The following studies were made in order to clarify whether the intracranial pressure pulse wave (ICPPW) varies according to the pathological changes at the same level of intracranial pressure (ICP). The mean ICP and the ICPPW [particularly the pulse pressure (PP), and the tangent (rising slope)] were examined in four groups of anesthetized dogs under artificial respiration; 1) cisternal saline injections (control), 2) hypercapnia induced, 3) acute hydrocephalus, 4) chronic hydrocephalus. The following results were obtained: (1) In the control group, the PP and the tangent rose linearly with ICP; (2) At the same ICP level, hypercapnia increased the PP to a level higher than that of the control group. This is due to the fact that hypercapnia produced a significant increase in dv (pulsatile change in cerebral blood volume); (3) At an ICP level, acute hydrocephalus increased the PP and the tangent to levels higher than those of the control group. This may have been caused by an increase in the intracranial liquor and the isolation from the spinal sac, which acts to modulate pressure. (4) At an ICP level, chronic hydrocephalus increased the PP to a level higher than that of the control group. This may have been caused by an increase of intracranial liquor. It is concluded that ICPPW is influenced not only by ICP but by intracranial pathological changes.
Epidural pressure (EDP) pulse waves in acute intracranial hypertension was clinically and experimentally analyzed in order to clarify the origin of the EDP pulse wave and its clinical significance. The cases in this study included eight males and one female, ranging in age between 17 and 76 years, who were admitted with a diagnosis of hypertensive intracerebral hemorrhage, severe head injuries, or intracerebral hematoma caused by a ruptured cerebral aneurysm or a arteriovenous malformation. They were all operated on within 17 hours after the onset and manifested marked intracranial hypertension within several days after surgery. EDP was measured with an intracranial pressure (ICP) monitor system from the parietal extradural space on the operated side. Systemic blood pressure (BP) was simultaneously recorded from the radial artery with a pressure transducer in all instances. The fidelity of these pressure measuring systems was determined as acceptable. Both EDP and BP pulse waves were analyzed by measuring upstroke (U) time determined by the time from the rising point (S') in the ascending slope and the peak of a pulse wave, S'-C time determined as the time from S' to incisura (C) or dicrotic notch expressed as C in the descending slope of a pulse wave, and the pulse amplitude. Recording of the pressure pulse waves of the internal carotid artery and the femoral artery as well as EDP pulse wave were carried out in five Japanese monkeys with acute intracranial hypertension produced by the epidural balloon method. Each component of the EDP pulse wave corresponded well with that of the BP pulse wave, when ICP was below 15 mmHg. But an increase in the amplitude of the EDP pulse wave was recorded with an elevation of ICP, and prolongation of U time in the EDP pulse wave was observed at EDP of 20 to 30 mmHg. The increase in the amplitude was most significant at EDP as high as 40 to 50 mmHg. In the experimental study, changes in EDP pulse wave-form observed in intracranial hypertension was in accord with that of the internal carotid artery showing an increase of the tidal wave. These results indicated that the changes in the EDP pulse wave were induced mainly by changes in the intracranial hemodynamics and pressure transmission, secondary to intracranial hypertension. Thus, analysis of the EDP pulse wave can promote early detection of intracranial dynamic changes in intracranial hypertension.
Serial changes of intracranial pressure (ICP), electrophysiological dysfunction and the effect of postoperative barbiturate therapy were studied in 40 patients with acute subdural hematoma. The Glasgow Coma Scale (GCS) score before surgery was 8 or less in all cases and the mean age was 49 years. The outcome was assessed by the Glasgow Outcome Scale 3 months after injury. ICP measured from the extradural space and the blood velocity of the common carotid blood flow (CBFV) using the Doppler ultrasonic technique was also observed. For the evaluation of CBFV, the mean velocity during the cardiac diastole (Md) and mean velocity during the cardiac cycle (M) were calculated. The electrophysiological brain function was assessed by multimodality evoked potentials (MEP), consisting of the auditory evoked brainstem response, cortical somatosensory evoked potential and visual evoked potential. Each potential and MEP was graded from grade I to IV after Greenberg et al. ICP measured via the burr hole before craniectomy was higher than 40 mmHg in all instances and a rapid reduction in the ICP was produced by hemicraniectomy. Postoperative ICP was classified into 3 types. Md showed a progressive decrease with a rise of ICP higher than 30 mmHg. MEP grade was improved within 14 days after injury, when the postoperative ICP remained under 35 mmHg. The grade deteriorated within 7 days after injury in patients with elevated ICP above 35 mmHg. A marked aggravation of the MEP was recorded in patients with uncontrollable ICP. Postoperative barbiturate therapy was employed for patients with a GCS score of less than 6 and with an elevated ICP above 30 to 35 mmHg. The ICP was reduced by 5 to 20 mmHg and the mortality rate was reduced from 83.3 to 50%. These results indicate that a progressive decrease of the blood flow through the internal carotid artery was induced when the ICP was elevated by more than 20-30 mmHg and that aggravation of MEP was recorded in intracranial hypertension of more than 30 mmHg. It is also suggested that the outcome of acute subdural hematoma could be improved by reducing the ICP under 30 to 35 mmHg with barbiturate after decompressive hemicraniectomy.
Systematic anterior pituitary function tests were performed in 53 patients with ruptured cerebral aneurysm, and the results were assessed for correlation with various clinical factors. The subjects were 24 patients with aneurysm of the anterior communicating artery, 14 with aneurysm of the internal carotid-posterior communicating artery, 7 with aneurysm of the middle cerebral artery, 3 with aneurysm of the posterior inferior cerebellar artery, 2 with aneurysm of the peripheral anterior cerebral artery, 2 with aneurysm of bifurcation of the internal carotid artery, and 1 with aneurysm of the superior cerebellar artery. In the radio-immunoassay, growth hormone and cortisol were determined during the insulin tolerance test (regular insulin, 0.15-0.20 U/kg), luteinizing hormone and follicle stimulating hormone under luteinizing hormone-releasing hormone (100 μg), thyroid stimulating hormone and prolactin under thyrotropin-releasing hormone (500 μg). The impaired rate was calculated for each patient as the number of impaired anterior pituitary hormone secretions divided by the number of effectively examined anterior pituitary hormones. The data were assessed statistically by a variance analysis for age, sex, clinical symptoms, disease stage at the test time, complications, and location of the aneurysm, and the impaired rate. The results were as follows. 1) Growth hormone, thyroid stimulating hormone, cortisol, luteinizing hormone, prolactin, and follicle stimulating hormone secretions were impaired in 52%, 45%, 23%, 15%, 11%, and 9% of the cases, respectively. 2) The case incidence of impaired anterior pituitary hormonal secretion was 77%, but its intensity was mild in most of the patients. 3) The impaired rate was significantly higher in patients with a high-grade or early-stage subarachnoid hemorrhage, complication such as hydrocephalus or angiospasm, and aneurysm of the anterior communicating artery.
Systematic anterior pituitary function tests were performed in 49 patients with hypertensive intracranial hematoma, and the results were assessed for correlation with various clinical factors. The subjects were 18 patients with putaminal hemorrhage, 21 with thalamic hemorrhage, 6 with subcortical hemorrhage, and 3 with cerebellar hemorrhage. In the radio-immunoassay, growth hormone and cortisol were determined during the insulin tolerance test (regular insulin, 0.15-0.20 U/kg), luteinizing hormone and follicle stimulating hormone under luteinizing hormone-releasing hormone (100 μg), thyroid stimulating hormone and prolactin under thyrotropin-releasing hormone (500 μg). The impaired rate was calculated for each patient as the number of impaired anterior pituitary hormone secretions divided by the number of effectively examined anterior pituitary hormones. The data were assessed statistically by analysing the variance due to age, sex, clinical symptoms, disease stage at the test time, complications, and location of the hematoma, and the impaired rate. The results were as follows. 1) Growth hormone, thyroid stimulating hormone, prolactin, cortisol, follicle stimulating hormone, and luteinizing hormone secretions were impaired in 47%, 45%, 29%, 22%, 22%, and 20% of the cases, respectively. 2) The case incidence of impaired anterior pituitary hormonal secretion was 86%, but its intensity was mild in most of the patients. 3) The impaired rate was significantly higher in patients with consciousness disturbance and hydrocephalus. 4) The impaired rate was higher in large hematoma patients in the putaminal and thalamic hemorrhage groups.
Clinical gradings for the cerebral aneurysm, advocated by Botterell, Nishioka or Hunt have been commonly used for evaluating the patient condition and the indication of the aneurysm surgery. In this study, new clinical grading classifying the patient condition according to their level of consciousness, herniation sign and also the accompanying conditions, which are evaluated by computerized tomography (CT) and angiography were reported. These include massive subarachnoid hemorrhage (SAH) in CT, intracerebral hematoma (ICH) with mass signs, such as midline shift and deformity of the ventricle, and vasospasm (VS) detected in angiography. Clinical results of the treatment for aneurysm cases in the acute stage are also reported. Two hundred ninety-one cases of anterior communicating, internal carotid and middle cerebral artery aneurysms which were admitted within 7 days after the last attack were studied. Of these 260 cases were operated on. The mortality of all cases was 16.2% and the morbidity was 13.7%. Number of cases having accompanying conditions were increasing as the grading. Most of the cases in grade 2 and 3 without accompanying conditions recovered to a good condition, except for cases with a rebleeding attack after the admission. The cause of the poor outcome in grade 2 and 3 with SAH and VS was cerebral ischemia following VS. Incidences with the two or three accompanying conditions increased in cases with grade 4 or more. Twenty out of 28 severe cases in grade 5b and 6 showed massive ICH on admission. Good outcome in cases with grade 4 or more were obtained in cases without VS. The accompanying conditions showed the cause of severity in a high grade case and helped to estimate the secondary pathophysiological state and to take preventive methods against it in a low grade case. Acute hydrocephalus was not rated as an accompanying condition, because no correlation was found between clinical severity and outcome. Clinical grading, based on level of consciousness, herniation signs and accompanying conditions were well correlated with the outcome and showed the operative timing and indication.
In this paper, two interesting cases are introduced, one a multiple cerebral aneurysm with an infundibular dilatation of the left posterior communicating artery and a small bleb of the left anterior cerebral artery, both of which grew to large aneurysms in 10 years; the other an aneurysm of the middle cerebral artery, which recurred 6 years after treatment by neck clipping combined with muscle wrapping. These cases have motivated to conduct a histological experimental study, using 64 intracranial arteries of mongrel dogs, to evaluate the various materials so far used for the wrapping of cerebral aneurysms. The findings obtained were: 1) Muscle, fascia, and dura began to show necrotic and absorbable changes within 1 to 2 months after the operation, suggesting their unreliability as free pieces. 2) Lyodura® adhered poorly to vascular walls and showed detectable gaps against vessels. In addition, it showed necrosis and absorption in the bent site. 3) When Aron alpha A® alone was used for coating, its adhesion was unexpectedly poor; it easily peeled off from the vascular wall as a result of mutual interaction with vascular beating. It further became fragile and easily degradable with the passage of time. 4) Bemsheet® was superior in its adhesion to vascular walls, since it contributed greatly to the construction of a reinforced wall by proliferating collagen fibers in the space of the stereo-reticular structured cotton fiber. When Bemsheet® was fixed with Aron alpha A®, the latter permeated into the space of the reticular structured cotton fiber to form a sufficiently firmly reinforced wall immediately after treatment. The cotton fiber itself remained unchanged and gave almost no inflammatory reaction even after 12 months.
In the cervical disc disease, computed tomography (CT) myelographic and conventional myelographic findings were surgically confirmed. The authors classified the disc protrusion into two types, and demonstrated the characteristic features of these two types in CT myelography and conventional myelography. Moreover, the correlation with the localization of the disc protrusion and the laterality of the myelopathy are discussed. All cases were obtained using a late generation scanner and the patient in the supine position with the neck in the neutral position. Using conventional myelography, all examinations were obtained with the neck in a flexion, neutral and extended positions. Twenty-two patients with cervical disc disease operated on by an anterior approach were studied by CT myelography and conventional myelography. According to the style of the compression on the spinal cord, the cervical disc protrusion was classified into two main groups, the subligamentous type and epiligamentous type. This study included 10 patients of the subligamentous type and 12 patients of the epiligamentous type. The localization of the disc protrusion and the laterality of the myelopathy often corresponded with each other. Not only the localization of the lesion, but also the pincer effect, especially the oblique pincer effect, which is reinforced by dynamic factors, are important in the understanding of the manifestations of myelopathy. In the subligamentous type, the main cause of the myelopathy is considered to be the mechanical pressure by the prolapsed nucleus pulposus. In the epiligamentous type, on the other hand, it is believed to be the pincer effect, reinforced by dynamic factors.
The method and results for preoperative embolization are described in 36 cases with intracranial meningiomas. Embolization materials were injected through a transfemoral catheter, selectively placed in the external carotid artery. Chopped gelfoam served as embolization material in 29 patients and ivalon particles were used in 7 patients. In 19 out of 36 cases the feeding arteries arose only from the external carotid artery system and were completely occluded (complete embolization) except in 3 cases. The remaining 17 cases also had feeders of the tumor capsule or at the site of the insertion arising from the internal carotid artery system (partial embolization). Thirty-three cases were followed by computed tomography (CT) between embolization and operation. Contrast enhancement effect decreased in 10 cases without marked changes in the plain CT. Tumors developed a low density area, which suggested necrosis in 14 cases, and were irregularly enhanced. In 3 out of these 14 cases, a high density area appeared within the low density area, suggesting an intratumoral hemorrhage, but this disappeared within several days. Through intraoperative findings the effectiveness of embolization was graded as very effective (19 cases), effective (14 cases) and ineffective (3 cases). Changes in the follow-up CT were correlated with complete or partial embolization and predicted the effectiveness of preoperative embolization. The location of the meningioma played an important role in the result of embolization. Convexity meningiomas were most commonly indicative of preoperative embolization and good results were achieved. But small convexity meningiomas which should be excised “en bloc” did not benefit from preoperative embolization, if the internal carotid artery system vascularized the tumor capsule. Satisfactory results were achieved in the parasagittal, falx, sphenoidal ridge, posterior and middle cranial fossa meningiomas. Some basal meningiomas tended to diffusely invade the skull and were difficult to reach at operation. This and especially the frequent necessity of piecemeal removal, indicated preoperative embolization with excellent results. Complications of embolization were seen in about 75% of all cases. But serious complications, such as cranial nerve palsy or aggravated neurological deficits due to reflux of emboli into the internal carotid artery system did not develop in this series.
The authors present an unusual case of meningioma with extensive histological vacuolization. A 47-year-old woman had an episode of generalized convulsion with loss of consciousness. A plain computerized tomography (CT) scan revealed a diffuse hypodense mass lesion in the right parietal region. The postcontrast scan showed a diffuse and homogeneous enhancement of the mass. Total removal of the tumor was performed. Microscopic examination demonstrated extensive vacuolization of most of the tumor cells with numerous small blood vessels, except for small meningothelial and angioblastic components. The authors experienced another case, in which the microscopic findings contained variable sized vacuoles and microcysts. The CT scan showed a well defined large mass with large and small cysts, and a low density area. In general, cyst or necrotic hypodense areas are occasionally seen within meningioma by CT scans, but no diffusely hypodense meningioma has been reported except for three cases. This low density is due to extensive vacuolization, which bears histological resemblance to the subarachnoid space. The pathogenesis of the cyst formation in meningioma is still obscure. It is suggested that forming of the macroscopic cysts from the microscopic vacuoles appeared to mimic the developmental process of the subarachnoid space in the embryo.
A 70-year-old man was brought in semi-comatose 30 minutes after being hit by a motorcycle. The blood pressure was 60/40 mmHg. The pupils were isocoric and light reflex was noted. The face was markedly swollen by massive bleeding. Open fracture of the left leg was also present. Intratracheal intubation was immediately performed and 10, 000 ml of blood and fluid were administrated. X-ray films showed fractures of the nasal bone, the zygomatic bones, the zygomatic arches, the orbitae, the maxilla, and the mandibula. Fractures of the iliac bone, the left tibia and fibula were also noted, but no signs of abdominal and vertebral injuries were present. Computed tomography (CT) showed a slight cerebral contusion. Epistaxis was controlled by Brighton balloons, but bleeding from other portions continued. To maintain hemodynamics, reduction and fixation of the facial bones by a halo-external fixation apparatus were performed. Intramedullary nailing of the leg was also done. Cerebral contusion was treated conservatively. One year after the accident, he can walk and live a comfortable life without severe malformations. In craniofacial injuries, bleeding is sometimes massive and uncontrollable. In this case, the haloexternal fixation controlled the bleeding perfectly. This apparatus is very compact and has a high degree of flexibility in various situations. Because the metal frame disturbs CT scanning, intracranial pressure monitoring is essential when intracranial lesions are suspected.
A case of acute epidural hematoma of the posterior fossa caused by fronto-temporal impact was reported. A 43-year-old man hit the right fronto-temporal region against the pole on the road, while driving a motorcycle after drinking. Immediately after the injury, he was conscious, but disoriented and was brought to a local hospital 30 minutes after the accident. He was then confused and was treated by mannitol and steroid. The patient was transferred 36 hours after injury because he remained somnolent of stuporous. On admission, a swelling of the right fronto-temporal region was noticed. Plain skull X-ray failed to reveal a skull fracture, other than equivocal skull depression at the right fronto-temporal region. Computed tomography scan demonstrated a biconvex hyperdense lesion in the right posterior fossa which extended to the supratentorial region. Surgery disclosed a 20 g epidural hematoma of the right posterior fossa and the supratentorium and the clot was completely evacuated. The source of bleeding could not be identified. Opening of the posterior fossa dura revealed no abnormality in the subdural space or cerebellar surface. The postoperative course was uneventful and the patient was discharged without any neurological deficits. The possible mechanisms in the production of the posterior fossa hematoma in this case is discussed.