A Reconstruction Method Using Musculopericranial Flaps that Prevents Cerebrospinal Fluid Rhinorrhea and Intracranial Complications after Extended Anterior Skull Base Resection

Anterior skull base defects after extended anterior skull base resection including unilateral orbit and the dura were reconstructed using the temporal musculopericranial (TMP) flaps or frontal musculopericranial (FMP) flap in 14 patients. Dural defect was reconstructed with the TMP or FMP flap by making it overlap on the remaining dura around the defects. These flaps were also used, in principle, for the separation of the nasal cavity. For bone defects on the anterior skull base, a bone graft was transplanted in the place between the flap for dural reconstruction and the flap for the separation of the nasal cavity. Bone grafting was nor performed in patients who had an extensive defect and for whom a free flap was used for the separation. After surgery, CSF rhinorrhea did not occur in the 14 patients. Twelve patients did not develop any postoperative complications. Two patients had epidural abscess, but with debridement and the drainage to the nasal cavity, they did not develop severe intracranial complications. We conclude that reconstruction using musculopericranial flaps is a reliable and versatile method with minimum invasion and the shortest operation hours. In particular, musculopericranial flap for dura reconstruction was highly efficacious for the prevention of CSF rhinorrhea.

Genetic polymorphism in collagen type 1 alpha 2 intron 33 can be used for the initial screening of East Asians quickly and easily by a heteroduplex analysis

To save time and simplify the matching genetic information of bereaved family with the collected samples for identification of individuals in a mass-scale disaster and terrorism using molecular biological methods, we propose a method to initially screen samples according to different populations. We found a unique deletion (26822-3) in an allele that 62.0% of East Asian individuals had in intron 33 of type I collagen alpha 2 (COL1A2), while most Europeans and Africans did not have it. By making a heteroduplex complex, a visual discrimination was possible using 10% PAGE. A PCR and heteroduplex analysis could identify genetic polymorphism of COL1A2 intron 33 both clearly and accurately, even from decomposed samples or very small amounts of samples within a very short time period (approximately within 150min). As a result, genetic polymorphism of COL1A2 intron 33 is thus considered to be useful to quickly and easily screen East Asians from vast number of samples using a heteroduplex analysis. Consequently, we consider that an initial screening method for East Asians which use a heteroduplex analysis of genetic polymorphism of COL1A2 intron 33 can smoothly and effectively perform various identifications among East Asians when supplies are logistically poor after a mass-scale disaster or terrorism.

Characteristics of cognitive function in patients after traumatic brain injury assessed by visual and auditory event-related potentials

OBJECTIVE

Using auditory and visual stimuli including facial affective stimuli, we analyzed the P300 components of event-related potentials (ERPs) in patients after traumatic brain injury (TBI) to assess their cognitive characteristics.

DESIGN

Twenty TBI patients and 32 age-matched control subjects were recruited. Using conventional oddball paradigms, visual ERPs were recorded using images of crying and smiling babies as visual stimuli. Auditory ERPs were obtained using 2-kHz tones as stimuli without affective stimuli. The peak amplitude and latency for P300, and the latency for N200, were recorded.

RESULTS

: In visual ERPs, the P300 amplitudes were significantly smaller in patients than in controls for the crying baby, but the amplitudes were similar between groups for the smiling baby. Controls showed smaller P300 amplitudes for the smiling baby than for the crying baby, but patients showed no difference. In patients, the P300 latency for both smiling and crying babies was longer than in the controls. Patients' auditory ERPs showed smaller P300 amplitudes but similar P300 latencies compared with controls. The N200 latency in patients was significantly longer than in controls only for the crying baby.

CONCLUSIONS

Visual ERPs are a potentially useful marker for evaluating cognitive dysfunction in patients after TBI.

Full-scale granular sludge Anammox process

The start-up of the first full scale Anammox reactor is complete. The reactor shows stable operation, even at loading rates of 10 kg N/m3.d. This performance is the result of the formation of Anammox granules, which have a high density and settling velocities exceeding 100 m/h. With this performance, the Anammox granular sludge technology has been proven on full scale.

Effect of inorganic carbon on nitrite accumulation in an aerobic granule reactor

Pilot scale experiments were performed to evaluate the potential of nitrite type nitrification process with an airlift reactor and granular biomass. Initially, oxygen limitation was used as the main control parameter for accumulating nitrite in the effluent. After 30 d operation, the maximum nitrite conversion rate reached 2.5 kgNO2-N m(-3) d(-1), average diameter of the granule was 0.7 mm. Nitrite type reaction continued over 100 d, but nitrate formation increased after 150 d of operation. Once nitrate formation increased, oxygen limitation could not eliminate nitrite oxidising bacteria from granule. To overcome nitrate formation, laboratory scale batch experiments were conducted and it revealed a high concentration of inorganic carbon which had a significant effect on nitrite accumulation. Following this new concept, inorganic carbon was fed to the pilot scale reactor by changing pH adjustment reagent from NaOH to Na2CO3 and nitrite accumulation was recovered successfully without changing DO concentration. These results show that a high concentration of inorganic carbon is one of the control parameters for accumulating nitrite in biofilm nitrification system.

Formation of stable foam by the cells and culture supernatant of Gordonia (Nocardia) amarae

Gordonia amarae is the cause of foaming activated sludge. In this study, the mechanism of foam formation by G. amarae SC1 was investigated. A liquid culture of SC1 cells generated a stable foam when shaken reciprocally. This foam formation was dependent on the presence of both bacterial cells and culture supernatant. A high-molecular-weight fraction (Mw>10000) of the supernatant was capable of emulsifying n-hexadecane in addition to exhibiting foaming activity, indicating that it contains a surface-active substance(s). The bacterial cells showed a high affinity to hexadecane. This hydrophobic cell surface property might be involved in the attachment of cells to air bubbles to generate a stable foam. The results demonstrated the participation of cells and the extracellular biosurfactant in the formation and stabilization of foam in G. amarae SC1 culture.

Operation of a nitrite-type airlift reactor at low DO concentration

Laboratory scale experiments were performed to evaluate the feasibility and potential of nitrite-type nitrification process with an airlift reactor having aerobic granular biomass. Oxygen limitation was selected as the main control parameter for inhibiting the growth of nitrite oxidizer and thus achieving only nitritation. To enhance granule formation, seeding of methanogenic anaerobic granules was used to serve as an initial carrier material. After 90 days of operation at low DO concentration of less than 1.0 mg/l, the maximum nitrite conversion rate of 2.6 g NO2-N/L/d could be achieved. During the continuing year-long stable operation, the granular mass of nitritation granules increased to about 15 g VSS/L with an average granule size of 0.7 mm. Nitrate-N concentration was observed to be below 10 mg/L during the whole operational period. From the results of the experiments, it is concluded that a granule-type airlift reactor with DO control is feasible for achieving stable nitritation.

Granulation of Anammox microorganisms in up-flow reactors

Experimental studies were performed to evaluate the feasibility of granulation of Anammox microorganisms for biomass retention in up-flow reactors. Two experimental studies, one using a 6.4-L lab-scale reactor with synthetic medium and the other using a 200-L pilot-scale reactor with half-nitrified reject water from a sludge digester were conducted. To enhance the granulation process, seed granules from a UASB reactor were added to both experimental reactors. Granulation of Anammox microorganisms was observed using both the synthetic medium and the reject water. The core of a large proportion of Anammox granules retained part of the original seed biomass. The Anammox granules had a slightly lower density than the seed granules from the UASB process, but the size and other physical properties were comparable. The successful granulation of the Anammox microorganisms led to a stable nitrogen removal performance. The maximum nitrogen removal rate of the lab-scale reactor was observed to be 2.9 kg/(m3 x d) after 173 days of operation and that of the pilot-scale reactor was 6.4 kg/(m3 x d) after 12 months of operation.

Circulating endothelial cells in Kawasaki disease

Recent reports have demonstrated that circulating endothelial cells (CECs) are observed in several diseases with vascular injury. Because Kawasaki disease (KD) is one type of systemic vasculitis, we hypothesized that an increased number of CECs may be associated with the appearance of complicated coronary artery lesions (CAL). In the present study we investigated the enumeration and origin of CECs in 20 patients with KD, using an immunohistochemical method with monoclonal antibodies: clone P1H12 against ECs and clone AC133 against endothelial progenitor cells (EPCs), which were derived from the bone marrow. The mean number of CECs increased significantly (P < 0.05) from the acute through the subacute phases of KD compared with both the convalescent phase of KD and healthy children. The mean number of CECs was significantly (P < 0.05) higher in six KD patients with CAL than in 14 KD patients without CAL. The population of EPCs in the total CECs in KD was 4.4 +/- 1.2% (range 0-18%). The number of EPCs during the subacute phase was also significantly higher (P < 0.05) in KD patients with CAL than in those without CAL. Our findings indicate that the number of CECs increase in KD vasculitis and suggest that the increased numbers of CECs and EPCs may reflect the EC damage of this disease.

Characteristic profile of intestinal microflora in Kawasaki disease

To investigate whether the ecology of the intestinal microflora may change in the acute phase of Kawasaki disease (KD), the distribution pattern was studied of common micro-organisms in feces from 20 patients with KD, 20 patients with acute febrile diseases (disease control) and 20 healthy children. KD patients had a significantly lower (p < 0.001) incidence of Lactobacillus (2/20, 10%) than disease control patients (16/20, 80%) and healthy children (14/20, 70%). KD patients had no significant incidences of other microbial genera, compared with both disease control and healthy children.

CONCLUSION

The results suggest that a lack or loss of the beneficial Lactobacillus genus in the enteric microflora may occur during the acute phase of KD.

Optimal process configuration for anaerobic digestion with ozonation

Economical source minimization of excess sludge production is an attractive option to deal with the problem of sludge disposal under strict disposal standards. In this paper long-term operational results for two different process configurations that combine oxidative ozone treatment with anaerobic sludge digestion are described. In the first configuration ozone pretreatment was combined with chemostat anaerobic digestion while in the second configuration ozone pre/post-treatments were combined with an anaerobic digester operated without solid removal. From the results of chemostat experiments, the ozone pretreatment solubilized around 19% and 37% of the solids at 0.015 and 0.05 gO3/gTS ozone dose respectively. The ozone pretreatment resulted in improved TVS reduction efficiencies and the degradation efficiencies were observed to depend on the applied ozone dose and system SRT. The TVS degradation efficiency for pre-ozonated sludge at an ozone dose of 0.05 gO3/gTS was 59% as compared to 31% for the control reactor fed with un-ozonated sludge. Test results with the second configuration indicated that overall TVS removal efficiencies for a process scheme with post-ozonation could be improved up to 85% with a minimum ozone dose of 0.045 gO3/gTVS-fed. However, since no solids (except that for sampling) were withdrawn in this configuration, the accumulated total solids in the reactors increased to 28 g/l to 30 g/l at pseudosteady state. The average specific methane recoveries were observed to be 0.36 lCH4/gTVS fed which were slightly lower than theoretically expected. Based on the experimental results, important points in the choice of process configuration are discussed.

Anaerobic digestion of excess activated sludge with ozone pretreatment

Source minimization of excess sludge production by economical means can be considered an attractive option to deal with the problem of sludge disposal under strict disposal standards. In this paper long-term operational results for a process that combines the oxidative ozone pretreatment with anaerobic sludge digestion are described. The ozone pretreatment solubilized around 19% and 37% of the solids at 0.015 and 0.05 gO3/gTS ozone dose. The solubilization ratios during ozonation did not show any significant difference for the sludge concentrations ranging from 1.8-2.6%. The TVS concentrations after ozone treatment were observed to be about 3% lower than the feed sludge concentrations suggesting only partial mineralization during ozonation. The ozone pretreatment resulted in improved solid reduction efficiencies during anaerobic digestion leading to higher methane recovery. The TVS removal efficiencies during anaerobic digestion were observed to increase by a maximum of 35-90% depending on the applied ozone dose during ozone pretreatment. The improvement in TVS degradation efficiency at different applied ozone doses correlated well with the extent of solubilization during ozonation. Long-term data also suggested that biomass acclimation to ozonated sludge was necessary before higher degradation efficiencies could be achieved.

Delayed apoptosis of circulating neutrophils in Kawasaki disease

Circulating polymorphonuclear neutrophils (PMNs) are known to increase in number and are functionally activated in the acute phase of Kawasaki disease (KD). In the present study, we investigated whether the apoptosis of PMNs is deregulated in KD. When the isolated PMNs were cultured in vitro, the proportions of spontaneous apoptotic PMNs (annexin V+ cells and cells with fragmented DNA) were found to be significantly lower (P < 0.01) in the patients with KD (n = 25) than in the patients with a bacterial infection (n = 20) or a viral infection (n = 20), or in healthy children (n = 20). The proportion of circulating Fas-positive PMNs was also significantly lower (P < 0.01) in the acute KD patients than in the other groups. In the acute phase of KD, the proportion of spontaneous apoptotic PMNs showed a significant positive correlation (P < 0.01) with the proportions of circulating Fas-positive PMNs. Furthermore, the agonistic anti-Fas MoAb (CH-11) induced a significant increase in the proportion of apoptotic PMNs in the patients with a viral infection and healthy children, but not in either the patients with KD or the patients with a bacterial infection. In the intracellular expression of anti- and pro-apoptotic proteins, the A1/Bax ratio was significantly higher in acute KD than in the other groups. These findings indicate that PMN apoptosis is inhibited during the acute phase of KD and also suggest that both the resistance against the Fas-mediated death signal and the down-regulation of the mitochondrial apoptotic signalling pathway due to an altered balance of Bcl-2 protein expression are responsible for the delayed PMN apoptosis.

Production of platelet-activating factor by neuronal cells in the rat brain with cold injury

The production and localization of platelet-activating factor (PAF) in the brain following focal brain injury were examined. Immunofluorescent staining was used to detect PAF in the rat brain with cold-induced local brain injury. After cold injury, immediate-early PAF staining was observed within the cold lesion followed later by immunoreactivity in the ipsilateral white matter. PAF immunoreactivity was also clearly seen both in cortical neurons adjacent to the cold lesion and in the ipsilateral hippocampus which showed delayed neuronal degeneration. The data suggest that PAF synthesis occurs in the neuronal cells in the perilesional area and hippocampus as well as within the cold lesion site during the early stages of cold-induced brain injury. PAF expression may contribute to the onset and progression of further brain damage, such as delayed axotomy and delayed neuronal loss.

Elevated serum levels of matrix metalloproteinase-9 (MMP-9) in Kawasaki disease

Matrix metalloproteinases (MMPs) play an important role in the progression of tumour cells and the invasion of inflammatory cells by degrading the extracellular matrix. In the MMP family, MMP-9 gelatinase is thought to contribute to the pathogenesis of inflammatory arteritis by disrupting the elastic lamina. The aim of the present study is to investigate the potential role of MMP-9 in Kawasaki disease (KD), an acute type of systemic vasculitis in children. We studied the total levels of MMP-9 (free proMMP-9 and free MMP-9) in the sera using a new assay system and the expression of MMP-9 mRNA in the leucocytes using reverse transcription-polymerase chain reaction in 18 patients with KD, 10 patients with sepsis and 10 healthy children (HC). The serum MMP-9 levels were significantly higher (P < 0.01) in the acute phase of KD than in the acute phase of sepsis and HC. In the time course of KD, the serum MMP-9 levels decreased significantly (P < 0.01) from the subacute through the convalescent phases. In the acute phase of KD, the serum MMP-9 levels showed a significantly positive correlation (P < 0.05) with the circulating leucocyte counts, especially the neutrophil counts. Furthermore, the expression of MMP-9 mRNA in the circulating leucocytes increased in the acute phase of KD and decreased from the subacute through the convalescent phases. These findings indicate that an excessive amount of MMP-9 is present in the plasma during the acute phase of KD, thus suggesting that circulating leucocytes may be a source of the MMP-9 secreted into the circulation.

High-grade adenoid cystic carcinoma originating from the lacrimal gland

Among primary lacrimal gland tumors, adenoid cystic carcinoma (ACC) is the most common malignant epithelial neoplasm; it is characterized by local intracranial invasion. A case with unusual dumbbell-type intracranial extension representing cavernous sinus syndrome is described. A 49-year-old woman was admitted to our hospital with right cavernous sinus syndrome. Computerized tomographic (CT) scans and magnetic resonance (MR) imaging demonstrated well-enhanced intraorbital and middle fossa tumors mimicking multifocal mass lesions. Operative findings revealed an ACC originating from the lacrimal gland and extending into the right cavernous sinus and middle fossa along the nerve sheath in the superior orbital fissure. Although MR image findings of intracranial ACC often resemble the image findings for meningiomas, intracranial ACC is very aggressive in comparison with meningioma. It is best treated surgically and aggressively.

Cervical myelopathy due to compression by bilateral vertebral arteries--case report

A 69-year-old man presented with progressive cervical myelopathy due to vascular compression of the upper cervical spinal cord. Vertebral angiography and magnetic resonance imaging revealed that the elongated bilateral vertebral arteries (VAs) had compressed the spinal cord at the C-2 level. The spinal cord was surgically decompressed laterally by retracting the VAs with Gore-Tex tape and anchoring them to the dura. The patient's symptoms improved postoperatively. Decompression and anchoring of the causative vessels is recommended due to the large size of the VAs.

Intraventricular malignant triton tumour

The authors present the clinical and pathological features of a malignant triton tumour (MTT) in the lateral ventricle with neurofibromatosis type 1. A 57 year-old man presented with disorientation and memory disturbance. A Computed tomographic scan and magnetic resonance imaging studies revealed an enhancing lesion in the left lateral ventricle. A parieto-occipital transcallosal approach was taken and resection of the lesion was performed. The operative findings suggested that the tumour arose from the perivascular nerves. The final pathological diagnosis was a MTT. This is the first case of an intraventricular MTT. Aggressive treatment including radical surgery combined with radiochemotherapy is recommended for a MTT of the central nervous system.

Delayed CSF pseudocyst following shunt malfunction after myelomeningocele repair

We report a case of delayed cerebrospinal fluid (CSF) pseudocyst following shunt malfunction in a 20-year-old patient with myelomeningocele. Magnetic resonance (MR) images and a radioimmunoassay shunt-gram detected the CSF fistula at the old scar of the myelomeningocele repaired 20 years before. Since the revision of the shunt system failed to keep the pseudocyst, the lesion was successfully directly repaired. Treatment of the delayed CSF pseudocyst following shunt malfunction thus requires a radical operation of the lesion.

Neurochemical monitoring in the management of severe head-injured patients with hypothermia

The neuroprotective action and effect of hypothermia on the neurochemical system is not well understood. The present study was performed using six patients with GCS scores of 5 or less to clarify the relationship between monitored brain temperature, intracranial pressure (ICP), cerebral perfusion pressure (CPP) and oxygen saturation of the jugular venous blood (SjO2). Changes in concentration of excitatory amino acids, glutamate (GLU) and aspartate (ASP), and NO2 were studied using intracerebral microdialysis as well as in jugular venous blood and cerebrospinal fluid (CSF). Changes in brain temperature, CPP and SjO2 resulting from hypothermia and brain death associated with markedly higher concentrations of and fluctuations in the concentrations of GLU, ASP and NO2 were observed in the dialysate than in the jugular venous blood or CSF. Hypothermic treatment significantly reduces excitatory amino acid and NO2 concentrations, a finding which was associated with an improvement in CPP and SjO2. Measurement of GLU and ASP using intracerebral microdialysis is a clinically useful method for clarifying abnormal neurochemical events associated with severe head injury and for evaluating the effects of hypothermia.

Efficacy of temporal musculopericranial flap for reconstruction of the anterior base of the skull

Since March 1988 the temporal musculopericranial (TMP) flap has been used as our flap of choice to reconstruct defects of the anterior base of the skull that are larger than 2 x 3 cm, including the dura mater, in 33 patients. The primary diseases were malignant head and neck tumours (n = 16), trauma (n = 15), meningioma (n = 1), and teratoma (n = 1). The dura mater was reconstructed with a unilateral TMP flap, after which the cranial and nasal cavities were closed with the opposite TMP flap. In addition, bone was grafted by sandwiching the bone between the two flaps and fixing it to the surrounding residual bone. When a large area was resected, making it impossible to use a TMP flap, a frontal musculopericranial (FMP) flap or a free flap (usually the rectus abdominis myocutaneous flap) was used to close the cranial and nasal cavities. Thirty of the 33 patients recovered with no postoperative complications. Two patients developed extradural abscesses in the anterior base of the skull and one developed mild meningitis, but they were successfully treated conservatively. When bilateral TMP flaps were used for the reconstruction, no patient had aesthetic problems in the forehead region. The TMP flap is extremely effective for the reconstruction of the anterior base of the skull because it is minimally invasive and causes few aesthetic problems in the forehead region.

Syringobulbia caused by delayed postoperative tethering of the cervical spinal cord - delayed complication of foramen magnum decompression for Chiari malformation

Postoperative tethering of the high cervical spinal cord is a rare cause of neurological deterioration after foramen magnum decompression (FMD) with duraplasty for Chiari type I malformation. A review of the literature revealed that only 5 cases have been reported. This entity is not widely known to occur as a complication of the common surgical procedure for Chiari type I malformation. A 17-year-old boy experienced rapidly progressive neurological deterioration over a 3-month period. FMD and duraplasty with lyophilized cadaver dura had been performed 8 years previously. Follow-up MR images showed that the cerebrospinal fluid (CSF) space dorsal to the cord was gradually disappearing and that syringobulbia had developed. Opening the dura mater of the posterior fossa revealed dense fibrous scarring, arachnoid thickening over the cervicomedullary area, and tethering the cord to the dura from the medulla to C2. The adhesions were dissected free, and the tethering was released. A syringosubarachnoid (SS) shunt was inserted and duraplasty was performed with an expended polytetrafluoroethylene sheet (Gore-Tex). Postoperative MR images demonstrated that the syringobulbia had completely collapsed and that a dorsal CSF space was present. Follow-up MR images provided significant information on the cervical spinal cord tethering after FMD with duraplasty for Chiari malformation. We encourage sharp surgical detethering and duraplasty with Gore-Tex to avoid retethering. Early recognition and treatment of this unusual but important complication are emphasized.

Reduction cranioplasty for macrocephaly. Two case reports

Multi-stage reduction cranioplasty was performed on two children with severe macrocephaly secondary to hydrocephalus. One patient underwent a four-stage operation, and the other underwent a two-stage operation. The postoperative course of both patients was uneventful. Reduction cranioplasty improved quality of life for both patients, and good cosmetic results were achieved. Reduction cranioplasty is effective for the treatment of macrocephaly, and multi-stage surgery can reduce the associated risks.

[A case of aneurysmal neck clipping following incomplete neck clipping and coil embolization]

We report a case with radical neck clipping following incomplete embolization with coils and imperfect neck clipping. A 43-year-old woman suffered from a subarachnoid hemorrhage (Hunt & Hess Grade IV) due to the rupture of a left paraclinoid internal carotid aneurysm on 28 October, 1996. Neck clipping of the aneurysm was performed at day 1. Follow-up angiogram at 2 weeks after surgery showed however a small residual aneurysm. The second angiogram 1.5 months later showed the growth of the residual aneurysm. The residual part of the aneurysm was then treated with endovascular embolization using interlocking detachable coils (IDC), resulting in incomplete occlusion of the aneurysm. The direct surgical clipping of the residual aneurysm was performed via Dolenc approach. A fenestrated clip was applied to the partial embolized aneurysm, when the aneurysmal wall was ruptured between the occluded part of the aneurysm and the residual dome. The fenestrated clip was then reapplied successfully under temporary occlusion of the parent artery. Because of the stenosis of the parent artery, STA-MCA anastomosis was then performed. Postoperative recovery of the patient was uneventful and postoperative angiogram showed stenosis of the parent artery with patent bypass flow. The patient was discharged without complications. Technical problems in neck clipping following incomplete embolization with coils are discussed.

Cranioplasty with split lateral skull plate segments for reconstruction of skull defects

This paper reports the use of cranioplasty using segments of split lateral skull plate to correct large skull defects (larger than 8 x 8 cm). The subjects consisted of 10 patients with head trauma who had undergone decompression surgery, and two patients who had undergone tumour resection. Bone grafts were obtained by cutting approximately 2 cm wide strips from the lateral skull plate using a bone saw that was inserted from a free margin of the bone defects. By cutting strips laterally from the bone defect, the necessary amount of split lateral skull plate can be obtained without performing craniotomy. The pieces of split lateral skull plate are then fixed to the defect using wire or titanium mini-plates. At this point, the selection of bone grafts that match the curvature of the dura mater is important, so that no dead spaces are created between the dura mater and the bone grafts. Infection was not detected in any of the 12 patients, and all bone grafts took completely. One of the 12 patients suffered from a pathological fracture and bone resorption 6 months after surgery. The fracture occurred because the use of basket-shaped reconstruction plates resulted in large spaces between the plate segments, and in addition the intracranial pressure was kept low by a V-P shunt, thus rendering the patient more vulnerable to atmospheric pressure.

[A case of crushing head injury with bilateral abducens and facial nerve palsies]

A 20-year-old male was admitted to our hospital suffering from a crushing head injury. At accident, his head had been compressed by the printing machine on both temporal regions. He remained at dull conscious. On admission one hour after the injury, he showed bilateral sixth-nerve and seventh nerve palsies and bleeding from the nose. CT scan showed marked pneumocephalus, traumatic subarachnoid hemorrhage, fluid collections in the bilateral sphenoid sinuses and right mastoid air cells. Bone CT disclosed bilateral temporal bone fractures. MRI did not show cerebral parenchymal damage. He recovered fully conscious at four hours after the injury, but cranial nerve palsies sustained over 30 days after the injury. Bilateral decompression of the facial canal were performed at day 31. At one year after the injury, bilateral abducens nerve palsies and facial nerve palsies recovered incompletely (grade III). The case report and the mechanism of such cranial nerve injuries by low-velocity crushing head injury is described.

Fatal hemorrhage from rupture of the intracranial internal carotid artery caused by aspergillus arteritis

To the best of our knowledge, this is the first reported case of combined intracranial and extracranial hemorrhage due to aspergillus cerebral arteritis. Knowledge of the imaging and the importance of early diagnosis and treatment are emphasized. A 78 year old man developed progressive right-sided visual impairment and diplopia. Magnetic resonance imaging demonstrated a mass lesion located in the right orbital apex, with extension to the cavernous sinus and the right middle cranial fossa. Cerebral angiography showed no aneurysmal dilatation. He was scheduled for transnasal biopsy. However, the patient died of massive epistaxis and intracranial hemorrhage. Postmortem examination revealed an aspergillus granuloma of the orbit and the skull base involving the intracranial and extracranial internal carotid artery. Aspergillus fumigatus was identified by culture. The characteristic feature of the fungal infection is a low-intensity signal on T2-weighted magnetic resonance images. This finding may be useful in diagnosing fungal infection.

Significance of vessel count and vascular endothelial growth factor in human esophageal carcinomas

The purpose of this study was to determine the angiogenic profile of human esophageal carcinomas. The expression of vascular endothelial growth factor (VEGF) was examined in 6 esophageal carcinoma cell lines and 119 human esophageal carcinoma tissues by Northern blot analysis and immunohistochemistry, respectively. Immunohistochemistry using antibodies against CD34 (endothelial cell specific) was carried out on archival specimens, and microvessels were quantitated by counting vessels in a x200 field in the most vascular area of the tumor. All of the cell lines constitutively expressed VEGF mRNA at various levels. A total of 71 of 119 (59.7%) tumors showed intense VEGF immunoreactivity in the cytoplasm of cancer cells. Vessel count was significantly higher in the VEGF-positive tumors than it was in the VEGF-negative tumors. VEGF expression correlated with the depth of tumor invasion, tumor stage, venous invasion, and lymphatic invasion. The survival rate of patients with high vessel density in the tumor was significantly worse than that of patients with low vessel density in the tumor. There was a tendency for poorer prognosis in the group with VEGF-positive tumors compared with that of the group with VEGF-negative tumors. Overall, these results suggest that VEGF is associated with tumor progression by stimulating angiogenesis in human esophageal carcinoma.

Clinicopathological features of intraorbital neurinoma--report of two cases

Clinicopathological features of intraorbital neurinomas were investigated in two patients. Magnetic resonance imaging (MRI) findings in Case 1 were similar to those in Case 2. The central region of the neurinomas showed a slightly high intensity area with a marginal low intensity on T1-weighted images (T1WI), whereas on T2-weighted images (T2WI), the central area of the tumor was very low intensity with a marginal high intensity area. After gadolinium-DTPA (Gd-DTPA) injection, these areas were homogeneously enhanced in both cases. The deference in enhancement after Gd-DTPA injection reflected the distribution of cellularity and vessels in the tumor.

Ultrastructure of obstructive tissue in malfunctioning ventricular catheters without infection

The obstructive tissue in eight malfunctioning ventricular catheters without infection was studied using scanning and transmission electron microscopy. Shunt obstruction was due to debris from ventricular structures such as the choroid plexus and ependymal tissue. There was a preponderance of collagen fibers, and many fibroblasts were present within these tissues. The cytoplasm of the fibroblasts contained extended endoplasmic reticulum. The tissues filled the lumen of the catheters in radially arranged layers. Peeling the silicone was seen on the surface of the ventricular catheters but was not present in normal silicone catheters. Finger-like microvilli were observed on the free surface of the tissue. Many vessels were seen in the transverse section of the tissue. Activated fibroblasts and vascularization may be important in tissue growth in ventricular catheters.

Posttraumatic edema in the corpus callosum shown by MRI

MRI was performed on 120 patients who sustained closed head injury of varying severity. Patients ranged in age from 4 to 87 years (average, 32 years). All patients had an initial MRI within 28 days (median 12 days) of injury. MRI disclosed areas of abnormal signals in the corpus callosum of 21 (18%) of the 120 patients; 1 (2%) of the 44 patients who sustained mild injuries (GCS > or = 13), 3 (10%) of the 31 moderate injuries (GCS 9-12), and 17 (38%) of the 45 severe injuries (GCS < or = 8) (p < 0.0001). All but 2 of the 21 patients with corpus callosum lesions had other parenchymal lesions that were visualized by MRI. Of these 21 patients, MRI was repeated in 19. In 13 of the 19 patients, repeat MRI scans at 25 to 42 days after injury showed the disappearance of lesions that had on the first MRI shown a high signal on T2-weighted and FLAIR images and a normal signal on T1-weighted images. The MRI findings and time source of the disappearance of the corpus callosum lesions mirrored those of paracontusional edema in the subcortical white matter. Patients in whom the corpus callosum lesion disappeared had a better outcome than those in whom the lesion remained (good recovery/moderate disability; 92% vs 63%). The present MRI results suggest that some lesions in the corpus callosum following closed head injury are reversible, thus resembling edema that may be produced by a relatively mild shear strain force to the corpus callosum.

Orbital hemangiopericytoma--case report

A 43-year-old male presented with swelling involving the right eye. T1-weighted magnetic resonance imaging demonstrated a round tumor in the lateral region of the right orbit, which was isointense relative to the cerebral gray matter and homogeneously enhanced by gadolinium-diethylenetriaminepenta-acetic acid with a flow-void signal area in the mass. The tumor was totally resected through the transcranial and fronto-orbitotemporal approach after embolization of feeding arteries arising from the external carotid artery. The histological findings were characteristic of hemangiopericytoma. No radiation therapy was administered. The transcranial and fronto-orbitotemporal approach provides a wide operative field with excellent exposure of the highly vascular orbital tumor.

[Postoperative complications of anterior and middle skull base surgery]

The authors present the postoperative complications of skull base surgery based on a 10-year experience with 26 patients operated on via the supraorbital trans-basal or orbitozygomatic approach. The lesions included 19 malignant tumors and seven benign tumors. Postoperative cerebrospinal (CSF) leak occurred in one of the two patients in whom the dural defects were repaired with a fascia lata graft. None of the remaining 24 patients who were repaired with a musculopericranial flap suffered postoperative CSF leak. Three patients developed epidural abscess, but no infection was seen in the patients who had been reconstructed with a vascularized musculo-cutaneous flap to occlude the dead space. Preoperative radiation therapy correlated with a high incidence of postoperative infection. Cranial nerve deterioration or palsy occurred in four patients. Intraoperative injury of the internal carotid artery occurred in one patient who developed severe neurological deterioration. After an average follow-up period of 40 months (range 12 to 109 months), 68% of patients with malignant tumors and 100% of patients with benign tumors were alive with no evidence of recurrence.

Intracranial plasma-cell granuloma: a case report

A 57-year-old woman presented with right-sided ptosis and diplopia. CT scans showed a tumor in the right cerebellopontine angle attached to the tentorium. Subtotal resection was conducted prior to local irradiation (20 Gy). Histological examination of the resected specimen indicated a diagnosis of plasma-cell granuloma. Diffuse thickening of the tentorium and falx were seen on follow-up MR imaging six years after the operation. Only eleven cases of intracranial plasma-cell granuloma have been reported in the literature. This paper reports a new case with unusual recurrence on neuroimagings.

New surgical treatment of middle fossa arachnoid cyst

BACKGROUND

A new surgical treatment of middle fossa arachnoid cyst is reported. The benefit of our surgical procedure is to maintain the physiologic pathway of the cerebrospinal fluid (CSF) without a shunting procedure.

METHODS

Following a small frontotemporal craniotomy, a linear incision in the outer wall of the cyst is made. The basal subarachnoid cisterns and distal sylvian cisterns are widely opened microsurgically. The outer wall of the cyst is then closed to prevent CSF leakage (arachnoidplasty).

RESULTS

We have experienced six patients who underwent this new surgical treatment. All their cysts showed nor or delayed influx of the contrast medium on preoperative computed tomography cisternogram. A favorable outcome was attained in the long-term follow-up without any complications.

CONCLUSIONS

The present technique was designed to secure physiologic CSF circulation and to avoid the use of a shunting system. A total of six patients treated with our new technique have been followed-up 6 years, and a good clinical outcome has been observed in all of them without complications.

Transient global amnesia and dural arteriovenous fistula of the anterior cranial fossa

Dural arteriovenous fistula (AVF) of the anterior cranial fossa is associated usually with cerebral hemorrhage or subarachnoid hemorrhage, while an association with transient global amnesia has not been reported previously. A case presenting the latter unusual symptom is described and the surgical treatment of AVF is discussed. A 64-year-old woman was hospitalized complaining of transient memory impairment. Magnetic resonance (MR) imaging demonstrated a flow void in the left frontal lobe and temporal pole. Cerebral angiography revealed an AVF in the anterior cranial fossa, which was fed bilaterally by the ethmoidal arteries and by branches of the external carotid arteries. The AVF drained into the superior sagittal sinus and the superficial sylvian vein via large varices. Following transfemoral embolization, surgical treatment was carried out. Postoperative angiography revealed complete obliteration of the anomaly. There were no further episodes of amnesia. In our presented case, there is an association between the presenting symptoms and the AVF. The combination of ischemia and congestion in the frontal and temporal lobes may have caused transient memory impairment. From our surgical experience, the excision of the vascular connection between the dura and the frontal lobe following the coagulation of the dura mater of the anterior part of the base of the skull without extensive excision seems to be recommended.

A case of pituitary apoplexy in a child

A case of pituitary apoplexy is reported in a 14-year-old girl who presented with headaches and progressive visual disturbance. Magnetic resonance imaging demonstrated subacute hemorrhage into a pituitary adenoma. Transsphenoidal removal of the tumor was performed successfully. Pituitary apoplexy in children is rare. Thus we will discuss the clinical features and neuroradiological findings.

Effect of platelet-activating factor antagonist on brain injury in rats

The ability of a platelet-activating factor (PAF) antagonist to reduce infarct size has been reported in a animal model of focal brain ischemia. The authors studied the effect of PAF antagonist (TCV-309) on cold brain injury in rats. Twenty-four hours after injury, water content was determined by both drying-weighing and specific gravimetric techniques, and ischemic brain damage was assessed with 2,3,5-triphenyltetrazolium chloride in multiple coronal sections. Pretreatment with TCV-309 (lmg/kg) significantly reduced the water content (p < 0.01) and volume of ischemic damage (p < 0.001) produced by the cold brain injury. These results indicate that PAF antagonist can ameliorate secondary brain tissue damage following brain injury.

Monitoring of severe head-injured patients with transcranial Doppler (TCD) ultrasonography

Intracranial haemodynamics were studied in 36 patients with severe head injury and experimental animals with acute intracranial hypertension by the use of TCD ultrasound. The mean flow velocity (FV) in the basal cerebral arteries commonly decreased on the side of the haematoma depending on intracranial pressure (ICP) elevation and cerebral perfusion pressure (CPP) reduction in focal brain injury. The FV decreased bilaterally and there was no difference between the right and left sides in diffuse brain injury without a clear relationship between the FV and CPP. The FV of the middle cerebral artery and blood flow in the internal carotid artery exhibited flow patterns which changed correlatively depending on CPP reduction in experimental animals. Monitoring with TCD ultrasound is valuable in evaluating compression ischaemia in focal brain injury. But many complicated factors are considerable in diffuse brain injury.

Coexisting diffuse axonal injury (DAI) and outcome of severe head injury

The importance of coexisting diffuse axonal injury (DAI) and outcome were studied in 107 patients with diffuse and focal brain injury. Comprehensive neuropathological study was undertaken in 26 fatal patients. There was a clear rank order of the mortality rate in the lesion type. The rank order of good recovery and moderate disability was also similar to the inverse of the mortality ranking. The pathological "marker" of DAI, macroscopic lesions in the corpus callosum and dorsolateral quadrant of the upper brainstem and histological evidence of axonal retraction balls, were commonly found not only in patients with diffuse brain injury but also in focal brain injury. The type of intracranial lesion in severe head injury is thus an important factor in determining outcomes and DAI of varying severity is the common subjacent lesion in the fatal patients.

Superficial esophageal carcinoma: a report of 27 cases in Japan

Twenty-seven patients with superficial esophageal carcinoma were investigated to determine their clinical and pathological features. All 21 male patients were habitual drinkers, and 17 were heavy smokers. Histological examination showed that three tumors were intraepithelial, five were mucosal, and 19 were submucosal. Fifteen of the 27 patients were asymptomatic, including seven of the eight with intraepithelial or mucosal carcinoma. Twelve of the 13 patients with polypoid tumors had submucosal invasion, whereas two patients with flat tumors and four of the seven with erosive tumors had either intraepithelial or mucosal carcinoma. Six of the eight patients with intraepithelial or mucosal carcinoma had normal routine radiological studies. All these eight patients had no lymph node involvement, whereas four of the 19 with submucosal carcinoma had lymph node metastases. An aggressive approach to endoscopy in asymptomatic high-risk individuals (middle-aged male drinkers and smokers) may increase the detection of early esophageal carcinoma, although the cost-effectiveness should be evaluated further. In addition, in the interest of prevention, our results show that encouraging people to stop smoking and limit their alcohol intake to an occasional drink might be an important factor in lessening the risk for esophageal carcinoma.

[Pseudoaneurysm of the extracranial vertebral artery; a case report]

Traumatic injury of the vertebral artery is rare and only a few reports have been presented. We treated a case of iatrogenic pseudoaneurysm of the extracranial vertebral artery. A 65-year-old man complained of headache and had a pulsating mass in the soft tissue of the neck which had continued for one month after evacuation of hypertensive cerebellar hemorrhage. The left VAG revealed a large pseudoaneurysm at the third portion of the vertebral artery and the right retrograde VAG revealed agenesis of the vertebral artery. To select the proper treatment was a dilemma. This case was treated by embolization using an occluding spring embolus with direct transcutaneous puncture of pseudoaneurysm. Following this treatment, the mass and associated symptoms resolved without neurological deficit.

Diffuse axonal injury and early intracranial sequelae in severe head injury

The importance of diffuse axonal injury (DAI) and early intracranial sequelae was studied in 107 patients with diffuse and focal brain injuries. Comprehensive neuropathological study was also undertaken in 24 fatal patients. The mortality rate was clearly the highest in traumatic subarachnoid hemorrhage, followed by acute subdural hematoma, cerebral contusion with delayed hematoma formation, traumatic intracerebral hematoma, diffuse cerebral swelling, DAI with classical features, and finally nearly normal on computed tomographic scans. The mean flow velocities in the middle cerebral artery recorded by transcranial Doppler ultrasound were variable in diffuse brain injury, but commonly decreased on the hematoma side depending on increased intracranial pressure and decreased cerebral perfusion pressure in focal brain injury. Deep-seated hemorrhagic lesions did not expand in diffuse brain injury, but sizable hematoma developed within 24 hours in focal brain injury. The platelet count was significantly lower in patients with poor outcomes in focal brain injury. Histological evidence of classical DAI was found in eight (50%) of 16 cases with focal brain injury. DAI of varying severity is the common subjacent lesion in patients with severe head injury, but the final outcome varies greatly with different lesion types.

Rapid growth of untreated esophageal squamous-cell carcinoma in 10 patients

We documented the natural history of esophageal carcinoma and its rapid growth by measuring the change in tumor diameter radiographically in 10 patients during an observation period because the diagnosis had been missed. Nine men and one woman (age range, 48-74 years; mean, 60 years) were included in the study. Eight patients had undergone esophagography for gastrointestinal complaints and had lesions missed on the initial interpretation that were apparent on retrospective review after the patient had returned with more severe complaints and undergone repeat studies; two patients had refused treatment. The tumor was squamous-cell carcinoma in all. The treatment-free retrospective observation period ranged from 4 to 19 months (mean, 12.2 months) and was shorter for elevated (mean, 9.2 months) than for depressed lesions (mean, 16.8 months). The longitudinal diameter increased from 10-100 mm initially (mean, 30.5 mm) to 32-150 mm (mean, 74.9 mm). No correlation existed between the increase in size and histologic features. This documentation of the rapid increase in the size of esophageal carcinoma involving at least the submucosa confirms clinical impressions of the aggressive nature of this lesion and offers an explanation of why this disease is seldom detected at an early stage and long-term survival is so poor after the early stage of disease.

[Entirely suprasellar symptomatic Rathke's cleft cyst]

Two rare cases of entirely suprasellar Rathke's cleft cyst were reported. Case 1. A 62-year-old man was admitted to our hospital on the 14th of January, 1988, complaining of headache and diplopia. A plain skull x-ray showed the sella turcica was normal. CT scan and MRI demonstrated a lesion mass located entirely in the suprasellar cistern. Right frontotemporal craniotomy was performed, and the cyst wall was resected subtotally. Microscopic sections of cyst wall showed ciliated single layer with focal stratified epithelium. Case 2. A 51-year-old man was hospitalized complaining of visual impairment in the left eye. Endocrinological examination showed no abnormalities. CT and MRI demonstrated a lesion mass located entirely in the suprasellar region. Right frontotemporal craniotomy was performed. The mass was opened and a large amount of yellowish fluid was released. Histologically, the specimens were simple ciliated cuboidal epithelium. Postoperative courses of these patients were uneventful. The findings on CT and MRI of the cases located entirely in the suprasellar region were varied. The histopathogenesis and embryological pathogenesis of Rathke's cleft cyst in the literature, particularly the entirely suprasellar type, were discussed.