Atsuo Masago

Pituitary apoplexy after pituitary function test: A report of two cases and review of the literature.

BACKGROUND Although most of pituitary apoplexy occur spontaneously, some precipitating factors have been reported. We experienced two cases of pituitary apoplexy after a pituitary function test. METHODS In order to clarify the causal relation between the pituitary function test and apoplexy, we presented our two cases and reviewed 20 cases in the literature. RESULTS (Case 1) A 48-year-old man with a pituitary macroadenoma received an injection of 500 micrograms thyrotropin-releasing hormone (TRH), 100 micrograms gonadotropin-releasing hormone (GnRH), and 0.1U/kg insulin as a preoperative test of pituitary function. Fifteen minutes later, he complained of diminished vision and headache. (Case 2) A 54-year-old man with a large cystic adenoma had an administration of 500 micrograms TRH and 100 micrograms GnRH. Ten minutes later, he complained of blurring of his left eye and headache. Although, in both cases, CT scans showed neither intratumoral hemorrhage nor infarction, the surgical specimen showed necrotic and hemorrhagic adenoma. The patients made excellent clinical recoveries after surgical decompression. Twenty-two reports including our two cases were reviewed. In 15 cases (68%), TRH was associated with apoplectic events and seemed to be the agent most likely to have an etiologic role because of its vasoactive properties. Eighteen patients (82%) had pituitary macroadenomas with suprasellar extension. In 72% of 18 surgical cases, some recovery of visual function was obtained. CONCLUSIONS An apparent relationship between the test and the apoplectic events raises the possibility of the development of pituitary apoplexy after a pituitary function test. Unless there is a specific indication, pituitary function test should be avoided especially in patients with a large pituitary tumor.

Subarachnoid hemorrhage induces c-fos, c-jun and hsp70 mRNA expression in rat brain

TO detect stress responses of the brain to subarachnoid hemorrhage (SAH), we investigated the expression of immediate early genes (IEGs) and hsp70 mRNA by in situ hybridization. Experimental SAH was produced in 49 rats by endovascular penetration. We also monitored the intracranial pressure (ICP) changes. The genes c-fos and c-jun were induced in the cerebral cortex, hippocampus and dentate gyrus in the penetrated side. mRNA coding for hsp70 was induced in the cerebral cortex, hippocampus, thalamus, hypothalamus and caudoputamen in the penetrated side and extended to the contralateral hemisphere. IEGs in the cerebral cortex were completely blocked by MK-801 pretreatment, but hsp70 mRNA was not. This suggests that the expression of IEGs correlates with spreading depression. The IEGs and hsp70 expression may reflect the severity of SAH impact and relate to the mechanisms of symptomatic vasospasm.

Significance of the Hemorrhagic Site for Recurrent Bleeding: Prespecified Analysis in the Japan Adult Moyamoya Trial

Background and Purpose— The primary results of the Japan Adult Moyamoya Trial revealed the statistically marginal superiority of bypass surgery over medical treatment alone in preventing rebleeding in moyamoya disease. The purpose of this analysis is to test the prespecified subgroup hypothesis that the natural course and surgical effects vary depending on the hemorrhagic site at onset. Methods— The hemorrhagic site, classified as either anterior or posterior, was the only stratifying variable for randomization. Statistical analyses were focused on the assessment of effect modification according to the hemorrhagic site and were based on tests of interaction. Results— Of 42 surgically treated patients, 24 were classified as anterior hemorrhage and 18 as posterior hemorrhage; of 38 medically treated patients, 21 were classified as anterior and 17 as posterior. The hazard ratio of the primary end points (all adverse events) for the surgical group relative to the nonsurgical group was 0.07 (95% confidence interval, 0.01–0.55) for the posterior group, as compared with 1.62 (95% confidence interval, 0.39–6.79) for the anterior group (P=0.013 for interaction). Analysis within the nonsurgical group revealed that the incidence of the primary end point was significantly higher in the posterior group than in the anterior group (17.1% per year versus 3.0% per year; hazard ratio, 5.83; 95% confidence interval, 1.60–21.27). Conclusions— Careful interpretation of the results suggests that patients with posterior hemorrhage are at higher risk of rebleeding and accrue greater benefit from surgery, subject to verification in further studies. Clinical Trial Registration— URL: http://www.umin.ac.jp/ctr/index.htm. Unique identifier: C000000166.

Differential induction of immediate early gene mRNAs following cryogenic and impact trauma with/without craniotomy in rats

Expression of immediate early gene (IEG) mRNAs following traumatic brain injury in 3 different models-cryogenic injury, impact injury with craniotomy and impact injury without craniotomy-was investigated using in situ hybridization. Cryogenic brain injury resulted in c-fos and c-jun mRNA expression throughout the ipsilateral cortex, piriform cortex and dentate gyrus on the injured side, with peak at 30 min to 1 h post-injury. Impact injury with craniotomy was associated with hybridization signals in the same areas and also in the subcortical white matter or ependyma underlying the impact site at 30 min post-injury. The expression was rather more prolonged than with cryogenic injury. Impact injury without craniotomy induced the expression of both mRNAs throughout the ipsilateral cortex, piriform cortex and dentate gyrus at 30 min post-injury, but this was promptly attenuated by 1 h post-injury, except for bilateral elevation in the dentate gyrus. The present study, thus, demonstrated that regional and temporal expression of IEG mRNAs is influenced by the intensity, quality and manner of application of the insult. Differences in the expression of IEGs may alter the late response gene expression and affect the succeeding events.

Traumatic injury in vitro induces IEG mRNAs in cultured glial cells, suppressed by co-culture with neurons.

Glial changes following traumatic injury to glial monolayers as well as to neuronal-glial co-culture systems in vitro were examined with a focus on the expression of mRNAs coding for the immediate early genes (IEG) c-fos, c-jun and zif/268, demonstrated using in situ hybridization. Glial cells along scratch wound lines extended cytoplasmic processes as early as 10 min post-injury and the whole wound was covered with gliosis by 24 h. For complete restoration in the case of glial cells co-cultured with neurons, this required 48 h. Induction of the three IEG mRNAs was eminent along the edges of scratch wound, peaking at 30-60 min post-injury and subsiding by 3 h. The peak expression of IEG mRNAs was delayed to 1-3 h post-injury and became undetectable at 6 h in neuronal-glial co-cultures. The data suggest that mechanical injury to glial cells causes gliosis and the expression of IEG mRNAs, which are suppressed by co-culture with neurons, indicating some influence of neuronal-glial interactions.

p53-independent transient p21(WAF1/CIP1) mRNA induction in the rat brain following experimental traumatic injury.

The expression of the cyclin-dependent kinase inhibitor p21WAF1/CIP1 mRNA after traumatic brain injury in rats was investigated using an in situ hybridization technique, along with regulating gene p53 and stress response gene hsp70 mRNA levels. At 3h postinjury, p21WAF1/CIP1 mRNA was markedly increased in the cortex, white matter, thalamus, CA2, a part of CA1,3 and dentate gyrus of the injured side. Hybridization signals remained elevated at 6 h in injured cortex and hippocampus and returned to the baseline by 24 h post-insult. On the other hand, p53 mRNA induction was not observed in any brain sections throughout the post-injury time course. Slight expression of hsp70 mRNA was detected in the injured cortex 3-6 h following injury and this was similar to the temporary pattern of p21WAF1/CIP1 mRNA expression. This study showed p21WAF1/CIP1 mRNA to be transiently induced after traumatic brain injury, independent of p53, this possibly being an early stress response to protect cells by arresting them in the cycle and allow DNA repair.

GLAST mRNA expression in the periventricular area of experimental hydrocephalus

Glutamate transporters play an important role in maintaining the extracellular glutamate concentration below the neurotoxic level. We investigated the expression of glutamate/aspartate transporter (GLAST) mRNA in the periventricular region of rats with kaolin-induced hydrocephalus by in situ hybridization (ISH). The density of GLAST mRNA-positive cells and the level of hybridization signals per positive cell significantly increased in the acute stage of hydrocephalus. We also demonstrated co-localization of GLAST mRNA and GFAP immunoreactivity in a single cell using the combined methods of ISH and immunohistochemistry. These findings suggest that GLAST is expressed in the reactive astrocytes of the periventricular area and regulates extracellular glutamate concentration after hydrocephalic brain injury.

A metabotropic glutamate receptor antagonist, α-methyl-4-carboxyphenylglycine, attenuates immediate early gene mRNA expression following traumatic injury in cultured rat cortical glial cells

The effects of three glutamate receptor antagonists, (5R,10S)-(+)-5-methyl-10,11-dihydro-5H-dibenzo[a,d]-cyclohepten-5,10-imine hydrogen maleate (MK-801) for the N-methyl-D-aspartate receptor, 1,2,3,4-tetrahydro-6-nitro-2,3-dioxo-benzo[f] quinoxaline-7-sulfonamide (NBQX) for the alpha-amino-3-hydroxy-5methyl-4-isoxazole propionate /kinate receptor and (S)-alpha-methyl-4-carboxyphenylglycine (MCPG) for the metabotropic receptor, on c-fos and c-jun mRNA expression were investigated in cultured cortical glial cells following traumatic scratch injury. Expression of the two genes along the edges of wounds detected by in situ hybridization was not affected by MK-801 and NBQX. However, 100 and 500 microM of MCPG remarkably reduced the hybridization signals for both c-fos and c-jun mRNAs. The present results suggest that group I metabotropic glutamate receptors might have some association with immediate early gene induction after in vitro traumatic injury in glial cells.

Hemodynamic Flow Patterns Evaluated by Transcranial Color-Coded Duplex Sonography after STA-MCA Bypass for Internal Carotid Artery Occlusion

Extracranial-intracranial (EC-IC) bypass surgery had been widely performed for the treatment of internal carotid artery occlusion. However, it is presently difficult to predict how the bypass flow will contribute to intracranial circulation. We examined intracranial hemodynamics by transcranial color-coded duplex sonography (TCCD) after superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and retrospectively studied the relationship between the postoperative contribution of the bypass flow and the preoperative collateral circulation and cerebrovascular perfusion status in 10 patients. Hemodynamics in the MCA detected by TCCD were classified into three patterns. In pattern A, perfusion of the whole MCA area is completely dependent on the bypass flow. In pattern B, perfusion of the M2 segment is dependent on the bypass flow, but perfusion of the M1 segment is independent of the bypass flow. In pattern C, perfusion of the whole MCA area is supplied by collateral flow and the bypass does not function efficiently. Preoperative absence of collateral flow via anterior communicating artery and cerebral perfusion status type 3 (reduced regional cerebral blood flow and regional cerebral vasoreactivity) seems to predict hemodynamic usefulness of the bypass flow after surgery. TCCD is an easy and noninvasive method for evaluating intracranial cerebral circulation after EC-IC bypass surgery.

Marked alteration of c-fos and c-jun but not hsp70 messenger RNA expression in rat brain after cold-induced trauma: An in situ hybridization study.

Immediate early gene (IEG) mRNA induction by cryogenic injury was examined using an in situ hybridization approach and the results compared with the heat shock protein mRNA expression. Hybridization signals for c-fos and c-jun mRNA were found after 30 min in the ipsilateral cortex, the hippocampal dentate granule cells and the piriform cortex, c-jun mRNA was also detected in the contralateral dentate gyrus and the piriform cortex, but was less extensive. Return to baseline values was observed at the 24 h time point. Peak induction, with silver grains observed mainly over the neurons on emulsion autoradiograms, was demonstrated in all cases 30 min to 1 h post-injury. In contrast, only slight hsp70 mRNA expression by the neurons surrounding the cold-injured site could be detected by microautoradiography, at 6 h following the trauma. The results indicate that cryogenic brain injury induces IEGs in a similar way to mechanical modes of injury such as lateral fluid percussion, but that hsp70 mRNA is hardly expressed, implying the possible existence of differences in stress response pathways.