Neurologia medico-chirurgica

Combination Therapy of Fasudil Hydrochloride and Ozagrel Sodium for Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage

Susumu NAKASHIMA, Kazuo TABUCHI, Shoko SHIMOKAWA, Kouzou FUKUYAMA, Tos ...

1998 Volume 38 Issue 12 Pages 805-811
Published: 1998
Released on J-STAGE: April 10, 2006

DOIhttps://doi.org/10.2176/nmc.38.805

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Fasudil hydrochloride is a new type of intracellular calcium antagonist, different from the calcium entry blockers that are commonly employed for clinical use. Since September 1995, the combination of fasudil hydrochloride and ozagrel sodium, an inhibitor of thromboxane A₂ synthesis, has been used to treat 60 patients at risk of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. The effectiveness of this combination therapy was investigated by comparison with the outcome of 57 patients previously treated with only ozagrel sodium. The combination therapy was significantly more effective (p < 0.01) in reducing the incidence of low density areas on computed tomography scans, and reduced, but not significantly, the occurrence of symptomatic vasospasm. The combination therapy of fasudil hydrochloride and ozagrel sodium has superior effectiveness over only ozagrel sodium in treating patients at risk of vasospasm after aneurysmal subarachnoid hemorrhage.

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In Vitro Inhibition of Binding of Tumor Necrosis Factor (TNF)-α by Monoclonal Antibody to TNF Receptor on Glioma Cell and Monocyte

Satoshi TANAKA, Tadashi NAGASHIMA, Tomokatsu HORI

1998 Volume 38 Issue 12 Pages 812-818
Published: 1998
Released on J-STAGE: April 10, 2006

DOIhttps://doi.org/10.2176/nmc.38.812

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The use of monoclonal antibodies to the tumor necrosis factor (TNF) receptors, the TNF-p55 receptor (TNF-p55R) and the TNF-p75 receptor (TNF-p75R), was evaluated to reduce the effects of TNF caused by binding to TNF-p75R. Competitive binding of anti-TNF-p55R (mAbp55R) and anti-TNF-p75R monoclonal antibodies (mAbp75R) with iodine-125-labeled TNF-a to GL-9 glioma cells and U937 histiocytic lymphoma cells was evaluated. The effects of mAbp55R and mAbp75R on the growth suppression by TNF-a of GL-9 cells and TNF-a production in U937 cells were also examined. mAbp75R bound to U937 cells competitively with TNF-a and suppressed TNF-a production by U937, but had no effect on the growth inhibition of GL-9 human glioma cell by TNF-a in vitro. These findings suggest that co-administration of TNF-p75R antagonist with TNF-a may decrease the toxicity of TNF-a administration resulting in a better therapeutic result.

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Ultramicroscopic Structures of the Leptomeninx of Mice with Communicating Hydrocephalus Induced by Human Recombinant Transforming Growth Factor-β1

Junpei NITTA, Tsuyoshi TADA

1998 Volume 38 Issue 12 Pages 819-825
Published: 1998
Released on J-STAGE: April 10, 2006

DOIhttps://doi.org/10.2176/nmc.38.819

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An experimental model of communicating hydrocephalus was developed based on intrathecal injection of human recombinant transforming growth factor-β1 (hrTGF-β1) in the mouse. To clarify the mechanism of this hydrocephalus model, the ultrastructure of the leptomeninx in the process of ventricular dilation was examined in C57/BL6 mice injected intrathecally with 60 ng of hrTGF-β1. The leptomeninx was examined at various periods after injection by light and electron microscopy. Immunostaining for fibroblasts and macrophages was also performed. Leptomeninx within a week after injection showed that the thin cytoplasmic processes of leptomeningeal cells formed a laminated structure with a meshwork, which was almost the same as the controls. In the second week, many cells with a round nucleus appeared in the leptomeninx. Immunohistochemically, these cells were positive for anti-fibroblast antibody and negative for anti-Mac-1 and anti-macrophage BM-8 antibodies. Three weeks later, the laminated structure was disrupted and abundant deposition of collagen fibers was found in the intercellular space of the leptomeninx. Such inter-meningeal fibrosis would disturb cerebrospinal fluid flow in the mouse leptomeninx and cause slowly progressive ventricular dilation.

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Large and Giant Middle to Lower Basilar Trunk Aneurysms Treated by Surgical and Interventional Neuroradiological Methods

Waro TAKI, Ichiro NAKAHARA, Nobuyuki SAKAI, Keiko IRIE, Kenichi MURAO, ...

1998 Volume 38 Issue 12 Pages 826-835
Published: 1998
Released on J-STAGE: April 10, 2006

DOIhttps://doi.org/10.2176/nmc.38.826

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Treatment of large and giant aneurysms of the basilar artery remains difficult and controversial. Three large or giant aneurysms of the lower basilar artery were treated with a combination of surgical and interventional neuroradiological procedures. All patients underwent the balloon occlusion test with hypotensive challenge (blood pressure reduced to 70% of the control value). The third patient did not tolerate the test. In the first patient, both vertebral arteries were occluded through a craniotomy. In the second patient, both the aneurysm and the basilar artery were occluded by detached balloons. In the third patient, one vertebral artery was occluded by surgical clipping and the other by detached helical coils and fiber coils. In spite of anti-coagulation and anti-platelet therapy, postoperative thrombotic or embolic ischemia occurred in the second and third patients. Fibrinolytic therapy promptly corrected the ischemic symptoms, but the second patient developed hemorrhagic complications at the craniotomy area 2 hours later. At follow-up examination, the first patient had only 8th cranial nerve paresis, the second patient who had a hemorrhagic complication was bed-ridden, and the third patient had no deficit. Interventional occlusion requires a longer segment of the parent artery compared to surgical occlusion of the parent artery and might cause occlusion of the perforating arteries. However, selected use of various coils can occlude only a short segment of the parent artery. Thus, the postoperative management of thromboembolic ischemia after the occlusion of the parent artery is easier using the interventional technique.

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Combined Carotid Endarterectomy and Coronary Artery Bypass Graft

Kiyoyuki YANAKA, Kotoo MEGURO, Kiyoshi NARUSHIMA, Ikuo FUKUDA, Yuichi ...

1998 Volume 38 Issue 12 Pages 836-843
Published: 1998
Released on J-STAGE: April 10, 2006

DOIhttps://doi.org/10.2176/nmc.38.836

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Atherosclerosis is a generalized disease which afflicts a considerable number of patients in both the carotid and coronary arteries. Although the risk of stroke or death due to combined carotid endarterectomy (CEA) and coronary artery bypass graft (CABG) is thought to be higher than that of each individual operation, the combined procedure is generally preferred over staged operations to treat such patients. We performed the combined procedure safely with the aid of intraoperative portable digital subtraction angiography (DSA). This report describes our experience with the operative strategy of simultaneous CEA and CABG. Ninety CEA and 404 CABG were carried out between January 1989 and December 1997. A total of six patients received the combined procedure with the aid of intraoperative DSA; they were studied retrospectively. Postoperative mortality and morbidity after the combined procedure was 0%. In the combined procedure, neurological complications are difficult to detect after CEA because the patient must be maintained under general anesthesia and extracorporeal circulation during the subsequent CABG. However, intraoperative DSA can confirm patency of the internal carotid artery and absence of flap formation after CEA, and the CABG can be performed safely. Intraoperative portable DSA between CEA and CABG is helpful in preventing perioperative stroke in the combined procedure.

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Significance of Acute Cerebral Swelling in Patients with Sylvian Hematoma due to Ruptured Middle Cerebral Artery Aneurysm, and its Management

Shuji NIIKAWA, Hideomi KITAJIMA, Naoyuki OHE, Yoshiaki MIWA, Akio OHKU ...

1998 Volume 38 Issue 12 Pages 844-850
Published: 1998
Released on J-STAGE: April 10, 2006

DOIhttps://doi.org/10.2176/nmc.38.844

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A retrospective study of 75 patients treated surgically for ruptured middle cerebral artery (MCA) aneurysm within 48 hours evaluated clinical grade at admission, secondary development and management of cerebral swelling associated with space-occupying hematoma, cerebral infarction caused by vasospasm, development of hydrocephalus, and clinical outcome. Clinical grade at admission was significantly better in patients without than in those with hematoma (p < 0.01). Twenty-seven patients with sylvian hematoma caused by ruptured MCA aneurysm often developed ipsilateral cerebral swelling in the early period after subarachnoid hemorrhage. Seventeen of these patients developed serious cerebral swelling and received barbiturate therapy. Nine of these 17 patients had good outcome, but six patients died of cerebral swelling. The incidence of hydrocephalus was significantly higher in patients with than in those without hematoma (p < 0.01). The incidence of infarction was more pronounced in patients with sylvian hematoma. Clinical outcome was significantly better in patients without than in those with sylvian hematoma (p < 0.01). Development of cerebral swelling in patients with sylvian hematoma due to ruptured MCA aneurysm has a significant effect on outcome, and improvements in management are required.

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Clinical Importance of c-Met Protein Expression in High Grade Astrocytic Tumors

Yuichi HIROSE, Masaru KOJIMA, Masachika SAGOH, Takuro HAYASHI, Hideki ...

1998 Volume 38 Issue 12 Pages 851-859
Published: 1998
Released on J-STAGE: April 10, 2006

DOIhttps://doi.org/10.2176/nmc.38.851

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The clinical importance of the expression of c-Met protein, the receptor of hepatocyte growth factor/scatter factor, was evaluated in neuroepithelial tissue tumors. c-Met immunohistochemistry was performed using the streptavidin-biotin-peroxidase complex method with anti-c-Met polyclonal antibody. Specimens were classified as c-Met negative (< 30%) or c-Met positive (≥ 30%) according to the proportion of immunopositive cells under microscopic examination. All c-Met-positive cases occurred in high grade astrocytic tumors, not in other neuroepithelial tissue tumors. Most c-Met-positive astrocytic tumors were classified histologically as high grade tumors. Epidermal growth factor-receptor (EGFR) and MIB-1 immunohistochemistry were also performed for high grade astrocytic tumors. Survival analysis was performed for patients with these tumors with variables including c-Met positivity, EGFR positivity, and MIB-1 labeling index. Positivity of c-Met was independent from EGFR positivity and MIB-1 labeling index, and the c-Met-positive group showed a significant shorter survival (p < 0.05). cMet immunopositivity may be a parameter of biological aggressiveness in high grade astrocytic tumors. Examination of c-Met expression in astrocytic tumors provides significant clinical information, especially as a prognostic factor.

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Rupture Mechanism of a Thrombosed Slow-growing Giant Aneurysm of the Vertebral Artery —Case Report—

Toshihiro YASUI, Hiroaki SAKAMOTO, Hiroshige KISHI, Masaki KOMIYAMA, Y ...

1998 Volume 38 Issue 12 Pages 860-864
Published: 1998
Released on J-STAGE: April 10, 2006

DOIhttps://doi.org/10.2176/nmc.38.860

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A 76-year-old male developed left hemiparesis in July 1991. The diagnosis was thrombosed giant vertebral artery aneurysm. He showed progressive symptoms and signs of brainstem compression, but refused surgery and was followed up without treatment. He died of rupture of the aneurysm and underwent autopsy in March 1995. Histological examination of the aneurysm revealed fresh clot in the aneurysmal lumen, old thrombus surrounding the aneurysmal lumen, and more recent hemorrhage between the old thrombus and the inner aneurysmal wall. The most important histological feature was the many clefts containing fresh blood clots in the old thrombus near the wall of the distal neck. These clefts were not lined with endothelial cells, and seemed to connect the lumen of the parent artery with the most peripheral fresh hemorrhage. However, the diameter of each of these clefts is apparently not large enough to transmit the blood pressure of the parent artery. Simple dissection of the aneurysmal wall by blood flow in the lumen through many clefts in the old thrombus of the distal neck may be involved in the growth and rupture of thrombosed giant aneurysms of the vertebral artery.

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Secondary Glioblastoma Remarkably Reduced by Steroid Administration After Anaplastic Transformation from Gliomatosis Cerebri —Case Report—

Yuichi HIROSE, Takuro HAYASHI, Masachika SAGOH, Hideki MURAKAMI

1998 Volume 38 Issue 12 Pages 865-870
Published: 1998
Released on J-STAGE: April 10, 2006

DOIhttps://doi.org/10.2176/nmc.38.865

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A 45-year-old female presented with gliomatosis cerebri manifesting as hemiballismus-like involuntary movement in the arm, motor weakness in the leg, and hypesthesia in her left side. Computed tomography showed only diffuse swelling of the right cerebral hemisphere, but T₂-weighted magnetic resonance imaging revealed a diffuse lesion spreading from the right thalamus to the temporal, parietal, and occipital lobes on the same side. No abnormal enhancement was recognized. Cerebral angiography showed no specific finding. A right occipital lobectomy was performed to confirm the diagnosis of gliomatosis cerebri. Anaplastic transformation was recognized 5 months later. The disease did not resolve with radiation or interferon administration, but steroid therapy achieved remarkably effective tumor regression. The patient died due to pneumonia. Autopsy showed the features of diffuse glioblastoma. Steroid therapy may be an effective treatment for gliomatosis cerebri before the terminal stage.

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Contralateral Deafness Following Unilateral Suboccipital Brain Tumor Surgery in a Patient with Large Vestibular Aqueduct —Case Report—

Tatsuya NISHIOKA, Masatsune ISHIKAWA, Akinori KONDO, Hideyuki FUKUSHIM ...

1998 Volume 38 Issue 12 Pages 871-874
Published: 1998
Released on J-STAGE: April 10, 2006

DOIhttps://doi.org/10.2176/nmc.38.871

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A 68-year-old female developed contralateral deafness following extirpation of a left cerebellopontine angle epidermoid cyst. Computed tomography showed that large vestibular aqueduct was present. This unusual complication may have been caused by an abrupt pressure change after cerebrospinal fluid release, which was transmitted through the large vestibular aqueduct and resulted in cochlear damage.

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Pneumocephalus Associated with Ethmoidal Sinus Osteoma —Case Report—

Yoshiya NAKAYAMA, Akira TANAKA, Yuushi UENO, Kazuya NARITOMI, Shinya Y ...

1998 Volume 38 Issue 12 Pages 875-878
Published: 1998
Released on J-STAGE: April 10, 2006

DOIhttps://doi.org/10.2176/nmc.38.875

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A 35-year-old female suffered sudden onset of severe headache upon blowing her nose. No rhinorrhea or signs of meningeal irritation were noted. Computed tomography (CT) with bone windows clearly delineated a bony mass in the right ethmoid sinus, extending into the orbit and intracranially. Conventional CT demonstrated multiple air bubbles in the cisterns and around the mass in the right frontal skull base, suggesting that the mass was associated with entry of the air bubbles into the cranial cavity. T₁- and T₂-weighted magnetic resonance (MR) imaging showed a low-signal lesion that appeared to be an osteoma but did not show any air bubbles. Through a wide bilateral frontal craniotomy, the cauliflower-like osteoma was found to be protruding intracranially through the skull base and the overlying dura mater. The osteoma was removed, and the dural defect was covered with a fascia graft. Histological examination confirmed that the lesion was an osteoma. The operative procedure resolved the problem of air entry. CT is superior to MR imaging for diagnosing pneumocephalus, by providing a better assessment of bony destruction and better detection of small amounts of intracranial air.

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