Agents for the treatment of overactive detrusor. VII. Synthesis and pharmacological properties of 2,3- and 3,4-diphenylcyclopentylamines, 2,3-diphenyl-2-cyclopentenylamines, and related compounds

As part of our search for new agents for the treatment of overactive detrusor, 2,3- and 3,4-diphenylcyclopentylamines (3), 2,3-diphenyl-2-cyclopentenylamines (4), and related compounds (5 and 18) were synthesized and evaluated for inhibitory activity (i.v.) against urinary bladder rhythmic contraction in rats. Among them, some compounds involving N-tert-butyl-2,3-diphenyl-2-cyclopentenylamine (4b) exhibited inhibitory activity against bladder contraction superior to that of terodiline (2). Mydriatic activity (i.v.) of compound 4b in rats, an index of its side effects due to antimuscarinic activity, was found to be relatively weak in comparison with its inhibitory activity against bladder contraction. The pharmacological profile of 4b was examined in comparison with that of terodiline. Most of the objective amines (3, 4, 5) were synthesized by preparation of Schiff bases from the corresponding cyclic ketones (6, 7, 8) and amines in the presence of TiCl4 in CH2Cl2 and subsequent reduction with NaBH4 in the presence of MeOH in one pot (method A).

The temporo-polar approach to basilar artery aneurysms with or without zygomatic arch translocation

Since the publication of the temporo-polar approach to basilar artery aneurysms by Sano (1980 and 1987), various modifications of the approach were reported. The approach provides a better view and a wider operating field than the subtemporal or pterional ones. Usually the approach does not need temporary remove of the zygomatic arch. If however, a basilar tip aneurysm is located very high above the posterior clinoid, temporary removal of the zygomatic arch is necessary which is sutured back to its original position at the end of the operation.

Agents for the treatment of overactive detrusor. VI. Synthesis and pharmacological properties of acetamide derivatives bearing cyclic amines in N-substituents

With the aim of improving of the efficacy and decreasing the side effects of oxybutynin (1), N-[(tetrahydro-3- or 4-pyridyl)methyl]-, N-(4-piperidyl)-, and N-(3- or 4-piperidylalkyl)-2-hydroxyacetamides (3a-n, 4a-g) and the related carboxamides (3o-r, 4h-k, 13', 17) were synthesized and evaluated for inhibitory activity against urinary bladder rhythmic contraction in rats and for mydriatic activity in rats. Some of these compounds were superior to oxybutynin in both inhibitory activity against bladder contraction and selectivity between inhibitory activity against bladder contraction and mydriatic activity. Among them, N-[(1,2,3,6-tetrahydro-4-pyridyl)methyl]- and N-[(1,2,3,6-tetrahydro-1-methyl-4-pyridyl)methyl]-2-hydroxy-2,2- diphenylacetamide (3e, 3f) exhibited the most potent inhibitory activity against bladder contraction (ED30 = 0.005 and 0.003 mg/kg i.v., respectively). Judging from the effect of 3e on detrusor contraction in vitro in guinea-pigs, it appeared that the inhibitory activity of 3e against bladder contraction in vivo was related mainly to its inhibitory activity against detrusor contraction in vitro induced with carbachol (antimuscarine-like activity). The selectivity (20-fold) of 3e between inhibitory activity against bladder contraction and mydriatic activity was greatly superior to that (0.48-fold) of oxybutynin. Compound 3e was synthesized by debenzylation (method E or F) of the corresponding N-[[1-(4-methoxybenzyl)-tetrahydro-4-pyridyl]methyl] derivative (3k), which was prepared by acylation (method B) of the corresponding (tetrahydro-4-pyridyl)methylamine (7k) or by reduction (method D) of the corresponding pyridinium chloride (14k) with NaBH4.

Effect of sevoflurane on hypoxic pulmonary vasoconstriction in the perfused rabbit lung

BACKGROUND

In vitro studies have shown that isoflurane, enflurane, and halothane inhibit the hypoxic pulmonary vasoconstriction (HPV) with essentially the same potency. The aim of this study is to compare the effects of sevoflurane and isoflurane on HPV in constant-flow perfused rabbit lungs.

METHODS

Constant-flow perfused lungs from Japanese white rabbits were tested. The lungs were divided into three groups: isoflurane alone (n = 6), sevoflurane alone (n = 6), and sevoflurane with ibuprofen pretreatment (n = 6). Baseline HPV responses were measured as the pulmonary arterial pressure increased after changing inspired oxygen concentration from 95% for 15 min to 3% (with 5% CO2) for 5 min without anesthetic administration. Next, three different concentrations of anesthetics were added to the inspired gas for 15 min in random order. The HPV response in the presence of anesthetic was expressed as a percentage of the pressor response in the absence of anesthetics, and dose-response relationships were calculated using the nonlinear least-squares method.

RESULTS

Isoflurane and sevoflurane both depressed the HPV response in a dose-related manner. The half-inhibition values (ED50) of HPV with isoflurane and sevoflurane were 0.85 +/- 0.22 MAC and 1.00 +/- 0.12 MAC (mean +/- SD), respectively, and were not statistically different. Ibuprofen pretreatment did not alter ED50 and slope of dose-response curve, although the absolute value of pressor response in the sevoflurane group with ibuprofen pretreatment was greater than that in the sevoflurane alone group at every concentration of sevoflurane.

CONCLUSIONS

Sevoflurane inhibits the HPV response in a dose-related manner, and its potency is similar to that of isoflurane in vitro. Cyclooxygenase products do not mediate the inhibition of HPV by sevoflurane.

The problem of macular sparing after unilateral occipital lesions

Whether or not unilateral occipital damage produces sparing of central vision, namely macular sparing, is controversial. We tested two subjects with left occipital lesions by means of fundus perimetry combined with fundus image analysis. This method made it possible to measure the distance of the stimulus projected on the retina from the foveal centre defined as the centre of the foveal reflex. The results indicated that macular sparing, if it exists, must be less than 0.4 degree wide. Two of the four eyes during the stimulus presentation often but not always showed eccentric fixation of a small magnitude, whose mean was less than 0.6 degree from the foveal centre in the right hemiretina.

Intramuscular metastasis of carcinoma

Four cases of intramuscular metastasis of carcinoma are reported. The preoperative clinical diagnosis of all four cases was soft-tissue sarcoma. Definitive diagnoses, made by open biopsy, were uterine carcinoma, gastric carcinoma, lung carcinoma, and hypopharyngeal carcinoma. All patients died from lung, liver, or brain metastasis several months after open biopsy despite surgery, chemotherapy, or radiation therapy. Case reports of macroscopic metastases to muscle are rare, and the authors report four such cases experienced during a 15-year period.

Cerebral blood flow and glucose metabolism in the squirrel monkey during the late phase of cerebral vasospasm

A double-isotope autoradiography technique was used to evaluate cerebral blood flow (CBF) and cerebral glucose metabolism (CMRglu) during the late phase of vasospasm in a squirrel monkey subarachnoid haemorrhage (SAH) model. Cisternal blood injections induced both global and focal changes in CBF and CMRglu six days following SAH, the timepoint of maximal late spasm in this model. There was a global decrease in CBF of about 30% accompanied by an increase in deoxyglucose uptake of about 50%. Four of seven animals also had foci with flow decreased to 40% of control and deoxyglucose uptake increased to 300% of control. There was an altered but still present interdependence between flow and metabolism post SAH.

Revised technique of cardiopulmonary bypass in one-stage repair of interrupted aortic arch complex

Twenty infants with interrupted aortic arch associated with various intracardiac anomalies underwent primary complete repair using pulsatile high-flow cardiopulmonary bypass with a short period of circulatory arrest. Age at repair ranged from 11 to 126 days (mean age, 43 days). Weight ranged from 2.2 to 5.5 kg (mean weight, 3.4 kg). Associated cardiac lesions included ventricular septal defect (14 patients), truncus arteriosus (3), transposition of the great arteries (2), and aortopulmonary window (1 patient). Left ventricular outflow tract obstruction was relieved in 2 patients. The aortic arch was reconstructed with a polytetrafluoroethylene graft in 7 patients and by direct anastomosis in the most recent 11 patients. An arterial cannulation method has been devised to facilitate direct anastomosis between the ascending aorta and the descending aorta, to lessen circulatory arrest time, and to prevent dangerous laceration and postoperative narrowing of the thin, small ascending aorta at the cannulation site. Two patients died, a surgical mortality rate of 10%. There has been one late death, which was due to severe truncal valve insufficiency. The other patients are doing well with a mean follow-up of 3 years 6 months. Restenosis of the direct anastomosis has not been noted in any patient. However, subaortic stenosis with pressure gradients of 30 to 40 mm Hg developed in 3 patients. In conclusion, one-stage repair including direct anastomosis for the aortic arch reconstruction and repair of all coexisting intracardiac defects is thought to be the treatment of choice.

Brain stem haemorrhage during transsphenoidal surgery. Possible risk of the manoeuvre of increasing the endexpiratory pressure in a case of pituitary adenoma associated with dural arteriovenous malformation. Case report

The authors report a case of pituitary adenoma associated with dural arteriovenous malformation (AVM), which caused brain stem haemorrhage during transsphenoidal surgery. The manoeuvre of increasing the endexpiratory pressure in order to push the suprasellar component of the adenoma down to the sella turcica could be the reason of this bleeding. The authors therefore recommend that in cases of such a combination any manoeuvres which are likely to increase the intracranial venous pressure or otherwise affect the intracranial pressure, are avoided. The dural AVM spontaneously regressed after haemorrhage.

Agents for the treatment of overactive detrusor. IV. Synthesis and structure-activity relationships of cyclic analogues of terodiline

A series of pyrrolidine derivatives were synthesized and examined for inhibitory activity on detrusor contraction in vivo. Among those compounds, 5,5-dimethyl-2-(2,2-diphenylethyl)-3-isopropylidenepyrrolidine+ ++ hydrochloride (41.HCl), 2-(2,2-di(4-fluorophenyl)ethylene)-5,5-dimethyl-3-isopropylidenepyrro lidine hydrochloride (42.HCl), (+)-5,5-dimethyl-2-(N,N-diphenylaminomethyl)-3-isopropylidenepy rrolidine hydrochloride (+)-(43a.HCl), (-)-5,5-dimethyl-2-(N,N-diphenylaminomethyl)-3-isopropylidenepy rrolidine hydrochloride (-)-(43a.HCl), and 2-(N,N-di(4-fluorophenyl)aminomethyl)-5,5-dimethyl-3-isopropylidenepy rrolidine methanesulfonate (43b.MsOH) showed stronger inhibitory activity on detrusor contraction than terodiline.

Effect of spantide, a substance-P antagonist, on cerebral vasospasm in primates

Experimental SAH in the squirrel monkey induces an angiographically demonstrable late spasm of about 23% at six days post subarachnoid haemorrhage (SAH). The late spasm is associated with a generalized reduction in cerebral blood flow (CBF) of about 30%. Intracisternal administration of the substance P (SP) antagonist spantide two hours and three days post SAH significantly reduces the degree of late spasm and also decreases the degree of CBF reduction. The findings suggest that SP is involved in the development of both angiographical spasm and CBF changes post SAH.

Cerebrovascular changes following administration of gammaglobulins against substance P or calcitonin gene related peptide in monkey with subarachnoid haemorrhage

Cerebrovascular changes after intrathecal (ith) administration of gammaglobulins against substance P (SP) or calcitonin gene-related peptide (CGRP) were investigated before and following a simulated subarachnoid haemorrhage (SAH) in the squirrel monkey. The SAH was produced by injection of homologous blood into the interpeduncular fossa and the cisterna magna. The gammaglobulins were given both prior to the blood injections and daily in 5 days post-SAH. The effect of the gammaglobulins was examined by angiography pre-SAH and at 10 min and at 6 days post-SAH, i.e. the time points for maximal acute and late spasm in the present model. Cerebral blood flow (CBF) was measured under general anesthesia at day 6 post-SAH with an autoradiographic technique. Five of nine animals treated with CGRP antigammaglobulin died from respiratory failure. Four animals received SP antigammaglobulin and two control animals received normal globulin. SP antigammaglobulin per se had no effect on baseline arterial diameter, while CGRP antigammaglobulin significantly reduced the diameter of the arteries. SP antigammaglobulin prevented the occurrence of acute spasm and significantly reduced the degree of late spasm. Moreover, the reduction in CBF noted in the control SAH animals was significantly reduced. In contrast, CGRP antigammaglobulin treatment had no effect on the degree of spasm and did not cause any change in CBF as compared to controls. The finding that CGRP but not SP antigammaglobulin significantly reduces the arterial diameter in conjunction with our previous demonstration that a post-, but not preganglionic trigeminal lesion reduces the baseline arterial diameter, indicates that CGRP could be the transmitter involved in a peripheral axon reflex. The function of SP might be as a neurotransmitter conveying information to the brainstem. The transmitter role is supported by the effect of SP antigammaglobulin impairing SP containing neurons and, in that way, mimicking a bilateral trigeminal rhizotomy.

Effect of lesioning of medullary catecholamine neurons or the median eminence on the development of cerebral vasospasm in the squirrel monkey

Injections of blood into the interpeduncular fossa and cisterna magna in the squirrel monkey produce an angiographically demonstrable, biphasic cerebral vasospasm with a maximal acute spasm at ten minutes and a maximal late spasm at six days after the subarachnoid haemorrhage (SAH). Selective lesioning of the A2 nucleus in the medulla oblongata or the median eminence in the hypothalamus prior to the SAH prevents the development of both the acute and late cerebral vasospasm. The present data indicate that the A2 nucleus and the median eminence participate in the development of vasospasm in the squirrel monkey.

A primate model for acute and late cerebral vasospasm: angiographic findings

A subarachnoid haemorrhage (SAH) in the squirrel monkey was produced by injection of blood via a permanently implanted catheter connected to the cisterna magna and a cannula stereotactically inserted into the interpeduncular cistern. Repeated angiographic examinations of the vertebro-basilar and right internal carotid arteries revealed a biphasic vasospasm with a maximal acute spasm at ten minutes and maximal late spasm at six days after blood injection. The present study has shown that a reproducible biphasic vasospasm can be produced in the squirrel monkey and evaluated by repeated angiographic examinations. The model is suitable in the study of basic mechanisms underlying vasospasm in a primate and, due to the size of the animal, autoradiographic evaluation of the cerebral blood flow and metabolism can be performed at an acceptable cost.

Agents for the treatment of overactive detrusor. III. Synthesis and structure-activity relationships of N-(4-amino-2-butynyl)acetamide derivatives

A series of N-(4-amino-2-butynyl)acetamides were synthesized and examined for their inhibitory activity on detrusor contraction and mydriatic activity as an index of anticholinergic side effect. Among those compounds synthesized, (+)-2-cyclohexyl-N-(4-dimethylamino-2-butynyl)-2-hydroxy-2-phenylacet amide hydrochloride ((+)-13b.HCl), 2-cyclohexyl-2-hydroxy-N-(4-methylamino-2-butynyl)-2-phenylacetamide+ ++ hydrochloride (13c.HCl), N-(4-dimethylamino-2-butynyl)-2,2-diphenyl-2-hydroxyacetamide hydrochloride (14a.HCl), and 2,2-diphenyl-N-(4-ethylamino-2-butynyl)-2-hydroxyacetamide hydrochloride (14b.HCl) showed equipotent inhibitory activity on detrusor contraction to oxybutynin (1) and less mydriatic activity. Further evaluation of these compounds as an agent for the treatment of overactive detrusor has been examined.

Agents for the treatment of overactive detrusor. II. Synthesis and inhibitory activity on detrusor contraction of 1,1'-biphenyl-2,6-dicarboxylic acid diesters with an aminoalkyl group in the ester function

A series of 1,1'-biphenyl-2,6-dicarboxylic acid diesters with an aminoalkyl group in the ester function were synthesized and examined for their inhibitory activity on detrusor contraction in vitro and in vivo. In the in vivo test, arrhythmia was observed as a side effect. Among those compounds synthesized, 2-methyl 6-[4-(1-methylpiperidinyl)] 3-hydroxy-5-methyl-2'-nitro-1,1'-biphenyl-2,6-dicarboxylate (18) showed strong inhibitory activity on detrusor contractions in vivo (ED50 = 0.54 mg/kg i.v., ED50 = 7.2mg/kg i.d.) and good separation from the side effect. Compound 18 was chosen for further pharmacological evaluation as an agent for the treatment of overactive detrusor.

[Evaluation of halothane induced HPV inhibition with analysis of pressure-flow curve]

We investigated the effect of halothane on the hypoxic pulmonary vasoconstriction using in vivo measurement of the pressure-flow curve of the left lower lobe in the dog. With hypoxic ventilation of the left lower lobe, the pressure-flow curve shifted to the right and the slope of the curve became flatter. Although inhalation of 1 MAC halothane by the left lower lobe during hypoxic ventilation had no effect on the pressure-flow curve configuration, inhalation of 3, 5 MAC made the slope steeper. We analyzed these changes by the distensibility model proposed by W. Mitzner et al, and our data support the hypothesis that hypoxic ventilation decreases the small pulmonary vessels of 1-4 orders and also increases the compliance of the orders of vessel where the constriction has occurred, and halothane antagonizes the HPV response by further increasing the compliance of the constricted vessels. The inhibitory effect of halothane on HPV was weaker in in vivo preparation compared with the effect in in vitro preparation. Some humoral factors in the perfusate could contribute to this effect.

Central projections of the sensory innervation to the middle cerebral artery in the squirrel monkey

To analyze the brainstem projections of the innervation to the middle cerebral artery (MCA) in the squirrel monkey, transganglionic tracing of wheat germ agglutinin conjugated with horseradish peroxidase (WGA-HRP) was used. After application of WGA-HRP to the middle cerebral artery (MCA), labelled cell bodies were identified in the ipsilateral trigeminal and superior cervical ganglia. In the brainstem, positive labelling indicative of preterminals and terminals occurred in a discontinuous pattern throughout the trigeminal brainstem nuclear complex. At the level of the obex, nerve terminations were identified in the nucleus tractus solitarius, nucleus motorius dorsalis nervi vagi and the nucleus nervi hypoglossi. Positive WGA-HRP profiles were also observed in the periaqueductal gray matter.

Effect of unilateral pre- and postganglionic lesioning of the trigeminal nerve on the development of cerebral vasospasm in the squirrel monkey: angiographic findings

Bilateral carotid angiography was performed in the squirrel monkey before and after unilateral pre- and postganglionic trigeminal lesioning. A unilateral postganglionic lesion caused a significant constriction of about 27% of the ipsilateral cerebral arteries, while a preganglionic lesion did not change the baseline arterial diameter. Following a subarachnoid haemorrhage (SAH) the degree of vasoconstriction in the animals with a preganglionic lesion did not differ significantly from that seen in controls. In the postganglionically lesioned animals, the vasoconstriction was more pronounced (12% at both 10 min and 6 days post SAH) on the lesioned as compared with the non-lesioned side. At day 6 post SAH the degree of vasoconstriction was 19% more pronounced on the lesioned side in post- as compared with the preganglionically lesioned animals. There was no difference in the degree of spasm on the non-lesioned side between the two groups. The findings indicate that the trigeminal system has both a peripheral and a central function. The peripheral, or axon reflex mechanism, exerts a tonic effect on the cerebral vessels. Following a SAH the axon reflex seems to attenuate cerebral vasospasm.

Effect of pre- and postganglionic lesioning of the trigeminal nerve on cerebral blood flow and glucose metabolism following a subarachnoid haemorrhage in the squirrel monkey

Simultaneous cerebral blood flow (CBF) and glucose metabolism (CMRglu) studies with a double isotope autoradiographic technique were applied to squirrel monkeys submitted to a unilateral pre- or postganglionic trigeminal lesion. The CBF values were not affected following a pre- or postganglionic lesion per se. In contrast, there was a global increase in the cerebral glucose uptake of about 50% as compared to controls following both kinds of lesions. Following a subarachnoid haemorrhage (SAH) 2-4 weeks after pre- or postganglionic trigeminal lesioning, there was a decrease in CBF similar to that seen in the control group. In the animals with a preganglionic lesion, the 50% increase in glucose uptake was not further augmented by a SAH and the increase in CMRglu was comparable to that found in control SAH animals. In the postganglionically lesioned monkeys, a SAH induced an additional increase in glucose uptake of about 50%. The findings suggest that the trigeminal system is involved in the regulation of cerebral metabolism via a brainstem centre.

[Recommendation for open heart surgery in infancy]

Progress in infant open-heart surgery last 10 years was reviewed mainly based on the surgical experiences in Fukuoka Children's Hospital. Recent advances and present problems in patient's care, cardiopulmonary bypass methods and cardioplegia were discussed. Low surgical mortality of 4.8% in 245 infant open-heart repairs between 1988 and 1990 in Fukuoka is highly suggestive of early primary repair for most of congenital heart diseases.

Anomalous origin of the right pulmonary artery from the ascending aorta

Five cases of anomalous origin of the right pulmonary artery from the ascending aorta were seen at our hospital. Patients 1 and 2 had an intact right pulmonary artery originating from a right posterior aspect (proximal form), and primary anastomosis of the right pulmonary artery and main pulmonary trunk was performed. Patients 3 and 4 showed a narrowing right pulmonary artery originating from near the base of the innominate artery (distal form). The stenotic right pulmonary artery was reconstructed with an 8-mm graft in patient 3, whereas patient 4 became inoperable because complete obstruction had developed in the right pulmonary artery during the 3 months that the patient was waiting to undergo operation. In patient 5, primary anastomosis was undertaken, but morphologically the anomalous origin was of the distal form, so the occurrence of stenosis in the reconstructed right pulmonary artery was a matter of concern. The morphological type was found to be related to the surgical options in this anomaly. Therefore, primary anastomosis was considered the best choice for a correction of the proximal form, whereas a graft interposition with a resection of the stenotic portion on the right pulmonary artery was deemed preferable in the distal form.

Agents for the treatment of overactive detrusor. I. Synthesis and structure-activity relationships of 1,1'-biphenyl derivatives

A series of 1,1'-biphenyl-2,6-dicarboxylic acid diesters were synthesized and examined for their inhibitory activity on guinea-pig detrusor muscle contraction at electrical field stimulation in vitro. Among them, 6-isopropyl 2-methyl 3-hydroxy-5-methyl-2'-nitro-(1,1'-biphenyl)-2,6-dicarboxylate, FR75513 (8a) was one of the potent compounds (IC50 = 3.3 x 10(-6) g/ml). This compound (8a) exhibited a strong inhibitory activity on detrusor contraction after intravenous administration in anesthetized rats (ID50 = 0.04 mg/kg).

[Diagnosis and surgical treatment of accessory mitral valve with associated congenital heart disease]

Accessory mitral valve (AcMV) is a rare cardiac anomaly that may possibly cause left ventricular outflow tract (LVOT) obstruction. Five patients who underwent surgical resection of AcMV were reported. All these patients had associated cardiac anomalies, which include transposition of great arteries (TGA) in two cases, ventricular septal defect (VSD) in one, double outlet right ventricle (DORV) in one and membranous septal aneurysm (MSA) in one. Age at operation ranged from 23 days to 22 months. In these cases preoperative pressure gradient across the LVOT ranged from 10 to 35 mmHg. Resection of AcMV was performed together with radical operation for associated anomalies in all the patients. Approach for resection of AcMV consisted of trans-ventricular septum method in 3 patients of VSD, DORV or MSA and trans-pulmonary artery method in 2 cases of TGA. There was no operative death. The postoperative pressure gradient across the LVOT ranged from 0 to 13 mmHg. Two dimensional echocardiography was essential for the accurate preoperative diagnosis of AcMV in 4 out of the 5 patients. The trans-ventricular septum method, when the large VSD was present, for resection of AcMV was found to be quite useful especially for neonates in order to obtain an excellent operative field, as compared with the conventional method.

Chemotherapy of soft tissue sarcomas in the extremities

A retrospective study on chemotherapy against soft-tissue sarcomas in the extremities was carried out on 98 patients. The local recurrence rate was 10.3% with intensive chemotherapy in post-1980 patients with high-grade sarcomas but 46.7% without chemotherapy--a fairly significant difference (P less than 0.01). The survival rate was significantly higher with intensive chemotherapy in post-1980 patients with high-grade sarcomas. Thus, intensive chemotherapy based on a new protocol should be given in cases of high-grade sarcoma. Considering surgical margin, the local recurrence rate was 33.3% in post-1980 cases inadequately operated upon but 8.6% in those adequately operated upon, which shows a significant difference (P less than 0.05).

Venous infarction following the interhemispheric approach in patients with acute subarachnoid hemorrhage

Postoperative venous infarction following aneurysm surgery was studied in 48 patients with anterior communicating artery aneurysms operated on through the interhemispheric approach at the acute stage of subarachnoid hemorrhage (SAH). Of 23 patients whose bridging veins were sacrificed during surgery, 11 (47.8%) showed venous infarction in the frontal lobes. In contrast, only one (5.9%) of 17 patients whose bridging veins were preserved developed cerebral edema. None of eight patients who were operated on after Day 11 (the day of SAH was defined as Day 0) showed this complication, although bridging veins were sacrificed in six of them. Venous infarction following acute aneurysm surgery tended to occur more frequently in patients of higher SAH grade and/or more advanced age, but these correlations were not significant. However, the correlation between the sacrifice of veins and venous infarction was significant (p less than 0.025). Because this potential complication may compromise the benefit of acute aneurysm surgery and cause damage, it is important to preserve the venous system and in some instances to select another surgical approach based on the pattern of venous drainage in the frontal lobe.

Efficacy of recombinant human granulocyte colony-stimulating factor on neutropenia in patients with AIDS

The efficacy of recombinant human granulocyte colony-stimulating factor (rhG-CSF) on neutropenia was evaluated in 14 patients with AIDS and AIDS-related complex (ARC). In all patients, including 11 neutropenic patients, 100 or 200 micrograms/m2 of rhG-CSF significantly increased the neutrophil counts. The response was greater in patients with higher neutrophil counts before the treatment, and was also dose-dependent. Although the effect seemed to be less potent, the agent also increased the neutrophil counts even when zidovudine (azidothymidine, AZT) and other myelosuppressive antiviral agents were administered simultaneously. These observations indicate that rhG-CSF may be beneficial in preventing and treating some secondary infections, and will make it easier to continue therapy with antiviral agents in patients with AIDS or ARC.

[A case of large basal ganglia AVM totally removed by staged operation]

Large basal ganglia AVMs have been deemed inoperable because of their location in critical structures. Nonetheless, the unfavorable natural history of an untreated ruptured AVM in a young patient induced us to approach these lesions. We presented a case of a large basal ganglia AVM totally removed by a three-staged operation. A 26-year-old man who had twice experienced intracranial hemorrhage was admitted for examination. On admission, mild left hemiparesis, hypesthesia and left hemianopsia were disclosed. CT scan showed the AVM was located in the posterior thalamus with the hematoma cavity laterally. Right carotid and vertebral angiograms demonstrated a large AVM, 5cm in diameter, supplied by the anterior choroidal artery (AchoA), the lateral lenticulostriate arteries (I-LSAs), the lateral posterior choroidal artery (LPchoA) and the thalamo-perforating artery. Drainage was via the internal cerebral vein and the basal vein of Rosenthal. MRI demonstrated more clearly the anatomical relationship of the nidus and surrounding structures. The patient underwent a three staged operation. At the first operation AchoA was interrupted in the inferior horn of the lateral ventricle (IHL) via the hematoma cavity using the trans-sylvian approach. The anterior part of the nidus was dissected with all except one of the I-LSAs being disconnected. At the next operation by occipital interhemispheric approach, some feeders from the posterior cerebral artery were coagulated and disconnected. The medial and posterior part of the nidus was dissected from the thalamus along with the choroid plexus of the trigone of the lateral ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial protection by retrograde cardioplegia in arterial switch operation

Retrograde coronary sinus perfusion of cold cardioplegic solution was evaluated in infants undergoing an arterial switch operation for transposition of the great arteries. To assess myocardial injury during ischemia, hemodynamic measurements were conducted at weaning from cardiopulmonary bypass and a postoperative assay of creatine kinase isoenzyme MB was performed. In 22 infants with retrograde coronary sinus perfusion, the initial cardioplegic infusion was performed through the aortic root and additional infusion was repeated every 30 minutes by retrograde coronary sinus perfusion. The other 11 infants received additional solution by antegrade selective coronary artery perfusion. The aortic cross-clamp time in the retrograde coronary sinus perfusion group was significantly shorter than that in the antegrade selective coronary perfusion group (128 +/- 19 versus 143 +/- 21 minutes, p less than 0.05). There were no significant differences between the two groups in terms of postoperative hemodynamic variables and enzyme indexes. Eight neonates in the retrograde coronary sinus perfusion group also exhibited enzymatic and hemodynamic indexes similar to those of older infants. These results suggested that retroperfusion of cardioplegic solution was a safe and useful means of myocardial protection in infants and neonates because of the simplification of the operative procedure and the avoidance of traumatic injury to the coronary ostia.

Primary repair for complete atrioventricular canal: recommendation for early primary repair

Forty patients with complete atrioventricular canal (CAVC) underwent primary repair at Fukuoka Children's Hospital in Fukuoka, Japan, between August 1, 1981 and July 31, 1989. The age at repair ranged from 2 months to 6 years (mean 19 months); weight ranged from 2.3 to 22 kg. The surgical mortality was 2.5%. Justification for early primary repair was examined. Eleven patients underwent repair before 6 months of age (Group 1), 12 patients, between 7 and 11 months of age (Group 2), and 17 patients, after 12 months of age (Group 3). Degenerative changes in the atrioventricular valve increased significantly as age at repair increased (p less than 0.05 Group 1 versus Group 3). The incidence of residual mitral regurgitation tended to increase in the order of Group 1, 2 and 3, though the degree ranged from trivial to mild. Study of the left atrium/aorta ratio by echocardiography revealed that stable values of around 1.1 in Groups 1 and 2 and around 1.3 in Group 3 continued during the follow-up period of 3 years. Assessment of the diameter of the repaired mitral valve in the mean interval of 26 months in groups 1 and 2 revealed normal growth of the mitral valve annulus. The angle between the repaired mitral valve and ventricular septum, which can be affected by the growth of the ventricular septum, converged to normal range in the mean interval of 26 months. Postoperative pulmonary vascular resistance in Groups 2 and 3 was higher at 4.4 +/- 2.3 and 6.3 +/- 2.2, respectively, than in Group 1 at 3.3 +/- 2.2 (p less than 0.01 versus Group 3).(ABSTRACT TRUNCATED AT 250 WORDS)

Alterations of elastic architecture in human aortic dissecting aneurysm

Elastin of the ascending aortic media of 10 cases with type A dissecting aneurysm, 14 hypertensive cases, and 30 control cases were prepared by the treatment of aortas with hot formic acid, and three-dimensional architecture was observed by scanning electron microscopy. In the control cases, elastin showed framework-like continuous structure consisting of elastic laminae, and interlaminar fibers that interconnected the laminae. In 6 of 10 cases of dissecting aneurysm, the interlaminar fibers were apparently irregular in arrangement and shape, and decreased in number, especially in the outer media. This architectural alteration resulted in a rarefaction of interconnection between the elastic laminae in the media, and possibly resulted in the local weakness against the dissecting force of the laminae. This medial weakness may be related to the mechanism of initiation and progression of dissecting aneurysm. The cystic medial necrosis (CMN) was found in 3 cases, but only 1 of them was accompanied by a mild decrease of the interlaminar fibers in the area outside of CMN, suggesting that the initiation of CMN did not directly relate to the decrease of the interlaminar fibers. The aortic media of hypertensives generally showed an increase of interlaminar fibers, but their focal decrease was encountered in the outer media of 3 cases. These findings suggest that the decrease of the interlaminar fibers of medial elastin seen in dissecting aneurysms were related to hypertension.

Postoperative arteriovenous fistula between the middle meningeal artery and the sphenoparietal sinus

The authors report a case of postoperative middle meningeal arteriovenous fistula found after craniotomy for aneurysmal surgery using the pterional approach. It was no longer demonstrable at the follow-up examination 3 months later.

Enhanced vasoconstrictor effect of endothelin in cerebral arteries from rats with subarachnoid haemorrhage

The contractile response to endothelin has been examined in cerebral arteries from rats subjected to a prior subarachnoid haemorrhage (SAH) and compared with saline-injected controls. Endothelin elicited concentration-dependent contractions of rat basilar artery segments. The endothelin-induced contractions were much stronger in the SAH compared to control animals, which suggests a role in the pathophysiology of cerebral vasospasm.

[Effects of prostacyclin (PGI2) on the hypoxic pulmonary vasoconstriction in dogs]

Effects of exogenous PGI2 on the hypoxic pulmonary vasoconstriction (HPV) were investigated by measuring %QLLL and the ratio of the left lower lobe blood flow (QLLL) to the total pulmonary blood flow (QT), in separately ventilated canine in vivo model. With PGI2 infusion, %QLLL, that had decreased from 20.7 +/- 1.9% to 4.1 +/- 1.1% by the hypoxic gas ventilation, gradually increased to 16.4 +/- 3.2% at the maximum dose (1.0 micrograms kg-1. min-1). Simultaneously both pulmonary artery pressure and PaO2 decreased significantly. Systemic blood pressure dropped markedly but cardiac output remained at the initial level. These results suggest that exogenous PGI2 improves the pulmonary circulation by reducing pulmonary hypertension induced with HPV, while PGI2 induces hypoxia by inhibiting HPV response and systemic hypotension by dilating the peripheral resistance vessels. Therefore, we have to consider these two opposite effects of PGI2 on its clinical application.