[Brain metastasis of rhabdomyosarcoma with intratumorous hemorrhage: a case report and literature review]

A 56-year-old male suffered from primary rhabdomyosarcoma on the left internal thoracic wall, which was treated by chemotherapy, and local irradiation following biopsy. Four months after the diagnosis, he suddenly complained of headache and left paresthesia occurred followed by generalized convulsion and left hemiplegia. CT scan revealed a high density mass in the right parietal lobe. The patient was referred to our department and underwent emergency evacuation of the hematoma together with tumor removal. The pathological specimen showed spindle or oval-like cells with hypercellularity and some mitotic figures. Immunohistochemical study demonstrated that many cells were positive for desmin and myoglobin, which is specific to myogenic tumor. These characteristics were compatible with those of the primary thoracic lesion, and a diagnosis of metastatic rhabdomyosarcoma was made. Five weeks after the craniotomy, the metastatic brain tumor recurred in the same site and also in the bilateral occipital lobes. Although radiotherapy to the brain decreased the tumor size, the patient died of respiratory failure eleven and a half months after the initial diagnosis. Sarcomas metastasizing to the brain are rare and only 16 cases of rhabdomyosarcoma metastasizing to the brain have been reported so far. Recent advances in chemotherapy, however, have been able to show the increased incidence of sarcoma metastasis to the brain. Therefore, the necessity of follow-up CT scan for sarcoma patients of long survival is to be stressed, even if the patient shows no neurological symptoms.

[Clinical research of patients with epilepsy over age 50 years--a retrospective study of early onset case]

One hundred-sixteen patients with epilepsy over 50 years old were investigated to explore the clinical characteristics of epilepsy in elderly persons. Eighty-four patients having seizures within the last 3 years (residual group) were compared with 32 patients having no seizures within the last 3 years (disappeared group). Regarding the epilepsy type, there were 87 partial epilepsies (64 in the residual group and 23 in the disappeared group) which were approximately 70 percent of the total patients. Generalized epilepsies were comparatively rare in the both groups. Eleven patients with progressive myoclonus epilepsy were observed in the residual group. Regarding the seizure type, generalized convulsive seizures (GCS) were more likely to disappear than partial seizures regardless of number of seizures the patient had. Thirty-eight patients (29 in the residual group and 9 in the disappeared group) had histories of psychiatric problems. Paranoid states were most commonly seen in 12 patients in the residual group and 5 patients in the disappeared group. Intellectual disturbance was seen more frequently in the residual group.

Intracarotid amobarbital injection produces hippocampal EEG changes in patients with temporal lobe epilepsy

EEGs of hippocampi of both sides were analyzed during intracarotid amobarbital tests in 12 patients with temporal lobe epilepsy. The number of paroxysms occurring 1 min before the injection ipsilaterally and contralaterally was compared with that occurring 1 min after the injection. The hippocampal EEG ipsilateral to the injection showed an increase in paroxysms irrespective of the laterality of the epileptogenic side. Contralateral to the amobarbital injection an increase in paroxysms was observed in the epileptogenic hippocampus only.

Massive cerebral air embolism following cardiopulmonary resuscitation. Report of two cases

Cerebral air embolism can occur in a number of situations. We report two cases of massive cerebral arterial air embolism following cardiopulmonary resuscitation, and its mechanism is discussed.

[Penetrating injury of the common carotid artery: report of a case]

An eighty-year-old man slipped in the bathroom and received a deep slash wound in his left neck caused by a broken fragment of the bathroom door. A fragment of the glass stuck into his left neck. He was carried to our clinic after 20 minutes in a state of shock and showed right hemiparesis and aphasia. Following immediate orotracheal intubation and emergent therapy for shock, he was transferred to the operation theater for massive arterial bleeding from the wound. The left common carotid artery and internal jugular vein were exposed by extending the skin incision from the cervical wound along the anterior border of the left sternocleidomastoideus. The left common carotid artery and the internal jugular vein were simultaneously transected, and end-to-end anastomosis of the carotid artery was performed under the administration of 300 ml of Sendai Cocktail. The occlusion time of the left common carotid artery was approximately 50 minutes. Right hemiparesis and total aphasia did not change immediately after the surgery. The postsurgical CT scan showed an infarction in the posterior portion of the left middle and posterior cerebral arteries. However, after undergoing rehabilitation for a month, the patient could walk alone, and his aphasia improved. Many large series of penetrating injuries to the carotid artery were reported after World War II. Most casualties were younger males injured by gunshot. In middle cervical injury, the common carotid artery is the most vulnerable vessel, although other large vessels such as the external and internal carotid arteries as well as the internal jugular vein may be involved, often causing neurological deficits and shock.(ABSTRACT TRUNCATED AT 250 WORDS)

[A patient with gigantic heterotopic gray matter with epileptic seizures]

We report a patient with partial seizure and gigantic heterotopic gray matter. A 23-year-old young man was admitted to our hospital with complaints of frequent epileptic seizures and psychiatric symptoms. There was psychomotor delay in infancy. At the age of 4 years, afebrile convulsions appeared on several occasions. Seizures characterized by a lapse of consciousness started at the age of 13 years. He often stayed in a fantasy world and became very emotional at such time. Cranial CT demonstrated an irregularity in the wall of right lateral ventricle and disappearance of the posterior horn on the same side. This lesion, adjacent to that wall, had a signal intensity that was similar to that of the gray matter on each sequence in MRI. Histopathology of this lesion showed a number of large and small neurons. Therefore, heterotopic gray matter was diagnosed. MRI demonstrated wide cortices suggesting polymicrogyria in the right parietal lobe. Complex partial seizures with eye deviation to the left were recognized. Interictal EEG showed frequent high voltage spikes in the right temporal, fronto-temporal and parieto-occipital areas independently. Therefore, epileptic foci were thought to exist in or around those lesions.

Aneurysms arising from the proximal (A1) segment of the anterior cerebral artery. A study of 38 cases

This study reviews aneurysms of the proximal segment (A1) of the anterior cerebral artery in 38 patients (23 men and 15 women) and their surgical, angiographic, and clinical management. Thirty-seven aneurysms were saccular and one was fusiform. The incidence of A1 aneurysms among a total of 4295 aneurysm cases treated was 0.88%. Multiple aneurysms occurred in 17 patients (44.7%) of the 38 cases; in 10 (58.8%), there was bleeding from the A1 aneurysm. The aneurysms were classified into five categories according to the mode of origin of the aneurysm in relation to the A1 segment: in 21 cases, aneurysms originated from the junction of the A1 segment and a perforating artery; in eight, from the A1 segment directly; in six, from the proximal end of the A1 fenestration; and in two, from the junction of the A1 segment and the cortical branch. One patient had a fusiform aneurysm. Computerized tomography (CT) of these aneurysms revealed bleeding extending to the septum pellucidum similar to that of anterior communicating artery aneurysms. When performing radical surgery it is very important to recognize the characteristics of A1 aneurysms, including multiplicity, a high incidence of vascular anomalies (especially A1 fenestration), and their similarity to anterior communicating artery aneurysms on CT.

Acid cholesteryl ester hydrolase activity of mononuclear leukocytes in patients with non-insulin-dependent diabetes mellitus: studies before and after treatment of diabetes

The change of acid cholesteryl ester hydrolase activity in mononuclear leukocyte following treatment of diabetes mellitus was studied in 21 patients with non-insulin-dependent diabetes mellitus (NIDDM). Enzyme activity before treatment in the patients was significantly lower than that in 14 age-matched healthy subjects (1.20 +/- 0.15; mean +/- S.E. vs. 2.20 +/- 0.17 nmol/mg protein/h, P less than 0.01). Enzyme activity before treatment in the patients was significantly increased (P less than 0.05) after 4-8 weeks of treatment. However, enzyme activity of 1.43 +/- 0.14 nmol/mg protein/h observed after treatment in the patients was significantly lower (P less than 0.01) than that in the healthy subjects. There was a significant negative correlation between enzyme activity before treatment and the increase in enzyme activity following treatment (rs = -0.555, P less than 0.01, n = 21). These results indicate that low level of enzyme activity may be insufficiently improved by the treatment of diabetes, and the risk for the development of atherosclerosis as viewed from the enzyme activity may persist even after the treatment in NIDDM.

[Clinical analysis of cerebral infarction in children]

Six cases of cerebral occlusive disease in children were reported. The cerebral arterial occlusive disease had its onset at the age of less than 4 years, except for one case of a 9 year-old. The causes of occlusion were, trauma in two cases, infectious disease in one case, intraarterial myxoma in one case and an unknown reason in two cases. Initial symptoms were sudden onset of hemiplegia in 5 cases, and headache in one case. Angiography revealed stenosis of the main trunk of the middle cerebral artery, or of the anterior cerebral artery in 4 cases. Angiographical manifestations of stenosis in 4 cases were classified into two types, diffuse stenosis and localized stenosis. No stenotic changes were demonstrated in two cases, in which CT revealed a small low density area in the putamen. Follow up angiogram in three cases revealed improvement of stenosis. Though therapy in all cases was conservative, their prognosis is not so poor as had been considered. As the rate of recanalization in children was assumed to be high as compared with adult cases, it was considered that surgical revascularization in the acute stage had to be undergone very carefully.

10-year follow-up study of epilepsy with psychosis

Thirty-three cases of psychosis associated with epilepsy were followed in our clinic for 10 years. In 12 cases, the psychotic symptom appeared episodically and 9 of them had more than one relapse and 7 of them more than 2 relapses. Only 3 cases had no relapse. In 21 cases, the psychotic symptoms were continuous, lasting more than 2 years. In 8 of them, the symptoms were stable and remained unchanged but in 13 of them, the symptom showed exacerbation and partial remissions. In 11 cases, a decrease or discontinuation of antipsychotic drugs (mostly haloperidol) significantly provoked or aggravated the psychotic symptoms.

[Superoxide anion (O2-) production by polymorphonuclear leukocytes in insulin dependent diabetes mellitus (IDDM)]

The superoxide anion (O2-) production in polymorphonuclear leukocytes stimulated by phorbol myristate acetate in IDDM and non-insulin dependent diabetes mellitus (NIDDM) was determined by the method of Johnston et al, compared with that of each age matched controls. And the correlation between O2- production and hemoglobin (Hb) A1 and A1c value was investigated. The O2- production in IDDM was 24.4 +/- 7.4 (mean +/- SD, n mol per 4 X 10(5) cells) at 10 min. and 51.4 +/- 8.7 at 30 min., in NIDDM each 31.6 +/- 9.3, 60.2 +/- 14.4, and in controls each 40.5 +/- 4.2, 72.4 +/- 3.1. O2- production in IDDM was significantly lower than that in NIDDM (p less than 0.001 at 10 min. and p less than 0.01 30 min.) and controls (p less than 0.001 at 10 and 30 min.). O2- production at 10 and 30 min. possessed a negative correlation with Hba1 and A1c value (HbA1: p less than 0.01 at 10 min. p less than 0.05 at 30 min., HbA1c: p less than 0.01 at 10 and 30 min.). These findings suggest that impaired O2- production might be one of the factors accounting for depressed bactericidal activity of polymorphonuclear leukocytes in IDDM, and that a protracted hyperglycemia might shed some effect on O2- production.

[Delayed traumatic vasospasm: correlation between cerebral vasospasm and contusion]

The pathogenesis of delayed traumatic vasospasm is not yet fully understood. We present six cases of delayed traumatic symptomatic vasospasm along with CT scan and angiographic findings. The cases ranging in age from 16 to 78 years all had head injury caused by traffic accidents. The Glasgow coma scale on admission was 9 - 15 except in one severe case GCS 6. Initial CT scans were obtained on the day of injury in four patients and on the 2nd and 3rd days in the other two cases respectively. There was no distinct subarachnoid hemorrhage in the suprasellar cistern. Subarachnoid hemorrhage in the Sylvian cistern was observed with particular care in all patients. However the severity of subarachnoid hemorrhage was mild (isodensity or slight high density by CT) in 4 cases. Brain contusions on CT scan were observed in the temporal and/or frontal region of 5 of 6 patients. Ischemic symptoms occurred during the period between 5 and 13 days after head injury. The cerebral angiogram taken after the occurrence of these symptoms revealed spasms in all patients, the spasm being bilateral in 2 of them. Spasms were recognized on the main arteries at the base of the brain such as C1, M1, M2 and A1. In 5 cases, the cerebral contusion and the spasm were located on the same side. Angiographically the vasospasms lasted 2 to 5 weeks. The prognosis based on the Glasgow outcome scale was good recovery in 3 patients and moderate disability in one. Two elderly patients with bilateral spasms were in a vegetative state and severe disability, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolated hypoglossal nerve palsy and Horner's syndrome with benign course

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Early CT features of ruptured cerebral aneurysms of the posterior cranial fossa

This report describes our retrospective evaluation of CT features of the acute phase in 34 cases of ruptured cerebral aneurysms of the posterior cranial fossa. The results are as follows. 1. Examination of cisternal haematoma distribution revealed that SAH had extended to the supra- and infratentorial cisterns in 28 cases (82%). There were only 6 cases (18%) in which SAH was confined to the posterior cranial fossa only but even when there was subarachnoid haematoma in both the supra- and infratentorial cisterns, thick haematomas were seen at the periphery of the brain stem. In cases of vertebral artery-posterior inferior cerebellar artery aneurysms (VA-PICA AN), haematomas in the ambient cistern were thicker on the aneurysm side. In addition, in cases of basilar artery-bifurcation (BA-Bifurcation AN) and basilar artery-superior cerebelli artery aneurysms (BA-SCA AN), there were many thick, high-density haematomas in the interpeduncular cistern. 2. The rate of intracerebral haemorrhage was extremely low (1 patient). 3. The rate of intraventricular haemorrhage was high, and these haemorrhages demonstrated a reflux pattern. 4. The rate of hydrocephalus was high (76.5%) in comparison with that noted in association with SAH due to the rupture of anterior circulation aneurysms.

Two cases of spontaneous internal carotid artery occlusion due to giant intracranial carotid artery aneurysm

Although spontaneous thrombosis of a giant intracranial aneurysm is relatively common, occlusion of its parent artery is rare. We describe two recent patients in whom the parent artery spontaneously occluded. One patient had severe stenosis of the left internal carotid artery, with delayed appearance of a faint shadow of vascular widening near the posterior clinoid process. One month later, complete occlusion of the left internal carotid artery was shown angiographically. The second patient had dysarthria and left hemiparesis, resulting in the diagnosis of a left internal carotid artery giant aneurysm. He had suffered an episode of visual disturbance of the right eye 5 years before. Angiography showed the right cervical internal carotid artery to be occluded. We believe the mechanism of parent artery occlusion in our two patients to be due first to stretching of the internal carotid artery by the enlarged aneurysm, followed by compression of the internal carotid artery by the aneurysm itself. Next, the anterior clinoid process and the optic nerve are involved, and, finally, thrombosis of the aneurysmal cavity extends into the internal carotid artery itself.

Deteriorating epilepsies: severely deteriorated cases

A total of 28 cases of severely deteriorated epileptic patients were seen at out- and inpatient services in the past 12 years. In 22 out of these 28 cases, the etiology for the deterioration was considered to be due to either repetitive intractable seizures or antiepileptic drugs (AEDs) or both. Although differential diagnoses were difficult in many cases as to the responsible causes, namely seizure vs. AEDs, it was considered in 6 cases that AEDs took a major role in their deterioration. Details of such cases are presented. Special emphasis was made to the fact in which they frequently showed episodes of acute or ataxia and confusion often associated with febrile illness. They took a course of acute or subacute exacerbation and partial remission. Discussion was held on the nature and possible avoidance of these deteriorations.

Acid cholesteryl ester hydrolase activity of mononuclear leukocyte in type 2 (non-insulin-dependent) diabetic patients

Acid cholesteryl ester hydrolase activity of mononuclear leukocytes was measured in 52 Type 2 (non-insulin-dependent) diabetic patients. Enzyme activity was significantly lower in the diabetic patients than in 14 age-matched control subjects (0.89 +/- 0.08 (mean +/- S.E.) vs. 2.20 +/- 0.17 nmol/mg protein/hr, p less than 0.01). In diabetic patients undergoing diet treatment only, the enzyme activity was significantly lower in poorly controlled patients than in well controlled patients (0.43 +/- 0.03 vs. 1.15 +/- 0.24 nmol/mg protein/hr, p less than 0.01). In the diabetic patients, there was a significant negative correlation between the enzyme activity and serum total cholesterol or low density lipoprotein cholesterol level (r = -0.361, p less than 0.01, n = 52 or r = -0.630, p less than 0.01, n = 28). These results suggest that a low level of acid cholesteryl ester hydrolase activity in mononuclear leukocyte might play an important role in the progression of atherosclerosis in Type 2 diabetes.

[Posterior fossa subdural hematoma in the newborn caused by birth injury]

Among various cases of intracranial hemorrhage in the newborn caused by birth injury, posterior fossa subdural hematoma is of serious nature in many cases and often results in death after critical clinical course due to compression of the respiratory center of the medulla oblongata. We have recently experienced two cases of subdural hematoma in the posterior fossa caused by birth injury, which we successfully treated non-surgically. Herein, we report these two cases and present a sequential CT scan of each. The first case is a full-term (39 weeks gestation) male infant. Delivery was carried out spontaneously with double footling presentation. At 20 hours of age, cyanosis and convulsion occurred. CT scan was performed and revealed high density areas in the posterior fossa, quadrigeminal cistern and longitudinal cerebral fissure. Bloody CSF was discharged per lumbar puncture and glycerol was infused intravenously, but the ventricle became enlarged. At this point at 9 days of age, the infant was admitted to our hospital. While he showed poor activity on admission, hematoma was absorbed gradually and disappeared at 3 months of age by conservative treatment. Now, at 6 years and 6 months of age, the patient has no neurological deficits. The second case is a full-term (40 weeks gestation) twin female infant. Due to breech presentation, delivery was conducted per breech extraction. At three days of age, vomiting, fontanel bulging and hypotonia were observed. CT scan revealed hematoma similar to that seen in the first case, and steroid and glycerol were infused intravenously. Conservative treatment was performed in this case also, and changes shown by CT scan were almost the same as those seen in the first case. The patient has no neurological deficits at 5 years and 7 months of age. Since the introduction of CT scan, early diagnosis of a subdural hematoma in the posterior fossa has been possible. But reports of successful surgical treatment are not so frequent.(ABSTRACT TRUNCATED AT 250 WORDS)