A case of iatrogenic carotid artery dissection treated with radial artery graft

A case of iatrogenic intracranial artery dissection is reported. A 52-year-old female developed severe headache and nausea. Brain CT showed diffuse subarachnoid hemorrhage. On admission, carotid angiography revealed an aneurysm in the right middle cerebral artery and the intact right internal carotid artery. The aneurysm was clipped successfully. Carotid angiography on day 7 revealed dissection in the right internal carotid artery. Repeated angiograms at 10 and 31 days showed progression of the carotid artery dissection. Findings of ECD-SPECT on day 31 (Balloon occlusion test) suggested low perfusion of the right internal carotid artery territory. The patient underwent surgical reconstruction of the right internal carotid artery using a radial artery. She presented with right abducens nerve palsy three days after the radial artery graft. The patency of the radial artery graft was proved by the post-operative angiography. Internal carotid artery dissection may occur spontaneously or as a result of trauma. An iatrogenic dissection is an uncommon complication of cerebral angiography. There are no evidence-based guidelines for the treatment although anticoagulation therapy is most commonly used. The present case emphasizes the usefulness of radial artery graft for traumatic carotid artery dissection.     

Failure of low-dose radiosurgery to control temporal lobe epilepsy.

Radiosurgical treatment of intractable epilepsy has emerged as a noninvasive alternative to resection. Although gamma knife surgery (GKS) reportedly is effective when the radiation dose is sufficient to cause a destructive reaction in the targeted medial temporal lobe, the optimal target area and dose distribution are largely unknown. Some investigators have suggested that focused irradiation from a nondestructive dose is also effective. In this article the authors report two cases of medial temporal lobe epilepsy in which the patients underwent GKS performed using a 50% marginal dose of 18 Gy covering the amygdala. hippocampal head and body, and parahippocampal gyrus. In both cases this procedure failed to control seizures. Both patients became seizure free after undergoing anterior temporal lobectomy 30 and 16 months, respectively, after radiosurgery.     

Mitral Regurgitation After Partial Left Ventriculectomy As the Cause of Ventricular Redilatation

BACKGROUND: It remains unclear whether ventricular redilatation after partial left ventriculectomy (PLV) is due to underlying pathology or to continued volume overload amenable to surgery. METHODS: Among patients undergoing PLV, 32 had Doppler echocardiography preoperatively, immediately after surgery (< 1 week), early after surgery (1-3 months), and late after surgery (8-14 months). Patients were divided into groups with mitral regurgitation (MR; MR+, n = 16) and without postoperative MR (MR-, n = 16) and were compared for ventricular size, performance, and survival. RESULTS: After initial surgical reduction, left ventricular dimension on average gradually increased back to the preoperative level in subgroups of patients with valvular disease and cardiomyopathy and in all patients combined. Most patients showed drastically reduced left ventricular dimension early after PLV. In MR+ patients, dimension increased back to the preoperative level within 3 months after surgery, whereas the MR- group maintained reduced dimension throughout the first year in all patients combined and in a subgroup of patients with cardiomyopathy. Occurrence of significant MR after PLV appeared to be related to severity of fibrosis in excised myocardium but not to severity of preexisting MR, etiology, or performance of mitral valvuloplasty. CONCLUSIONS: Early postoperative MR, residual or new, appeared to play an important role in dictating early hemodynamics and late outcome in patients undergoing PLV. Results suggest an aggressive simultaneous approach to abolish MR. Causative role of myocardial fibrosis remains unclear and needs further study.     

Spatial and temporal collagen gene expression in lumbar intertransverse fusion in the rabbit

We have examined the process of fusion of the intertransverse processes and bone graft in the rabbit by in situ hybridisation and evaluated the spatial and temporal expression of genes encoding pro-alpha1 (I) collagen (COL1A1), pro-alpha1 (II) collagen (COL2A1) and pro-alphal (X) collagen (COL10A1). Beginning at two weeks after operation, osteogenesis and chondrogenesis occurred around the transverse process and the grafted bone at the central portion of the area of the fusion mass. Osteoblasts and osteocytes at the newly-formed woven bone expressed COL1A1. At the cartilage, most chondrocytes expressed COL2A1 and some hypertrophic chondrocytes COL10A1. In some regions, co-expression of COL1A1 and COL2A1 was observed. At four weeks, such expressions for COLlA1, COL2A1 and COL10A1 became prominent at the area of the fusion mass. From four to six weeks, bone remodelling progressed from the area of the transverse processes towards the central zone. Osteoblasts lining the trabeculae expressed a strong signal for COL1A1. At the central portion of the area of the fusion mass, endochondral ossification progressed and chondrocytes expressed COL2A1 and COL10A1. Our findings show that the fusion process begins with the synthesis of collagens around the transverse processes and around the grafted bone independently. Various spatial and temporal osteogenic and chondrogenic responses, including intramembranous, endochondral and transchondroid bone formation, progress after bone grafting at the intertransverse processes. Bone formation through cartilage may play an important role in posterolateral spinal fusion.     

Continuous perfusion of pulmonary arteries during total cardiopulmonary bypass favorably affects levels of circulating adhesion molecules and lung function

OBJECTIVES: Lung injury is a serious complication of cardiopulmonary bypass in infants with congenital heart disease and pulmonary hypertension. Cessation of blood flow in the pulmonary arteries during cardiopulmonary bypass is known to provoke lung dysfunction. We assessed the effect of continuous pulmonary perfusion on circulating adhesion molecules and on lung function. METHODS: Fourteen infants with congenital heart disease and pulmonary hypertension were enrolled in the study. During total cardiopulmonary bypass, 8 patients underwent continuous perfusion of the pulmonary arteries (perfusion group), and the remaining 6 patients did not (control group). Plasma levels of circulating intercellular adhesion molecule 1, soluble granule membrane protein 140, and sialyl Lewis(x) and PaO (2)/fraction of inspired oxygen ratios were measured before commencement and serially for 24 hours after termination of bypass. RESULTS: Plasma levels of circulating intercellular adhesion molecule 1 decreased significantly at the termination of bypass in both groups but returned to prebypass levels immediately in the control group, whereas in the perfusion group the values remained significantly less than those before bypass. Plasma levels of soluble granule membrane protein 140 in the control group were significantly higher at 6 and 12 hours after bypass than levels before bypass, whereas in the perfusion group the values remained at the prebypass level throughout the postbypass period. Trends of plasma levels of sialyl Lewis(x) were alike in both groups. PaO (2)/fraction of inspired oxygen ratios in the control group decreased significantly from 6 hours after bypass, whereas values in the perfusion group remained at the prebypass value throughout the postbypass period. CONCLUSIONS: This study suggests that in infants having congenital heart disease and pulmonary hypertension, continuous pulmonary perfusion during total cardiopulmonary bypass minimizes ischemic insult and neutrophil-endothelial interaction mediated by adhesion molecules in the pulmonary microvessels.     

Cancer of the gastric tube reconstructed through the posterior mediastinal route after radical surgery for esophageal cancer

Among 750 patients diagnosed with esophageal carcinoma in our department between 1972 and 1997, we reviewed our 10 cases in which cancer occurred within gastric tubes reconstructed through the posterior mediastinal route after radical surgery for esophageal cancer. The interval between esophagectomy and cancer onset in the reconstructed gastric tube was relatively long (mean interval: 72 months). Five of our 10 subjects had gastric tube cancer detected at follow-up endoscopy. Four underwent total or partial gastric tube resection with open thoracotomy using colonic or jejunal reconstruction; 3 underwent endoscopic resection. To the best of our knowledge, this is the first report on patients undergoing total resection of gastric tubes reconstructed through the posterior mediastinal route after esophagectomy and rereconstruction using the pedicled colon for the gastric tube cancer.     

Formation of human fibroblast aggregates (spheroids) by rotational culture

In the current study, we attempted to form aggregates of fibroblasts by rotationally shaking, declining fibroblast-material interactions, and augmenting cell-cell interactions. In addition, to promote cell-cell interactions, the medium was supplemented with insulin, dexamethasone, and basic fibroblast growth. Under such improved culture conditions, normal neonatal human dermal fibroblasts formed spheroidal aggregates within 1 day of rotation on a rotational shaker. The aggregates that formed had irregular shapes and were composed from only several cells after 12 h. However, they became nearly spheroidal after 24 h of shaking. The aggregates were approximately 240 microm in diameter. After 36 h of shaking, their shape became more rounded and their surfaces became smoother. No evidence of necrosis in the center of the aggregates was observed, although a small number of dead cells was scattered throughout the aggregates. After 24-36 h, aggregates of normal human fibroblasts were collected and reinoculated onto a scaffold composed of polyglycolic acid. which is used commercially as a scaffold for artificial skin, coated with collagen. The aggregates were successfully trapped to the mesh of polyglycolic acid and became attached within 24 h. Therefore, the aggregates could provide an alternative method for seeding fibroblasts to scaffold for an artificial skin, such as a mesh of polyglycolic acid.     

The giant schwannoma in the pelvic cavity: a case report

A 62-year-old man presented with a giant tumor in the pelvic cavity that was incidentally revealed by abdominal ultrasonography. Abdominal magnetic resonance imaging showed the heterogenous tumor in the pelvis with cystic components. The tumor was 10.8 × 10.5 × 11.7 cm in diameter and adhered to the sacral wall. The tumor was extirpated following diagnosis as a benign neurogenic tumor by needle biopsy. The pelvic cavity was occupied by the tumor rigidly adhered to the sacrum. The histopathological diagnosis of the specimen was benign schwannoma, type Antoni A.     

Endoscopic submucosal dissection and preoperative assessment with endoscopic ultrasonography for the treatment of rectal carcinoid tumors

Background

Rectal carcinoid tumors 10 mm in diameter or smaller located within the submucosal layer can be cured by local excision including endoscopic treatment. But complete resection of these tumors with endoscopic polypectomy is difficult. This study aimed to evaluate the usefulness of endoscopic submucosal dissection (ESD) and endoscopic ultrasonography (EUS) for the treatment of rectal carcinoid tumors.

Methods

In this study, 22 rectal carcinoid tumors in 21 patients were evaluated with EUS and treated using ESD from January 2004 to December 2008.

Results

The mean size of the resected tumors was 6.1 mm (range, 2.0–10 mm) on histopathologic evaluations. When the sizes of the tumors shown by EUS and histopathologic evaluation were compared, the mean values were not significantly different. All the tumors were located within the submucosal layer, and the accuracy of the preoperative depth determination with EUS was 100% (22/22). The mean duration of the ESD procedure was 37 min (range, 20–71 min). The overall rate of en bloc resection with ESD was 100% (22/22). Although postoperative bleeding occurred in two cases (9%), both cases were successfully managed by endoscopic hemostasis. No perforation or recurrence was observed during the mean follow-up period of 30 months (range, 7–66 months).

Conclusions

Endoscopic submucosal dissection and preoperative assessment with EUS are effective for treating rectal carcinoid tumors and enabling en bloc resection.     

Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for large superficial colorectal neoplasias including ileocecal lesions

Background

Large superficial neoplasias of the ileocecal region pose an increased degree of complexity for endoscopic resection. This study aimed to evaluate the safety and efficacy of endoscopic submucosal dissection (ESD) for large superficial colorectal neoplasias including ileocecal lesions.

Methods

A total of 33 superficial colorectal neoplasias, including eight neoplasias in the ileocecal region, were treated with ESD from December 2005 to April 2009. Therapeutic efficacy, complications, and follow-up results were retrospectively evaluated among three groups: ileocecal region, colon, and rectum.

Results

The mean size of all resected neoplasias was 35 ± 15 mm (range, 20–80 mm) and that of all resected specimens was 41 ± 15 mm (range, 23–82 mm). The mean procedural time was 121 ± 90 min (range, 22–420 min). The difference in mean values among the three groups was not significant. The overall rate of en bloc resection was 91% (30/33). Histopathologically, both the lateral and vertical margins in the specimens resected en bloc tested negative (30/30). The rate for en bloc resection in the ileocecal region did not differ significantly from that for the other two groups (p = 0.20 compared with the rate for the colon and p = 0.12 compared with the rate for the rectum). Complications such as perforation and postoperative bleeding did not occur in the ileocecal group. No recurrence was observed in any cases during the mean follow-up period of 20 ± 12 months (range, 4–44 months).

Conclusions

The ESD approach is safe and effective for treating large superficial neoplasias of the ileocecal region such as other colorectal neoplasias.