Neurologia medico-chirurgica

Intracranial Meningiomas : Experiences at the Mayo Clinic

Collin S. MACCARTY, WILLIAM F. TAYLOR

1979 Volume 19 Issue 7 Pages 569-574
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.569

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Classification and Treatment of Aneurysms of the Vertebro-Basilar System

Hans Werner PIA

1979 Volume 19 Issue 7 Pages 575-594
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.575

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In continuation of my concept of classification of ICA-system aneurysms the classification of the vertebro-basilar-system aneurysms is presented. The classification takes into consideration the variability and anomalies of the vessels and the site and projection of the aneurysm. The aim of this classification is to improve the preoperative topographic diagnosis and the choice of approach. The operative management has been pioneered by one man : C. G. Drake, who described the technique in detail on hand of his enormous experience with 469 aneurysms of the vertebro-basilar system. The necessity of a “normal aneurysm neurosurgeon” treating such aneurysms requires certain modifications of indication, approach and dissection. Experience with microsurgical technique of management of aneurysms is absolutely necessary.
Transoral, transclival access facilitates the direct isolation of the aneurysm at the difficult border level of the lower clivus and should become a routine similarly to the transsphenoidal operation. Electrothermic dissection of the aneurysm diminishes the risk of rupture during the isolation of the sack and facilitates the isolation of the neck.
The statistics of Drake provide full data for the prognosis of these aneurysms. It is to note that in the recent time the results reported from different centers in which aneurysmal surgery is performed became more and more similar. The embolization of large bulbous or spheric and giant aneurysms by inflatable balloon-technique possibly may replace the risky direct or indirect operations.

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Early Diagnosis of Acoustic Neurinoma—Clinical Experience of 108 Cases

Eiji SAKATA, Chigiri KANAZAWA

1979 Volume 19 Issue 7 Pages 595-603
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.595

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The majority of acoustic neurinoma cases, especially schwannoma, commence with disturbances of the peripheral vestibular system. The patient, however, often complains of tinnitus, hearing loss, unusual sensation of the tip of tongue, and slight loss of balance, but not vertigo, because the vestibular dysfunctions are compensated by the central nervous system. The disease is not always detected at this early stage and is diagnosed only when the acoustic neurinoma has grown to compress the brain stem and cerebellum.
Since acoustic neurinoma develops in the internal auditory canal, “early diagnosis” must be established while the symptoms and signs remain within the 7th and 8th cranial nerves. Problems concerning the early diagnosis of acoustic neurinoma are discussed based on results of our investigation of 108 cases, which are grouped into Stages 0 to IV.
Concerning the Stage 0 cases, the following seven points as disclosed by Sakata12) were noted: 1) severe disturbance or no reaction to caloric stimulation; 2) severe sensory neural deafness; 3) disturbance of taste over the anterior two-thirds of the tip of the tongue; 4) spontaneous nystagmus to the opposite side; 5) elevation of protein in CSF; 6) enlargement of the meatus acousticus internus (Stenver's view); and 7) facial paresis.
Concerning all of the Stage I to IV cases, the following points were noted: 1) only slight disturbance of caloric nystagmus was recognized in 2 cases; 2) nearly normal hearing was found in 3 cases; 3) elevation of the CSF protein was only 46 mg/dl at minimum; 4) no differences between right and left sides for taste were found in 4 cases; 5) nystagmus appeared in all but 2 cases of bilateral acoustic neurinoma; and 6) it is instructive that hearing loss appeared in the form of sudden deafness in 7 of the total 108 cases.
Early diagnosis at ambulatory and bedside examinations is obtained not by the complex and expensive instruments available but by practical and functional analysis of symptoms and signs.

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Diagnostic Significance of Brainstem Auditory Evoked Responses in Acoustic Neurinomas and Other Posterior Fossa Lesions

Isao HASHIMOTO, Yoji ISHIYAMA, Genkichi TOTSUKA, Hiroshi MIZUTANI

1979 Volume 19 Issue 7 Pages 605-615
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.605

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Brainstem auditory evoked responses (BER) have been studied in 67 supratentorial lesions, 10 midbrain lesions, 23 intrinsic pontine lesions and 27 extrinsic compressions of the pons, including 15 acoustic neurinomas. BER in supratentorial lesions showed completely normal records. In midbrain lesions wave V was specifically altered. As wave I is a far field reflection of the VIII nerve potential and wave V the midbrain potential, waves II to IV can be inferred to originate in the central auditory pathway between the peripheral VIII nerve and the midbrain. Alterations of these waves correlated well with the location and nature of brainstem lesions. The BER in large acoustic neurinomas showed no response to clicks on the affected side and waves of delayed latencies with stimulation on the normal side. In small to medium-sized tumors with preservation of hearing, wave I of normal or delayed latency was recorded and subsequent components were absent in the majority of cases. These alterations of BER are closely related to the size and location of the tumors.

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Otoneurological Approach to Diagnosis and Removal of Acoustic Neuroma

Naoaki YANAGIHARA, Kiyofumi GYO, Yasushi MATSUMOTO, Eiji YUMOTO

1979 Volume 19 Issue 7 Pages 617-621
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.617

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Twenty one patients operated on by transtemporal microsurgical approaches are reviewed. Although the series is small, the results of operation indicate definite advantages of the translabyrinthine approach while the tumor size is adequate. With the advancement of diagnostic procedures and surgical experiences, the results continue to improve and total removal of the tumor can be achieved in all patients with very low morbidity. Emphasis is placed on systematic otoneurological examinations which suggest the presence of the acoustic neuroma at its early stage. Polytomography and meatocisternography are particularly valuable for early detection of the tumor.

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Bilateral Acoustic Tumors : Its Clinical Features and Surgical Treatment

Hiroyuki SHIMIZU, Hideaki MASUZAWA, Keiji SANO

1979 Volume 19 Issue 7 Pages 623-627
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.623

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The authors have experienced 18 cases of bilateral acoustic tumors. They were found to occur most often in relatively young subjects and often to be associated with von Recklinghausen's disease. In spite of the existence of bilateral tumors, the patients frequently retained unilateral auditory function. Visual disturbance due to secondary optic atrophy was observed occasionally.
The mortality rate of operation was fairly high. The cause of death was mostly brainstem damage induced by simultaneous removal of large bilateral tumors. In many of the surviving patients, auditory function was sacrified in spite of fair postoperative course.
The most advisable stratagem for surgery is thought to be as follows.
1) Bilateral large tumors should be submitted to surgery in two sessions.
2) The maintenance of residual hearing function should be considered superior to radical removal of tumors.
3) Decompressive craniectomy alone is not effective.

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Supine-lateral Approach versus Sitting Operation—Statistical Analysis of Brainstem, Cranial Nerve and Cerebellar Function in 165 Acoustic Neurinomas

Chikayuki OCHIAI, Hideaki MASUZAWA, Shinya MANAKA, Keiji SANO, Ken KIT ...

1979 Volume 19 Issue 7 Pages 629-635
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.629

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Among 165 cases of unilateral acoustic neurinomas operated on at the Department of Neurosurgery, University of Tokyo, 29 cases were treated in the sitting position and 18 cases by the supine-lateral approach both using a microscope. In spite of the difficulty of keeping the operative field clear, the supine-lateral approach has certain advantages. Not only the danger of air embolism is avoided, but also a wide field providing access to the brainstem can be facilitated without undue retraction of the cerebellar hemisphere.
Our operative results indicate that in the supine-lateral approach the period of postoperative hospitalization is shortened, that the facial nerve is better preserved and that postoperative residual neurological complaints, especially staggering gait are less frequent.

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Microsurgery for Acoustic Neurinoma—Lateral Position and Preservation of Facial and Cochlear Nerves

Kenichiro SUGITA, Shigeaki KOBAYASHI, Naomi MUTSUGA, Yoshio SUZUKI, Te ...

1979 Volume 19 Issue 7 Pages 637-641
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.637

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Twenty two cases of acoustic neurinoma were operated upon in the lateral position under an operating microscope during the past three years. Anatomical and physiological preservation of the facial nerve was successfully achieved in 19 cases. Electrical stimulation of the facial nerve using bipolar forceps proved to be very useful. Sound monitoring with tremorgraphy pick-ups on the face was designed for observation of facial movement driven by nerve stimulation. Hearing acuity could be preserved postoperatively in three large sized neurinomas with the aid of direct recording of action potentials on the cochlear nerve during surgery. Advantages of the lateral position and some instrumental improvements for surgery are discussed.

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Stationary Potential of the Brain : Part I. Basic Studies

Shinya MANAKA, Keiji SANO

1979 Volume 19 Issue 7 Pages 643-653
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.643

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The existence of stationary potential (SP) of the brain is demonstrated by experimental studies. The polarity of SP was positive and the magnitude of SP was 7.6±2.4 (SD) mV in rats, 9.8±2.4 mV in rabbits, 10.2±1.8 mV in cats, and 10.9±2.2 mV in dogs. The magnitude of SP in human was estimated by clinical observations at about 20 mV.
The retina of cats also had SP. The magnitude was on the order of 5 mV. The retinal SP may correspond to the so-called “resting potential” of the retina. A mass of cells without neurons, for example the liver or glioma, did not possess SP. The neurons were thought to be the essential component to originate the SP.
SP was very stable in physiological conditions, but it changed in intracranial organic lesions and, extensive metabolic disorders such as anoxia or generalized convulsive seizures.
SP may reflect the ionic distribution on the neuronal surface which constitutes the neuronal membrane potential, because SP is closely correlated to the membrane potential of neurons and extracellular potassium concentration, whereas it was independent of cortical or blood pH changes or glial membrane potentials.

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Stationary Potential of the Brain : Part II. Clinical Studies

Keiji SANO, Shinya MANAKA, Hiroyuki MIYAKE, Yoshiaki MAYANAGI, Tokuro ...

1979 Volume 19 Issue 7 Pages 655-664
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.655

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Stationary potential changes through the scalp and those on the cortex were measured by a high impedance chopper stabilized DC amplifier and calomel half-cell electrodes. For clinical use, a new SP encephalograph was devised. It can detect SP changes at 90 points automatically. SP encephalogram in normal subjects shows a symmetrical voltage distribution over the hemisphere with the highest potential in the vertex (ranging from 10 to 20 mV when the reference electrode was on the nasion). Clinical studies in 345 cases and intraoperative SP measured in 28 cases together with supplemental animal experiments indicated that if the lesion involves the cortex, the SP over the area shows negativity as compared with the normal portion on the order of 5-20 mV, whereas if the lesion is in the subcortex, the cortex over the lesion shows positivity on the order of 5-10 mV. The polarity of SP change is decided by the relationship -between the location of the lesion to the cortex. If the lesion is an expanding type such as meningioma, the SP shows “crateriform potential change, ” that is, negative in the center of the tumor and positive surrounding it. Slight cortical compression also exhibits slight positivity. Based on the above-mentioned principle of SP change, SP encephalography may be of help in estimating the area, depth, degree and nature of the lesion.

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Changes in Enzyme Activities of the Choroid Plexus and Brain Tissue following Bilateral Carotid Ligation in Correlation with the Formation of Cerebrospinal Fluid

Kenichiro HIGASHI, Mitsunori HATANO, Yasuo FUKUDA

1979 Volume 19 Issue 7 Pages 665-674
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.665

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The activity of four enzymes which are thought to be correlated to the production of CSF, such as acid and alkaline phosphatase, carbonic anhydrase, and Na-K ATPase, were determined biochemically in the choroid plexus and the frontal lobe brain tissue in adult rabbits. The activities of these enzymes, except Na-K ATPase, were transiently enhanced in the choroid plexus after bilateral ligation of the common carotid arteries, although considerable decrease was found in the brain tissue. Since the above results had suggested that enhancement of secretory activity of the choroid plexus followed bilateral carotid ligation, the rate of CSF formation was measured by means of the ventriculocisternal perfusion method in the same species of animals before and after bilateral carotid ligation. However, no significant changes were observed in the rate of CSF formation until 2 hours after carotid ligation. After bilateral occlusion of the common carotid arteries, vertebral blood flow, measured electromagnetically, immediately increased to twice its normal rate. Also, resin casts made of the choroid plexus after bilateral carotid ligation, confirmed that there was an adequate blood supply to the entire choroid plexus through the vertebral-posterior choroidal artery system. Considering the dual source of CSF production, it is likely that the secretory activity of the choroid plexus not only is unaffected by a sudden change of cerebral blood flow but also may compensate for the reduced production of CSF in the brain for at least a temporary period. Therefore, in face of ischemic-anoxic changes in the brain this could lead to the maintenance of a normal rate of CSF production by a homeostatic control mechanism.

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Immunohistochemical Studies of Brain Tumors Associated with Precocious Puberty : A Preliminary Report of Correlation between Tumor Secreting Hormone and Leydig Cells in Precocious Puberty

Masahiro KURISAKA, Nobuo MORIYASU, Kiyoaki KITAJIMA

1979 Volume 19 Issue 7 Pages 675-682
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.675

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Pathogenesis of precocious puberty in patients with pineal tumor and ectopic pinealoma was studied immunohistochemically, focusing on the endocrine function of the tumors and on the correlation between the tumor secreting hormone and Leydig cells. Optic chiasmal germinomas secrete β-subunit-like FSH and LH, while choriocarcinoma in the pineal region secretes hCG (α, β). Precocious puberty is recognized only in the latter case. On the other hand, endogenous gonadotropins are localized in immature Leydig cells of the fetus, infant and adult testes. The number of hCG positive immature Leydig cells increased 3 hours after hCG injection. Thus it became obvious that not only endogenous LH (hCG) but also exogenous LH (hCG) bind to immature Leydig cells; that is, Leydig cells exist as target cells of the gonadotropin. These Leydig cells synthesize steroid hormones such as androgen, and the hormones give the sexuality of a male to a boy. As a result, it can be concluded that precocious puberty is induced by the tumor secreting gonadotropin.

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Operative Treatments for Acromegaly: Comparison of Transsphenoidal Cryogenic and Microsurgical Hypophysectomy

Akinori KONDO, Hajime HANDA, Hiroshi MATSUMURA, Yasumasa MAKITA

1979 Volume 19 Issue 7 Pages 683-693
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.683

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Surgical treatments for acromegaly both by transnasal transsphenoidal cryogenic ablation and by transsphenoidal microsurgical dissection were carried out in two different series and the postoperative follow-up results of HGH level and other pituitary hormones of both groups were compared and discussed for the first time. There were no significant differences in postoperative changes of pituitary functions between each operative method, whereas as for long-term satisfactory lowering of HGH level, i.e. radical cure of acromegaly, the microsurgical treatment was concluded as more reliable than cryogenic ablation of pituitary adenomas.

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Increased Intracranial Pressure and Tentorial Shear Strain

Shunichi YONEDA, Hiroshi GOTO, Masayuki MATSUDA, Eimei TSUDA, Hajime H ...

1979 Volume 19 Issue 7 Pages 695-702
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.695

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Tentorial herniation is caused by a pressure gradient between supra and infratentorial compartments and the herniated brain is burdened with a force, which is called shear strain at the edge of the tentorium. The purpose of the present study is to clarify the relationships between increased intracranial pressure, the pressure gradient and the tentorial shear strain. Twenty-three monkeys were used and intracranial pressure was raised by inflation of an epidural balloon placed in the right temporal region. The supratentorial pressure was found to be always higher than the infratentorial pressure and the pressure gradient became greater as intracranial pressure increased. The shear strain at the tentorial edge began to develop as soon as the balloon was expanded, and showed a slow and steady increase even when the intracranial pressure was only slightly increased and the pressure gradient did not have any effect. The degree of the tentorial edge descent observed by X-ray was, however, variable depending upon the animals used. The tentorial edge ceased to descend at the moment the tentorial shear strain was 80-140 mm Hg. At this point and thereafter, the characteristics of both herniated brain and tentorial edge changed from elastic to plastic, and the damage caused by the strained tentorial edge is thought to be tremendously extensive. Our dynamical study of transtentorial herniation shows clearly that the magnitude of shear strain was greater as a local forced pressure than supra and infratentorial pressure.

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Measurement of Brain Interstitial Fluid Pressure in Acute Head Injury Patients

Susumu NAKATANI, Kentaro KOSHINO, Takashi KONDO, Takuya IKEDA, Heitaro ...

1979 Volume 19 Issue 7 Pages 703-715
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.703

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We have tried and succeeded in continuous recording of the brain interstitial fluid pressure (BIFP) in 7 acute head injury patients. Pressure gradients were obtained between CSF, non-edematous brain tissue and edematous brain tissue. A higher BIFP was obtained in the lower density edematous area than in the normal density area of the CT scans of the head injury patients, which confirmed the experimental data reported by other investigators. These pressure gradients first became larger and then smaller with propagation of edema into a generalized uncontrollable increased ICP. In cases of severe head injuries in which decompressive craniectomies were performed, initial subcutaneous pressure was low, whereas BIFP deep in the edematous brain tissue was high. From the data obtained, better surgical management of acute head injury patients was inferred by theoretical reasoning. It is concluded that, although intensive medical treatments are being carried out, internal decompression is the choice of surgical policy in the early management of head injury. An external decompression performed prophylactically may induce in some instances intracerebral hemorrhage, intraventricular bleeding, and hydrostatic edema propagation.

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Large Decompressive Craniectomy in Management of Severe Cerebral Contusion. A Review of 207 Cases

Akira YAMAURA, Kenichi UEMURA, Hiroyasu MAKINO

1979 Volume 19 Issue 7 Pages 717-728
Published: 1979
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.19.717

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Since 1966, large decompressive craniectomy has been performed in acute severe cerebral contusion with or without concomitant intracranial hematomas. A total of 207 cases have been treated up to this time and short-term and long-term follow-up studies have been conducted. The long-term follow-up study of children and adults in Series 1 of 154 patients showed 17% and 33% mortality and 100% and 73% functional recovery rates, respectively. Prognosis was markedly different for patients under and over 30 years of age. Prognostic key signs of pupillary changes, decerebration and respiratory disturbance, and grading of the above factors were confirmed to be practical and reliable guidelines in forecasting surgical outcome. The accuracy of the grading system was tested in Series 2, which consisted of 53 more recent cases.
In spite of the development of various methods for treatment of severe head injury, decompressive craniectomy is stressed as being indispensable if the appropriate time for surgery is not missed.

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