Clinical investigations on surgical treatment of hypertensive intracerebral hemorrhage have been carried out in the Department of Neurosurgery at Iwate Medical University for the last 14 years. Operative cases numbered 174, excluding cases of secondary pontine nor cerebellar hemorrhage, and the data presented concern operative mortality and morbidity. As to the operative mortality within one month after surgery, death occurred in 59 (33.9 %) out of 174 patients. However, patients who had been operated on during the last 5 years, death occurred in 23 out of 99. In the latter series, of 28 patients who had been alert or somnolence with minor neurological deficits (Grade I in our neurological classification), none died, but 14 (25.5 %) of 55 Grade II patients who had been stuporous with moderate neurological deficits died. Of 45 Grade III patients who had been semicomatose with normal or abnormal size of the pupils, hemiplegic and with mild vegetative disturbances 15 (33.3 %) died. Of 32 Grade IV patients who had been semicomatose with abnormal size of the pupils, tetraplegic or hemiplegic with decerebrate or decorticate rigidity and with severe vegetative disturbances 17 (53.1 %) died. Of 14 Grade V patients who had been comatose with abnormal size of the pupils, tetraplegic or hemiplegic with decerebrate regidity and with severe vegetative disturbances 13 (92.9 %) died. The operative mortality under 39 years of age was 16 %, while it was approximately 40 % in each decade above 40 years. Of the total cases, 126 patients had the lateral type of hematoma which was located outside the internal capsule and 31 patients had the combined type of hematoma which was located in the internal capsule and the thalamus. The former showed 24.6% operative mortality, while the latter showed 71 %. Total evacuation of the hematoma was performed in 147 patients and the operative mortality was 29.3 %. The result was better than in cases of partial evacuation (63.2 %) and of internal or external decompression only (50 %). Operative mortalities according to the timing of the operation after the attack of hemorrhage varied as follows: One day—25 %, 2-3 days—24 %, and 4-9 days—9.1 %. Follow-up study from four months to 13 years after surgery was carried out with 98 patients, and the results showed that 32 (32.9 %) were well (able to work fully with minimal disability), 21 (21.4 %) were partially disabled, and 11 (11.2 %) were totally disabled. Death occured in 34 out of the 98 patients and the mortality was 34.4 during follow-up period.
Mortality and morbidity are reviewed in cases of cerebral hemorrhage patients who were transported to and were treated conservatively at the Research Institute of Brain and Blood Vessels, Akita, from May, 1969 through April, 1974. Of 104 cases, there were 85 cases with hematoma of basal ganglia, 15 cases of pontine hemorrhage, and four cases of cerebellar hemorrhage. Of the total 74 cases (71%) were admitted within the first day of stroke. The level of consciousness on admission was semicomatose or comatose in 54 cases (52 %). Most of the cases were transported to the hospital by a hospital ambulance with a doctor, and a nurse as soon as possible after the onset of stroke. Patients were treated in the NCUs (Neurovascular Care Units) or sub-NCUs, depending on the type of stroke and the severity. The survival rates within one month in the hospital was 59 % for patients with hematoma of basal ganglia, 27 % for patients with pontine hemorrhage, and none for patients with cerebellar hemorrhage, or 52 % for all 104 cases. One-month survival rates was 39 % for cases admitted within the first day of attack, 78 % for those transported between two to three days, 87 % for cases admitted between four to seven days, and 100 % for those transported between eight to fourteen days, following stroke. Among 104 cases, 12 cases (11 %) died within the first day after the attack, 37 cases (35 %) within seven days, 50 cases (48 %) within one month, 54 cases (52 %) within six months, and 58 cases (56%) within one year following the stroke. Survival rates of one week, one month, six months, and one year, were 41 %, 20 %, 17 %, and 13 %, respectively, in the semicomatose or comatose patients group, 86 %, 81 %, 76 %, and 73 %, respectively, in the somnolent or stuporous patients group. All cases but one, who died of other than cerebrovascular disease, survived in the group with clear consciousness upon admission. Therefore, it can be concluded that there is good correlation between the level of consciousness upon admission and the prognosis in this series. Morbidity of one year after the onset in 50 patients who survived more than one month, are as follows : eleven patients improved well enough to live and work without any difficulty, sixteen were capable of taking care of themselves in dialy chores, but incapable of work, eight needed on other's aid, nine were confined to their beds, and six patients died. Patients who were in disturbed consciousness three months following cerebral hemorrhage, could not get alert both six months and one year after the incident of apoplexy. Of 50 survivers with basal ganglionic hemorrhage, four cases (8 %) were in akinetic mutism or apallic state. All survivors with pontine hemorrhage were always in the state of akinetic mutism. Of 50 autopsies, 42 cases (84 %) of complicated ventricular bleeding were observed, 19 cases (38%) of uncal or cingulate or tonsillar herniation, and 13 cases (19%) of pontine bleeding secondary to basal ganglionic hemorrhage. The incidence of systemic complications in 50 autopsied cases were gastrointestinal abnormalities (61%), pneumonia (23%), and urinary tract infection (19 %). In other words, complications were found most markedly in the gastrointestinal tract and frequency of infections appeared to be relatively lower.
Tumor cells or tumor fragments can often be found in the CSF of patients with brain tumor. Thus, it is considered possible to verify the existence of tumors by an immunological approach, due to the fact that tumor specific antigen (TSA) can easily be obtained from the CSF of patients by means of lumbal puncutre. Our investigation has revealed that the serum in patients with glioma has tumor specific antibody against TSA. Therefore, this makes the immunological diagnosis of the brain tumor possible in man, using an immunoadherence hemagglutination technique in an autochthonous place. Using the technique developed by the authors eighty nine cases of various brain diseases were investigated. This immunoadherence hemagglutination technique revealed positive results in thirty seven of the fifty four with brain tumors. All cases except one of ependymoma showed positive reaction in glioblastomas, astrocytomas, ependymomas, and oligodendrogliomas. Eight of fourteen cases were positive in medulloblastomas. Thus, as for the gliomas, positive results were obtained in thirty of thirty five cases, or in 86 %. Besides these tumors all cases of craniopharyngiomas and four out of five cases of pinealomas were positive, though the reactions were more feeble than in those of gliomas. One case of four metastatic brain tumors showed positive reaction. On the other hand, none of meningiomas, pituitary adenomas and dermoid cyst were positive. Considering these results, it is evident that, by means of this immunological diagnostic technique, it is possible to differentiate the gliomas from other brain tumors. Besides these tumors, thirty five cases of non-neoplastic brain diseases were also investigated using this technique. Positive results were obtained in six of these cases, including one case of Creutzfeldt-Jacob disease and five cases of meningitis or encephalitis. This technique is a very sensitive diagnostic procedure. In some cases by using this method abnormality in the central nervous system can be located before any other neurological diagnostic techniques could verify the existence of brain lesions. This technique has also other advantages. It can be performed with a very small amount of specimen, ordinarily 0.5 ml of the CSF, at an usual clinical laboratory and within two hours. It is also possible to apply this technique to pre-operative histological diagnosis, and also in the evaluation of the effect of various therapy in the post-operative course. It can be concluded that this technique is a useful way to screen test brain tumors, particularly in cases of gliomas.
The lateral projections of pneumoencephalograms were studied in controls and sellar and suprasellar tumor cases, with the reference points at the tuberculum sellae, foramen Monroi, dorsum sellae, the entrance of the aqueduct and tips of the third ventricle. In the 20 control cases, the anterior part of the third ventricle always stayed within the angle made by tuberculum sellae-foramen Monroi and tuberculum sellaeaqueduct. In chromophobe adenomas with suprasellar extension, craniopharyngiomas and pinealomas in the chiasmal region, was the anterior part of the third ventricle was indented superiorly and also anteriorly. In tuberculum sellae meningiomas was the anterior part of the third ventricle showed characteristic change of posterior displacement like pendulum. Chromophobe adenoma cases with abnormally high blood levels of prolactin showed larger deformity of sella turcica and the third ventricle than non-functioning chromophobe adenoma. After treatment of chromophobe adenoma with suprasellar extension the third ventricle with significant deformity tended to normalize on pneumoencephalogram.
The authors investigated immediate endocrinological reactions due to various direct operations of intra and para-sellar disorders and also their long-term results. With regards to hypofunction of the pituitary gland, the order of susceptibility of each hormone was observed as shown: GH, LH and FSH, TSH, ACTH. This order has already been accepted in common as noted in a number of publications. Pituitary hypofunction worsened after operation when pituitary adenoma was totally removed, whereas, it improved in some cases when the tumor was partially removed by operation. No improvement of pituitary hypofunction was observed immediately after craniopharyngioma operation. The level of every hormone, with the exception of TSH, was low in cases of craniopharyngioma. After the operation of other parasellar tumors, pituitary hypofunction usually improved. In case of intracranial aneurysm, especially anterior communicating artery aneurysm, various combinations of pituitary hypofunction hormones were observed prior to as well as after operation. This phenomena was attributed to the position and extent of the aneurysmal dome toward the sella turcica. Operative stress, i.e. aneurysmal rupture in the course of direct approach or circulatory disorder of the feeding artery to the pituitary gland and hypothalamus by local dissection, may have significant ill effects on the postoperative pituitary hypofunction.
Topographic anatomy, anatomic variations, and angiographic anatomy of the veins which drain the quadrigeminal plate proper were studied and described in detail. The diagnostic values of the quadrigeminal veins were also discussed in brain stem lesions. Specific veins which drained the quadrigeminal plate proper were constantly found in the anatomic specimens. We designated these veins as “Quadrigeminal veins.” There were two types of variations of the quadrigeminal veins in anatomic studies. These veins had a close, anatomic, and angiographic correlation with the quadrigeminal plate. They outlined the position and configuration of the quadrigeminal plate on the lateral projection of the venous phase of the vertebral angiography. The whole structure and each part of the mesencephalon were delineated from the quadrigeminal veins in combination with other mesencephalic veins, such as the posterior mesencephalic veins, lateral mesencephalic veins, and the mesencephalic segment of the anterior ponto-mesencephalic veins. The quadrigeminal veins showed characteristic findings in the course and configuration in the pontine and mesencephalic tumors. They were also of use in the diagnosis of tumor extension of brain stem tumors. The atrophy of the brain stem and posterior fossa structures were evaluated by the mesencephalic and cerebellar veins, such as quadrigeminal veins, anterior pontomesencephalic vein, precentral cerebellar veins, and supraculminate vein. The quadrigeminal veins were of great diagnostic value in these respects as described above.
We devised a semiconductor film strain transducer (SFT) for continuous measurements of epidural or subdural intracranial pressure and blood pressure. The metal diaphragm of this transducer facing the dura mater was made of high quality stainless steel (sus 27, 30μ in thickness). A strip of SFT element is bonded on the counter surface of the diaphragm at its center, and the rim of the diaphragm is fixed at the edge of the stainless steel cylindrical housing base. The inner space is sealed except for an 1 mm diameter polyethylene tube which is used to balance the inner space pressure against the outer. For the detection of SFT resistance change a bridge method was employed. The transducer was calibrated by a comparison method, giving both positive and negative air pressure. We also developed a new telemetric system consisting of transducer bridge circuits with IC amplifier and transmitter circuits. The miniature transmitter measures only 5×1×3 cm in size, but it was still too large to be implanted. The transmitter and its receiving system utilize the pulse transmitting circuits (3 and 80 MHz), and its radius of action is approximately 10 meters. The SFT was used for continuous recording of epidural pressure (EDP) in 41 neurosu rgical patients for a period ranging from one to nine days (3.5 days on an average). No untoward complications such as infection or hemorrhage at the site of implantation were experienced. Induction of general anesthesia caused an acute rise in the EDP in almost all cases. Intraoperative recording of the EDP was performed in the supine, sitting and prone positions. The sitting position proved to be very useful in reducing the EDP for posterior fossa craniectomy. Irrespective of the positioning of the patients, the EDP was restored to a lower and adequate level as soon as an extreme flexion or rotation of the neck was corrected. In one case the development of a postoperative intracerebral hematoma was detected by monitoring the EDP. Telemetric monitoring of the EDP was performed in two patients during their daily life in the neurosurgical ward, such as eating, drinking, sitting, standing or going to stool. The EDP and systemic blood pressure were recorded simultaneously in one of them. When those patients went to stool, the EDP increased sharply at the beginning of straining and the diastolic pressure also increased at the same time, but the systolic pressure decreased. At the end of straining both the systolic and diastolic pressure increased. Of particular interest was the fact that the magnitude of the EDP rise during straining at stool differed significantly by the posture of the patients, such as lying on a bed-pan, seating on a toilet or squatting over a Japanese style toilet.