Although superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis has been considered to be a safe surgical procedure for middle cerebral artery (MCA) stenosis, a few postoperative ischemic events as well as progression from stenosis to occlusion have been reported. One effective means of studying these problems is to evaluate the hemodynamic changes associated with anastomosis using a hydraulic model. A model of the anterior circulation of the circle of Willis, similar in its dimensions to that of an average adult human, was constructed of glass and silicone tubes. After adjusting the blood flow and pressure to correspond to those of human major cerebral arteries, the proximal MCA (M1 portion) was occluded in stages with or without STA-MCA anastomosis. Throughout these procedures, blood flow was measured, either by an electromagnetic flowmeter or by the drop counting method, in the proximal MCA, distal MCAs, and STA. With varying degrees of M1 stenosis, distal MCA flow increased after STA-MCA anastomosis. The increment, however, was usually smaller than that of the STA inflow volume, and this was ascribed to the cdncomitant decrease in M1 flow. The degree of flow changes was found to depend largely on the flow volume of the cut STA or the diameter of the STA. When the M1 stenosis was mild (around 20%), a steady increase in distal MCA flow and a marked decrease in M1 flow were observed with the increase of the STA diameter. Under moderate M1 stenosis (about 40% and 60%), not only a marked increase in distal MCA flow but also a steady decrease in M1 flow were found. When the stenosis had progressed to about 80%, the distal MCA flow increased markedly, in proportion to the increasing diameter of the STA, while the M1 flow did not change. In conclusion, from a biorheological point of view, the decreased M1 flow observed after STA-MCA anastomosis is considered to play an important role in the progression of the stenosis to occlusion.
The effect of partially purified rat tumor necrosis factor (TNF) was tested against 9L rat brain tumor both in vivo and in vitro. The TNF-containing serum (TNS) was produced by intravenous injection of OK432 and lipopolysaccharide (LPS). Injection of TNS significantly (p <0.05) prolonged the survival time of brain tumor-bearing rats (29.9±12.6 days after tumor cell inoculation, as compared to 20.8±4.4 days in the untreated group). In the in vitro assay, medium containing 50% TNS significantly decreased the viability of 9L brain tumor cells, by 57.6%, 50.0%, and 57.0% at 3, 5, and 7 days after the beginning of culture, respectively. TNS also displayed significant inhibition of cell growth, indicating a cytostatic effect. To verify TNF activity, TNS was partially purified by means of the DEAE-Sephadex A 50 batch ion exchange method and Sephadex G 200 column chromatography. Four fractions were tested in TNF-sensitive L (S) cells, TNF-resistant L (R) cells, and 9L brain tumor cells. Fraction 4 of TNS demonstrated 37.5%, 88.1 %, and 43.2% cell viability against L (S), L (R), and 9L cells, respectively. On the other hand, fraction 4 of normal rat serum showed 87.5%, 87.8%, and 82.2% cell viability, respectively. These results strongly suggest the presence of TNF in the TNS produced by OK432 and LPS.
Accurate diagnosis of brain tumors is necessary for decisions concerning therapy, determination of prognosis, and evaluation and comparison of therapeutic modalities. The authors attempted to identify difficult tumors and atypical cases of various histological types by means of Sternberger's peroxidase-antiperoxidase (PAP) method, which utilizes primary antibodies to glial fibrillary acidic protein (GFA) and carcinoembryonic antigen (CEA) in combination with conventional stains. The GFA-PAP method was useful diagnostically, especially for invasive astroglial tumors composed of either abundant mesodermal elements or round or oval cells with no Mallory's phosphotungstic acid hematoxylin-positive glial cell processes. The CEA-PAP stain, which is positive in many different carcinomas, was used in the differential diagnosis of metastatic versus astroglial tumors, namely, an astroglial tumor composed of epithelial-like cells and a metastatic tumor resembling a glioma.
Intramedullary tumors are conventionally regarded as fusiform enlargement of the spinal cord shadow on myelography and computed tomography myelography. With exophytic growth, however, these tumors resemble intradural extramedullary tumors, since a cap defect of the metrizamide column and a shift of the spinal cord are seen on contrast studies. Seventeen cases of intramedullary tumors were evaluated, six of which involved exophytic tumor growth documented radiologically and at surgery. These tumors were predominantly located from the lower cervical to the upper thoracic region or in the conus medullaris. They were infrequently associated with a syrinx or cyst, and occupied shorter segments of the spinal axis than do tumors without exophytic growth. These tumors could be divided into two types. Type I tumors were accompanied by swelling of the spinal cord and, in some cases, a cap defect of the metrizamide column on the rostral side. Those of Type II had no cord swelling but cord deformity was present, and they were seldom associated with a syrinx or cyst. Cap defects were observed on both the rostral and caudal sides of the tumors. Thus, Type I tumors are mainly intramedullary, whereas Type II tumors are extramedullary. Since it is difficult to differentiate Type II tumors from intradural extramedullary tumors, one should keep in mind the possibility of exophytic growth of intramedullary tumors.
Plasma levels of physiological amine metabolites are rarely reported because of the technical difficulties in their measurement. The authors measured plasma levels of both physiological amines and their main matebolites in 14 patients with subarachnoid hemorrhage, using a simplified method of high-performance liquid chromatography employing electrochemical detection, devised by one of the authors (A.M.). Sequential measurements were made during the acute stage (generally, for a 2-week period). The amines and their main metabolites assayed were norepinephrine (NE), epinephrine (EN), dopamine (DA), 3-methoxy-4-hydroxyphenyl glycol (MHPG), 3-methoxy-4-hydroxyphenyl acetic acid (HVA), 3, 4-hydroxyphenyl acetic acid (DOPAC), and 5-hydroxyindole-3-acetic acid (5-HIAA). Five patients were seriously ill and nine were not seriously ill. In the seriously ill group the average maximum concentrations were as follows: NE, 550.4±303.4 pg/ml; EN, 672.4±567.6 pg/ml; DA, 119.8±83.2 pg/ml; MHPG, 17.3±6.2 ng/ml; DOPAC, 2.0±1.9 ng/ml; HVA, 33.3 ± 23.0 ng/ml; and 5-HIAA, 11.2±8.0 ng/ml. In the group not seriously ill the averages were as follows: NE, 764.0±550.4 pg/ml; EN, 1, 258.7± 2, 199.8 pg/ml; DA, 122.4±91.1 pg/ml; MHPG, 7.5±2.6 ng/ml; DOPAC, 4.9±7.5 ng/ml; HVA, 17.2±9.0 ng/ml; and 5-HIAA, 12.4± 9.0 ng/ml. The only significant difference between the two groups was in plasma MHPG, a major metabolite of brain NE, which is highly concentrated in the hypothalamus. Therefore, its marked elevation in plasma in the seriously ill group, and the lack of a significant correlation with plasma NE, may reflect accelerated metabolism of NE in the brain and possibly in the hypothalamus. Thus, measurement of plasma MHPG may be of use in studying the role of the hypothalamus in cerebral angiospasm in subarachnoid hemorrhage. Although there was no significant difference in HVA levels between the two groups, its elevation in plasma coincided with deterioration of the consciousness level in the group who were not seriously ill.
To re-evaluate the angiographic indications for carotid endarterectomy (CEA) in the presence of symptomatic internal carotid artery stenosis, the authors followed 65 patients clinically and angiographically for periods of 3 to 5 years. Twenty-six patients underwent CEA and 39 were treated without CEA. They were divided into eight groups according to degree of stenosis and existence of wall irregularity on the initial angiogram. In each group, differences in outcome in patients treated with and without CEA were investigated. The development of symptoms was accompanied by disease progression in six patients treated without CEA. In each of these six cases, more than 50% stenosis and wall irregularity were observed on the initial angiogram, and disease progression was confirmed on the subsequent angiogram. It can be concluded that, in patients with symptomatic internal carotid artery stenosis, the angiographic indications for CEA are more than 75% stenosis with or without wall irregularity, and 50-75% stenosis with wall irregularity.
Four patients with unilateral atypical moyamoya disease, ages 19, 42, 43, and 47 years, presented with intracerebral and/or intraventricular hemorrhage and underwent surgery. Preoperative carotid angiograms of the affected side showed severe stenosis at the terminal portion of the internal carotid artery with development of collaterals via transdural, cortical, and transparenchymal pathways. The contralateral internal carotid arteries were completely normal. Two patients were treated by encephalo-myo-synangiosis (EMS), the third by encephalo-myo-arterio-synangiosis, and the fourth by EMS and superficial temporal-middle cerebral artery anastomosis. Postoperative angiograms revealed good neovascularization through numerous branches of the external carotid artery. The process of neovascularization in these four cases was similar to that observed in typical moyamoya disease. The authors believe that the four cases presented do not represent arteriosclerotic cerebrovascular occlusive disease and should be included in the category of moyamoya disease.
A method of determining the prognosis for thalamic hemorrhage was tested in 36 patients with this disorder. The volume and the location of the hematomas were disclosed by computed tomography scans. In the group of small-volume hematomas (≤ 20 ml; 25 patients), the quoad vitam outcome was good, so the quoad functionem outcome in this group was very important. The clinical manifestations and outcomes differed because the locations of the hematomas differed, although they were almost identical in volume. Thus, the small-volume thalamic hemorrhages were classified according to the affected thalamic nuclei. It was found that this method of classifying small-volume thalamic hemorrhages is a reliable prognostic indicator for small-volume thalamic hemorrhages, and that the main prognostic determinants for such hemorrhages are the volume and location of the hematoma. In the group of the large-volume hematomas (>25 ml; 9 patients), the quoad vitam outcome was very severe under conservative treatment.
Childhood syringomyelia is rare and its clinical symptoms differ from those in adults. From 1982 to 1985, the authors studied 19 children with syringomyelia with high-resolution computed tomography (Siemens Somatom II) and with magnetic resonance imaging (MRI) (0.15 tesla imager, Toshiba MRT 15A). There were 14 patients with spina bifida (eight with meningomyeloceles associated with Chiari malformation, and six with lipomas), four with Chiari malformation (type undetermined) and one with idiopathic syringomyelia. Scoliosis and pes cavus were predominant symptoms. Scoliosis was demonstrable in 80% and pes cavus in 40% of the patients with Chiari malformation and idiopathic syringomyelia. Surgery was performed in four patients with Chiari malformation and in two with lipoma. Five patients were treated with a syringo-subarachnoid shunt and one patient with a syringostomy. Five patients improved neurologically and one remained unchanged. The results indicate that syringomyelia in children is not as rare as previous reports suggest, and should be diagnosed and treated early. MRI appears to be very useful in the diagnosis of this disorder, which, in children, is frequently expressed as scoliosis and pes cavus. Subarachnoid shunting is effective for the patient with Chiari malformation, provided the syrinx is large and associated with swelling of the spinal cord.
In an analysis of 46 patients with traumatic pneumocephalus, the disorder was classified into two types —brainstem and non-brainstem— according to the location of intracranial air on the computed tomographic image. In the brainstem type (n=23), air could be seen around the brainstem, whereas in the non-brainstem type (n=23), air could be seen throughout the entire cranial cavity but not around the brainstem. The mortality in patients with the brainstem type was 57% and in those with the non-brainstem type, only 13%. All 23 patients with the brainstem type suffered from cerebral contusion, intracranial hematoma, and subdural hematoma. However, among those with the non-brainstem type, only 14 suffered from similar pathology. Twenty patients with brainstem type pneumocephalus were at consciousness levels II or III on admission, whereas only 10 patients with non-brainstem type had similarly impaired consciousness. The authors' evidence suggests that most cases of brainstem type pneumocephalus resulted from severer impact than that causing the non-brainstem type and that the brainstem type carries a higher mortality.
From January, 1969 to May, 1986, 114 titanium plate cranioplasties were performed following decompressive craniotomies, removal of skull tumors and for repair of depressed or comminuted skull fractures. The patients were 70 males and 44 females ranging in age from 6 months to 74 years, and the longest follow-up period was 11 years. Infection developed in only two cases (1.8%), tissue reaction was insignificant, and subgaleal fluid collection was rare. The titanium plate is relatively radiolucent and nonferromagnetic. Therefore, there was little chance of artifacts that might prevent proper interpretation of angiograms, computed tomograms, electroencephalograms, and magnetic resonance imaging. Three plates were dented inward as a result of injury at the cranioplasty site, but no significant symptoms occurred. The titanium plate is economical and easy to handle, and this long-term follow-up study confirmed its advantages as an alloplastic material.
A 69-year-old female presented with a dural arteriovenous malformation (AVM) in the cavernous sinus, which manifested by subarachnoid hemorrhage. On angiography a small vascular malformation arising from the meningohypophyseal artery was found. The draining vein from the cavernous sinus wound up to the right sylvian fissure and drained further into the vein of Labbe. There was no opacification of the cavernous sinus. A computed tomography scan revealed high-density areas in both the right sylvian fissure and the frontal lobe. On day 7 after the ictus, right abducens palsy and chemosis appeared and gradually progressed during the next 7 days, along with symptoms of increased intracranial pressure. After diagnosis of spontaneous carotid-cavernous fistula (CCF), conservative treatment was continued. Eye signs of CCF completely subsided 1 month after onset, and carotid angiography demonstrated spontaneous closure of the dural AVM. Possible mechanisms of the development of the CCF and spontaneous closure of the dural AVM is discussed.
A 33-year-old woman had been operated on for a tumor of the thyroid gland in December of 1976, and was admitted to Saku Central Hospital in April of 1983 because of pulmonary and ovarian metastases. She underwent surgical removal of the metastatic ovarian tumor and chemotherapy, but developed headaches in June of 1983. Computed tomography (CT) scan revealed a well-defined, homogeneously enhanced mass in the right occipital region. Angiography showed a homogeneous, well-defined tumor stain supplied by the right posterior cerebral artery, the posterior branch of the middle meningeal artery, and the meningeal branch of the occipital artery. The tumor was removed in July of 1983. It was situated in the right occipital lobe and was supplied by numerous small meningeal vessels. Histologically, it was composed of small, oval-shaped cells, some with mitotic figures, and giant cells, occasionally forming a follicular structure. Three months later, the headaches reappeared, and a recurrence of brain metastasis was demonstrated by CT. In October of 1983, the second metastatic brain tumor and the dural bed were removed and local radiation therapy was administered. In this case, meningioma-like features were demonstrated by CT scan and angiography, and these findings may be characteristic of brain metastasis of follicular carcinoma of the thyroid gland.
A 25-year-old male complained of intermittent, sharp pains about the left eye and in the left side of the chest. Neurological examination revealed paresthesia and impaired perception of touch and pin-pricks in the dermatomes of Th8 and Th9 on the left side. In all four extremities, the muscle stretch reflexes were equal and slightly hyperactive, without weakness or sensory deficits. Metrizamide myelography showed defective filling at the level between the upper 8th and 9th thoracic vertebrae. The lesion was also demonstrated by computed tomography (CT) scan performed 1 hour later, appearing as an oval, radiolucent mass in the left dorsal spinal canal, which compressed the spinal cord forward and toward the right. Serial sections of the spinal canal revealed the lesion to be partly filled with contrast medium. Repeat CT scan 24 hours after metrizamide myelography showed more contrast medium in the periphery of the lesion, giving it a doughnut-shaped appearance. At surgery a smooth-surfaced cyst containing sebum and white hair was totally removed from the intradural extramedullary space. The histological diagnosis was dermoid cyst. There have been a few reported cases of intracranial epidermoid cyst in which filling of the cyst was suggested on metrizamide CT myelography. These findings may complicate the differential diagnosis of arachnoid cyst and dermoid or epidermoid cyst when only CT is used.
A 50-year-old male with advanced gastric cancer underwent artificial anal colostomy to improve ileus under lumbar anesthesia. After surgery the patient developed paraplegia. Myelography and computed tomography revealed an intradural hematoma at the thoracolumbar region. Emergency laminectomy showed that the subarachnoid hematoma was compressing the spinal cord at the levels from Th10 to L2. Lumbar puncture, myelography, and lumbar anesthesia are performed very often because of their clinical importance and benefits, and complications of these procedures are infrequent and usually insignificant. However, on rare occasions serious complications do occur, among which intraspinal canal hematoma causing paraplegia is the most severe. According to the literature, epidural hematomas occur most often, followed by subdural hematomas, whereas subarachnoid hematoma after lumbar puncture is extremely rare. Among the proposed factors that lead to this complication are bleeding tendency, thrombocytopenia, anticoagulant drug therapy, multiple punctures, and pre-existing narrow spinal canal.