Ryosuke Matsuda

Cotransplantation of mouse embryonic stem cells and bone marrow stromal cells following spinal cord injury suppresses tumor development.

Embryonic stem (ES) cells are a potential source for treatment of spinal cord injury (SCI). Although one of the main problems of ES cell-based cell therapy is tumor formation, there is no ideal method to suppress tumor development. In this study, we examined whether transplantation with bone marrow stromal cells (BMSCs) prevented tumor formation in SCI model mice that received ES cell-derived grafts containing both undifferentiated ES cells and neural stem cells. Embryoid bodies (EBs) formed in 4-day hanging drop cultures were treated with retinoic acid (RA) at a low concentration of 5 × 10–9 M for 4 days, in order to allow some of the ES cells to remain in an undifferentiated state. RA-treated EBs were enzymatically digested into single cells and used as ES cell-derived graft cells. Mice transplanted with ES cell-derived graft cells alone developed tumors at the grafted site and behavioral improvement ceased after day 21. In contrast, no tumor development was observed in mice cotransplanted with BMSCs, which also showed sustained behavioral improvement. In vitro results demonstrated the disappearance of SSEA-1 expression in cytochemical examinations, as well as attenuated mRNA expressions of the undifferentiated markers Oct3/4, Utf1, Nanog, Sox2, and ERas by RT-PCR in RA-treated EBs cocultured with BMSCs. In addition, MAP2-immunopositive cells appeared in the EBs cocultured with BMSCs. Furthermore, the synthesis of NGF, GDNF, and BDNF was confirmed in cultured BMSCs, while immunohistochemical examinations demonstrated the survival of BMSCs and their maintained ability of neurotrophic factor production at the grafted site for up to 5 weeks after transplantation. These results suggest that BMSCs induce undifferentiated ES cells to differentiate into a neuronal lineage by neurotrophic factor production, resulting in suppression of tumor formation. Cotransplantation of BMSCs with ES cell-derived graft cells may be useful for preventing the development of ES cell-derived tumors.

Embryonic stem cells reduce liver fibrosis in CCl4-treated mice.

We transplanted undifferentiated embryonic stem (ES) cells into the spleens of carbon tetrachloride (CCl4)‐treated mice to determine their effects on liver fibrosis. Carbon tetrachloride at 0.5 ml/kg of body weight was injected intraperitoneally into C57BL/6 mice twice weekly for up to 20 weeks. Four weeks after the first injection, the mice were divided into two groups and those in group 1 received 1 × 105 ES cells genetically labelled with enhanced green fluorescent protein (GFP) in the spleens, while group 2 mice received 0.1 ml of phosphate‐buffered saline. In group 1, GFP‐immunopositive cells were retained and found in areas of fibrosis in the liver, and reduced liver fibrosis was observed as compared with group 2. Secondary transplantation of ES cells at 12 weeks after the initial transplantation enhanced the reduction in liver fibrosis. No teratoma formation or uncontrolled growth of ES cells in organs, including the liver and spleen, was observed in any of the mice. In the livers of group 1 mice, metalloproteinase 9‐immunopositive cells derived from ES cells as well as those from the recipient were observed. These cells were also found to be immunopositive for the hepatoblast marker Delta‐like (DlK‐1), a member of the DlK‐1 family of transmembrane proteins. These results suggest that ES‐based cell therapy is potentially useful for liver fibrosis treatment and that reduction in CCl4‐induced liver fibrosis by transplantation of ES cells may be related closely to the emergence of metalloproteinase‐producing hepatoblast‐like cells.

Involvement of the right inferior longitudinal fascicle in visual hemiagnosia: a brain stimulation mapping study.

Neural foundations underlying visual agnosia are poorly understood. The authors present the case of a patient who underwent awake surgery for a right basal temporooccipital low-grade glioma in which direct electrostimulation was used both at the cortical and subcortical level. Brain mapping over the inferior longitudinal fascicle generated contralateral visual hemiagnosia. These original findings are in agreement with recent tractography data that have confirmed the existence of an occipitotemporal pathway connecting occipital visual input to higher-level processing in temporal lobe structures. This is the first report of a true transient visual hemiagnosia elicited through electrostimulation, supporting the crucial role of inferior longitudinal fascicle in visual recognition.

Two-stage management for vertebral osteomyelitis and epidural abscess: technical note.

OBJECTIVE:The incidence of spinal infections has increased in recent years, and vertebral osteomyelitis and epidural abscess are issues of great concern for spine surgeons. We retrospectively reviewed our cases treated by two-stage management for vertebral osteomyelitis and epidural abscess. METHODS:The series consisted of nine patients (five men and four women); their ages ranged from 49 to 77 years (mean age, 60.6 yr). Coexisting medical conditions were diabetes mellitus in one case and long-term steroid intake in another. Myelopathy or radicular pain was caused by osteomyelitis and an epidural abscess in all patients. Cervical, thoracic, and lumbar osteomyelitis was detected in three, four, and two patients, respectively; epidural abscess was pyogenic in four patients, tuberculous in three, and unknown in two patients. Our surgical strategy involved anterior debridement or drainage and application of an external orthosis postoperatively during the first stage. After clinical control of the infection by using organism-specific intravenous antibiotics as far as possible, as confirmed by normal erythrocyte sedimentation rate and/or C-reactive protein, second stage surgery was performed. This included complete debridement of all necrotic bone and soft tissues, and stable reconstruction with or without instrumentation (six and three patients, respectively). RESULTS:The postoperative course was uneventful with relief of the symptoms after the second surgery. No evidence of recurrence or residual infection was observed in any patient, as shown by erythrocyte sedimentation rate and/or C-reactive protein levels during a follow-up period averaging 26.6 months (range, 2–56 mo). CONCLUSION:Without denying the efficacy of the single-stage surgery, two-stage management can be a reasonable alternative for carefully selected patients who have spinal infection.

Early Inhibition of Natriuresis Suppresses Symptomatic Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage

Background: Hyponatremia is a common complication occurring in one third of patients after subarachnoid hemorrhage (SAH). One mechanism that likely mediates the development of hyponatremia in SAH is cerebral salt wasting syndrome (CSWS), which induces natriuresis and reduces total blood volume, resulting in a risk of symptomatic vasospasm (SVS). The mineral corticoid fludrocortisone acetate enhances sodium reabsorption in the renal distal tubules and may help prevent post-SAH hyponatremia. However, management with fludrocortisone acetate is ineffective if hyponatremia is advanced, because CSWS and subsequent SVS develop rapidly. Therefore, an additional earlier marker is required to predict the development of hyponatremia for the initiation of immediate treatment in select patients. However, no conclusive evidence exists showing that hyponatremia influences the risk of SVS, and no standard treatment protocol exists for treating hyponatremia in patients with SAH. This study was undertaken to evaluate whether selective early treatment of hyponatremia prevents SVS in patients with increased urinary sodium excretion in the early phase following SAH. Methods: A total of 103 patients with aneurysmal SAH were managed for a postoperative electrolyte disorder after aneurysmal clipping or coil embolization. Between 2004 and 2007 (period 1), 54 patients started treatment to correct the electrolyte disorder after hyponatremia had occurred. Between 2007 and 2011 (period 2), 49 patients were prospectively subjected to sodium replacement treatment according to their daily sodium balance, and inhibition of natriuresis with fludrocortisone acetate was initiated just after an increase in urinary sodium excretion >300 mEq/day. The occurrence of hyponatremia, SVS, and outcomes were compared between the two periods. Results: Hyponatremia was observed in 14 patients (26%) in period 1 and 7 patients (14%) in period 2. The incidence of fludrocortisone acetate administration was significantly higher, and initiation of electrolyte correction was significantly earlier, in period 2 patients. We observed a significant difference in the frequency of SVS, which occurred in 10 patients (18.5%) in period 1 and 3 patients (6.1%) in period 2. Both urinary sodium excretion and urine volume at day 7 were significantly different between the two periods. However, no significant difference was observed in overall outcome between the two periods. Conclusions: Early inhibition of natriuresis with fludrocortisone acetate before the occurrence of hyponatremia prevented SVS after aneurysmal SAH. Increased urinary sodium excretion in the early phase of SAH is a good indicator for the initiation of electrolyte correction with fludrocortisone acetate.

Awake mapping for resection of cavernous angioma and surrounding gliosis in the left dominant hemisphere: surgical technique and functional results: Clinical article

OBJECT Maximal resection of symptomatic cavernous angioma (CA), including its surrounding gliosis if possible, has been recommended to minimize the risk of seizures or (re)bleeding. However, despite recent neurosurgical advances, such extensive CA removal is still a challenge in eloquent areas. The authors report a consecutive series of patients who underwent awake surgery for CA within the left dominant hemisphere in which intraoperative cortical-subcortical electrical stimulation was used. METHODS Nine patients harboring a CA that was revealed by seizures in 6 cases and bleeding in 3 cases underwent resection. All CAs were located in the left dominant hemisphere: 3 temporal, 2 insular, 2 parietal, and 2 in the parietotemporal region. Awake mapping was performed in all cases by using intraoperative cortical-subcortical electrical stimulation and ultrasonography (except in 1 insular CA in which a neuronavigation system was used). RESULTS Total removal of the CA was achieved in all patients, with identification and preservation of language and sensory-motor structures. In addition, the pericavernomatous gliosis was removed in 7 cases, according to the functional boundaries provided by intraoperative subcortical stimulation. In 2 cases, subcortical mapping revealed eloquent areas within the surrounding gliosis, which was voluntarily avoided. There was no postsurgical permanent deficit, no rebleeding, and no epilepsy in 7 cases (2 patients had rare seizures in the 1st year or two after surgery, and then complete arrest), with a mean follow-up of 28.5 months (range 3-64 months). CONCLUSIONS These results suggest that intraoperative cortical-subcortical stimulation in awake patients represents a valuable adjunct to image-guided surgery with the aim of selecting the safer surgical approach for CAs involving eloquent areas. Moreover, such online mapping can be helpful when removing the pericavernomatous gliosis while preserving functional structures, which can persist within the hemosiderin rim. Thus, the authors propose that awake surgery be routinely considered, both to optimize the resection and to improve the quality of life through seizure control and avoidance of (re)bleeding for CAs located in the left dominant hemisphere.

Treatment of Parkinson's disease model mice with allogeneic embryonic stem cells: necessity of immunosuppressive treatment for sustained improvement.

Abstract Objective: The purpose of the present study was to examine the efficacy of transplantation of mouse embryonic stem (ES) into Parkinsons disease (PD) model mice as well as the necessity of immunosuppression in allogeneic donor-host combinations. Materials and methods: ES cells, derived from SvJ129 strain mice, were differentiated into tyrosine hydroxylase (TH)-positive neurons in vitro by an embryoid body (EB)-based multistep differentiation method and used as graft cells for PD mice, which were prepared by injection of 6-hydroxydopamine (OHDA) into C57BL/6, BALB/c and C3H/HeN strains. Mice from each strain were divided into Groups 1–3. Four weeks after the 6-OHDA injection, Group 1 received phosphate-buffered saline in the striatum wounds, while Group 2 received 2 × 104 graft cells, and Group 3 mice received 2 × 104 graft cells and were also treated with cyclosporine A. Results: Apomorphine-induced rotational behavior was improved in Groups 2 and 3, but not in Group 1. However, the behavioral improvement ceased later in Group 2, whereas sustained improvement was observed in Group 3 throughout the 8 week observation period after transplantation. ES-derived TH+ cells were found at the grafted sites at the end of the experiment in Groups 2 and 3, and tended to be more abundant in Group 3. Conclusion: Intra-striatum transplantation of ES-derived dopaminergic neurons was effective in treating PD mice, even in allogeneic donor-host combinations. Immunosuppressive treatment did not have an effect on initial behavioral restoration after transplantation; however, it was necessary for sustained improvement over a prolonged period.

Delayed reconstruction by titanium mesh-bone graft composite in pyogenic spinal infection: a long-term follow-up study.

Objective: Use of instrumentation in spinal osteomyelitis remains controversial because of the perceived risk of persistent infection related to a devitalized graft and spinal hardware. Particularly, limited information is available regarding the long-term follow-up of patients. We retrospectively reviewed the use of titanium mesh-bone graft composite after corpectomy in pyogenic spinal infection with a minimum 3-year follow-up outcome. Methods: Four patients, two men and two women, with cervical and thoracic myelopathy caused by cervical (two cases) and thoracic (two cases) osteomyelitis and epidural abscess, were treated. Their age ranged from 49 to 74 years (mean age 58 years). In one case, the coexisting medical condition was diabetes. Neurologic deficits caused by direct spinal cord compression due to epidural abscess, segmental deformity, and instability were observed in all cases. After infection was clinically controlled by intravenous antibiotics, anterior debridement and fusion using titanium mesh cage along with anterior plate were performed. Two-stage treatment was performed in two cases. Results: The postoperative course was uneventful; all patients experienced relief of symptoms. No evidence of recurrence or residual infection was observed in any patient during the average follow-up period of 42-56 months (average 49.0 months). Conclusions: Once infection is clinically controlled, a titanium mesh-bone graft composite and plate in combination with aggressive debridement might provide an effective therapy for spinal osteomyelitis requiring surgery. Despite studying a small number of patients, we can conclude that titanium mesh reconstruction can be useful as a surgical method in selected low-risk patients with vertebral osteomyelitis.

Subarachnoid hemorrhage in a case of segmental arterial mediolysis with coexisting intracranial and intraabdominal aneurysms

The authors report the rare case of a 58-year-old man with segmental arterial mediolysis (SAM) with associated intracranial and intraabdominal aneurysms, who suffered subarachnoid hemorrhage (SAH) due to rupture of an intracranial aneurysm. This disease primarily involves the intraabdominal arterial system, resulting in intraabdominal and retroperitoneal hemorrhage in most cases. The patient presented with severe headache and vomiting. The CT scans of the head revealed SAH. Cerebral angiography revealed 3 aneurysms: 1 in the right distal anterior cerebral artery (ACA), 1 in the distal portion of the A(1) segment of the right ACA, and 1 in the left vertebral artery. The patient had a history of multiple intraabdominal aneurysms involving the splenic, gastroepiploic, gastroduodenal, and bilateral renal arteries. He underwent a right frontotemporal craniotomy and fibrin coating of the dissecting aneurysm in the distal portion of the A(1) segment of the right ACA, which was the cause of the hemorrhage. Follow-up revealed no significant changes in the residual intracranial and intraabdominal aneurysms. An SAH due to SAM with associated multiple intraabdominal aneurysms is extremely rare. The authors describe their particular case and review the literature pertaining to SAM with associated intracranial and intraabdominal aneurysms.

Rheumatoid arthritis-induced lateral atlantoaxial subluxation with multiple vertebrobasilar infarctions.

Study Design. Case report. Objective. To highlight the probability that lateral atlantoaxial subluxation (AAS) exists in patients with rheumatoid arthritis (RA) and induces vertebrobasilar infarctions that are more foregrounded than compressive myelopathy. Summary of Background Data. Although lateral subluxation is a well-known subtype of AAS, a case of cerebral ischemia associated with lateral AAS has not been reported before. Methods. A 52-year-old male with a 6-year history of RA had a sudden onset of visual field defect and mild right cerebellar ataxia. Head magnetic resonance imaging revealed acute multiple infarctions in the vertebrobasilar area, and magnetic resonance angiography revealed stenosis of the left vertebral artery (VA). Lateral radiograph of the cervical spine in the neutral position revealed atlanto-occipital assimilation and anterior AAS. T2-weighted sagittal images on cervical magnetic resonance imaging revealed high signal intensity in the spinal cord at C1–C2. Cerebral angiography revealed right VA occlusion and severe stenosis of the left V3 segment of VA. Three-dimensional computed tomography angiography of the craniovertebral junction revealed lateral AAS, which was due to severe erosive changes of the facet joints, and the left V3 portion was stenosed by a bony component. During conservative therapy, the patient experienced left occulomotor nerve palsy due to a second stroke. Results. Two months later, the patient underwent occipitocervical posterior fusion with an iliac bone graft. His postoperative course was uneventful, and the left VA stenosis disappeared. At the 45-month follow-up, he had no further infarctions. Bony fusion was radiologically confirmed, and 3-dimensional computed tomography angiography revealed good patency of the affected left VA. Conclusion. In patients with RA, the potential risk of AAS should be recognized. Lateral AAS in particular may induce cerebral ischemia by positional VA occlusion in advanced stages of the disease. Level of Evidence: N/A