Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
Volume 16pt2, Issue 5
Displaying 1-10 of 10 articles from this issue
    1976 Volume 16pt2 Issue 5 Pages 379-386
    Published: 1976
    Released on J-STAGE: December 28, 2006
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    1976 Volume 16pt2 Issue 5 Pages 387-395
    Published: 1976
    Released on J-STAGE: December 28, 2006
    Occurrence of no-reflow phenomenon (NRP) has been repeatedly reported in various experimental models of cerebral ischemia. These models were, however, those of cessation of arterial blood supply to the brain by obliteration of arteries. Since cerebral blood flow (CBF) is lowered by raised intracranial pressure (ICP), occurrence of NRP in such an experimental model is also conceivable. In the present study, the mode of occurrence of NRP was investigated in a raised ICP model in dogs.
    After immobilization by intravenous infusion of Galamine, artificial ventilation was continued to maintain the normal level of arterial blood gases. Pressure of 200 mmHg was applied to the cisterna magna for 15 min by infusion of warmed saline. CBF was monitored by a double-needle type thermocouple. The cisterna magna pressure, arterial blood pressure, EEG and cerebral impedance according to the method of Mori et al. were continuously recorded on a polygraph.
    Three hours after cisternal infusion, the brain was perfused with carbon black solution (Pelikan biological ink) via the thoracic aorta of a pressure of 120 mmHg. Prior to sacrifice, 50 ml of 5 % Evans blue was injected intravenously. Specimens for electron microscopy were taken by core-biopsy in a few dogs of each experimental groups.
    The dogs were divided into three groups. Group I: (5 dogs) Only cisternal infusion was carried out. Group II : (16 dogs) The systemic arterial pressure was lowered to 60-80 mmHg by administration of Arfonad during cisternal infusion. Post-ischemic (PI) arterial pressure was brought up to the normal level by administration of Angiotensin II and Norepenephrine as quickly as possible. Group iII : (5 dogs) Immediately after cisternal infusion combined with arterial hypotension as in group 1 1, cerebral perfusion was carried out.
    In group I, very rapid and pronounced appearance of reactive hyperemia (RH) was noted, indicating decrease of cerebral vascular resistance (CVR). EEG activity recovered almost completely and the result of cerebral perfusion was also normal. In the group II, however, the appearance of RH was slower and less pronounced than in group I (group II-A, 10 dogs), or entirely absent (group II-B, 6 dogs). Since PI cerebral perfusion pressure was kept in almost the same range in all the groups, this marked reduction of CBF in group II was ascribed to increase of CVR, i.e., presence of NRP. Occurrence of NRP was further confirmed in group f, in which cerebral perfusion carried out immediately after cisternal infusion revealed extensive non-filling of parenchymal capillary networks.
    As seen in the courses of CBF and cerebral impedance, NRP was transient in group II-A and persistent in group II-B. Recovery of CBF and appearance of RH always preceded the normalization of cerebral impedance and recovery of CBF.
    Presence of cerebral edema was confirmed in group II-B by macroscopic and electron-microscopic observations.There was also leakage of Evans blue in the cerebral parenchyma. Although this cerebral edema apparently seems due to the result of persistence of NRP, further investigations are required to clarify their causal relationship.
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    1976 Volume 16pt2 Issue 5 Pages 397-403
    Published: 1976
    Released on J-STAGE: December 28, 2006
    Nine cases of traumatic hematoma of the posterior fossa are reported and the diagnostic value of the vertebral angiography is emphasized.
    1. The diagnosis of an acute posterior fossa hematoma by physical examination is known to be difficult. It is our practice to perform emergency vertebral angiography, when the patients with occipital bone fracture develop disturbances of consciousness and changes of vital signs. We prefer preoperative vertebral angiography to exploratory trephination without angiography.
    2. In five of our nine cases there were combined supra and infratentorial hematomata, all of which were found by preoperative angiographies. On the other hand there were two cases of frontal intracerebral hematoma diagnosed by angiography, whose clinical diagnosis had been posterior fossa hematoma. Retrograde right brachial angiography is an excellent mean to see both supra-and infratentorial lesions simultaneously.
    3. One can differentiate a posterior fossa epidural hematoma from a subdural hematoma by angiography since an avascular area. of the subdural hematoma does not extend the cerebellar tentorium.
    4. In one case extravasation of contrast medium from the posterior inferior cerebellar artery during angiography clearly demonstrated the bleeding point. In some other cases the deformity of the lateral sinus suggested the site of lateral sinus injury. In another case extravasation of contrast medium from the lateral sinus was suspected.
    Some surgeons feel that one should perform immediate exploratory trephination without vertebral angiography, when posterior fossa hematoma is suspected. However, we are of opinion that an emergency vertebral angiography can be performed without wasting time, while the emergency operation is being prepared. Vertebral angiography can provide invaluable informations for planning the operation about the site, size and multiplicity of the hematoma.
    In conclusion, it is important to have the neurosurgical service system in which emergency vertebral angiography can be performed without delay in any circumstances.
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    1976 Volume 16pt2 Issue 5 Pages 405-410
    Published: 1976
    Released on J-STAGE: December 28, 2006
    Acute traumatic hematoma within the posterior fossa has been considered to be difficult to diagnose in its early stage because of the perplexity of clinical findings and the paucity of localizing signs. For the purpose to obtain the diagnostic criterion in its early stage, clinical findings of 8 cases of acute forms were analysed.
    In most cases, the impact was received on the back of the head. Deterioration of consciousness was rapidly progressive in all cases. However lucid intervals within two hours were seen in 5 cases. The most important neurological finding in the early diagnosis was bilateral pyramidal sign which was found in 5 out of 8 cases. Unilateral signs which might mimic the supratentorial hematoma were found in 5 cases; thus 5 cases showed unilateral pyramidal sign, 3 cases showed unilateral mydriasis. Although these unilateral signs might indicate the supratentorial hematoma concomitant with the posterior fossa hematoma, it must be stressed that these signs could be developed by the posterior fossa hematoma only. Posterior fossa skull fractures were recognized by X ray examinations in 6 cases. Carotid angiogram showed findings of internal hydrocephalus in 5 cases. Vertebral angiogram was the most useful diagnostic aid of the posterior fossa hematoma. 7 cases of acute forms and I case of subacute form were correctly diagnosed by this method. It is emphasized that this examination is the procedure of first choice when one is faced with the possibility of the posterior fossa hematoma.
    Concerning about the operative results, 5 out of 7 cases operated on died, 70% of mortality rate. However, among 4 cases in which the early diagnosis was possible, only I case was lost.
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  • —Its Endocrinological and Pathological Findings—
    1976 Volume 16pt2 Issue 5 Pages 411-418
    Published: 1976
    Released on J-STAGE: December 28, 2006
    We are reporting 4 cases of the intracranial human chorionic gonadotropin (HCG) producing tumors.
    Case 1 was a 21-year-old female with visual disturbance, diabetes incipidus, and hypogonadism. Case 2 was an 11-year-old male with visual disturbance, diabetes incipidus and precocious puberty. Case 3 and 4 were 10-year-old males who had progressive left hemiparesis and precocious puberty.
    According to the endocrinological examination of hypothalamic pituitary function by radioimmunoassay, serum luteinizing hormone (LH) levels were abnormally high, and serum follicle stimulating hormone (FSH) levels were scanty in all cases. As the result of radioimmunoassay using antibody to native HCG and β-subunit of HCG, native HCG as well as α and/or β-subunit of HCG were identified in sera of all cases, in CSF of 2 cases, in tumor tissue of 1 case and in urine of 1 case.
    Tumors were confirmed to be located in suprasellar, hypothalamic and thalamic region by neuro-radiological examinations.
    Two out of four cases were operated and were diagnosed to be choriocarcinoma and two-cell-pattern pinealoma (germinoma).
    Following LINEAC irradiation in all cases, HCG levels in the serum and in the CSF became negligible. Serum LH and FSH levels in all cases and plasma testosterone concentration in 3 males who were diagnosed as precocious puberty fell into normal range.
    Histologically, a part of intracranial human chorionic gonadotropin producing tumors seemed to be germ cell origin.
    Endocrinological examinations by radioimmunoassay are very useful to make diagnosis and therapy as well as to predict prognosis.
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    1976 Volume 16pt2 Issue 5 Pages 419-426
    Published: 1976
    Released on J-STAGE: December 28, 2006
    Recent studies have disclosing the presence of the tumor specific transplantation antigens (TSTA's) in most of animal tumors, similar type of antigens (TSA's) in some human neoplasms, and immune responses in tumorbearing-hosts to the tumors.
    “Malignant” tumors, however, grow progressively, then kill the hosts. Because the tumor specific antigen may be poorly developed, or immune response of the hosts may be paralysed, the tumor growth cannot be suppressed. And also the blocking factors in the serum inhibits cell-mediated immune response against tumor associated antigens.
    We have employed the microcytotoxicity assay method to study the lymphocyte cytotoxicity of rats bearing ethylnitrisourea (ENU) induced gliomas and that of human bearing glioblastoma, and to determine the serum blocking effect of these. To verify above facts, those of normal rats and humans, and of human with other type of brain tumors were examined.
    Cultured cells derived from ENU induced rat glioma (RG) and human glioblastoma (KG, IG) were used for the target cells.
    The possibility to establish the immunological diagnostic method of brain tumor (glioblastoma) is discussed based upon following facts.
    The lymphocytes from rat with glioma or from human with glioblastoma attacked specifically target cells and destroyed. The serum obtained from these rat or human blocked such effect in a specific manner.
    In the control study, the lymphocytes from normal rat or human could attack and destroy target cells slightly, but this effect is weaker, and the blocking effect is none in the serum of these.
    Mixed culture of immunized lymphocytes and target cells was performed, and examined morphologically by conventional microscope, phase contrast microscope and electron microscope. To observe more dynamic state of immune reaction between immunized lymphocytes to target cells, slow speed movie film was taken with phase contrast microscope.
    In one group, RG was transplanted to new born rats subcutaneously.
    After tumor grew to thumb-tip sized, “immunized” lymphocytes were collected from each animal, then 106-7 autochthonous lymphocytes suspended in 2 ml of normal saline was inoculated into each tumors. For control, normal lymphocytes or only physiological saline were injected into the tumors. In the autochthonous lymphocyte group, some tumor growth were suppressed, and even regressed. In normal lymphocyte group, some tumors were occasionally suppressed, but in physiological saline group, all tumors grew uninhibited.
    For clinical approach, 107-8 autochthonous lymphocytes suspended in 2-6 ml of normal saline were inoculated into tumor, through Ommaya reservoier which had been established at the time of operation.
    Five patient out of nine have already died. Clinically, there seems to be considerable prolongation of the life. Marked necrosis of tumor tissue accompanied lymphocytes infiltation was found at autopsy examination.
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    1976 Volume 16pt2 Issue 5 Pages 427-435
    Published: 1976
    Released on J-STAGE: December 28, 2006
    Arterial bifurcations in the circle of Willis were observed three-dimensionally in 44 cases of cerebral aneurysm and 45 control cases. Variations of the circle of Willis were also studied in relation to cerebral aneurysm. The following results were obtained :
    1. Aneurysm always occurred at the apex of the cerebral arterial bifurcation where axial flow in the parent artery immediately proximal to the aneurysm was assumed to impinge.
    2. A statistically valid correlation was found between cerebral aneurysm and anterior middle cerebral artery. A statistically valid correlation was also noted between the external diameter of the parent arteries and the side of aneurysms in 19 anterior communicating aneurysms and 5 posterior communicating aneurysms. When the proximal portion of the anterior cerebral artery or when the posterior communicating artery was thicker than the contralateral one, the aneurysm tended to occur on the thicker side.
    3. One aneurysm developed on a dilated feeding artery of an associated cerebral arterio-venous malformation. Another one developed at the proximal branching point from an associated accessory middle cerebral artery.
    These results show the preponderence of the occurrence of cerebral aneurysm at sites where blood flow is relatively abundant because of some variation in the form of the circle of Willis. They also suggest that hemodynamic stress plays an important role in the pathogenesis of cerebral aneurysm.
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  • —With Special Reference to the Human Growth Hormone Secretion—
    1976 Volume 16pt2 Issue 5 Pages 437-444
    Published: 1976
    Released on J-STAGE: December 28, 2006
    The present study was performed to evaluate the hypothalamo-pituitary function in cases with cerebral aneurysm.
    1. To assess the hypothalamo-pituitary function, serum human growth hormone (HGH) levels were measured after insulin-induced hypoglycemia, befor and after the surgery.
    2. Impairment of HGH secretion was observed in 69 cases out of 142 cases (41 %) before the operation and 47 cases out of 96 cases (49%) after the operation.
    3. A high frequency of impaired HGH level was found in the cases which were measured in the acute phase within 4 weeks after the subarachnoid hemorrhage (22 cases out of 34 cases: 65%) and 2 weeks after the surgery (28 cases out of 48 cases: 58%), which had shown prolonged disturbance of consciousness after the subarachnoid hemorrhage (26 cases out of 43 cases: 60%) and continued to show the various neurological deficits (30 cases out of 55 cases: 55%).
    4. The aneurysms at the internal carotid artery, followed by those at the anterior communicating artery (13 cases out of 50 cases: 26% and 11 cases out of 63 cases: 17%, respectively), were most likely to produced the severe impairment of HGH levels. On the contrary, the impairment was rare in the middle cerebral aneurysms (2 cases out of 24 cases: 8%).
    5. The moderate to severe impairments were seen in 3 cases out of 4 cases with the giant aneurysm in the internal carotid artery and all 4 cases showed severe internal hydrocephalus.
    6. The newly appeared impairment after the surgery was not seen when the microsurgical techniques were used in the operation.
    7. In case of anterior communicating aneurysms, the projection of the aneurysmal dome influenced on the HGH levels after the surgery; the upward projection impaired the function more frequently than the downward projection.
    8. We think that impaired HGH levels were caused by several factors as follows; the circulatory disturbance and brain damage in the hypothalamo-pituitary region after the subarachnoid hemorrhage, surgical maneuver and direct compression by the giant aneurysm on the same region, and presumably the corticosteroid administration in acute phase after the surgery.
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    1976 Volume 16pt2 Issue 5 Pages 445-452
    Published: 1976
    Released on J-STAGE: December 28, 2006
    The surgical attitude has changed over the few years to a more active approach, because early closure of ruptured meningomyelocele appear to have prevented the death and decreased the occurence of disability. But, long term results of early operation of infants born with ruptured meningomyelocele are disapointing in spite of an immense effort to minimize their handicaps.
    Although it is indicated that the improvement of early operation does not lead to fewer, but to more, handicapped children, authors have recently applied microsurgical technique and electrical stimulation at the early stage operation (8-24 hours after birth) as described detail in this paper.
    Thirty cases are selected by the criteria shown in Fig. 1 for candidate of operative treatment. Sixteen cases of them are treated by microsurgical operation at early stage and other 14 cases are treated by conventional operative method.
    On the both group, the clinical evaluation about occurence of hydrocephalus, disturbance of bladder and sphincter control and motor activity of the lower extremities are comparatively done at pre and 6-14 months after operation.
    The outcomes following the early microsurgical operation described in this paper are as follow; 1) there is no operative mortality, 2) 33% of all cases can walk and 42% can stand up without any help, 3) sphincter function is normalized in 50% of all cases. Rectanal reflex changes to normal response in 40% of all cases, 4) bladder function becomes normal in 64% and its recovery is not always related with recovery from disturbance of anal reflex nor motor function, 5) but the incidence of hydrocephalus following the operation is almost same as that of conventionally operated cases.
    It might be concluded that the early operation to preserve functioning exposed neural tissue by using microscope and electrical stimulation is a better treatment for the ruptured meningomyelocele.
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    1976 Volume 16pt2 Issue 5 Pages 453-459
    Published: 1976
    Released on J-STAGE: December 28, 2006
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