Hiroshi Sakaida

Novel scoring system and algorithm for classifying chronic rhinosinusitis: the JESREC Study.

Chronic rhinosinusitis (CRS) can be classified into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). CRSwNP displays more intense eosinophilic infiltration and the presence of Th2 cytokines. Mucosal eosinophilia is associated with more severe symptoms and often requires multiple surgeries because of recurrence; however, even in eosinophilic CRS (ECRS), clinical course is variable. In this study, we wanted to set objective clinical criteria for the diagnosis of refractory CRS.

Neuroradiological examination of thoracic radiculo-myelopathy due to ossification of the ligamentum flavum

SummarySixteen cases of thoracic radiculomyelopathy due to ossification of the ligamentum flavum (OLF) were analyzed. The patients ranged in age from 39 to 78 years (average 57 years). There were 13 men and 3 women. A significant predilection of OLF for the lower thoracic spine (T9/10, T10/11, T11/12) was noticed. Plain X-ray of the thoracic spine and multidirectional tomography could give important information about the site of ossification. Computed tomography with the intrathecal injection of the water-soluble contrast material clearly demonstrated the ossification and the degree of compression of the spinal cord. The disadvantages of using computed tomography for diagnosing OLF included the necessity for the scan level to be previously decided by other methods because computed tomography of the entire spine was impractical. Magnetic resonance imaging was performed in 14 patients and gave important information about OLF and the compression of the spinal cord. The combination of MRI and computed tomography seems the most useful for the precise diagnosis of OLF.

Determinants of Poor Outcome After Aneurysmal Subarachnoid Hemorrhage when both Clipping and Coiling Are Available: Prospective Registry of Subarachnoid Aneurysms Treatment (PRESAT) in Japan

OBJECTIVE To examine current determinants of poor outcome after aneurysmal subarachnoid hemorrhage (SAH) when ruptured aneurysms are treated with either microsurgery (clipping) or endovascular treatment (coiling) depending on each patients characteristics. METHODS Between March 2006 and February 2007, 534 patients with SAH were enrolled in the Prospective Registry of Subarachnoid Aneurysms Treatment (PRESAT) project. Patients were treated according to the preference of investigators who were experienced in performing both clipping and coiling. Factors influencing poor outcome (12-month modified Rankin Scale [mRS], 3-6) were determined using multivariate logistic regression analyses. RESULTS In this cohort, 32.4% of patients were World Federation of Neurosurgical Societies (WFNS) grade IV-V, and 28.1% had a poor outcome. Clipping was preferably performed for small aneurysms with a wide neck and for middle cerebral artery (MCA) aneurysms, whereas coiling was preferred for larger, internal carotid artery (ICA) and posterior circulation aneurysms. In addition to increasing age, admission WFNS grade IV-V, preadmission aneurysmal rerupture, vasospasm-induced cerebral infarct, pneumonia, sepsis, shunt-dependent hydrocephalus and seizure, postclipping hemorrhagic complications (odds ratio 4.8, 95% confidence interval 1.5-15.3, P < 0.01), and postcoiling ischemic complications (odds ratio 4.4, 95% confidence interval 1.3-15.2, P < 0.05) significantly caused poor outcomes, although the complications did not affect mortality. Type of treatment modality and size and location of aneurysms did not influence outcome. CONCLUSIONS Introducing an endovascular treatment option has made aneurysm characteristics less important to outcome, but procedural complications are problematic and should be reduced to improve outcome.

Inflammatory Biomarkers in Atherosclerosis: Pentraxin 3 Can Become a Novel Marker of Plaque Vulnerability

Inflammation is crucially involved in the development of carotid plaques. We examined the relationship between plaque vulnerability and inflammatory biomarkers using intraoperative blood and tissue specimens. We examined 58 patients with carotid stenosis. Following carotid plaque magnetic resonance imaging, 41 patients underwent carotid artery stenting (CAS) and 17 underwent carotid endarterectomy (CEA). Blood samples were obtained from the femoral artery (systemic) and common carotid artery immediately before and after CAS (local). Seventeen resected CEA tissue samples were embedded in paraffin, and histopathological and immunohistochemical analyses for IL-6, IL-10, E-selectin, adiponectin, and pentraxin 3 (PTX3) were performed. Serum levels of IL-6, IL-1β, IL-10, TNFα, E-selectin, VCAM-1, adiponectin, hs-CRP, and PTX3 were measured by multiplex bead array system and ELISA. CAS-treated patients were classified as stable plaques (n = 21) and vulnerable plaques (n = 20). The vulnerable group showed upregulation of the proinflammatory cytokines (IL-6 and TNFα), endothelial activation markers (E-selectin and VCAM-1), and inflammation markers (hs-CRP and PTX3) and downregulation of the anti-inflammatory markers (adiponectin and IL-10). PTX3 levels in both systemic and intracarotid samples before and after CAS were higher in the vulnerable group than in the stable group. Immunohistochemical analysis demonstrated that IL-6 was localized to inflammatory cells in the vulnerable plaques, and PTX3 was observed in the endothelial and perivascular cells. Our findings reveal that carotid plaque vulnerability is modulated by the upregulation and downregulation of proinflammatory and anti-inflammatory factors, respectively. PTX3 may thus be a potential predictive marker of plaque vulnerability.

Periprocedural hemodynamic instability with carotid angioplasty and stenting

BACKGROUND Carotid angioplasty and stenting is used for treatment of carotid stenosis. Stent deployment may induce HDI and thereby cause systemic or neurologic deficits. This study defines characteristics and predictors of HDI with CAS. METHODS A total of 132 patients who had undergone CAS were evaluated for periprocedural and postprocedural HDI (hypertension, systolic blood pressure >160 mm Hg; hypotension, systolic blood pressure <90 mm Hg; or bradycardia, heart rate <60 beats per minute). RESULTS Frequencies of HDI were 6.8% for hypertension, 32.6% for hypotension, and 15.9% for bradycardia. In addition, CAS of the right side (P < .01), carotid bulb lesions (P < .05), eccentric posterior carotid plaque (P < .0001), and general anesthesia (P < .05) were associated significantly with postprocedural HDI. Male sex (OR, 3.4; 95% CI, 1.8-67.2; P < .001), age of 80 years or older (OR, 0.4; 95%CI, 0.1-1.4; P = .011), and plaque ulceration (OR, 0.5; 95% CI, 0.1-9.5; P = .008) independently predicted postprocedural hypertension. Male sex (OR, 2.5; 95% CI, 1.3-24.9; P < .001), preprocedural major stroke (OR, 0.1; 95% CI, 0.01-0.8; P = .002), carotid bulb lesions (OR, 1.6; 95% CI, 1.1-25.9; P = .024), and contralateral carotid occlusion (OR, 0.6; 95% CI, 0.2-4.9; P = .040) all predicted postprocedural hypotension. Bradycardia was associated with diabetes mellitus (OR, 0.7; 95% CI, 0.3-2.4; P = .033), preprocedural TIA (OR, 1.7; 95% CI, 1.4-17.9; P = .020), and minor stroke (OR, 1.5; 95% CI, 1-10.9; P = .037). In 5 patients, HDI predisposed neurologic or systemic deterioration. CONCLUSIONS Hemodynamic instability is common with CAS; hypotension and bradycardia are more frequent than hypertension. Some clinical, angiographic, and procedural variables can predict these HD changes.

Thoracic spinal angiomyolipoma with extracanal extension to the thoracic cavity : A case report

Study Design. Case report and review of the literature. Objective. To describe a 72‐year‐old man with thoracic spinal angiomyolipoma in the ventral aspect of the epidural space and extracanal extension to the posterior mediastinum, to discuss the clinical and radiologic features and unique biologic behavior of this entity, and to review of the literature on angiolipoma and angiomyolipoma. Summary of Background Data. Spinal angiolipoma and angiomyolipoma are rare tumors, which are localized almost exclusively in the dorsal epidural space of the thoracic spine. Most reported cases have no tendency to involve the surrounding tissue. Methods. The authors describe the radiologic, surgical, and pathologic findings of this patient and review the findings from other reported cases. Results. Anterior decompression was performed using a right transthoracic incision, and the neurologic symptoms improved immediately. There were no signs of recurrence of the tumor or neurologic deficit within a 2‐year follow‐up period. Conclusion. Results of a literature survey of these tumors support management by prompt and radical surgical intervention for long‐term cure, even in cases in which the infiltrating nature is recognized.

Endovascular management of vertebral artery dissecting aneurysms: review of 25 patients.

AIM Management of Vertebral Artery (VA) dissections remains controversial. The clinical and angiographic variables of VA dissections were evaluated to demonstrate the safety and efficacy of endovascular intervention in treatment of VA dissecting aneurysms. MATERIAL AND METHODS 25 patients with 27 VAdissecting aneurysms were treated with endovascular intervention during the last 10 years.17 patients were admitted with subarachnoid hemorrhage. 23 aneurysms treated using destructive endovascular trapping, while reconstructive techniques were used in 3 aneurysms treated with stent-assisted coiling and one aneurysm treated with false lumen embolization. RESULTS The right VA was involved in 14 patients, the left VA in 9 patients, while 2 patients had bilateral VA dissection. The pearl and string sign was the commonest angiographic sign in 12 aneurysms. Perioperative complications included; rebleeding in one patient, symptomatic brain stem infarction in two patients and silent cerebellar ischemic lesion in one patient. Afavorable outcome was evident more in patients with unruptured VA dissection (100%) versus (76.5%) in patients presented with SAH. CONCLUSION The endovascular technique should be individualized according to the clinical status of the patient, angiographic variables, condition of the posterior circulation and the available supplies.

High-Risk Plaque for Carotid Artery Stenting Evaluated With 3-Dimensional T1-Weighted Gradient Echo Sequence

Background and Purpose— Preventing cerebral embolisms is a major concern with carotid artery stenting (CAS). This study evaluated 3-dimensional T1-weighted gradient echo (3D T1GRE) sequence to predict cerebral embolism related to CAS. Methods— We performed quantitative analyses of the characteristics of 47 carotid plaques before CAS by measuring the signal intensity ratio (SIR) and plaque volume using 3D T1GRE images. We used T1-weighted turbo field echo sequence to obtain 3D T1GRE images. We also evaluated diffusion-weighted images (DWI) of the brain before and after CAS to detect ischemic lesions (DWI lesions) from cerebral emboli. Results— SIR (2.17 [interquartile range 1.50–3.07] versus 1.35 [interquartile range 1.08–1.97]; P=0.010) and plaque volume (456 mm3 [interquartile range 256–696] versus 301 mm3 [interquartile range 126–433]; P=0.008) were significantly higher in the group of patients positive for DWI lesions (P-group: n=26) than DWI lesion-negative patients (N-group: n=21). In multivariate logistic regression analysis, SIR (P=0.007) and plaque volume (P=0.042) were independent predictors of DWI lesions with CAS. Furthermore, SIR (rs=0.42, P=0.005) and plaque volume (rs=0.36, P=0.012) were positively correlated with the number of DWI lesions. From analysis of a receiver-operating characteristic curve, the most reliable cutoff values of SIR and plaque volume to predict DWI lesions related to CAS were 1.80 and 373 mm3, respectively. Conclusions— Quantitative evaluation of carotid plaques using 3D T1GRE images may be useful in predicting cerebral embolism related to CAS.

Squamous cell carcinoma of the nasolacrimal duct

Tumors originating from the nasolacrimal duct are exceedingly rare. Only a few cases have been reported previously. In advanced cases with extended tumor, differential diagnosis from lacrimal sac tumor is difficult. A 68-year-old Japanese man with intractable dacryocystitis was examined with intranasal endoscopy, computed tomography (CT) and magnetic resonance imaging (MRI). Squamous cell carcinoma extended from a medial site in the left orbit to the lacrimal orifice. En bloc resection was performed and histopathological examination of the surgical specimen using serial section suggested that the origin of the tumor was located in the nasolacrimal duct. This is the first case in nasolacrimal duct carcinoma whose differential diagnosis of origin has been studied in detail. We showed that pathological study using serial section along the duct provides useful information for diagnosing the tumor origin in addition to that obtained from imaging studies.

Measurement of Japanese Cedar Pollen-Specific IgE in Nasal Secretions

BACKGROUND Japanese cedar pollen (JCP) is the most common allergen for seasonal allergic rhinitis in Japan. Little is known about local production of immunoglobulin (Ig)E in people with or without Japanese cedar pollinosis. The aims of this study were to measure levels of JCP-specific IgE in nasal secretions and determine correlations with levels in serum. METHODS Forty-six subjects were enrolled in this study, comprising 24 symptomatic subjects, 9 asymptomatic subjects sensitized to JCP, and 13 subjects not sensitized to JCP. Nasal secretions were obtained during a period of Japanese cedar dispersal, and levels of JCP-specific IgE were measured with CAP-fluorescent enzyme immunoassay. Serum JCP-specific IgE and total IgE were also measured using the same method. RESULTS Among the 46 subjects enrolled, JCP-specific IgE in nasal secretions was measureable in 43 subjects. Irrespective of symptom development, sensitized subjects showed higher levels of JCP-specific IgE in nasal secretions than non-sensitized subjects. A significant moderate correlation was observed between JCP-specific IgE levels in nasal secretions and serum in all 43 subjects. With stratification by subject group, only symptomatic subjects showed a substantial correlation between JCP-specific IgE levels in nasal secretions and serum. CONCLUSIONS Our results imply a certain association between JCP-specific IgE in nasal secretions and sensitization of Japanese cedar pollinosis. Therefore, levels of allergen-specific IgE in nasal secretions can be used as an alternative diagnostic marker for allergic rhinitis patients.