The author presents a review of published literatures on the surgical treatment of atherosclerotic occlusive lesions at the cervical carotid bifurcation. This review is an analysis of progress in the past and predictable development in the near future, rather than a comprehensive report of the literature. The review will be made in three parts. In this first part, attention was focused on the surgical treatment of “total occlusion” of the internal carotid artery. The analysis included such surgical procedures as endarterectomy of the contralateral carotid stenosis, endarterectomy of the external carotid artery, stumpectomy and other techniques in addition to EC-IC bypass operation. The author chosen particularly to emphasize the importance of cerebral blood flow measurement as an adjunct to the objective selection of “total occlusion” patients for the surgical treatment. Limitted usefulness of presently available rCBF method was discussed in comparison with feasibility of “Xe-enhanced CT scan” method.
—Significance of Oxyhemoglobin, Fibrin Degradation Products and Breakdown Products of White Ghost in the Pathogenesis of Cerebral Vasospasms. Treatment of Vasospasms with Gabexate Mesilate and Diphenhydramine—
In the previous studies, oxyhemoglobin or its allied polypeptides was found to be one of the most important causal factors of vasospasms. Haptoglobin has been found to be effective in releasing vasospasms in experimental models, but its beneficial effects in clinical cases were rather inconsistent. This is a report of our further studies, to find new spasmogenic substances in addition to Hb and to make the effects of Hp therapy more consistent and reliable. In in vitro models vasoactivity of test substances was checked using a spirally cut strip of canine basilar artery. In the in vivo system, vasospasms were examined by cerebral angiography after the injection of the vasoactive substances directly into the chiasmatic cistern. Breakdown products of the erythrocyte-membrane were found to be vasoactive in vitro. Its activity was markedly decreased after the procedure of lipid extraction and was partially blocked by the addition of serum albumin. However, less contractile response of the ghost breakdown products was observed in the in vivo experiments. Fibrin degradation products (FDP), especially low molecular weight FDP (LMW FDP) demonstrated strong vasoactivity. Vasoactivity of FDP could be blocked by diphenhydramine. It was also found that FDP potentiated the vasocontractile action of Hb, and also augmented contraction induced by an aged erythrocyte-CSF mixture. When FDP was injected into the basal cistern in combination with hemoglobin, the marked vasospasms of a prolonged nature were demonstrated in the repeated angiograms. The degree of vasospasm thus produced was much greater than that induced by a single injection of hemoglobin. This vasospasm could be effectively released by the topical use of diphenhydramine and Hp. Gabexate mesilate(FOY) was moderately effective in releasing vasospasms even when it was administered intravenously. Systemic administration of gabexate mesilate and diphenhydramine was also effective for prolonged vasospasms induced by cisternal injection of autogeneous arterial blood in some cases. In the other cases additional topical application of Hp and diphenhydramine after removal of the subarachnoid hematoma by the transclival approach might be needed to release the vasospasm effectively.
Sequential ultrastructural changes in the canine basilar artery in experimental vasospasms were examined by means of electron microscopy. To induce vasospasm, 5 ml of fresh isologous arterial blood was injected through the optic canal into the basal cistern. Angiographically the vasospasm occurred in a biphasic fashion. Early vasospasms occurred immediately after injection of the fresh blood and lasted for about 1 to 2 hours. Late vasospasms appeared about 2 to 3 hours after the injection of the fresh blood and continued for about 7 days. In the early vasospasms, no ultrastructural change of the basilar artery was observed in electron microscopy level, whereas narrowing of the lumen with corrugation of internal elastica could be seen in light microscopy. In the late vasospasms, the ultrastructural changes of the intima and adventitia preceded those of the media, which were striking between 24 hours and 3 days after injection of fresh blood. In the intima, endothelial cells were swollen, became more vivid under the microscopy and contained intracytoplasmic vacuoles of various sizes. Marked loss of tight junctions was observed. The internal elastica appeared to be swollen and showed less electron density. In the media, smooth muscle cells showed diminution and fragmentation of myofibrils and disruption of sarcolemma, and contained vacuoles of various sizes and degenerated organelles. The interstitial areas were edematous. In the adventitia, fibrocytes exhibited pyknosis of varying degrees. Occasional axons of nerve fibers became condensed and lost their structures. Myelin sheaths were markedly disfigured. Two weeks after injection of fresh blood when the blood clot in the subarachnoid space vanished and there was angiographically no evidence of vasospasm, the endothelial cells assumed a normal configuration with intact tight junctions, and the adventitia appeared normal. Six months later, however, many smooth muscular cells still contained numerous dense bodies.
During study of the characteristics of various brain tumors in tissue cultures, it was found that craniopharyngiomas showed a unique growth pattern, different from other brain tumors including glioma. Reports on tissue cultures of craniopharyngioma have been few, probably due to the difficulty of in vitro propagation. The present report concerns some in vitro growth patterns of this epithelial tumor. The biopsied materials were cut into small fragments, about 1-2 mm in diameter, and directly cultured at 37°C in 199 medium containing 10% calf serum, 100 units/ml of penicillin and 100 μg/ml of dihydrostreptomycin. The medium was changed every three days. By this simple methods, six tumors out of nine different cases were successfully cultured. Four to five days after being placed in a glass bottle, a monolayer sheet developed from each fragment extending out in eccentric direction from the center. The cells of the monolayer sheet had a polygonal, rich cytoplasm and an oval nucleus, and were in close contact with each other. In the marginal zone, cells with an extremely large cytoplasm and acellular circular spaces were frequently seen. The free margin of the cell sheets was always sharp without any surrounding scattered cells. In electron microscopy (plate parallel sectioning method), abundant desmosomes and tonofilaments could be seen as in the original tumors. On the other hand, in scanning electron microscopy, the surface of this cultured cell was relatively smooth and abundant microvilli were observed. From these findings, it was concluded that the cultured cells in the monolayer sheets originated mostly in the epithelial cells of craniopharyngioma but not in glial cells of fibrocytes. The growth rate of the epithelial cell sheets could be estimated by measuring the area of the cell sheets. During the initial ten days, most sheets increased two to five times in area and grew less rapidly for 30 to 40 days until the diameters of the sheets became 5 to 15 mm. Thereafter, they were not enlarge but survived for 150 to 430 days. In these experiments, in vitro propagation of cells seemed independent of whether or not the patients received previous irradiation or administration of chemotherapeutic agents such as bleomycin. In addition, it seemed also likely that trypsin digestion was inadequate for long-term proliferation of cells. Cultured craniopharyngiomas may be useful for studying distinct characteristics from various aspects including screening of the effects of chemotherapeutic agents.
This paper deals with the clinicopathological findings in two cases of cerebellar mudulloblastoma with extraneural metastasis. These two cases fulfill Weiss' minimal criteria for confirmation of extraneural metastasis of a glioma. The first case was an 18 month-old boy with a 14 month clinical history. A ventriculoperitoneal shunt was performed, followed by three series of Linac irradiations, for a total dose of 13, 750 rads. An autopsy revealed a cerebellar vermis tumor accompanied by ventricular and spinal subarachnoidal seeding. Milliary metastatic nodules were noticed macroscopically in the liver, and microscopic deposits were also recognized in the right ventricular wall of the heart, pericardium, lumbar vertebrae, capsules of the pancreas and spleen, and adipose tissue surrounding the adrenal gland. Tumor cell invasion in a small vein within the vermis tumor was thought to be a cause of blood-stream metastases. The second case was a 10 year-old boy with a clinical history of 16 months. The cerebellar vermis tumor was partially removed and a ventriculoperitoneal shunt was performed at the same time. The patient was given radiotherapy, 4, 000 rads in the whole brain, 4, 000 rads in the upper spinal canal and 3, 000 rads in the lower spinal canal. One month later he felt pain in the hip joint and lower back. Radiography showed osteolytic changes in the pelvis and femoral bone, and later in the humerus, ribs and scapulas. Local irradiation of bony metastase was effective for a while. An autopsy revealed a small tumor remnant in the cerebellar vermis accompanied by spinal subarachnoidal seeding. Systemic bony metastasis was confirmed with no metastasis to the internal organs and lymphoid tissues. The dura mater at the primary site of the tumor was invaded by tumor cells, and this seemed to be the route of blood-spread metastasis. Approximately 80 cases of cerebellar medulloblastoma with extraneural metastasis have been reported in assorted report. The mode and site of metastasis, diagnosis and treatment are critically reviewed in this paper.
A case of meningioma in the pineal region is reported. The patient, a 40 year-old male, was referred because of a slight headache and the presence of a calcified lesion in plain skull X-rays. A neurological examination revealed a slight memory disturbance, minimum hemiparesis and a sensory disturbance on the left side. Plain X-rays and tomography of the skull showed large calcification 3 cm in diameter in the pineal region. A 99mTc pertechnetate brain scan showed an area of increased activity in the same region. Angiography showed no tumor stain in any phase. In the venous phase, upward displacement of the vein of Galen and the straight sinus was demonstrated. Pneumoencephalography revealed that the size of the mass corresponded exactly to the size of the calcification. It was also demonstrated that the mass was free from the edge of the tentorium. Right parietooccipital craniotomy was performed and the tumor in the pineal region was removed subtotally. This tumor was considered to have originated from the velum interpositum. The postoperative course was uneventful. Preoperative symptoms and signs improved except for the left lower quadrant hemianopsia which was produced by surgical manipulation. The pathological diagnosis was meningothelial meningioma with psammoma bodies. A review of the previously reported 35 cases can be summarized as follows. The origin of the meningiomas in the pineal region was either the velum interpositum (12 cases) or the junction of falx and tentorium (21 cases). This series of 36 cases including the present case consisted of 11 males, 21 females and four undescribed cases. In comparison with germinoma, characteristic clinical signs of meningioma in the pineal region were as follows. 1) The incidence of upward gaze palsy was much lower than that in germinoma cases. 2) Cerebellar signs, pyramidal signs and mental disturbances were found more commonly in meningioma cases than in germinoma cases. 3) Dysarthria and hypoglossal nerve palsy were seen only in meningioma cases. In seven cases (22.6%), characteristic calcifications were demonstrated on plain skull films. However, tumor stains were found by angiography in only a few cases. The prognosis of this tumor was generally poor. Only four cases were reported to be cured without neurological defects by total removal. Improvements in preoperative symptoms were obtained in nine of the cases. The overall mortality was 60.6% and operative mortality was 27.3%. When removing meningioma in the pineal region, considerable attention must be paid to preventing damage in the deep cerebral veins and surrounding structures.
Operative results of microsurgical anterior discectomy for cervical spondylotic radiculomyelopathy are reported. Anterior discectomy was carried out using Smith & Robinson's method under an operating microscope and all compressive components against the spinal cord and the radicula, such as degenerated disks, osteophytes, barridges and calcified ligaments, were completely removed using curettes and air-drills. Uncectomy was also performed whenever necessary to relieve the radicular compression. A total of 38 patients, 24 males and 14 females, on whom conservative treatment had not been effective, underwent surgery. Myelopathy was present in all 38 patients, and among these moderate weakness of the lower extremities and spastic gait were seen in 19 patients (50%), and severe paraparesis including a bed-ridden state were noted in 9 patients (24%). Neurogenic bladders were observed in 13 patients (34%). Radiculopathy was also present in 20 patients. In roentgenograms, sagittal A-P diameter of the cervical vertebral canal at C5 ranged between 16.4 mm and 10.4 mm (mean 13.5±1.6), and developmental narrow canals with a value of less than 12.0 mm were noticed in 9 patients. Discectomy at a single level was performed on 22 patients, two levels on 14 and three levels on 3. There was a total of fifty-six discectomies. Fortyseven spaces were fused by autogenous iliac bone grafts and nine were without grafts. Follow up results over 6 months were evaluated on 36 patients (average observation period: 20 months) according to a modified Odom's scale. Twenty patients were judged as excellent, ten good and six fair. As a result 30 out of 36 cases (83%) regained full daily activity with minimum disabilities. Radiculopathy was relieved in 19 patients (95%). Neurogenic bladder disappeared in all 13 patients. There was no operative deterioration. Ages over 60 years old and preoperative periods of over a year were considered as factors deferring postoperative recovery. Severe myelopathy showing a transverse syndrome was also a poor prognostic factor, but all four of the bed-ridden patients became ambulatory. In summary, total removal of the compressing components of cervical spondylosis under a microscope proved to be warrantted treatment for both myelopathy and radiculopathy.
A simple and harmless method is described for detecting the patency of ventriculo-peritoneal shunts with a pair of small disk thermistors. This method is based on the principle that when a moving column of fluid is locally cooled, a drop in temperature can be recorded at some distance from the place of application in the direction of the movement. A disk thermistor, measuring 6 mm in diameter covered with Epon 812 is taped to the chest skin just above the shunt tube 4 cm distal from the cooling point, and the other thermistor, the reference one, is also taped to the skin beside the shunt tube 4 cm distal from the cooling point. They are balanced so that, when the measuring thermistor detects a drop in temperature, a pen-deflection occurs. As a cold source we use an ordinary cube of ice in a vinyl sack for one minute. In the experiment a shunt tube was embedded in clay, the results of which showed a significant pen-deflection between different flow velocities, ranging from 5 ml/h to 60 ml/h (120 ml/24 hrs and 1, 440 ml/24 hrs). In clinical data there were 23 hydrocephalic children and 9 adult patients with normal pressure hydrocephalus, and they were examined 26 and 10 times respectively. Three out of 23 hydrocephalic children could not be examined because of their violent movements, but all of the adult patients could be examined. In all 25 patients whose clinical pictures suggested functioning shunts, the proper diagnosis of shunt patency was obtained by this method. In 6 patients whose clinical pictures were dubious as to whether the shunt was patent or not, this method revealed that all shunts were patent and their CT scans and follow-up data supported shunt patency. In 2 patients whose clinical pictures suggested shunt malfunction, this method revealed no pen-deflection, and their shunt obstructions were proved by operations. This method is a simple and safe procedure which may be repeated at frequent intervals.
Thyrotropin releasing hormone tartrate (TRH-T) has been found to activate the central nervous system and its pharmacological role has recently received much attention. We studied the effects of TRH-T on EEGs of rat's brains of with isolated perfusion undergoing temporary ischemia. Its clinical effect on persistent disturbance of consciousness was also examined in 38 cases of brain tumor, cerebrovascular disease, head injury, normal pressure hydrocephalus and infectious brain disease. The following results were obtained. 1. TRH-T was found to improve EEGs of rat's brains with isolated perfusion undergoing temporary ischemia. 2. Beneficial clinical responses to TRH-T therapy were observed in 81.6% of the patients with persistent disturbances of consciousness due to brain tumors, cerebrovascular disease, head injury, normal pressure hydrocephalus or infectious brain disease. Among the responses, 26.3% was rated as excellent, 5.3% as good, and 50.0% as fair. 3. The therapeutic efficacy was found to be higher in patients with shorter durations and shorter fixed periods of disturbed consciousness, and in patients with relatively wild disturbances of consciousness at the start of therapy. 4. No noteworthy side effects or changes in data from hematological examinations, blood chemistry tests and urinalyses were observed.