Hemorrhagic venous infarction after excision of an arteriovenous malformation: case report

A case of arteriovenous malformation (AVM) in which postoperative hemorrhagic infarction developed, probably because of occlusion of the former draining veins, is reported. The hemorrhage developed in the temporal lobe 3 days after the initial operation and was located in the immediate vicinity of the site of the AVM. The following findings suggest that the postsurgical hemorrhage probably resulted from a venous thrombosis: 1) no evidence of residual AVM; 2) delayed onset of the hemorrhage, inconsistent with the time course of a hemorrhage developing according to the breakthrough theory or with insufficient hemostasis with a high-pressure afterload; 3) good correlation between the location of the hemorrhage and the occlusion of the draining veins; and 4) multifocal hemorrhage affecting both the gray matter and the subcortical white matter. Postoperative hemorrhagic infarction caused by thrombosis in the draining veins is rare, but it should be considered as a distinct postoperative complication after removal of an AVM.

[Pharmacokinetic basis of mannitol administration in the treatment of raised ICP]

To study the most effective way of mannitol administration for the treatment of raised intracranial pressure (ICP), pharmacokinetics of mannitol were analysed, and the relationship among mannitol concentration, serum osmolality and changes of intracranial pressure (ICP) were examined in cats. 10%, 20% and 30% of mannitol were made and intravenously administrated with the same volume and speed (0.667 ml/kg/min) for 15 minutes to each mannitol concentration group of cats. Sequential changes of ICP were monitored and serial mannitol concentration, serum osmolality and electrolytes were then performed. Changes of mannitol concentration showed a biexponential curve and best fitted to the two-compartment model analysis. There was a strong positive correlation (r = 0.9286) between mannitol concentration and extrinsic serum osmolality. The disposition of mannitol in cats was similar to that which had been reported in dogs and humans. The distribution half-time was faster in 30% mannitol, but the elimination half-time was similar in all groups. The integrated values of mannitol concentration difference between the central (Cc) and the peripheral compartment (Pc) were greatly correlated with the changes of ICP reduction during mannitol administration (for 15min). The time to vanish the mannitol concentration difference between Cc and Pc showed strong reverse correlation with the time to reach the lowest ICP level. The result indicates that the more rapidly mannitol was administrated, the more rapidly the concentration difference between the two compartments was created, and, the higher the effective osmolality was developed, then, the more profound and prolonged ICP reduction can be obtained.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative efficacy of acid reflux inhibition by drug therapy in reflux esophagitis

The advent of histamine H2 receptor antagonists (H2-RA) has allowed the treatment of reflux esophagitis (RE) to be controlled over a relatively long term. The authors have experienced some cases resistant to H2-RA, but it was revealed that these cases can be successfully treated with proton pump inhibitors. It has been suggested that esophagogastric dysmotility can lead to RE. RE has been treated for many years by using GI-prokinetic agents, which theoretically inhibit acid reflux and improve esophageal acid clearance. In order to compare the effects on acid reflux of an H2-RA (famotidine), a proton pump inhibitor (omeprazole) and a GI-prokinetic agent (cisapride), we measured the 24-hour pH in the esophagus and stomach simultaneously, before and after treatment in 17 patients with RE. It was found that the proton pump inhibitor was the most effective drug for inhibiting esophageal acidification, followed by famotidine and then cisapride. Furthermore, we found that cisapride often actually exacerbated acid reflux. The differences in inhibitory effects on acidification allowed us to draw conclusions regarding the treatment of RE. It was concluded that the stronger the inhibitory effect of a drug on acid secretion, the more useful it was in the treatment of RE. The GI-prokinetic drug did not inhibit acid reflux as much as we had expected.

Fluctuating CPAP (F-CPAP) versus conventional CPAP (C-CPAP) in dogs with blood aspiration

Fluctuating CPAP(F-CPAP) is a combination of spontaneous ventilation and fluctuating PEEP, in which end-expiratory pressure (EEP) is periodically changed within a certain range. In a dog model with localized lung injury induced by the aspiration of non-heparinized blood (2 ml.kg(-1) body weight), we carried out a comparative study of the effects of F-CPAP in which the EEP was cyclically changed from 4 to 12 cmH(2)O with periods of 10 min and those of conventional CPAP with a fixed EEP of 8 cmH(2)O (C-CPAP), on hemodynamics and pulmonary oxygenation. The blood aspiration produced significant increases in the intrapulmonary shunt (Qsp/Qt), the alveolar-arterial difference of partial pressure of oxygen (A-aD o(2)), and the respiratory rate (RR). Although both F-CPAP and C-CPAP reduced Qsp/Qt and A-aD o(2) and RR, 7 dogs treated with F-CPAP showed a significantly greater recovery of Qsp/Qt and A-aD o(2) than 7 dogs treated with C-CPAP. There were no significant differences in hemodynamic variables between the two groups. These results suggest that F-CPAP is more useful in the treatment of some kinds of hypoxic respiratory failure due to uneven distribution of lung injury.

Capsular and thalamic infarction caused by tentorial herniation subsequent to head trauma

Five patients (4 male and 1 female) were observed to have capsular and thalamic infarction ascribed to descending transtentorial herniation (DTH) caused by head injury. A lucid interval immediately after the trauma and the presence of an epidural hematoma (EDH) characterized all five cases. At the time of hospitalization consciousness was seriously impaired and signs of cerebral herniation were apparent. Two to four days after the trauma, low attenuation in the computed tomography (CT) images pinpointed intracerebral damage in the anterolateral part of the thalamus and in the internal capsule on the same side as that of the EDH in three patients, and in the other two patients bilateral thalamic and capsular damage was noted. The low attenuation implicated the perforating arteries, that is the anterior thalamoperforating and anterior choroidal arteries, suggesting infarcted regions caused by occlusion of these arteries. Findings in the present study suggest that arterial occlusion in closed head injury may result from DTH. Moreover, infarction may be attributed to the delayed effects of injury.

Retrograde thrombosis of feeding arteries after removal of arteriovenous malformations

Five cases of retrograde thrombosis of former feeding arteries after removal of an arteriovenous malformation (AVM) are reported. The clinical features of these patients were studied and compared to those of 71 patients without this complication. The following characteristics were found to correlate with retrograde thrombosis: 1) advancing age of the patient; 2) large AVM size; and 3) markedly dilated and elongated feeders. It is suggested that the slow flow in the former feeding arteries that was observed immediately after AVM removal and pathological changes in these vessels due to long-standing hemodynamic stresses contributed to the development of retrograde thrombosis. Neurological manifestations related to retrograde thrombosis were noted in three of the five cases. Although infrequent, this complication should be considered as a serious possibility following removal of an AVM.

Neurinoma of the oculomotor nerve--case report

Only 10 cases of oculomotor nerve neurinoma have been reported previously. The authors report the rarity of a neurinoma originating from Schwann cells of the oculomotor nerve. The diagnosis was based on the initial sign of oculomotor nerve paresis without involvement of other cranial nerves, neuroradiological and surgical findings, and histological features of the specimen obtained at surgery.

[Postoperative intracranial pressure in severe cases with hypertensive intracerebral hematoma]

The relationship between the postoperative ICP and the size of hematoma on CT scan and the time of operation was studied to evaluate their influence on the therapeutic results in the severe cases with hypertensive intracerebral hematoma. Twenty one patients of putaminal hemorrhage with severe neurological deficit (semicoma) were studied. ICP was monitored continuously by the Subdural balloon method after craniotomy to remove the hematoma. The relationship between the postoperative ICP level (High ICP: above 40 mmHg, Moderate ICP: 40-20 mmHg, Low ICP: below 20 mmHg), the size of hematoma estimated from CTscan (Large: more than 80 ml, Medium: less than 80 ml), the time from onset to removing hematoma and the therapeutic results were evaluated. The outcome six months after onset was determined according to the Glasgow Outcome Scale. Of 6 cases with Medium hematoma operated on within 8 hours, Low ICP was found in 5 cases (83%) and Moderate ICP was in one case (17%). Of 6 cases with Medium hematoma operated on after 8 hours, High and Moderate ICP were found in 3 cases (50%), respectively. In the cases with Large hematoma, Low ICP was not observed, but High ICP was found in 4 of 7 cases operated on within 8 hours (57.1%) and the other three indicated Moderate ICP (42.9%). High ICP was found in two cases with Large hematoma operated on after 8 hours (100%). The outcome of High ICP cases was severe disability in 4 cases, vegetative state in one and dead in 4, and that of Moderate ICP cases was moderate disability in 3 cases and severe disability in 4.(ABSTRACT TRUNCATED AT 250 WORDS)

[Blunt injury of the vertebral artery: report of three cases]

The authors reported three cases, whose vertebral arteries had been injured by blunt trauma to the neck which was followed by cerebello-brainstem infarctions. Case 1: a 32-year-old man, who developed severe vertigo and nausea 7 days after a traffic accident. He showed neck pain and horizontal nystagmus on admission. Three days later, he became drowsy. CT scan of the head demonstrated right-side cerebellar infarction, and the angiography revealed an occlusion of the right vertebral artery at C4-5 level. After the removal of the right cerebellar hemisphere, he recovered neurologically and was discharged from the hospital, able to walk. Case 2: a 47-year-old man, who suddenly became comatose 6 hours after an accident. Plain CT demonstrated a highly dense basilar artery. Angiography revealed the occlusion of the left vertebral artery, and severe stenosis of the right vertebral artery. The basilar artery was not visualized. Anticoagulant therapy was started immediately. He survived, but he developed locked-in syndrome. Case 3: a 53-year-old man, who developed transient apnea after an injury. On admission, neurological examination showed horizontal nystagmus, weakness of his right upper limb, and sensory disturbance in the left side of the body. Neck traction was done for spinal C1 and C2 fractures. Twenty-one hours after the injury, he became comatose suddenly. The four-vessels angiography revealed the occlusion of both vertebral arteries. The basilar artery was visualized through the posterior communicating arteries. He died on the 6th day after the trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term survival in malignant atrophic papulosis: a case report and review of the Japanese literature]

Malignant atrophic papulosis (MAP) is characterized by skin lesion and high mortality rate caused by perforation of the GI tract or involvement of the central nervous system. Approximately 100 cases have been reported in the world literatures, but etiology is unknown. A 44-year-old female patient was admitted for chest and abdominal pain with characteristic papuloses, which had been noted by the patient seven years ago. Because of positive peritoneal irritation and intraabdominal free air, exploratory laparotomy was done. Multiple red inflammatory or yellow atrophic maculae on the entire intestine with no obvious perforation but with air-leak were found. Those perforations were closed with seromuscular sutures. The patient is doing well sixteen months after surgery. Fourteen MAP cases have been reported in the Japanese literature. As is found in the world literature, the mortality rate is extremely high. All of reported cases were initially diagnosed because of the particular skin lesions. Abdominal symptoms developed in 10 cases and six of these died. Three cases died within three weeks after bowel resection. There are three surviving cases. One was treated conservatively even though intraabdominal free air was present. Two had three operations, including one simple closure and two intraabdominal explorations. According to this result, a bowel resection should not be performed on MAP patients because of this high mortality. Administration of anticoagulants, i.e., heparin, prostaglandin E1 and ticlopidine seems to be effective in alleviating symptoms and might prevent further deterioration.

Fluctuating PEEP (F-PEEP) versus conventional PEEP in dogs with asymmetrical lung injury

Fluctuating PEEP (F-PEEP) is a newly developed PEEP in which end-expiratory pressure (EEP) is periodically changed within a certain range. In a dog model with unilateral lung injury induced by the introduction of hydrochloric acid, F-PEEP in which the EEP was periodically changed from 0.5 to 1.5 kPa at periods of 6 min, and conventional PEEP (C-PEEP) with an optimized EEP of 1.0 kPa, were each applied for 30 min. F-PEEP produced a significantly greater improvement of PaO2 and intrapulmonary shunt (QS/QT) than C-PEEP, and at the low EEP phase, the greatest improvement accompanied by an increased dynamic compliance and a large cardiac output was obtained. These results suggest that F-PEEP provides a useful mode of artificial ventilation for the treatment of unilateral lung injury.

Comparison between fluctuating PEEP and conventional PEEP in dogs with lung injury induced by blood aspiration

It has been documented that in some patients with acute hypoxic respiratory failure the application of positive end-expiratory pressure (PEEP) may produce no improvement or even a deterioration of pulmonary oxygenation due to an increase in ventilation-perfusion mismatching. Fluctuating PEEP (F-PEEP) is a newly developed PEEP in which end-expiratory pressure (EEP) is periodically changed within a certain range. In a dog model with localized lung injury induced by the aspiration of non-heparinized blood (2 ml.kg body weight-1), F-PEEP in which the EEP was periodically changed from 0.5 to 1.5 kPa at frequencies of 10 min, and conventional PEEP with 3 different fixed EEPs, 0.5, 1.0 and 1.5 kPa (C-PEEP0.5, C-PEEP1.0 and C-PEEP1.5) were each applied for 60 min. F-PEEP produced a periodical change in PaO2 and hemodynamic variables including cardiac output, and in comparison with C-PEEP0.5, C-PEEP1.0 and C-PEEP1.5, a significantly greater improvement of A-aDO2 and dynamic compliance with relatively large cardiac output in the low EEP phase. These results suggest that F-PEEP is a useful mode of artificial ventilation for treating some kinds of acute hypoxic respiratory failure due to increased ventilation-perfusion mismatching.

[A clinical study of severe cases of hemorrhagic cerebral arteriovenous malformations]

The clinical study was undertaken on 24 poor risk patients out of 69 cases with hemorrhagic cerebral arteriovenous malformations, AVMs, and the surgical problems of poor risk patients with the lesions were discussed. The 24 cases, 35%, out of 69 hemorrhagic AVMs cases showed disturbances of consciousness of 3 digits (100-300) according to the Japan Coma Scale at the time of admission. All cases of these poor risk patients were observed less than 24 hours after the onset of the symptoms. Fifteen of these 24 cases showed brainstem signs including anisocoria and/or decerebrate rigidity and/or respiratory arrest. Eighty-three per cent of 24 poor risk patients had serious neurological defects as a result of the first hemorrhage. Therefore, it was impossible to prevent serious state from occurring in poor risk patients. Of the 69 cases with hemorrhagic AVMs, 56 cases were operated upon. Although 90% out of 38 good risk patients whose level of consciousness was 0 to 30 according to the Japan Coma Scale showed good recovery, only 44% of 18 poor risk patients recovered well. It could not be said that the surgical treatment gave satisfactory results for the poor risk patients when compared with the surgical results of the good risk patients. In respect to the location of AVMs, all three poor risk patients with AVMs in the corpus callosum and the ventricles showed good recovery, whereas of the poor risk patients with AVMs in the cerebrum or the cerebellum, only 4 out of 9 cases (44%) and 1 out of 6 cases (17%) showed good recovery respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Serial changes in acute extradural hematoma size and associated changes in level of consciousness and intracranial pressure

The authors report the cases of 37 patients encountered during the past 4 years who exhibited acute extradural hematoma but were initially treated conservatively because no or only small hematomas were observed on admission. The frequency of hematoma enlargement, hematoma size, and changes in the level of consciousness and intracranial pressure (ICP) were examined in these patients. The hematomas enlarged in 24 (64.9%) of the 37 patients, and attained a maximum thickness of 25 mm or greater in 19 patients (51.3%). The level of consciousness could be closely observed during enlargement of the hematomas in 13 patients: the level remained unchanged in eight, deteriorated in two, and improved in three, indicating relative stability in the state of consciousness despite the marked changes in hematoma size. The patients whose hematoma enlarged after the initial examination included three who underwent initial CT examination 5 hours after the injury. In five patients enlargement of extradural hematomas was observed unexpectedly during conservative treatment under ICP monitoring. The ICP also remained stable in three patients until the follow-up examination, but showed a rapid increase in two after a period of stability. However, there was no difference in the final size of the hematomas between the patients showing an increase in ICP and those who did not. These findings suggest that extradural hematomas enlarge progressively at rates varying with the condition of the source of hemorrhage. Moreover, a period of stability in the level of consciousness, such as the lucid interval seen in patients with extradural hematoma, is considered to be a period during which compensatory mechanisms can maintain the stability of the intracranial condition during progressive enlargement of the hematoma.

An immediate and steep increase in ATP concentration in response to reduced turgor pressure in Escherichia coli B

Osmotic treatment with sodium chloride of Escherichia coli B growing in the logarithmic phase induced an immediate increase in ATP concentration in response to increased concentrations of added solute in its growth medium in the first 10 min of the addition. After that, ATP concentration decreased gradually. Sodium arsenate and potassium fluoride almost abolished the ATP increase. The time course of the increase was quite different from that of cells treated with inhibitors of protein synthesis. The osmotic treatment did not decrease the viability of cells. In addition, there was no degradation of RNA by 5 min after sodium chloride addition, and, further, the lag time of ATP increase was extended by an inhibitor of nucleotide synthesis. These results indicated that a major fraction of the stress-increased ATP resulted from de novo synthesis, and that it was mainly dependent upon the reaction of substrate-level phosphorylation, which is regulated by turgor pressure.

Effects of salbutamol and hyperventilation on the rise in serum potassium after succinylcholine administration

It is known that circulating catecholamines stimulating beta 2-receptors and the acid-base balance play important roles in the regulation of serum potassium (K+). The present study was undertaken to investigate the effect of salbutamol (SB), a highly selective beta 2 agonist, and hyperventilation (HV)-induced alkalosis on the change in serum K+ after succinylcholine (SCh) administration in dogs. Pretreatment with SB (0.4 microgram.kg-1.min-1 for 30 min) produced sustained decreases in serum K+ and mean arterial pressure, and transient increases in cardiac output and serum insulin concentration. Maintaining respiratory alkalosis with HV (PaCO2 = 2.6-3.3 kPa) produced sustained decreases in serum K+ and cardiac output. Although both pretreatment with SB and HV-induced alkalosis significantly reduced the absolute increases in serum K+ after SCh, the effect of SB was more remarkable than that of HV. These results suggest that the degree of beta 2-receptor activity can strongly modulate the change in serum K+ after SCh administration.

[Myelopathy caused by hypertrophy of the posterior longitudinal ligament (HPLL): case report]

A case of myelopathy caused by hypertrophy of the posterior longitudinal ligament at the cervical spine is reported. A 71-year-old man was hospitalized with myelopathy with progressed during the last two months. Plain X-ray of the cervical spine revealed only mild spondylotic change. Myelography demonstrated completely blocked contrast medium at C4 to C5 vertebral height due to epidural mass. This epidural mass was localized ventral to the spinal cord from C3 to C5. CT scan revealed slightly high density area behind the vertebral body. On surgery, no evidence of disc fragment but only hypertrophied posterior longitudinal ligament which was removed was found to be a cause of cord compression. Excellent recovery of neurological symptoms after operation was obtained. On histological study, remarkable hypertrophy, edema, hyalinoid degeneration and a little calcification of the ligament was found, which did not show any evidence of new bone formation. HPLL was characterized by thickened and broad epidural mass in the ventral side of cervical cord with Hounsfield number of 90-156 on CT scan, which is not very easy to differentiate from metastatic epidural tumor. The cause of HPLL is not well elucidated, though, this may be a new category of compression myelopathy.

New equations to calculate temperature correction factors for PO2 in human blood

Effects of hemoglobin concentration (Hb), pH, and body temperature (T) on the relationships between delta log PO2/delta T and PO2 were studied by means of a mathematical model using a Newton-Raphson iteration method. The functions between delta log PO2/delta T and PO2 were affected by the above three factors. New equations considering the effects of Hb, pH, and T were proposed by modifying the equation reported by Severinghaus: delta log PO2/delta T = (L +(U-L)/(A(vPO237)B + 1))(10(-2) where U = 3.15-0.45(7.4-pH37) L = 0.68-0.09(7.4-pH37) A = 5.86(exp10(0.074(T)-0.294(7.4-pH37)-11))((Hb)0.913) B = 6.33(exp10(-0.0051(T)))((Hb)-0.113) + 0.24(7.4-pH37) and vPO237 is virtual PO237 which may exist when PO237 is corrected to standard conditions (pH = 7.4, BE = 0) by the following equations: vPO237 = PO237(exp10(fB(7.4-pH37)-0.0013(BE))) fB = (PO237/26.6)0.08-1.52 where fB is the Bohr factor. The above equations provided values of delta log PO2/delta T which fit closely to those obtained by the complex iteration method with maximum differences of less than 1.3 X 10(-3) at T = 27, indicating that maximum % errors for PO2 at T (PO2T) are less than 3.0% at T = 27 and that our equations can be applied over a wide range of Hb, pH37 and T.

[The usefulness of prolonged high dose delayed contrast computed tomography for the diagnosis of intracranial angiographically occult vascular malformations]

It is difficult to diagnose angiographically occult vascular malformations. When conventional CT (plain & contrast enhancement) can not demonstrate the lesions, it was impossible to diagnose in the past. We developed a new technique which enabled us to diagnose them. Materials and methods; Seven cases of spontaneous intracerebral hemorrhage, in which no abnormality was detected by repeated magnified serial angiography with subtraction technique and prolonged injection technique, were examined. In each case, conventional CT (plain & enhancement using 100 ml of 60% meglumine iothalamate) was performed first, which was immediately followed by the administration of 220 ml of 30% meglumine iothalamate for one hour. CT is taken at the end of the infusion. It, we call, is prolonged high dose delayed contrast CT: PHDD-CT. Total dose of iodine used in this technique was 59.22 gI (1.0 gI/kg body weight: BW). Results; Contrast enhancement effect of PHDD-CT was much better than that of conventional CT in all the cases. In three cases, the lesions were more clearly delineated in PHDD-CT. In four cases, only PHDD-CT could demonstrate the lesions. No side effect was observed. Comments; Several techniques for better enhancement have been reported, however they used large volume of contrast medium such as 1.5 or 2.0 gI/kg BW. Our technique can be performed with more security. Based on our good results, we recommend to use this PHDD-CT technique for the diagnosis of angiographically occult vascular malformations.

[The mechanism of intracranial pressure-reducing effect of mannitol]

The effect of mannitol to decrease the raised ICP is well documented and mannitol is now widely used in clinical practice. However, its mechanism of lowering ICP still remains controversial, especially under the condition of vasogenic edema. The objective of this study is to reexamine and delineate the mechanism of ICP reducing effect of mannitol, using quantitative vasogenic edema model, specific gravimetric technique to measure the brain water content, and the method to estimate the CSF dynamics without disturbing the physiological condition of intracranial compartments in cats. Quantitative increase of water content of the white matter was produced by the infusion of 0.5 ml of normal saline though stereotaxically inserted 25-G needle into the left frontal white matter. In control group, cats were sacrificed and water content of the gray and white matter of each coronary sliced brain was measured by specific gravimetric technique. In the mannitol group, 20% of mannitol (2 g/kg) was administrated via femoral vein within 3 minutes. The maximum reduction of ICP was achieved at the average of 30 minutes. At this time, the cats were sacrificed and the water content of brain was measured in the same way as in the control group. PVI, Ro, If (Marmarou) were calculated before and after mannitol administration. In parameter group, BP, ICP, CVP, serum osmotic pressure and osmolarity were measured without terminating the experiment. The changes of water content of the gray and white matter before and after mannitol administration in the area of infusion edema were 80.7% to 80.8% and 76.8% to 77.1% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pisio-hamate hiatus syndrome]

Two patients with atrophy and weakness of intrinsic had muscles innervated by the deep branch of the ulnar nerve except abductor digiti quinti muscle and without any sensory symptoms were reported. They were house-wives aged thirty and fourty-four, respectively, without any specific history of trauma or occupation. Neurological and neurophysiological examination pointed out that the lesion situated in the deep branch of the ulnar nerve. Both of them were operated on. At operation, no abnormal structure were found in the canal of Guyon, though, the deep branch of the ulnar nerve was enlarged at the pisio-hamate hiatus where the branch to the abductor digiti quinti has taken off. In one of the cases, microsurgical removal of the epineurium of the deep branch revealed that each funiculus has lost its course into irregularly enlarged mass, which thought to be neoplastic change. In this case the deep branch was replaced by cable grafts about two centimeters in length by using the sural nerve. Histological findings of this case were as follows: there was no neoplastic or inflammatory change, there was no normal axon pa surviving and that very little regenerated axon and marked interneural fibrosis were observed, which indicates that the nerve lesion was caused by chronic compression. In the other case, the attachment of the membranous tendon of the flexor digiti quinti brevis and opponence digiti quinti muscle to the hook of the hamate was removed. No marked improvement was obtained in both of the cases, because they were too late to be operated on (ten and three years has passed since they noticed muscular atrophy, respectively).

[Posterior longitudinal myelotomy as a surgical treatment of acute cervical spinal cord injury]

Although it is of great tragedy to lose motor and sensory function of the spinal cord by spinal cord injury, there is no effective measure for complete cord lesions. In the central gray of the spinal cord at the region of injury, hemorrhagic necrosis and edema advance causing secondary damage to the spinal cord in rather early stage after injury. It has not been proved whether to remove necrotic tissue in the central gray matter can be effective to prevent secondary damage of the spinal cord or not. Operative result of six patients with acute physiologically complete cervical spinal cord lesion who have been subjected to posterior longitudinal myelotomy and removal of hematoma and necrotic tissue of the central gray of the spinal cord were evaluated. All of them admitted to Kitasato University Hospital within 24 hours after injury. They were five males and one female aged twenty to fifty-three. All the patients showed complete block of contrast medium on myelography at the level of one to two segments above the neurologically estimated level or injury of the spine, indicating marked swelling of the spinal cord. Average duration from injury to operation was sixteen hours ranging from six to thirty nine. Posterior longitudinal myelotomy was performed by using microsurgical technique. Skull traction was performed by using Crutchfield tongs for six weeks in five and twelve weeks in one of the patients. On admission forty mg of dexamethasone was used as steroid therapy followed gradual reduction.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute traumatic hydrocephalus]

We have experienced two rare cases of acute traumatic hydrocephalus which developed within several hours after head injury. Case 1. A 4-year-old boy was stuck by an automobile. After losing consciousness for a few minutes, he became agitated and vomited. He was brought to our hospital 3 hours after accident. On admission, he scored 8 points on the Glasgow Coma Scale. CT scan on admission disclosed slightly enlarged ventricles, but there were no findings indicating cerebral contusion nor intracranial hemorrhage. His state of consciousness gradually deteriorated, thereafter right sided convulsive seizures occurred. 7 hours after accident, CT scan was repeated and demonstrated a marked enlargement of the ventricles. Continuous ventricular drainage was performed. The ventricular fluid was slightly bloody. After the ventricular drainage, the state of consciousness improved rapidly. 6 days after the accident, ventricular drainage was discontinued. Afterward, size and shape of the ventricles became nearly normal and the patient was discharged 36 days after the head injury without any neurological deficits. Case 2. A 3-year-old girl was buried under a burden. 30 minutes after the accident, her consciousness began to deteriorate with vomiting. She was brought to our hospital 3 hours after the accident. On her arrival, she scored 13 points on Glasgow Coma Scale. CT scan, which performed 4.5 hours after the accident, showed slightly enlarged ventricles and intraventricular hemorrhage in the third and fourth ventricles. Her state of consciousness gradually worsened with generalized seizures. Repeated CT scan 8 hours after the accident, demonstrated a marked enlargement of the ventricles. Following ventricular drainage, the patient's state of consciousness improved rapidly.(ABSTRACT TRUNCATED AT 250 WORDS)

[An operated case of cervical spontaneous hematomyelia]

We have reported a case of cervical spontaneous hematomyelia caused by cavernous hemangioma. A 47-year-old woman experienced a sudden onset of pain in the neck on 5 December 1979. One week after the onset she began to have tetraparesis. There was a rapidly increasing weakness of the extremities and she was referred to our department on 25 December 1979. At the time, the positive neurological findings were flaccid tetraplegia, bilateral loss of all sensory perception below the C4 level and urinary retention. Chest x-ray films demonstrated an elevation of right diaphragma. Roentgenograms of the cervical spine were normal. Emergency myelography via cisternal puncture revealed a central filling defect at the level of C3-C5. But there was no displacement of dentate ligament on lateral view, suggesting an intramedullary mass lesion. Laminectomy from C2 to Th1 and evacuation of the intramedullary blood clot at C3-C5 level were performed successfully. Microscopic examination of clots revealed cavernous hemangioma. The postoperative course was uneventful and the patient gradually improved in her motility. In the review of the literature including our case, vascular malformations are the commonest cause of spontaneous hematomyelia. They are found 12 out of 18 cases (Table 1). The symptoms of spontaneous hematomyelia are characterized by sudden onset of pain and rapid development of long tract sign in a previously asymptomatic individual. Operated cases are summarized in table 2. Good operative results are obtained 6 out 9 cases. We will emphasize that in a case of spontaneous hematomyelia with acute progression of transverse myelopathy, early diagnosis and operation are extremely important, and for this purpose, myelography is considered to be one of the most useful examinations.

Rapid enlargement of ventricles within seven hours after head injury

We report a case of acute enlargement of the ventricles within 7 hours after head injury that was documented by repeated computerized tomography. It is suggested that the pathophysiological mechanism for this rapid enlargement of ventricles may be due to the raised intracranial pressure (ICP) that results from obstruction of cerebrospinal fluid pathways by subarachnoid hemorrhage, in addition to the elevation of ICP aggravated by frequent focal convulsive seizures.

Cervical radiculomyelopathy caused by deposition of calcium pyrophosphate dihydrate crystals in the ligamenta flava. Case report

A case of cervical radiculomyelopathy caused by multiple calcified nodules in the ligamenta flava is presented. Roentgenological examination of the cervical spine showed radiopaque nodular lesions, 7 x 7 x 5 mm in size, located in the paramedian portion of the posterior spinal canal. The nodules were removed surgically and they were confirmed to be calcifications of ligamenta flava. Microscopic examination of the nodules with the polarized light revealed extensive deposition of crystals. By x-ray diffraction study, the crystal was determined as calcium pyrophosphate dihydrate (CPPD: Ca2P2O7 . 2H2O). Although CPPD deposition in the cartilage has been known as pseudo-gout syndrome, deposition in the ligament has been reported only in a few cases. This is the first case with radiopaque calcified nodules in the ligamenta flava causing spinal cord compression, the composition of which proved to be CPPD.

[A case of spontaneous 3rd ventriculostomy (author's transl)]

We have reported a rare case of spontaneous 3rd ventriculostomy with spontaneous arrest of obstructive hydrocephalus. A 41 year old man, who had had an intermittent headache for about a year, was admitted to the department of neurosurgery Kitasato University with chief complaints of sudden onset of severe headache, vomiting and disturbance of consciousness. At the time of admission, 30 minutes after the onset of symptoms, the positive neurological findings were delirious state of consciousness, miotic pupils with sluggish reaction to light, mild hemiparesis on the left site and slight nucnal rigidity. He lapsed into coma after two hours, however he gradually relieved from these symptoms since the forth hospital day. Cerebrospinal fluid was bloody. Radiograms of the skull revealed decalcification of posterior clinoid process and postero-inferior displacement of pineal calcification. Brain scanning and vertebral angiography demonstrated tumor stain in the posterior portion of the 3rd ventricle. Dimer-X ventriculography revealed the obstruction of posterior portion of the 3rd ventricle and the leakage of Dimer-X through the floor of the 3rd ventricle into the intrasellar subarchnoid space. The patient died after about one year from the onset of symptoms. Any signs of increased intracranial pressure had not been noticed since the forth hospital day; At autopsy we confirmed the posterior portion of the 3rd ventricle was obstructed by tumor. In the floor of the 3rd ventricle there was a round opening which was patient and measured about 3 mm in diameter. Microscopic examination of the tumor showed an oligodendroglioma. Neoplastic cells partially infiltrated into the surface facing to the 3rd ventricle and slight gliosis was observed around the site of rupture. The surface along the subarachnoid space was lined with pia-aracnoid membrane except at the site of rupture. In the past literatures only 6 cases of spontaneous 3rd ventriculostomy have been reported. Three cases were observed spontaneous arrest of obstructive hydrocephalus. Our case is the first reported case of spontaneous 3rd ventriculostomy through the floor of the 3rd ventriculostomy through the floor of the 3rd ventricle. We suggested the pathogenesis of spontaneous 3rd ventriculostomy is a result of destruction at normally weak points of 3rd ventricle (ex. anterior, posterior wall and floor of 3rd ventricle), which has the reultant internal hydrocephalus caused by recurrent obstruction of C.S.F. pathway or long-standing obstructive hydrocephalus.

[Bilateral traumatic abducens nerve palsy without skull fracture or intracranial hematoma-a report of 3 cases and consideration of the mechanism of injury (author's transl)]

Three cases of bilateral traumatic abducens nerve palsy were presented and the mechanism of damage to the abducens nerve was discussed in relation to the analysis of traumatic force at the time of impact and topographical anatomy of the abducens nerve in detail. Case 1. A 70 year old man sustained a traffic accident with one hour loss of consciousness. Physical examination revealed a contused area on the medial side of his right forehead. Neurological examination revealed bilateral abducens nerve palsy (Fig. 1). There were no ther cranial nerve abnormalities. Roentgenograms of the skull, including views of the base and orbit showed no fracture. At follow up examination 12 months later, bilateral Duane's retraction syndrome could be noticed with slight increase in size of the pupil on each side of lateral gaze (Fig. 2). Case 2. A 32 year old women sustained a traffic accident with 31 days of loss of consciousness. At the time of admission, bilateral abducens nerve palsy and slight left hemiparesis were noticed in semicomatose condition. Right carotid angiogtam showed no evidence of intracranial hematoma. One month later, the right eye began to abduct and 2 months later, the left eye began to abduct. Three months after the injury, bilateral abducens nerve palsy could no longer be demonstrated. No retraction syndrome was observed during this period. Case 3. A 3 year old boy sustained a traffic accident with 32 days of loss of consciousness. At the time of admission, neurological examination showed bilateral abducens palsy and left sided decerebrate posture in comatose condition. At the time of discharge 3 months after admission, bilateral abducens palsy, right hemiataxia, left spastic hemiparesis and scanning speach were noticed. Three months later, right eye began to abduct and 4 months later, the left eye began to abduct. At follow up examination 6 months later, there was no evidence of abducens nerve palsy. Topographical details of anatomy of the abducens nerve are shown in Fig. 3, 4. It is greatly speculated that both abducens nerves are streched by the lineal accerelated force on mid sagittal plane at the time of impact, then the apex of petrous pyramid acts as the fulculum, so that the abducens nerves are compressed, contused and streched at this point (Fig. 5-a). The authors pointed out that the abducens nerve are impossible to be damaged at the petroclinoid ligament (Grüber's lig.) by the upward movement of the brainstem, because the abducens nerve is fixed downward below this ligament by the dura and apex of the petrous pyramid (Fig. 4-b, c). One case showed bilateral acquired retraction syndrome with slight increase in size of the pupil on each side of lateral gaze, the fact greatly suggesting that the sympathetic nerve have intimate relationship to the miss direction during the recovery stage of abducens nerve palsy.

[Paratrigeminal epidermoid originated in the meckel's cave (author's transl)]

We have reported a case of paratrigeminal epidermoid originated in the Meckel's cave. A 30 years old man was admitted to the department of neurosurgery with chief complaints of continuous right facial pain and numbness of entire right side of the face of three years duration. The positive neurological findings were hypesthesia over the distribution of the right trigeminal nerve, absence of the right corneal reflex and nystagmus on left lateral gaze. Caloric response was absent on the right side, however the audiogram showed normal. Cerebrospinal fluid examination was within normal limit. Electromyography showed giant spike in the right masseter and temporal muscles. Radiogram of the skull revealed a bone-destroying lesion over the medial florr of the right middle fossa involving the apex of the petrous bone (Fig 1). Right carotid angiography showed straightening and forward displacement of C4- C5 portion of the carotid siphon in the lateral view, and vertebral angiography showed displacement of basilar artery to the left side, upward displacement of the right posterior cerebral and superior cerebellar artery in the frontal view (Fig. 2, 3). At the time of operation, an epidermoid was identified in the Meckel's cave and totally removed microsurgically. Small amount of the tumor extending into the posterior fossa was also removed (Fig. 4, 5, 6, 7). Postoperative course was uneventfull except for an episode of headache and high fever of short duration, suggesting the signs of meningial irritation. Two months postoperativelly patient was relived of facial pain and was discharged with sensory impairment of the right trigeminal nerve distribution. Only 11 cases of paratrigeminal epidermoid, including the cases localized in the Meckel's cave have been reported in the past literatures (Table 1). In this paper we have discussed about the symptomatology and clinical data of paratrigeminal epidermoid and compared with those of trigeminal neurinoma, and meningioma originated in the same region. We would like to emphasize that the importance of differentiating the idiopathic trigeminal neuralgia from the paratrigeminal epidermoid, if the initial symptom of this tumor were tic douloureux. The total removal of epidermoid with capsule is essential treatment following the early diagnosis, however the attempt of total removal is sometimes difficult because of the relationship between the origin, size and extension of this kind of tumor to other important brain structures. And if some of the tumor is left behind at the time of operation, cholesterin meningitis is an important complication.