Neurologia medico-chirurgica

Permeability Change of Cerebral Vessels in Acute Hypertension and External Decompression

Junpei KOIKE

1983 Volume 23 Issue 5 Pages 325-335
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.325

JOURNAL FREE ACCESS

Show abstractHide abstract

The role of hydrostatic factors, such as acute hypertension and decompressive craniectomy, which contribute to the permeability of cerebral vessels and to brain edema were evaluated.
Adult mongrel cats were subjected to induced hypertension by means of inflation of a balloon catheter placed in the descending aorta immediately distal to the left sub-clavian artery. Craniectomy of 2×1.5 cm was done on the right front-parietal area. The animals were divided into four groups: 1) intact control group; 2) arterial hypertension group; 3) craniectomy group; 4) combined hypertension and craniectomy group. Evans blue and horseradish peroxidase were used as tracers to quantify the extent of damage to the blood-brain barrier. The water content of the regional cerebral tissues was determined by the dry-weight method. Induced hypertension produced multifocal cortical lesions staind by Evans blue. Craniectomy also resulted in similar multifocal cortical edema in both hemispheres, though more marked on the side of the craniectomy. These lesions were mainly located at the arterial boundary zones of major cerebral arteries and leakage of tracers ceased within 24 hours. No changes were observed in either brain water content or morphological findings 48 hours after insult. When a cat was subjected to both hypertension and craniectomy, these changes became markedly intensified and Evans blue, migrated further into the adjacent white matter. When the brain was examined 48 hours later, rather extensive hemispheric edema with midline structure shift was noted.
The results suggested that edema of this type is sufficiently specific in its developmental pattern and is initiated by the hydrostatic pressure gradients between blood and tissue, and between areas with different tissue pressures.

View full abstract

Download PDF (1282K)
Correlation of ICP and Outcome in Severe Head Injuries

Masami YANO, Hiroyuki YOKOTA, Shiro KOBAYASHI, Yasuhiro YAMAMOTO, Tosh ...

1983 Volume 23 Issue 5 Pages 336-342
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.336

JOURNAL FREE ACCESS

Show abstractHide abstract

During 1980-1981, 66 patients with severe head injury were admitted and underwent intracranial pressure (ICP) monitoring by the subarachnoid catheter method. Ninety percent of the patients were admitted within 6 hours after injury and 70 percent were started on ICP monitoring within 12 hours of injury. All patients were of Glasgow Coma Scale 8 or less. Their average age was 37.2 years. The periods of continuous ICP monitoring were 1-17 days (average 6.0±3.5 SD). After admission, vital signs and neurological states were checked, endotracheal tube was intubated with or without barbiturate anesthesia, and CT scanning was carried out. Fifty percent of patients needed intracranial operations. All of the patients were uniformly treated; all received high dose corticosteroids, osmotic agents, and mild mechanical hyperventilation and, if ICP was 25 mmHg or greater, barbiturates were administered. ICP was related to outcome one year after of injury. Cases with initial ICP within the ranges of 0 to 9 mmHg, 10 to 19, 20 to 29, 30 to 39, and over 40 mmHg showed mortalities of 26.7, 40, 53.8, 60.0, and 100%, respectively (χ² = 17.57, P<0.01). Maximal ICP within the ranges of O to 19 mmHg, 20 to 29, 30 to 39, 40 to 59, and over 60 mmHg was related to the mortalities of 11.1, 20.0, 25.0, 60.0, and 87.5%, respectively (χ² = 24.99, P<0.01). Thus, there were significant correlations between initial and maximal ICP levels and outcome.

View full abstract

Download PDF (469K)
Cerebral Arterial Blood Flow Measured with an Electromagnetic Flow Meter during Surgery

Takeshi SHIMA, Masahiro NISHIDA, Yoshikazu OKADA, Tohru UOZUMI, Shiger ...

1983 Volume 23 Issue 5 Pages 343-348
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.343

JOURNAL FREE ACCESS

Show abstractHide abstract

Intracranial cerebral arterial blood flow was measured in 33 patients with an electromagnetic flow meter to investigate the hemodynamic state during surgery for cerebrovascular disease. These cases were composed of 25 intracranial aneurysms, 1 arteriovenous malformation, 1 hemangioblastoma, and 6 STA-MCA anastomosis. Specially designed probes were made and an electromagnetic flow meter with the auto-zero balance system was used to facilitate measurement of the cerebral arterial blood flow. A probe with an appropriate size and sensitivity was applied to the carefully exposed cerebral artery. Blood flow could be measured in the internal carotid artery (ICA) (14 cases), M₁ (7 cases) and M₂ portion (3 cases) of the middle cerebral artery (MCA) and in the surperficial temporal artery (STA) after bypass surgery. The collateral potential of the circle of Willis was evaluated from the changes in MCA blood flow following test occlusion of the ICA in 2 cases. The effects of brain retraction (8 cases) and induced hypotension with ATP infusion method (8 cases) were also studied.
The mean arterial blood flow in the ICA, M₁ and M₂ portion of the MCA were 144 ml/min, 81 ml/min, and 28 ml/min, respectively. The anastomotic blood flow in the STA was 27 ml/min on the average. Test occlusion of the ICA demonstrated the patient's collateral capacity through the anterior and posterior communicating arteries in each case. Induced hypotension showed that the arterial blood pressure threshold of the autoregulatory response was 58 mmHg in normotensive patients. Brain retraction, ranging from 150 to 300 mmH₂O (average 250 mmH₂O), decreased blood flow by approximately 20 percent of the control value.
It was suggested that the specially designed probes and electromagnetic flow meter could investigate the intracranial arterial blood flow during surgery without any serious side effects. Measurements of the cerebral arterial blood flow with this method gave important clues to the management of the main cerebral arteries and to the protection of the brain from ischemic insult.

View full abstract

Download PDF (489K)
Intraocular Hemorrhage in Ruptured Intracranial Aneurysm

Clinical Study of 172 Cases and Reference to Terson's Syndrome

Jun SHINODA, Makoto IWAMURA, Tomohiko IWAI, Tatsuo IWATA, Tatsuaki HAT ...

1983 Volume 23 Issue 5 Pages 349-354
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.349

JOURNAL FREE ACCESS

Show abstractHide abstract

Among 172 patients with ruptured intracranial aneurysms, there were 32 cases (18.6%) with intraocular hemorrhages (IH). Eighty-one cases were male, 15 (18.5%) of which had IH, and 91 cases were female, 17 (18.7%) of which had IH. The difference between male and female was not significant. With respect to the site of the supratentorial aneurysms, the incidences of IH were 15.0% of internal carotid artery, 20.0% of anterior communicating artery, and 21.6% of middle cerebral artery aneurysms. The differences were not significant (χ²=1.099, f=2, P > 0.1). The incidence of IH according to the duration of unconsciousness at the time of subarachnoid hemorrhage was 11.2% of 89 patients without unconsciousness, 16.7% of 42 with unconsciousness of less than one hour, and 36.6% of 41 with unconsciousness of more than one hour. There were significant differences among these three groups (χ²=11.868, f=2, P<0.005). When occurrence of IH was correlated with the clinical grade of Hunt & Hess on admission, the significance was more pronounced. Thus, the incidences of IH of 77 Grade I patients, 42 Grade II, 33 Grade III, 16 Grade IV, and 4 Grade V were 6.5%, 23.8%, 21.2%, 43.8%, and 75.0%, respectively (χ²=23.426, f=4, P<0.005). The outcomes of the patients were classified into three groups. The incidences of IH were 14.2% or 16 out of 113 patients who recovered, 18.2% or 6 of 33 patients requiring care, and 38.5% or 10 of 26 patients who died. These differences were also significant (χ²=8.256, f=2, P<0.05). The mortalities were 31.3% in the IH group and 11.4% in the non-IH group, with a highly significant difference (χ²=7.919, f=1, P<0.005). There were four cases (2.3% of all cases) with Terson's syndrome. Two cases (Cases 2 and 4) had aneurysms at the anterior communicating artery, one case (Case 1) at the A₁, and the fourth (Case 3) at the right middle cerebral artery. On admission, clinical evaluation was Grade III or Grade IV in three cases (Cases 1, 2, and 4); only one case (Case 3) was Grade II. Of these four cases, one case (Case 2) died.
It was concluded that ruptured intracranial aneurysms with IH were generally more severe in their clinical course and worse in prognosis than those without IH.

View full abstract

Download PDF (374K)
Ruptured Aneurysms within 24 Hours after Subarachnoid Hemorrhage

Surgical Results of 69 Cases

Hirotoshi SANO, Takashi NAKAGAWA, Youko KATOH, Junji NAGATA, Kazuhiro ...

1983 Volume 23 Issue 5 Pages 355-360
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.355

JOURNAL FREE ACCESS

Show abstractHide abstract

Timing of operative treatment of SAH in the acute stage is still controversial. Since September 1976, 291 cases of aneurysm were operated. Two hundred twenty-three cases out of 291 were operated by the same neurosurgeon. Of the 223 cases, 69 cases for which surgery was performed in the acute stage, within 24 hours after SAH, were analysed.
There were 2 fatal cases in the acute stage surgery in the neurological Grades II and III; the remaining 30 cases in Grades II and III recovered. In 22 Grade IV cases, 6 were fatal. In Grade V there were 19 fatal cases out of 23; only one case recovered well. The mortalities in acute stage surgeries were 39% including Grade V and 6.7% when confined to Grades II and III. On the contrary, mortalities in late surgery were 2.4%. Cases of chronic stage surgeries (operated after two weeks) were mainly of Grades I and II. Of the 48 cases which were treated conservatively, 40 cases were fatal. Therefore the overall mortality of delayed cases was 26.6%. Vasospasms occurred in over 40% of cases of subacute stage surgeries (operated from 2 to 14 days). However, in acute stage surgeries (within 24 hours) vasospasms occurred only in 10.6%. In chronic stage surgeries, vasospasms occurred in 8.1% of cases which were waiting for surgery. Symptomatic vasospasms occurred more often (18.2%) in delayed cases (over 24 hours) than in acute stage surgery cases (10.9%). Frequency of vasospasms was high in cases in which CT revealed packed hematoma in the basal cistern, even if the surgery was delayed until the chronic stage. However, vasospasms occurred less often in cases of acute stage surgery (within 24 hours after SAH).
Therefore, acute stage surgery within 24 hours should be absolutely indicated in cases in which CT revealed packed hematoma in the basal cistern.

View full abstract

Download PDF (438K)
Effects of Radiotherapy on Non-specific Immunological Parameters in Patients with Malignant Brain Tumors

Dissociation between PPD Skin Test and PHA Blastogenesis

Junkoh YAMASHITA, Kazuo IWAKI, Shin-ichi OHTSUKA, Toshiki YAMASAKI, Hi ...

1983 Volume 23 Issue 5 Pages 361-369
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.361

JOURNAL FREE ACCESS

Show abstractHide abstract

The non-specific immunological parameters of 37 patients with malignant brain tumors were analysed by means of 1) purified protein derivative (PPD) skin test, 2) lymphocyte counts, and 3) phytohemagglutinin (PHA) blastogenesis. The PPD skin reaction and PHA blastogenesis were already depressed preoperatively in patients with malignant brain tumors as compared to those in normal controls. When radiotherapy was confined to the head, lymphocyte counts and PHA blastogenesis were further depressed, but gradually recovered to preoperative levels within 6 months after the completion of radiotherapy. In the cases with medulloblastoma and germinoma who received whole cerebrospinal axis irradiation, lymphocyte counts and PHA blastogenesis were more markedly depressed and took more than 6 months after completion of the radiotherapy to recover to their preoperative levels. The result of the PPD skin test, on the other hand, was not affected and was rather enhanced by radiotherapy, showing a marked dissociation from the changes in lymphocyte counts and PHA blastogenesis. The results of PPD skin test on discharge from hospital were relatively well correlated with the prognosis of the patients.
The profound immunosuppressive influence of radiotherapy and the natural course of recovery should be taken into consideration if any immunological treatments are to be undertaken with or after the course of radiotherapy.

View full abstract

Download PDF (655K)
Spinal Sub-pial Schwannoma

Case Report

Kiyohiro HOUKIN, Hiroshi ABE, Yoshinobu IWASAKI, Mitsuo TSURU, Kazuo M ...

1983 Volume 23 Issue 5 Pages 370-374
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.370

JOURNAL FREE ACCESS

Show abstractHide abstract

The patient, a 42-year-old female, was admitted with a 5-year history of progressive numbness of the bilateral lower limbs. Neurological examination disclosed left-sided weakness with hyperreflexia and hypesthesia under the Th₄ level. Metrizamide myelography showed a severe cord swelling from C₂ to C₇. Metrizamide CT scan revealed a severe cord widening at the C_{5, 6} level and displacement of the cord and the anterior median fissure to the right side at the C_{6, 7} level. In addition, an exophytic extension to the left side at the C₇ level was recognized. Laminectomy was performed from C₂ through Th₁. The tumor was located on the posterior surface of the spinal cord at the C_4-6 levels and covered by the pia mater, and the left posterior root penetrated the tumor. Another tumor was found at the C₇ level, in accordance with the pre-operative CT scan finding. The tumors were totally removed. Histopathological examination revealed a typical Antoni type A schwannoma. This case was a sub-pial schwannoma originating from the posterior root entry zone. Usage of the term “sub-pial” has been coined with the lipoma located under the pia mater. Nevertheless, the authors proposed that the present case should be classified as the spinal subpial tumor.

View full abstract

Download PDF (482K)
Epidermoid Cyst in the Cerebellopontine Angle Cistern Presenting as Trigeminal Neuralgia

Diagnostic Values of the Orbicularis Oculi Reflex and Metrizamide CT Cisternography—Case Report—

Takashi UEDA, Tomokazu GOYA, Kazuo KINOSHITA, Masashi FUKUI

1983 Volume 23 Issue 5 Pages 375-380
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.375

JOURNAL FREE ACCESS

Show abstractHide abstract

This 29-year-old male had been suffering from left trigeminal neuralgia one year prior to admission. Admission was prompted by the development of pain in the third division of the left trigeminal nerve. Physical and neurological examinations were not remarkable except for the facial pain. The orbicularis oculi reflex showed delayed latency of R₁ on the affected side. CT scans performed pre- and post-contrast enhancement revealed a low density area in the left cerebellopontine angle cistern. Metrizamide CT cisternography clearly revealed the margin of the lesion as the contrast media did not enter into the low density area. A left suboccipital craniectomy was performed. The trigeminal nerve was surrounded by a thin-capsulated mass and cholesteatoma materials. Histological diagnosis was epidermoid cyst. Since this surgical procedure, the trigeminal neuralgia has not recurred for one year.
Without objective neurological deficits, it is difficult to distinguish symptomatic trigeminal from idiopathic neuralgia. Therefore, minor change of the orbicularis oculi reflex should help in objectively detecting dysfunction of the trigeminal nerve. Metrizamide CT cisternography is also useful in diagnosis of cystic lesions.

View full abstract

Download PDF (486K)
Acute Subdural Empyema

With Special Reference to CT Findings and Surgical Treatment —Case Report—

Masahiro SASAHIRA, Kenichi TAKAGI, Kazumasa HASHIMOTO, Satoshi INOU, T ...

1983 Volume 23 Issue 5 Pages 381-386
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.381

JOURNAL FREE ACCESS

Show abstractHide abstract

The patient, a 19-year-old male, began suffering from severe headache, vomiting, and high fever. Two days later the patient was admitted in a semicomatose state and with left hemiplegia. Nuchal rigidity and choked disc were not noticed. WBC count was 12, 500/mm³. CT scan disclosed marked swelling of the right cerebral hemisphere with midline shift. Except for a small lucent space in the parafalcial region, no extracerebral collection was noted in either pre- or post-contrast scans. Plain craniograms showed clouding of the left frontal, ethmoidal, and sphenoidal sinuses. Carotid angiography revealed prolongation of the circulation time and stenosis of the supraclinoidal portion of the right carotid artery. Right fronto-parietal decompressive craniectomy was performed. Subdural empyema was found and evacuated. Curettage and drainage of the empyema in the paranasal sinuses were also done. A bone defect 4 mm in diameter was detected on the medial-upper wall of the left frontal sinus. The causative organism was confirmed as α-Streptococcus. Both systemic and local antibiotics were administered and the patient recovered well and was discharged without any neurological deficit.
The authors emphasized that cerebral angiography is necessary for its accurate diagnosis of subdural empyema in its acute stage and that emergency intracranial and rhino-otological operations should be concomitantly performed.

View full abstract

Download PDF (460K)
Mid-line Arachnoid Cyst of the Brain

Katsuzo FUJITA, Kazuhiko ISHIDA, Norihiko TAMAKI, Satoshi MATSUMOTO

1983 Volume 23 Issue 5 Pages 387-392
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.387

JOURNAL FREE ACCESS

Show abstractHide abstract

Arachnoid cysts located in the mid-line (mid-line arachnoid cysts) include inter-hemispheric, suprasellar, quadrigeminal, and retrocerebellar cysts. The clinical picture, diagnostic study and treatment of 9 cases of mid-line arachnoid cysts were presented.
The clinical symptoms and signs were increased intracranial pressure without lateralizing signs (midline syndrome) due to hydrocephalus, precocious puberty, and the supra-collicular sign due to direct compression of the adjacent structures. Endocrinological study of the pituitary gland showed no abnormal findings. Metrizamide CT cisternography and CT ventriculography could be considered safe and reliable neurological procedures for evaluating the communication between the cyst and the subarachnoid spaces, as well as CSF dynamics. These patients were treated with ventriculo-peritoneal shunt, followed by craniotomy with resection of the cyst wall, with good results.

View full abstract

Download PDF (409K)
Huge Epithelium-lined Cyst in Infancy

Case Report

Tatsuo YOSHIDA, Susumu NAKATANI, Kazuo YAMADA, Yukitaka USHIO, Tohru H ...

1983 Volume 23 Issue 5 Pages 393-397
Published: 1983
Released on J-STAGE: November 10, 2006

DOIhttps://doi.org/10.2176/nmc.23.393

JOURNAL FREE ACCESS

Show abstractHide abstract

An infant case of huge epithelium-lined cyst in the posterior fossa is reported. The cyst was located in the prepontine region of the posterior fossa with extension to the bilateral middle cranial fossae, through the tentorial incisura. It had no communication with the ventricular system or subarachnoid space. The cyst wall was lined with ciliated columnar and cuboidal epithelial cells which were completely invested by a basement membrane. The diagnosis and the management of such cases were discussed and the pathogenesis of the cyst was reviewed.

View full abstract

Download PDF (400K)

Register with J-STAGE for free!