Neurologia medico-chirurgica

Assessment of Local Cerebral Glucose Utilization and Protein Synthesis in a Rat Brain Tumor Model

Simultaneous Measurement by Quantitative Double-tracer Autoradiography

Michihiro KIRIKAE

1988 Volume 28 Issue 11 Pages 1039-1045
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1039

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Quantitative assessment of local cerebral glucose utilization (lCGU) with [¹⁸F] 2-fluoro-2-deoxy-D-glucose (18FDG) and of local cerebral protein synthesis (lCPS) with L-[1-¹⁴C]-valine (¹⁴C-valine) were simultaneously performed by double-tracer autoradiography in an implanted rat brain tumor model in awake animals. lCPS was measured by both the three-compartment kinetic method and the free ¹⁴C-valine washout method. In tumor tissue, the lCGU rate was significantly greater than that in control brain cortex (p<0.05). The lCPS rate was also significantly higher in tumor tissue than in normal brain cortical tissue (p<0.001), according to both methods of measurement. lCGU and lCPS were also assessed in peritumoral brain tissue. In the parietal cortex ipsilateral to the tumor, the lCGU rate was lower than that on the contralateral side and was reduced by 30% as compared to normal brain cortex (p<0.05). No significant difference in the lCPS rate was observed between the ipsilateral and contralateral cortices. Also, there was no significant difference in the lCPS rate as measured by the kinetic and ¹⁴C-valine washout methods. The results of this study imply that, in brain tumor tissue, the rate of protein synthesis is significantly greater than that of glucose utilization. The lCGU rate in the cortex ipsilateral to the tumor was always depressed, whereas the lCPS rate was similar in the two cortices. Histopathological evaluation revealed normal cell structure in the ipsilateral cortex. The author concludes that lCPS is a more suitable marker than lCGU in the evaluation of brain tissue function.

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A New Numerical Representation of Visual Field in Patients with Chiasmal Tumors

Kaoru SAKATANI, Satoshi MANNO, Keiichi YAMADA, Ryusuke OGAWA, Tomio OH ...

1988 Volume 28 Issue 11 Pages 1046-1051
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1046

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A new numerical representation of visual field based on the density of the receptive fields of retinal ganglion cells was applied to evaluate the clinical courses in 30 cases of chiasmal tumors. Preoperatively, on the basis of Goldmann's perimetric projection, the visual field defects were subdivided into four groups: normal, incomplete hemianopia, complete hemianopia, and marked defect. The mean numerical value (visual field volume) of each group was related to the degree of the visual field defect. Postoperatively, the visual field volume improved in 58%, was unchanged in 17%, and worsened in 25%. In terms of the change in visual field volume, there was no significant difference between the transfrontal and transsphenoidal approaches. The degree of visual improvement was correlated with the extent of the preoperative visual field defect. In cases of incomplete hemianopia, surgical removal may restore the visual field to almost normal. However, once complete hemianopia has occurred, vision cannot be completely restored.

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Intraoperative Monitoring of Somatosensory Evoked Potentials

Takayuki OHIRA, Shigeo TOYA, Moriichirou TAKASE, Yoshiki NAKAMURA, Hir ...

1988 Volume 28 Issue 11 Pages 1052-1058
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1052

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Somatosensory evoked potentials (SEPs) were monitored during 20 operations, 13 for tumors in the posterior fossa and upper cervical region and seven for the treatment of aneurysms or carotidcavernous fistulae. Monitoring was technically satisfactory in 16 patients (80%). In two patients, monitoring was compromised by contamination with electrical noise. Two patients with mass lesions in the upper cervical region and posterior fossa were operated in the park bench position and SEP wave forms disappeared, probably because of the positioning, which included head flexion and rotation.
Three of the 16 patients (19%) showed alterations in SEP wave forms. The changes were transient in two patients, who had no postoperative neurological deficits, and permanent in one, who exhibited motor palsy postoperatively. Intraoperative SEP alterations corresponded to the postoperative neurological findings in 14 cases (88%). Two patients with no intraoperative SEP alteration were found to have pyramidal tract damage postoperatively (false negative results). Intraoperative SEP monitoring appears useful in terms of minimizing the risk of neurological damage during occlusion of major cerebral arteries and also during manipulation in the upper cervical region. However, it appears necessary to develop a new monitoring method that will reflect the functional integrity of the motor pathway itself. SEPs and brainstem auditory evoked potentials (BAEPs) were simultaneously monitored during 10 posterior fossa operations, and SEP monitoring appeared to be a less sensitive indicator of brainstem function than BAEP monitoring. The authors' results suggest that alterations in the SEP wave form are reversible, reverting to normal if surgical manipulation is stopped immediately after the disappearance of the wave form.

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Cerebrospinal Fluid Lactic Acidosis in Bacterial Meningitis

Clinical Course and Influence on Arterial Blood Acid-base Balance

Masami SHIMODA, Shinya YAMADA, Isao YAMAMOTO, Ryuichi TSUGANE, Osamu S ...

1988 Volume 28 Issue 11 Pages 1059-1064
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1059

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The concentration of lactate, PCO₂, HCO₃^-, Na, K, Cl and the pH of cerebrospinal fluid (CSF) and arterial blood were measured simultaneously in 104 samples obtained from 17 patients with bacterial meningitis. These values were compared with those of 12 control subjects, including patients with pituitary adenoma or individuals with non-neurological disease. Initially, patients with bacterial meningitis had significant CSF lactic acidosis, arterial respiratory alkalosis, low CSF HCO₃^-, low CSF and arterial Na and Cl, and high CSF K in comparison to the control group. CSF PCO₂ did not differ significantly between the two groups. Subsequently, following successful treatment of meningitis, these parameters gradually normalized. The most significant correlations were found between CSF pH and CSF HCO₃^-, between arterial blood pH and CSF lactate, and between arterial blood PCO₂ and CSF HCO₃^-. There was no significant relationship between electrolyte changes and the acid-base balance.
In conclusion, brain metabolic changes in patients with bacterial meningitis were similar to those observed in other neuropathological states, such as head trauma and cerebrovascular disease. Assessment of lactate concentration and acid-base balance in both arterial blood and CSF was useful in differentiating bacterial meningitis from aseptic meningitis and proved to be a good indicator of intracranial microchemical status in cases of bacterial meningitis.

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Computed Tomographic Features of Cerebral Malignant Glioma following Treatment and Regrowth

Tumor Response to Radiochemotherapy

Isami SATO, Ryuichi TANAKA, Norio TAKEDA, Yasuo SUZUKI, Hiroaki HONDO

1988 Volume 28 Issue 11 Pages 1065-1072
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1065

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Changes in tumor volume after radiochemotherapy were studied in 48 patients with anaplastic glioma (glioblastoma) by means of repeat contrast-enhanced (CE) computed tomography (CT). The tumor volume was determined by calculation of the area of the CE lesion on three-dimentional CT slices. Three patterns of tumor response were identified. In the eight patients in Group 1 (17%), the tumor volume progressively increased following the completion of therapy. The tumors in the 23 patients in Group 2 (48%) showed little change for 5.6±2.7 months after therapy, and increased progressively thereafter. In Group 3, the 17 patients' (35%) tumors shrank by more than 30% after treatment. A maximum reduction of 68±17% was observed 6.4± 3.2 months post-treatment, and the tumors exhibited regrowth 11.7±4.3 months after therapy. In 11 Group 2 and six Group 3 patients, the tumor volume transiently increased by 3 to 36% 1.5±1.1 months after therapy. In 14 of these 17 patients, perifocal low density surrounded the CE lesion. The tumor expansion abated within 2 months, and was considered a transient reaction to the radiochemotherapy.

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Computed Tomographic Features of Cerebral Malignant Glioma following Treatment and Regrowth

Growth Patterns of Recurrent Tumors

Isami SATO, Ryuichi TANAKA, Norio TAKEDA, Yasuo SUZUKI, Hiroaki HONDO

1988 Volume 28 Issue 11 Pages 1073-1080
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1073

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Patterns of growth and extension of recurrent cerebral anaplastic gliomas (glioblastomas) were studied by computed tomography (CT) in 48 patients. In 34 cases the original tumor was subcortical and in 14 cases it was deep-seated. All of the patients underwent surgical removal of the original tumor followed by radiation therapy and chemotherapy. Follow-up CT scans were obtained at intervals of 1.0±0.6 months. Only contrast enhanced (CE) lesions were regarded as recurrent tumors. Four patterns of tumor growth and extension were observed: extension to subcortical white matter (38 cases, 79%); extension along the periventricular region (40 cases, 83%); extension toward the basal ganglia (21 cases, 44%); and metastasis via cerebrospinal fluid to the brain surface and posterior fossa (10 cases, 21%). Every patient exhibited one or more of these patterns during follow-up. In the subcortical tumor group, CE lesions extended step-wise to the ipsilateral periventricular region, corpus callosum, contralateral periventricular region, and entire ventricles at 0.5±1.5, 2.7±3.1, 4.0±3.8, and 6.1±2.9 months, respectively, after recurrence was first detected, and death occurred after the subsequent 1.8±2.0 months. Similar step-wise growth patterns were also observed in the deep-seated tumor group, but the tumor sites were so varied that it was difficult to draw prognostic conclusions for this group.

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Characteristics of Traumatic Intracerebral Hematomas in Children

Mikiro MATSUMOTO, Kenji SANPEI, Hideto NISHIKAWA, Tadakazu SEKI, Iekad ...

1988 Volume 28 Issue 11 Pages 1081-1088
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1081

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The authors retrospectively compared various features of traumatic intracerebral hematoma (TICH) in 15 children and 25 adults. The patients were divided into two groups according to the hematoma site, i.e., cortical/subcortical and central, and their clinical courses, neurological findings and, in particular, computed tomography (CT) scans were analyzed.
Most of hematomas in the cortical/subcortical group developed as a result of cerebral contusion. The majority of children in this group were males and trauma was mainly incurred in traffic accidents. On the other hand, falls as well as traffic accidents were the primary causes of TICH in the adults. Most cortical/subcortical hematomas developed soon after head injury, although some evolved gradually in an area that had appeared isodense on the initial CT scan. Completion of this type of hematoma took longer in children than in adults. In pediatric patients, TICHs often were located in the occipital and parietal lobes, whereas most of the adult TICHs developed in the frontal and anterior temporal lobes. TICHs and their causative contusions were generally smaller in the pediatric population and less frequently required surgery, the operative rates being 22.2% among children and 85.7% among adults. In children, the outcome of cortical/subcortical TICH was favorable.
Small hematomas in the corpus callosum, basal ganglia, and paraventricular region were included in the central hematoma group. These hematomas were believed to have developed through shearing strain. The incidence of central hematoma was significantly higher in children than in adults, and the adults in this group tended to be young. The outcome in children was somewhat better than that in adults.

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Clinical Outcome following Surgery for Intracerebral Hematoma associated with Ruptured Middle Cerebral Artery Aneurysm

Shingo KAWAMURA, Akifumi SUZUKI, Ichiro SAYAMA, Nobuyuki YASUI

1988 Volume 28 Issue 11 Pages 1089-1095
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1089

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The clinical significance of intracerebral hematoma (ICH) following rupture of a middle cerebral artery (MCA) aneurysm was studied in 31 surgical patients having a mean age of 52 years. Sixteen patients were not included in this study, because of massive intraventricular bleeding (2), postoperative complications (7), operation trouble (5), and symptomatic vasospasm (2). One patient died in postoperative period. The remaining 30 patients were followed for a mean of 3.7 years postoperatively. Sixteen patients almost fully recovered, nine were self-sufficient with some deficits, two were partially dependent, one was fully dependent, and three died. The locations of the ICH were as follows: temporal lobe in 18 cases; frontal lobe in five; frontal and temporal lobes in three; temporal and parietal lobes in four; and temporal lobe and internal capsule in one. Fourteen patients had permanent neurological deficits. Left homonymous hemianopsia occurred in one patient who had a large hematoma in the right temporal lobe but became self-sufficient. Motor disturbances were mild in 11 cases, and severe in three (hemiplegia in two and tetraparesis in one). Six of the 11 patients with dominant hemispheric ICH experienced motor dominant aphasia and one had global aphasia. Although there was no definite correlation between hemisphere and outcome, patients with medium to large ICH in the dominant hemisphere tended to develop motor dominant aphasia. In terms of motor disturbance and aphasia due to ICH following MCA aneurysm rupture, the prognosis appears fairly good because these ICH are originally subcortical.

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Etiology of Arachnoid Cysts

Review of Surgical and Postmortem Findings

Yoshinobu NAKAGAWA, Kenki NISHIDA, Keizo MATSUMOTO, Jorge CERVÓ ...

1988 Volume 28 Issue 11 Pages 1096-1102
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1096

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Postoperative reduction in the size of arachnoid cysts was examined in 48 surgical cases. In these and 11 autopsy cases, the cyst walls were examined histologically. Nine cases showed less than 20% reduction, 27 exhibited reduction of 30 to 80%, and 12 showed over 90% reduction in cyst volume. The outer walls of every cyst were found to contain arachnoid membrane. Interestingly, the walls of two cysts contained choroid plexus. One of these, initially detected by computed tomography, was in the middle cranial fossa. Because of its transparent, glistening membrane, observed at operation, it was considered to be an arachnoid cyst. Recurrence of symptoms and cyst formation rendered reoperation necessary. In the outer membrane of the wall of the cyst removed at the second operation, choroid plexus-like tissue was observed microscopically. In the second case, a small cyst resembling an arachnoid cyst was incidentally found at autopsy in the cerebellopontine angle. A small tuft containing choroid plexus was present on the floor of the cyst. Both cases were diagnosed as arachnoid cysts on the basis of histological examination of specimens of their outer membranes. The authors postulate that heterotopic choroid plexus in the subarachnoid space can secrete cerebrospinal fluid (CSF) and may split the arachnoid membrane, thus forming a growing cyst. In another interesting case, after craniotomy and total removal of a malignant choroid plexus papilloma, a large cyst resembling an arachnoid cyst appeared in the left frontal lobe along the tract of the ventricular drainage. The cyst seemed to have formed from CSF secretion from the metastatic choroid plexus. This case appears to support the authors' hypothesis.

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Residual Symptoms after Microvascular Decompression for Trigeminal Neuralgia Previously Treated by Percutaneous Nerve Blocking

Jun NIWA, Satoru TAKAYA, Masafumi OTAKI, Shigefumi MORIMOTO, Sumiyoshi ...

1988 Volume 28 Issue 11 Pages 1103-1106
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1103

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Thirty-seven patients with trigeminal neuralgia and prior treatment by percutaneous nerve blocking underwent microvascular decompression between June, 1985 and September, 1986. On admission, hypesthesia in the affected branch of the trigeminal nerve was recognized in 29 of the 37 patients. Thirteen had dysesthesia and one had paresthesia. Microvascular decompression was carried out via suboccipital craniotomy, and a piece of muscle was inserted between the trigeminal nerve and the offending vessel. Postoperatively, dysesthesia increased in three cases and paresthesia in one case. The degree of hypesthesia was unchanged postoperatively in all 29 patients with this symptom. However, pain relief was experienced by all 37 patients. The incidence of residual sensory disturbance was unrelated to the site of the previous nerve blocks, the anesthetic agents administered, or the number of blocking procedures performed. The nerves showed neither degenerative changes due to blocking nor trauma as a result of the surgical procedure.

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Early Surgery for Ruptured Intracranial Aneurysms associated with Neurogenic Pulmonary Edema

Report of Two Cases

Takeshi KONDOH, Keiichi KUWAMURA, Masaru MIYATA, Junichi IKEGAKI

1988 Volume 28 Issue 11 Pages 1107-1112
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1107

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Two cases of ruptured intracranial aneurysm associated with neurogenic pulmonary edema are described. One patient, a 53-year-old female, was Hunt and Kosnik grade 4 on admission and was expressing pinkish, foamy sputum. A ruptured aneurysm in the anterior communicating artery was clipped 3 hours later. The second patient, a 55-year-old female, was also grade 4 on admission and she, too, exhibited signs of pulmonary edema. A ruptured aneurysm at the junction of the right internal carotid-posterior communicating arteries was clipped 4 hours later. In both cases, intraand postoperative respiratory maintenance with positive end-expiratory pressure was successfully carried out. Both patients were discharged without major neurological deficits.
The optimal timing of surgery for ruptured cerebral aneurysms associated with neurogenic pulmonary edema has not been clearly determined. In these two cases, very early surgery combined with aggressive management of the pulmonary edema was successful. The importance of early diagnosis and treatment of pulmonary edema is stressed, and the timing of surgery after subarachnoid hemorrhage is discussed.

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Cerebellopontine Angle Lipoma

Case Report

Satoshi NAKAO, Toyoshiro YAMAMOTO, Taro FUKUMITSU, Sadahiko BAN, Takah ...

1988 Volume 28 Issue 11 Pages 1113-1118
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1113

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Intracranial lipomas are rare, especially in the cerebellopontine angle. Only 21 cases have so far been reported. In this communication, the case of a left cerebellopontine angle lipoma in a 48-year-old male is described and the relevant literature is reviewed.

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Giant Cell Tumor of the Skull associated with Paget's Disease of Bone

Case Report

Masami SHIMODA, Takanori MATSUOKA, Naoki SHIBUYA, Osamu SATO

1988 Volume 28 Issue 11 Pages 1119-1122
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1119

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A case of giant cell tumor of the skull associated with Paget's disease of bone is described and the eight previously reported cases are reviewed. The patient, a 41-year-old female, presented with a palpable mass, which had gradually enlarged over a 4-month period, in the right posterior parietal region. Physical examination revealed an elastic, nontender, nonmovable mass about 6 × 4 cm in size. Laboratory studies were negative, with the exception of elevated serum alkaline phosphatase. A skull X-ray showed cotton-wool-like lesions, which are characteristic of Paget's disease. Computed tomography demonstrated a homogeneously enhanced mass in the right posterior parietal region without intracranial extension. A bone scan with ^99mTc-methylene diphosphoric acid disclosed abnormal uptake in the skull, pelvis, sacrum, and lumbar spine. A posterior parietal craniotomy was performed, and the tumor was totally removed. The tumor was not well demarcated from the bone, but there was no evidence of intracranial invasion. The pathological diagnosis was giant cell tumor (grade I to II) complicating Paget's disease. Radiation therapy was not administered postoperatively. The tumor had not recurred as of the 7-month follow-up examination.

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Metastatic Pituitary Tumor presenting as Bitemporal Visual Field Defects

Case Report

Akio KIMURA, Akihiko KUROIWA, Akira TERAMOTO, Yoshiaki MAYANAGI, Makot ...

1988 Volume 28 Issue 11 Pages 1123-1127
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1123

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Autopsies fairly often reveal metastatic malignant tumors in the pituitary gland, but most were asymptomatic when the patients were alive. The literature contains only 11 reports of cases in which such tumors manifested as bitemporal visual field defects. The authors present the case of a 57-yearold male with bitemporal visual field defects due to pituitary metastasis from a pulmonary small cell carcinoma. Diabetes insipidus was the most remarkable finding in this patient, but anterior lobe involvement was also documented. Skull X-rays showed only minimal abnormality of the sella, but computed tomography revealed a high-density suprasellar mass 1.5 cm in diameter. The tumor was isointense on T₂-weighted magnetic resonance imaging. The tumor was partially removed through a frontal craniotomy and postoperative irradiation was administered. The tumor was markedly reduced in size and the visual field defects abated.

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Transorbital Intracranial Penetration by Chopstick

Case Report

Koki KADOTA, Tetsuhiko ASAKURA, Masatoshi TAMURA, Kaneto SENO, Kohsaku ...

1988 Volume 28 Issue 11 Pages 1128-1132
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1128

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A 38-year-old female was struck in the eye with a wooden chopstick during a quarrel with her husband. The chopstick penetrated and lodged in her brain. Neurological examination revealed left hemiparesis and hemihypesthesia and right cranial nerve palsy of the 2nd, 3rd, 4th, and 6th nerves and the 1st branch of the 5th nerve. Computed tomography revealed a narrow, straight, low-density extending from the right orbit via the right parasellar region to the pons. A right carotid angiogram revealed a traumatic low flow/low pressure carotid-cavernous fistula. Magnetic resonance imaging yielded a low signal intensity image passing through the orbit and extending to the pons. A craniotomy was performed by the pterional approach. So that the pons and neighboring structures would not be damaged, the chopstick was first gently divided into two portions at the prepontine cistern by a high-speed airdrill and then resected piece by piece. The intraorbital portion of the chopstick was lodged firmly in the bony structure of the superior orbital fissure and could not be removed.
The authors discuss the characteristics of transorbital intracranial foreign bodies, with particular emphasis on diagnostic procedures and the indications for and timing of their surgical removal.

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