Leptomeningeal dissemination of malignant gliomas. Incidence, diagnosis and outcome

To understand the clinicopathology features of leptomeningeal dissemination of malignant gliomas, a total of 157 consecutive patients treated between 1978 and 1989 were analysed. Twenty-two patients (14%) were judged to have dissemination. In 20 patients, the dissemination was diagnosed antemortem. Eleven patients had neurological deficits due to dissemination, whereas the other 9 without these had CT or myelographic evidence of dissemination. The peak incidence of dissemination was seen in the first and second decades of life. The mean age of 22 patients with dissemination was 31 years, significantly lower than that (44.5 years) of patients without dissemination. Fifteen patients developed dissemination within one year after diagnosis (early dissemination), 60% of them were less than 30 years of age. All patients with late dissemination (more than one year after diagnosis) underwent a second craniotomy for tumour removal before dissemination, while none of the 15 patients with early dissemination did. Survival after diagnosis in patients with dissemination was shorter, although statistically not significant, than that of patients without dissemination. Survival after dissemination was limited in all patients (mean 19 weeks, range 2-39 weeks). Immunohistochemical study revealed that the disseminated tumour expressed less glial fibrillary acidic protein than the primary tumour. Our results suggest that dissemination does not seem to result from extended survival of the patients, but may occur at any time in malignant gliomas. Some malignant gliomas, especially in younger patients, have a capability to acquire biological characteristics suitable for dissemination in the earlier stage of the disease.

[Intravenous pirenzepine reduces salivary secretion rapidly]

We evaluated the effects of pirenzepine on salivary secretion and heart rate, comparing them with those after atropine. Forty-two patients for gynecological operations were divided into three groups. P, A and C groups received pirenzepine 10 mg, atropine 0.5 mg and saline 1 ml intravenously 4 min before induction. Salivary secretion was aspirated at 30, 60 and 120 min after induction. Heart rate was recorded at 1, 30, 60 and 120 min after injection. In P and A groups, salivary secretion decreased significantly, but there was no significant difference between them. In A group, heart rate increased at 1, 30 and 60 min after injection, but at 120 min there was no difference among three groups. We conclude that intravenous pirenzepine as well as atropine reduces salivary secretion, but it does not increase heart rate as atropine.

[Long survival after removal of a huge brain tumor which had metastasized from a lung cancer: case report]

Patients with large metastatic brain tumors are considered to have poor prognosis. We report a case of a patient with more than 33 months survival after complete resection of a huge temporal tumor which had metastasized from a lung cancer. A 57-year-old woman presented left hemiparesis and disturbance of consciousness. Magnetic resonance images revealed a huge cystic mass lesion in the right temporal lobe. After a macroscopically complete excision of the tumor, she received radiation therapy (whole brain 50 Gray). She had received lung surgery for the primary lung cancer, 2 years prior to brain metastasis. Histological examination showed papillary tubular adenocarcinoma which was similar to the previously resected lung cancer. Thirty three months after the resection of the intracranial tumor, she has no neurological deficits and no signs of recurrence of either brain tumor or lung tumor. We discuss the size of metastatic brain tumor and the postoperative prognosis of patients with metastatic brain tumor.

[A case of epileptic laughter associated with temporal epidermoid cyst: surgical treatment combined with subdural grid electrode study]

A case of epileptic laughter associated with deep right temporal epidermoid cyst is reported. Interictal EEG with subdural grid electrodes demonstrated multifocal spike discharges in the right temporal lobe. Ictal EEG localized the epileptogenic foci at the base of the anterior medial temporal lobe. After standard temporal lobectomy, the tumor was completely removed. The patient is free from seizures postoperatively.

Prostaglandin E1 induces c-Fos and Myc proteins and protects rat hippocampal cells against hypoxic injury

We investigated the effects of prostaglandin (PG) E1 on the hypoxic injury of fetal rat hippocampal cells. Primary hippocampal cell cultures (embryonic day 18) were established and maintained. After 72 h in culture, PGE1 was added to the serum-free medium at a final concentration of 10(-5)-10(-9) M. Cultures were divided into two groups: The normoxia group was in culture for another 48 h, and the hypoxia group was exposed to 24 h of hypoxia followed by continuation of culture for another 24 h. As a quantitative measure of cell death, lactate dehydrogenase (LDH) activity was estimated in the culture medium. The LDH activity, released by the hypoxic insult, was significantly smaller with PGE1 treatment at 10(-6), 10(-7), and 10(-8) M (p < 0.01) and 10(-9) M (p < 0.05) compared with the control. No differences in the LDH activities were observed in the normoxia group. Glial culture was not affected by the hypoxia. Western blot analysis showed an increased induction of 62-kDa c-Fos and 58, 60, and 66 kDa Myc proteins in rat hippocampal cells with 10(-7) M PGE1 treatment. We conclude that PGE1 at concentrations of 10(-6)-10(-9) M protects rat hippocampal neurons against hypoxic insult.

Ethylene vinylacetate copolymer particles dissolved in polyvinyl alcohol (2,000-mer) solution as an embolic material for vascular anomalies. A preliminary study

We have prepared a new material for embolisation: ethylene vinylacetate copolymer dissolved in polyvinyl alcohol. When in contact with blood, polyvinyl alcohol rapidly becomes a soft gel, which is accompanied by wedging of the ethylene vinylacetate copolymer. We analysed the histopathology of intra-arterial microemboli in rats, after intracarotid injection of this material. We confirmed that it was applicable to embolisation for neurosurgical treatment.

Expression of basic fibroblast growth factor receptor messenger RNA in the periinfarcted brain tissue

The present study examined whether expression of basic fibroblast growth factor receptor (bFGFR) messenger ribonucleic acid (mRNA) was upregulated by focal ischemia. We have studied the in situ hybridization autoradiography for bFGFR mRNA in the rat model of middle cerebral artery (MCA) occlusion. Male Wistar rats were used for occlusion of the left MCA, and were sacrificed 1, 3, 7 and 14 days after MCA occlusion. In situ hybridization was performed on the brain sections of these animals and sham controls by using 35S-labeled antisense and sense (control) RNA probes for rat bFGFR. Expression of bFGFR mRNA was observed in the periinfarcted area of the rats within 1-14 days after MCA occlusion. Expression was evident in the whole hemisphere of the infarcted side, especially at 1 and 3 days after ischemia, but no expression was detected in the contralateral side. On microautoradiograms, the signals of bFGFR mRNA were detected in both neurons and non-neural cells located in the periinfarcted area. Upregulation of bFGFR mRNA detected in the periinfarcted brain tissue suggests that receptor-mediated action of bFGF may be related to preservation of neurons injured by ischemia.

Evaluation of masked neurological disorders in the chronic stage after middle cerebral artery occlusion in rats--methamphetamine-induced rotation and regional glucose metabolism in basal ganglia

Neurofunctional changes in rats in the chronic stage of focal cerebral ischemia induced by left middle cerebral artery (MCA) occlusion were examined. Neurological disorders and behavioral changes were observed with or without methamphetamine administration. Metabolic changes in the basal ganglia following methamphetamine intraperitoneal injection were evaluated by [14C]deoxyglucose autoradiography 30 days after occlusion. Neurological examination revealed persistent spontaneous rotation to the lesioned side in two of 18 rats, and forelimb flexion to the lesioned side in nine of 18 rats during a 28-day observation period after occlusion. Intraperitoneal administration of methamphetamine (4 mg/kg) induced full 360 degrees rotation toward the lesion side in 14 of 17 rats. The number of rotations was inversely correlated with the size of the intact striatum on the lesion side, especially in rats with cerebral infarct located only in the striatum. Rats with extensive cortical lesion in addition to striatal lesion did not demonstrate this relationship. Deoxyglucose autoradiography in methamphetamine-untreated rats showed symmetrical local cerebral glucose utilization in the basal ganglia except for the subthalamic nucleus, striatum and sensorimotor cortex. Autoradiography in methamphetamine-treated and MCA-occluded rats showed a remarkable increase in glucose utilization in the anterior striatum, entopeduncular nucleus, substantia nigra pars reticulata, and sensorimotor cortex contralateral to the occlusion side, but not on the lesioned side. Rotational movements observed in methamphetamine-treated rats are related to lack of stimulation of the basal ganglia system on the ischemic side.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of severe localized cerebral vasospasm following recurrent hemorrhage from middle cerebral artery aneurysm--case report

A 52-year-old female presented with localized but severe cerebral vasospasm induced by recurrent aneurysmal subarachnoid hemorrhage. The middle cerebral artery (MCA) aneurysm was clipped and the subarachnoid hematoma evacuated 1 day after recurrent hemorrhage. The cerebral vasospasm, localized in a region near the MCA aneurysm, was reduced by papaverine and nicardipine vasodilating agents delivered via an Ommaya cerebrospinal fluid reservoir placed at craniotomy.

The paradoxical blood pressure-flow relationship in the brain with an arteriovenous malformation

The responses of regional cerebral blood flow (CBF) to decrease in arterial blood pressure were studied in eight patients with arteriovenous malformations using the Xe-133 inhalation method. Measurements were performed twice for each study; before and during hypotension induced by trimethaphan camsylate (Arfonad). In all cases, there were regions where cerebral blood flow increased remarkably in response to hypotension. When the studies were repeated in five cases after total resection of the malformations, increase in the cerebral blood flow in response to hypotension was not observed. The underlying mechanisms that operate in such paradoxical blood pressure-flow relationship are discussed.

[Spinal extradural angiolipoma: a case report]

Growth of angiolipoma of the central nervous system is a rare occurrence. Only about 40 cases can be collected in the literature. A 67-year-old man was admitted because of intermittent severe pain in both legs after walking. He had chillness in both legs during the past 5 years which gradually worsened. MR image showed a spinal mass lesion at the level of Th12 to L1. The lesion was isointense on T1-weighted image and slightly hyperintense on T2-weighted image. The tumor was located on the left side of the spinal cord and was markedly enhanced after intravenous Gd-DTPA. At the operation, a soft, dark-red mass was found situated in the epidural space at the level of Th12 to L1, which was totally removed. On histological examination, the tumor was shown to be mainly composed of mature fatty cells and of numerous blood vessels with enlarged lumens. Postoperative course was uneventful and the symptoms subsided during the following few months.

Effect of mild hypothermia on uncontrollable intracranial hypertension after severe head injury

Recent experimental studies have demonstrated that mild hypothermia at about 34 degrees C can be effective in the control of intracranial hypertension. A randomized controlled study of mild hypothermia was carried out in 33 severely head-injured patients. All patients fulfilled the following criteria: 1) persistent intracranial pressure (ICP) greater than 20 mm Hg despite fluid restriction, hyperventilation, and high-dose barbiturate therapy; 2) an ICP lower than the mean arterial blood pressure; and 3) a Glasgow Coma Scale score of 8 or less. The patients were divided into two groups: one received mild hypothermia (16 patients) and one served as a control group (17 patients). Mild hypothermia significantly reduced the ICP and increased the cerebral perfusion pressure. Eight patients (50%) in the hypothermia group and three (18%) in the control group survived (p < 0.05), while five (31%) in the hypothermia group and 12 (71%) in the control group died of uncontrollable intracranial hypertension (p < 0.05). In five patients in the hypothermia group, cerebral blood flow was measured by the hydrogen clearance method and arteriojugular venous oxygen difference was evaluated before and during mild hypothermia. Mild hypothermia significantly decreased the cerebral blood flow, arteriojugular venous oxygen difference, and cerebral metabolic rate of oxygen (p < 0.01). The results of this preliminary investigation suggest that mild hypothermia is a safe and effective method to control traumatic intracranial hypertension and to improve mortality and morbidity rates.

Transient and repetitive rises in blood pressure synchronized with plasma catecholamine increases after head injury. Report of two cases

The authors report two patients with repetitive episodes of acute transient rise in blood pressure synchronized with increases in plasma catecholamine after severe head injury. In both cases, the paroxysmal hypertension occurred suddenly on the 2nd day posttrauma, and its frequency declined gradually, disappearing with time. The pathophysiological basis of this peculiar clinical manifestation is discussed.

Absorption, plasma concentration, and excretion after single administration of 14C-(+-)-3-(benzylmethylamino)-2,2-dimethylpropyl methyl 4-(2-fluoro-5- nitrophenyl)-1,4-dihydro-2,6-dimethyl-3,5-pyridinedicarboxylate hydrochloride in rats and dogs

The absorption, plasma concentrations, and excretion of a newly synthesized calcium antagonist, TC-81 ((+-)-3-(benzylmethylamino)-2,2-dimethylpropyl methyl 4-(2-fluoro-5-nitrophenyl)-1,4-dihydro-2,6-dimethyl-3,5- pyridinedicarboxylate hydrochloride, CAS 96515-74-1) were studied following a single oral or intravenous administration of 14C-labelled compound. After oral administration, 14C-TC-81 was rapidly and well absorbed from the gastrointestinal tract. The peak plasma concentrations of radioactivity were observed at 0.5-1 h (rats) and 1-2 h (dogs) h after dosing. The elimination of the radioactivity in plasma was biphasic with a half-life of 3.8-5.2 h (a phase) and 42.9-56.2 h (beta phase) in the rats or 3.2 h (a phase) and 61.5 h (beta phase) in dogs. Maximum plasma concentrations of unchanged drug after oral administration of TC-81 to male rats at the doses of 0.5, 1.0, and 3.0 mg/kg were 1.7, 7.3 and 15.6 ng/ml, respectively. They were attained at 0.5 h after dosing in every dose examined. Plasma levels of unchanged drug declined with a half-life of 0.39-1.15 h. When TC-81 was orally administered to male dogs at the doses of 0.1, 0.2 and 0.5 mg/kg, plasma concentrations of unchanged drug reached the maximum level at 0.5 h after dosing and the values were 0.8, 3.3 and 9.6 ng/ml, respectively. They were eliminated with a half-life of 2.4-2.8 h. The absolute bioavailability of unchanged drug was estimated to be 2.6-7.0% (rats) and 5.3-15.5% (dogs) of the dose.(ABSTRACT TRUNCATED AT 250 WORDS)

Direct approach to a traumatic giant internal carotid artery aneurysm associated with a carotid-cavernous fistula. Case report

The case is reported of a giant intracranial internal carotid artery aneurysm associated with a carotid-cavernous fistula following a closed head injury. The aneurysm and the fistula disappeared after only the neck of the aneurysm was clipped. This is the first case in which a direct surgical approach was successful in sparing the internal carotid flow. Reports of similar cases are reviewed.

Four forms of cytochrome P-450 in human fetal liver: purification and their capacity to activate promutagens

Four forms of cytochrome P-450 were separated and purified to electrophoretic homogeneity from human fetal livers. These forms of cytochrome P-450, termed P-450HFLa, P-450HFLb, P-450HFLc and P-450HFLd, were distinguishable from each other in their molecular weights, spectral properties, immunochemical properties and mutagen-producing activities from promutagens. The molecular weights of P-450HFLa, b, c and d were estimated to be 51,500, 49,000, 51,500 and 50,000, respectively. Antibodies to P-450HFLa recognized P-450HFLc but not P-450HFLb or d, and antibodies to rat P-448-H (P-450IA2) cross-reacted with P-450HFLb but not with other forms of cytochrome P-450. The N-terminal amino acid sequence of P-450HFLc was highly homologous, but not identical, to that of P-450HFLa. Each form of cytochrome P-450 catalyzed mutagenic activation of aflatoxin B1 (AFB1), 2-amino-3-methylimidazo[4,5-f]quinoline (IQ) and 2-amino-6-methyldipyrido-[1,2-a:3',2'-d]imidazole (Glu-P-1) at different rates. P-450 HFLa showed activities to produce mutagen(s) from AFB1, IQ and to a lesser extent from Glu-P-1. P-450 HFLb activated IQ at a faster rate than did the other forms. P-450 HFLc produced a mutagen from AFB1 and Glu-P-1 but not from IQ. P-450 HFLd did not activate these promutagens at significant rates.

Gd-DTPA-enhanced MR imaging of cryptococcal meningoencephalitis

This report describes magnetic resonance (MR) imaging of biopsy-proved cryptococcal central nervous system (CNS) infection in a 31-year-old HIV negative man. Initial MR imaging revealed multi-focal Gd-DTPA enhancement and showed more lesions than contrast enhanced CT. The lesions regressed after antifungal therapy. MR imaging aids in diagnosis as well as helps to monitor the response to the pharmacological therapy of cryptococcal meningoencephalitis and possibly provides valuable insights into the pathophysiology of this condition.

Angiographic demonstration of acute phase of intracranial arterial spasm following aneurysm rupture. Case report

A case documenting the acute phase of intracranial arterial spasm following rupture of an aneurysm arising from the left internal carotid artery is reported. The patient deteriorated due to recurrent hemorrhage while undergoing angiography 12 hours after the initial aneurysm rupture. The acute deterioration was accompanied by dilatation of the ipsilateral pupil and occurred during injection of contrast material. There was delayed filling of the middle cerebral artery complex along with this narrowing. The arterial narrowing was confirmed to have completely disappeared on an angiographic series performed 14 minutes after the first series of films. The etiology of the acute vasospasm is discussed.

Metabolic activation of aflatoxin B1 and 2-amino-3-methylimidazo[4,5-f]-quinoline by human adult and fetal livers

The mutagenic activation of promutagens by human adult and fetal livers was investigated using the umu test system. Among the promutagens studied, aflatoxin B1 (AFB1) and 2-amino-3-methyl-imidazo[4,5-f] quinoline (IQ) were efficiently activated to mutagens by both adult and fetal livers. 7,8-Benzoflavone inhibited the activation of IQ by fetal livers, but the inhibition observed in fetal livers was much less than that observed in adult livers. Antibodies to P450HM1 (P450111A4) and P450HFLa markedly inhibited the activation of AFB1 by adult and fetal livers, respectively. The formation of genotoxic product(s) from IQ in human adult livers was almost completely inhibited by anti-P448H (P4501A2) antibodies but not by anti-P450HM1 antibodies, whereas that in fetal livers was inhibited by both anti-P450HFLa and anti-P450IA2 antibodies. P450HFLa catalyzed the mutagenic activation of both AFB1 and IQ in a reconstituted system. On the contrary, P450HM1 catalyzed the mutagenic activation of AFB1 but not IQ. A preparation of cytochrome P450 partially purified from human fetal livers and cross-reactive with anti-P450IA2 antibodies was found to be active for mutagenic activation of IQ in a reconstituted system. These results indicate that P450HFLa and P450HM1 are mainly involved in the genotoxic product formation from AFB1 in fetal and adult livers, respectively, and that the metabolic activation of IQ in fetal livers is catalyzed by two forms of cytochrome P450, P450HFLa, and cytochrome P450 immunochemically related to P450IA2 but that in adult livers it is mainly catalyzed by cytochrome P450 related to P450IA2.

[A case report of postoperative thyroid crisis accompanied with struma ovarii]

A 39-year-old female without any specific past history was scheduled to receive an operation for myoma uteri and ovarian cyst. She was premedicated with atropine. Anesthesia was induced with thiopental and was maintained with nitrous oxide and enflurane. Tachycardia shortly after premedication with atropine and remarkable sweat during the operation were observed. On the 1st postoperative day an outbreak of thyroid crisis as well tachycardia of 180.min-1 and fever (39.3 degrees C) were observed. Such outbreak of thyroid crisis indicated that the patient had been suffering from Grave disease. Pathological diagnosis of extirpated ovarian cyst was struma ovarii. It is, however, still uncertain whether struma ovarii induced thyroid crisis in this case. It might be concluded that screening of hyperthyroidism at preoperative rounds is essential for prevention of thyroid crisis.

Respiratory function in handicapped children

The aim of this study was to evaluate respiratory function of severely handicapped children. Tidal volumes and respiratory rates were determined in a total of 130 children with different clinical motor abilities. Tidal volume of non-sitters (n = 39) was significantly lower than ambulators (n = 49) or sitters (n = 42) (p less than 0.01). There was no difference in respiratory rate among the three groups. Among 45 children whose vital capacity could be determined, the tidal volumes showed a significant correlation with vital capacity (r = 0.56, p less than 0.001). Among four children whose tidal volume was less than 200 ml and respiratory rate was more than 30 cpm, blood gas analysis revealed hypoxia in three of them. The tidal volumes, therefore, would be a useful guide to estimate respiratory functions. It was concluded that the respiratory function in a non-sitter with reduced tidal volume is impaired, and that preventive measures must be taken against respiratory infection.

[Coronary artery spasm under thoracic epidural anesthesia]

Three paroxysmal episodes of ST-segment elevation in lead II of ECG were observed during bullectomy and chest closing under epidural anesthesia supplemented with enflurane in compressed air in a patient who had history of variant angina with 50% obstruction of right coronary artery. The first and the third episodes were followed by ventricular tachycardia, complete A-V block and hypotension. These attacks were preceded by decreases in heart rate and blood pressure. It was suspected that coronary artery spasm developed with increased vagal tone under thoracic epidural block. The first and the second attacks were successfully treated with intravenous injection of nitroglycerin and lidocaine. The third attack needed additional treatments which included intravenous administrations of atropine, epinephrine, isoproterenol and phenylephrine and direct heart massage through the thoracic incision. Postoperative serial examinations of ECG showed inverted T in lead V1-V4, and serum enzymes (GOT, GPT, LDH, CPK, CPK-MB) were elevated. However ratio of CPK-MB to total CPK was only 1.5%. The patient was discharged two weeks after the operation with normal ECG and serum enzymes. It is speculated that coronary artery spasm was induced by hypotension and vagal stimulation under epidural anesthesia which blocks cardiac sympathetic nerves.

Mutagenic activation of aflatoxin B1 by P-450 HFLa in human fetal livers

The genotoxic and mutagenic activation of promutagens by human fetal livers was measured by the induction of umu gene expression in Salmonella typhimurium TA1535/pSk1002. Liver homogenates of human fetuses were the most active for the mutagenic activation of aflatoxin B1 (AFB1), followed by 2-amino-3-methylimidazo(4,5-f)quinoline (IQ), and to a lesser extent by 2-amino-6-methyldipyrido(1,2-a:3',2'-d)imidazole (Glu-P-1). The amounts of P-450 HFLa immunochemically determined in human fetal livers correlated highly with the induction of umu gene expression by AFB1 (r = 0.98, n = 5). P-450 HFLa catalyzed the mutagenic activation of AFB1 in a reconstituted system: cytochrome b5 markedly stimulated the activation. Anti-P-450 HFLa antibodies inhibited the mutagenic activation of AFB1 in a dose-dependent manner. These results strongly support the idea that P-450 HFLa is responsible for the mutagenic activation of AFB1 in human fetal livers.

Immunochemical studies for the presence of P-450 HFLa, a form of cytochrome P-450 in human fetal livers in human hepatocellular carcinoma cells

Immunohistochemical localization of P-450 HFLa, a form of cytochrome P-450 in human fetal livers was investigated in human hepatocellular carcinoma. The cytoplasm of carcinoma cells positively reacted with anti-P-450 HFLa antibodies. It was found that the carcinoma cells showing a pseudoglandular pattern or poorly differentiated appearance exhibited a weaker reactivity with anti-P-450 HFLa antibodies than did relatively differentiated carcinoma cells. In the case of hepatoblastoma, the polygonal or round-shaped tumor cells which differentiated into epithelial structure exhibited a positive reaction with anti-P-450 HFLa antibodies, whereas the spindle-shaped tumor cells which showed a sarcomatous appearance did not react with the antibodies.