Neurologia medico-chirurgica

Lysosomal Enzymes in Cerebrospinal Fluid as a Marker of Brain Tumor

Hiroshi SONODA, Yasuhiko MATSUKADO, Shozaburo UEMURA, Jun-ichi KURATSU ...

1984 Volume 24 Issue 3 Pages 149-156
Published: 1984
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.24.149

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Lysosomal enzymes, β-glucuronidase, acid phosphatase, and β-N-acetylglucosaminidase, in the cerebrospinal fluid of the patients with brain tumor were assayed by fluorospectrophotometric techniques.
Three hundred and three CSF samples were obtained from 128 patients suffering from various kinds of neurological diseases and the activity of the three lysosomal enzymes was assayed. Student's t-test was used for statistical analysis. In the cases of glioblastoma, medulloblastoma, malignant lymphoma, and pineal tumor, enzyme activity was found significantly elevated, and, was further enhanced when the tumor showed subarachnoid dissemination. Irradiation to the neural axis or intrathecal administration of chemotherapeutic agent elevated the enzyme activity. The activity then showed gradual attenuation while the therapeutic effect was sufficient for decreasing the size of the tumor mass. By contrast, the activity remained unchanged or increased, if the treatment was not effective and the tumor kept growing. In cases of subarachnoid dissemination or metastases the activity of the lysosomal enzymes became elevated before clinical manifestation. It was also elevated with clinical recurrence of the resected tumors. In vitro experiments were performed using a monolayer culture of rat C6 glioma cells. Enzyme activity of the culture medium with irradiation or with chemotherapeutic agent was examined. The activity was elevated as the cell growth reached the plateau phase, became maximum when the monolayer culture showed degeneration and desquamation, and then markedly decreased as the culture cells reduced in number. The activity was found to correlate well with the number of cultured cells in each experimental condition. It was considered that the lysosomal enzyme activity indicated cell damage from the therapeutic effect and the attenuation of the activity was due to subsequent cell loss. In conclusion, lysosomal enzyme activity can be a good biochemical marker of brain tumor, especially in clinical observation of tumor recurrence or dissemination.

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Radionecrosis after Radiotherapy for Brain Tumor

Yoshihiko YOSHII, Yutaka MAKI, Junichi TOSA, Koji TSUBOI, Akira MATSUM ...

1984 Volume 24 Issue 3 Pages 157-168
Published: 1984
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.24.157

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The neurological deterioration after radiotherapy of brain tumor may depend on radionecrosis or regrowth of the tumor. In the present study, five patients with brain tumor were irradiated with doses of 3, 900 to 6, 800 rads. The neurological deterioration appeared 3.5 to 46 months after radiotherapy in three patients, who received 5, 000 to 5, 680 rads, immediately after radiotherapy in one patient, who received 6, 800 rads, and during radiotherapy in one patient, who received 3, 900 rads. Ring enhancement was observed on sequential CT scans. This enhanced area was surgically removed and the correlation between histology and CT scans and superimposed dose distributions was studied in order to differentiate radionecrosis from regrowth of tumor. The radionecrosis was confirmed at the second operation in five patients, but regrowth of the tumor was also observed in the brain adjacent to radionecrosis in three out of five patients. Coagulation necrosis and fibrinoid necrosis were observed microscopically at the rim of the ring enhancement and necrotic and hyalinized debri were observed in the central low density area of the ring enhancement. Viable tumor cells were noted in the enhanced area adjacent to the ring enhancement on CT scans. Both radionecrosis and regrowth of tumor were observed in the dose distribution area of 3, 500 to 6, 120 rads on CT scans. This suggested that the superimposed dose distributions could not differentiate radionecrosis from tumor regrowth.
Forty-eight cases of cerebral radionecrosis gathered from the literature were reviewed. The radionecrosis was classified into 2 groups; one is the tumoral radionecrosis in patients with glioma and the other is the remote tumoral radionecrosis in patients with head and neck cancer and pituitary adenoma. It was suggested that neither tumoral or remote tumoral radionecrosis correlated with the patient's age at radiotherapy, the interval after radiotherapy, and the total radiation dose. It was concluded that tumoral radionecrosis should be removed by surgery, if it was associated with a mass effect and neurological deterioration, in order to differentiate it from regrowth of tumor.

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Consistency and CT Scan Finding in Acoustic Neurinoma

Taizo NITTA, Naohide WAKOH, Katsuji SHIMA, Hideo UENO, Satoru WATANABE ...

1984 Volume 24 Issue 3 Pages 169-172
Published: 1984
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.24.169

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Ten cases of acoustic neurinoma were investigated with regards to CT density. The degree of enhancement, tumor stain on angiograms, operative findings, and histological findings in order to see whether the consistency of acoustic neurinoma is predictable by preoperative CT scan findings.
Four out of the five cases of the tumor, which were found to be solid and hard by surgery, presented a plain CT density of over 50 Hounsfield units. In four out of five cases, low density areas with their density under 30 on plain CT were cystic and soft. There was no correlation between the consistency of acoustic neurinoma and degree of enhancement on CT scan. Tumors stained by transbrachial retrograde vertebral angiography were mostly solid and needed sharp dissection at operation. There was no correlation between CT findings and histological findings.

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Transfemoral Catheter Embolization of Intracranial Meningiomas

With Reference to Pathological Findings of the Tumor

Saburo SAKAKI, Hitoshi FUJITA, Yoshihiko MATSUO, Kenzo MATSUOKA, Shini ...

1984 Volume 24 Issue 3 Pages 173-179
Published: 1984
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.24.173

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Preoperative embolization has been performed between 1 and 7 days prior to surgery to reduce blood loss during surgical excision of 12 intracranial meningiomas, which possessed predominant external carotid vascularization; 5 convexity, 3 falx, 2 sphenoidal ridge and 2 parasagittal meningiomas. Cerebral catheterizations were performed through the retrograde transfemoral route. The embolization in all cases was effected with pieces of gelfoam in two different sizes, measuring 1×1×1 mm and 2×2×5 mm. The smaller pieces of gelfoam were firstly delivered through a catheter, followed by the larger ones. On computed tomography (CT) scanning after embolization, reduction of contrast enhancement was demonstrated in 9 cases, which coincided with the cases of successful occlusion of the main feeding arteries. On pathological examination of the surgical specimens, fragments of the gelfoam were demonstrated in the arterial lumen of the dura mater attached to the tumor, but no fragments were found in the fine vessels deep within the tumors. There were local or extensive hemorrhagic infarctions with an infiltration of inflammatory cells and acute ischemic necrotic lesions of the tumors with an infiltration of foamy cells. Macroscopic hemorrhage around the tumor was also found in a case. There were marked ischemic lesions in 5 cases and moderate lesions in 3 cases. These pathological findings tended to be more remarkable in the cases, in which main feeders had been occluded completely and the reduction of contrast enhancement had been shown on CT scanning. The pathological evaluation of the tumors suggests the possibility of hemorrhage within and around the tumors after embolization. The results of embolization evaluated on the basis of operative findings were effective in 10 cases.
From this study, it was concluded that embolization of the intracranial meningiomas can facilitate the surgery by reducing the great risk of hemorrhage during operation, and that surgical excision of the tumor should be performed as early as possible after embolization.

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Dorsal Column Stimulation for Post-apoplectic Spastic Hemiplegia

Report of Three Cases

Saburo NAKAMURA, Takashi TSUBOKAWA, Yoshio SUGANE

1984 Volume 24 Issue 3 Pages 180-186
Published: 1984
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.24.180

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Dorsal column stimulation (DCS) was tried on post-apoplectic spastic hemiplegia for reduction of spasticity.
Three patients with spastic hemiplegia due to apoplexia were selected for DCS. Electrodes of Medtronic's SCS system were placed at the dorsal part of the lower cervical or upper thoracic spinal cord extradurally. Stimulation with waves of 35-100 Hz and 1.0-1.5V was continued for 12-14 hours during the day everyday.
Reduction of the spasticity was observed 3 to 9 days after the stimulation. In Case 1, a 74-yearold male, spasticity of the lower extremity was reduced and his gait improved remarkably. In Case 2, a 47-year-old male, spasticity of the upper extremity was reduced slightly and his gait also improved. In Case 3, a 47-year-old male, spasticity of the upper extremity was reduced at an early period after the stimulation. However, walking speed and motor function of the extremities temporarily dropped two weeks after the stimulation. Electrophysiological evaluation of the spasticity with Hreflex showed remarkable improvement in all three patients.
Reduction mechanism of the spasticity has not been clarified yet. The direct or indirect effect to the reticulo-spinal tract is supposed to play a role. The DCS does not promote the function of the injured pyramidal tract itself, but it may help the physical treatment for post-apoplectic hemiplegia by reducing the spasticity which interferes with the recovery from paretic motor disorders.

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Measurement of Plasma Antidiuretic Hormone and its Significance in Subarachnoid Hemorrhage

Yoshio MIYASAKA, Toshio BEPPU, Kuniaki MATSUMORI, Kenji NAKAYAMA, Taka ...

1984 Volume 24 Issue 3 Pages 187-193
Published: 1984
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.24.187

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The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) occasionally follows subarachnoid hemorrhage (SAH). Plasma ADH level in patients with SAH mainly due to cerebral aneurysms was studied, and the risk for developing SIADH following SAH was discussed. Plasma ADH was measured using radio immunoassay in 25 control subjects and in 36 patients with SAH. Repeated plasma ADH measurements were made preoperatively in cases with SAH until 4 weeks after SAH. The mean (±SD) plasma level of ADH in control subjects was 3.8±1.2 pgml. Plasma ADH levels in cases with SIADH were 6.4±2.9 pgl, inappropriately elevated for the corresponding serum osmolarities and significantly higher than that of control subjects (P<0.001). The majority of cases with SIADH were Grade III or IV after Hunt & Hess. Even though the mean value of serum sodium or osmolarity was not significantly different from the controls, the mean plasma level of ADH in cases with Grade III or IV was significantly higher than the controls. The mean (±SD ) plasma level of ADH in cases with Grade III or IV measured within 14 days following SAH was, 7.8±2.8 pgml, significantly elevated (P<0.001). When compared with control subjects, cases with SAH did not show any significant increase of plasma aldosterone, blood urea nitrogen, and hematocrit which would have suggested blood volume depletion. Therefore, it was suggested that the excessive release of ADH recognized in the present study was due to non-physiological (inappropriate) release of ADH caused by non-osmotic factors other than blood volume depletion.
From the present study, it was concluded that patients with Grade III or IV, especially in an acute stage following SAH, were unable to suppress ADH release properly and to excrete a water load normally. Therefore, these patients were susceptible to SIADH in spite of usually normal serum sodium. Thus, fluid intakes and electrolytes should be closely observed.

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Clinical Application of Cerebral Endovascular Balloon Catheter for Arteriovenous Malformation

Case Report

Rihei TAKEDA, Takashi USAMI, Joji NAKAGAWARA, Hidetoshi FUJIWARA, Sumi ...

1984 Volume 24 Issue 3 Pages 194-201
Published: 1984
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.24.194

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A case of occipital arteriovenous malformation (AVM), successfully treated by using a detachable balloon catheter, was reported. The patient was a 25-year-old female who developed a photogenic seizure. Selective left internal carotid angiography showed an AVM in the occipital lobe (Luessenhop Grade II). Selective angiography using a non-detachable balloon catheter (elimination method) was performed for the detailed preoperative examination. A tolerance test during the temporary occlusion of each feeder was performed. At the same time the oxygen content of arterial and internal jugular blood was measured before and after occlusion of main feeders. Just before the operation, selective embolization of the main feeding arteries from the posterior cerebral artery with a detachable balloon was performed. The angiography following embolization showed devascularization of two-thirds of the AVM nidus. Surgical resection was performed without difficulty. Total blood loss was estimated to be less than 200 ml.
Embolization using a detachable balloon catheter seemed to be an effective adjunctive treatment prior to operative removal of AVM.

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Anterior Communicating Artery Aneurysm following Middle Cerebral Artery Stenosis

Case Report

Shoji TSUCHIMOTO, Tetsuya SHIRAISHI, Kohgo KINOSHITA

1984 Volume 24 Issue 3 Pages 202-206
Published: 1984
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.24.202

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A 41-year-old male was admitted with a transient left hemiparesis in 1974. No neurological deficits were noted but his systemic blood pressure was high. Right carotid angiography revealed only right M1 stenosis and no aneurysm was seen. Systemic hypertension has not been controlled. In 1981, this patient was readmitted because of a subarachnoid hemorrhage. Right carotid angiography revealed an anterior communicating artery aneurysm and the same right M1 stenosis as before. Left carotid angiography revealed hypoplasia of left Al segment and the blood flow of bilateral distal anterior cerebral arteries was supplied mainly through the right A1. No aneurysm was seen in the posterior circulation. Right frontotemporal craniotomy was performed and neck clipping of the aneurysm was done, and a ventriculoperitoneal shunt was added because of normal pressure hydrocephalus.
The postoperative course was uneventful. The present case indicates that hemodynamic stress following middle cerebral artery stenosis, as well as systemic hypertension and anomaly of the circle of Willis, might have played a role in the pathogenesis of intracranial arterial aneurysm.

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Intracranial Aneurysms Associated with the Accessory Middle Cerebral Artery and Duplication of the Middle Cerebral Artery

Report of Two Cases

Isao FUWA, Yasuhiko MATSUKADO, Hidetaka WADA

1984 Volume 24 Issue 3 Pages 207-211
Published: 1984
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.24.207

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Two cases of intracranial aneurysms, arising from the origin of anomalous middle cerebral arteries were reported. One case showed a rather classical history of subarachnoid hemorrhage and duplication of the middle cerebral artery beside the ruptured aneurysm. The other case was found incidentally with chronic subdural hematoma while performing carotid angiography, and an accessory middle cerebral artery was seen originating from the A1 portion of the anterior cerebral artery as well as an IC-PC aneurysm.
According to Teal's definition, an anomalous middle cerebral artery arising from the anterior cerebral artery should be termed as the accessory middle cerebral artery, whereas the duplication of the middle cerebral artery should originate from the internal carotid artery proximal to the Al-M1 origin. Twenty-three cases of aneurysms associated with those anomalous middle cerebral arteries have been reported, among which 8 cases were found to have the accessory middle cerebral artery and 15 cases were with duplication of the middle cerebral artery. Location of these aneurysms suggested both congenital and acquired factors as the etiology.

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Parasellar Cavernous Hemangioma Presenting with Hyperprolactinemia

Case Report

Hiroshi SHIMABUKURO, Sohji SHINODA, Naoshi YAMADA, Hideaki IWASA, Tosh ...

1984 Volume 24 Issue 3 Pages 212-216
Published: 1984
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.24.212

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A case of a parasellar cavernous hemangioma, which manifested a galactorrhea-amenorrhea syndrome without abnormal neurological findings is reported.
A 41-year-old female was admitted showing galactorrhea and amenorrhea for three months. The endocrinological tests were almost normal except for hyperprolactinemia. A plain skull X-ray revealed a double floor of the sella turcica. A computerized tomography scan revealed an isodensity area which was enhanced slightly with a contrast medium in the parasellar region of the right middle fossa. The angiograms showed an avascular mass lesion from the sella turcica to the right middle fossa. The sinograms of cavernous sinus clearly demonstrated an indentation in the right cavernous sinus. A pituitary adenoma with lateral extension was suspected. The tumor was subtotally removed and was histologically diagnosed as a cavernous hemangioma. The postoperative course was uneventful. The galactorrhea and amenorrhea ceased in one month postoperatively and the prolactin level in the serum became normal forty days after the operation.
Cases similar to this have never been previously reported. The possible cause of the hyperprolactinemia of this case is discussed.

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Rupture of Brain Abscess into the Lateral Ventricle

Akimune HAYASHI, Hiromichi HOSODA, Tsunemi SEKINO, Kazuhiko TOKORO

1984 Volume 24 Issue 3 Pages 217-220
Published: 1984
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.24.217

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A case of a brain abscess which ruptured into the lateral ventricle was reported. A 51-year-olc left-handed male was admitted because of lethargy, motor aphasia, and left hemiparesis. Finding: of impending intraventricular rupture prompted emergency right frontoparietal craniectomy wits external drainage of the abscess cavity. His immediate post-operative condition was poor witll findings of intraventricular rupture by CT scan and by plain skull X-rays. With intensive antibiotic therapy, however, his condition gradually improved. CT scan 28 days post-operatively showed small residual cavity. Forty-nine days post-operatively, this cavity completely resolved. There ha: been no sign of recurrence. The authors reviewed the literature and discussed recent therapeutic trends.

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