As part of an on-going clinical trial of immunotherapy for recurrent malignant gliomas, using alkaline phosphatase-anti-alkaline phosphatase method with monoclonal antibodies, we investigated the correlation between expression of the major histocompatibility complex (MHC) and the subpopulation of tumor-infiltrating lymphocytes (TILs) in 38 glioma specimens (20 grade IV, 11 grade III, and 7 grade II) from 33 patients. Thirty specimens (78.9%) were positive to class I MHC antigen and 20 (52.6%) were positive to class II MHC antigen. The correlations between class I MHC antigen expression and the number of infiltrating T8 (p < 0.01), and also between class II MHC antigen expression and the number of infiltrating T4 (p < 0.05) were significant. We conclude that TILs are the result of immunoreaction (host-defense mechanism). 31.6% of specimens had perivascular infiltration of T cells. The main infiltrating lymphocyte subset in moderate to marked perivascular cuffing was T4. Our results may indicate that lack of MHC antigen on the glioma cell surface has a share in the poor immunogenicity in glioma-bearing patients. In addition, considering the effector/target ratio, the number of infiltrating lymphocytes against glioma cells was too small, so the immunological intervention seems to be essential in glioma therapy. Previous radiation therapy and chemotherapy, including steroid therapy, did not influence lymphocyte and macrophage infiltration.
Stable xenon (Xes) is used as a contrast agent because it freely diffuses to cerebral tissues through the blood-brain barrier. In this study, 2 axial levels for Xes enhancement analysis were selected from a baseline series of computed tomographic (CT) scans and 6 serial CT scans were obtained every 20 seconds for each scan level during the 240 seconds inhalation period of 30% Xes in 10 volunteer controls and in 52 patients with ischemic cerebrovascular diseases (ICVD). The serial CT scans were added and averaged in each pixel. This was used to make a new CT picture (addition CT scan). The CT scans before the Xes inhalation, the scan at the end of the Xes inhalation, and the addition CT scan were compared to see whether gray matter and ischemic areas could be differentiated from white matter. The addition CT scans could differentiate the three structures very well in both the acute and chronic stages of ICVD. This technique is thought to be a very simple and useful method to detect the small infarcted areas and low perfusion areas that cannot be visualized on precontrast CT scans.
Twenty-seven patients with minor completed and major stroke in the chronic stage underwent superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. The regional cerebral blood flow (rCBF), using inhalation of stable xenon and computed tomographic scanning (Xes CT-CBF study), and the mode of transit time (MTT) in the MCA territory using intra-arterial digital aortography were measured. Activated rCBF and MTT was measured 20 minutes after the administration of acetazolamide (10 mg/kg) in 14 patients. Nineteen of the 23 patients with minor stroke (Group 1) showed immediate improvement in their neurological state within a few days of the operation, while four patients with minor stroke (Group 2) and four patients with major stroke (Group 3) showed no improvement. Based on the rCBF obtained with the Xes CT-CBF study, affected side rCBF/unaffected side rCBF and %f [(peak DSA number/affected side MTT)/(peak DSA number/ unaffected side MTT)] were compared. There was a significant positive correlation. Affected side MTT in Group 1 was 6.41 ± 1.16 sec, preoperatively, and significantly decreased to 5.13 ± 0.91 sec after the operation. On the other hand, preoperative MTT in Group 2 was 4.40 ± 0.81 sec and 4.76 ± 0.89 sec, postoperatively. Preoperative %f in Group 1 was 0.514 ± 0.143 and significantly increased to 0.739 ± 0.154, postoperatively. Group 2 showed no change. Vasodilatory capacity with acetazolamide showed a marked improvement in Group 1, postoperatively. Our study indicated that if MTT is moderately lengthened, %f is moderately decreased, and vasodilatory capacity is impaired, in patients with minor ischemic stroke will benefit from STA-MCA anastomosis.
In this study, changes in blood coagulation and fibrinolysis in the acute stage of subarachnoid hemorrhage (SAH) from ruptured intracranial aneurysms were investigated, and the effects of the platelet aggregation inhibitor ticlopidine and cisternal drainage were evaluated. All of the 53 patients underwent early surgery, and 27 patients received ticlopidine postoperatively. Cisternal drainage was implemented in 15 cases of severe SAH treated after late 1986. Of the hematologic factors studied, the activated partial thromboplastin time, fibrin and fibrinogen degradation products, fibrinogen, and platelet aggregation rate were found to be abnormal in the acute phase of SAH, and the “intravascular factor” scale obtained was also noted to be significantly (p < 0.01) related to the outcome. Ticlopidine was consistently effective in reducing platelet aggregation but had little effect on other blood parameters. Cisternal drainage resulted in a significantly (p<0.01) lower incidence of symptomatic vasospasm and higher rate of good outcome. These results suggest that ticlopidine therapy plus cisternal drainage is highly beneficial in SAH, and that coagulation and fibrinolysis data are useful in determining the prognosis.
Tumors at the trigone of the lateral ventricles are relatively rare. The authors have operated on eight cases with trigonal tumors during a 10-year period. Four cases were true intraventricular tumors arising from the ventricular walls, consisting of two meningiomas, one cavernous angioma, and one choroid plexus papilloma. On the other hand, the remaining four cases were paraventricular tumors originating in the adjacent brain and consisted of three astrocytomas and one glioblastoma multiforme. Although these trigonal tumors were readily detected with computed tomographic (CT) scanning, differential diagnosis was difficult because of their similar appearances on CT scans. The initial symptoms were headache in seven, and the neurological examination revealed personality changes, choked disc, visual field defects, hemiparesis, etc., in four, and no deficits in the remaining four cases. All cases were operated on via superior or middle temporal gyrus incision, and the surgical results were good except for one case who died of postoperative brain edema. In the four cases with tumors located in the dominant hemisphere, two were left with sensory aphasia, dyslexia, dyscalculia, and hemianopsia which improved within 6 months. In these two cases, postoperative CT scans revealed cerebrospinal fluid retention with severe edema along the surgical route which disappeared spontaneously within 3 months. We consider that the temporal gyrus incision was the safest approach, even though the tumor was located in the dominant side.
Since 1984, we have treated 11 malignant glioma patients with intracarotid infusion of ACNU [1-(4-amino-2-methyl-5-pyrimidinyl)-methyl-3-(2-chloroethyl)-3-nitrosourea hydrochloride] in addition to surgical removal and irradiation. We experienced three patients, who showed clinical manifestation of leukoencephalopathy and computed tomographic (CT) findings of diffuse low-density areas in the white matter on the side of ACNU infusion. Two of the three patients showed an additional CT finding of ring enhancement in the temporo-occipital region. The histological diagnosis of the first case was radiation necrosis, while that of the others was recurrent tumor with coagulation necrosis in the surrounding brain. Our experience suggests that intracarotid ACNU infusion increases the hazard of radiation necrosis, and the optimum dose and effective mode of administration should be evaluated.
Two cases of dolichoectatic basilar artery with a mass effect to the brainstem structure were treated by reducing hemodynamic stress. In one case, angiograms showed the dolichoectatic basilar artery creating a turbulent flow in the vertebrobasilar junction, and unilateral vertebral artery clipping in addition to posterior fossa decompression was performed. The other case, a combination with bilateral internal carotid artery occlusion, underwent bilateral superficial temporal artery-middle cerebral artery anastomoses. The possible surgical treatments of dolichoectasia are discussed.
The authors report a case of subependymal giant cell astrocytoma associated with tuberous sclerosis in a 15-year-old boy. Computed tomographic scans showed a large intraventricular mass with peritumoral calcification and a cyst in the left lateral ventricle. Left dominant unilateral hydrocephalus was also revealed. Magnetic resonance images clearly demonstrated the lesion. The tumor was subtotally removed and a ventriculoperitoneal shunt was performed because of the hydrocephalus. The proliferation potential was assessed by measuring the bromodeoxyuridine (BUdR) labeling index employing the in vitro labeling method, and determining the deoxyribonucleic acid (DNA) content by flowcytometry. BUdR-positive cells were found to be rare, and the DNA histogram demonstrated no evidence of high proliferative activity or aneuploidy.
We present a rare case of primary intracranial melanoma in the right occipital region of a 76-year-old male. Magnetic resonance imaging showed an isointensity mass with shorter T1 and T2 relaxation times than those of the opposite hemisphere. A well-defined, dark black tumor was totally removed and histologically diagnosed as malignant melanoma. Eight months postoperatively, however, the tumor recurred and was excised again. He was doing well 1 year after the second operation without additional treatment. In our case, 1) no systemic melanomas were found in close clinical examinations; 2) there was a single nodular tumor attached to the leptomeninges; and 3) a favorable outcome was obtained by surgical treatment alone. These results are consistent with the diagnosis of primary intracranial melanoma.
The authors describe a case of choroid plexus hemangioma in a 49-year-old male. Computed tomographic scan showed an isodense mass at the trigone of the right lateral ventricle with homogeneous enhancement. He also displayed a port-wine nevus on the ipsilateral side of the face. At operation, the tumor was found not to adhere to the lateral ventricular wall but to be connected to the choroid plexus, and was colored similarly to the facial nevus. Histological examination showed a capillary hemangioma with many crowded capillaries. This case was not included in the category of Sturge-Weber syndrome but is thought to be closely related, considering the syndrome from the viewpoint of generalized neurocutaneous hemangiomatosis.