Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
Volume 21, Issue 11
Displaying 1-11 of 11 articles from this issue
  • SYOJI ASARI, MASARU SAKURAI, YUJI YAMAMOTO, KAZUHIKO SADAMOTO
    1981 Volume 21 Issue 11 Pages 1095-1104
    Published: 1981
    Released on J-STAGE: November 10, 2006
    JOURNAL FREE ACCESS
    Usefulness of computed cerebral angiotomography for direct detection of intracranial aneurysms was studied.
    Among forty-one aneurysms in the series, thirty-one (80.5%) were detected by computed cerebral angiotomography. Detection rates of aneurysms depended on the size, i.e., 56.3% in 16 aneurysms smaller than 5 mm in diameter, 94.7% in 19 between 6 and 10 mm, and 100% in six aneurysms larger than 10 mm. The smallest aneurysm detected by computed cerebral angiotomography was 5×4×4 mm in size on the angiogram. Location of the aneurysms, affected the detection rate as follows: 88.2% in 17 anterior cerebral artery aneurysms (16 anterior communicating artery aneurysms and one A, portion), 77.8% in nine middle cerebral artery aneurysms, 87.5% in eight aneurysms of supraclinoid portion of the internal carotid artery (ICA), 0% in two internal carotid-ophthalmic artery aneurysms, 75 % in four aneurysms of upper half of the basilar artery and 100% in one posterior cerebral artery aneurysm. It seems difficult to detect aneurysms in the infraclinoid portion of ICA. Of 24 patients with subarachnoid hemorrhage, ruptured aneurysms were detected in 22 by computed cerebral angiotomography. Initial CT findings in 64% of these 22 patients showed no evidence of blood or diffuse or symmetrical high density areas in the subarachnoid space. In these patients, computed cerebral angiotomography was useful for topographical diagnosis of the ruptured aneurysm. Incidental asymptomatic aneurysms were detected in nine out of 33 patients in this series. An aneurysm may be suggested by a round or oval isodensity defect in the Sylvian fissure or suprasellar cistern, defect of the edge of the so-called “pentagon” in plain CT and then if its density is highly and homogeneously increased and continuous with the main cerebral arteries on computed cerebral angiotomogram.
    Computed cerebral angiotomography raised the detection rate of intracranial aneurysms. It was possible to recognize not only aneurysms themselves but also afferent and efferent arteries continuous with aneurysms, the relation between the aneurysm and cistern, parenchymal brain tissue and hematoma surrounding the aneurysm by computed cerebral angiotomography. Nine cases of incidental asymptomatic aneurysms were detected directly by computed cerebral angiotomography. This non-invasive method seems to be useful as a screening procedure to discover non-ruptured asymptomatic aneurysms. There is a possibility that location of an aneurysm can be shown by computed cerebral angiotomography before invasive angiography.
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  • TAKASHI FUJII, SHUZOH MISUMI, FUMIKAZU TAKEDA
    1981 Volume 21 Issue 11 Pages 1105-1112
    Published: 1981
    Released on J-STAGE: November 10, 2006
    JOURNAL FREE ACCESS
    Polyuria following pituitary surgery (removal of the adenomas, hypophysectomy and neuroadenolysis) was studied in 64 cases. Most of the postoperative polyuria were diabetes insipidus showing Randall's triphasic pattern and disappeared within 6 months. A successive observation of hourly urinary volume was carried out, and four patterns of diurnal excretion were classified. The continuous pattern, continuously sustained polyuria, was observed in the 1st postoperative day when polyuria started within 6 hrs after pituitary surgery. It was commonly followed by a rhythmic pattern after the 2nd postoperative day. The rhythmic pattern showed one to three peaks in which an abrupt increase in hourly urinary volume at constant clock time was demonstrated. This pattern was observed following pituitary surgery and in idiopathic diabetes insipidus. Intermittently administered pitressin and inadequate drip infusion of electrolyte solution often affected the rhythmic pattern, resulting in appearance of false peaks, and the genuine peaks revived when the inapproprate treatment were corrected. A transient pattern was observed in the polyuria which disappeared within a day. This pattern was also seen in the pnlyuria induced by diuretics administered in the postoperative stage of surgery other than pituitary surgery.
    A unspecific pattern was shown during recovery stage of the postoperative polyuria with the rhythmic pattern. It was also seen in the acute stage following the pituitary surgery when inadequate drip infusion and/or a overdose of sodium were given, and was frequently accompanied by a gain in body weight. Free water clearance was constantly increased at the time of the peaks in the rhythmic pattern. The mechanism through which the diurnal patterns of polyuria were induced still remained to be determined, but it was assumed that surgical intervention on the pituitary gland would decrease ADH secretion and suppress the diurnal change.
    In the management of the polyuria following pituitary surgery, checking for the diurnal pattern of urinary excretion had many advantages in terms of simplicity of procedure to differentiate the nature of polyuria, excluding inappropriate treatment and predicting the prognosis. Rectal administration of indomethacin suppositories was recommended for the reduction of urinary volume in the acute postoperative stage without affecting the diurnal patterns of polyuria following pituitary surgery.
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  • EIJI YOSHINO, KIMIYOSHI HIRAKAWA, MASAHITO FUJIMOTO, NORIHIKO MIZUKAWA ...
    1981 Volume 21 Issue 11 Pages 1113-1121
    Published: 1981
    Released on J-STAGE: November 10, 2006
    JOURNAL FREE ACCESS
    The authors report on 16 women with prolactin-secreting pituitary adenomas and discuss the indication of surgery and bromocriptine treatment. Cases were classified into four groups according to Hardy's classification. Grade I patients were 5, Grade II: 3, Grade III: 6, and Grade IV: 2. Thirteen patients sustained amenorrhea with galactorrhea and three patients sustained only amenorrhea. Four women complained of visual disturbances.
    Operations were performed on five patients. Of these patients, one had a microadenoma (Grade I) and four had suprasellarly extending macroadenomas (Grade II, III and IV). Results of the operations were satisfactory in patients of Grades I and II, but unsatisfactory in patients of Grades III and IV. Grade I and II patients reached a normal prolactin level and resumed regular menstruation after the operation, but in Grade III and IV patients, plasma prolactin remained high and they did not resume menstruation.
    Bromocriptine was administered to fourteen patients. Ovulation was restored in 11 patients by bromocriptine treatment only. Of seven patients who desired to be pregnant, four became pregnant. In two cases CT scan demonstrated tumor reduction after bromocriptine treatment. Thus results of bromocriptine treatment were satisfactory in hyperprolactinemic patients with prolactinomas, but there are some problems with bromocriptine treatment. These include the rise of plasma prolactin after discontinuance of bromocriptine treatment, increased risk of tumor enlargement during pregnancy, possible teratogenic effects and tolerance to bromocriptine.
    From observations of these data the following methods for treatment of female patients with prolactinomas are proposed. Patients with microadenomas should be operated on. There is a good possibility that the removal of the microadenoma will produce a biological cure without significant risk of damaging the normal gland. However, if patients desire to become pregnant, bromocriptine treatment should be applied without surgery after a careful discussion with the patient. If the tumor is not very large and not very invasive, an operation should be performed before bromocriptine treatment. However, if patients desire to become pregnant, bromocriptine treatment should be applied in consideration of postoperative pituitary functions. In such cases, pregnant patients should be carefully monitored for tumor enlargement during pregnancy. For large invasive adenoma, bromocriptine treatment should be given priority over operations.
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  • OSAMU SATO, SUMIYOSHI TANABE, HIROMI TSUCHITA, TOSHIO NAKAGAWA, YOSHIT ...
    1981 Volume 21 Issue 11 Pages 1123-1133
    Published: 1981
    Released on J-STAGE: November 10, 2006
    JOURNAL FREE ACCESS
    The authors investigated factors responsible for cessation of galactorrhea or restoration of ovulation in 30 women with PRL-secreting pituitary adenomas after surgery with or without bromocriptine. All the patients complained of sterility and 25 patients had galactorrhea. Microsurgical removal of adenomas was performed in all the patients and 15 patients received oral bromocriptine after surgery on account of sustained elevated serum PRL levels.
    Galactorrhea ceased in 19 out of 25 patients (76.0%) after the treatment. The PRL levels where galactorrhea ceased ranged from three to 1, 177 ng/ml. Galactorrhea ceased even at the elevated PRL levels in nine patients and four patients sustained galactorrhea at the normal PRL levels. Therefore, the normal PRL levels per se did not inevitably ensure cessation of galactorrhea after the treatment. However, the PRL level below 140 ng/ml was considered to ensure cessation ofgalactorrhea. There was no difference in the frequency of cessation ofgalactorrhea after the treatment between microadenomas and macroadenomas although there was a prevalence of microadenomas after surgery. Another favorable factor for cessation of galactorrhea was a longer postoperative interval of more than three months after surgery. Preoperative serum PRL levels, age of the patients at surgery, duration of galactorrhea, history of nursing, severity of galactorrhea and serum estradiol or progesterone levels had no correlation with cessation of galactorrhea.
    Ovulation was restored in 18 out of 30 patients (60.0%) after the treatment and pregnancy was established in 12 patients. The PRL levels where ovulation was restored ranged from three to 57 ng/ml. Ovulation was restored even at elevated PRL levels in seven patients and nine patients sustained anovulation at the normal PRL levels. Therefore, the normal PRL levels per se did not inevitably ensure restoration of ovulation. There was no difference in the frequency of restoration of ovulation after the treatment between patients with preoperative PRL levels below 200 ng/ml and those with the levels over 200 ng/ml, although there was a prevalence of patients with levels below 200 ng/ml after surgery. There was a prevalence in the frequency of restoration in amenorrhea Grade I, preoperative duration of sterility of less than five years, microadenomas, a longer postoperative interval normal serum basal LH levels and peak LH levels in response to LH-RH and the presence of positive feedback control to surge LH in response to estrogen. Age of the patients at surgery, elevated dopamine activity in the hypothalamus and serum estradiol or progesterone levels were not correlated with restoration of ovulation.
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  • MASAHIRO OGATA, SHINICHI SATO, SATOSHI NAKAO, SADAHIKO BAN, KOH NANBA, ...
    1981 Volume 21 Issue 11 Pages 1135-1145
    Published: 1981
    Released on J-STAGE: November 10, 2006
    JOURNAL FREE ACCESS
    The authors' principle of surgical treatment for nine cases of skull base space-occupying lesions extending both intra and extracranially, performed by combined surgical teams consisting of neurosurgeons, otolaryngologists, ophthalmologists and plastic surgeons are reported.
    Advantages of the simultaneous combined surgical procedure for skull base lesions are as follows: Two surgical teams (i.e. intra and extracranial teams) can exchange information regarding relationships of the lesion extending both intra and extracranially, as well as the process of each surgical procedure, thus eliminating ‘dead angles’, and making the procedure more radical. Under direct observation from the intracranial side, preventive measures against possible postoperative infection can be safely taken from the extracranial side. Therefore, intracranial extension of frequent complications such as mucoceles, pyoceles, cholesteatomas and paranasal sinusitis can be successfully prevented. Closure of the dural or bony defect at the skull base can readily be performed with a pedicled flap (e.g. periosteum, galea, fascia, muscle or dura), together with an autograft of bone if necessary. Continuous spinal drainage is sometimes added as a further precaution against possible CSF leakage. Completeness of closure of the defect is confirmed from both intra and extracranial sides. By performing the two different procedures (i.e. intra and extracranial procedures) simultaneously, the patient's physical and psychological burden can be lightened, and anesthetic time is also shortened.
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  • HIROSHI NISHIMOTO, TAKASHI TSUBOKAWA, TAKASHI TSUKIYAMA, TAKAMITSU YAM ...
    1981 Volume 21 Issue 11 Pages 1147-1152
    Published: 1981
    Released on J-STAGE: November 10, 2006
    JOURNAL FREE ACCESS
    Far field acoustic responses (FARs) were recorded at the vertex in 104 cases suffering from severe head injury. Alterations in the responses were compared with Glasgow coma scale scores, CT findings and outcome. In 30 cases, FARs elicited by bilateral monoaural stimulations and binaural stimulations were recorded for evaluation of the asymmetrical abnormalities. These results may be summarized as follows:
    Two different types of alterations in the responses were recognized in the acute stage of severe head injury. These two types were (i) prolonged latency or disappearance of the 5th waves and (ii) disappearance of the 1st to 5th waves. The former type is suggesting damage to the midbrain improved within two weeks after the trauma. In contrast, the latter type indicates the dysfunction of the pons and medulla remained. These alterations in the responses were correlated with the outcome three months after the trauma. In 73% of 22 cases whose severity were less than seven on the Glasgow coma scale, abnormalities of FARs indicating the dysfunction of the brain stem were shown. Asymmetrical abnormalities of 5th waves were found in 30% of 30 cases suffering from severe head injury. However, this lateralization of the upper brain stem lesions by FARs were not significant for predicting the outcome three months after the trauma.
    Based on these results, it was concluded that the FAR is a useful indicator and predictor concerning the function of the brain stem in patients with severe head injury.
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  • SHODO FUJIOKA, YASUHIKO MATSUKADO, MOTOYUKI KAKU, NOBUYOSHI SAKURAMA, ...
    1981 Volume 21 Issue 11 Pages 1153-1160
    Published: 1981
    Released on J-STAGE: November 10, 2006
    JOURNAL FREE ACCESS
    One hundred cases of chronic subdural hematoma, admitted during the past 2 years, were analyzed with CT scanning with respect to the clinical manifestation and the enlarging process of the hematoma. Their symptoms and signs, such as headache, motor paresis and mental disturbance, were not well correlated to the degree of the midline shift in CT scan, but rather to the patients' age. However, disturbed consciousness was more attributable to the midline shift or the intracranial mass effect. To investigate the mechanism of progressive development of chronic subdural hematoma, CT scan findings were classified into seven groups according to the density of the hematoma. In this study the morbid period of the patient was estimated from the onset of any clinical symptom and the clinical course of each patient was compared with the CT findings.
    As a result, high density group and hematomas with niveau formation were found in cases of acute onset and, particularly, all of the clinical courses of niveau forming hematomas were of the apoplectiform type. All of the cases in low density group were observed within the range of 40 morbid days. Conversely, all of the cases with morbid periods longer than 40 days showed fluctuations of symptoms and the hematoma periods belonged to the isodensity group. It was considered that CT findings of the hematoma were dependent on the extent of capsular hemorrhage and the clinical course was probably diversified by the subsequent hemorrhagic process. Initially the hematoma space was seen in CT scans as a low density area, which later became high dense and then isodense as it matured.
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  • —II. Measurements of Cerebral Circulation and Metabolism by Use of the Argon Desaturation Method in Pre- and Post- Neurosurgical Procedures—
    JUN KARASAWA, HARUHIKO KIKUCHI, YOSHIHIRO KURIYAMA, TOHRU SAWADA, MASA ...
    1981 Volume 21 Issue 11 Pages 1161-1168
    Published: 1981
    Released on J-STAGE: November 10, 2006
    JOURNAL FREE ACCESS
    The cerebral blood flow (CBF) and cerebral metabolic rate of oxygen (CMRO2) were measured in 17 children with “Moyamoya” disease (mean age of 8.6±3.4 years), by the argon method and medical mass spectrometry. Sequential changes of CBF and CMRO2 were monitored before surgery and the second day, 1st month, 3rd month and 6th month after surgery. Seventeen children were divided into three groups according to the neurological symptoms : groups with a transient ischemic attack (TIA), with a minor stroke, and with a major stroke, respectively.
    Before surgery the CBF in the TIA, minor stroke, and major stroke groups were 40.0, 38.2, and 39.6 ml/100 g/ min., respectively. The CMRO2 in the TIA, minor stroke, and major stroke groups were 2.73, 2.21, and 1.86 ml/ 100 g/min., respectively. The CBF and CMRO2 decreased with advancing age. The mean ages of the cases with a TIA, minorstroke, and majorstroke were 9.5±4.0, 10.3±2.4, and 5.4±2.2 years, respectively. From these results, the CBF and CMRO2 in the major stroke group seemed to definitely decrease when compared with the other groups. The cerebrovascular resistance (CVR) in groups of TIA, minor stroke, and major stroke were 2.21, 2.43, and 2.80 mmHg/ml/100 g/min., respectively. ST-MC anastomoses were performed in 12 hemispheres and encephalo-myo-synangiosis in 10 cerebral hemispheres. The CBF after these neurosurgical procedures increased on the 2nd day, and then decreased until the end of the 1st month. The CBF gradually increased thereafter. The CBF 6 months after surgery significantly increased when compared with that before surgery. The CMRO2 6 months after surgery also increased, when compared with that before surgery. The CVR 6 months after surgery decreased, when compared with that before surgery. In the patients who had transient ischemic neurological symptoms at their acute stages after surgery, a marked reduction of CMRO2 was characteristic, in spite of the increase in CBF. This uncoupling phenomenon between CBF and CMRO2 might be ascribed to the brain edema following disruption of the blood brain barrier due to surgery.
    From this evidence the main feature of pathophysiology of cerebral circulation and metabolism in cases of “Moyamoya” disease was a marked hypoperfusion and reduction of oxygen consumption of the brain. After neurosurgical interventions the cerebral blood flow and the cerebral oxygen consumption gradually increased and this was compatible with the clinical improvement.
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  • —SLTA (Standard Language Test of Aphasia) Follow up Study and CT Classification—
    MASATO MURAMOTO, KAZUHIKO FUJITSU, TAEKO KOJIMA, KIM ILLU, TAKEO KUWAB ...
    1981 Volume 21 Issue 11 Pages 1169-1176
    Published: 1981
    Released on J-STAGE: November 10, 2006
    JOURNAL FREE ACCESS
    CT scans of 21 cases of left-sided putaminal hemorrhage were classified into four types, i.e., Type I, IIa, IIm and lip and the degree of aphasia was evaluated by the SLTA, 1, 3, 6 and 12 months from onset. As a rule, surgery was selected for the treatment of large hemorrhages (above 4-5 cm in the longest diameter).
    A characteristic aphasic pattern of each type of hemorrhage was found as follows;
    Type I hemorrhage: All cases of Type I hemorrhage, both operative and conservative cases, had good recovery and fell into the normal range of standard deviation on the SLTA by 3 months from onset. Type I Ia hemorrhage: This type of hemorrhage showed diffuse and severe impairment on the SLTA and had poor recovery. Type IIm hemorrhage: Both hearing and speech were moderately impaired on the SLTA, but the former had good recovery. Type IIp hemorrhage: Large hemorrhages showed various degrees of impairment on the SLTA in accordance with the size of hemorrhages. Hearing was predominantly impaired but later recovered. Impairment in speech remained.
    Reading was usually not so remarkably impaired on the SLTA in Type I, Type IIm and Type Hp. Each type showed various degrees of recovery by 3 months from onset, after which further recoveries were gradual and Small slight.
    The CT classification of the putaminal hemorrhage might make it possible to predict recovery in speech functions.
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  • —Report of Two Cases—
    TAKAMASA KAYAMA, TERUAKI MORI, TOKUO WADA
    1981 Volume 21 Issue 11 Pages 1177-1182
    Published: 1981
    Released on J-STAGE: November 10, 2006
    JOURNAL FREE ACCESS
    Two cases of primary brain tumors with systemic metastasis via ventriculoperitoneal shunt ars reported.
    The first case was a 4-year-old girl who developed a generalized tonic-clonic convulsion. She was admitted because of headache, nausea and left hemiparesis. Subtotal removal of the right frontal tumor was performed. A ventriculoperitoneal shunt was carried out on the 11th postoperative day, and then 3, 000 rads of 60Co irradiation were given. Five months after the ventriculoperitoneal shunting, abdominal tumors were revealed and she died. Autopsy revealed systemic metastases (peritoneum, liver, GI tract, pancreas and spleen) of the brain tumor via the shunt tube. Microscopical diagnosis was ependymoma.
    The second patient, a 59-year-old female, was admitted because of severe frontal signs. Subtotal removal of the right frontal tumor was carried out and 6, 000 rads were irradiated by 11Co postoperatively. A ventriculoperitoneal shunt was performed four months postoperatively. Nine months after the shunting operation, an abdominal tumor was found. She died and autopsy revealed metastasis of the brain tumor via the ventriculoperitoneal shunt. Intraperitoneal tumors were found in the peritoneum, liver, G-I tract and pancreas. Microscopical diagnosis showed glioblastoma.
    Ventriculoperitoneal shunts are very popular and effective procedures to control intracranial pressure. However it should be considered whenever a shunt is performed on a brain tumor, an artificial route for metastasis via the shunt tube is also created. Protection and treatment for metastasis of brain tumors via ventriculoperitoneal shunts should be prepared.
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  • TAKUO HASHIMOTO, NORIO NAKAMURA, MASAHARU YASUE, TAKAHARU FUSE, KYOICH ...
    1981 Volume 21 Issue 11 Pages 1183-1189
    Published: 1981
    Released on J-STAGE: November 10, 2006
    JOURNAL FREE ACCESS
    A case of neurenteric cyst in the lumbosacral region is reported. A 54-year-old woman was admitted with symptoms of increased intracranial pressure. Neuroradiological examinations revealed no abnormal findings in the intracranial region except for communicating hydrocephalus. Myelography showed complete block in the lumbar region. A tumor of the a lumbosacral region was diagnosed and considered to be responsible for the increased intracranial pressure. Subtotal removal of the tumor was performed. After the surgical treatment, the symptoms of increased intracranial pressure disappeared. Microscopic examination of the cyst wall disclosed loose fibrous connective tissue lined with ciliated columnar cells. Histological diagnosis was a neurenteric cyst. The clinical and embryogenic features are discussed.
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