In recent years, patients with various respiratory disturbances to be treated with artificial ventilation for prolonged period have been increasing in number. In such case, the decision for adequate tidal volume and O₂ concentration is the most fundamentally important factor, but the effect of artificial ventilation to the central nervous system must be considered. We discussed in this paper the effect of prolonged artificial ventilation with O₂ to brain.
Adult cats were used for experimental animals. Systemic BP, ICP, EEG and ECG were monitored and recorded under artificial ventilation with room air or pure O₂, and arterial blood gas was analyzed intermittently. When animals sacrificed, the brain was irrigated with barium-gel. Sections were made for histopathological examination, and soft X-ray for microcirculation.
Pure O₂ inhaled animals showed ICP increase and elevation of systemic BP within 24 hours. In fetal cases, pressure wave phenomenon was observed within 48 hours, i.e., acute brain swelling was developed. The mortality rate of this group was 67%.
On the contrary, room air animals showed ICP and BP were stabilized until the termination of the experiments.
The examination for microcirculation in pure O₂ animals revealed severe circulation disturbance and decrease of capillaries in number in all animals. Histological examination revealed pathological changes in whole brain; degeneration of neurones, gliosis, demyelination, disruption and swelling of axons, and vacuolations. Especially on the cerebellum, degeneration of Purkinje' cells and status spongiosus in granular layer were observed.
At this time, we cannot clearly explain the pathological effect of O₂ to brain, but prolonged artificial ventilation with highly concentrated O₂ is responsible for the development of such severe condition by the tissue toxicity or vasoconstriction of O₂.

View full abstract

On the basis of reports about the clinical application of Transfer Factor (TF) which was first reported by Lawrence in 1955, we investigated the possibility whether or not the immunological application of the TF for glioblastoma is available.
1. Microassay of cytotoxic activity of lymphocyte was performed in cases of glioblastoma pre and postoperatively. Tumor cells from a glioblastoma cell line and strain were used as target cells, and they were mixed with lymphocytes by Takasugi and Klein's method. Survival rate of the tumor cells were lower in 8 preoperative cases (11.0±17.4%) than in 10 postoperative cases within one month after removal of the tumor (78.5±13.9%).
2. The influence of TF of cytotoxic activity of lymphocyte was examined with the same method. The TF was obtained from cases of glioblastoma and control cases by Lawrence's method and was added to the mixed lymphocytes-tumor cells cultured. As the result, only the TF obtained from glioblastoma patients showed the augmentation effect for cytotoxic activity of lymphocyte in glioblastoma patients. In this group, the cytotoxic activity of lymphocyte was increased by TF about 43%, 32% (target cell; KS-1 cell, target cells/lymphocyte ratio; 1/250, 1/125), and 39%, 30% (target cell; GL-2 cell, target cells/lymphocytes ratio; 1/250, 1/125).
These observations suggest the possibility of immunological diagnosis of glioblastoma by cytotoxic activity test of lymphocytes utilizing glioblastoma cells and of immuno-therapy of glioblastoma by TF.

View full abstract

The authors investigated the temporal response to the enhancement by the contrast medium infusion in the computed tomography for the differential diagnosis of intracranial tumors. In ten cases of intracranial tumors (two cases of meningiomas, acoustic neurinomas, glioblastomas and metastatic cancers and one case of pituitary chromophobe adenoma and craniopharyngioma), the effect of the enhancement was examined at 15, 30, 60, 120 and 180 minutes after the infusion of the contrast medium. The results were analysed about both the enhanced figures of the lesion on the monitor TV and the estimation of the attenuation value of the lesions.
The results about the enhanced figures were as follows; 1) each part of the lesion did not always show the synchronous appearance or withdrawal, 2) there were time differences in the appearance or withdrawal of the enhanced effect according to the kinds of the intracranial tumors and 3) the precise size or form of the lesions could not be sufficiently demonstrated in the early scan within 30 minutes and the delayed scan was mandatory for the precise diagnosis.
According to the analysis of the attenuation response by the print-out data, glioblastomas and metastatic cancers with marked destruction of the blood-brain barrier showed late but prolonged response to the enhancement and meningiomas with rich vascular beds showed early appearance and rapid withdrawal of the response. The other tumors showed the intermediate pattern of the response.
In conclusion, the analysis of the delayed scan in computed tomography will add more precise information about the differential diagnosis of the intracranial tumors.

View full abstract

This paper reports an analysis of a series of primary brainstem injury resulted from blunt head trauma. The records of 25 patients with the diagnosis of primary brainstem injury, with decerebration, disturbed consciousness, typical manifestations of brainstem damage with no intracranial hematomas or other severe complications were studied retrospectively.
Our purpose is to define some of the factors affecting the prognosis of these patients. The particular factors we have evaluated are the age, the duration of decerebration, recovery time from the disturbed consciousness, other neurological findings and vital signs.
Their age varied from 3 to 67 years. Many cases in this series had a blow to the frontal or occipital region as a site of cranial impact. Skull fractures were found in 14 cases (56%). The mortality in this series was 56% (14 cases), 12 cases of which died within 7 days after the trauma.
Survived cases were classified by the residual deficits as minimal (2 cases), marked (4 cases) and prolonged coma (5 cases). Since the two cases with minimal deficits were children, it seems that the age of the patients is the most important factors for the prognosis.
The average duration of decerebration in the survived cases was 21 days in the cases with marked deficits and 14 days in the cases with minimal one. The duration less than 7 days of decerebrate state was a better prognostic sign than that more than 14 days.
Variable levels in the state of consciousness with fluctuations were found in this series. In the cases with marked deficits, mean recovery time was 77 days, whereas in those with minimal ones it was 42 days. It seems the shorter the period of the recovery, the better the prognosis.
Variable degrees of pyramidal signs, ocular symptoms or abnormalities in vital signs were seen. The mortality rate was high in the cases with bilateral pyramidal signs, dilated pupils without light reaction, anisocoria and marked fluctuations of vital signs.
These seem to be a poor prognostic signs.
There was no correlation between the pressure and appearance of cerebrospinal fluid and the quality of survivors.
The use of parenteral corticosteroids and tracheostomy were not related to the improvement of the prognosis.
It is concluded that the age was one of the most important factors affecting the prognosis of primary brainstem injury, and that the mortality and morbidity were clearly influenced by the duration of decerebration and recovery time from the state of vital signs.

View full abstract

The mechanism of no-reflow phenomenon (NRP) is still in dispute. The present study was undertaken to evaluate the role of the intravascular component, i.e., platelets and red blood cells (RBC) in the post-ischemic period. Cerebral ischemia was induced in mechanically ventilated dogs by infusion of physiological saline into the cisterna magna at the pressure of 150-200 mmHg for 10-20 minutes. The local cortical CBF (1 CBF) was recorded with a double-needle type thermocouple. The systemic arterial pressure, cisterna magna pressure and cerebral impedance were also monitored.
Blood samples were obtained from the superior sagittal sinus (SSS) and the femoral vein. The three dimensional changes of platelets and RBC were observed by scanning electron microscope and the platelet aggregability to ADP was recorded by Evans aggregometer. The course of 1 CBF was divided into two patterns in the post-ischemic period. In the first, reactive hyperemia was pronounced and in the second, it was only slight or none.
In the latter group with apparent NRP, the changes of platelets and RBC were remarkable especially in the SSS.
Platelets took the activated forms, i.e., pseudopod formation, spreading, surface folds and irreversible membrane fusion (platelet aggregation). Concerning RBC, discocytic shapes were transformed into echinocyte, keratocyte, schizocyte and so on, but no RBC aggregates were found. Platelet aggregability to ADP became lower after cerebral ischemia, being especially prominent in the no-reflow group.
It is concluded that activation of platelet aggregability as well as the morphological change of platelets and RBC are induced by cerebral ischemia, both of which may contribute to the pathogenesis of no-reflow phenomenon.

View full abstract

The treatment of subarachnoid hemorrhage following rupture of cerebral aneurysms should be performed from the early period. The authors obtained favorable results by conducting early operation on ruptured cerebral aneurysms using a continuous ventricular drainage during and after the operation.
There were 137 cases of ruptured cerebral aneurysms operated between November 1973 and June 1976. The continuous ventricular drainage was indicated on: 1) acute cases (operation was performed within 7 days after the hemorrhage) ; 2) cases of disturbed consciousness; 3) cases in which vasospasm and dilated ventricles were observed on the preoperative cerebral angiography; 4) cases in which clot, bloody CSF or other troubles were observed during the operation. Thus, the continuous ventricular drainage was performed in 56 cases (40.9%), and in addition, V-P shunt was conducted in 26 of them 11.6 days in average after the operation. Fluctuations of ventricular fluid pressure after the operations of cerebral aneurysms were observed and treated. Because that the cases of the early operation were still under the state of acute hydrocephalus the continuous ventricular drainage was very effective and necessary for monitoring and controlling the postoperative intracranial pressure. As the advantages of continuous ventricular drainage, it prevents the secondary cerebral damage due to increased intracranial pressure, improves cerebral blood flow, decreases the occurrence and progress of vasospasm due to bloody CSF exudation, indicates the precise intracranial pressure, and it helps in making a decision of shuntoperation at the early period. Owing to this last advantage, the occurrence of secondary so-called normal pressure hydrocephalus will be prevented before irreversible changes being induced. In the 10 cases treated by the continous ventricular drainage along with the continuous chiasmatic cisternal drainage, the chiasmatic cisternal pressure was quite parallel to the ventricular fluid pressure in cases having no block in the basal cistern. The ventricular drainage may be replaced by the continuous chiasmatic cisternal drainage.
Thus the authors suggested that the early operation should be positively performed on ruptured cerebral aneurysms using the continuous ventricular drainage.

View full abstract

One thousand and eighty intracranial saccular aneurysms were experienced at Tohoku University between June 1961 and Sep. 1975. Direct surgery, clipping and/or ligation of the aneurysm neck, was performed in 1000 cases with a mortality rate during hospitalization of 6.1 percent.
The causes of death in fifty-five of the 61 deaths were retrospectively classified into one due to inappropriateness for surgery, due to complications during surgery and due to complications after surgery. The causes of death in six cases could not be understood sufficiently. They were operated on without complications between the third and seventh day after the initial aneurysmal hemorrhage. Based on the study of these pre and post-operative states and the operative and autopsy findings, the criteria for early surgery are discussed.
If the patient is in the uphill course of consciousness, direct surgery should be done within 24 hours and at latest 48 hours after the attack in order to avoid severe angiospasm caused by massive subarachnoid hemorrhage. During the operation subarachnoid clots should be aspirated as thoroughly as possible, and postoperatively, continuous ventricular drainage should be employed to control intracranial pressure.
Early operations within 48 hours are strongly recommended since the probability of death from severe intracranial vasospasm or irreversible neuropsychiatric complications increases progressively. When the chance for early surgery has been lost, we would like to recommend to delay the direct surgery until the 10th to 14th day when angiospasm may be released. Even in the surgery during this period, appropriate administration of Sodium Nitrite may be effective in preventing severe vasospasm.
Though generally we recommend early direct surgery, cases in the vegetative state or in low consciousness levels should be only treated by shunt operation, and not by intracranial surgery.

View full abstract

Coexistence of spinal arteriovenous malformation and aneurysm is quite rare. Eleven cases verified by angiography and/or operation had been reported so far in literature. The authors reported a case of cervical spinal arteriovenous malformation combined with aneurysm. This case was third case in Japan.
A 21 years old woman suddenly developed intractable headache with nuchal pain on May 13, 1976. Lumbar puncture showed blood in the cerebrospinal fluid. Positive neurological findings on admission were mild left-sided hemiparesis, diminished left biceps and triceps jerks, thermohypesthesia below L4 dermatome and urinary retention. Left vertebral angiography demonstrated typical arteriovenous malformation with fusiform aneurysm.
On June 17, clipping of feeding arteries, partial removal and obliteration through coagulation of arteriovenous malformation were performed by the use of operating microscope. Postoperative course was uneventful.

View full abstract