Serial changes in platelet and white blood cell (WBC) counts and other blood parameters were analyzed in 103 patients with aneurysmal subarachnoid hemorrhage (SAH). The WBC counts during days 3-5, 6-8, 9-11, and 12-14 after the onset of SAH were significantly higher in patients with than in patients without symptomatic vasospasm. Platelet counts during days 0-2, 3-5, 6-8, 9-11, 12-14, 15-17, 18-21, and 22-28 after SAH were significantly higher in patients with than in patients without symptomatic vasospasm. Monitoring of platelet and WBC counts may provide an indicator of the occurrence of symptomatic vasospasm.
Cerebrospinal fluid (CSF) leakage through dural sutures after craniotomy increases the risk of complications such as persistent CSF fistulas, meningitis, and subcutaneous, graft bone, or epidural infections. The effectiveness of fibrin glue for preventing CSF leakage through dural closure was investigated in 183 patients who underwent frontotemporal craniotomy for unruptured aneurysm. Fibrin glue was used in 138 patients, but not in the other 45. Computed tomography was used to evaluate postoperative extradural fluid collection as a minimal volume of low-density area. Postoperative computed tomography demonstrated transient increases in extradural fluid collection in 55 patients. However, none of these patients received a second surgery for dural repair. Fluid collection occurred in 19 of 45 patients (42%) in whom fibrin glue was not used, and in 36 of 138 patients (26%) in whom fibrin glue was used. The fibrin sealant on the dural suture was a significant factor in reducing the incidence of the fluid leakage (p < 0.05, chi-square test). Fibrin glue is a useful surgical tool for the prevention of postoperative extradural fluid collection through the dural sutures.
The effect of iridium-192 brachytherapy (BRTX) on the survival of patients with malignant gliomas was evaluated in 83 patients with malignant gliomas (42 astrocytoma grade III, 41 glioblastoma multiforme) over a period of 8.5 years. Fifty patients (Group 1) received only standard external beam radiotherapy (EBRT) (mean dose 51.5 ± 12.4 Gy in 2.0 Gy fractions), and 33 patients (Group 2) received EBRT (mean dose 51.0 ± 10.8 Gy) combined with BRTX (mean dose 50.2 ± 13.2 Gy, dose rate of 0.3-0.4 Gy/hr). The median survival periods for patients in Groups 1 and 2 were 12.2 and 23.7 months, respectively (p = 0.0145). The median survival for 17 patients in Group 2 with glioblastoma multiforme was 21.9 months. Using BRTX as an adjuvant to EBRT appeared to confer survival benefits compared to only EBRT (p = 0.0284). Univariate and multivariate analysis identified the variables of histological diagnosis, location, Karnofsky performance status, and BRTX as relevant risk factors for survival time (p < 0.05 for each factor). Among these factors, BRTX was the most important for prolonging survival (p = 0.0015). Adjuvant iridium-192 BRTX and conventional EBRT appears to greatly improve the survival time of patients with malignant gliomas compared to only EBRT and may be the treatment of choice in selected patients with tumors located in deep-seated or eloquent areas.
The effects of bromocriptine and terguride on the estrogen-stimulated anterior pituitary gland of the female Wistar rat were investigated. Pituitary weight and serum prolactin (PRL) levels were reduced by treatment with bromocriptine or terguride. Immunohistological staining for proliferating cell nuclear antigen (PCNA) revealed that the PCNA labeling index of PRL-producing cells was significantly decreased by treatment with bromocriptine or terguride compared with untreated cells. The number of apoptotic cells analyzed by the terminal deoxynucleotidyl transferase-mediated deoxyuridinetriphosphate-biotin nick end labeling method was significantly increased in rats treated with bromocriptine or terguride. Suppression of cell proliferation and induction of apoptosis are important effects of bromocriptine and terguride in the treatment of prolactinomas and other hyperprolactinemias.
A 65-year-old male with a giant aneurysm of the vertebral artery, which had caused minimal neurological deficits for a few years, suffered rapid onset of respiratory disturbance followed by coma. Serial neuroimaging studies showed the thrombosed aneurysm continued to enlarge, resulting in increasing compression of the brainstem. Intraoperative observation and histological examination revealed that the aneurysm was composed of totally organized thrombus. Total extirpation of the giant aneurysm resulted in the patient regaining spontaneous respiration and clear consciousness, suggesting that growth of this aneurysm is due to increases in the size and number of the intrathrombotic capillary channels.
A 58-year-old male suffered a massive intratumoral hemorrhage after placement of a ventriculoperitoneal shunt before treatment for pineocytoma. At admission, he complained of headache, urinary incontinence, gait disturbance, and recent memory disturbance. His neurological examination revealed impaired memory and papilledema from hydrocephalus. Two days after the placement of the ventriculoperitoneal shunt, he suddenly became stuporous and Parinaud''s sign appeared. Computed tomography showed a massive intratumoral hemorrhage occupying the third ventricle which had extended into the lateral ventricle. The infratentorial supracerebellar approach was used to remove the hematoma and the tumor. The histological diagnosis was pineocytoma. Intratumoral hemorrhage in pineocytoma after the placement of a ventriculoperitoneal shunt is rare, but should be kept in mind when a ventriculoperitoneal shunt is placed before a craniotomy.
A 68-year-old male developed a solitary metastasis in the choroid plexus of the right lateral ventricle 7 years after left nephrectomy for renal cell carcinoma. The lesion was totally removed and the patient has been free from recurrence for 30 months postoperatively. Pure solitary metastasis to the choroid plexus is very rare, but five of the 15 cases originated from renal cell carcinoma. There may be a link between this type of metastasis and the slowly progressive type of renal cell carcinoma.
A 34-year-old female presented with occlusive cerebrovasculopathy without definite ischemic symptoms and regrowth of a cystic tumor in the third ventricle. She had been treated for a craniopharyngioma 19 years previously by internal irradiation with 198Au colloid combined with intracavitary administration of bleomycin via an Ommaya reservoir. Cerebral angiography demonstrated complete occlusion of the clinoid portion of the left internal carotid artery and stenosis of the left posterior cerebral artery, and numerous transdural anastomoses which had developed after craniotomy. Endoscopic management achieved collapse of the cystic tumor. No treatment for the occlusive cerebrovasculopathy was necessary because of the collateral blood supply. Careful follow-up examinations to detect occult cerebrovasculopathy after such treatment is recommended.
A 12-year-old boy presented with Rasmussen''s encephalitis. Serial magnetic resonance (MR) imaging one year after the onset of seizure showed no abnormality. T2-weighted imaging detected a high intensity lesion in the left frontal cortex when the frequency of seizures increased 11 months later. MR imaging showed the lesion rapidly spread into the white matter, then gradually regressed after biopsy and immunoglobulin therapy, and mild focal atrophy of the left frontal lobe in spite of recurrence of seizures 3 months after the therapy. Histological examination of the biopsy sample showed the characteristic findings of Rasmussen''s encephalitis. Five months after the biopsy, another new high intensity lesion was detected next to the previous one, although his seizures were well controlled at that time. Although the extent of the high intensity lesion did not correlate with the frequency of seizures, such sequential changes in MR imaging appearance seemed to reflect the course of this disease.
Two adults (aged 71 and 74 years) developed cerebellar mutism after posterior fossa surgery for a mass lesion in the superior cerebellar hemisphere or upper vermis. Histological examination showed one was a hemangioblastoma, the other a metastatic brain tumor. The tumors were totally removed via the occipital transtentorial approach. Both patients developed mutism on the 2nd postoperative day, which persisted for 3-4 weeks and was followed within 2-4 months by cerebellar dysarthria. Thereafter, their condition improved. Transient cerebellar mutism usually occurs in pediatric patients after the removal of a mass lesion in the upper vermis. Cerebellar mutism in adults is rare. The predominance of cerebellar mutism in children may be attributable to the predilection for vermian tumor and their tendency to experience personality and behavioral changes after posterior fossa surgery.