Usefulness of posterior transpetrosal approach for the large solid cerebellopontine angle hemangioblastoma fed from multiple blood supplies: A technical case report

Background

Extra-axial cerebellopontine angle (CPA) hemangioblastomas are rare clinical entity and surgical treatment is challenging due to the anatomical difficulties and multi-directional blood supplies. On the other hand, the risk of endovascular treatment for this disease has also been reported. Herein, we successfully applied a posterior transpetrosal approach to remove a large solid CPA hemangioblastoma without preoperative feeder embolization.

Case Description

A 65-year-old man presented with a complaint of diplopia during downward gaze. Magnetic resonance imaging revealed a solid tumor with homogeneous enhancement measuring about 35 mm at the left CPA, and the tumor compressed a left trochlear nerve. Cerebral angiography disclosed tumor-staining fed by both left superior cerebellar and left tentorial arteries. After the operation, the patient's trochlear nerve palsy improved dramatically.

Conclusion

This approach offers more optimal surgical working angle to the anteromedial part compared to the lateral suboccipital approach. In addition, the devascularization from the cerebellar parenchyma can be performed more reliably than the anterior transpetrosal approach. After all, this approach can be particularly useful when vascular-rich tumors receive blood supplies from multiple directions.

[A Case of Primary Central Nervous System Lymphoma Originated from Optic Chiasma and Presenting Difficulty in Diagnosis]

We report a case of primary central nervous system lymphoma(PCNSL)originating from an optic chiasma, which was difficult to diagnose but was finally diagnosed by biopsy. A 62-year-old immunocompetent man presented with bilateral visual field disturbance, hypopituitarism, and diabetes insipidus;an optic chiasm lesion was detected on MRI. After starting steroid supplementation for adrenal insufficiency, visual field disturbance immediately improved. Since the lesion completely disappeared three months after its onset, it became the follow-up without histological confirmation. Six months after the onset, visual field disturbance progressed, and the lesion recurred. We performed a left optic nerve biopsy to maintain the right visual field, which remained partially. The pathology was PCNSL. We performed postoperative chemoradiotherapy, and the patient showed remission and improvement of the visual field. Isolated PCNSLs arising from optic chiasma are very rare. The diagnosis of optic chiasm lesions is difficult due to their similarity with a variety of inflammatory/autoimmune disease and neoplastic lesions. When a lymphoma is considered to be differentiated, early biopsy should be performed before administering a steroid. The approach and sampling site to prevent the function are also important for biopsy.

Novel method of ASV titration for patient with severe heart failure. (Not for AHI improvement but for cardiac output)

Background

Adaptive servo-ventilation (ASV) is reportedly beneficial for the treatment of heart failure in patients with central sleep apnea syndrome. However, the recent SERVE-HF trial reported that ASV treatment increased mortality in these patients. One cause of the negative result was considered to be the low output induced by high expiratory positive airway pressure (EPAP) against the background of low left ventricular ejection fraction (LVEF).

Hypothesis

We hypothesized that optimized ASV settings can be determined by evaluating outflow by using echocardiography, thereby ensuring benefits for patients with severe heart failure (HF).

Methods

Between July 2016 and March 2017, we optimized ASV settings by using hemodynamic parameters on echocardiography in hospitalized patients with severe HF treated with catecholamine or who were candidates for heart transplantation. We calculated stroke volume (SV) by using the time-velocity integral in the left ventricular outflow tract and compared the response to ASV with EPAP settings of 2, 4, 6, or 8 mmHg. We determined the optimal setting at which the SV reached the maximum value and compared this with the settings at baseline and discharge. We also compared rehospitalization and all-cause mortality between the patients who used ASV with titration (n=28) and without titration (n=37).

Result

We evaluated 28 patients with severe HF (mean EF, 32%). ASV treatment improved the SV (from 53.4 to 58.8 ml, P<0.05) when optimal settings were used. However, the SV decreased when ASV was performed with a higher-than-optimal EPAP setting. Moreover, at discharge, the EPAP setting was lower than at baseline (mean EPAP, 4.75 cmH2O decreased to 3.71 cmH2O, P<0.05). During the follow-up (median, 420 days), more hospitalizations and deaths occurred in the patients without ASV titration (48.8% vs 37.8%) than in those with ASV titration (28.6% vs 21.4%, respectively; Figure 1).

Conclusion

In patients with severe HF, high EPAP decreased the SV and optimal settings were different at baseline and after treatment. The result indicated that the optimal setting for ASV may be beneficial for preventing rehospitalization and death. Whether optimal ASV settings reduce mortality in these patients must be investigated.

Figure 1

Funding Acknowledgement

Type of funding source: None

Parieto-Occipital Interhemispheric Transfalcine, Trans-Bitentorial Approach for Radical Resection of Falcotentorial Meningiomas

OBJECTIVE

 Falcotentorial meningioma occurs close to the falcotentorial edges and the confluence of the vein of Galen. The posterosuperior approach conventionally used to reach this site does not allow direct visualization of the tumor matrix, making detachment difficult. Meningiomas at this location are therefore among those that are not well amenable to radical resection. We devised an alternative anterolateral approach that, when used in addition to the posterosuperior approach, provides an operating field which allows to overview large, bilaterally extending tumors. We report this parieto-occipital interhemispheric transfalcine, trans-bitentorial approach, together with associated procedural modifications.

METHODS

 We used the approach in four patients with falcotentorial meningioma between February 2008 and July 2017. We began by extending a parieto-occipital craniotomy slightly beyond the midline, to pass across the most caudal bridging vein on the rostral side. We then created a fan-shaped fenestration as large as possible in the falx, between the superior sagittal sinus and the inferior sagittal and straight sinuses (window 1). We further performed wedge-shaped resections of both tentorial edges to the left and right of window 1 (windows 2 and 3). Tumor debulking was then carried out via these three windows (the triple-window method). Finally, we detached the tumor in the area of the falcotentorial edges and the confluence of the vein of Galen. To obtain a superorostral operating field as wide as possible from laterally, thereby exposing the potential blind spots, the operating surgeon used both hands while retracting the precuneus, and the assistant surgeon used both hands to turn over the falcotentorial edges (twosome four-hand retractorless microsurgery).

RESULTS

 The wide operating field provided by this parieto-occipital interhemispheric transfalcine, trans-bitentorial approach and twosome four-hand retractorless microsurgery provides a direct view of delicate structures at the falcotentorial edges and the confluence of the vein of Galen, a site that is most likely to be a blind spot in conventional approaches. Retraction of the precuneus on the nondominant side enabled radical resection with no neurologic deficit in any of the patients.

CONCLUSIONS

 The parieto-occipital interhemispheric transfalcine, trans-bitentorial approach with the triple-window method opens an anterolateral operating field in addition to a posterosuperior operating field in large tumors located in the falcotentorial and pineal region, extending anteroposteriorly and bilaterally. The twosome four-hand retractorless technique via this approach enables visualization of the tumor matrix at sites, which are barely visible with the conventional approach. Thus, the tumor can be removed more radically and safely.

Superior Oblique Myokymia: A Case Report of Surgical Treatment, Review of the Literature, and Consideration of Surgical Approach

BACKGROUND

Superior oblique myokymia (SOM) is a rare disorder characterized by episodic microtremor of the eyeball. in patients with SOM, intermittent contraction of the superior oblique muscle causes irregular and rotatory eye movement, causing oscillopsia and diplopia. Microvascular decompression (MVD) of the trochlear nerve is potentially a definitive treatment method for SOM; however, owing to its rarity, this disorder is not well-known to neurosurgeons, and thus the optimal surgical approach has not yet been determined.

CASE DESCRIPTION

A 77-year-old woman with left SOM had experienced oscillopsia for 2 years. MVD was performed via a left lateral superior cerebellar approach with the patient in the park-bench position. Her symptom resolved immediately after the surgery.

CONCLUSIONS

We believe that MVD via a left lateral superior cerebellar approach can be safely performed to SOM in elderly patients like our patient. Therefore, MVD should be considered as the definitive treatment method for more patients with SOM.

Intracranial epidermoid cyst with proliferative folliculosebaceous epithelium: Report of a rare case and discussion on pathogenesis

Intracranial epidermoid cysts are rarely known to increase in size over a brief period. While malignant transformations of epidermoid cyst have been previously described, no reports to date have described rapid proliferation accompanied by mature hair follicles and sebaceous glands without malignant transformations. The present case involved a 71-year-old man who visited a local physician with disturbance of equilibrium. A mass lesion was detected at the left cerebellopontine angle and was subsequently removed. Histopathological diagnosis of this lesion was as an epidermoid cyst. Seventeen years after this initial surgery, worsened left hypoacusis, disorientation, eating disorder and gait disturbance appeared, and the patient visited the physician again. Local recurrence of the lesion was observed, and the patient was referred to our hospital for its removal. Intraoperative findings revealed a pearly white tumor, histopathologically diagnosed as an epidermoid cyst. Three years later, local recurrence was observed, and the cyst was again removed. Intraoperative findings revealed a partially pearly white tumor similar to the tumor observed during the second surgery, but the majority of the tumor was non-shiny, ochre-colored and suckable. Histopathological diagnosis was an epidermoid cyst with an epidermis-like structure. Postoperative activities of daily living were independent thereafter, but from March of the following year, he began to experience increasing difficulty in walking and subsequently visited our hospital again. Tumor recurrence was observed and was removed again in November of the same year. Intraoperative findings revealed a tumor that was primarily ochre-colored, non-shiny, brittle and suckable. The histopathological diagnosis was folliculosebaceous epithelial proliferative lesion accompanied by an epidermis-like epithelium and a differentiation into hair follicles and sebaceous gland,s and the tumor was determined to be an epidermoid cyst with proliferative folliculosebaceous epithelium.

Intraoperative cochlear nerve mapping with the mobile cochlear nerve compound action potential tracer in vestibular schwannoma surgery

OBJECTIVEThe authors describe the usefulness and limitations of the cochlear nerve compound action potential (CNAP) mobile tracer (MCT) that they developed to aid in cochlear nerve mapping during vestibular schwannoma surgery (VSS) for hearing preservation.METHODSThis MCT device requires no more than 2 seconds for stable placement on the nerve to obtain the CNAP and thus is able to trace the cochlear nerve instantaneously. Simultaneous bipolar and monopolar recording is possible. The authors present the outcomes of 18 consecutive patients who underwent preoperative useful hearing (defined as class I or II of the Gardner-Robertson classification system) and underwent hearing-preservation VSS with the use of the MCT. Mapping was considered successful when it was possible to detect and trace the cochlear nerve.RESULTSMapping of the cochlear nerve was successful in 13 of 18 patients (72.2%), and useful hearing was preserved in 11 patients (61.1%). Among 8 patients with large tumors (Koos grade 3 or 4), the rate of successful mapping was 62.5% (5 patients). The rate of hearing preservation in patients with large tumors was 50% (4 patients).CONCLUSIONSIn addition to microsurgical presumption of the arrangement of each nerve, frequent probing on and around an unidentified nerve and comparison of each waveform are advisable with the use of both more sensitive monopolar and more location-specific bipolar MCT. MCT proved to be useful in cochlear nerve mapping and may consequently be helpful in hearing preservation. The authors discuss some limitations and problems with this device.

Unicystic Ameloblastomatoid Cystic Craniopharyngioma: Pathological Discussion and Clinical Significance of Cyst Formation in Adamantinomatous Craniopharyngioma

An 8-year-old boy presented complaining principally of headache and vomiting. A single large cystic lesion extending from the suprasellar region to the ventral brainstem was identified, and total extirpation was performed via a right orbitozygomatic, transtemporal transchoroidal fissure approach. The cyst contents resembled motor oil, and no strong adhesions were identified between the tumor and the surrounding tissue except at the site of origin of the tumor, allowing easy dissection. The tumor originated at the junction of the adenohypophysis and the pituitary stalk. Although the histopathological diagnosis was adamantinomatous craniopharyngioma, the cyst walls comprising the majority of the tumor were not thin, fragile tissues formed by squamous metaplasia, but were thick and robust, bearing a close resemblance to unicystic ameloblastoma mixed with solid tissue. The existence of this type of cyst wall represents corroborating evidence that craniopharyngiomas are derived from the oral primordium. The existence of such tumors that can be totally extirpated in a single procedure while preserving hypothalamo-pituitary function may be taken as a warning not to rush at random to perform treatments that might encourage recurrence or regrowth by carrying out cyst fenestration and drug injection with the addition of stereotactic radiotherapy.

Drainage Pathway of the Superior Petrosal Vein Evaluated by CT Venography in Petroclival Meningioma Surgery

Objectives This study aimed to clarify the drainage location of the superior petrosal vein (SPV) in relation to Meckel's cave and the internal acoustic meatus (IAM) and to discuss its significance in petroclival meningioma surgery. Design Prospective clinical study. Setting Hospital-based. Participants Five patients with petroclival meningioma and 50 patients (primarily unruptured supratentorial aneurysm patients, with a few hemifacial spasm patients) with no posterior fossa lesions. Main Outcome Measures On computed tomography venography (CTV), the drainage site was classified into three patterns based on its relationship to Meckel's cave and the IAM: Meckel's cave type, Intermediate type, and Meatal type. Results In all patients, the SPV was patent and emptied into the superior petrosal sinus (SPS). In patients without posterior fossa lesions, 35% had Meckel's cave type, 54% had Intermediate type, and 11% had Meatal type. Of the five patients with petroclival meningioma, three had Intermediate type, and two had Meckel's cave type. Conclusion The SPV is a significant vein that should be preserved to prevent venous complications. Preoperative knowledge of the SPV drainage site is helpful for planning the approach and preserving the SPV in petroclival meningioma surgery.

[Deep sylvian meningioma without dural attachment: a case report]

A 34-year-old female presented with an 8-year history of temporal lobe epilepsy. Magnetic resonance imaging showed a multilobular, well-demarcated and homogeneous tumorous lesion of 5 cm in diameter deep in the left sylvian fissure. Intraoperative findings revealed that the tumor was mainly in the left insular region without dural attachment and strongly adhered to the left middle cerebral artery and its perforators. The histopathological diagnosis was transitional meningioma without malignancy. There are few reported cases of deep sylvian meningioma without dural attachment. We review the literature and summarize the clinicopathological characteristics of this condition.

Identification of an inhibitor for interleukin 4-induced epsilon germline transcription and antigen-specific IgE production in vivo

IgE plays a key role in the pathogenesis of allergic disease. Interleukin (IL) 4 is a potent and critical stimulator of immunoglobulin class switching from IgM to IgE in B cells. IL-4 induces the expression of epsilon germline transcript (epsilonGT), which is critical to initiate IgE production. While searching for molecules that inhibit epsilonGT expression induced by IL-4, we found that polyphenol strictinin, which was isolated from tea leaves, was able to inhibit the IL-4-induced epsilonGT expression in the human B cell line DND39. Strictinin also acted on human peripheral blood mononuclear cells obtained from healthy donors to inhibit IL-4-induced epsilonGT expression. Strictinin demonstrated similar inhibitory activity in peripheral blood mononuclear cells obtained from atopic donors. Interestingly, strictinin decreased ovalbumin-induced IgE production in mice, whereas the production of IgG and IgM was not affected. Furthermore, we found that the IL-4-induced STAT6 tyrosine phosphorylation, which is essential for IL-4-induced epsilonGT expression, was inhibited in DND39 cells upon treatment with strictinin. Taken together, these results suggest that strictinin can inhibit IgE production through the inhibition of IL-4-mediated signaling in B cells.

[Comparison of the circadian variation of the time of onset of acute myocardial infarction and of attack of vasospastic angina without significant stenosis]

OBJECTIVES

To study the involvement of vasospasm as the trigger of acute myocardial infarction without significant stenosis, the circadian variation of the time of onset of acute myocardial infarction was compared with that of vasospastic angina without significant stenosis.

METHODS

The subjects consisted of 3 groups, 64 patients with acute myocardial infarction without significant stenosis, 101 patients with acute myocardial infarction with one vessel disease and 98 patients with vasospastic angina without significant stenosis. The times of onset of acute myocardial infarction and spontaneous attack of vasospastic angina were recorded and classified according to the 4 periods (0:00-6:00, 6:00-12:00, 12:00-18:00, 18:00-24:00) and the pattern of distribution was compared between the 3 groups.

RESULTS

The time distribution of acute myocardial infarction without significant stenosis showed a double peaked pattern at 6:00-12:00 and 18:00-24:00 and was similar to the pattern of acute myocardial infarction with one vessel disease(p = 0.93). Only a single peak in 0:00-6:00 was found in the pattern of distribution of vasospastic angina without significant stenosis and differed significantly from acute myocardial infarction(p < 0.01).

CONCLUSIONS

The circadian variation of the time of onset of acute myocardial infarction was similar in patients with or without significant stenosis, and differed significantly from that in patients with vasospastic angina.

An equation to predict the changes in peak left ventricular pressure in hypertrophic obstructive cardiomyopathy after treatment: application to the administration of disopyramide

A theoretical equation was derived based on the time-varying elastance model to predict theoretically the relationship between the delay in the onset of left ventricular outflow obstruction and the reduction in peak left ventricular pressure (LVP) caused by treatment in hypertrophic obstructive cardiomyopathy (HOCM). ECG, LVP, and other hemodynamic parameters were measured during catheterization at a constant heart rate with atrial pacing in 16 patients with HOCM before and after intravenous administration of disopyramide (1 mg/kg). After disopyramide administration, the duration between the R wave of the ECG and the onset of obstruction (T1) was prolonged significantly (from 117 +/- 30 to 155 +/- 32 ms, P < 0.0001), and peak LVP was reduced significantly (from 222 +/- 42 to 177 +/- 39 mmHg, P < 0.0001). The relation between the prolongation of T1 and the percent reduction in peak LVP was predicted well by the theoretical equation (coefficient of determination R2 = 0.926). Our model simplifies the therapeutic strategy for reducing the left ventricular outflow pressure gradient in patients with HOCM, which is to delay the time of onset of obstruction by some methods.

[Cardiac events in vasospastic angina: site and morphology of coronary artery spasm is related to the long-term prognosis of vasospastic angina]

To determine whether the site and morphology of coronary artery spasm provoked with acetylcholine can predict the long-term prognosis of vasospastic angina, coronary artery spasm (more than 90% narrowing) provoked with acetylcholine was studied in 66 consecutive patients (56 males, 10 females, mean age 56 +/- 9 years) with vasospastic angina. All patients were followed for 6.7 +/- 0.9 years and the incidence of cardiac events such as sudden death, myocardial infarction or worsened unstable angina was compared with the site and morphology of provoked spasm. The site of spasm was regarded as proximal when spasm occurred in the proximal site of 3 major coronary arteries which was designated as segment 1, 6 or 11, according to the classification of the American Heart Association, and distal in other segments. The morphology of spasm was classified into 3 types, focal (12 cases, localized more than 90% narrowing with adjoining parts constricting less than 25%), diffuse (17 cases, diffuse more than 90% narrowing), and intermediate (37 cases, localized more than 90% narrowing with adjoining parts constricting 25-90%). The site of spasm was classified into 2 types, the proximal group (24 cases) and the distal group (42 cases). Cardiac events occurred in 7 patients during the follow-up period: sudden death in 2, myocardial infarction in 2, and worsened unstable angina in 3. As to the site of spasm, the incidence of cardiac events was 21% (5/24 patients) in the proximal group, significantly higher than 5% (2/42) in the distal group (p < 0.05). As to the site of spasm, the incidence of cardiac events was 41% (5/12) in the focal group, significantly higher than 3% (1/37) in the intermediate group and 6% (1/17) in the diffuse group (p < 0.001). The presence of proximal and focal coronary artery spasm was associated with a significantly higher incidence of cardiac events. The site and morphology of coronary artery spasm provoked with acetylcholine is related to the long-term prognosis of vasospastic angina.

Disopyramide improves the balance between myocardial oxygen supply and demand in patients with hypertrophic obstructive cardiomyopathy

We evaluated the effects of disopyramide in terms of the balance between myocardial oxygen supply and demand in patients with hypertrophic obstructive cardiomyopathy (HOCM). The myocardial oxygen supply was evaluated by measuring coronary flow velocity and the myocardial oxygen demand was assessed by the pressure-volume area (PVA). The time velocity integral of coronary flow did not change significantly (20 +/- 6 to 21 +/- 8 cm), but the peak left ventricular pressure and left ventricular external work decreased significantly (206 +/- 44 to 157 +/- 37 mmHg, P < 0.001; 1.09 +/- 0.33 to 0.80 +/- 0.23 J/beat, P < 0.001) after disopyramide administration. From theoretical analysis using these data, we concluded that disopyramide improves the myocardial oxygen supply-demand balance in patients with HOCM.

Intravenous diltiazem versus isosorbide dinitrate for unstable angina: comparison of coronary angiographic morphology in the unstable and stabilized states

BACKGROUND

The efficacy of intravenous infusion of diltiazem was compared with that of isosorbide dinitrate (ISDN) for the early treatment of unstable angina.

METHODS

Sixty-four patients with at least 70% organic stenosis of the culprit artery and prolonged rest angina were enrolled. Coronary angiography was performed on admission. Subsequently, patients were randomly assigned to receive either intravenous diltiazem or ISDN. Coronary angiography was repeated when the angina was under control, and the findings were compared with those on admission.

RESULTS

Diltiazem was more effective than ISDN, and symptoms were resolved in 84% of the diltiazem group compared with 47% of the ISDN group (P = 0.0038). Repeat coronary angiography showed that the degree of stenosis remained unchanged in the majority of patients (n = 47, 75.8%). There was no difference between the two groups with regard to the coronary angiographic findings.

CONCLUSIONS

Since diltiazem was more effective than ISDN even though the coronary angiographic findings of the two groups were similar, it is possible that some action other than vasodilatation (such as a direct protective effect on the myocardium) may be responsible for the remission of unstable angina.

[Histopathological findings of coronary artery lesions resected by directional coronary atherectomy]

Eleven directional coronary atherectomy procedures were performed in seven patients with angina pectoris and four patients with myocardial infarction, 10 men and 1 woman aged 41 to 69 years (mean 57 +/- 7 years). The onset of angina pectoris or myocardial infarction had occurred 2 months to 17 years previously. The preoperative mean diameter of stenosis was 80 +/- 8%, and the mean residual diameter of stenosis was 6 +/- 9% (p < 0.01). Seven left anterior descending arteries and four right coronary arteries were treated. Five of the 11 patients received partial-thickness resections of medial tissue and two of the five patients received full-thickness resections of the media with adventitial tissue. No lesions showed aneurysms or perforations during coronary arteriography after the procedure. The resected tissue was examined microscopically. Intimal tissues stained with Masson's trichrome were classified into four groups according to the characteristics fibrous tissue and the amount of proliferative cells: Type I was old dense fibrous tissue, type II was relatively old fibrous tissue containing many proliferative cells, type III was new loose fibrous tissue containing many proliferative cells, and type IV was atheromatous plaque. The intimal tissues were type I in 48.0%; type II in 35.5%; type III in 14.8%; and type IV in 1.7%. Resected lesions without prior treatment (primary lesions) from five patients with histories of 3 months or less were characterized by much type II and type III tissue; (type I tissue, 33.8%; type II tissue, 51.1%; type III tissue, 14.5%; type IV tissue, 0.6%).(ABSTRACT TRUNCATED AT 250 WORDS)

The response to drug therapy in unstable angina on the basis of coronary angiography findings

Among 366 unstable angina pectoris patients at our hospital, myocardial infarction was common (15.7%) in those with attacks of chest pain lasting for at least 20 min. There was also a high incidence (30.3%) when chest pain continued after the start of inpatient treatment. To investigate the etiology of unstable angina, coronary arteriography was performed in both the unstable and stable stages in these patients and the results were compared. The role of coronary spasm and coronary thrombosis in unstable angina was investigated, and the efficacy of continuous infusion of either diltiazem or isosorbide dinitrate as treatment for these patients was compared. Coronary arteriography in the unstable stage showed, no clear differences in the morphology of the stenotic site and the degree of stenosis between the patients with and without infarcts when urokinase or isosorbide dinitrate were injected into the coronary arteries. When drug treatment was effective, the angina was stabilized without any improvement in the degree of stenosis or the morphology of the involved coronary vessel. Thus, it was difficult to predict the response to treatment from coronary arteriography performed in the unstable stage. Diltiazem was more effective than isosorbide dinitrate, and it appears that some action other than coronary dilatation was involved in achieving the remission of unstable angina.

Upper respiratory tract involvement in adult T-cell leukemia

Adult T-cell leukemia (ATL) is characterized by peripheral lymph node enlargement, hepatosplenomegaly and skin lesions. The association of local mass lesions of other organs with ATL is extremely rare. This report describes a 57-year-old woman with chronic type ATL with associated local tumor masses in the nasal cavity, paranasal sinuses and larynx as well as skin infiltration. Histologic investigation of the skin lesion and nasal mucosa revealed non-Hodgkin lymphoma, diffuse, mixed type. Her chief complaints were progressive dyspnea and hoarseness. Leukemic cell masses in her upper respiratory tract caused narrowing of the airway, which was responsible for her complaints.

Serum haloperidol levels of schizophrenics receiving treatment for tuberculosis

Serum haloperidol levels were studied in schizophrenic patients with and without antituberculosis therapy, and the effect of these agents on serum haloperidol level was evaluated. Rifampicin caused significant suppression of serum haloperidol levels in all cases studied (n = 7). The serum haloperidol clearance rate was accelerated in patients taking rifampicin, with a shortened half-life (4.9 h) compared with the control group (9.4 h). Among 18 schizophrenic patients receiving isoniazid, three showed significantly elevated serum haloperidol levels. It is possible that isoniazid can elevate haloperidol levels in some patients depending upon some unknown factors. The elevation of serum haloperidol level was though to be due to prolonged clearance of haloperidol secondary to isoniazid interaction with hepatic enzymes involved in drug metabolism. These observations suggest that haloperidol doses in schizophrenic patients receiving rifampicin or isoniazid must be carefully monitored.

A case of hypophyseal prolactinoma with treatable delusions of dermatozoiasis

The case of an autopsied patient with hypophyseal prolactinoma and dermatozoic delusions is reported, and the mechanism of onset of this special form of delusion is discussed from the neuroendocrinological view point, including response to medications, and neuropathological and pituitary hormonal studies. The subject (69-year-old female) with dermatozoic delusions suffered hypophyseal prolactinoma with high serum prolactin level. Major tranquilizers, minor tranquilizers, or drugs enhancing cerebral blood flow and/or cerebral metabolism did not expell the delusion. Bromocriptine (dopamine agonist) was administered for prolactinoma treatment. After bromocriptine treatment, small doses of haloperidol successfully expelled the delusion. The neuropathological study indicates that the genesis of this delusion is not based on any organic change, but is induced by functional changes related to the prolactin and dopamine systems.