Noninvasive measurement of human spinal cord blood flow (SCBF) has not yet been established. The authors successfully measured human SCBF by using xenon and a CT scanner (Shuttle method). This method was clinically applied in 10 patients without spinal cord pathology. Mean SCBF of the normal adult at the C5 level was 42.3 ± 6.3 ml/ 100 g/min. CO2 reactivity in SCBF was also detected. This method may well be used in the clinical study of human SCBF.
UFT, an antitumor agent newly synthesized by Fujii et al., a mixture of FT-207 and uracil in a molar ratio of 1:4, has been noticed to have higher antitumor activity than FT-207 alone. The authors used high performance liquid chromatography to study the pharmacokinetics of UFT after its oral administration (equivalent to 900 mg FT-207) to 3 cases of malignant glioma and 4 cases of metastatic brain tumor. Most of the unmetabolized FT-207, 5-FU, and uracil were excreted in the urine within 24 hrs. The half-life of distribution of FT-207 was 4.59 hrs and its half-life of elimination was 9.99 hrs, while for 5-FU the values were 0.75 hrs and 11.04 hrs, respectively. These results indicated that both FT-207 and 5-FU stayed in plasma for longer periods than when FT-207 alone was used in other studies. In CSF, the concentration of 5-FU was 0.42 μg/ml after 4 hrs and 0.21 μg/ml after 6 hrs. Mean concentrations of FT-207, 5-FU, and uracil in malignant glioma tissues were 17.11, 0.20, and 10.12 μg/g, respectively, while in metastatic brain tumor tissues, they were 16.71, 0.47, and 33.57 μg/g, showing that 5-FU and uracil were in higher concentrations in metastatic brain tumor tissues than in malignant glioma tissues. Moreover, concentrations of FT-207 and 5-FU in the tissues adjacent to malignant brain tumor were similarly as high as in the tumor tissues themselves. Thus, UFT maintained high concentrations of 5-FU in plasma, CSF, and tumor tissues. It could be considered that uracil inhibited the degradation of 5-FU. Therefore, UFT showed be expected to show a higher antitumor activity than FT-207 when treating malignant brain tumors.
Fifty-three patients with primary or metastatic brain tumors were treated with 1-(4-amino-2-methyl-5-pyrimidinyl) methyl-3-(2-chloroethyl)-3-nitrosourea hydrochloride (ACNU) and 5-fluorouracil (5-FU) and their response was analyzed. Histological classification of these tumors were as follows: 31 glioblastomas, 4 astrocytomas, 2 ependymomas, 1 oligodendroglioma, 1 meningioma, 2 malignant lymphomas, 3 metastatic tumors, and 9 unverified tumors. Most patients received conventional surgery before chemotherapy and concomitant radiotherapy. ACNU was administered intravenously at a dose of 2 mg/kg once a week for two consecutive weeks. 5-FU was administered at a dose of 10 mg/kg on five consecutive days. If no considerable side effect was observed, ACNU administration was repeated every eight weeks. The effectiveness of the chemotherapeutic regimen was evaluated by CT findings. The results of the present study can be summarized as follows. The overall response rate of the combined treatment was 24%. There was no statistically significant difference in the responsiveness according to tumor type and dose of ACNU. Survival rates of the patients with glioblastoma (31 cases) were 90% for six months, 67% for 1 year, 27% for 2 years, 8% for 3 years, and 0% for 5 years. As for side effects, 58% of the patients showed delayed bone marrow depression in the form of leukocytopenia, thrombocytopenia, or both between the fourth and fifth week after treatment. This was the major toxic manifestation and was usually transient. The results were sufficiently encouraging to support further study of these chemotherapeutic agents.
Though radiographically-proven calcifications in pituitary adenomas are rare, a higher incidence of microscopically-proven calcified adenomas has been recently reported. Therefore, the incidence of radiological and microscopical calcifications in various types of pituitary adenomas in a consecutive series of 169 cases (71 acromegalies, 54 prolactinomas, 24 Cushing's diseases, 2 FSH-producing adenomas, 1 TSH-producing adenoma and 17 non-functioning adenomas) were reviewed. Intra or supra-sellar calcifications visible on plain skull films or sellar tomograms were counted only in 4 cases (3 prolactinomas and 1 acromegaly). Including these 4, 22 of the 169 cases had microscopicallyproven calcifications, the majority (20 cases) were prolactinomas and only 2 acromegalies. Histologically, these calcifications in pituitary adenomas were divided into 3 types; that is, 1) calcifications in the intratumoral hematoma, 2) calcifications in the degenerative adenoma tissue, and 3) scattered psammoma bodies between the adenoma cells. The last type of calcification seemed to be characteristic of almost all of the calcified prolactinomas. The first and second types of calcification were seen in 2 cases of acromegaly, and were thought to be the result of degenerative or hemorrhagic change of the adenoma. No significant differences between calcified and non-calcified prolactinomas were detected as regards serum PRL levels, the length of hyperprolactinemic state, patient's age and sex, or operative findings.
Auditory brain-stem responses (BSR) were evaluated in 37 head injured patients with Glasgow Coma Scale (GCS) scores of less than 10, with particular reference to abnormal findings in the Vth wave. Within three days of injury BSR were recorded by monoaural stimulation with an acoustic intensity of 80 dB hearing level and thereafter repeated. The patients were divided into two groups, those exhibiting wave V and those without. The 9 patients with absence of wave V (4 patients presented with no wave, 4 patients with wave I or II, and 1 patient with wave I to IV) died within 4 days of injury. The disappearance of wave V and patient outcome reflected brainstem injury, which was confirmed by CT and neurological findings. Twenty-one of the 26 patients in whom wave V was recorded survived and the remaining 5 died 5 days or over after injury due to complications (2 meningitis, 1 sepsis, 1 diabetes insipidus, 1 asphyxia). Prolonged latency of wave V was not an effective indicator for localizing brainstem injury or supratentorial lesions, and was unrelated to outcome. Prolonged latency of wave V was observed 24 times in 8 patients. These patients also revealed prolonged latency of wave I (22 times, 92%), wave III (22 times, 92%), and interpeak latency of wave I to V (23 times, 96%). The changes in the latency of wave V reflected the changes in brainstem functioning. From these findings, it can be said that prolonged latency of wave V reflects deteriorated brainstem function as a whole, rather than the presence of midbrain lesions.
Eighteen patients of delayed traumatic intracerebral hematoma (DTICH) were experienced among 268 head injured patients seen over a 32 month period. The interval from the admission computerized tomography (CT) to CT diagnosis of DTICH varied from eight hours to 13 days. All patients were comatose on admission. Three had acute epidural hematoma (EDH), one brain prolapse, and 17 exhibited acute subdural hematoma. Thirteen patients, including three EDH cases received evacuation of hematoma and craniectomy (external decompression) while the remaining five were not operated on but were treated with barbiturates to prevent or reduce intracranial hypertension. All the patients had laboratory studies for disseminated intravascular coagulation (DIC) over 7 days. The parameters were platelet counts (PC), active partial thromboplastin time (APTT), prothrombin time (PT), serum fibrinogen, fibrin degradation products (FDP), and protamine sulphate test (PS-test). All the patients showed severe hypofibrinogenemia during the first 24 hours which recovered abruptly to beyond the normal range within the next 24 hours. Hyperfibrinogenemia continued for at least seven days after trauma. PC's were almost normal on admission but decreased promptly within 24 hours and remained low for the following four days. All cases revealed low or borderline level PT throughout the monitoring period, while APTT revealed no abnormalities. These and serum FDP and PS-tests revealed no statistically significant difference between DTICH cases and controls. DTICH was found either in coup or contre-coup lesions along the extension line of impact, and the initial CT demonstrated abnormal densities in 14 (low, or salt & pepper) and normal in four. It was concluded that DIC was not responsible for the development of DTICH while primary direct contusion was a major factor in its evolution.
Forty patients with hemifacial spasm were treated by neurovascular decompression during the 4 years from June 1978 through June 1982. Of 40 patients, 31 were female and 9 were male, with ages ranging from 31-71 years (mean 52). In 24 patients the left side was involved and in 15, the right side. One had bilateral hemifacial spasms. As symptoms concomitant to hemifacial spasm, tinnitus synchronous with spasm, and hyperlacrimation and hypersalivation on the affected side were frequently present. Facial paresis of the peripheral type due to previous nerve blocks was observed in 10 cases. Vertebral angiography performed in 38 cases showed tortuous and elongated vertebral arteries protruding to the cerebellopontine angle in 12, and a common AICA and PICA trunk branching off from the vertebral or basilar artery in 19. The causative artery was confirmed at surgery to be AICA in 25, vertebral artery in 8, and PICA in 7. Electromyography of typical hemifacial spasm showed abnormal discharges of two types; one was continuous, tonic discharges at low amplitude, and the other was intermittent, coarse, clonic discharges at high amplitude. Blink reflex demonstrated synkinetic R1 discharge in both the orbicularis oculi and orbicularis oris muscles. Postoperatively, the synkinetic discharge disappeared concomitantly with disappearance of clinical facial spasm. Postoperative courses of hemifacial spasm were divided into four types. In Type 1 (18 cases), spasm disappeared immediately after surgery. In Type 2 (9 cases), the spasm gradually decreased within about one week, and in Type 3 (8 cases), within about one month. Spasm disappeared immediately after surgery in the 4th type (4 cases), but reappeared in a few days to a lesser degree, then gradually decreased and again disappeared within about one month. The temporary suppression of the spasm immediately after surgery was assumed to be due to minor surgical trauma to the 7th nerve. According to Jannetta's classification, operative results in these 40 cases were excellent in 29, good in 8, fair in 2, and poor in one.
In attempt to prevent angiospasm following early operation of ruptured aneurysm, intrathecal irrigation with plasminogen activator (Urokinase; UK) solution which may promote dissolution and washing-out of subarachnoid perivascular clot was employed. Clinical application was preceded and supported by the experimental survey in dogs with induced subarachnoid hemorrhage (SAH). This method was applied to all cases of early operation performed from November 1980 to March 1982, accompanied with other treatments such as systemic corticosteroids in all cases, external decompression and systemic UK in most cases, and induced hypertension in a few cases. Continuous irrigation with UK solution was started on the second postoperative day and carried out for 2 to 13 days, 8.3 days in average. 500 to 2, 500 ml of irrigation fluid containing 12 to 36 U/ml of UK was used daily. In many cases, the postoperative clinical course was much better than expected from the preoperative neurological status and CT findings. In cases of severe SAH, rapid disappearance of the clot in the basal cisterns was frequently recognized in postoperative sequential CT scans. Washing-out of the clot in the contralateral insular cistern was, however, slower and incomplete. The outcome of the 27 cases, which consisted of 2 cases of preoperative Grade I (after Hunt & Hess), 13 cases of Grade II, 7 cases of Grade III, and 5 cases of Grade IV, were as follows. Fifteen patients showed full recovery. Four returned to their work with partial restriction. Two stayed home without nursing. Three needed further nursing but were not vegetative. Three died. No undesirable reaction of the central nervous system was observed throughout the procedure. Only one case of severe meningitis was experienced. With further modification of the dose and the UK concentration in the irrigation fluid and of the adjunctive treatments, this method will become more effective.
Two cases of giant middle cerebral artery aneurysm with feeding artery occlusion were presented. The first case was a 40-year-old male. The patient had had a transient ischemic attack and subsequently a complete stroke. Arteriography on admission revealed a large aneurysm of the right middle cerebral artery with intraluminal thrombus. Follow-up arteriography performed 6 days later revealed a right middle cerebral artery occlusion at the M1 portion, and no aneurysm. At surgery, the lumen of the aneurysm was filled with thrombus. Superficial temporal artery middle cerebral artery (STA-MCA) anastomosis and partial removal of the aneurysm were performed. The second case was a 65-year-old male with a fatal subarachnoid and intracerebral hemorrhage. Existence of a large aneurysm of the right middle cerebral artery with intraluminal thrombus and calcification of the wall was suspected from the plain skull film and CT scan. Arteriography revealed a right internal carotid artery occlusion at the C1 portion. Eleven cases reported in the literature were reviewed; ischemic attack due to compromised circulation through the middle cerebral artery is one of the important clinical symptoms, and the risk of rupture is present even in an aneurysm with calcification of the wall. Therefore, resection of the aneurysm together with STA-MCA anastomosis seemed to be the essential treatment of choice for the giant middle cerebral artery aneurysm.
The authors reported a case of an arteriovenous malformation (AVM) which showed a giant aneurysmal dilatation and caused an intracerebral hemorrhage in a 3-year-old girl. The patient suffered from severe headache and vomiting after a Jacksonian convulsion. On admission 25 hours from the onset, she was delirious and showed motor weakness of the right extremities. The CT scan on admission demonstrated a ring-like high density area surrounding an isodense area which was markedly enhanced by the contrast medium. Carotid angiography demonstrated the nidus of an AVM with a giant aneurysm 4.0 cm in diameter, fed via the A2 portion of the left anterior cerebral artery (ACA). The operation performed immediately was very difficult because of massive bleeding from the ruptured giant aneurysm. The hemorrhage was controlled by temporary occlusion of the left ACA under the intravenous administration of 20% mannitol; the feeding artery was therefore safely occluded for 32 minutes under normal body temparature. The nidus with the giant aneurysm was totally removed and no neurological deficit remained postoperatively. The child is now leading a normal school life. Histology of the serial sections of the nidus showed that the aneurysmal portion was an extensively dilated vascular component which consisted of a mixture of arterial and venous structures.
A 27-year-old female, who was 17 weeks pregnant at the time of her admission, complained of gait disturbance and numbness in both legs. Six years prior to admission, she had undergone a Caesarean section under spinal anesthesia. She had had no episode of back injury. On admission, her physical and neurological examinations were normal except for ataxic gait, parapresis, sensory disturbance at the lower part of L1, and Romberg's sign. A complete block from Th10 to Th12 was detected using metrizamide myelography. Under the diagnosis of an intradural extramedullary tumor at the Th11 level, the tumor was removed. The operation was attended by a gynecologist who monitored the fetus by means of a doppler ultrasonic cardiogram. The tumor was located in the intradural extramedullary space at the Th11 level and was not adherent to the surrounding structures. The histopathological diagnosis was epidermoid. The postoperative course was uneventful and the patient was discharged after a short period of rehabilitation. Epidermoid tumors in the spinal region are very rare, representing less than 1% of all spinal tumors. Epidermoid tumors are classified as either acquired or congenital. The etiology of the present case was discussed.