Cox's proportional hazard model was applied to evaluate the role of nimustine hydrochloride (ACNU)/etoposide(VP16) combination chemotherapy for patients with malignant glioma in comparison with interferon-β (IFN)/ACNU combination therapy. Fifty-six patients with malignant glioma ranging in age from 7 to 80 years old were divided into 2 groups according to the mode of chemotherapy ; 23 patients with ACNU/VP16 therapy and 33 patients with IFN/ACNU therapy. All patients underwent surgical resection followed by irradiation in combination with chemotherapy. ACNU/VP16 group received ACNU(80mg/m^2 i.v.) on Day 1 and VP-16(80mg/m^2 i.v.) on Day 2 and 3 of each 6-week cycle. IFN/ACNU group received IFN(3×10^6IU i.v.) from Day 1 to Day 7 and ACNU(2mg/kg i.v.) on Day 2 each 6-week cycle. Cumulative survival curves were estimated by using Kaplan-Meier's nonparametric method for the mode of chemotherapy in consideration of prognostic factors. Multivariate Cox's modeling procedures were used to investigate prognostic variables for patient survival and to estimated survival rate. Kaplan-Meier's cumulative survival curves for the mode of chemotherapy showed that median survival time was 20.0 months for patients undergone ACNU/VP16 therapy, while 12.2 months for patients undergone IFN/ACNU therapy (p=0.008). Univariate analysis for the mode of chemotherapy in consideration of prognostic factors demonstrated that age of onset, histological diagnosis, Karnofsky performance status (KPS) on admission and mode of therapy (ACNU/VP16 therapy) were significantly correlated with survival, but there was no correlation between the extent of surgical resection and patient survival both in patients undergone ACNU/VP16 therapy and IFN/ACNU therapy. Multivariate analysis showed that the variables strongly correlated with outcome were patients age of onset, KPS&gnE;70%, and mode of therapy (ACNU/VP16 therapy) respectively. Estimated cumulative survival plots for the mode of chemotherapy revealed that ACNU/VP16 therapy significantly extended a survival rate (Likelihood test : p<0.001). The present results suggested that ACNU/VP16 therapy was an effective adjuvant chemotherapy for malignant gliomas.

View full abstract

In a comparative study of nimustine hydrochloride (ACNU)/etoposide (VP16) combination chemotherapy and interferon/ACNU therapy for malignant gliomas, we have reported effectiveness of ACNU/VP16 therapy for patients survival was statistically significant. The aim of this report is to determine whether ACNU/VP16 therapy is appropriate adjuvant chemotherapy for patients with malignant glioma in consideration of response rate, recurrence rate, side effect, and hospital stay for this chemotherapy. Twenty-three patients with malignant glioma ranging in age from 22 to 80 years old were included. All patients underwent surgical resection followed by irradiation in combination with chemotherapy. They received ACNU(80mg/m^2 i.v.) on Day 1 and VP16 (80mg/m^2 i.v.) on Day 2 and 3 of each 6-week cycle. Three out of 18 patients in which immediate postoperative neuroimagings showed some degree of residual tumor responded to ACNU/VP16 therapy. All patients but one underwent gross total resection showed no recurrence in follow-up period. Therefore, overall response rate was estimated to be 34.8%. Overall recurrence rate was 65.2%. The mean time elapsed to recurrence was 7.6 months, but there was no significant difference in recurrence rate between the patients with glioblastoma and anaplastic astrocytoma. Significant myelosuppression was encountered in 5 patients (21.8%) leading to skip or to wait the administration of drugs. Overall occurrence of side effects was found in 14 patients (60.9%). Only 2 patients were ceased from this adjuvant chemotherapy because of patients' request. An average hospital stay for one course of this chemotherapy was 5.8 days. These results suggested that ACNU/VP16 combination chemotherapy was an effective adjuvant chemotherapy for patients with malignant gliomas.

View full abstract

Purpose : To verify the importance of CT cisternography (C-CT) and epidural pressure monitoring (EDPM) as determining factors for surgical indications and the selection of surgical procedures in the treatment of traumatic subdural fluid collection (SDFC). Subjects and Methods : A total of 75 patients, admitted at our hospital during the 5-year perid, January 1993 to December 1997, and diagnosed as having SDFC with CT, were subjected to the present study. These patients were all had a 1 month follow-up after the onset of SDFC. After that, C-CT and EDPM were subsequently performed on 31 patients (male : female=22 : 9 ; age range of 31 to 82 with a mean age of 62.4 ; bilateral cases : unilateral caes=20 : 11), 21 with unchanged or aggravated SDFC, and 10 with altered absorption values on repeated CT. These cases were investigated with regard to (1) examination results, (2) surgical indications and the selection of surgical procedures, and (3) surgical results and prognosis. Results : (1) On C-CT, no filling (N), delayed filing (D), and early filling (E) were observed in 11, 18, and 2 cases respectively, the majority (29 cases ; 93.5%) categorized as N and D. EDPM revealed continuous high pressure (CH), intermittent high pressure (IH) and continuous low pressure (CL) in 9, 17, and 5 cases respectively, the majority (26 cases ; 83.9%) categorized as CH and IH. (2) Surgery was performed on 29 cases, including those with altered absorption values on repeated CT, N and D cases on the C-CT, CH and IH cases on the EDPM, and symptomatic E cases on the C-CT with symptomatic CL on EDPM. As surgical treatment, irrigation+drainage were performed on 10 cases of the absorption value changed group ; irrigation+indwelling of Ommaya resrvoir were performed on 6 cases of the SDFC unchanged or aggravated group with N cases on C-CT and CH cases on EDPM, and subdural-peritoneal (S-P) shunt operation was performed on the other 13 cases of SDFC unchanged or aggravated group. S-P shunting was performed on 4 recurrence cases. (3) During the postoperative follow-up which lasted from 2 months to 4 years and 4 months, SDFC eventually disappeared from all cases. Two cases without no surgery showed aggravation of SDFC on CT or symptoms during the follow-up period of between 6 months and 2 years and 4 months. Conclusion : C-CT and EDPM were confirmed to be useful determining factors for surgical indications and the selection of surgical procedures, allowing us to produce a flowchart for therapeutic guidance.

View full abstract

Three-dimensional computed tomography angiography (3D-CTA) indicated for the diagnosis of agenesis of the internal carotid artery in a 51-year-old male admitted to our hospital with head trauma. Magnetic resonance (MR) imaging revealed dilated vertebral artery and absence of the flow voids corresponding to the bilateral internal carotid arteries. MR angiography also showed absence of the bilateral internal carotid arteries. 3D-CTA revealed the absence of the bilateral carotid canals and internal carotid arteries, and the dilated basilar artery supplying the anterior and middle cerebral arteries via the bilateral posterior communicating arteries. Aortography showed thickened vertebral arteries and thinned common carotid arteries. Bilateral carotid angiography demonstrated the absence of the internal carotid arteries. Vertebral angiography revealed thickened vertebrobasilar arteries, and supply of the bilateral anterior and middle cerebral arteries via the ipsilateral posterior communicating arteries. 3D-CTA can demonstrate absence of the carotid canal, which is a skull base disease, and absence of the internal carotid artery, which is a cerebrovascular disease. Therefore, 3D-CTA can provide a diagnosis of agenesis of the internal carotid artery.

View full abstract

We report 2 cases of ruptured aneurysms of the distal posterior inferior cerebellar artery (PICA) and review 85 cases reported in the literature. Case 1 : A 72-year-old man had headaches. Computed tomography (CT) revealed intraventricular hemorrhage (IVH) and hydrocephalus without subarachnoid hemorrhage (SAH). Cerebral angiography showed an aneurysm located on the telovelo-tonsillar segment of the left PICA. The aneurysm ruptured again during angiography, causing the patient's death. Case 2 : A 72-year-old man experienced disturbance of consciousness. CT revealed SAH and IVH with hydrocephalus. Cerebral angiography showed an aneurysm located on the tonsillo-medullary segment of the left PICA. The aneurysm was clipped successfully and the patient underwent ventriculo-peritoneal shunting. The postoperative course was uneventful. Whereas angiography in Case 1 showed that the aneurysm had bled through the roof of the fourth ventricle and into the ventricle but showed no apparent SAH, the surgical findings in Case 2 suggested that intracisternal blood had entered the ventricle. These contrasting findings indicate that the pathology of IVH varies among different segments of the PICA. Review of the literature revealed that the incidence of IVH after the rupture of aneurysms of the distal PICA is 55%. In the case of the telovelo-tonsillar segment, the incidence is 71%, which is clearly higher than that for other segments of the PICA. The outcome of distal PICA aneurysms in reported series is good in 72.4% of patients. IVH alone is not necessarily a factor affecting the prognosis of distal PICA aneurysms, but when complicated by hydrocephalus tends to worsen the prognosis.

View full abstract

The authors report 2 cases of ascending pharyngeal artery originating from the internal carotid artery, which caused troublesome bleeding during carotid endarterectomy. The frequency of these findings is reported to be less than 2% for carotid endarterectomy. If the inadvertent bleeding occurs at the time of carotid incision, especially in the cases of high positioned carotid bifurcation (higher than the upper margin of 3rd vertebral body), the presence of external carotid artery branches originating from the internal carotid artery must be remembered.

View full abstract

A 44-year-old woman was admitted to our department because of recurrent lumbago. On examination, no apparent neurological deficits were noticed. Plain X-ray films showed no spina bifida. Myelography showed no apparent abnormality. Plain CT scan showed a mildly hyperdense mass at the lateral recess of L 5 level. T1-WI of MRI showed an iso-intensity mass at the L 5 vertebral body, which was homogeneously enhanced. At operation, an extradural tumor was totally removed. Histologically, the tumor was composed of fatty tissues and thin-walled vessels, diagnosed as spinal angiolipoma. Forty-nine reported cases of spinal angiolipoma were reviewed. Spinal angiolipomas occur at the mid-thoracic level with high incidence. Only 4 cases of spinal angiolipoma were reported in the lumbar level.

View full abstract

We reported a case of dural arteriovenous fistula of the transverse-sigmoid sinus with pure leptomeningeal drainage. A 51-year-old man presented with generalaized convulsions. Neurological examination was normal. CT scans demonstrated a small hemorrhage in the left temporal lobe. Left external carotid angiograms showed dural arteriovenous fistula of the transverse-sigmoid sinus fed by occipital, posterior auricular, middle meningeal arteries. The draining vein was vein of Labbe. Left internal carotid angiograms demonstrated venous congestion in the left temporal lobe. Transverse and sigmoid sinuses were patent. ^123I-IMP SPECT revealed a low perfusion area in the left temporal region. Dynamic CT scans revealed venous congestion in the left temporal region. We considered that the venous congestion had caused the hemorrhage in the left temporal lobe. Initially, we embolised the dural arteriovenous fistula using a transarterial approach with HEMA-MMA. However, recanalization was detected after a short period. Therefore, we interrupted the draining vein of the dural arteriovenous fistula. Angiographic cure was obtained and the postoperative course was uneventful. We discussed the clinical features, the hemodynamic findings and the management of this case.

View full abstract