Neurologia medico-chirurgica

Mutual Relations between the Local Shift of the Brain Stem, Change in Brain Stem Function, and Transtentorial Herniation during the Process of the Gradual Expansion of an Intracerebral Balloon

Norio Misu, Hiroji KUCHIWAKI, Nagatoshi HIRAI, Sohshun TAKADA, Hitoshi ...

1986 Volume 26 Issue 10 Pages 751-758
Published: October 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.751

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A local shift of the brain stem and transtentorial herniation are studied in the state of increased intracranial pressure (ICP) induced by a supratentorial mass lesion. Analysis of ICP dynamics is based on the correlations between an increased ICP and the local shifts of the brain.
Simultaneous measurement of brain shifting, ICP, systemic blood pressure, respiration, cerebral blood flow (CBF), electroencephalogram, and the size of pupils were carried out using 18 mongrel dogs and 5 monkeys. In the initial phase of mass expansion, tentorial herniation was observed on the balloon side, and the midbrain shifted to the ventral and contralateral side with a gradual increase in ICP. The pons and the ponto-medullary junction were also dislocated to ventral direction. With further mass expansion, tentorial herniation was also observed on the contralateral side, and the midbrain altered its displacement to dorsal and to the balloon side, while the pons and the ponto-medullary junction continued to shift ventrally. At the steepest rise in ICP, dorsal shift of the midbrain reached a maximum, while irregular respiration, hypotension, and a decrease in CBF were observed, and the midbrain turned its shift to ventral direction again.
In conclusion, an acute deterioration of the brain stem was induced by the adverse shift of the brain stem between the midbrain and the pons during an acute increased ICP.

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Serial Rotatostereography—A New Diagnostic Method

Development of Real Time Display Method: Continuous Semi-rotation Stereo Display Method

Michinori OTTOMO, Takeshi NAKANISHI

1986 Volume 26 Issue 10 Pages 759-764
Published: October 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.759

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In order to view the cerebral vessels as continuous stereoscopic views from left lateral, through anteroposterior, to right lateral projections, a new stereoscopic X-ray diagnostic device was devised. A gantry, which was equipped with an X-ray tube (Circlex 0.6W/0.8PG 38B) and a 9" image intensifier (Philips 9/5 High Lens) was rotated through 180° in 1.8 seconds by a motor power unit (Tsubaki SCU Motor: Type 022DMLB). A television unit, AX-2000A, with a Plumbicon (QX1072) camera tube, was used (Stereotom Type II) . In the previous study using cine, a cine film stereoprojector showed the adjacent two frames of cine film simultaneously, such as frames 1 and 2, 2 and 3, 3 and 4, and so on, consecutively. Because some intracranial lesions require emergency surgery immediately after angiography, a real time display method of serial rotatostereography was necessary. In order to show the consecutive adjacent two frames of a video disc simultaneously, using the same method as with the cine stereoprojector, a video disc recorder (VDR) (VMI000M) and two video memories (Image Σ) were required. This VDR has the ability of advancing, stopping, and reversing the display of memories. A control unit was manufactured in order to display these memories advancing and reversing continuously. As a result of this continuous semirotation stereo display, the anteroposterior projection was reversed, showing the posteroanterior view during “reversing mode.” Thus a lead relay circuit was manufactured to prevent this phenomenon. Recording was done using a memory disc recorder (FOM 2200F), which has the ability of recording 10, 000 frames per disc. Each frame can also be recorded on imaging film using O·X Multi Camera 400X. Finally, stereoscopic views of cerebral circulation, using a single injection of contrast media and rapid rotation of the gantry, were obtained using two cathode-ray tubes (CRTs) and a stereoviewer (Continuous Semi-rotation Classical Stereo Display Method). Stereoscopic views were also obtained using a single CRT, which displayed the images in a semirotating fashion similar to a oscillating fan head (Continuous Semi-rotation New Stereo Display Method).

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Diagnostic Value of the Digital Subtraction Angiography of Brain Tumors

With Special Reference to the Significance of Tumor Stains

Yoshifumi HIRATA, Yasuhiko MATSUKADO, Mutsumasa TAKAHASHI

1986 Volume 26 Issue 10 Pages 765-770
Published: October 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.765

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Digital subtraction angiography (DSA) in 110 cases of brain tumors were studied in comparison with conventional angiography (CA). The dural sinuses and tumor stains of meningiomas, particularly tuberculum sellae meningioma, were better shown by intravenous DSA (IV-DSA) than by CA. IV-DSA clearly demonstrated bilateral carotid arteries and was able to rule out the coexistence of the intracranial aneurysm in 88% of 32 cases with pituitary adenomas. Combination of IV-DSA and high resolution computed tomography has replaced CA to determine surgical indication of patients with pituitary adenomas. Intra-arterial DSA (IA-DSA) was diagnostic and well comparable to CA in identifying main cerebral vasculature over 1 mm in diameter. As to the small arteries under 1 mm and fine tumor vessels, IA-DSA provided less information or none at all. However, IA-DSA was superior to CA for visualization of tumor stains. Not only in most of meningiomas and hemangioblastomas, but in some astrocytomas and oligodendrogliomas, marked tumor stains were well demonstrated on DSA, and DSA provided surgical anatomy for neurosurgeons because of high contrast resolutions. Careful attention should be paid because tumor stains may overestimate tumor vascularity.

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Diagnosis of Absence of Cerebral Circulation by the Ultrasonic Doppler Method as a Confirmatory Test of Brain Death

Shoju HIRAGA, Mamoru TANEDA, Toshihisa SAKAMOTO, Nobumitsu SHIMADA, Ak ...

1986 Volume 26 Issue 10 Pages 771-777
Published: October 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.771

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The usefulness of a non-invasive ultrasonic Doppler method in the diagnosis of absence of cerebral circulation under brain death was studied. The probe was placed over the bilateral internal carotid and vertebral arteries of 30 patients. Angiograms showed non-filling of cerebral vessels in 15 cases, and normal cerebral circulation in the other 15 control group patients. The blood flow patterns were monitored by an audible Doppler and recorded as sonograms (flow-velocity wave forms). In patients with normal circulation, the examination showed continuous one-way flow patterns. In the patients with angiographic non-filling patterns, a discontinuous bi-directional pattern was observed in all the vessels. The difference in sonographic patterns between these two groups was also distinguishable by auscultation of the Doppler sound patterns. In 4 cases, slow filling of the cerebral circulation by contrast medium was observed before the non-filling state developed. A low velocity continuous flow pattern with a weak reverse flow element was observed in all of them. Thus, an ultrasonic Doppler study can clearly diagnose the absence of cerebral circulation by studying the four major vessels in the neck and differentiate the absence of flow from a low cerebral blood flow state.

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Relationship between Hypoxemia and Urinary Catecholamines Excretion in Subarachnoid Hemorrhage and Hypertensive Intracerebral Hemorrhage

Hajime TOHO, Tohru SAWADA, Jun KARASAWA, Haruhiko KIKUCHI

1986 Volume 26 Issue 10 Pages 778-784
Published: October 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.778

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Relationship between pulmonary insufficiency and urinary catecholamines excretion in 34 patients with hypertensive intracerebral hemorrhage or subarachnoid hemorrhage in the acute stage was evaluated. The hypoxemia was not induced by pulmonary hypoventilation but by an increase in alveolar-arterial oxygen difference. As it was known that administration of catecholamines brought an increase in intrapulmonary shunt, the relationship between alveolar-arterial oxygen difference and urinary catecholamines excretion was investigated. Alveolar-arterial oxygen difference positively correlated with urinary catecholamines excretion. The patients with increased alveolar-arterial oxygen difference had an increased intrapulmonary shunt. Maximum diameter of hematoma in 20 patients with hypertensive intracerebral hemorrhage had a significantly positive correlation with their alveolar-arterial oxygen difference. Administration of phentolamine and propranolol decreased the intrapulmonary shunt followed by a decrease in alveolar-arterial oxygen difference through reducing pulmonary vascular resistance and cardiac output, respectively. Trimethaphan camsilate also decreased these two values without any change in pulmonary vascular resistance or cardiac output. From these facts, it can be speculated that an overactivity of the sympathetic nerves exists in the acute stage of hypertensive intracerebral hemorrhage and subarachnoid hemorrhage, and that elevated catecholamines play an important role in increasing the intrapulmonary shunt followed by hypoxemia through acting on the pulmonary vascular bed, through action on the efferent sympathetic nerves to the pulmonary vascular bed, and/or through increasing cardiac output.

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New Category of Unruptured Cerebral Aneurysms

Shoji ASARI, Yuji YAMAMOTO

1986 Volume 26 Issue 10 Pages 785-791
Published: October 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.785

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Thirty outpatients with unruptured cerebral aneurysms were screened by noninvasive cerebral computed angiotomography at Matsuyama Shimin Hospital between 1979 and 1984. Seventeen were male and 13 were female. The ages at diagnosis ranged from 41 to 74 years (mean, 57.7 years), and their distribution was as follows: seven were 40 to 49 years, 10 were 50 to 59 years, 10 were 60 to 69 years, and three were over 70 years. Clinical problems were: headaches in eight, neurological deficits in 11, seizure in three, and tinnitus in one. These clinical problems were mild and unrelated to screened unruptured aneurysms in all. Six had a personal or family history of apoplexy. One was screened during the medical checkup in human dock. Thirty patients had 32 aneurysms; four were on internal carotid arteries, eight were on anterior cerebral arteries (one was distal anterior cerebral artery aneurysm and seven were anterior communicating artery aneurysms), 14 were on middle cerebral arteries, two were on posterior cerebral arteries, and four were on vertebro-basilar tree. The size of aneurysms varied; being 5 mm in eight patients, 6 mm in five, 8 and 9 mm in three each, 4, 7, 10, 13, and 22 mm in two each, and 18, 20, and 29 mm in one each. The aneurysms less than 10 mm in size were 78.1 Yo. Thus, unruptured cerebral aneurysms in the critical range of rupture could be screened by the noninvasive method.
In the 15 patients who did not receive operation, eight showed no change of condition, two worsened and four expired due to other causes, and one expired as a result of aneurysmal rupture. Of the 15 patients who were operated on, 11 showed no neurological morbidity and three had transient minor neurological symptoms postoperatively, and one experienced acute cardiac infarction 1 month after operation. The long-term results showed 10 patients in good condition, two in deteriorated conditions, and three who expired due to other causes.
The results show that these unruptured cerebral aneurysms should belong to a new category of unruptured cerebral aneurysms. Generally, unruptured cerebral aneurysms, once discovered, should be operated on from the standpoint of prevention of the subarachnoid hemorrhage. However, the indication for surgery is still controversial.

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Symptoms and Regional Cerebral Blood Flow in Chronic Subdural Hematoma

Kiyonobu IKEDA, Haruhide ITO, Tetsumori YAMASHIMA, Kenichi SAITO, Shin ...

1986 Volume 26 Issue 10 Pages 792-800
Published: October 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.792

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Relationship of clinical manifestations to regional cerebral blood flow (r-CBF) was analyzed in 21 adult patients with unilateral chronic subdural hematoma (CSH) before and after operation. The r-CBF was measured by the ¹³³Xe inhalation method and was represented by the initial slope index from Fourier analysis. All the cases showed bilateral decrease in mean hemispheric CBF (mCBF) values, and in 90% of cases the m-CBF values of compressed side by the hematoma were less than or approximately equal to those of contralateral side. The m-CBF values of all the patients with headaches and 56% of cases with neurological deficits stayed within age-matched normal values. The preoperative r-CBF values in the headache group were normal in all detector sites of bilateral hemispheres, while those in the hemiparesis group decreased, especially at the Rolandic motor and sensory area of the hematoma side, which normalized with neurological recovery after hematoma evacuation. In the groups of consciousness disturbance and mental symptom, preoperative r-CBF patterns, which normalized after operation, could be divided as follows: 1) bilateral and total decrease below normal value; 2) no local decrease from the normal value. Some cases showed the relative decrease in r-CBF at a part of frontal lobe. It is suggested that neurological deficits of CSH result from the local circulatory disturbance of blood flow at the brain cortex compressed by hematoma.

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Outcome Prediction by Recovering Signs in Acute Head Injury

Kiyohiro KITO, Umeo ITO, Hiroki TOMITA, Shin TSURUOKA, Yutaka INABA

1986 Volume 26 Issue 10 Pages 801-806
Published: October 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.801

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Correlation between outcome and various initial recovering signs was investigated in 40 head injury patients whose Glasgow Coma Scale (GCS) on admission were 11 and/or less. Recovering signs, including spontaneous limb movement (SLM), open eyes (CIE), obey commands (OC), and pursuit eye movement (PEM) were chronologically followed. Light reflex seemed to be the best predicting factor among the other initial factors. The patients with admission GCS of 6-8 showed various outcomes and patterns in recoveries of signs. The predicting power of the recovering signs, such as OC and PEM, gradually became stronger after head injury. These signs were stronger than any initial factors following the 6th day after head injury. The predicting powers of simple signs, such as OE and SLM, were more powerful than those of complicated signs, such as OC and PEM, immediately after head injury. However, the predicting power of complicated signs became stronger than that of simple signs after 3-6 days following head injury. Continuous follow-up of the recovering signs should be important in predicting outcome, because each predicting factor changes its predicting power, depending on elapsed time following head injury.

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Facial Nerve Neurinoma with Crocodile Tear Syndrome

Case Report

Shinichi ITAGAKI, Kiyotada YAMADA, Senshi KAWAKAMI, Osamu NAKAI, Isao ...

1986 Volume 26 Issue 10 Pages 807-810
Published: October 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.807

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A case of neurinoma originating from the horizontal portion of the facial nerve is reported. The patient was a 29-year-old male complaining of tinnitus, facial palsy, hearing loss, and crocodile tear syndrome on the left side. Neurological examination on admission revealed peripheral type facial palsy on the left, hyposalivation of the left submandibular gland, diminished sense of taste on the anterior two thirds of the tongue on the left side, and loss of the stapedial reflex on the left. Schirmer's lacrimation test showed crocodile tear and slight decrease in lacrimation on the left. A hearing test revealed a slight hearing loss of the conductive type on the left. Plain films of the skull and tomograms of the temporal bone revealed destruction of the petrosal bone in the semicircular canal and the attic on the left. Computed tomography scan showed a mass in the left middle cranial fossa which was enhanced homogeneously after infusion of the contrast medium. Surgery was performed and the tumor was removed by the middle cranial fossa extradural approach. The tumor originated from the horizontal portion of the facial nerve, extending to occupy the geniculate portion and the attic. Histological diagnosis was typical neurinoma. The authors discuss the interesting clinical findings of facial nerve neurinoma with a review of the literature.

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Traumatic Dural Arteriovenous Malformation

Case Report

Norihiro HAYAMA, Kazuaki SUGIURA, Motoki BABA, Eiichiroh KAMATSUKA, Ta ...

1986 Volume 26 Issue 10 Pages 811-815
Published: October 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.811

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Traumatic dural arteriovenous malformation (AVM) is a rare cerebral vascular disease. Traumatic dural AVM fed by cortical artery has rarely been reported so far in the literature. A 57year-old male developed bruit, thrill and tenderness over the injured region about a year after he had been hit on the occipital region of the head. A linear skull fracture was found to cross over the transverse sinus and a dural AVM in the region of the transverse sinus was detected angiographically. It was considered that this dural AVM was traumatic. Postoperatively, the cortical arteries became feeders of the AVM, so that pure dural AVM changed to mixed pial-dural AVM. The mechanism by which a cortical artery became a feeder of AVM might be that the “rete mirabile” artery started as a channel to the nidus in reverse direction.

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Von Hippel-Lindau Disease

Report of Two Cases

Yasuhiro KOJIMA, Noriyuki SUZUKI, Masaharu ODA, Yusuke ISHIWATA, Takao ...

1986 Volume 26 Issue 10 Pages 816-821
Published: October 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.816

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Two cases of von Hippel-Lindau disease are presented. Case 1 was a 52-year-old male with four lesions: a cerebellar hemangioblastoma, an intraventricular metastatic tumor, a renal cell carcinoma, and a liver cyst. The patient died of intraventricular hemorrhage due to a metastatic brain tumor of the renal cell carcinoma. Brain metastasis of the renal cell carcinoma of von HippelLindau disease is extremely rare. Case 2 was a 24-year-old male with five lesions: a cerebellar hemangioblastoma, a spinal hemangioblastoma, a pancreatic cyst, a pheochromocytoma, and multiple renal cysts. Spinal angiography was useful in the diagnosis of the spinal tumor. The elder brother of the patient has an asymptomatic renal cyst.
Twenty-five distinct lesions have been reported in von Hippel-Lindau disease. Computed tomographic screening seems to provide typical image of the central nervous and abdominal tumors.

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Dural Arteriovenous Malformation in the Anterior Cranial Fossa

Case Report

Hiroshi ISHIMITSU, Ken NISHIMOTO, Yasuhiro HARADA, Ichiro MIYATA, Nobu ...

1986 Volume 26 Issue 10 Pages 822-828
Published: October 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.822

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The patient is a 52-year-old man referred with an episode of loss of consciousness. His medical history showed a similar episode 30 years ago, with bloody cerebrospinal fluid. However, the etiology of the subarachnoid hemorrhage was not then established. He had been in good health until he experienced the loss of consciousness in August, 1980. Neurological and physical examinations were normal. Contrast-enhanced computerized tomography demonstrated an irregular linear density in the right anterior cranial base. Angiography revealed an arteriovenous malformation (AVM) in the anterior cranial base, fed by the anterior and posterior ethmoidal arteries, and draining into the olfactory and uncal veins via a dilated vascular sac. The diagnosis of dural AVM was made. A right frontal craniotomy was performed. Many feeding vessels penetrating the anterior cranial base were identified and coagulated. The dilated vascular sac on and in the dura mater was totally removed en-bloc with draining veins. Histologically, the wall of the vascular sac was thickened and degenerated. There were no angiomatous components. The postoperative course was uneventful, and an angiography revealed complete disappearance of the AVM.
Only 17 patients with dural AVM in the anterior fossa are found in the literature. Most of them are male, and all are over 40 years old (average: 54 years). The present case had a subarachnoid hemorrhage at the age of 23 years, which could have attributed to the rupture of the dural AVM found at the age of 52 years. The most remarkable characteristic of dural AVMs in this location is the frequent finding of a dilated vascular sac which often ruptures, thus resulting in intracranial hemorrhage.

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