Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
Volume 19, Issue 11
Displaying 1-10 of 10 articles from this issue
    1979 Volume 19 Issue 11 Pages 1027-1038
    Published: 1979
    Released on J-STAGE: November 10, 2006
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  • —A Classification According to the Dynamic Changes on Sequential CT's—
    1979 Volume 19 Issue 11 Pages 1039-1051
    Published: 1979
    Released on J-STAGE: November 10, 2006
    After the introduction of CT (Hitachi CT-H) in February, 1977, we experienced 34 cases of traumatic intracerebral hematoma (ICH). In our previous report, we classified 11 cases of these into four groups based on the CT findings. In this paper, we modified certain parts of this classification, according to the dynamic changes on CT. The first group includes six cases whose ICH's were removed soon after the admission and one patient who expired shortly after the admission. The second group includes three cases whose initial CT's revealed small ICH's but repeat CT's disclosed large ones. The third group consists of eight cases whose ICH's were supposed to have developed out of cerebral contusion. The fourth group includes 16 cases whose ICH's shrinked or disappeared spontaneously.
    From analytical studies of these groups, it was clarified that the enlargement or disappearance of the ICH on CT coincided well with the clinical deterioration or spontaneous improvement.
    Recently, Brown, et al. and Diaz, et al. reported cases in which ICH's were demonstrated by repeat CT's and gave them the generic name of, “delayed traumatic ICH”. We also experienced such cases, but we did not think that these patients had “delayed traumatic ICH's”. From the analysis of our material, we considered that in these cases, evolution of ICH's could only be demonstrated by repeat CT's during the acute stage of the usual traumatic ICH's.
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    1979 Volume 19 Issue 11 Pages 1053-1061
    Published: 1979
    Released on J-STAGE: November 10, 2006
    Two hundred patients who were treated in the emergency departments of two Osaka hospitals were selected for this study. These patients were suffering from single, closed head injury, were admitted within 12 hours of trauma, and were deeply unconscious (30 or more points in 3-3-9 classification) for more than 24 hours after trauma. The relationship between initial clinical signs upon admission and actual outcome one month after admission were studied retrospectively by the chi-square test. The patients were classified into four categories: 1) able to feed himself; 2) unable to feed himself; 3) death other than brain death; and 4) brain death. Five initial features (level of consciousness, size of pupils, pupillary reaction to light, motor paralysis, and age) proved to correlate significantly (p<0.01) with outcome. Change of consciousness, rigidity, Babinski's sign, skull fracture, respiration type, and elapse of time after injury were not significantly correlated with outcome. The discriminant function was calculated by “multivariate analysis” using a computer to investigate the relationship among the above stated five features. The following formula was obtained.
    Z=-1.52X1-0.57X2+0.12X3-0.40X4+0.40X5+0.36X6+0.65X7+0.29X8+0.75X9+0.02X10-0.65 (X1-9 = 0 or 1, X10=age)
    Good prognosis (Outcome 1) could be discriminated from poor prognosis (Outcomes 2, 3, 4) by the Z value of zero. The discriminant ratio of this function was 67% in the good prognosis group and 74% in the poor prognosis group.
    We recently applied this formula on 101 more patients and it proved to be correct in 80% of these new materials. Using the formula, we evaluated the results of treatment of 101 new patients compared with the 200 old patients by the F-test. We believe that this discriminant function can offer a prognostic index in individual patients. It is impossible to estimate the result of a therapy without such a reliable prognostic function.
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  • —As an Indicator of Vascular Reconstruction—
    1979 Volume 19 Issue 11 Pages 1063-1070
    Published: 1979
    Released on J-STAGE: November 10, 2006
    99mTc-dynamics study” and computed tomography (CT) were analyzed on patients with ischemic lesions of the unilateral middle cerebral artery. Regions of interest (ROIs) were placed symmetrically on both hemispheres in frontal static scanning image, and their count ratios to the background were plotted on the time scale. Mode of transit time (MOTT) of the patients were prolonged bilaterally compared to the controls. The prolongation was more marked on the lesion side especially in acute cases, and it gradually became normal with the passage of time from onset. The plotted curves (count ratio dynamics) of the ROIs on the lesion side were clearly divided into the following four types: gradually increasing pattern (Type I); pattern of higher count ratio than contralateral side without gradual increase (Type II) ; decreasing pattern and lower count ratio than contralateral side (Type III) ; and gradually decreasing pattern almost identical to the contralateral side (Type IV). There is no correlation between MOTTs and the four types of count ratio dynamics. Therefore, the factors affecting the MOTT (the primary hemodynamics) seemed to be different from those of count ratio dynamics (pathological changes following ischemia). These types were very characteristically distributed by the duration from onset. The majority of Type I was distributed after the 4th week from onset and a small percentage in earlier phases. Type II was similar to Type I, but it seemed to be seen in relatively earlier phases. Type III was characteristically distributed in two phases; ultra-acute phase and late chronic phase. Type IV was distributed over all phases, except ultra-acute. The findings of CT also had close correlations to difference in type. The results from Type I indicated that the increasing pattern of gamma-ray ratio in acute cases seemed to reveal the accumulation of radio-isotope (RI) at the extravascular spaces probably due to disruption of blood-brain barrier (B.B.B.). In chronic cases, the accumulation of RI would be due to neovascularization without B.B.B. and/or to necrotic brain tissue. Type II suggested focal hyperemia (luxury perfusion). The ultra-acute cases in Type III usually showed normal CT findings but they frequently changed to Type I or Type II along the course of time. Type III seen in the ultra-acute phase was thought to reveal the state of low perfusion not associated with massive disruption of B.B.B. In late chronic phase having massive low density (LD) without mass effect (ME) or contrast enhancement (CE), may suggest the terminal stage of massive infarction. Type IV suggests mild or no change of cerebral circulation.
    It is concluded that Type I and Type II cases with ME and CE are contraindicative for surgical revascularization in acute phase, because they have disrupted B.B.B. massively. On the other hand, Type III and Type II cases with normal CT findings have an indication for vascular reconstructive surgery.
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    1979 Volume 19 Issue 11 Pages 1071-1075
    Published: 1979
    Released on J-STAGE: November 10, 2006
    C3H mice aged 56-70 days, weighing 27-37 g. were used throughout this experiment. A transplantable fibrosarcoma arising spontaneousely from C3H mice was used. For experiment, 104 tumor cells suspended in 0.025 ml of saline solution were injected into the cerebral hemisphere by a 26 gauge needle with a micrometer syringe under nembutal anesthesia.
    Whole brain irradiation was performed at 7 days after injection of the tumor cells and the radiation doses were 2, 000 and 20, 000 rads, respectively. The feature of x-rays were 200 kVp, 20 mA, 0.5 mm Cu + 0.5 mm Al filtration and TSD 20 cm. The dose-rate was 340-360 R/min.
    The articles of this study were as follows:a) Determination of LD50 values for the mice, tumor-bearing in the brain or non-tumor-bearing; and b) Observation of clinical features and gross autopsy findings of the mice following irradiation.
    The LD50 values for 2, 000 rad irradiation in the tumor-bearing or non-tumor-bearing mice were 10.9 and 11.4 days, respectively. LD50 values of 3.7 days and 4.3 days were the results for the tumor-bearing and non-tumorbearing mice irradiated by 20, 000 rad, respectively. On the other hand, the LD50 value for the control group, i.e. non-irradiated mice, was 6.7 days.
    At postmortem examinations, gastrointestinal bleeding was observed frequently in mice bearing tumor in the brain.
    Whole brain irradiation is effective to prolong the life of tumor-bearing mice. However, in some instances, deaths have occurred earlier in tumor-bearing mice compared to the control group.
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    1979 Volume 19 Issue 11 Pages 1077-1084
    Published: 1979
    Released on J-STAGE: November 10, 2006
    The anterior falx artery which is a small meningeal branch of the anterior ethmoidal artery from the ophthalmic artery was described by Kuru (1967). Shiga(1968), Pollock and Newton (1968) reported the anatomy, angiographic features and some clinical evaluations of this artery.
    In this report, we shall demonstrate the angiographic findings and clinical evaluation of the anterior faix artery, based on a thousand patients, or 1254 serial angiograms which were taken between July, 1973 and June, 1978. All these angiograms were of good quality. Through the analysis of these material, the following results were obtained:
    The anterior falx artery was visualized in 21% of 217 normal cases and in 35% of pathologic cases (Table 1). This artery was visualized in 33.2% of left carotid angiograms, but only in 18.2% of right carotid angiograms. We also noticed that this artery is opacified more frequently in the pathologic side than the other side (Table 2). Bilateral carotid angiograms were taken in 221 patients and 94(42%)showed anterior falx arteries. In eight cases, two different anterior falx arteries were demonstrated.
    Anterior falx artery is important for collateral circulation in moyamoya disease and cerebral thrombosis. This artery sometimes supplies the meningioma, the arterio-venous malformation and other tumors invading into the dura. In addition, it could be stressed that there was dilatation of this artery in many patients with chronic subdural hematoma, subacute meningitis or malignant leptomeningeal dissemination. These dilatations may be due to compression of bridging vein and/or to circulatory change. Another important feature is the change of visualization of this artery in the same patient.
    In 15 of 28 patients in whom carotid angiographies were repeated, the visualization of the anterior faix arteries varied following clinical course from one examination to another.
    These differences were demonstrated between preoperative and postoperative angiograms in cases of subdural hematoma, cerebral tumor and acute head injury. These observations have convinced us that the anterior faix artery often has important clinical significance.
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    1979 Volume 19 Issue 11 Pages 1085-1093
    Published: 1979
    Released on J-STAGE: November 10, 2006
    It is well known that cerebral vasospasm following ruptured cerebral aneurysm affects the prognosis very seriously after direct surgery. However, the pathogenesis of cerebral vasospasm remains obscure. Furthermore, the precise brain damage following it has not been made clear histopathologically.
    The histopathological postmortem studies of intracranial arteries with angiographycally demonstrated arterial narrowing have been carried out in 44 cases.
    The cerebral arterial wall corresponding to the angiographic vasospasm showed various structural changes, which could be divided into five groups according to histological findings.
    In Group 1, the intraluminal size of arterial wall was reduced even though the medial thickening, marked corrugation of the internal elastic lamina and intimal edema were demonstrated. In Group 2, necrosis of smooth muscle cells in the tunica media, partial break of internal elastic lamina and the profuse deposition of acid mucopolysaccharides were seen. In Group 3, marked intimal thickening and the medial atrophy were seen. In Group 4, dilatation of luminal size with improvement of the intimal thickening and the remarkable medial atrophy were noted. In Group 5, regeneration of smooth muscle cell in the tunica media was observed.
    These histological findings suggest the time course of cerebral arterial spasm from onset to remission.
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    1979 Volume 19 Issue 11 Pages 1095-1105
    Published: 1979
    Released on J-STAGE: November 10, 2006
    Carcinoembryonic antigen (CEA) in plasma, cerebrospinal fluid (CSF) and cystic fluid of patients with various intracranial tumors were determined by a radioimmunoassay using Dainabot and Roche CEA Kits.
    Slightly elevated levels of plasma CEA were noted in 6 (4%) out of 161 (6/161) patients with primary brain tumors: gliomas, 3/67; pituitary adenomas, 0/30; meningiomas, 0/28; acoustic neurinomas, 1/12; pineal tumors, 2/12 (germinomas, 1/8; teratoma, 0/1 ; teratoblastoma, 0/1 ; embryonal carcinoma, 1/1 ; not verified histologically, 0/1); craniopharyngiomas, 0/6; hemangioblastomas, 0/2; epidermoid tumor, 0/1; reticulum cell sarcoma, 0/1; choroid plexus papilloma, 0/1; chondroma, 0/1. The plasma CEA levels of these 6 patients varied from 2.6 to 3.8 ng/ml. On the other hand, 17 (37%) out of 46 patients with metastatic brain tumor showed definite elevation of CEA levels in plasma and most of them showed values higher than 5.1 ng/ml ranging from 3.0 to 2, 317 ng/ml.
    CEA in CSF of 55 patients with intracranial tumors were determined. Since CEA levels in CSF obtained from 38 control subjects were mostly 0 ng/ml, ranging from 0 to 0.5 ng/ml, an upper limit of normal CEA level in CSF by one step sandwich method was proposed to be 0.5 ng/ml. Significant elevation of CEA levels in CSF was noted in the one of 37 patients with primary brain tumors, a patient with pineal germinoma showing a spinal metastasis, and in 8 (44%) out of 18 patients with metastatic brain tumor. All of 6 patients with leptomeningeal carcinomatosis showed elevated levels of CEA in CSF.
    CEA in cystic fluid were measured in 17 patients with intracranial tumors, including 12 gliomas, 2 craniopharyngiomas, 2 metastatic brain tumors and 1 meningioma. Elevated levels of the tumor fluid CEA were noted in 2 patients with craniopharyngioma (8.6 ng/ml and 11.0 ng/ml, respectively) and in one with metastatic brain tumor from breast cancer (14300 ng/ml). Mean value of the tumor fluid CEA of 12 glioma patients was 0.6 ± 0.6 ng/ml. A meningioma and one metastatic tumor showed low levels of CEA less than 0.5 ng/ml in the tumor fluids.
    Study on sequential determination of CEA in plasma or CSF performed on three patients revealed that CEA levels were well-correlated with the activity of the tumors and could be used for evaluation of treatment or foreknowledge of recurrence of tumors.
    In conclusion, determination of CEA in plasma or CSF is valuable for differential diagnosis between primary and metastatic brain tumors, evaluation of treatments, or fore-knowledge of recurrence of tumors. Determination of CEA in CSF could be very useful especially for diagnosis of leptomeningeal carcinomatosis.
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    1979 Volume 19 Issue 11 Pages 1107-1113
    Published: 1979
    Released on J-STAGE: November 10, 2006
    Clinical study was conducted on 14 cases of large prolactinoma. Such cases were most common in patients in their 20s and 30s; i.e. in comparatively young persons. Of the total, 7 were male and 7 were female. Visual disturbance was observed in all cases (anisocoria 3, disturbance of EOM 4, cerebellar signs and hearing disturbance 1, amenorrhea 4, and primary amenorrhea 2). Two cases (female) were accompanied by galactorrhea. Prolactin in blood showed unusually high values in the range of 1, 050 to 15, 000 ng/ml. Incidences of impaired growth hormone response to ITT was 92%, that of impaired LH and FSH responses to LH-RH were 69 and 61 %, respectively, and that of impaired TSH response to TRH was 38%.
    Plain skull films revealed irregular destruction of sella turcica in many cases. Pneumoencephalography and CT scan showed 7 cases of suprasellar extension. In the remaining 7 cases, 2 cases of parasellar extension besides suprasellar extension, 2 temporal extension, one posterior (infratentorial) extension, and 2 panaivasive extension, with a tendency to further develop and extend in all directions, were noted. For these reasons, results of removal of the tumors by the transfrontal approach were insufficient in many cases. In one case, decline of prolactin in blood was insufficient even after extirpation, but reduction of the size of tumor and decrease of prolactin were obtained by the administration of bromocryptine (CB-154).
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  • —Part VII Neuro-otological Findings of Acoustic Tumors (1)—
    1979 Volume 19 Issue 11 Pages 1115-1120
    Published: 1979
    Released on J-STAGE: November 10, 2006
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