medication. An enhanced computed tomography (CT) scan revealed intramural thrombosis in the SMA. We were concerned that the narrowing of the SMA lumen might progress to complete occlusion, resulting in a high likelihood of mortality. After dissolution of the SMA thrombosis, the original symptoms almost completely disappeared. However, intracranial hemorrhage occurred 8 hr after thrombolysis, requiring surgical intervention. Transcatheter thrombolysis is thought to be a useful treatment for SMA thrombosis, especially in elderly patients with a high operative risk; however, the possibility of intracerebral hemorrhage must be taken into consideration.