Role of coil embolization and arterial injection in elderly subarachnoid hemorrhage patients: preliminary report

With the recent advanced aging seen in society, the number of elderly patients with aneurismal subarachnoid hemorrhage (SAH) is increasing. We focused on current management of SAH in patients who were over 75 years old. From January 1st, 2004 to the end of June, 2007, we had treated 170 SAH patients including 39 who were over 75 years old. We divided the patients into three groups : Coiling Group, Clipping Group, and conservative treatment group (Conservative Group). We analyzed the Hunt-Kosnik grade (H-K), the rate of symptomatic vasospasm, the rate of shunting operation, the Glasgow Outcome Scale (GOS) at 30 days after the onset of SAH, bed rest periods and rate of shunt operation retrospectively. The Conservative Group included many H-K poor grade cases. Symptomatic vasospasm occurred significantly less in the Coiling Group. Rates of shunting operation did not have any significant change. GOS of the Coiling Group and Clipping Group had no significant change, due to the effectiveness of arterial injection for vasospasm. Patients in the Coiling Group started walking significantly earlier than members of other groups. Twenty-five percent of the Clipping Group needed a shunt operation but no patients of the Coiling Group needed a shunt. For elderly SAH patients, we recommend doing coil embolization or clipping and maintaining the patients' activity in daily life. Interventional treatment is necessary to improve results for elderly SAH patients.     

Bone Mineral Density Before and After Surgical Cure of Cushing’s Syndrome Due to Adrenocortical Adenoma: Prospective Study

Osteoporosis is a major complication of Cushing’s syndrome. The aim of the present study was to assess the chronologic effect of surgical cure on bone mineral density (BMD) in patients with Cushing’s syndrome due to adrenal adenoma. BMD was examined in 28 patients before laparoscopic adrenalectomy; 17 patients with reduced BMD were then included in the longitudinal evaluation. BMD was determined using dual energy X-ray absorptiometry (DXA) before and at 3, 6, 12, 18, and 24 months after adrenalectomy. The prevalence of osteoporosis was 64% (95% confidence interval 44–81%). Preoperative BMD of the lumbar spine in the lateral projection was significantly lower than that of the femoral neck (mean ± SD score: −3.53 ± 0.75 vs. −1.54 ± 0.22, p = 0.003). A significant increase in BMD was observed at 3 months after surgery in the lumbar spine (p = 0.0004). Improvement at both sites was maintained at 24 months after surgery. The postoperative percentage change in BMD of the lumbar spine was significantly higher than that of the femoral neck (mean ± SD 36.7% ± 26.5% vs. 11.2% ± 12.1%, p = 0.01). The change in the seven premenopausal patients was significantly higher than that in the three postmenopausal patients (p = 0.0006). Surgical cure of hypercortisolism provides significant improvement in BMD in patients with Cushing’s syndrome due to adrenal adenoma. The improvement is particularly apparent in the lumbar spine measured in the lateral projection. Premenopausal women are more likely to benefit from surgery in terms of secondary osteoporosis.     

Re-expansion pulmonary edema (RPE) during surgery for intraabdominal giant tumor

A 50-year-old woman with massive ovarian cancer underwent a tumor resection and lymph node resection. Oxygenation was impaired preoperatively and chest X-ray film and computed tomogram revealed an elevation of the two diaphragms and atelectasis of the lower parts of the lungs. Induction of anesthesia was uneventful. During the surgery, oxygenation was improved after laparotomy but deteriorated again about 90 minutes after the tumor resection. Just before the termination of the surgery, we found bubbly sputum coming out from the tracheal tube. We had her chest X-ray taken and found bilateral consolidation of the lower parts of the lungs with air-bronchogram and loss of diaphragm profiles. The diagnosis of RPE was made and she was, transferred to ICU without extubation. Evacuation of pneumothorax or pleural effusion is the most common cause of RPE; but, removal of the intraabdominal mass would provide a good chance for RPE. Although, slow expansion of the collapsed lungs to prevent RPE is recommended, this consideration may not always be warranted.     

Regeneration of the inferior vena cava with a bioabsorbable polymer implant: a histological study

BACKGROUND: Cell implantation into ischemic regions has recently been introduced as a novel strategy for therapeutic angiogenesis. Little is known, however, about the process of blood vessel regeneration, particularly that of the inferior vena cava (IVC). The indicators of normal angiogenesis are also unestablished. PURPOSE: To investigate the process of regeneration of the IVC from a histological viewpoint and to speculate on how the new formation and regeneration of the blood vessels proceed. MATERIALS AND METHODS: Our previous studies showed that a bioabsorbable polymer patch implanted into the IVC formed vessels resembling the native IVC (J Gastrointest Surg 2005;9:789). Using this model system, we investigated the histology and time course of IVC regeneration in the graft site. A 3 x 2 portion of infrahepatic IVC was substituted by a bioabsorbable polymer patch of the same size in hybrid pigs. The patched area was excised for histology at 2 weeks and 3, 6, and 12 months after implantation (n = 3, each). RESULTS: By 2 weeks, the patched area had developed vascular endothelial cells of the same type seen in native veins. The polymer implant was still detectable at 2 weeks but histologically absorbed at 3 months. Smooth muscle was barely formed at 2 weeks, but the ratio of smooth muscle to subendothelial connective tissue gradually increased as time advanced to 3, 6, and 12 months. Even at the last observation at 12 months, however, the amount of smooth muscle formed made up no more than one-half of the native IVC. The case with the elastic fibers accounted for about 90% of the total number of native fibers at 12 months. On gross examination, the patched area resembled the native IVC at 3 months after implantation. CONCLUSION: These results demonstrated that the subendothelial tissue regenerated gradually, requiring more than 1 year to resemble native tissue, whereas the vascular endothelium regenerated in the early phase after injury. Our findings make it possible to establish criteria by which to evaluate venous regeneration.     

Radiofrequency (RF)-Assisted Hepatectomy May Induce Severe Postoperative Liver Damage

Background Radiofrequency (RF) ablation for the treatment of the section line prior to liver resection has been proposed as a way to reduce blood loss during hepatectomy. Our group compared hepatectomy with and without RF ablation to determine whether this technique actually reduces blood loss during liver resection and whether it affects the perioperative outcome. Method Of 151 patients who underwent a hepatectomy between January 2002 and October 2005 at the Division of Gastrointestinal Surgery in the Department of Surgery of Saitama Medical University, 48 who had a partial hepatectomy or resection of a portion of liver smaller than a single Couinaud segment were included in the study. Twenty patients who had RF-assisted hepatectomy [RF (+) group] and 28 patients who had hepatectomy without ablation [RF (-) group] were studied to compare the rates of intraoperative blood loss and the effects of RF ablation on the perioperative outcome. Results Intraoperative blood loss was significantly reduced in the RF (+) group. In contrast, the alanine aminotransferase activity in the RF (+) group was significantly elevated immediately after the operation. There was no significant difference in the incidence of postoperative complications between the groups, although bile leakage did occur in three RF (+) patients. Conclusions Our results demonstrate that the RF ablation technique can be a useful way to reduce surgical blood loss. In view of its association with severe postoperative liver damage, the technique must be applied with caution. The danger may be especially relevant to patients with chronic liver disease and decreased liver reserve.     

Cavernous sinus dural arteriovenous fistula associated with the development of sphenoidal ridge meningioma--case report

A 76-year-old man presented with a cavernous sinus (CS) dural arteriovenous fistula (AVF) associated with the development of a meningioma without venous sinus occlusion. Initial digital subtraction angiography did not reveal the CS dural AVF, which appeared simultaneously with the enlargement of the meningioma and lead to right oculomotor nerve paresis. In this case, the development of meningioma possibly increased the vascular tumor bed and affected the venous hemodynamic return, thus leading to the dural AVF.     

Adrenal adrenaline- and noradrenaline-containing cells and celiac sympathetic ganglia are differentially controlled by centrally administered corticotropin-releasing factor and arginine-vasopressin in rats

The adrenal glands and sympathetic celiac ganglia are innervated mainly by the greater splanchnic nerves, which contain preganglionic sympathetic nerves that originated from the thoracic spinal cord. The adrenal medulla has two separate populations of chromaffin cells, adrenaline-containing cells (A-cells) and noradrenaline-containing cells (NA-cells), which have been shown to be differentially innervated by separate groups of the preganglionic sympathetic neurons. The present study was designed to characterize the centrally activating mechanisms of the adrenal A-cells, NA-cells and celiac sympathetic ganglia with expression of cFos (a marker for neural excitation), in regard to the brain prostanoids, in anesthetized rats. Intracerebroventricularly (i.c.v.) administered corticotropin-releasing factor (CRF) induced cFos expression in the adrenal A-cells, but not NA-cells, and celiac ganglia. On the other hand, i.c.v. administered arginine-vasopressin (AVP) resulted in cFos induction in both A-cells and NA-cells in the adrenal medulla, but not in the celiac ganglia. Intracerebroventricular pretreatment with indomethacin (an inhibitor of cyclooxygenase) abolished the CRF- and AVP-induced cFos expression in all regions described above. On the other hand, intracerebroventricular pretreatment with furegrelate (an inhibitor of thromboxane A2 synthase) abolished the CRF-induced cFos expression in the adrenal A-cells, but not in the celiac ganglia, and also abolished the AVP-induced cFos expression in both A-cells and NA-cells in the adrenal medulla. These results suggest that centrally administered CRF activates adrenal A-cells and celiac sympathetic ganglia by brain thromboxane A2-mediated and other prostanoid than thromboxane A2 (probably prostaglandin E2)-mediated mechanisms, respectively. On the other hand, centrally administered AVP activates adrenal A-cells and NA-cells by brain thromboxane A2-mediated mechanisms in rats.     

Aberrant Methylation of <Emphasis Type="Italic">IL-12Rβ2</Emphasis> Gene in Lung Adenocarcinoma Cells Is Associated with Unfavorable Prognosis

Background Interleukin-12 receptor β2 (IL-12Rβ2) knock-out mice develop lung adenocarcinoma, and epigenetic silencing by CpG methylation leads to loss of this gene in B-cell malignancies. The aim of this study was to determine whether IL-12Rβ2 methylation is a common feature in human lung cancer. Methods We examined mRNA expression of IL-12Rβ2 in lung cancer cell lines, and normal bronchial, and tracheal epithelial cells using RT-PCR, and we examined the methylation status of IL-12Rβ2 in primary lung cancers. Results Loss of expression was found in 10 of 13 (77%) NSCLC cell lines, and 2 of 5 (40%) SCLC cell lines compared with normal bronchial or tracheal cells. Treatment of 11 expression-negative cell lines with a demethylating agent restored expression in all cases. Aberrant methylation status of IL-12Rβ2 gene was reversely concordant with its mRNA expression. IL-12Rβ2 methylation was detected in 96 of 230 primary NSCLCs (42%) and 3 of 6 primary SCLCs (50%). IL-12Rβ2 methylation correlated with poorer prognosis in lung adenocarcinomas (hazard ratio = 2.33, P = 0.0059). Conclusions We conclude that epigenetic silencing of IL-12Rβ2 is a frequent event in lung cancers. Aberrant methylation of this gene seems to be a useful predictor of long-term outcome for adenocarcinoma of the lung.