Extracranial-intracranial bypass for internal carotid/middle cerebral atherosclerotic steno-occlusive diseases in conjunction with carotid endarterectomy for contralateral cervical carotid stenosis: clinical results and cognitive performance

Clinical results as well as cognitive performances after extracranial to intracranial (EC-IC) bypass in conjunction with contralateral carotid endarterectomy (CEA) are poorly understood. Data from 14 patients who underwent unilateral EC-IC bypass for atherosclerotic internal carotid artery (ICA)/middle cerebral artery (MCA) steno-occlusive disease in conjunction with CEA for contralateral cervical carotid stenosis were retrospectively reviewed. Postoperative results were evaluated by MRI imagings. Nine patients also underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised (WMS-R) before and about 6 months after bilateral surgeries. Postoperative MRI follow-up (median, 8 months; interquartile range, 7–8 months) confirmed successful bypass in all patients, with no additional ischemic lesions on T2WI when compared with preoperative imaging. Further, MRA showed patent bypass and contralateral smooth patency at CEA portion in all patients. In the group rate analysis, all five postoperative NPE scores (Verbal IQ, Performance IQ, WMS-memory, WMS-attention, and Average scores of all those four scores) were improved relative to preoperative NPE scores. Performance IQ and Average score improvements were statistically significant. Clinical results after EC-IC bypass in conjunction with contralateral CEA were feasible. Based on the group rate analysis, we conclude that successful unilateral EC-IC bypass and contralateral carotid endarterectomy does not adversely affect postoperative cognitive function.     

Prognosis After Brain Metastasis from Differentiated Thyroid Carcinoma

Background

In patients with differentiated thyroid carcinoma (DTC), lung and bone metastasis sometimes occur. However, brain metastasis (BM) is extremely rare. Because most previous reports about BM from DTC included a relatively small number of cases, the clinical characteristics and outcomes of BM are still unclear.

Patients and methods

Between 1965 and 2013, among 961 patients who had died because of DTC, 24 patients were diagnosed with BM from DTC. One patient with BM from DTC is still alive. To identify the prognostic factors for longer survival after BM, the medical records of these 25 patients were retrospectively reviewed.

Results

The median age at BM diagnosis was 66 years. Typical symptoms associated with BM had appeared in 20 patients (80 %). The Karnofsky Performance Status (KPS) was good (≥70) in 10 patients and poor (≤60) in 15 patients. Seven patients had a single intracranial lesion of BM, 6 patients had 2 or 3 lesions, and 9 patients had 4 or more. Eleven patients did not receive any treatment for BM, and 14 patients underwent surgical resection, radiation therapy, or both. One-year and 5-year disease-specific survival rates were 28 and 10.6 %, respectively. Good KPS (≥70), small number of intracranial lesions (≤3), and treatment for BM were prognostic factors for long survival on univariate analysis (p < 0.05). On multivariate analysis, only treatment for BM was significant.

Conclusion

Treatment of BM from DTC is indicated in patients who have a good KPS and fewer intracranial lesions, and some of them may achieve long survival.

     

Coronary ostium occlusion by coronary cusp displacement in Williams syndrome

Williams syndrome is a contiguous gene deletion syndrome resulting from a heterozygous deletion on chromosome 7q11.23, and is characterized by distinctive facial features and supravalvular aortic stenosis (SVAS). This syndrome rarely presents unpredictable cardiac death, and yet, as illustrated in the present case, it is still not possible to predict it, even on close monitoring. We herein describe the case of a 6‐year‐old Japanese girl with Williams syndrome, who had sudden cardiac collapse due to cardiac infarction after pharyngitis. Cardiac failure followed a critical course that did not respond to catecholamine support or heart rest with extracardiac mechanical support. Although marked coronary stenosis was not present, the left coronary cusp abnormally adhered to the aortic wall, which may synergistically cause coronary ostium occlusion with SVAS. Altered hemodynamic state, even that caused by the common cold, may lead to critical myocardial events in Williams syndrome with SVAS.     

Spleen Tyrosine Kinase Modulates Fibrous Airway Obliteration and Associated Lymphoid Neogenesis After Transplantation

Chronic lung allograft dysfunction, the major cause of death following lung transplantation, usually manifests as irreversible airflow obstruction associated with obliterative bronchiolitis (OB), a lesion characterized by chronic inflammation, lymphoid neogenesis, fibroproliferation and small airway obliteration. Spleen tyrosine kinase (Syk), a tyrosine kinase that regulates B cell function and innate immunity, has been implicated in the pathogenesis of chronic inflammation and tissue repair. This study evaluated the role of Syk in development of OB, using an intrapulmonary tracheal transplant model of OB with the conditional Syk‐knockout Syk^flox/flox//rosa26‐CreER^T2 mice and a Syk‐selective inhibitor, GSK2230413. BALB/c trachea allografts were transplanted into Syk‐knockout (Syk^del/del) mice or wild‐type C57BL/6 recipients treated with GSK2230413. At day 28, histological analysis revealed that in the Syk^del/del and GSK2230413‐treated C57BL/6 recipients, the graft lumen remained open compared with allografts transplanted into Syk‐expressing (Syk^flox/flox) and placebo control–treated C57BL/6 recipients. Immunofluorescence showed lymphoid neogenesis with distinct B and T cell zones in control mice. In contrast, lymphoid neogenesis was absent and few B or T cells were found in Syk^del/del and GSK2230413‐treated mice. These observations suggest that inhibition of Syk may be a potential therapeutic strategy for the management of OB following lung transplantation.     

Validation study of arm positions for evaluation of global spinal balance in EOS imaging

Background

The sagittal vertical axis (SVA) is important in the evaluation of spinal sagittal balance. Although the “fists-on-clavicles” (FOC) position has been widely used in radiographic examinations, it does not define shoulder flexion in detail. Meanwhile, in EOS imaging, the “hands-on-cheeks” (HOC) position is widely used but has not been well investigated. The purpose of this study was to investigate the relative usefulness of FOC and HOC in investigating SVA.

Materials and methods

Mean SVA was measured by EOS imaging using standing lateral radiographs of 34 volunteers in four different positions: relaxed (RLX), shoulder flexion at 90° with FOC (FOC90), elbows touching the trunk with FOC (FOCET), and HOC.

Results

The mean SVA was 2.0 ± 2.1 cm in RLX; ?1.4 ± 3.2 cm in FOC90; ?0.5 ± 3.0 cm in FOCET; and ?0.2 ± 2.9 cm in HOC. The negative shift from RLX was significantly greater in FOC90 than in FOCET (?3.4 ± 2.2 vs ?2.5 ± 2.4 cm; p = 0.0182). The negative shift from RLX in HOC was almost equal to that in FOCET; the difference was 0.3 cm (?2.2 ± 2.2 vs ?2.5 ± 2.4 cm; p = 0.2560).

Conclusion

FOC90 showed a negative SVA shift in comparison with FOCET. The difference in the mean SVA between HOC and FOCET was 0.3 cm, a clinically small difference.