We had five cases with intracranial hemorrhage occured during long-term oral anticoagulant drug therapy (particularly warfarin therapy).
Intracranial hemorrhages comprised chronic subdural hematoma in 4 cases and subcortical hematoma in 2 cases, including one case chronic subdural hematoma following subcortical hematoma five years later.
Surgical management was performed upon discontinuing and neutralyzing warfarin by Vitamin K at that period of diagnosis, raising thromb-test over 50%. The interval of discontinuing warfarin was 1-3 weeks postoperatively, examining blood coagulating system and no case had bleeding tendency nor cerebral embolus except for one case with a bleeding episode postoperatively.
Management of intracranial hemorrhage occured during long-term anticoagulant drug therapy, including chronic subdural hematoma and subcortical hematoma which indicate good prognosis, should be carried out surgically, discontinuing, neutralyzing anticoagulant drug and controlling blood coagulating factors.

View full abstract

A case of medullary hemorrhage is reported. A 28-year-old man with sudden vertigo, nausea and vomiting was admitted to Matsue Red Cross Hospital on February 8, 1988. Computed tomography revealed a high density area in the left lateral side of the medulla oblongata. Cerebral angiography showed no vascular lesions. In magnetic resonance imaging (MRI), there was the lesion of high intensity on SE image. On admission, neurological examination showed Wallenberg's syndrome. He was treated conservatively, and Wallenberg's syndrome dissolved gradually. He left our hospital on foot, on March 30, 1988. Spontaneous, nontraumatic hemorrhage in the medulla oblongata is very rare, and only 5 cases of medullary hemorrhage have been reported in literatures. According to these papers, the rarity of medullary hemorrhge is attributed to the vascular construction of brain stem and the distribution of intracerebral vascular malformations. MRI was useful not only for the diagnosis but also for the follow-up observation of the medullary hemorrhage. MRI could show even an old hemorrhagic lesion which could not be detected by CT scan.

View full abstract

Attention has recently been drawn to the magnetic resonance imaging (MRI) of the corpus callosum. Therefore, the pathological study of the corpus callosum is important for establishing a basis of MRI diagnosis.
We studied the pathological changes of the corpus callosum mainly in ischemic cerebrovascular disease.
Localized callosal infarctions were found 21 out of 1000 brains (2.1%) of elderly patients studied by post-mortem examinations. These were classified into 3 groups : an attenuation group, a non-attenuation group, and posterior cerebral artery area (PCA) group.
In 38 cases of progressive subcortical vascular encephalopathy (PSVE), we found many callosal lesions due to ischemia or degeneration.
In 19 cases of anterior cerebral artery area (ACA) infarctions (including ACA + MCA infarctions), the corpus callosum showed infarcts that were mainly localized in the half of the infarcted side.
In 7 cases of middle cerebral artery area (MCA) infarctions, the main callosal lesions were slight secondary degeneration.
Only 1 of 13 cases with PCA infarctions showed lesion in the splenium of corpus callosum.
We present MRI findings from 3 cases thought to have small callosal infarctions.

View full abstract

A case of 31-year-old woman with curious membranous stenotic lesion of the left carotid artery was reported. She admitted to the hospital due to head trauma. CT scan revealed subarachnoid hemorrhage on admission. Cerebral angiography showed membranous stenotic lesion caused about 70% stenosis at the origin of the left carotid artery. She had no risk factors of atherosclerosis in laboratory examination. She was asymptomatic but CBF study revealed mild ischemia of the left cerebral hemisphere. Carotid endoarterectomy was performed to prevent ischemic attack. At the operation, the membronous lesion localized strictly at the origin of the carotid artery and no sclerotic changes were observed in the common, external and internal carotid arteries. The lesion was ressected and processed for histopathological examination. Formalin-fixed and paraffin-embedded specimens were serially sectioned and stained with H & E and van Gieson method. This lesion showed the histopathological appearance near to fibrous plaque of atherosclerosis. However, it was actually different from atherosclerosis because of the age of the patient, strict localization of the lesion, the lack of a sclerotic changes in another carotid and cerebral arteres and the lack of risk factors of atherosclerosis.

View full abstract

Homocystinuria, an inherited inborn error of methionine metabolism, is characterized by marked accumulation of homocysteine in blood and tissues. It is known to be associated with precocious arteriosclerosis and cerebral infarction (CI). It has been suggested that the accumulation of homocysteine produces arteriosclerosis. The aim of our study is to explore a possible contribution of homocysteine to the development of adult CI. We measured total homocysteine in plasma by means of a high performance liquid chromatograhy method in 42 patients with CI in chronic stage and compared with 84 controls pair-matched for age, sex and hypertension. There were no significant differences in body mass index, fasting plasma glucose, the proportion of smokers, and serum concentrations of cholesterol, triglycerides, creatinine and uric acid between patients and controls. The concentrations of total homocysteine in plasma were significantly higher in patients with CI than in controls (p<0.000001). In conclusion, our findings suggest that a high level of plasma homocysteine could be one of independent risk factors for arteriosclerotic CI.

View full abstract

A case of Dejerine's syndrome in which MRI detected a lesion localized medially in the medulla oblongata was reported. The patient was a 68-year-old male who had a past history of hypertension. He was hospitarized with an initial manifestation of weakness of the right side of his body. Neurological findings revealed right flaccid hemiplegia sparing the face, decrease in the tactile and deep sensation of the right half of the body, left paralyis of the tongue and left weakness of palate and pharynx. The left weakness of palate and pharynx improved promptly after admission, leading to the diagnosis of Dejerine's syndrome. Cerebral angiography revealed occlusion of the left vertebral artery at the level of C1. Bone artifact prevented CT scan from demonstrating abnormality in the brain tern. MRI clearly visualized infarction involving the left medulla oblongate medially and occlusion of the left vertebral artery. The affected region visualized in MRI was consistent with the neurological findings of Dejerine's syndrome, appearing to be the lesion responsible for the patient's condition. Dejerine's syndrome being very rare, the present case is the first reported case in which MRI clearly visualized small infarction of the left medulla oblongata.

View full abstract

The importance of atheromatous carotid leions in the pathogenesis of TIA and stroke is well recognized.
We used an ultrasonic duplex scanner which permitted B mode arterial images and a pulsed Doppler flowmeter to evaluate atheromatous extracranial carotid lesions. The velocity information was evaluated using a spectral analyser which permitted real time qualification of the frequency content of the Doppler signal.
The maximal velocity of systolic phase in the common carotid artery (VmaxCCA) and internal carotid artery (VmaxICA) was examined to evaluate the caroid lesions in patients with TIA or stroke.
VmaxICA in 14 normal carotid ranged from 1440 Hz to 3320 Hz. VmaxICA in 21 stenotic carotid ranged from 1840 Hz to 7720 Hz. Utilizing VmaxICA greater than 2000 Hz, the specificity was 50% and sensitivity was 95%. Utilizing VmaxICA greater than 2500 Hz, specificity was 93% and sensitivity was 43%.
Flow velocity ratio (ratio of the maximal internal carotid artery flow velocity to the maximal common carotid artery flow velocity) in the normal carotid ranged from 0.78 to 1.36. Flow velocity ratio in the stenotic carotid ranged from 1.13 to 4.40. Utilizing flow velocity ratio greater than 1.10, sensitivity was 100% and specificity was 86%.
The degree of stenosis in stenotic internal carotid artery was significantly correlated with VmaxICA and flow velocity ratio. However, the differentiation between mild and moderate stenosis was difficult. It was found that this method was useful to predict the stenosis in the internal carotid artery.

View full abstract

Thirty-two patients who underwent surgery for intracranial aneurysm (clipping with non-ferromagnetic Sugita's clip in 30 and wrapping in two) were studied by MRI and the findings were compared with those of CT. On MRI, the artifacts around the clip consisted of a central signal void and a peripheral rim of increased signal intensity, but they were much smaller than those on CT. MRI apparently was superior to CT in delineation of associating lesions such as lacunar infarction, intraparenchymal hemorrage or periventricular edema. Although the size of ischemic area due to vasospasm and the sensitivity of detecting it on MRI were not different from those on CT, MRI provided figures with better contrast. An increased number of lacunar infarctions in deep cerebral white matter and/or basal ganglia were detected in the post-operative MRI, seemingly due to vasospasm. On the serial MRI, no consistent findings were found in the chronological changes of signal intensities in the subarachnoid space.

View full abstract

It is well known that blood viscosity is increased in patients with occlusive cerebrovascular disease (OCVD) and also that red blood cell aggregation (RBC-A) is one of the most important determinants of blood viscosity, especially at low shear rate. In this paper, RBC-A in OCVD is discussed with particular attention to the distinction between perforating branch infarction (POI) and cortical branch infarction (CBI).
The subjects comprised 64 cases with occlusive CVD, (34 PBI, 30 CBI) and 67 age-matched controls. Heparinized whole blood was sampled and RBC-A was quantitated by measuring light transmission through the blood after stasis. Values of RBC-A · T1/2 were 5.0 ± 1.4 sec, 4.8 ± 1.0 sec, 5.3 ± 1.7 sec and 6.4 ± 2.0 sec in whole OCVD, PBI, CBI and controls, respectively. RBC-A · T1/2 was shortened (accelerated) in occlusive CVD as compared with the control group (p<0.01). RBC-A · T1/2 was more shortened in PBI than in CBI, although the difference was not statistically significant. Duration after onset and volume of infarction were not related to RBC aggregation time.
Whole OCVD patients were divided into two groups, cerebral thrombosis and embolism. Values of RBC-A · T1/2 were 5.2 ± 1.5 sec (thrombosis) and 4.7 ± 1.1 sec (embolism) and there was no significant difference between them.
Red blood cell volume (RBV), hematocrit (Hct) and plasma proteins, [total protein (TP), albumin (Alb), gamma globulin (γ-G1) and fibrinogen (Fib)] were studied in these patients. RBV and Hct were slightly but significantly higher (although the value was within normal limits) in occlusive CVD than in the controls (p<0.05). In the control group, there were significant negative correlations of RBC-A · T1/2 with Hct, TP, γ-Gl and Fib, but no correlation with Alb. In occlusive CVD, there was no correlation between RBC-A · T1/2 and these parameters, suggesting that the higher RBC and higher Hct did not influence the acceleration of RBC-A. Serum Alb level was higher in PBI (p<0.05), but other parameters showed no significant difference between PBI and CBI. There was no correlation between RBC-A · T1/2 and plasma factors in PBI. In CBI, there was only a negative correlation between RBC-A · T1/2 and γ-Gl [R=-0.449 (n=25), p<0.05]. These results indicate that the plasma factors which affect RBC-A in controls may not contribute to the acceleration of RBC-A in OCVD. In occlusive CVD, some factors in RBC themselves may contribute to the acceleration of RBC-A.
Clinical risk factors such as hypertension (HT), atrial fibrillation (Af), diabetes mellitus (DM) or glucose tolerance impairment (GTI), hyperlipidemia (HL), cigarette smoking and alcohol drinking were also studied. HT and smoking were more frequent in PBI, and Af was more frequent in CBI. However there was no relation between RBC-A and such risk factors.
Acceleration of RBC-A may be determined by intrinsic properties of the RBCs themselves as mentioned above. Under the influence of atherosclerosis or stenotic change of cerebral vessels and so on, such properties of RBC would lead to a reduction of cerebral blood flow, especially in low flow areas such as distal parts of the perforating branch which would be easily affected by hemorheological change.

View full abstract

Surgical treatment of multiple intracranial aneurysms in the acute stage requires special stratagic consideration. The authors present the surgical results of multiple aneurysms of 80 cases drawn from 348 consecutive cases over 5 years. Of 54 patients treated at the same procedure, 8 patients (14.8%) had surgical complications, and 20.5% died. There was no mortality in 15 patients in whom all aneurysms were treated in a subsequent operation. A severe preoperative neurological deficit (Grade IV) existed in 12.5% of the patients, 70% with unsatisfactory outcome. In 3 cases of anterior circulation aneurysms with a posterior circulation aneurysm had one stage operation through the same approach, there was no good results. 29 patients had unilateral one stage operation. In this group, the risk of the surgical complications was 6.9%, and 13.5% in bilateral one stage operation group.
We recommend that one stage operation through bilateral approaches should be done preferably in good-risk patients.

View full abstract

Forty adult cats were subjected to this study in order to examine the changes in permeability of major cerebral arteries after subarachnoid hemorrhage by using three kinds of tracers with varied molecular sizes.
Experimental cerebral vasospasm was produced in 25 cats. Three days after intracisternal injection of 3 ml of autologous blood, the basilar artery was exposed by transclival approach, then continuously irrigated with the mixture of blood and CSF for 4 hours. After gross vasospams in the basilar artery was seen, the three tracers, HRP (horseradish peroxidase), NF (native ferritin), CG (colloidal gold, 5 nm and 20 nm particle size), were administered through the subclavian artery. The basilar artery was examined under transmission electron microscopy. Tracer study was also performed in 15 normal animals.
In the basilar artery contracting for 4 hours, endothelial cells were deformed along the corrugated internal elastic lamina, and smooth muscle cells were distorted. HRP reactive products and NF were observed in the endothelial plasmalemmal vesicles, interendothelial spaces, subendothelial spaces, and widened intercellular spaces in smooth muscle layer. However, CG was not observed in the vessel wall. Most noticeable routes to the smooth muscle layer appeared to be interendothelial spaces with broken tight junctions following subarachnoid hemorrhage. In the normal basilar artery, no tracer was observed in the vessel wall, although HRP reactive products filled some plasmalemmal vesicles of endothelial cells.
These results suggests that intraluminal vasoactive substances, with smaller molecular sizes than NF, may penetrate the vessel wall of major cerebral arteries in the early stage of subarachnoid hemorrhage, resulting in the progressing and long-lasting vasospasm in the major cerebral arteries. These permeability changes of major cerebral arteries may play an important role in the pathogenesis of cerebral vasospasm.

View full abstract

To predict postoperative ischemic brain complications due to temporary or permanent carotid occlusion is very important for surgical treatment of occlusive cerebrovascular disease. We studied CBF changes by SPECT and EEG changes by computed mapping of EEG (CME) preoperatively and ICA stump pressure and somatosensory evoked potential (SEP) were measured intraoperatively. Mean CBF in the affected MCA territory was 47 ml and 37 ml on the average before and after CCA compression. There was a significant difference between them. CME showed an appearance or increase in delta-activity by compression of CCA in six cases and no evident change was observed in other 15 cases. Mean CBF was 33 ml in six cases in whom appearance or increase in delta-activity was observed by the compression. On the other hand, mean CBF was 42 ml in other cases with no change in deltaactivity. With respect to the relation-ship between ICA stump pressure and changes in delta activity of EEG in the affected hemisphere, mean stump pressure was 40 mmHg in cases with changes of EEG and 63 mmHg in cases without changes. These values are significantly different. In relation to SEP measured in surgery and stump pressure, in cases with the amplitude of the early component of SEP was reduced by 50% or more were found to have a stump pressure of <40 mmHg.
In addition to preoperative compression (Matas) CBF measurement and CME, intraoperative monitorings are considered necessary to minimize postoperative complications.

View full abstract

We have diagnosed a case of recurrent optic gloma associated with moyamoya vascularity 8 years after postoperative irradiation.
A 12-year-old girl, who was initially admitted to our hosptial at the age of 4 years with a diagnosis of suprasellar tumor with obstructive hydrocephalus and treated by partial removal of the tumor followed by postoperative irradiation with a tumor dose of 49.5 Gy, developed headache associated with enlargement of the tumor. Left carotid angiography revealed stenosis of the terminal portion of the internal carotid artery, Ml portion of the middle cerebral artery, and Al portion of he anterior cerebral artery with ethmoidal and vault moyamoya. Right side showed stenosis of the M1 portion of the middle cerebral artery with ethmoidal moyamoya.
Possible causes of the occlusive arteriopathy in this case were compression by the supraellar tumor or secondary arterial changes due to radiotherapy of the tumor. We believe that the latter was the more possible cause becaue the suprasellar tumor was a benign glioma and smaller in size on this admission compared with preoperative tumor size.
The clinical features of radiation-induced intracranial occlusive vascular disease were analyzed for our case and for other reported in the literature.

View full abstract

To evaluate the clinical effects of thrombolytic therapy with Urokinase and heparin for acute stroke, functional outcome at the end of 3 month has been studied on 87 cases with clinically diagnosed lacunar infarct in a prospective controlled trial.
Eighty-seven patients less than 72 hours duration with first lacunar infarction were divided in a randomized trial into two groups; UK group (n=43) consist of 18 cases (High-dose UK-H group) with high-does UK (Total 3, 040, 000 I.U./two weeks) and heparin (5, 000-2, 500 I.U./day) administration, and 26 cases (Low-dose UK-H group) with low-dose UK (Total 840, 000 I.U./two weeks) and heparin (2, 500 I.U./day) administration; control group (N=44) without UK nor heparin. Each group had little differences with age, risk factors (Hypertension, Diabetes Mellitus, Atrial fibrillation), distribution of the gradings of weakness at lower limb, and timing on rehabilitation. And all the patients were examined by cerebral angiography and CT scan.
In the patients with severe weakness at lower limb (0/5-2/5 in DeJong's gradings), the outcome in UK-H subgroup (n=12) was better than that in control subgroup (n=14) (p<0.05). And the improvement of the paresis within two weeks after stroke was observed in ten cases of UK subgroup (N=12) consist of the patients with severe weakness, but in 7 cases in control subgroup (n=14). In the patients with moderate or slight weakness (more than 3/5 in DeJong' gradings), there were no differences in functinal outcome at 3 months between UK-H subgroup and control subgroup. And there were no differences in functional outcome between High-dose UK-H group and Low-dose UK-H group.

View full abstract

The authors analyzed 18 patients with large or giant aneurysms of intracavernous carotid artery with special reference to the long-term results. The 8 patients were treated surgically and the 10 patients were managed nonsurgically. The sex ratio was 15 female to only 3 male patients, with the age distribution showing 13 patients (78%) were aged patients over 60 years old. The follow-up period ranged from 1.6 to 16 years, with an average of 6.6 years. The most common symptom was cranial nerve palsy, mainly extraocular palsy. Among 18 patients, only one patients had intracranial rupture who died of rebledding 2 weeks later. Surgical treatment was as follows; ligation of internal carotid artery (ICA) in the neck in 6 patients, trapping of ICA in 1 patient, and balloon occlusion of ICA in 1 patient. As to the surgical results of these procedures, 3 patients had improvement of pre-existing extra-ocular palsies with marked shrinkage of aneurysms, and the other 3 patients remained unchanged in extraocular palsies. One patient with ICA ligation developed postligation ischemic deficits partially resolved. On the other hand, the long-term results of nonsurgical patients were favorable, excluding 1 dead case from unrelated cause. The recurrence of ocular symptom occurred in only 1 patient.
Recently, direct surgical approach to intracavernous aneurysm was successfully performed. However, because the intracranial rupture was exceedingly rare and the long-term results of nonsurgical cases were favorable in intracavernous aneurysm, the surgical indication should be carefully decided, especially in aged patients.

View full abstract