Neurologia medico-chirurgica

A New Computed Tomography-guided Stereotactic Instrument

Takaaki TAKIZAWA

1986 Volume 26 Issue 8 Pages 589-594
Published: August 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.589

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A new stereotactic system guided by computed tomography (CT) is reported. This instrument is composed of a square head frame, one arc frame, and a needle holder. The needle holder has a ball bearing function which does not limit the approach trajectories. The target point can be read out accurately from the CT image with dimension adjustable attachments. This system has the following advantages: 1) In spite of its simplicity, its mechanical accuracy is clinically satisfactory. 2) The entry point can be selected freely during operation. 3) Intraoperative manipulation is simplified by microcomputer calculation. 4) Three-dimensional relationship among target, entry point and the instrument is easily understood. 5) Surgical procedures in the CT room are made possible by using the plastic frame which gives little artifact.

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Experimental Cerebral Infarction in the Dog

Scanning Electron Microscopy with Vascular Endocasts of the Microvessels in the Ischemic Brain

Kenji TSUTSUMI

1986 Volume 26 Issue 8 Pages 595-600
Published: August 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.595

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Large-sized infarctions of the cerebral hemisphere (LSICH) were experimentally induced in 17 dogs by injecting two silicone cylinders through the right cervical internal carotid artery. The LSICH models were perfused with heparinized saline and fixed with 1.5% glutaraldehyde solution through the contralateral carotid artery. Then 24 hours after the embolization, Mercox® CL-2B and CL-2R were injected manually. The brains were immediately removed, and specimens were obtained from the basal ganglia and the ectosylvian cortex. Disruptions of the degenerated arterioles with numerous erythrocytes and Mercox were observed in the area of massive hemorrhagic infarct in the basal ganglia. On the other hand, disruptions of degenerated venules with a few erythrocytes and Mercox around the vessels were observed in the petechial hemorrhagic infarct in the corticomedullary junction area. Dilatation of the perivascular space of the microvessels and vacuolation of the neuropiles were related to the severity of the vasogenic edema. Microvessels were narrowed and decreased in flexibility in severe vasogenic edema. Some arterioles ran parallel and branched convergently. It was suggested that changes in the microvascular structure were caused by disturbance of the autoregulation of the cerebral microcirculation.

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Local Cerebral Blood Flow Measurement by SPECT using ¹²³I-IMP in Patients with Occlusive Cerebrovascular Disease

Takashi UEDA, Kazuo KINOSHITA, Katsushi WATANABE, Hiroaki HOSHI

1986 Volume 26 Issue 8 Pages 601-607
Published: August 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.601

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N-isopropyl-p-[¹²³I] iodoamphetamine (¹²³I-IMP) is a lipid-soluble radiopharmaceutical that penetrates the normal blood-brain barrier, and has a high first-pass extraction efficiency in the brain. When ¹²³I-IMP is given intravenously, its activity in the brain is maintained for several hours and its distribution is postulated to be proportional to the local cerebral blood flow (ICBF). When combined with single photon emission computed tomography (SPECT), the regional activity of ¹²³I-IMP can be quantified.
Tomographic images of ICBF were obtained with both the ¹³³Xe inhalation method and intravenous administration of ¹²³I-IMP in patients with occlusive cerebrovascular diseases. Four patients with transient ischemic attacks showed normal X-ray CT but had decreased ICBF on SPECT in the areas corresponding to neurologic deficits. SPECT images showed low ICBF earlier and larger than X-ray CT abnormalities which appeared in patients with cerebral infarction. SPECT with the ¹³³Xe inhalation method gives absolute ICBF values and has the advantage over ¹²³I-IMP of short examination time. However, higher spatial resolution is obtained by ¹²³I-IMP SPECT. X-ray CT will maintain a major role in the investigation of neurologic diseases when assessment of anatomic and morphologic changes is needed, and ¹²³1-IMP SPECT perfusion images should have a complementary role in the menagement of neurologic diseases associated with alteration of ICBF.

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What is Comprehensible from the Infusion Test?

Experimental Analysis of the Pressure-response Curve after a Bolus Infusion

Koichi KITAMI, Hiromi NISHIMURA, Nobuyuki YASUI

1986 Volume 26 Issue 8 Pages 608-614
Published: August 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.608

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The purpose of this report is to clarify the origin of the pressure-response (p-r) curve after a bolus normal saline injection into the subarachnoid space. Eighteen adult mongrel dogs weighing 9-13 kg were intubated and ventilated artificially. A bolus normal saline injection (0.8 ml-sec) was performed and the changes in intracranial pressure, superior sagittal sinus pressure, and systemic arterial pressure were monitored and recorded continuously for 30 minutes. The following results were elicited: 1) The shape of the p-r curve was determined by three resistances: resistance to the cerebrospinal fluid (CSF) absorption (r), blood inflow resistance into the sinus (Ri), and blood outflow resistance from the sinus to the extracranial venous system (Ro). A new intracranial volume-pressure model was proposed for detailed analysis of the volume-pressure relationship. 2) Changes in the CSF pressure after a bolus injection were characterized by two components. The steep decay of the p-r curve was thought to occur because of the CSF absorption, and the gentle decay should be the result of sinus outflow resistance which might be equivalent to the CSF absorption resistance, since the CSF absorption resistance should be rapidly changeable and pressure dependent. Patterns of the p-r curve were divided into three groups, namely “normal, ” “borderline, ” and “delayed” patterns. The last one could result either from high r state or from high Ro conditions. The borderline group contained dogs in which the intracranial cavity was tight.
The CSF absorption resistance could be obtained by careful analysis of the p-r curve, but it might be modified by the spatial compensation of the venous system. It is thought to be important for the reasonable analysis of the p-r curve that the shape consideration, the baseline-peak pressure gradient (pressure increment), and the recovery time to the baseline pressure should all be included in a single analytical theory.

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What is Comprehensible from the Infusion Test?

Experimental Analysis of the Intracranial Volume-pressure Relationship

Koichi KITAMI, Hiromi NISHIMURA, Nobuyuki YASUI

1986 Volume 26 Issue 8 Pages 615-620
Published: August 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.615

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In the previous report a new model was proposed for the understanding of the intracranial mutual pressure interactions after a bolus volume loading. In this report the intracranial volume-pressure relationship (VPR) is examined in 15 dogs. They were separated into two groups: the steady-state infusion group (9 dogs) and the epidural balloon inflation group (6 dogs). The former contained 3 dogs in which 50 mg/kg of kaolin emulsion had been injected into the basal cistern a week before the experiment. They were regarded as a model of cerebrospinal fluid (CSF) malabsorption. In comparison with the actual volume-pressure (VP) curves, theoretical curves were displayed which were extracted mathematically by using the pressure-response (p-r) curve of each dog.
The plateau level of the theoretical VP curve was always lower than the actual steady-state infusion curve. It was thought that more spatial compensation of the vascular bed occur in the actual plateau of the steady-state infusion than in the theoretical plateau, which was based on a single bolus injection. The r value calculated by the actual steady-state infusion was therefore very high because it demonstrated an exaggerated absorption rate under the pressure buffering effect of the venous system. So the CSF absorption resistance obtained by analyzing the p-r curve of a bolus injection should be closer to the true value than that obtained by steady-state infusion.
The shape of VP curves derived from steady-state infusions and balloon compressions were not monoexponential. The latter developed a plateau level under the maximal pressure buffering by the vascular bed. Consequently analytical methods in which the hypothesis that the VPR was exponential was used were proved to be untrustworthy.

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Experimental Study of Deep Brain Radiation with Nd-YAG Laser

A Possible New Treatment for Deep-seated Brain Tumor

Ichiro FUJISHIMA, Hiroshi RYU, Kenichi UEMURA, Tsuneo SAKAI, Shoji NAK ...

1986 Volume 26 Issue 8 Pages 621-627
Published: August 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.621

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Deep brain irradiation with an neodymium-yttrium-aluminum-garnet laser (Nd-YAG laser) was experimentally studied in 25 adult cats. The quartz fiber of an Nd-YAG laser with a convex tip was inserted into the thalamus and a spheric lesion was successfully made. Smoke of vaporized or burned tissue was led out through a Teflon-coated guide tube. Four distinct zones (vaporized, carbonized, necrotized and edematous zones) were identified, and no bleeding was seen in any zone (except in one case of a technical failure). The size of the lesion can be controlled according to the delivered laser energy (irradiation time • power) with continuous irradiation but not with pulse irradiation. The temperature of the laser-irradiated tissue was measured. With pulse irradiation temperature increased by only a few degrees at a point 15 mm away from the irradiation center.

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Malignant Histiocytoma with Brain Metastasis

Case Report

Yuji NIKAIDO, Shozo KAWAI, Manabu HISANAGA, Makoto HONDA, Mototsugu MA ...

1986 Volume 26 Issue 8 Pages 628-633
Published: August 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.628

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A case of malignant histiocytoma associated with brain metastasis was reported. The patient was a 33-year-old male who was admitted with complaints of headache, visual field defect, and left motor paresis. Computed tomography scan showed a mass lesion with ring enhancement in the right occipital lobe. Cerebral angiography disclosed a tumor stain which was fed by branches of the posterior cerebral artery. Craniotomy was performed and a tumor 5 cm in diameter was totally removed. Microscopically, the tumor was composed of epithelial-like cells and foam cells. It was diagnosed as malignant histiocytoma, a variant of malignant fibrous histiocytoma, by immunohistological study, phagocytosis test, and electron microscopic study. The patient developed metastases to the cervical lymph nodes four months later and died of pulmonary insufficiency seven months after the operation. Autopsy findings included multiple metastases to the heart, liver, adrenals, lumbar spine, peritoneum and lymph nodes. The primary tumor focus proved to be in the lung. The clinical features of this tumor are discussed.

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Transverse Sinus Thrombosis treated by Venous Bypass Surgery

Case Report

Iwao SAIKI, Kiyoshi KURODA, Takayuki NAGANO, Haruyuki KANAYA, Teruo OY ...

1986 Volume 26 Issue 8 Pages 634-638
Published: August 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.634

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This report deals with a case of transverse sinus thrombosis with heart failre.
A 29-year-old female was admitted with signs of high intracranial pressure (ICP) and high fever. A diagnosis of sinus thrombosis was made after cerebral angiography, and conservative treatment was immediately initiated. However, ICP increased to 540 mmH₂O and the patient's consciousness level decreased to somnolence. Therefore, surgical treatment was chosen. A Gore-Tex® graft covered with a silicone tube was used as the venous bypass from the right transverse sinus through a bone window to the right internal jugular vein. After surgery, alert consciousness returned and neurological deficits disappeared. ICP decreased to 310 mmH₂O. One week after surgery, there was evidence of cardiac tamponade in the chest film and electrocardiogram, abducens nerve palsy, and signs of high ICP again. After pericardiocentesis and drainage, all these symptoms disappeared and the patient went home 3 weeks later.
Transverse sinus thrombosis with heart failure is rare, but microsurgical venous bypass is available for cases in which conservative therapy is not effective.

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Multiple Primary Intracranial Tumors of Different Cell Types

Case Report

Shoichiro KAWAGUCHI, Hideyuki OHNISHI, Takashi YUASA, Hiroyuki HASHIMO ...

1986 Volume 26 Issue 8 Pages 639-643
Published: August 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.639

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A case of multiple primary intracranial tumors of different cell types, diagnosed preoperatively, and operated on at the same time, is reported. Histologically, the right parietal tumor showed fibrous meningioma, and the left parietal tumor showed glioblastoma.
Multiple primary intracranial tumors of different cell types are rare. Ninety-seven cases could be found in the literature. However, only three cases were diagnosed preoperatively and operated on at the same time. This is the first case with the tumors present in different cerebral hemispheres. The incidence, etiology, clinical presentations, and therapy of multiple primary intracranial tumors of different cell types are discussed.

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Bifrontal Cystic Falx Meningioma

With a Reference to the Diagnosis and Etiological Background of Cyst Formation —Case Report—

Toshiro YAMAGUCHI, Yasuhiko MATSUKADO, Jun-ichi KURATSU, Shozaburo UEM ...

1986 Volume 26 Issue 8 Pages 644-648
Published: August 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.644

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A case of bifrontal cystic falx meningioma is reported, and the etiological background of cyst formation is conjectured from computed tomography (CT) scan and immunochemical findings. A 58-year-old female was admitted in May, 1983, because of an episode of generalized convulsion. Preoperative diagnosis of cystic meningioma (Nauta's type 2) was made by neuroradiological examinations. Most of the reported cases of Nauta's type 2 cystic meningioma revealed solid enhancement and delicate ring-like enhancement in CT scan and a less vascular mass on cerebral angiography. In surgery, a tumor was found adherent to the falx with bifrontal intratumoral cysts. Histological examination revealed meningotheliomatous meningioma. Microscopic examination disclosed abundant deposition of eosinophilic and hyaline-like substances in the interstitial area and tumor cells. These substances were periodic acid-Schiff negative and Alcian-blue positive, and contained immunoglobulin G. It was the authors' impression that these substances were secreted from the tumor cells, and consequently the tumor formed an encapsulated cyst.

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Surgical Management of Extensive Multisegmental Spinal Cord Astrocytoma

Case Report

Seigo NAGAO, Tomohisa FURUTA, Yoshihiro YAMAMOTO, Akira NISHIMOTO, Mot ...

1986 Volume 26 Issue 8 Pages 649-654
Published: August 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.649

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A case of intramedullary spinal cord astrocytoma extending from the second cervical (C2) to sixth thoracic segments (Th6), with successful surgical treatment, is reported.
A 12-year-old boy was admitted with the chief complaints of progressive weakness of all four extremities and neck pain continuing for 2 months. Neurological examination disclosed quadriparesis which was worst in the upper right extremity, hyperreflexia of the bilateral lower and upper right extremities, gait disturbance, limitation of neck movement and neck stiffness. No sensory disturbance, and no bladder and bowel dysfunction was observed. Radiological examination revealed an intramedullary spinal cord tumor involving the segments from C2 to Th6. A cervicothoracic laminectomy and a myelotomy from C2 to Th6 was performed and the tumor was subtotally removed using microsurgical techniques. Histologically, the tumor was diagnosed to be low-grade astrocytoma. Postoperatively, the patient recovered remarkably without any serious complications, and is now attending school, although he has some instability of neck movement and a light kyphosis in the cervicothoracic spine.
Spinal cord astrocytoma extending over 10 vertebrae is extremely rare. The significance of total removal of the tumor using microsurgical techniques in the treatment of an extensive intramedullary spinal cord tumor is emphasized.

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Diverticulum of Lateral Ventricle Trigone in Communicating Hydrocephalus

Case Report

Akira GEGA, Takashi YUASA, Kazuhiro YOKOYAMA, Toru HOSHIDA, Yoshiki II ...

1986 Volume 26 Issue 8 Pages 655-660
Published: August 15, 1986
Released on J-STAGE: September 21, 2006

DOIhttps://doi.org/10.2176/nmc.26.655

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The paper reports a case of diverticulum in the medial wall of the trigone in a 46-year-old male with symptoms of paroxysmal headache, blurred vision, and visual field narrowing.
The occurrence of diverticulum in the medial wall of the trigone has been known as a partial cystic enlargement caused by the rise of intraventricular pressure in the extreme phase of non-communicating hydrocephalus. However, this was a case with mild communicating hydrocephalus. It is assumed that the congenital abnormalities in the cerebrum and ventricular formation may have been contributing factors in this case, since asymmetrical dilatation of the lateral ventricles and asymmetrical thickness of the cerebral mantle were observed, and the enlargement of the trigone and posterior horn was larger than that of the anterior horn.

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