[Descending aorta perfusion through median sternotomy in primary repair of aortic interruption complex]

Circulatory arrest is frequently used in aortic arch reconstruction in pediatric cardiac surgery. However, risks of postoperative acute renal failure and neurological deficit can not be ignored. We performed primary repair of aortic interruption in one-month old girl. After commencing extracorporeal circulation with bicaval venous cannulae and with arterial cannulae into the pulmonary trunk and the innominate artery, the descending aorta was cannulated just superior to the diaphragm. The cannula in the pulmonary trunk was then removed. Arch reconstruction and closure of the ventricular septal defect were performed with continuous perfusion to the brain and the lower body. The extracorporeal circulation time and the aortic cross-clamp time were 117 min and 21 min, respectively. Postoperative renal function was excellent, and there was no finding of neurological deficit. Cannulation of the descending aorta is a simple and useful technique with safety, in arch reconstruction in infants.

[Clinical results of mitral valve surgery in children]

The clinical results of mitral valve surgery in children were evaluated. Fifty children (age ranged between 1 month and 12 years) with mitral valve regurgitation have undergone valve surgery with low operative mortality (2%). Valve plasty using several techniques including annuloplasty have been performed with quite high success rate (92%), while valve replacement was required in four patients who had the prolapse of the anterior mitral leaflet (8%). Reoperation was required in 5 patients (10%), and there were 4 late deaths. Introduction of the reconstructive technique of the chordae tendinae using artificial chordae resulted 100% success rate of mitral repair for the prolapse of the anterior mitral leaflet without death and reoperation. The reoperation free rate and the actuarial survival rate at 15 years of the patients with mitral regurgitation were 70 +/- 12% and 85 +/- 7%, respectively. In ten patients with mitral valve stenosis (age ranged between 1 month and 5 years), 5 patients required valve replacement (50%), and 2 patients died (20%). The clinical results of the surgery for the mitral stenosis were still unsatisfactory, and the reoperation free rate at 2 years was 42 +/- 30% and the actuarial survival rate at 13 years were 32 +/- 18%.

Clinical results of arterial switch operation for double-outlet right ventricle with subpulmonary VSD

OBJECTIVE

An arterial switch operation is considered a good alternative for the repair of double-outlet right ventricle (DORV) with atrioventricular concordance connection and subpulmonary ventricular septal defect (VSD) when intraventricular rerouting is not feasible. The clinical results of an arterial switch operation with ventricular septal defect closure for this anomaly were studied.

METHODS

Between 1986 and 1997, 27 patients ranging from 10 days to 5 years of age (mean 0.4 years) underwent an arterial switch operation with ventricular septal defect closure for the correction of double outlet right ventricle with subpulmonary VSD. The 50% rule was used to define double-outlet right ventricle. Arch anomalies were associated in nine cases, and were corrected either previously or simultaneously. A subarterial muscle resection was performed in 14 without any subsequent stenosis of the ventricular outflow tract. The relationship of the great arteries was mostly anteroposterior in 15 and mostly side by side in 12. The left coronary artery (main trunk or circumflex artery) courses behind the pulmonary artery in 15/27 (six/15 in the anteroposterior relation and ten/12 in the side by side relation). The Lecompte maneuver was used to reconstruct the pulmonary artery in all but five cases with a side by side relationship of the great arteries.

RESULTS

There was one operative death (3.7%) and three late deaths. The actuarial survival rate was 83 +/- 8% at 9 years. Right ventricular outflow tract obstruction including peripheral pulmonary stenosis developed in seven cases operated on in the early era. The reoperation free rate was 46 +/- 20% at 9 years.

CONCLUSION

Although double-outlet right ventricle with subpulmonary VSD has complex features, including an aortic arch obstruction and coronary artery anomalies, an optimal definitive surgical repair using an arterial switch operation can be performed safely with a thorough understanding of this variable anomaly. The prevention of right ventricular outflow tract obstruction at the time of an arterial switch operation may thus help improve the rate of late morbidity.

A new technique of surface anatomy MR scanning of the brain: its application to scalp incision planning

BACKGROUND AND PURPOSE

Surface anatomy scanning (SAS) is an established technique for demonstrating the brain's surface. We describe our experience in applying SAS with superposition of MR venograms to preoperative scalp incision planning.

METHODS

In 16 patients, scalp incision planning was done by placing a water-filled plastic tube at the intended incision site when we performed SAS using half-Fourier single-shot fast spin-echo sequences. Two-dimensional phase-contrast MR angiograms were obtained to demonstrate the cortical veins and then superimposed upon the SAS images. The added images were compared with surgical findings using a four-point grading scale (0 to 3, poor to excellent).

RESULTS

In each case, neurosurgeons could easily reach the lesion. Surgical findings correlated well with MR angiogram-added SAS images, with an average score of 2.56.

CONCLUSION

Our simple technique is a useful means of preoperatively determining brain surface anatomy and can be used to plan a scalp incision site.

[Spinal anesthesia for a patient with long-term SMON]

SMON (subacute myelo-optico-neuropathy) may result from clioquinol neurotoxicity. An 81-year-old woman underwent internal fixation for left intertrochanteric fracture. She had been diagnosed as having SMON twenty years previously. Sensory examination revealed paresthesia and decreased deep sensation in the lower extremity. A recent neuropathological report shows that in long-term SMON of about fifteen years, degeneration is located from the medulla oblongata to T5-6. We performed spinal anesthesia of which the level of analgesia was below T5-6 in the present case. The level of anesthesia was determined by the pinprick test, and was recognized as below T10. Postoperatively, both the sensory level of analgesia and vital signs remained stable. There was no worsening of neurological findings after spinal anesthesia, including the postoperative period. In conclusion, spinal anesthesia which was limited to below the level of degeneration could be applied in a case of long-term SMON.

A combined surgical and endovascular treatment for a case with five vertebro-basilar aneurysms and bilateral internal carotid artery occlusions

BACKGROUND

Whereas multiple aneurysms may be found in 20% of patients in whom one aneurysm is discovered, the identification of five vertebrobasilar aneurysms is distinctly rare. We described such a case treated by surgical and endovascular method.

CASE DESCRIPTION

A case of multiple aneurysms treated with combined surgical clipping and intravascular surgery is described. Five separate posterior circulation aneurysms and bilateral internal carotid artery occlusion were identified in one patient. Three of the aneurysms were treated surgically. Access to the fourth aneurysm was deemed difficult because of its location and because of the previously placed surgical clips; this aneurysm was treated by endovascular approaches that provided optimum therapy in this unusual multiple aneurysms case.

CONCLUSIONS

We have described an unusual case of multiple posterior circulation aneurysms in the setting of bilateral internal carotid occlusions, treated by a combination of surgical and endovascular therapies. We will be able to provide safer treatment for such difficult cases in the future.

Mixed type of total anomalous pulmonary venous connection

BACKGROUND

The mixed type of total anomalous pulmonary venous connection is a rare condition in which some diagnostic and surgical problems still remain to be solved.

METHODS

In 9 patients a single pulmonary vein was connected to the systemic vein at a site different from the drainage site of the confluence of three other pulmonary veins. In 2 other patients, four pulmonary veins made a confluence which had two drainage sites. Correct diagnosis was made in all 7 patients who received cardiac catheterization but only in 5 of the 9 patients by color Doppler echocardiography. Total correction was performed in 3 patients and the single anomalous pulmonary vein was left uncorrected in 8 other patients.

RESULTS

There were two in-hospital deaths. Seven patients with a single residual anomalous pulmonary vein have been in good condition without clinical symptoms of congestive heart failure or pulmonary hypertension.

CONCLUSIONS

Diagnosis of mixed type of total anomalous pulmonary venous correction by echocardiography is sometimes difficult. When a mixed type is suspected, cardiac catheterization is recommended if the condition of the patient permits it. A single anomalous pulmonary vein may be left uncorrected without serious complications, but close observation is needed to prevent congestive heart failure and pulmonary vascular obstructive disease.

[A case of ruptured P4 segment aneurysm of the posteior cerebral artery: therapeutic pitfalls encountered when dealing with the multiple intracranial aneurysms]

A P4 segment aneurysm of the posterior cerebral artery has rarely been described. A case of ruptured P4 segment aneurysm, which re-ruptured after clipping procedure for unruptured internal carotid artery aneurysm, was reported. A 57-old-man had sudden onset of severe headache and vomiting and was transferred to our hospital. CT scan on admission showed diffuse subarachnoid hemorrhage dominantly extending to the tentorial surface and the occipital interhemispheric tissue. Four-vessel angiography demonstrated a right internal carotid-posterior communicating artery junction aneurysm, and its neck clipping was performed on day 5. Intraoperative inspection of the whole appearance of the aneurysm was difficult because of the aneurysm existing on the ventral portion of the internal carotid artery and definite diagnosis of the bleeding source was not obtained. On day 23, he complained of severe headache and restricted vision and CT scan showed intracerebral hematoma in the left occipital lobe with intraventricular hemorrhage. The angiograms and CT scan on admission were reexamined, and another aneurysm on the left parieto-occipital artery (P4 segment) was retrospectively identified. The ruptured P4 segment aneurysm was obliterated via the interhemispheric approach and the patient enjoyed an uneventful postoperative course. When a thick subarachnoid hemorrhage distributed in the occipital interhemispheric fissure, quadrigeminal cistern, and ambient cistern is encountered, the existence of a possible P4 segment aneurysm should be suspected. Correct initial diagnosis and definite treatment of the ruptured lesion in the acute stage is essential in dealing with SAH-patient with multiple aneurysms. When they are unruptured lesions at a common aneurysm site, the existence of an unusually located aneurysm should not be overlooked as the possible source responsible for symptoms.

[Pretreatment with magnesium sulphate enhances vecuronium-induced neuromuscular block]

The interaction between magnesium sulphate (MgSO4) and vecuronium was investigated during isoflurane-nitrous oxide-oxygen anesthesia. Neuromuscular function was evaluated by recording the single twitch of the abductor policis muscle. Anesthesia was induced with thiamylal followed by injection of vecuronium. The effects of pretreatment with MgSO4 (20 or 40 mg.kg-1) on the potency of vecuronium were compared with observations in patients without MgSO4 pretreatment (control). We also examined the serum concentration of magnesium ions after administration of MgSO4. We found that the neuromuscular effect of vecuronium was not influenced by pretreatment with MgSO4 20 mg. On the contrary, the onset time of vecuronium was decreased and the duration of action until 25% recovery was increased by pretreatment with MgSO4 40 mg. The serum concentration of magnesium ions after administration of MgSO4 40 mg was significantly higher than that after 20 mg. We conclude that pretreatment with MgSO4 40 mg but not 20 mg enhances vecuronium-induced neuromuscular block.

Clinical results of the staged Fontan procedure in high-risk patients

BACKGROUND

For high-risk Fontan candidates, the introduction of a bidirectional Glenn shunt before total cavopulmonary connection (a two-staged strategy) may extend the indications for the Fontan procedure. The clinical results of the two-staged and one-staged Fontan procedure were thus reviewed and compared.

METHODS

Between November 1991 and July 1996, the two-staged strategy was performed in 40 high-risk Fontan candidates with a mean interval of 17.2 months after introducing the bidirectional Glenn shunt (staged group). We considered a young age (<2 years), high mean pulmonary arterial pressure (> or =20 mm Hg), high pulmonary vascular resistance (> or =3 Wood units), small pulmonary artery (Nakata index <200 mm2/m2), atrioventricular valve incompetence (> or = moderate), distortion of pulmonary artery, anomalous pulmonary venous return, and poor ventricular function as risk factors for the successful completion of Fontan circulation. During the same period, 68 patients underwent the modified Fontan procedure in a one-step fashion (primary group).

RESULTS

In the staged group after the bidirectional Glenn shunt, the mean pulmonary arterial pressure and ventricular end-diastolic pressure were both found to have decreased significantly to the same level as those in the primary group, whereas the pulmonary artery demonstrated a significantly smaller size than that in the primary group. Operative morbidity was similar in both groups. Operative mortality was also similar and low in both groups (1.5% in the primary group and 0% in the staged group).

CONCLUSIONS

A bidirectional Glenn shunt was found to be a useful interim palliation in high-risk Fontan candidates. This two-staged strategy may extend the operative indications for the Fontan procedure.

The surgical anatomy of the left ventricular outflow tract in hearts with ventricular septal defect and aortic arch obstruction

BACKGROUND

Profound understanding of the left ventricular outflow tract (LVOT) anatomy is crucial to improve surgical results in patients with aortic arch obstruction, ventricular septal defect, and subaortic stenosis.

METHODS

We studied the morphology of the LVOT in 32 postmortem hearts with aortic arch obstruction and a ventricular septal defect. In case of subaortic obstruction, the length of the subaortic muscular component was measured anteriorly and posteriorly within the left ventricle.

RESULTS

Seven of the 32 hearts had no subaortic stenosis. Nine had aortic override, which caused LVOT narrowing. Sixteen hearts contained a subaortic shelf, downstream to the ventricular septal defect, which deviated into the left ventricle in 15. In 10 of these the shelf was muscular; in 6 it was a fibrous ridge. In cases with a muscular shelf, the posterior part was significantly shorter than the anterior part (p < 0.004). In 9 hearts the LVOT was further narrowed because of the abnormal relationship between the mitral valve and the subaortic shelf.

CONCLUSIONS

The present study confirms the complexity of LVOT stenosis in aortic arch obstruction and ventricular septal defect and provides a better understanding of the options to achieve surgical relief.

Delayed cyst formation after radiosurgery for cerebral arteriovenous malformation: two case reports

Two patients who underwent gamma knife radiosurgery for ruptured cerebral arteriovenous malformations (AVM) developed cystic lesions at 78 and 111 months after undergoing treatment. Both patients presented initially with intracerebral hemorrhage. In one patient, the cystic lesion was discovered during routine follow-up imaging and clinical examination revealed homonymous hemianopsia; the second patient presented with seizure and the lesion was identified more than 9 years after radiosurgery. One patient underwent resection of the nidus and histologic analysis of the resected specimen showed vessels in various stages of obliteration. The present paper discusses the possible mechanism for the delayed development of cystic lesions, and the possibility that radiation-induced vascular changes may continue in a nidus even when angiography shows complete obliteration of the nidus.

[Anesthetic management of a patient with dilated cardiomyopathy using olprinone]

A 51-year-old man with dilated cardiomyopathy, who had been treated with medication for five years, was scheduled for abdomioperineal resection of the rectum. Preoperative echocardiography demonstrated left ventricular dilation and hypertrophy, with an ejection fraction of 0.34. Anesthesia was induced with ketamine 40 mg and fentanyl 0.5 mg intravenously. Endotracheal intubation was facilitated by administration of vecuronium 10 mg. Anesthesia was maintained with nitrous oxide-oxygen-sevoflurane and fentanyl. In order to regulate myocardial contractility and after-load, use of a phosphodiesterase III inhibitor was considered, although phosphodiesterase III inhibitors are known to induce arrhythmias, which should be avoided in dilated cardiomyopathy patients. We chose olprinone, because its inotropic action is not associated with arrhythmogenecity. Before infusing olprinone, cardiac output was 4.5 l.min-1 and systemic vascular resistance was 1306 dynes.sec.cm-5. When olprinone was continuously infused for one hour, cardiac output increased to 5.2 l.min-1 and systemic vascular resistance decreased to 958 dynes.sec.cm-5. Some premature ventricular contractions occurred, but they were easily controlled by administration of 50 mg lidocaine. These clinical data demonstrate that olprinone enhanced myocardial contractility, and decreased after-load and arrhythmogenecity in a dilated cardiomyopathy patients. In conclusion, olprinone is useful in the perioperative cardiovascular management of surgical patients with dilated cardiomyopathy.

Chronic encapsulated intracerebral haematoma in a patient with medically intractable epilepsy

A patient with a chronic encapsulated intracerebral haematoma presenting with medically intractable epilepsy is described. A tough capsule containing an old haematoma was confirmed surgically, and consisted of dense collagenous tissue with rich neovascularization. The radiological features, aetiology and treatment of this rare occurrence are discussed.

Prostaglandin E1 antagonizes hypoxic pulmonary vasoconstriction but reduces systemic blood pressure in dogs

OBJECTIVE

To investigate whether prostaglandin E1 (PGE1) directly inhibits hypoxic pulmonary vasoconstriction in dogs.

DESIGN

Prospective, longitudinal study.

SETTING

University research laboratory.

SUBJECTS

Six mongrel dogs in vivo.

INTERVENTIONS

The left thorax of anesthetized and ventilated dogs was opened and the left lower lobe was separately ventilated. The tip of the thermodilution pulmonary artery catheter was introduced into the left lower lobe pulmonary artery. The left lower lobe was ventilated with hyperoxic (95% oxygen and 5% CO2) or hypoxic (95% nitrogen and 5% CO2) gas. By manipulating the occluders placed on both pulmonary arteries, blood flow in the left lower lobe was regulated. Continuous pressure-flow plots for the left lower lobe were then obtained.

MEASUREMENTS AND MAIN RESULTS

Measurements included continuous pressure-flow plot generation, thermodilution cardiac output and blood flow in the left lower lobe, and blood gas analysis. Alveolar hypoxia of the left lower lobe caused blood flow in the left lower lobe to decrease from 371.8 +/- 63.4 to 95.0 +/- 23.4 mL/min and shifted the pressure-flow plot to the right, with a decreased slope and with an increase in the pressure-axis intercept. Subsequently, systemic venous infusion of PGE1 at a rate of 0.3 microg/kg/min had no effect on the pressure-flow plot configuration, blood flow in the left lower lobe, pulmonary vascular resistance, systemic vascular resistance, and PaO2. However, there was a decrease in the pressure-axis intercept of the pressure-flow plot. Infusion of PGE1 at a rate of 3.0 microg/kg/min (high-dose) during hypoxia reduced pulmonary vascular resistance and systemic vascular resistance by 19% and 25%, respectively, and returned the pressure-flow plot toward normal while blood flow in the left lower lobe increased to 122.6 +/- 21.0 mL/min. Consequently, PaO2 decreased from 270 +/- 31 to 144 +/- 32 torr (36.0 +/- 4.1 to 19.2 +/- 4.3 kPa).

CONCLUSION

High-dose PGE1 essentially inhibits hypoxic pulmonary vasoconstriction, at the expense of a deterioration in pulmonary gas exchange and systemic blood pressure in dogs.

The left ventricular outflow tract in atrioventricular septal defect revisited: surgical considerations regarding preservation of aortic valve integrity in the perspective of anatomic observations

OBJECTIVE

The anatomy of the left ventricular outflow tract in hearts with atrioventricular septal defect has been widely investigated, but controversies remain regarding detailed aspects of left ventricular outflow tract anatomy in the perspective of operative techniques to either prevent or relieve outflow tract obstruction.

METHODS

We investigated 29 postmortem hearts with an atrioventricular septal defect. Measurements were taken of the circumferences and of the widths of the components that make up the outflow tract, that is, the interventricular septum, the superior bridging leaflet, the left ventricular free wall, and the length of the tendinous cords.

RESULTS

The circumference of the left ventricular outflow tract immediately underneath the aortic valve was not different from that at the middle part of the outflow tract. Hearts with the partial type defect, characterized by separate atrioventricular orifices, had a smaller outflow tract than those with the complete variety. Although the anatomic constituents that contribute to left ventricular outflow tract obstruction are complex, this study showed that a reduced width of the interventricular septum was most intimately related to narrowing immediately underneath the aortic valve. Obstruction at the middle part of the left ventricular outflow tract was largely caused by reduced width of the interventricular septum together with short tendinous cords.

CONCLUSIONS

On the basis of these observations, we recommend detailed investigation of the anatomy of the left ventricular outflow tract immediately underneath the aortic valve, before surgical attempts to relieve outflow tract obstruction, because in some procedures the integrity of the aortic valve will be at stake.

Ruptured dissecting aneurysm as a cause of subarachnoid hemorrhage of unverified etiology

BACKGROUND AND PURPOSE

The clinical features of "aneurysmal" subarachnoid hemorrhage (SAH) of angiographically unverified etiology were reviewed to clarify the incidence and natural history of dissecting aneurysms as the hemorrhagic source of SAH.

METHODS

We reviewed 30 patients with SAH of unverified etiology in whom initial CT scan showed a diffuse or anteriorly distributed subarachnoid blood clot. Ten of the patients had stenotic or occlusive lesions (SOCL) on initial angiography, and these were the main focus of this study.

RESULTS

Among the 10 patients with SOCL on initial angiography, the lesions were located on the anterior circulation in 6 and on the posterior circulation in 4. Ruptured dissecting aneurysms were confirmed by exploratory surgery or autopsy in 6 patients. Subsequent rupture occurred in 6 of the 10 patients (60%), and all 6 of these patients died as a result.

CONCLUSIONS

The incidence (6/30) of dissecting aneurysms as the cause of SAH of unverified etiology was unexpectedly high, especially when initial angiography disclosed SOCL (6/10). The moribund patients with SOCL showed a high rate of rebleeding, and the untreated recurrent hemorrhages were fatal. Further MRI study is indicated for these patients to demonstrate the intramural hematoma. Compared with the devastating mortality caused by the subsequent ruptures, the extent of surgical morbidity was minor. Surgical intervention could therefore be justified when the following neuroradiological findings are present: (1) SOCL evident on angiography, (2) distribution of SAH on CT compatible with the location of the SOCL, and (3) intramural hematoma on MRI in the same region as the SOCL.

MR angiography of intracranial aneurysms: a comparison of 0.5 T and 1.5 T

The objective of this paper is to compare the diagnostic efficacy of 3 DFT time-of-flight MR angiography (MRA) at middle-field-strength and high-field-strength in diagnosis of intracranial aneurysms. Thirty-one patients, including 26 patients with angiographically confirmed intracranial aneurysms (n = 28), underwent MRA at 0.5 and 1.5 T. Images were interpreted by six trained observers who were blinded to diagnosis. Twelve projections of MRA of the circle of Willis, by maximum-intensity projection algorithm, were reviewed using continuous confidence-judgement scales. It was found that MRA at 1.5 T was more sensitive than that at 0.5 T in detection of aneurysms. The sensitivity of six observers ranged between 50 and 64% (mean 56%) at 0.5 T, and between 61 and 86 86% (mean 75%) at 1.5 T. In the smaller aneurysms less than 5 mm, the differences between the units became greater. The sensitivity for small aneurysms ranged from 23 to 54% (mean 32%) at 0.5 T, and from 31 to 69% (mean 58%) at 1.5 T. Our conclusion was that high field strength confers higher accuracy in the detection of intracranial aneurysms with MRA with current-generation MR imagers.

Intracranial vascular stenosis and occlusion: MR angiographic findings

PURPOSE

To investigate whether obtaining axial source images from three-dimensional Fourier transform (3DFT) time-of-flight MR angiography improves the detection of intracranial vascular stenosis and occlusion if added to maximum-intensity projection (MIP) images.

METHODS

The angiograms of 103 patients who had MR angiography for evaluation of possible intracranial vascular disease were reviewed retrospectively in a quantitative and nonquantitative fashion. Diameters of vessels on MR angiograms were measured quantitatively by two reviewers using a magnifying loupe and compared with the results from conventional angiograms. Degrees of stenoocclusive disease were categorized into five classes; an artery with stenosis of 50% or greater was considered to be diseased. Another five observers also reviewed the MIP images with and without source images in a blinded fashion by means of nonquantitative visual inspection.

RESULTS

In all, 23 stenoocclusive lesions of 50% or greater were available for review. In the quantitative analysis, with MIP images alone, 14 (78%) of 18 moderate and severe stenoses and four (80%) of five occlusions were identified correctly. The addition of the source images increased the sensitivity to 100% for moderate and severe stenoses and to 100% for occluded vessels. In the visual inspection study, however, no statistically significant differences were found between interpretations of MIP images alone and those of MIP images in combination with source images.

CONCLUSION

In the quantitative study, interpretation of source images rather than MIP images reduced the tendency to overestimate stenosis seen with MR angiography and improved the sensitivity for detecting stenosis of 50% or greater. There was a discrepancy between the quantitative study and visual inspection. Experienced observers had a tendency to underestimate the degree of stenosis.

Agents for the treatment of overactive detrusor. V. Synthesis and inhibitory activity on detrusor contraction of N-tert-butyl-4,4-diphenyl-2-cyclopentenylamine

N-tert-Butyl-4,4-diphenyl-2-cyclopentenylamine ((+/-)-3) was designed to restrict the conformation of terodiline 1 and was synthesized in a 6-step approach starting with diphenylacetaldehyde (10) or in a 4-step approach starting with 2,2-diphenyl-4-pentenoic acid (17). Using di-p-toluoyltartaric acid as a resolving agent, the synthetic (+/-)-3 was resolved into its optically pure forms, (-)- and (+)-3. The (-)-enantiomer (-)-3.HCl (FK584) showed about ten times more potent inhibitory activity on urinary bladder rhythmic contraction in rats (ED30 = 0.18 mg/kg, i.v.) than terodiline (ED30 = 1.9 mg/kg, i.v.), while the (+)-enantiomer (+)-3.HCl showed no inhibitory activity at 1.0 mg/kg i.v. Compound (-)-3.HCl (FK584) has pharmacological properties similar to those of terodiline, as evaluated by in vitro assay and is currently in clinical development for the treatment of overactive detrusor.

Trigeminal afferents and brainstem centers involved in the occurrence of cerebral vasospasm

Cisternal injections of blood in the rat and squirrel monkey produce an angiographically demonstrable biphasic vasospasm with a maximal late spasm at two days in the rat and six days post-subarachnoid hemorrhage (SAH) in the monkey. The SAH induces a decrease in cerebral blood flow of about 25% and a corresponding increase in glucose uptake of between 30% and 50%. In about half of the animals low-flow areas were noted in the cortex and the basal ganglia with a corresponding marked increase in glucose uptake. Lesioning of the A2-nucleus, its ascending pathway or the median eminence prevents the occurrence of spasm. Similarly, treatment with a substance P antagonist or gammaglobulin against substance P prevents or significantly reduces the degree of spasm. A unilateral post-ganglionic trigeminal lesion causes an ipsilateral constriction of the cerebral arteries of 27%, while a preganglionic lesion does not affect the baseline diameter. A pre- or post-ganglionic trigeminal lesion induces an increase in glucose uptake globally of about 50% without influencing cerebral blood flow. Following SAH the decrease in blood flow in both groups of lesioned animals is similar to that seen in controls. After SAH there is no further change in glucose uptake in the animals with a preganglionic lesion, while in the post-ganglionically lesioned animals there is an additional increase in glucose uptake of about 50% as compared to controls or the animals with a preganglionic lesion.

Successful management of junctional tachycardia by hypothermia after a Fontan operation

We report herein the findings of a 2-year-old boy in whom junctional tachycardia developed 2 days after he underwent a modified Fontan operation and thereafter was successfully treated by hypothermia without paralyzing and artificially ventilating the patient. Chlorpromazine was useful in achieving moderate hypothermia by surface cooling without producing any unfavorable effects associated with topical cooling.

Thromboxane synthetase inhibitor ameliorates delayed neuronal death in the CA1 subfield of the hippocampus after transient global ischemia in gerbils

Thromboxane A2 accumulates in the hippocampus after global ischemia and may play a key role in postischemic hypoperfusion. Thromboxane synthetase inhibitor (OKY-046) inhibits the accumulation of thromboxane A2 and promotes prostacycline production. Therefore, we set out to determine whether the inhibition of thromboxane synthesis would ameriolate postischemic neuronal death. Three groups of six Mongolian gerbils were subjected to different treatments: untreated control, untreated ischemia, and treated ischemia. Immediately after forebrain ischemia, OKY-046 (10 mg/kg) was injected intraperitoneally into the treated group. After 7 days of survival, the histopathology of the brain was examined. Pyramidal cell density in the CA1 sector in the treated group was 147 +/- 70 nuclei/mm (mean +/- SD), which was significantly (p < 0.05) higher than than in the untreated group (33 +/- 10 (nuclei/mm). The findings were 231 +/- 7 nuclei/mm for the control group. No significant difference was seen in the profile of temporal muscle temperature before and after ischemia between the groups. Ultrastructurally, the vessels in the CAI sector showed lumen patency in the treated group, whereas occluded vessels with an extended perivascular space were observed in the untreated group. Thromboxane synthetase inhibitor thus partly ameliorates the selective vulnerability of the hippocampus after forebrain ischemia, suggesting that thromboxane A2 is involved in the development of delayed neuronal death, independently of any thermal effect.

Agents for the treatment of overactive detrusor. IX. Synthesis and pharmacological properties of metabolites of N-tert-Butyl-4,4-diphenyl-2-cyclopentenylamine (FK584) in human urine

We synthesized the racemates of the five presumed metabolites (1b-f) of (S)-(--)-N-tert-butyl-4,4-diphenyl-2-cyclopentenylamine hydrochloride (FK584, S(--)-1a), a novel agent for the treatment of overactive detrusor syndrome, in order to confirm the structures of the metabolites and also to evaluate their inhibitory activity against detrusor contraction. (+/-)-N-tert-Butyl-4-(4-hydroxyphenyl)- and 4-(4-hydroxyphenyl)- and 4-phenyl-2-cyclopentenylamines (1b--e) were synthesized via 5-(4-methoxyphenyl)- and 5-(4-benzyloxy-3-methoxyphenyl)-5-phenyl-2-cyclopenten-1-one (9g, h), respectively. Compounds 1b-f prepared in this study were identical with the metabolites in human urine in gas chromatography-mass spectrometry and analytical HPLC. The inhibitory activity of compounds 1b-f against detrusor contraction in vitro induced by electrical field stimulation in guinea-pigs was less potent than that of FK584.

The effect of thoracic epidural anesthesia on hypoxic pulmonary vasoconstriction in dogs: an analysis of the pressure-flow curve

The aim of the present study was to examine whether hypoxic pulmonary vasoconstriction (HPV) is preserved during one-lung ventilation combined with thoracic epidural anesthesia (TEA) in dogs. Using a separately ventilated left lower lobe (LLL) in situ, the pressure-flow (P-Q) curve was obtained. The HPV response was assessed by the shift of the P-Q curve, changes in blood flow diversion rate (FDR) and decrease in PaO2 during hypoxic gas ventilation of LLL. In the control group (n = 7), the shift of P-Q curve, changes in FDR, and decrease in PaO2 remained constant during four consecutive hypoxic stimulations. In the TEA group (n = 6), the P-Q curve shifted to the left during hyperoxia, but the magnitude of the shift during hypoxia was unchanged. FDR and decrease in PaO2 were significantly reduced compared with baseline values (P < 0.05 with analysis of variance). TEA reduced heart rate, cardiac output, mean arterial pressure, mean pulmonary arterial pressure, and mixed venous oxygen tension. Our results suggest that TEA did not affect the primary pulmonary vascular tone at baseline or during lobar hypoxia, but enhanced the diversion of blood flow and arterial blood oxygenation during lobar hypoxia. This enhanced HPV response probably reflects hemodynamic changes, such as decreased cardiac tension, due to sympathetic nerve activity blockade by TEA.

Selective cerebral perfusion technique during aortic arch repair in neonates

We describe selective cerebral perfusion techniques for repair of the aortic arch in neonates. These techniques may help protect the brain from ischemic injury caused by a cessation of cerebral perfusion for aortic arch reconstruction in patients with hypoplastic left heart syndrome or interrupted aortic arch.

Intracranial aneurysms: diagnostic accuracy of MR angiography with evaluation of maximum intensity projection and source images

PURPOSE

To determine whether evaluation of source images from magnetic resonance (MR) angiography in addition to maximum-intensity projection (MIP) images improves the detection of aneurysms.

MATERIALS AND METHODS

Conventional and MR angiography were performed in 193 patients with various intracranial vascular lesions or normal findings. Images were evaluated in a blinded manner. Two readings were performed 6 weeks apart by evaluating MIP images with and without source images. Results were evaluated with receiver operating characteristic analysis.

RESULTS

Sensitivity for the detection of aneurysms increased slightly when source images were included. The detection rate of internal carotid artery aneurysms was most improved with the addition of source images. No statistically significant differences in performance were found between the readings with MIP images alone and with source images.

CONCLUSION

Sensitivity may improve with combined reading of nonselective MIP and source images.

General pharmacology of the new non-xanthine adenosine A1 receptor antagonist (+)-(R)-[(E)-3-(2-phenylpyrazolo[1,5-a]pyridin-3-yl)acryloyl]-2- piperidine ethanol

FK 453 ((+)-(R)-[(E)-3-(2-phenylpyrazolo[1,5-a]pyridin-3-yl) acryloyl]-2-piperidine ethanol, CAS 121524-18-3) is a potent non-xanthine adenosine A1 receptor antagonist with diuretic and renal vasodilatory activity. The general pharmacology of FK 453 was investigated in mice, rats, guinea-pigs and dogs. In in vivo tests, FK 453 had little effect on the central nervous system (general behaviour, spontaneous motor activity, potentiation of barbiturate anesthesia, anticonvulsant activity, analgesic activity and body temperature), hematological system (bleeding time, coagulation time and recalcification time) and intestinal charcoal transit. FK 453 also did not show any cardiovascular (blood pressure, heart rate and femoral blood flow) or respiratory effects. In in vitro tests, although FK 453 had little effect on noradrenaline-induced contraction in rat vas deferens and histamine-induced contraction in guinea-pig trachea, FK 453 inhibited the acetylcholine-, histamine- and barium-induced contraction in isolated guinea-pig ileum and serotonin-induced contraction in isolated rat stomach. FK 453 also exerted significant inhibitory activity on collagen- and U 46619-induced platelet aggregation. However these effects of FK 453 on isolated tissue and platelet were observed only at high concentrations. These results suggest that FK 453 possesses a selective pharmacological profile, and one promising therapeutic site for this drug is in the kidney.

Effect of folding on the optical quality of soft acrylic intraocular lenses

PURPOSE

To assess the effect of folding procedures on modulation transfer function (MTF) and resolving power (RP) in soft acrylic intraocular lenses (IOLs).

SETTING

Faculty of Engineering, Chiba University, Chiba, Japan.

METHODS

Folding procedures and other manipulations were performed on +18.0 diopter soft acrylic lenses (MA60BM, AcrySof, Alcon Surgical). The IOLs were then immersed in the water chamber of a model eye and MTF and RP under veiling glare light measured. The optical surfaces of the IOLs were examined microscopically.

RESULTS

After the IOLs had been folded for 30 seconds, MTF recovered 8 and 6 minutes after unfolding in 20 degrees C 37 degrees C balanced salt solution, respectively. Prolonged folding of 10, 20, and 60 minutes did not affect the final MTF, which was measured 30 minutes after unfolding. However, RP deteriorated after the 60 minute folding. Optic damage was observed after the 20 and 60 minute foldings. Neither parameter changed after the IOLs were tightly folded for 30 seconds; however, both deteriorated slightly after the IOLs were tightly folded for 5 minutes, and minor damage was seen on the optics. With fewer than 10 artificial linear cracks in the central 3 mm of the optic, MTF was not affected; with 20 or fewer, RP was not affected. After forceps pressure on the central optic, MTF recovered within 6 minutes.

CONCLUSION

The optical quality of soft acrylic IOLs are not easily affected unless extreme nonphysiological manipulations are applied.

Parasellar Aspergillus granuloma extending from the sphenoid sinus: report of two cases

BACKGROUND

Sphenoid sinus aspergillosis is a rare disease known to show an aggressive course with high mortality. Early diagnosis, though difficult, is required to prevent lethal fungal meningoencephalitis.

CASE REPORT

We describe two cases of parasellar Aspergillus granuloma extending from the sphenoid sinus clinically indistinguishable from intracranial neoplasms. In the first patient, the fungus colony was visualized by computed tomography (CT) and magnetic resonance imaging (MRI) as a calcified concretion and total removal was curative. In the second patient, partial removal and subsequent antifungal therapy had minimal effect.

CONCLUSIONS

The prognosis of the patients with this disease depends on prompt surgical treatment before intradural invasion occurs, and CT and MRI are useful diagnostic maneuvers for detecting calcified Aspergillus colonies.

[Medical care of AIDS patients by hospitals in Tokyo]

An anonymous questionnaire survey was performed in 1991 in all 749 hospitals in Tokyo, by the Tokyo Metropolitan Government's Acquired Immunodeficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV) Infection Research Team, to collect information relating to hospital services for persons with AIDS or HIV infection. The response rate was 61%. The following results were obtained: 1) Sixty-five hospitals (14%) had seen persons with AIDS or HIV infection. Hospitals with a greater number of beds had more experience in seeing persons with AIDS or HIV infection. Thirty-four hospitals (7%) provided outpatient services for patients with AIDS or HIV infection, and 30 hospitals (7%) had the facilities for inpatients. Three hundred forty-seven hospitals (78%) were capable of HIV antibody tests. Ninety-one hospitals (20%) had organized training courses for hospital workers to prevent HIV infection. Two hundred eight hospitals (46%) expressed preference that persons with AIDS or HIV infection be treated at public (non-private) hospitals. 2) The results of multivariate logistic regression analysis indicated that a hospital's acceptance of persons with AIDS or HIV infection for diagnosis or treatment was significantly related to past experience in seeing persons with AIDS or HIV infection, availability of an examination room that protects privacy of patients, presence of a department of internal medicine, and awareness of the availability of special AIDS counselor dispatch services by the Tokyo metropolitan government.

[Surgical results of valvuloplasty for common atrioventricular valve regurgitation in single ventricle]

From 1988 through 1994, 18 patients who had common atrioventricular valve regurgitation associated with single ventricle underwent valvuloplasty. All patients had isomerism heart (right isomerism: 16, left isomerism: 2). The preoperative degree of regurgitation was 3.3 +/- 0.4 (Sellers). Valvuloplasty was performed by two different procedures. Semi-circular annuloplasty was used in nine patients. Dividing the common atrioventricular valve orifice into two parts (bivalvation) with or without annuloplasty was used in nine. The concomitant procedures varied: three patients underwent systemic pulmonary shunt, two underwent repair of total anomalous pulmonary venous drainage, one underwent pulmonary arterial banding, five underwent bidirectional Glenn, shunt, and four underwent Fontan operation. One early death and three late deaths have occurred. The early postoperative degree of regurgitation was reduced to 1.3 +/- 1.0. In nine patients, however, the degree of regurgitation increased late postoperatively. Seven patients were reoperated on because of regurgitation: three patients had valve replacement and four had reannuloplasty. Increased incidence of deterioration of regurgitation in late period was seen in patients under 2 years old and those receiving a concomitant Blalock shunt. Lower event-free rate after 2 years was seen in patients with double inlet right or indeterminate ventricle and those underwent the annuloplasty alone. We conclude that the dividing common atrioventricular valve orifice into two parts with annuloplasty could effectively reduce the regurgitation in most patients with isomerism heart, and the concomitant ventricular unloading operation seems to offer promise for improving long-term results.

A novel non-xanthine adenosine A1 receptor antagonist

FK453, (+)-(R)-[(E)-3-(2-phenylpyrazolo[1,5-alpha]pyridin-3-yl) acryloyl]-2-piperidine ethanol, was examined for adenosine receptor antagonistic activity using isolated guinea-pig atria and aorta and for affinity for adenosine receptors in the rat cerebral cortex and striatum in comparison with FR113452 (S enantiomer of FK453), PD116948 (1,3-dipropyl-8-cyclopentylxanthine), theophylline (1,3-dimethylxanthine) and CGS15943 ([1,2,4]triazolo[1,5-c]quinazolone). FK453 showed potent inhibition of the negative inotropic activity elicited by 10 microM adenosine with an IC50 of 560 pM in guinea-pig atria. However, FK453 was less potent in inhibiting the relaxation induced by 3.2 microM adenosine and had an IC50 of 1.18 microM in guinea-pig aorta. The IC50 values for FR113452, PD116948, theophylline and CGS15943 were 1.18 microM, 1.31 nM, 20.2 microM and 74.2 nM in atria and > 100 microM, 656 nM, 239 microM, 127 nM in aorta respectively. In the binding study, FK453 antagonized [3H]N6-cyclohexyladenosine binding to the rat cortical adenosine A1 receptor with an IC50 of 17.2 nM. The IC50 values for FR113452, PD116948, theophylline and CGS15943 were 10.1 microM, 4.7 nM, 67.7 microM and 241 nM respectively. FK453 inhibited [3H]5'-N-ethylcarboxamideadenosine binding to rat striatum adenosine A2 receptor with an IC50 of 11.3 microM. FK453 had no adenosine A1 receptor agonistic activity, since it had no negative inotropic activity up to 100 microM in isolated guinea-pig atria. These results demonstrate that FK453 is a novel non-xanthine adenosine receptor antagonist and is potent and selective for the adenosine A1 receptor subtype.

[Postoperative pulmonary stenosis after arterial switch operation, comparison in three methods of pulmonary reconstruction: modified Pacifico, autologous pericardial patch, and equine pericardial patch]

To prevent postoperative pulmonary stenosis in arterial switch operation for transposition of the great arteries, pulmonary reconstruction without patch augmentation (modified Pacifico method: Pa-group) and reconstruction using W-shaped fresh autologous pericardium (AW-group) were introduced instead of the former method using equine pericardium (XW-group). Postoperative pulmonary stenosis (RV-PA pressure gradient greater than 30 mmHg) was not seen among the 17 cases in the Pa-group (0%), and was seen in 2/14 (14.3%) in the AW-group and in 4/14 (29%) in the XW-group. Progressive increase in pressure gradient was seen in the XW-group in the midterm cardiac catheterization (p < 0.01), but such tendency was not observed in the Pa-group and the AW-group. Sectional area at the pulmonary valve ring, at the anastomotic site in the main pulmonary artery, and at the pulmonary branches just distal to the bifurcation, standardized by the body surface area, increased in the Pa-group and the AW-group, but were unchanged or slightly decreased in the XW-group in the midterm cardiac angiography. We believe that postoperative pulmonary stenosis can be best avoided if modified Pacifico method is used. The cases in which postoperative pulmonary stenosis or coronary artery compression is anticipated such as those with side-by-side aortopulmonary relationship or after pulmonary artery banding, should be operated upon using fresh autologous pericardial patch.

Delayed parent artery narrowing occurring months after aneurysm surgery: a complication after aneurysm surgery--technical case report

The authors report two patients with a rare complication of parent artery narrowing that occurred 3 and 6 months after aneurysm surgery. In both cases, the stenosed arteries had been wrapped around their entire circumferences with neurosurgical sponge (cotton linter) and coated with plastic adhesive (cyanoacrylate compounds) and the aneurysmal neck had been clipped. This reinforcement procedure was considered to have caused the unusual delayed arterial narrowing. The importance of avoiding circumferential parent artery wrapping with plastic-adhesive coating is emphasized.

[Valve replacement in an infant with congenital mitral stenosis--report of a case which showed hemodynamics similar to that of hypoplastic left heart syndrome in neonatal period]

In the neonatal period, the patient showed severely hypoplastic left ventricle, severe mitral stenosis, patent foramen ovale and patent ductus arteriosus with right-to-left shunting, which resulted in the hemodynamics similar to that of hypoplastic left heart syndrome. However, progressive left ventricular growth was recognized after spontaneous closure of the foramen ovale, and the cardiac catheterization at the age of 6 months revealed almost normal left ventricular volume and systolic forward flow from the left ventricle to the descending aorta. The operation was performed at the age of 7 months under cardiopulmonary bypass with moderate hypothermia and cardiac arrest. The mitral leaflets were thickened and dysplastic, two short papillary muscles were hypertrophic and very closely related, and the chordae were extremely short and fused each other making the interchordal space obstructed. Because the mitral annular diameter (13 mm) was too small for conventional valve replacement, the prosthetic valve (CarboMedics #16) was sewn to the left atrial wall 5 to 10 mm above the mitral annulus. The ductus arteriosus was ligated. The postoperative cardiac catheterization showed residual pulmonary hypertension, but pulmonary vascular response to oxygen-inhalation was recognized. We consider that there were two important hemodynamic factors which led to successful biventricular repair in this case. First, early spontaneous closure of the foramen ovale accerelated the left ventricular growth and prevented right ventricular failure resulting from increased pulmonary blood flow. Second, considerable part of the systemic output was supplied through a large ductus arteriosus, and thus over-systemic pulmonary hypertension was avoided.

Agents for the treatment of overactive detrusor. VIII. Synthesis and pharmacological properties of 4,4-diphenyl-2-cycloalkenylamines including FK584 and 3,3- or 4,4-diphenylcycloalkylamines

This article describes the synthesis of 4,4-diphenyl-2-cycloalkenylamines (3, 5a) including FK584 (S(-)-3a) and 3,3- or 4,4-diphenylcycloalkylamines (2, 4, 5b) and their inhibitory activities against detrusor contraction. The order of inhibitory activity (i.v.) of the N-tert-butylamine derivatives against urinary bladder rhythmic contraction in rats was as follows: S(-)-4,4-diphenyl-2-cyclopentenylamine (FK584, S(-)-3a) > 4,4-diphenylcyclohexylamine (5b) = R(-)-3,3-diphenylcyclopentylamine (R(-)-4) > or = 3,3-diphenylcyclobutylamine (2) > or = terodiline hydrochloride (HCl) (1) = RS(+/-)-4,4-diphenyl-2-cyclohexenylamine (5a) > R(+)-4,4-diphenyl-2-cyclopentenylamine (R(+)-3a) > or = S(+)-3,3-diphenylcyclopentylamine (S(+)-4). Although the inhibitory activity of FK584 and compounds R(-)-4 and 5b against detrusor contraction in vitro induced with KCl in guinea-pigs was less potent than that of terodiline HCl, their inhibitory activities against detrusor contractions in vitro induced by electrical field stimulation and carbachol were more potent than those of terodiline HCl.

[Evaluation of inhibitory effect of isoflurane on the hypoxic pulmonary vasoconstriction response in dogs]

The effect of isoflurane on hypoxic pulmonary vasoconstriction (HPV) was examined using the separately ventilated left lower lobe lung model in dogs. When the HPV was induced with anoxic gas ventilation of the left lower lobe, the magnitude of HPV inhibition by isoflurane of 2 MAC was predominant, as assessed by the index of pressure-flow curve which is a novel indicator of pulmonary vascular tone in the left lower lobe. However, isoflurane 2 MAC attenuated the HPV by only 16%, as assessed by indices of the changes in left lower lobe blood flow rate and PaO2. This weak HPV inhibition, as shown by the latter parameters, may result from the net effect of isoflurane-induced HPV inhibition and secondary HPV enhancement due to decreases in cardiac output and pulmonary arterial pressure by isoflurane. However, none of the parameters showed inhibition of HPV when the HPV was induced by collapse of the left lower lobe. This discrepancy in the results may be caused by a lack of isoflurane reaching the hypoxic lobe when the HPV is induced with atelectasis. These results show that potency of HPV inhibition with isoflurane depends on the method of induction or evaluation of HPV, and that inhibition of HPV response with isoflurane at clinical concentrations is negligible in an atelectasis-induced HPV, in which no isoflurane is directly reaching the hypoxic lobe.

Cerebrovascular sensory innervation involved in the development of cerebral vasospasm following a subarachnoid hemorrhage

Cerebral vasospasm following subarachnoid hemorrhage was induced in the squirrel monkey in order to evaluate the involvement of cerebrovascular sensory nerves in the development of the vasospasm. A unilateral surgical section of the trigeminal nerve at post- but not at pre-Gasserian level caused constriction of the major ipsilateral cerebral arteries. A pre- or postganglionic trigeminal lesion induced an increased glucose uptake globally without influencing the cerebral blood flow. Following a subarachnoid hemorrhage, the decrease in cerebral blood flow was similar of that seen in control animals, while post-ganglionically lesioned animals had an additional increase in glucose uptake. Intrathecal injection of gamma-globulin against substance P prevented the occurrence of vasospasm and the decrease in cerebral blood flow, while calcitonin gene-related peptide (CGRP) anti-gamma-globulin injection significantly reduced the resting vessel diameter and did not influence spasm development. It is concluded that a nervous reflex mechanism could underlie cerebral vasospasm. The cerebrovascular sensory nerves have both a peripheral and a central function. A peripheral or axon reflex mechanism exerts a tonic effect on the cerebral arteries. Central neurotransmission seems to be involved in the regulation of cerebral metabolism and possibly in the coordination of cerebral blood flow and glucose metabolism. CGRP could be the transmitter involved in a peripheral axon reflex and substance P might be the neurotransmitter conveying information to the brainstem vascular centers.

[Reoperation for transposition of the great arteries: mid-term results and reoperation after arterial switch operation]

The arterial switch operation for transposition of the great arteries is now widely accepted as the therapeutic method of choice. As of December 1993, a total of 162 patients underwent the arterial switch. There were 100 patients with transposition and intact ventricular septum, 48 with a ventricular septal defect, 14 with ventricular septal defect and arch anomalies (coarctation: 11, interruption: 3). Early and late mortality were 3.7% (6 patients) and 4.5% (7 patients), respectively. Postoperative pulmonary stenosis (> 30 mmHg) was noted in 33 patients (22%), aortic regurgitation (> mild) in 20 (13%), supravalvular aortic stenosis (> 20 mmHg) in 5 (3%) and mitral regurgitation (> mild) in 5 (3%). Reoperation was performed in 27 patients with no mortality. Mean interval between the switch and the reoperation was 30 months. Twenty-three patients with pulmonary stenosis underwent patch plasty of pulmonary artery. Two children with severe aortic regurgitation underwent aortic valve replacement. Two patients who had undergone one-staged repair for interruption complex were reoperated due to supravalvular aortic stenosis and pulmonary stenosis. Actuarial survival and freedom from reoperation at 9 years were 90% and 69%, respectively.

[Practical CT classification for thalamic hemorrhage: relationship between localization of hematoma and prognosis]

It is not easy to predict functional outcome in patients with acute-stage thalamic hemorrhage. We analysed 100 cases of hypertensive thalamic hemorrhage less than 4 cm in diameter, and devised a practical CT classification for predicting the patients' prognoses. On an axial CT scan at the level of the pineal body, four lines were drawn as follows: line (a) between the lateral edge of the anterior horn and the midpoint of the third ventricle; line (b) vertical line to the sagittal line from the midpoint of the third ventricle; line (c) between the lateral edge of the trigone and the midpoint of the third ventricle; line (d) between the lateral edge of the anterior horn and the lateral edge of the trigone. The location of hematoma was divided into three types according to lateral extension as follows: type A (anterior type), center of hematoma located between line (a) and line (b); type P (posterior type), center of hematoma located between line (b) and line (c), and external margin of hematoma localized medial to line (d); type PL (postero-lateral type), center of hematoma located between line (b) and line (c), and showing lateral extension beyond line (d). Then, the correlation between hematoma location and severity of motor paresis at onset and its prognosis was investigated. Severe hemiparesis (MMT: 0-2) was observed in 15.3% of patients with type A, 21.8% with type P, and 59.3% with type PL hematoma in the acute stage.(ABSTRACT TRUNCATED AT 250 WORDS)

Studies on nilvadipine. IV. Synthesis of deuteriated and optically active isopropyl 2-cyano-3-methoxycarbonyl-4-(3-nitrophenyl)-6-methyl-1,4- dihydropyridine-5-carboxylate (nilvadipine)

Nilvadipine, I, has already entered clinical use for the treatment of hypertension. In the process of the developing nilvadipine, we prepared the deuteriated analogue of I as an internal standard for the determination of I in human plasma by capillary column gas chromatography-negative-ion chemical-ionization mass spectrometer. Nilvadipine has an asymmetric center at the C-4 position of the dihydropyridine ring, and characterization of the optical isomers with regard to their activity and bioavailability is of interest. Thus, we synthesized both the enantiomers of I by optical resolution via the 5-carboxy derivative (3), which was previously prepared as one of the metabolites of I.