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44 巻, 12 号
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Review Article
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Masanori ITO2004 年 44 巻 12 号 p. 617-628
発行日: 2004年
公開日: 2005/01/21
ジャーナル オープンアクセスThe health insurance system in Japan is compared to the U.S. system from a neurosurgeon's perspective. The Japanese entire population is enrolled in mandatory health insurance without choice based on employment and residence, called “Health-insurance-for-all.” Elderly Health Insurance for senior people aged 70 years or older is set within each health organization. As the relative financial conditions are variable among health insurance organizations, financial adjustment is done. The medical fee is set for all the procedures and products that are paid by health insurance which sets the prices. The same fee schedule applies to both private-practice physicians and hospitals. In the U.S. system, there are numerous fee schedules including both doctor fees and hospital fees. Any extra charges (balance billing) for procedures or materials that are not listed in the fee schedule are strictly prohibited. There is an escape clause that is called the specified medical fee system (“Tokutei Ryoyohi” in Japanese). Some designated items can be exceptionally paid by health insurance fee schedule. Many Japanese neurosurgeons express dissatisfaction with the lack of approval for medical materials which have already been used safely in other countries. The retrospective claim review process includes intermediaries, quasi-public organizations that act as payment makers to providers and claim review boards. Peer-review boards consist of about 8,000 physicians. The billing process itself using the same, uniform fee schedule is very uncomplicated, and has helped to diminish the need for well-trained and well-paid managers, and controlled administrative costs in Japan. Most medical expenses were consumed by a few patients who underwent high-cost medical care. Medical expenditure for the elderly is already taking 1/3 of national health expenditure, and is projected to reach 1/2 of national health expenditure by the year 2025. There is catastrophic coverage for high-cost care or a cap on monthly co-payment spending (High-Priced Medical Fee system: Kogaku Ryoyohi Seido). To maintain reliable and stable medical insurance systems in the aging society with fewer children in the 21st century, it is essential that fundamental reform is introduced across all systems.
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Original Articles
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—Etiology of Dissecting Aneurysms—Taku SATO, Tatsuya SASAKI, Kyouichi SUZUKI, Masato MATSUMOTO, Namio KO ...2004 年 44 巻 12 号 p. 629-636
発行日: 2004年
公開日: 2005/01/21
ジャーナル オープンアクセスHistological evaluation of dissecting aneurysms of the cerebral arteries has suggested that defects in the internal elastic lamina (IEL) induce dissection of the arterial wall. Dissecting aneurysms occur most frequently in the vertebral artery (VA). The present study examined sections of the normal VA to elucidate the mechanisms of arterial dissection. Bilateral VAs (20 vessels) were obtained from 10 patients who died of causes other than intracranial lesions. The VAs were detached from the VA union to the site 10 mm proximal from the point penetrating the dura mater. The VAs were cut at 5-mm intervals, and each segment was observed using modified Masson's trichrome staining for elastic fibers. The thickness of the media and adventitia significantly thinned after the origin of the posterior inferior cerebellar artery (PICA). IEL defects were observed at 35 sites in 11 vessels from six subjects. There was a high incidence of IEL defects in the extradural portion and near the origin of the PICA, areas frequently involved in arterial dissection. There was a high incidence of intimal thinning at areas of IEL defects (19 of 35), and thinning was particularly marked distal to the origin of the PICA. In the absence of intimal thickening, the vascular strength at the site of IEL defects may be reduced, which would promote the occurrence and progression of arterial dissection.
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Lei ZHANG, Tadashi MABUCHI, Eiji SATOH, Shuichiro MAEDA, Hideaki NUKUI ...2004 年 44 巻 12 号 p. 637-645
発行日: 2004年
公開日: 2005/01/21
ジャーナル オープンアクセスThe highly invasive and angiogenic characteristics of malignant gliomas depend on the production of growth factors and angiogenic factors. Heparin-binding growth-associated molecule (HB-GAM) is a secreted growth factor that is mitogenic for endothelial cells. To examine the expression profile of HB-GAM in malignant glioma cells, messenger ribonucleic acid (mRNA) expression was analyzed in 10 malignant glioma cell lines, two glioblastoma tissue specimens, and two normal brain tissue specimens by the reverse transcription-polymerase chain reaction. HB-GAM mRNA was expressed in all specimens including normal brain tissue specimens. Western blot analysis revealed that HB-GAM protein contents in glioma cell lines and glioblastoma tissues were 1.8 to 6.3 times higher than those in normal brain tissues. The effect of neutralizing anti-platelet-derived growth factor (PDGF) antibody was also examined on the production of HB-GAM in malignant glioma cells, since malignant glioma cells secrete PDGF that upregulates HB-GAM expression. Treatment of U251 and T98G glioblastoma cells with the anti-PDGF antibody did not affect the HB-GAM production. These results suggest that HB-GAM is overexpressed in malignant glioma cells and is involved in tumor growth.
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Case Reports
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—Case Report—Koichi FUKINO, Takeshi TERAO, Toyoyuki KOJIMA, Koji ADACHI, Akira TERA ...2004 年 44 巻 12 号 p. 646-649
発行日: 2004年
公開日: 2005/01/21
ジャーナル オープンアクセスA 58-year-old female with gastric cancer presented with left chronic subdural hematoma (CSH) without history of head injury. Magnetic resonance imaging revealed left CSH with atypical findings such as abnormal dural enhancement and swelling of the left cerebral hemisphere. One month after gastrectomy, motor aphasia and right hemiparesis developed. Irrigation of the left CSH was performed. The hematoma was abnormally mucinous and became solid immediately after irrigation. Histological examination showed that adenocarcinoma cells had metastasized to the dura mater and the outer membrane of the hematoma. The preoperative cerebral blood flow (CBF) in the affected cerebral hemisphere, measured by single photon emission computed tomography using N-isopropyl-p-[123I]iodoamphetamine, was much higher than that in the opposite hemisphere, whereas the postoperative CBF was almost equal in both hemispheres. Subdural hematomas secondary to dural metastases of extraneuronal malignancies are rare, and are usually the chronic type. Measurement of the pre- and postoperative CBF in the present patient with CSH following dural metastasis of the malignant tumor showed that preoperative hyperemia in the affected hemisphere may result from dilation of the cerebral vessels caused by the effects of the CSH.
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Idiopathic Hypertrophic Cranial Pachymeningitis Associated With Total Occlusion of the Dural Sinuses—Case Report—Yoshitsugu OIWA, Genhachi HYOTANI, Ichiro KAMEI, Toru ITAKURA2004 年 44 巻 12 号 p. 650-654
発行日: 2004年
公開日: 2005/01/21
ジャーナル オープンアクセスA 44-year-old man presented with a rare case of idiopathic hypertrophic cranial pachymeningitis manifesting as generalized seizure. Neuroimaging and pathological examinations showed the typical features of hypertrophic cranial pachymeningitis. Tuberculosis was a possible cause based on the positive purified protein-derived skin test, but the origin of the disease was not confirmed by further examinations. Cerebral angiography showed total occlusion of the dural sinuses with development of the emissary veins. Histological examination of the dura showed thickening of the fibrous tissue with rare inflammatory cells, suggestive of the extremely long duration of the disease. The diagnosis was idiopathic hypertrophic cranial pachymeningitis, but was treated only with anticonvulsants. The disease did not progress during follow up of 3 years. Idiopathic hypertrophic cranial pachymeningitis may have various causes related to unusual forms of infectious or autoimmune disorders.
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—Case Report—Masaki KOMIYAMA, Yasuhiro MATSUSAKA, Tomoya ISHIGURO, Shouhei KITANO, ...2004 年 44 巻 12 号 p. 655-659
発行日: 2004年
公開日: 2005/01/21
ジャーナル オープンアクセスA boy was born at 36 weeks gestation weighing 2,135 g, with a prenatal diagnosis of dural sinus malformation with arteriovenous shunts. Congestive heart failure and anuria at birth prompted emergency intervention. Transfemoral-transvenous coil embolization was performed on day 1, resulting in partial occlusion of the huge venous pouch with a total length of 2,355 cm of detachable coils. Transarterial glue embolization on days 7, 23, and 42 was required due to persistent heart failure. Transarterial embolization was performed by common carotid puncture because the transfemoral route could not be used due to the small size and compromised blood flow of the femoral artery. Transarterial embolization reduced the arteriovenous shunts markedly and resulted in clinical improvement. Early treatment of a high flow dural arteriovenous fistula in a low birth weight neonate can achieve an excellent result with an acceptable neurological outcome.
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—Case Report—Hidetoshi OOIGAWA, Takahito MIYAZAWA, Naoki OTANI, Shinji FUKUI, Hiros ...2004 年 44 巻 12 号 p. 660-664
発行日: 2004年
公開日: 2005/01/21
ジャーナル オープンアクセスA 51-year-old woman presented with a fourth ventricle meningioma manifesting as a 2-week history of dizziness and vomiting. Computed tomography (CT) and magnetic resonance (MR) imaging revealed a round mass lesion in the fourth ventricle. Thallium-201 chloride single photon emission computed tomography (201TlCl SPECT) showed high and rapid uptake on the early image and rapid washout on the delayed image. The preoperative diagnosis of meningioma could be established based on these findings. Total removal of the tumor was successfully performed. 201TlCl SPECT is useful for the preoperative diagnosis of fourth ventricle meningioma combined with CT, MR imaging, and angiography.
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—Case Report—Yutaka FUKUSHIMA, Hidehiro OKA, Satoshi UTSUKI, Kazuhisa IWAMOTO, Kiyo ...2004 年 44 巻 12 号 p. 665-668
発行日: 2004年
公開日: 2005/01/21
ジャーナル オープンアクセスA 35-year-old man presented with a rare case of nevoid basal cell carcinoma syndrome, or Gorlin's syndrome, associated with both medulloblastoma and meningioma, manifesting as visual field constriction due to multiple parasellar tumors. He had undergone resection of a medulloblastoma at the age of 1 year 9 months, followed by adjunctive irradiation with a total dose of 40 Gy. He presented with multiple subcutaneous nodules on his face and neck. Histological examination of biopsy specimens established the diagnosis of nevoid basal cell carcinoma syndrome. Tuberculum sellae meningioma was removed through a craniotomy, and his symptoms improved. Meningioma is known to occur in the field of therapeutic irradiation, so chemotherapy may be a better option for medulloblastoma associated with nevoid basal cell carcinoma syndrome.
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—Case Report—Manabu KINOSHITA, Shuichi IZUMOTO, Naoki KAGAWA, Naoya HASHIMOTO, Moto ...2004 年 44 巻 12 号 p. 669-673
発行日: 2004年
公開日: 2005/01/21
ジャーナル オープンアクセスAn 11-year-old Japanese girl presented with a right frontal lobe anaplastic ependymoma. The tumor was removed surgically. However, she developed a secondary lesion and extracranial metastasis in the cervical lymph node. In total, she underwent eight intracranial tumor removal procedures, five stereotactic radiosurgeries with six targets, and five cervical lymph node removal surgeries during the course of 7 years. She is currently alive with a good quality of life, and has no major neurological deficits except right facial nerve palsy. The combination of surgery and radiosurgery can achieve local control of anaplastic ependymoma. Multiple surgery or radiosurgery procedures can result in good outcome, if the tumor does not involve crucial structures, even if extracranial metastasis occurs.
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—Case Report—Sotaro SAKAI, Takuya AKAI, Takaaki IIDA, Hideaki IIZUKA2004 年 44 巻 12 号 p. 674-676
発行日: 2004年
公開日: 2005/01/21
ジャーナル オープンアクセスA 53-year-old man with renal failure presented with symptoms of shunt malfunction 11 years after placement of a ventriculoperitoneal shunt. Computed tomography showed high-density lesions on the lateral ventricle wall around the shunt tube. The shunt tube was replaced under monitoring with a neuroendoscope. The resected specimen from the ventricle wall lesion showed calcification and fibrosis. Disturbed calcium and phosphate metabolisms associated with renal failure may have been involved in this abnormal calcification on the ventricle wall.
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