Twenty-three patients with active acromegaly were subjected to transsphenoidal microsurgery, during the past two years. These patients were preoperatively classified into 14 TRH responders, 5 LH-RH responders and 2 nonresponders. L-DOPA and bromocryptine effectively reduced serum growth hormone (GH) levels in most of TRH responders, but in none of LH-RH responders and non-responders.
Pre and post-operative basal serum GH levels ranged between 9.0 and 484.0 ng/ml, 3.6 and 80.6 ng/ml, respectively. In 19 patients who could be followed up longer than 3 months, post-operative serum GH concentrations were below 10 ng/ml in 14 patients, but in many cases abnormal GH responses to TRH and LH-RH were still present. However, in 6 cases abnormal GH responsiveness to TRH or LH-RH was reverted to normal, preserving normal GH increase after insulin hypoglycemia. Overall results suggest that surgical success is very high when the tumor is localized in the sella.
Autonomy of GH secretion by the surgical specimen from 4 patients was found to be continuing a month later by the culture method and rich secreting granules were confirmed in the cytoplasm.
These results suggest that the primary lesion in acromegaly would be in the pituitary gland, being partly influenced by hypothalamic factors.
Revertion of abnormal GH responsiveness to non-specific releasing hormone is a good indicator of the completeness of the operation and these provocative tests are very useful for postoperative follow-up study in acromegaly. L-DOPA or bromocryptine treatment should be applied to cases with insufficient operative results.

View full abstract

This report reviews our experience with 52 cases of intracranial tumors in children under 2 years of age observed and treated in the Neurosurgical Department, Children's Memorial Hospital, Chicago and in the Department of Neurosurgery, Kobe University Hospital, in Kobe, Japan from 1962 to 1975. All tumors were diagnosed histologically under 2 years of age except for one case of so-called unverified glioma. The youngest was 4 days of age and the oldest was 24 months of age. 9 patients were newborn, 24 infants and 19 toddlers. There were 32 boys and 20 girls. The location of tumors of children under 1 year of age were predominantly in the supratentorial area. More astrocytoma (29%) were found than medulloblastoma (19%), optic glioma (15%), ependymoma (8%) or choroid plexus papilloma (8%). Pathohistological characteristics were the extensive tumor invasions. Especially in neonatal brain tumors, inmature cells, rapid tumor growth and high malignancy were the most frequent findings.
Since most brain tumors in early life were located along the cerebral axis, obstruction of cerebrospinal fluid circulation that resulted in hydrocephalus was the most common clinical finding. Enlarged head, vomiting and irritability were the cardinal symptoms. The younger the infant, the greater the incidences of increased head sizes, and the older infants and toddlers showed higher incidences of vomiting and irritability. Bobbing of the head was observed in 2 cases, one with a large craniopharyngioma and the other with a choroid plexus papilloma of the third ventricle. Forty-five patients underwent primary surgery for tumor removal. Out of 45 cases of hydrocephalic infants, 29 cases were treated with shunting procedures either after or before primary surgery. Our present approach for hydrocephalus due to the intracranial tumors is to stage our procedures so that the initial shunting operation is followed in one or two weeks by definitive surgical attack. Radiation therapies were conducted in 27 cases (51 %) including one case of highly vascular tumor of a deep cerebrum which was treated by radiation therapy alone. Seven cases had chemotherapy. Twenty-three patients had steroid therapy pre and post-operatively. Five of these, all with posterior fossa tumors, suffered gastrointestinal hemorrhage. None of the patients who did not receive steriod therapy developed gastrointestinal bleeding. In 45 cases, which were available for follow-up study, 19 cases (42.2%) expired in 3 months postoperatively. The longest survival, 11 years, was in a child with a choroid plexus papilloma of the lateral ventricle. Absolute 2-year survival of sarcoma was 75%, optic glioma 60%, astrocytoma 61.5%, ependymoma 33% and medulloblastoma 0%. Out of 7 cases of medulloblastoma available for follow-up, 6 patients expired in 3 months after primary surgery. The prognosis of the medulloblastoma under 2 years of age was extremely poor.

View full abstract

Thirty-nine samples of meningiomas were studied with respect to activities of N-acetyl-glucosaminidase, β-glucuronidase, acid phosphatase, and arylsulfatase. Meningiomas were classified as meningotheliomatous (4), transitional (12), fibroblastic (6), angioblastic (3), malignant (11), and unclassified types (3). Samples were obtained at surgery and homogenized in 0.32 M-sucrose. The total activities were measured using a Triton X-100 (0.1 %) activated sucrose suspension of tissue. Elevation in total activities of four enzymes in the tumor samples over the control grey and white matter values was highly significant except in samples of angioblastic meningiomas. This was particularly striking in glucosaminidase. Malignant meningiomas showed the greatest increase in total activities. A sevenfold increase of glucosaminidase and two to fourfold increase of β-glucuronidase, acid phosphatase and arylsulfatase were seen. Moderate increase of activities of four enzymes were seen in meningotheliomatous, transitional, and fibroblastic types. Activities of angioblastic meningiomas, three samples of hemangioblastic variant, did not show any increase compared with normal brain.
It appears, therefore, that the high activities of lysosomal enzymes are to be viewed as characteristic of malignant meningiomas and this can serve to distinguish them from other types of meningiomas.

View full abstract

Pathogenesis and etiologic factors in transient ischemic attack (TIA) were briefly reviewed with emphasis on intra and extracranial atherosclerotic changes and indication for surgery.
TIA is a clinical syndrome, which can only be defined by clinical features and is not confined to specific pathological changes in the brain or in the vascular system. Various pathogenic concepts and etiologic factors have been reported in the literature. The vasospasm theory in pathogenesis of TIA is now almost abandoned. There have been no experimental findings nor any other grounds to assume that vasospasm frequently causes TIA. Most patients with TIA become symptom-free by anticoagulation and many other evidences suggest that vast majorities of TIA are due to thromboembolism including so-called “microembolism.” However, transient fluctuations of cerebral perfusion pressure can also be a causative factor of TIA in a small number of cases, as pointed out by DennyBrown (so-called “cerebrovascular insufficiency”). In either case, the main etiologic factor can be attributed to atherosclerotic changes in the intra and extracranial arteries. Incidences of vascular changes in the intracranial cerebral arteries seem to be higher in this country than in European countries or in the USA.
In rare cases of TIA, various other pathogenic conditions, such as polycythemia, thrombocytosis, kinkings and coilings of the cervical arteries, subclavian steal syndrome, moyamoya disease, etc, have been reported or experienced.
Thromboendarterectomy of the cervical arteries and superficial temporal artery-to-middle cerebral artery (STA-MCA) anastomosis have been tried for surgical management of TIA. From a pathogenic point of view, thromboendartectomy is recommended for cases of TIA, which is caused by thromboembolism originated from atherosclerotic foci in the cervical arteries, while STA-MCA anastomosis might possibly be applied to cases of cerebrovascular insufficiency due to various vascular changes such as stenosis of the middle cerebral artery, internal carotid occlusion, and moyamoya disease.

View full abstract

The reactivity of pial arteries to local changes in pH, ion activity and alpha sympathetic agents was investigated during recovery from 1 hour's ischemia using a topical application on filter paper.
Cats were anesthetized with pentobarbital sodium and were submitted to one hour's complete cerebral ischemia by intrathoracic arterial clamping in combination with induced hypotension. Upon recirculation after one hour of ischemia, CBF increased above the preischemic level with marked dilatation of the pial vessels. Hyperemia lasted up to about one hour after recirculation, and was followed by delayed decrease in cerebral blood flow (postischemic hypoperfusion). The pial arteries at this time constricted by more than 20% indicating that the reduction in blood flow was due to an increased vascular tone. During this phase the vascular reactivity to pH and ion activity was distinctly reduced compared with that in normal state.
Blocking of calcium ions by EDTA or the topical application of high concentration of phentolamine, on the other hand, showed marked dilatation of the pial arteries up to 130% and the constricting effect of norepinephrine was similar to that in controls.
From the results obtained in this study, it is concluded that ischemic vessels are still able to respond to the topical application of pharmacological agents, although the reactivity to the changes in pH or ion activity is distinctly reduced. Failure of improving cerebral blood flow after ischemia by systemic administration of vasoactive drugs, therefore, seems to be due to the impermeability of the blood brain barrier rather than to the postischemic unresposiveness of pial arteries to these drugs.

View full abstract

A 28-years-old female was the only one case who had an aneurysm arising from the posterior communicating artery itself in a total of 1, 080 cases of saccular aneurysms handled by our clinic. Most of the so-called posterior communicating artery aneurysms are actually internal carotid-posterior communicating artery junction aneurysms. The incidence of aneurysms arising from the posterior communicating artery itself is reported to be 0 to 3.3% of the total cases. In our case, treatment by trapping at the posterior communicating artery was performed.

View full abstract

1. Psychological testing were applied to 20 hydrocephalic patients who had had shunt operations before 1973. Thirty percent of the patients showed IQ above 80, 15% between 79 and 70, and 55% below 69. Considering the cause of hydrocephalus, the best result was seen in the patients with unknown etiology. The next was in meningomyelocele. The worst was in meningitis.
2. There was a correlation between frontal cortical thickness and mental development. Patients with cortical thickness of less than 0.8 cm showed poor developement.
3. Mental developement cannot be evaluated sufficiently by IQ score alone. After analysing the pattern of subtest score, further systemic tests must be performed. On the basis of these examinations, mental rehabilitation or educational therapy are indicated.

View full abstract

Out of 8 cases of optic nerve injury patients treated between 1971 to 1974, the most recent 4 cases underwent decompression with the optic nerve sheath incision and these cases proved to have good postoperative recovery.
1. Sheath incision contributed to the early recovery (within 7 days) of visual acuity in most cases.
2. All sheath incision cases recovered useful visual acuity (0.01 or better) postoperatively.
3. Sheath incision is apparently useful to improve visual acuity in patients who suffered edema or circulatory insufficiency of the nerve.
4. Sheath incision can be applied in cases of total blindness as shown in Case 8 of our series.

View full abstract