Neurologia medico-chirurgica

Systemic Blood Pressure Autoregulator for Induced Hypertension (Part I)

Manufacture of the Device and its Experimental Use

Shiro NAGASAWA, Hidetoshi WATANABE, Hajime HANDA, Takashi MIKAMI, Kenj ...

1983 Volume 23 Issue 10 Pages 771-775
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.771

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Although induced hypertension therapy is believed to be one of the effective treatments of choice for cerebral vasospasm, it is difficult to achieve stable hypertension either by manually-controlled infusion or constant flow rate infusion of vasoconstrictors. To solve these problems, the authors developed a blood pressure control system for induced hypertension therapy.
The autoregulator consists of a systemic blood pressure measuring device, a microcomputer, and an infusion pump of the rotary type. Systemic blood pressure is elevated gradually to the target level (BP target) by manually increasing the infusion rate of dopamine. After an appropriate flow rate (flow initial) is determined, the program is started. The flow rate is changed every two minutes depending on whether the input blood pressure is lower than the BP target.
The function of the system was studied in anesthetized dogs. The femoral artery and vein were cannulated to monitor systemic blood pressure and central venous pressure, and for infusion of dopamine. Although slight changes of blood pressure (10-15 mmHg) at about 15 minute intervals were observed, stable hypertension of 200 mmHg was obtained. When dopamine was infused through another peripheral venous route, no marked blood pressure change occurred, because the infusion rate was automatically decreased. The effect of increased intravascular volume on induced hypertension was studied by the rapid infusion of hydroxyethyl starch solution (Hespander®). Although blood pressure increased by 50 mmHg under a constant flow rate of dopamine, little change was noted under computer control. From these results, this system was found to be effective in maintaining stable hypertension.

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Roentgenographic Positions of the Cranial Nerve Root (V, VII-XI) Proximal Zones with Reference to Microvascular Decompression

Tomomi OKAMURA, Hideo AOKI, Kazutoshi YANAI, Toshio ABE, Motou OH

1983 Volume 23 Issue 10 Pages 776-782
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.776

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The correlative positions of the entry-exit zones of the cranial nerve roots (V, VII-VIII, and IX-X-XI medullary root) were investigated in 12 adult cadaver brains to determine the most appropriate cut planes of vertebral angiotomography (VAT) for preoperative evaluations of microvascular decompression cases for trigeminal neuralgia or hemifacial spasm. The proximal zones of the left V, VII-VIII, and IX-X-XI medullary roots, 5 mm in length, were marked using Myodil-stained cotton sheets. Measurements were made in several angles on plane X-ray films. Statistical analysis on the position of these nerve roots yielded measurements for practical use. A convenient procedure was developed for locating the optimal cut plane for VAT. Clinical cases examined by this procedure were presented and the diagnostic usefulness was discussed.
Measurements for practical use, corrected for magnification, were as follows. For the V root proximal zone, the center of the entry zone in the lateral view was 12 mm from the clivus, and on a line crossing the external auditory canal (EAC) and perpendicular to the anthropologic base line. The zonal radius was 2.5 mm. In the A-P view, the most medial part was 16 mm from the midline. For the VII-VIII root proximal zone, the center of the zone in the lateral view was 14 mm from the clivus, and on a line 5 mm posterior from the posterior margin of the EAC and perpendicular to the anthropologic base line. The zonal radius was 2.5 mm. In the A-P view, the most medial part was 13 mm from the midline. For the IX-X-XI medullary root proximal zone, the entry zone in the lateral view was on a line from the VII-VIII root proximal zone to the midpoint of the foramen magnum. The lower border was 10 mm from the foramen magnum. In the A-P view, the medial part was 9-10 mm from the midline.

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Experiences with Electrothrombosis of Intracranial Aneurysms

Tokiwa SAKAKIBARA, Taizo NITTA, Shizuo HATASHITA, Yasuaki HOSAKA, Nobu ...

1983 Volume 23 Issue 10 Pages 783-788
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.783

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Direct obliteration of the intracranial aneurysm with copper electric thrombosis through craniotomy is an effective procedure in cases where clipping of the aneurysm is inapplicable.
Five intracranial giant aneurysms 2 to 3 cm in diameter were thrombosed using a copper wire. Two were on the internal carotid artery at the posterior communicating junction, one on the internal carotid artery at the ophthalmic junction, and the others on the cavernous portion. The follow-up was satisfactory. All of the cases had late arteriograms showing permanent thrombosis; two with complete obliteration of the aneurysm and three with 25 percent refilling. No cases bled during the follow-up period, which ranged from 4 to 22 months. In three out of five patients, third nerve palsy was present preoperatively. Two made a complete recovery and one showed ophthalmoplegia postoperatively.

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Spontaneous Carotid-Cavernous Fistula

Long-term Follow-up Result and Policy of Treatment

Hideaki NUKUI, Takashi SHIBASAKI, Osamu MIYAGI, Junpei TAMADA, Matomi ...

1983 Volume 23 Issue 10 Pages 789-796
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.789

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Long-term follow-up results were analysed in 20 cases with spontaneous carotid-cavernous fistulas. The age of the patients ranged from 20 to 76 years and 10 cases were under 60 years. The modality of the onset of initial symptoms was acute in six cases and gradual in 14.
Cervical carotid arteries were occluded in one case with severe neurological signs and symptoms and a high (100%) shunt rate from the affected internal carotid artery to the venous system. The other 19 cases were followed up from 13 months to 9 years 8 months without surgical treatment. Additional symptoms were noted in 15 cases during the follow-up period. The period from onset to peak of individual clinical pictures varied; within one month in seven cases, between one and 6 months in seven, and more than 6 months in five. The peak of the clinical pictures was usually recognized between one and 6 months in cases under 60 years of age and within one month or more than 6 months in cases over 60 years of age. Temporary reappearance of symptoms after their regression was noted within 2 months in four cases and 6 months in one. The regression of symptoms without reappearance for more than 6 months (6 months-6 years 10 months) was noted in 17 cases and marked improvement of symptoms was seen in one case during the follow-up period. The interval between the appearance and disappearance of symptoms in these 18 cases was as follows; within 6 months in four cases, between 6 months and one year in four, between one year and 2 years in four, and more than 2 years in six. The regression of symptoms was usually slow in cases under 60 years of age, in cases which showed slow progression of clinical pictures, and in cases with three draining veins.
From these results, conservative treatment is recommended in cases with spontaneous carotid-cavernous fistulas except in those with a very high shunt rate.

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Follow-up Study of Diabetes Insipidus after Surgery for Craniopharyngiomas in Children and Adults

Shobu SHIBATA, Kazuo MORI, Hiroaki YOKOYAMA, Shigeyoshi TERAMOTO

1983 Volume 23 Issue 10 Pages 797-801
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.797

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A follow-up from 10 months to 9 years 2 months of 13 patients (nine children and four adults) with diabetes insipidus (DI) after microscopic surgery of craniopharyngiomas was performed. Antidiuretic hormone (ADH) and cortisol in plasma was serially measured by radioimmunoassay. Primary surgical treatment consisted of total excision of the tumor in five children, and subtotal excision of the tumor in four children and four adults. Three of the children and three of the adults received radiotherapy. No recurrences occurred. Of the nine children, three had minimal to no DI for 2 years 11 months, 11 months, and 9 months respectively after surgical treatment, whereas six had persistent DI postoperatively for 10 months to 5 years. All of the four adults had no clinically significant DI 1 to 20 months after surgery, but two died as a result of endocrine deficits in the postoperative period after 1 year 9 months and 3 years 11 months. Plasma ADH levels of six children who had clinical features of DI postoperatively were below 1.8 μU/ml. Seven cases (three children and four adults) showed low values of plasma ADH below 1.9 μU/ml, although clinical manifestations of DI had disappeared. Plasma cortisol levels of 10 cases (seven children and three adults) were below 5 μg/dl in the postoperative period.
It was suggested that postoperative DI due to craniopharyngioma did not always show polyuria. It was also indicated that a long-term follow-up is necessary for the treatment of postoperative DI due to craniopharyngioma.

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Germ Cell Tumor of the Pineal Region with Elevation of Serum and CSF Alpha-Fetoprotein Levels Following Histological Change

Case Report

Hirofumi HAMADA, Kazumi MATSUDA, Masahiro SASAHIRA, Hiroshi AWA, Tetsu ...

1983 Volume 23 Issue 10 Pages 802-806
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.802

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A 12-year-old boy with a germ cell tumor in the pineal region showed elevation of serum and cerebrospinal fluid (CSF) alpha-fetoprotein (AFP) levels following histological changes.
The histological diagnosis of the specimen resected in the first operation was a typical germinoma, and AFP levels in both serum and CSF were within normal limits. A heterotopically recurrent tumor was removed 22 months after the first surgery. The histology of the tumor changed into that of a endodermal sinus tumor (yolk sac tumor) with a teratomatous elements according to Teilum's classification. AFP levels of both serum and CSF stayed high (500-600 ng/ml) from the time of the second admission to death.
Elevated AFP levels in intracranial germ cell tumors have been reported in endodermal sinus tumors (yolk sac tumor), embryonal carcinoma and immature (malignant) teratoma, but not in germinoma and mature (benign) teratoma. AFP estimation in the serum and CSF is valuable not only in diagnosis, but also in monitoring the results of therapy and assessing the presence of recurrences.

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Cervical AVM Associated with Neurofibromatosis Presenting Unilateral Pulsating Exophthalmos

Case Report

Takaho MURATA, Masahiko ARISAWA, Yoshifumi ODA, Yasufumi UCHIDA, Teizo ...

1983 Volume 23 Issue 10 Pages 807-813
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.807

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The authors reported a case of cervical arteriovenous malformation (AVM) associated with neurofibromatosis. There was only one previous report presented as a case of spontaneous extracranial vertebral AVM with neurofibromatosis.
A 46-year-old female was admitted because of neurofibromatosis and unilateral pulsating exophthalmos due to bone defect at the great wing of the sphenoid bone. Neurological examination showed hearing difficulty in the right with tinnitus due to vascular bruit at neck, right pulsating exophthalmos with total extraocular muscle paresis, tetraparesis with hyperreflexia dominant in the left upper extremity, as well as total sensory weakness. Cerebral angiography revealed abnormal vascular shadows at the level of C2 to C6, chiefly fed by bilateral vertebral arteries. Metrizamide myelography showed an incomplete block at the level of C5. Direct attacks to the cervical angioma were tried both by anterior and posterior approaches. The angioma situated at the cervical intra and extra-dural spaces and was treated by feeder clipping and trapping of left vertebral artery. Histological diagnosis was AVM. Postoperative angiography revealed a complete disappearance of the AVM. Five months later the bone defect at the great wing of the sphenoid bone was repaired. Postoperatively, pulsating exophthalmos with hearing difficulty and tinnitus disappeared, while motor and sensory disturbances were unchanged.

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Intracerebellar Hemorrhage in Full-term Newborn

Case Report

Ichiro SHIMOYAMA, Kaoru HINOKUMA, Mitsutoshi ENDOH, Toshiaki NINCHOJI, ...

1983 Volume 23 Issue 10 Pages 814-817
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.814

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A 20-day-old girl who was born in full term without perinatal problems (Apgar score 10) suddenly developed a respiratory distress with frequent episode of vomiting. On the following day, she had one attack of generalized convulsion and was admitted. Laboratory data on admission indicated normal blood counts, normal blood chemistry, and normal bleeding and coagulation times. Hepaplastin test was 55%. CT scan showed a hematoma in the posterior lobe of left cerebellar hemisphere, which was immediately evacuated without performing angiography, because the patient showed the evidence of impending tonsillar herniation. Histological examination with HE and van Gieson stainings showed no abnormality in the hematoma. Thus, no confirmation of precipitating cause could be obtained. Later, she underwent ventriculo-peritoneal shunt because of progressive hydrocephalus. Twelve months later, she showed normal physical growth and a moderate degree of mental retardation. Spontaneous intracerebellar hemorrhage was rare, particularly in a newborn after 2 weeks. Majority of such cases, previously reported, were premature babies. So far 12 cases have been reported in the literature among full-term newborns of less than 2 weeks in age.

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Shunt Trouble due to Silicone Degradation

Case Report

Tsutomu NAKAOKA, Teruhiko TANAKA

1983 Volume 23 Issue 10 Pages 818-820
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.818

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A case with a shunt trouble due to degradation of silicone was encountered. Problems in the manufacturing process of silicone or absorption of protein and lipid from the surrounding tissue were mentioned as possible causes of the degradation. These points need to be considered in cases of troubles in shunt systems which have been used over a long period of time.

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Herpes Simplex Encephalitis

Case Report

Masahiro SASAHIRA, Kenichi TAKAGI, Kazumasa HASHIMOTO, Toshimoto ARAI, ...

1983 Volume 23 Issue 10 Pages 821-827
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.821

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A 13-year-old boy was admitted because of fever, headache, convulsions and disturbed consciousness for 7 days. Neurological examinations on admission revealed disturbance of consciousness, signs of meningeal irritation and left hemiplegia.
CT scan showed a low density area in the right medial temporal lobe with irregular enhancement by contrast medium and accompanying mass effects. Encephalitis was suspected. Antibiotics and γ-globulin were administered and external decompression was performed on the same day, because of progressive decrease in consciousness. Four days later, a marked low density area in the right cerebral hemisphere and parafalcial low density were seen in CT scan and the level of consciousness fell with decerebrate posture. Ventricular drainage was performed. Complement fixation titer of herpes simplex in the serum was×1, 024. β-interferon therapy was started and continued for 11 days by means of both intravenous and intrathecal administration (3×10⁶ I.U. daily intravenously, 1×10⁶ I.U. for 1 day and 3×10⁶ I.U. for 3 days intrathecaly). Neurological and general condition of the patient improved gradually. There were no side effects of interferon except for fever. The follow-up CT scan showed a low density area in the right fronto-parietal region with cortical atrophy and ventricular dilatation. At follow-up 9 months later, the patient showed no hemiplegia nor memory disturbance and he could lead a daily life with some aid.

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