Neurologia medico-chirurgica

Ultrastructural Study of Arterial Endothelial Cells after Temporary Clipping

Kazuhiko TANI, Toshihiko KUBOTA, Tetsumori YAMASHIMA, Haruhide ITO, Sh ...

1988 Volume 28 Issue 2 Pages 109-116
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.109

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Sequential structural changes in endothelial cells after temporary arterial clipping were studied by both scanning and transmission electron microscopy. A Heifetz clip with an occlusive pressure of 120g was applied to the carotid arteries of 33 Wistar rats for 30 minutes. The animals were sacrificed at the following intervals after clipping: 0, 1, 3, 6, and 24 hours and 3, 5, 7, 14, and 30 days. Immediately after removal of the clip, there was severe endothelial desquamation, with platelets adhering to the exposed subendothelium. Three days after clipping, repair of the endothelium was accomplished by replication of adjacent undamaged endothelial cells and was completed within 1 week. Immature regenerating cells were characterized by numerous microvillous projections at the luminal surface. These projections were approximately 100 to 150nm in width and 0.2 to 1μm in length. The immature endothelial cells contained well developed rough endoplasmic reticulum and many free ribosomes but contained few Weibel-Palade bodies and pinocytotic vesicles. However, as the endothelial cells matured, pinocytotic vesicles and Weibel-Palade bodies increased, whereas microvillous projections decreased. Within 14 days of clipping, the microvillous projections had disappeared and the endothelial cells appeared normal. These data indicate that the endothelial damage caused by temporary arterial clipping does not result in thrombus or atherosclerotic lesions and is repaired within approximately 14 days.

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Hyperbaric Oxygen and Induced Hypotension as Adjuncts to Acute Reperfusion of Middle Cerebral Arterial Occlusion in Cats

Tetsuo YAMASHITA, Haruhiko KIKUCHI, Ikuo IHARA, Akira MATSUMOTO

1988 Volume 28 Issue 2 Pages 117-122
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.117

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The effects of hyperbaric oxygen and hypotension on postischemic cerebral edema were studied in cats. The middle cerebral artery (MCA) was transorbitally occluded for 3 hours and reperfused for 3 hours, and cats whose cortical blood flow (CoBF) decreased to lower than 10ml/100g/min with MCA occlusion were included in the study. Ten cats were used as controls, six were in the hypotension group, and six were in the hyperbaric group (hyperbaric oxygen plus hypotension). The hyperbaric oxygen (2 atm of pure oxygen) was started 1 hour after MCA occlusion and was administered for 1 hour. Just before and during reperfusion, the mean arterial blood pressure was lowered about 50mmHg from the baseline value via administration of adenosine triphosphate and dipyridamole. In the control group, the preocclusive CoBF (measured by the hydrogen clearance method) was 65.9±20.6ml/100g/min, whereas just after reperfusion it was 35.0±21.5ml/100g/min. Three hours after reperfusion the CoBF was 8.2±11.0ml/100g/min. In the hypotension group, these values were 53.9±14.0, 40.6±19.6, and 18.1±12.2ml/100g/min, respectively. In the hyperbaric group, the values were 49.8±8.9, 36.6±13.5, and 27.5±9.0ml/100g/min, respectively. The intracranial pressure (ICP) increased from 9.1±8.6 to 90.0±22.6mmHg in the control group, from 4.5±6.5 to 37.7±10.1mmHg in the hypotension group, and from 1.7±3.5 to 29.8±20.9mmHg in the hyperbaric group. The water content (measured by the drying/weighing method) of the affected hemisphere was 79.7±0.5% in the control group, 79.1±0.5% in the hypotension group, and 78.3±0.5% in the hyperbaric group.
Hypotensive reperfusion improved the CoBF, ICP, and water content. Hyperbaric oxygen plus hypotension were more effective than hypotension alone. Hypotensive reperfusion decreases the vascular volume and reduces the strain on the vasoparalytic vascular wall, thereby decreasing vasogenic edema. Hyperbaric oxygen improves the metabolism of the vascular wall during ischemia and maintains the strength of the vessel wall against intravascular pressure. Thus, hyperbaric oxygen reduces brain edema more than vascular volume. Together, hyperbaric oxygenation and hypotensive reperfusion are useful as adjuncts to acute cerebral revascularization.

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Fine Structural Study of the Mineralization Process in Craniopharyngioma

Kazufumi SATO, Toshihiko KUBOTA, Minoru HAYASHI, Shinjiro YAMAMOTO

1988 Volume 28 Issue 2 Pages 123-127
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.123

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The calcification process in eight cases of adamantinomatous craniopharyngioma was studied at the ultrastructural level. The neoplastic cells, which constituted the internal and intermediate zones of the tumor, frequently displayed abundant cytoplasmic tonofibrils and, occasionally, keratinization. In most of the degenerated keratinized cells, the intracytoplasmic organelles had disappeared. In these cells, membrane-bound vesicles measuring approximately 0.15 to 0.5μm in diameter, were frequently seen among the numerous tonofibrils. Needle-like, mineralized crystals were precipitated some vesicles. Tiny, calcified vesicles were sometimes aggregated and had coalesced with the adjacent tonofibrils to form a large, calcified mass.
These findings suggest that membrane-bound vesicles are derived from degenerated keratinized cells and play an important role as initial nidi of calcification in craniopharyngioma. Remnants of tonofibrils of degenerated cells may also serve as foci of mineralized crystal deposition.

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Intraoperative Monitoring of Facial Nerve Evoked Electromyography

Accurate Identification of the Facial Nerve during Surgery for Cerebellopontine Angle Tumors

Takayuki OHIRA, Shigeo TOYA, Ryuzo SHIOBARA, Jin KANZAKI, Yoshiki NAKA ...

1988 Volume 28 Issue 2 Pages 128-135
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.128

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The authors have developed an easy, effective method of monitoring intraoperative facial nerve evoked electromyography (IFeEMG) by means of direct electrical stimulation of the intracranial facial nerve. This method was applied in over 32 operations for acoustic neurinomas and other cerebellopontine (CP) angle tumors. With conventional intracranial stimulation the current readily flows through the cerebrospinal fluid and stimulates other cranial nerves, especially the trigeminal nerve, which often leads to false identification of the facial nerve. Because the new method allows both quantitative control of the stimulus and objective recording of the evoked response, it accurately distinguishes the facial muscle response from the responses of other cranial nerve muscles. Thus, IFeEMG facilitates identification and dissection of the facial nerve at the surface of tumors in the CP angle cistern and in the internal auditory canal. This method is superior to conventional techniques for identifying the facial nerve during surgery for CP angle tumors.

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Intraoperative Monitoring of Facial Nerve Evoked Electromyography during Surgery for Cerebellopontine Angle Tumors

Usefulness in Prognosis of Postoperative Facial Nerve Function

Takayuki OHIRA, Shigeo TOYA, Ryuzo SHIOBARA, Jin KANZAKI, Yoshiki NAKA ...

1988 Volume 28 Issue 2 Pages 136-141
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.136

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In another report (this issue) the authors described a method of monitoring intraoperative facial nerve evoked electromyography (IFeEMG) by direct electrical stimulation of the intracranial facial nerve and discussed its usefulness in the identification of the facial nerve during surgery for cerebellopontine angle tumors. This report concerns the usefulness of IFeEMG in making prognoses of postoperative facial nerve function. In 21 patients with acoustic neurinomas the correlation between the results of IFeEMG by stimulation of the morphologically preserved facial nerve and postoperative facial nerve function was determined. Patients with no IFeEMG response at the completion of tumor removal had severe postoperative facial palsy, which did not improve. Patients with a good response had no palsy or, at most, mild palsy. These findings suggest that severe postoperative facial palsy due to neurotmesis can be predicted intraoperatively by IFeEMG monitoring. Early surgical treatment is recommended for patients with morphologically preserved facial nerves but no IFeEMG response.

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Assessment of Risk of Carotid Occlusion with Balloon Matas Testing and Dynamic Computed Tomography

Tomoaki TERADA, Takashi OKUNO, Hiroshi MORIWAKI, Ekini NAKAI, Takashi ...

1988 Volume 28 Issue 2 Pages 142-147
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.142

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Temporary occlusion of the internal carotid artery with a balloon catheter (balloon Matas test) and simultaneous dynamic computed tomographic scanning (DCT) were performed in four patients with intracranial aneurysms in order to determine their tolerance for permanent carotid occlusion. Five DCT parameters were evaluated: appearance time (AT), peak time (PT), peak height fitting (PH), first effective moment (MT₁E), and transit time (TT). The results of DCT and balloon Matas testing disclosed three patterns. Type 1 consisted of two patients with no neurological dificit during the balloon Matas test, while DCT showed a parallel shift of the time-density curve in the region of the middle cerebral artery on the occluded side relative to that of the contralateral side. Whereas PH, MT₁E, and TT were the same on both sides, AT and PT were delayed on the occluded side. The DCT findings indicated that cerebral blood flow (CBF) was equally preserved in the two hemispheres during carotid occlusion. Thus, abrupt internal carotid arterial occlusion appears to be a safe procedure in Type 1 patients. In Type 2, the balloon Matas test showed no neurological deficit, but the time-density curve revealed deficits in all five DCT parameters in the area of the middle cerebral artery on the occluded side. These findings were confirmed by the functional images. A decrease in CBF on the occluded side was also suggested. Therefore, in Type 2 cases, extracranial-to-intracranial (EC-IC) bypass surgery should be performed to prevent ischemic insult. In Type 3, such neurological signs as disturbance of consciousness, aphasia, and right hemiparesis appeared just after the start of the balloon Matas test. The DCT findings were almost the same as those of Type 2 in the region of the middle and anterior cerebral arteries on the occluded side. Occlusion of the internal carotid artery is therefore contraindicated in Type 3 patients unless an EC-IC bypass procedure that can rapidly provide a large supply of blood (e.g., vein graft bypass) is performed. The authors conclude that the balloon Matas/DCT method offers a reliable means of predicting the risk of carotid ligation.

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Surgical Treatment of Patients with Aneurysmal Subarachnoid Hemorrhage associated with Main Artery Occlusion

Shingo KAWAMURA, Ichiro SAYAMA, Akifumi SUZUKI, Hidenori OHTA, Masahit ...

1988 Volume 28 Issue 2 Pages 148-156
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.148

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The purpose of this paper is to elucidate suitable surgical treatments in patients with aneurysmal subarachnoid hemorrhage (SAH) associated with main artery occlusion. The subjects were nine SAH patients with main artery occlusion (mean age, 53 years). The sites of their occlusions are as follows: internal carotid artery in five; middle cerebral artery (horizontal portion) in three; common carotid artery in one. None of the patients had had cerebral ischemia previously. Surgical results were evaluated at the time of hospital discharge, and were compared with a follow-up study.
Of the four patients who fully recovered, three had been operated on within 48 hours of the onset of SAH, and one underwent bypass surgery following the aneurysmal surgery. Another had symptoms of cerebral vasospasm (VS) 14 days after the SAH in the contralateral hemisphere, but the symptoms disappeared within 1 week and the aneurysm was operated on 21 days later. Among these four patients, the preoperative consciousness level was “alert” in three and “stuporous” in one. Postoperatively, four of the other five patients were partially or fully dependent, and one died. Four were operated on from 9 to 26 days after the SAH, and one underwent surgery 38 hours after the SAH. The preoperative consciousness level of this group was “alert” in three, “drowsy” in one, and “semicomatose” in one. In all five of these patients the main cause of the poor outcome was symptomatic VS, the symptoms of which appeared from 3 to 11 days after the SAH. Four patients had poor collateral circulation, as demonstrated angiographically from 6 to 12 days after the SAH. It is worth noting that a severe neurological deficit developed when a previously asymptomatic arterial occlusion became symptomatic following the occurrence of VS. In conclusion, a bypass procedure following surgery for an aneurysm should be performed within 2 to 3 days after the SAH in the interest of preventing the development of VS-induced cerebral ischemia in the hemisphere in which the arterial occlusion is present.

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Neurogenic Pulmonary Edema following Aneurysmal Subarachnoid Hemorrhage Report of Nine Cases

Shuji NIIKAWA, Hiroaki NOKURA, Toshiro UNO, Yasuo KAGAWA, Akio OHKUMA

1988 Volume 28 Issue 2 Pages 157-163
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.157

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Nine cases of neurogenic pulmonary edema (NPE) following aneurysmal subarachnoid hemorrhage were studied in a recent 1-year period. The incidence of NPE following aneurysmal subarachnoid hemorrhage was 26% during this period; thus, NPE was not a rare complication. The initial signs and symptoms included consciousness disorder, shock, hypertension, hyperventilation, cyanosis, and stridor. The incidence of NPE was highest in patients with grades III and IV according to Hunt and Kosnik, although two patients with NPE were grade II. Hemodynamic changes were studied under Swan-Ganz catheterization in seven cases and the results were analyzed in relation to various factors, such as cardiac output (CO), mean pulmonary arterial pressure (PAP), and mean pulmonary capillary wedge pressure. The mean PAP on initial monitoring was high in five of seven patients. Increased CO was accompanied by decreased systemic vascular resistance and pulmonary vascular resistance in all four patients examined. Hormonal studies at the time of admission in three cases showed an increase of aldosterone in all three, of antidiuretic hormone in two, and of catecholamines in one. In all cases, oxygenation was necessary for 3 to 17 days and NPE improved within 1 to 19 days. The aneurysms were operated on early in every case and the outcomes were surprisingly good. No patients died of NPE per se. It appears that the prognosis of NPE is considerably better than is generally assumed.

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Delayed Surgery for Traumatic Intracerebral Hematoma

Toshihisa SAKAMOTO, Yoshihiro KINOSHITA, Toshiharu YOSHIOKA, Tsuyoshi ...

1988 Volume 28 Issue 2 Pages 164-169
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.164

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The indications for surgery in cases of traumatic intracerebral hematoma (ICH) have not been firmly established. In the past, early operation was the rule, but it frequently entailed acute brain swelling, considerable blood loss during the surgery, and residual hematomas postoperatively. These complications are attributable to the obscurity of the border between the hematoma and the surrounding tissue, the hemorrhagic disposition, and the localized circulatory stasis that are common features of head injury. In this study of nine cases of traumatic ICH, surgery was delayed for 1 week after the injury, during which time conservative treatment was applied. With the conservative therapy there was fairly good recovery of hemostatic function. Then, during surgery, hemostasis was easily accomplished, and blood loss minimized, because the hematoma margins were clearly delineated. With this regimen, seven of the nine patients had improved consciousness and the other two reported alleviation of severe headache. None of the patients developed the complications associated with early surgery. Provided that intracranial pressure is not elevated and clinical signs and symptoms are not deteriorating, delayed surgery appears to be safer and more effective in the management of traumatic ICH.

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Effect of STA-MCA Anastomosis on Ischemic Cerebrovascular Disease

Correlation with Intelligence and Cerebral Blood Flow

Osamu SASAKI, Tetsuo KOIKE, Shigekazu TAKEUCHI, Shigeaki OHSUGI, Ryuic ...

1988 Volume 28 Issue 2 Pages 170-175
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.170

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The aim of this study was to assess the effect of superficial temporal-middle cerebral artery (STA-MCA) anastomosis, which was performed during the chronic stage of ischemic cerebrovascular disease on cerebral hemodynamics and neurologic function. Regional cerebral blood flow (CBF), and intelligence scores or intelligence quotient (IQ) were measured by the ¹³³Xe inhalation method and the Wechsler Adult Intelligence Scale, respectively, in 45 patients before and after the surgery. There was a significant correlation between preoperative mean CBF in the affected hemisphere (mCBF) and intelligence scores, especially performance scores. Preoperative reductions in mCBF and IQ were severe in cases of major artery occlusion, regardless of infarction, and mild in cases of major artery stenosis. Reduction in IQ was greater in performance than in verbal scale. Postoperatively, mCBF and intelligence scores improved significantly in patients with major artery occlusion without infarction in the cortex. Improvement occurred soon after surgery and steadily progressed. Performance scale improved more significantly than verbal scale. In major artery stenosis, on the other hand, mCBF and intelligence scores decreased slightly shortly after surgery and then returned gradually to near preoperative levels. At least in selected cases, STA-MCA anastomosis appears to improve neurologic function as well as cerebral hemodynamics in patients with cerebrovascular ischemic disease.

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Indications for Shunting in Normal Pressure Hydrocephalus

Time-dependent Analysis of EEG and Intracranial Pressure

Hiromu HADEISHI, Akifumi SUZUKI, Masahito NEMOTO, Hidenori OHTA, Nobuy ...

1988 Volume 28 Issue 2 Pages 176-182
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.176

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A new method has been developed for estimating the need for cerebrospinal fluid (CSF) drainage in patients with normal pressure hydrocephalus (NPH). The method was based on long-term electroencephalography (EEG) monitoring during CSF drainage and computerized analysis of the relationship between the EEG data and CSF pressure changes. Lumbar CSF pressure were monitored. Recordings were first obtained with a closed CSF drainage catheter in place. Subsequently, CSF drainage was carried out at various pressures and graphs of time-dependent trends in EEG parameters and CSF pressure were produced. According to the data obtained, if the magnitude or duration of alpha or beta waves increase and those of delta waves decrease in response to a reduction in CSF pressure, the patient is a good candidate for CSF drainage.
The authors applied this method to nine patients with cerebrovascular diseases who were diagnosed as having NPH on the basis of clinical and computed tomography findings. The seven patients who showed EEG improvement at different CSF pressures underwent ventriculoperitoneal, ventriculoatrial, or lumboperitoneal shunting procedures. One shunt was set at medium pressure (about 10cmH₂O) and two at low pressure (about 5cmH₂O), and four patients received shunts without a flushing device and slit valves, so that the pressure was 0cmH₂O. All seven of these patients improved clonicinically after the operation, although one patient suffered from chronic subdural hematoma.
Thus, this method proved reliable in predicting the usefulness of CSF shunting in patients with NPH. Also, optimal shunt pressure could be determined prior to the operation. However, we must be alert to the possibility of complications, such as subdural hematoma or effusion, in patients with a low-pressure shunt system.

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Factors affecting Cerebrospinal Fluid Flow in a Shunt System

Chikafusa KADOWAKI

1988 Volume 28 Issue 2 Pages 183-189
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.183

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Nineteen adult hydrocephalic patients under treatment with a medium-pressure Raimondi′s peritoneal catheter were studied for various factors believed to affect the cerebrospinal fluid (CSF) flow rate through the shunt system. Observation of body position in three patients revealed that the recumbent position mean flow rate was less than 0.01ml/min and that head elevation led to increases in the flow rate, of 0.04 to 0.08ml/min at an inclination of 30°, and of 0.14 to 0.43ml/min at 80° In most patients, coughing led to a sudden increase in flow rate, with a rapid elevation of intracranial pressure (ICP). Continuous electroencephalographic, electro-oculographic, electromyographic, respiratory, and ICP monitoring disclosed a slight increase in ICP during the rapid eye movement (REM) sleep in three of four patients studied. The CSF flow rate was highest between 10 pm and 7 am, and this nocturnal increase was considered to be related to the elevation of ICP during REM sleep. There did not appear to be any relationship between the rate of CSF flow and the volume of fluid intake. In two patients given rapid intravenous administration of 50g of glycerol or 500 to 1, 000ml of lactated Ringer′s solution there were no significant changes in CSF flow. In conclusion, increases in the flow rate of CSF through a shunt system were related to body position, coughing, and increases in ICP during the REM sleep.

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Calcified Chronic Subdural Hematoma in a Young Child

Yukihiko SHIMIZU, Yoshihide NAGAMINE, Takehide ONUMA

1988 Volume 28 Issue 2 Pages 190-194
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.190

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The patient, a male, had been born prematurely in October of 1980, at gestational week 32. His birthweight was 1, 820g. At 5 months of age he had a 5-minute episode of unconsciousness and was admitted to Sendai City Hospital. A computed tomography (CT) scan showed a very large, bilateral chronic subdural hematoma. The bilateral hematoma was evacuated and a right subdural peritoneal shunt was emplaced. In September of 1983 a left subdural peritoneal shunting procedure was carried out. However, 1 month later the latter shunt tube had to be removed because of infection. The hematoma then became calcified and gradually enlarged. In June of 1984 the organized, chronic subdural hematoma, which, together with the capsule, weighed 160g, was totally removed. The microscopic examination disclosed a relatively new hematoma within an old, organized hematoma. The postoperative course was uneventful and CT scans showed expansion of the brain.
There has been debate about whether or not a calcified chronic subdural hematoma should be removed. McLaurin reported that removal of such hematoma resulted in postoperative seizures and no improvement of mental retardation. The present case, however, showed improvement of CT findings and no postoperative seizures. The result suggests that, in infants and young children, calcified chronic subdural hematomas should be removed to prevent further brain atrophy and mental retardation.

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Intracranial Collision Tumor composed of Ganglioglioma and Meningioma

Case Report

Hiroshi WANIFUCHI, Hirotaka KADOWAKI, Osami KUBO, Koichi KITAMURA

1988 Volume 28 Issue 2 Pages 195-199
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.195

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A 25-year-old male with an intracranial collision tumor is presented. Plain computed tomography disclosed a low-density area in the left frontal lobe, which was markedly enhanced by contrast medium. Left carotid angiography revealed an avascular area that corresponded to the low-density area. The tumor was totally removed. Macroscopically, the tumor tissue was well demarcated and solid. Histological examination disclosed two components. One was a ganglioglioma containing large ganglion-like cells and Nissl substance (Klüver-Barrera staining). The other, a fibrous meningioma, consisted of partially calcified, spindle-shaped cells, which did not stain with glial fibrillary acidic protein. The diagnosis was collision tumor composed of ganglioglioma and fibrous meningioma. The authors could find no reports of intracranial collision tumors consisting of ganglioglioma and fibrous meningioma in the literature. The existing literature concerning intracranial collision tumors is discussed from a histopathological standpoint.

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Craniopharyngioma associated with Parathyroid Adenoma, Cerebral Arteriovenous Malformations, and Persistent Left Superior Vena Cava

Case Report

Jun TAKAHASHI, Yasumasa MAKITA, Sachio NABESHIMA, Taikyoku TEI, Atsush ...

1988 Volume 28 Issue 2 Pages 200-204
Published: 1988
Released on J-STAGE: August 17, 2007

DOIhttps://doi.org/10.2176/nmc.28.200

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A 36-year-old, right-handed male was hospitalized complaining of bilateral visual disturbance. A computed tomography (CT) scan revealed a suprasellar mass, which was diagnosed as craniopharyngioma. Preoperative examinations disclosed two cerebral arteriovenous malformations (AVMs) and hypercalcemia. Surgical resection of the mass followed by irradiation resulted in disappearance of the visual disturbance. Further examination showed that primary hyperparathyroidism was responsible for the hypercalcemia. In a second operation cerebral AVMs and a parathyroid adenoma, which had caused the primary hyperparathyroidism, were successfully resected. A persistent left superior vena cava (SVC), incidentally found by thoracic CT, was confirmed by angiography. The presence in one patient of two tumorous lesions, craniopharyngioma and parathyroid adenoma, and two vascular anomalies, cerebral AVMs and persistent left SVC, is extremely rare. It is possible that they have a common etiological source, although at present the authors can only speculate about the origin(s) of the multiple pathologies in this unusual case.

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