Neurologia medico-chirurgica

Hyperprolactinemia associated with Growth Hormone-secreting Pituitary Adenoma

Endocrinological and Histological Evaluation

Kengo KAWASHIMA, Tohru UOZUMI, Katsuaki SAKODA, Kazutoshi MUKADA, Masa ...

1988 Volume 28 Issue 12 Pages 1145-1151
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1145

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Forty patients with growth hormone (GH) -secreting pituitary adenomas were included in a histological and endocrinological investigation. Thirteen were found to have hyperprolactinemia. Light and electron microscopic studies showed no morphological differences between the adenomas of patients with and without hyperprolactinemia. Neither mammosomatotroph cell adenoma nor acidophil stem cell adenoma was detected in GH-secreting pituitary adenomas associated with hyperprolactinemia. Immunohistochemical study revealed 90% of the tumors to contain prolactin (PRL)-positive cells, in both patients with hyperprolactinemia and those with normal PRL values. These findings suggest that GH-secreting pituitary adenoma might more accurately be termed “mixed GH cell-PRL cell adenoma.” In addition, there was a statistically significant correlation between the preoperative serum PRL values and the proportion of immunoreactive PRL-secreting in the tumor cells (p <0.05) . Among the 13 hyperprolactinemic patients, three whose tumors contained few or no immunoreactive PRL-secreting cells were nonresponders to thyrotropin releasing hormone (TRH). In one of these patients the tumor protruded into the suprasellar region and the suspected cause of the hyperprolactinemia was interference with the release of prolactin inhibitory factor. In the other two patients the hyperprolactinemia could not be explained. The remaining 10 hyperprolactinemic patients responded to TRH and their tumors contained many immunoreactive PRL-secreting cells. Thus, it appears that in TRH responders the hyperprolactinemia was attributable to PRL secretion within the tumor.

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Preoperative Neurological Status of Elderly Surgical Patients with Ruptured Intracranial Aneurysms

Akifumi SUZUKI, Nobuyuki YASUI, Hiromu HADEISHI, Ichiro SAYAMA, Ken AS ...

1988 Volume 28 Issue 12 Pages 1152-1156
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1152

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Factors affecting preoperative disease severity were studied in 220 elderly and younger patients who underwent surgery for ruptured intracranial aneurysms during the acute stage (within 3 days after onset). The patients' clinical status was evaluated 3 months postoperatively and the findings were compared by age group. The incidence of poor outcome was significantly higher in patients over 64 years old than in those under 65. Therefore, in this study, “elderly”p was defined as over 64 years of age. There were 41 elderly patients (13 males and 28 females; 68±3 years old) and 179 younger patients (97 males and 82 females; 52±8 years old). The preoperative neurological status was graded according to the classification of Hunt and Kosnik, excluding subsidiary conditions. There were significantly fewer grade 2 patients and significantly more grades 3-5 patients among the elderly than among the younger population (p<0.05). Medical history, occurrence of aneurysm rerupture, and computed tomography (CT) findings were studied and compared for clarification of the reasons for the high incidence of poor neurological status in the elderly group. CT findings were evaluated according to the method of Ohta et al. The incidence of cerebrovascular disease and head trauma was significantly higher in the elderly group. Furthermore, there were significantly more elderly patients whose CT score was 6 or more. However, the incidence of preoperative aneurysm rerupture and the severity of individual CT findings did not differ significantly between the two groups. Thus, a higher incidence of cerebral dysfunction due to pre-existing disorders and more extensive intracranial pathology consequent to rupture of aneurysms were considered responsible for the poorer preoperative neurological status in the elderly patients.

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Causes of Poor Results of Early Surgery for Ruptured Intracranial Aneurysms in Elderly Patients

Akifumi SUZUKI, Nobuyuki YASUI, Hiromu HADEISHI, Ichiro SAYAMA, Ken AS ...

1988 Volume 28 Issue 12 Pages 1157-1162
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1157

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Factors affecting the outcome of early surgery (within 72 hours) for ruptured intracranial aneurysms were compared in an elderly and a younger population, and the causes of the relatively poor results among the elderly patients were analyzed. In this study, “elderly” was defined as 65 years of age or older, since the outcome was significantly poorer in these patients. There were 41 elderly patients (13 males and 28 females; 68±3 years old) and 179 younger patients (97 males and 82 females; 52±8 years old). The postoperative outcome, evaluated 3 months after onset, was rated in terms of the ability to carry out daily activities. Dependent and deceased patients were graded as having a poor outcome. The preoperative neurological status was graded according to the classification of Hunt and Kosnik, excluding the factor of serious systemic diseases. The proportion of elderly patients of grades 3-5 was significantly higher than that of younger patients (P<0.05). There was no significant difference in outcome among patients of grade 2, regardless of age. However, among patients of grades 3-5, the outcome was significantly poorer in the elderly group (p<0.05) . Therefore, the possible causes of the poor outcome among elderly patients of grades 3-5 were examined. Medical history, aneurysm rerupture, preoperative computed tomographic findings, surgical complications, vasospasm, and general and neurological postoperative complications were studied in particular. Vasospasm and general postoperative complications were identified as significant causes of poor outcome among the elderly. In addition, the incidence of severe vasospasm was significantly higher in the elderly group (p<0.025). In terms of general postoperative complications, the incidence of heart failure was significantly higher in the elderly patients (p<0.005). All patients who developed general complications also had vasospasm, and five of the seven elderly patients with heart failure developed severe vasospasm. These results suggest that, among elderly patients, poor outcome following early surgery for ruptured intracranial aneurysm is attributable to high incidences of poor preoperative neurological status, vasospasm, and general postoperative complications.

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Spontaneous Arterial Recanalization in the Acute Stage of Cerebral Infarction

Kiyohiro HOUKIN, Kazuyoshi UENO, Mitsuhiro TADA, Hiroshi IBARA

1988 Volume 28 Issue 12 Pages 1163-1169
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1163

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Thirty-nine patients with cerebral infarction were included in a comparative study of the effects of spontaneous arterial recanalization. In all cases, arterial occlusion was confirmed by angiography performed on admission. In 16 cases, spontaneous recanalization of the occluded arteries was disclosed by follow-up angiography. In the remaining 23 cases, follow-up angiography did not demonstrate recanalization. The features of recanalization can be summarized as follows: 1) the branches and secondary trunk of the middle cerebral artery were most often involved; 2) the cause of the occlusion was usually embolic and the onset of symptoms generally sudden; 3) approximately 50% of the patients died or had severe deficits; and 4) sequential measurement of cerebral blood flow revealed a temporary increase in the subacute stage, which was probably due to arterial recanalization. The features of nonrecanalization were: 1) the cervical internal carotid arteries and main trunk of the middle cerebral artery were most often occluded; 2) the cause of occlusion was mainly thrombotic and the stroke was usually of the progressive type; 3) the outcome was comparatively good, with 80% of the patients able to resume their previous lives; and 4) sequential measurement of cerebral blood flow showed lower flow in the affected than in the nonaffected hemisphere, with little change over time.

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Effect of STA-MCA Anastomosis on Regional Cerebral Blood Flow in Ischemic Cerebrovascular Disease

Long-term Follow-up

Osamu SASAKI, Tetsuo KOIKE, Shigekazu TAKEUCHI, Ryuichi TANAKA, Ryoji ...

1988 Volume 28 Issue 12 Pages 1170-1174
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1170

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The long-term effects of superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis on regional cerebral blood flow (rCBF) were evaluated in 54 patients with ischemic cerebrovascular disease who were operated on in the chronic stage. rCBF was measured by the Xe-133 inhalation method using initial slope index. The mean follow-up period was 26 months. In cases of major artery occlusion without infarction in the cortex, mean hemispheric CBF (mCBF) in the affected side increased and laterality (the difference in mCBF between the hemispheres) was reduced significantly 3 months after surgery. The improvement in mCBF was sustained for up to 3 years. In cases of major artery occlusion with infarction in the cortex, mCBF did not increase but laterality decreased soon after surgery and the reduction was sustained for a long period. In patients with major artery stenosis, mCBF decreased significantly within 3 months of surgery and then increased gradually, eventually approaching the preoperative levels. Laterality was unchanged. These observations indicate that, in selected cases, STA-MCA anastomosis confers long-term hemodynamic improvement in patients with ischemic cerebrovascular disease.

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Cervical Soft Disc

Clinical Analysis of 35 Cases

Junya HANAKITA, Hideyuki SUWA, Shinji NAGAYASU, Takanori SUZUKI, Shogo ...

1988 Volume 28 Issue 12 Pages 1175-1180
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1175

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Thirty-five cases of cervical soft disc were analyzed in terms of symptomatic, myelographic, and computed tomographic (CT) features. The patients, 24 males and 11 females, ranged in age from 33 to 69 years (mean, 48 years). The clinical manifestations were classified into six patterns according to the subjective and objective findings. On myelography, lateral views provided useful information in patients with myelopathy, whereas posteroanterior views were more informative in patients with radiculopathy. On the basis of metrizamide CT findings, the herniated discs could be classified as medial, mediolateral, or lateral. According to the operative findings, disc herniation could be characterized as either protruded, with an intact posterior longitudinal ligament, or prolapsed, with laceration of the ligament. A medial orientation was well correlated with protrusion and lateral and mediolateral herniation with prolapse. Although the mechanisms of myelopathy due to cervical soft disc are obscure, both direct compression by the herniated disc material and secondary circulatory disturbance within the spinal cord appear to play important pathogenetic roles.

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Asymptomatic and Symptomatic Colloid Cysts of the Third Ventricle

Atsushi KEYAKI, Asao HIRANO, Josefina F. LLENA

1988 Volume 28 Issue 12 Pages 1181-1185
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1181

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Colloid cyst of the third ventricle is a well known neuropathological entity with consistent anatomic locations and a characteristic epithelial appearance. The authors describe 14 cases of histologically verified colloid cysts and discuss the histological differences between these and other epithelium-lined cysts in the central nervous system. The study population comprised eight males and six females ranging in age from 28 to 82 years. Eight were autopsy cases (mean age, 67 years) in which the colloid cysts were found incidentally. None of these cysts obstructed the foramen of Monro. Their mean size was 9×8×8 mm and, without exception, they were located in the anterior roof of the third ventricle. Six of the patients were surgical cases and their mean age was 37 years. The reasons for hospitalization were paroxysmal headaches in three patients, two of whom exhibited deterioration of consciousness; sudden, severe headache and unconsciousness with no history of headache in two; and longstanding, mild dementia and gait disturbance mimicking normal pressure hydrocephalus in one. The cysts were lined by cuboidal to columnar epithelial cells. Among the operated cysts, cilia were found in four and goblet cells in two. Periodic acid-Schiffpositive cells were observed in all of the stained specimens. No histological differences were noted between symptomatic (operated) and asymptomatic (found at autopsy) cysts. The ciliated epithelium lining colloid cysts of the third ventricle is similar to that observed in Rathke's cleft cyst and some epithelial cysts found elsewhere in the central nervous system.

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Primary Intracranial Malignant Lymphoma

Report of Nine Cases

Mikiro MATSUMOTO, Takatsugu OHTSUKA, Takao KUROKI, Iekado SHIBATA, Hid ...

1988 Volume 28 Issue 12 Pages 1186-1192
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1186

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Nine cases of primary intracranial malignant lymphoma, which accounts for 3.3% of all intracranial tumors seen in the authors' institution, were studied in terms of diagnostic computed tomographic (CT) features, the tumors' histologic appearance, treatment, post-treatment blood immunologic and cerebrospinal fluid (CSF) characteristics, and outcome. The patients were seven males and two females aged 42 to 67 years. Their chief signs and symptoms on admission were intracranial hypertension, focal signs, and disturbance of consciousness. CT, which proved the most useful preoperative diagnostic technique, demonstrated multiple lesions in seven cases and, in all cases, regions of isodensity or slight high density that were enhanced by contrast medium. According to the patterns of enhancement, the tumors were classed as diffuse (three cases) or nodular (six cases). The former is considered typical of malignant lymphoma, whereas the latter type was sometimes indistinguishable from metastatic tumor and meningioma. At surgery, one patient underwent radical tumor excision, two partial removal, and six biopsy only. Histologic examination revealed one tumor to be of the diffuse small cell type, three of the medium cell type, and five of the large cell type (Lymphoma Study Group classification). Of seven tumors in which lymphocytes were examined by peroxidase-antiperoxidase staining, four were of the B cell type. Postoperatively, whole brain irradiation with 29 to 46 Gy was followed by local irradiation with 15 to 50 Gy. If the tumor persisted, one of three chemotherapies was administered. In one case, methotrexate was given intrathecally. Seven patients were divided into two groups: long remission (three) and recurrence (four). These two groups were compared in terms of serum immunoglobulin levels, T and B cell ratios, CSF characteristics, CT features, tumor cell type, and treatment. No clear differences were found.

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Effects of Radiation Therapy for Glioma in Children, with Special Reference to Brain Atrophy

Shin NARUMI, Haruyuki KANAYA, Takashi IWABUCHI, Masayoshi KOWADA, Jiro ...

1988 Volume 28 Issue 12 Pages 1193-1197
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1193

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The authors report the effects of radiation therapy for glioma in 61 children. Subsequent to irradiation the patients received long-term follow-up, which included computed tomographic (CT) scanning. Brain atrophy (BA) was considered to have occurred if one focus of cortical or brainstem atrophy, and/or ventricular dilatation, was identified on follow-up CT but had not been present on CT scans obtained immediately after the completion of radiation therapy. In 20 cases BA could not be evaluated. Thus, BA was found in 10 of the 41 cases (24.4%) at 33 months after radiation therapy. The mean whole brain irradiation doses in the BA (+) and BA (-) groups were 50.6 Gy and 28.7 Gy, respectively (p<0.001). All patients irradiated with more than 60 Gy developed BA. On the other hand, those who received less than 30 Gy had no BA. BA was not detected in cases of local brain irradiation. The authors also discuss typical radiation necrosis and calcification. Two of 61 patients (3.3%) developed radiation necrosis about 20 months after radiation therapy. Six (9.8%) were found to have local calcification, limited to the radiation field, about 30 months after irradiation.

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Clinical and Electromyographic Features of “Intermittent Tonic Facial Spasm” due to Acoustic Neurinoma

Report of Two Cases

Yasushi SUGIURA, Tetsuo YOKOYAMA, Hiroshi RYU, Kenichi UEMURA, Toshiak ...

1988 Volume 28 Issue 12 Pages 1198-1202
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1198

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The authors report two cases of acoustic neurinoma involving intermittent tonic contractions of the facial muscles on the affected side. The clinical features, and in one case the electromyographic (EMG) findings, were compared to those in cases of hemifacial spasm (HFS) due to neurovascular compression (NVC). Both patients exhibited intermittent facial tonic muscle contractions and deep nasolabial folds on the affected side despite facial weakness. In one case, EMG showed continuous muscle activity not only during contractions but also at rest. On the other hand, in HFS due to NVC, EMG demonstrated intermittent bursts of activity during spasm but little or no activity at rest. In both of these cases the tumor was large enough to compress the brainstem. In neither case could the facial nerve be identified during subtotal tumor removal. These findings suggest that the nature of the facial muscle contractions in these two cases was quite different from that of HFS due to NVC. The former appeared to be an incomplete form of the so-called “continuous tonic facial spasm” attributable to glioma of the brainstem. Such contractions might better be termed “intermittent tonic facial spasm.”

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Multiple Intracranial Epidermoid

Case Report

Takahiko ITOH, Yoshinori TERAI, Shunichiro FUJIMOTO, Kazuhiko HAYASHI

1988 Volume 28 Issue 12 Pages 1203-1208
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1203

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A rare case of intracranial epidermoid with interesting computed tomography (CT) findings in a 59-year-old male is reported. The patient had a 13-year history of generalized seizures and syncope and presented with disorientation, amnesia, acalculia, emotional lability, apocleisis, and urinary incontinence. CT disclosed many low-density masses (-92 to -104 HU) in the subarachnoid space, the largest of which was in the left sylvian fissure. A left frontotemporal craniotomy revealed a cream-colored, pearly tumor in the sylvian fissure. The content of the cyst was soft and easily aspirated. Removal of the cyst and irrigation of the operative field resulted in relief of the preoperative symptoms. Histologically, the stratified squamous cell lining of the cyst wall did not exhibit keratinization but was immunoreactive for keratin. To date, only one other case of intracranial multiple epidermoids has been reported. In that case, cerebrospinal fluid analysis suggested chemical meningitis. Therefore, it is plausible that multiple epidermoids result from damage to the cyst wall and dissemination of the cyst content within the subarachnoid space.

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Vacuolated Meningioma with Cyst Formation

Case Report

Takashi MATSUKAWA, Hirofumi NAGANUMA, Masami KANEKO, Tohru HORIKOSHI, ...

1988 Volume 28 Issue 12 Pages 1209-1213
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1209

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In 1983, a 67-year-old male was hospitalized because of headache, left hemiparesis, and numbness. He underwent craniotomy and fluid aspiration on three occasions. On readmission in 1985, plain computed tomography (CT) scan revealed a round, hypodense mass in the right parietooccipital region, which was markedly enhanced on contrast CT. Angiography showed a tumor stain fed by the right angular artery. The preoperative diagnosis was glial tumor. At surgery the tumor was found to adhere to the dura in the right parieto-occipital convexity, and intra and peritumoral cysts were observed. Microscopic examination of a tumor specimen disclosed both intra and extracellular vacuolization and microcysts. The histological diagnosis was vacuolated meningioma with cyst formation. Seventeen cases of vacuolated or microcystic meningiomas have been reported, and two salient features have been identified: a high rate of cyst formation and distinctive CT findings of hypodensity on plain scans and marked enhancement on contrast scans. It is speculated that vacuoles fuse to form microcysts and that further fusion eventually results in the formation of macrocysts.

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Monostotic Fibrous Dysplasia of the Parietal Bone

Case Report

Junki ITOH, Kazuo USUI, Yoshio HASHIZUME

1988 Volume 28 Issue 12 Pages 1214-1217
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1214

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A case of monostotic fibrous dysplasia of the left parietal bone in a 22-year-old woman is described. The patient was hospitalized because of a soft, painful mass in the left parietal region. The lesion had increased gradually in size during the previous month. The neurological examination and laboratory data were normal. Skull X-rays showed an osteolytic, well circumscribed lesion in the left parietal bone. A computed tomography scan revealed an area of lysis of the outer table with expansion of the diploic space. There was a soft-tissue mass contiguous to the bone lesion. Angiography disclosed abnormal vascularity. At surgery, the enlarged bone was excised to the extent possible and the cystic lesion, which contained dark green, viscous fluid, was curetted. There was no evidence of dural invasion. Microscopically, the excised bone lesion was confirmed to be typical fibrous dysplasia. No sarcomatous changes were found. The cyst wall was composed of multinucleated giant cells, hemosiderin-laden macrophages, and extravasated red blood cells. Although there were macroscopic differences, the specimen closely resembled an aneurysmal bone cyst microscopically. Its rapid growth may have been secondary to the cyst formation and hemorrhage that occur in fibrous dysplasia. The diagnosis and surgical treatment of this case are discussed.

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Intracranial Epidural Abscess: Radiologic Features and Therapy

Report of Two Cases

Toshikazu KUWATA, Ichiro KAMEI, Yuji UEMATSU, Munehisa IWAMOTO, Tsuyos ...

1988 Volume 28 Issue 12 Pages 1218-1222
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1218

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Two cases of epidural abscess are described. One patient was a 15-year-old male admitted because of left forehead swelling accompanied by paranasal sinusitis. A left frontal ring-like enhanced mass was demonstrated by computed tomography (CT). External carotid angiography revealed a diffuse homogeneous stain fed by the middle and accessory meningeal arteries. The abscess cavity disappeared after burr-hole aspiration and postoperative drainage. The second patient, a 56-yearold female, was unconscious and had right hemiparesis on admission. A large left temporal epidural abscess was diagnosed by means of CT. Following aspiration, the patient appeared to do well. However, a follow-up CT scan showed re-expansion of the abscess cavity and an external carotid angiogram disclosed a thin layer of staining at the periphery of the abscess capsule. The abscess was totally excised via craniotomy. Since this abscess had entered the chronic stage, its capsule was thick and hard; this may have been important in the induction of the recurrence. Although burr-hole aspiration is usually adequate for the therapy of epidural abscess, some chronic cases recur after aspiration. Angiography is helpful in determining the clinical stage and selecting the best treatment.

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Superficial Temporal Artery Aneurysm associated with Pathological Changes mimicking Cystic Medial Necrosis

Case Report

Shun-ichiro IKEDA, Takao WATANABE

1988 Volume 28 Issue 12 Pages 1223-1227
Published: 1988
Released on J-STAGE: September 05, 2006

DOIhttps://doi.org/10.2176/nmc.28.1223

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A case of spontaneous true aneurysm of the left superficial temporal artery (STA) is reported. The patient, a 15-year-old male, had no known history of trauma but had noticed a small, pulsating mass in the left preauricular region 1 month before admission. Physical examination revealed no abnormality other than the 15×10 mm pulsatile mass. Laboratory tests and other routine studies were within normal limits. Left selective external carotid angiography demonstrated a saccular aneurysm of the main trunk of the STA. The aneurysm was resected, and microscopic examination revealed it to be a true aneurysm. Its wall was composed of thickened, uniform tissue with proliferative myointimal cells and pooled acid mucopolysaccharides in the intracellular spaces. Mucoid pools within the residual media separated the cellular elements. In addition, the elastic laminae were disrupted. These findings are quite similar to the characteristic vascular changes of cystic medial necrosis, which often lead to the development of dissecting or saccular aneurysms in large vessels. Aneurysms of the STA are rare and usually post-traumatic. A survey of 165 reported cases of STA aneurysms yielded only 11 cases of spontaneous aneurysms. These aneurysms are assumed to have been congenital or arteriosclerotic. The STA aneurysm described here appears unique, as it was associated with pathological changes resembling those of cystic medial necrosis.

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