Surgical management of renal cell carcinoma invading into the liver: radical nephrectomy en bloc with right hepatic lateral sector

Renal cell carcinoma demonstrates expansive growth and invasion of adjacent structures. Direct liver extension, although uncommon, is a dismal prognostic sign. We propose radical nephrectomy en bloc with right lateral sector (segments 6 and 7) of the liver. The operative procedure was performed in 2 male patients, 61 and 81 years of age, both with renal cell carcinoma and direct hepatic extension. The patients had no evidence of disease at 100 and 57 months after resection. This procedure may help cure selected patients with renal cell carcinoma invading the liver.

Long-term results of the anterior floating method for cervical myelopathy caused by ossification of the posterior longitudinal ligament

STUDY DESIGN

Results of the anterior floating method used to decompress ossification of the posterior longitudinal ligament were studied for an average postoperative interval of 13 years.

OBJECTIVE

To investigate the long-term results of the anterior floating method used to manage ossification of the posterior longitudinal ligament.

SUMMARY OF BACKGROUND DATA

The anterior floating method is a technique that differs from the extirpation method used to manage ossification of the posterior longitudinal ligament. Reports of the long-term results from anterior decompression used to manage cervical ossification of the posterior longitudinal ligament are rare.

METHODS

The anterior floating method was used to decompress cervical ossification of the posterior longitudinal ligament in 63 patients. These patients were followed for more than 10 years with neurologic evaluations using a scoring system proposed by the Japanese Orthopedic Association (JOA score).

RESULTS

The recovery rate was 66.5% at 10 years and 59.3% at 13 years, the time of the final survey. Operative outcomes most closely reflected the preoperative duration and severity of myelopathy (JOA score) and the preoperative cross-sectional area of the spinal cord. There was no correlation with the canal narrowing ratio or the thickness of ossification of the posterior longitudinal ligament. Delayed deterioration was attributed to an original inadequate decompression and progression of ossification of the posterior longitudinal ligament outside the original operative field. There was no evidence of significant recurrent ossification of the posterior longitudinal ligament within the margins of prior decompression.

CONCLUSIONS

The anterior floating method appears to yield adequate long-term outcomes when used to manage ossification of the posterior longitudinal ligament.

Multiple sclerosis with very late onset: a report of a case with onset at age 82 years and review of the literature

This is a report of a patient with late-onset multiple sclerosis at age 82 years. The lesion involved was located on the spinal cord. Multiple sclerosis mainly affects young adults, making late onset of multiple sclerosis a rarity, particularly for cases after age 80 years. Common characteristics of late-onset multiple sclerosis reported in other publications are predominant involvement of the spinal cord and a progressively worsening course with a serious prognosis. In this case, magnetic resonance imaging revealed a large area of high signal intensity in the cervical and upper thoracic spinal cord on T2-weighted images. An increased immunoglobulin G level in cerebrospinal fluid also played a diagnostic role in ruling out cervical spondylotic myelopathy. Spontaneous improvement occurred 2 months after the onset. Unlike other patient described in the literature, the clinical course of this man was not as bleak.

Drug sensitivities of the primary afferents and their changes after inflammation

This study explored the possibility that altered sensitivities of the dorsal root and dorsal root ganglion to neuroactive substances released in inflamed tissue may be involved in radicular pain. The chemical sensitivities of the dorsal root and ganglion of rats were examined by monitoring nerve membrane potential. Endogenous pain inducing substances such as bradykinin, serotonin, acetylcholine, and histamine caused depolarizations of the dorsal root and the ganglion. Application of bradykinin or capsaicin to the dorsal root and ganglion on the isolated spinal cord preparation evoked spinal reflex activities in the lumbar ventral root. These results suggest that, when pain inducing substances are released at the dorsal root or its ganglion, they may initiate action potentials and cause pain. As an inflammation model, chromic gut was tied loosely around the lower lumbar nerve root. The dorsal root of the surgically treated rats showed an increased sensitivity to bradykinin when compared with sham operated rats. In contrast, the sensitivity of the dorsal root to gamma-aminobutyric acid, a major inhibitory transmitter in the spinal cord, was decreased. This result suggests that these reciprocal changes in the sensitivities of the dorsal root may play an important role in the pathogenesis of chemical radiculitis.

[Three cases of gastric cancer (Borrmann type IV) presenting with right back pain caused by right hydronephrosis as the first symptom]

We experienced three cases of right hydronephrosis, which were later diagnosed to have been caused by gastric cancer (Borrmann type IV). The patients were 25-, 38-, and 50-year-old women who complained of right back pain. Ultrasound sonography revealed right hydronephrosis in all three cases. We conducted drip infusion pyelography, computed tomographic scan and retrograde pyelography, but there were no signs of urinary stones or tumors, except for the presence of right ureteral stenosis. Since the patients had upper abdominal discomfort, they underwent gastrofiberscopy, which revealed scirrhous gastric cancer. We suspected that the right ureteral stenosis was caused by metastasis of gastric cancer. After a double J catheter was indwelt at the right ureter, combination chemotherapy of methetrexate + 5-fluorouracil was conducted. The right hydronephrosis diminished and all three patients became catheter-free.

Dynamic motion study of the whole lumbar spine by videofluoroscopy

STUDY DESIGN

Dynamic lumbar flexion-extension motion was assessed by videofluoroscopy.

OBJECTIVES

To identify the motion patterns of the whole lumbar spine in normal subjects and in patients with low back pain or spondylolisthesis during actual movement.

SUMMARY OF BACKGROUND DATA

Assessment of lumbar instability on terminal radiographs is controversial. Information regarding spinal kinematics during actual movement in vivo is scarce.

METHODS

Fluoroscopic lumbar sagittal motion videos were recorded in volunteers (n = 13; mean age, 22.3) and in patients with chronic low back pain (n = 8; mean age, 43.5) and degenerative spondylolisthesis (n = 8; mean age, 63.1) while the subjects bent forward from a standing neutral position (eccentric motion) and then returned to the original position (concentric motion). The videos recorded approximately 8 seconds of motion and were converted to still images at 5 frames per second. Disc angles from the horizontal line were measured to estimate sagittal rotation of each segment. Disc degeneration was evaluated on T2-weighted midsagittal magnetic resonance image.

RESULTS

In the volunteer group, six exhibited sequentially spreading motion, four exhibited simultaneous motion, and three showed an altered motion-spreading pattern in the eccentric phase. The first two patterns were considered normal. Six (67%) of the patients with chronic low back pain also showed normal patterns, but seven (88%) of the patients with degenerative spondylolisthesis showed disordered patterns. The order of motion in the concentric phase was also different among the three groups. Prolonged deflection of the slipped segment was observed more frequently in the patients with degenerative spondylolisthesis. Disc degeneration was not always associated with motion-spreading order and the motion patterns.

CONCLUSION

Segmental instability influences the whole lumbar motion in patients with degenerative spondylolisthesis. The patients with chronic low back pain did not show a significant difference when compared with the volunteers.

[The EMG findings of spasmodic torticollis--the character of the EMG findings of neurogenic torticollis]

Spasmodic torticollis is a clinical entity that is hard to treat though various symptomatic therapy have been tried. On the other hand, microvascular decompression operation have been established for cranial nerve vascular compression syndrome such as hemifacial spasm. Case reports on the decompression of the spinal accessory nerve for the treatment of spasmodic torticollis have been published on the basis of the concept of cranial nerve vascular compression syndrome. Thus, spasmodic torticollis related to unilateral accessory nerve has attracted much attention for selecting an optimal treatment, although there have not been any diagnostic criteria with electromyographic study. From the viewpoint of the clinical electrophysiological findings on hemifacial spasm those we have acquired by EMG study, we have examined the EMG findings of various types of spasmodic torticollis and here report the classification of spasmodic torticollis based on the EMG study. Thirty-five patients with spasmodic torticollis were analyzed. The symptoms were classified to the horizontal rotation type, the lateral bending type and the mixed type with the number of each group of 23, 2 and 10, respectively. As we have shown the criteria of the EMG findings on hemifacial spasm, the EMG of the patients with spasmodic torticollis were analyzed on four conditions as follows; (1) distribution of the involved muscles, (2) maximum firing rate of the abnormal spontaneous activity of the sternocleidomastoid muscle, (3) synkinetic discharge between the muscles innervated by unilateral accessory nerve and (4) alteration of the spontaneous muscle discharge by posture change. Abnormal spontaneous muscle discharges were recorded only from the sternocleidomastoid muscle and the trapezius muscle on the same side in twelve patients. Maximum firing rate of spontaneous muscle discharge was higher than that of maximum voluntary contraction in twenty-two patients. Abnormal synkinetic discharge was recorded between the sternocleidomastoid muscle and the trapezius muscle on the same side in twenty-one patients. Spontaneous EMG activities of the muscles innervated by the accessory nerve increased when the patients stood up from the resting supine position in thirty-one patients. Thus, ten patients out of thirty-five subjects had all four conditions mentioned above as typical patients with hemifacial spasm usually had. These ten patients with spasmodic torticollis were thought to have strong similarity to the EMG characteristics of hemifacial spasm that suggested hyperexcitability of unilateral accessory nervous system. This classification with EMG is considered to be useful in diagnosing the spasmodic torticollis related to unilateral accessory nerve and can be applied for selecting an optimal treatment.

Immunohistochemical detection of tumor marker in recurrent clivus enterogenous cyst--case report

A 26-year-old male presented with recurrence of an enterogenous cyst in the intracranial region 10 years after the first operation. The cyst was drained and the cyst wall partially resected at both operations with good outcome. Histological examination showed a change from one layer epithelium in the first specimen to glandular structures in the second. Alcian blue, periodic acid-Schiff, and immunohistochemical staining for epithelial membrane antigen, S-100 protein antigen, keratin, and carcinoembryonic antigen were used to confirm the accurate diagnosis. Immunohistochemical staining showed CA19-9 antigen was positive in both specimens. The CA19-9 level in the cerebrospinal fluid was extremely high (621.5 U/ml) at the second operation. Patients with enterogenous cyst should be monitored to detect possible recurrence.

Lumbar nerve root compression caused by lumbar intraspinal gas. Report of three cases

STUDY DESIGN

Three cases of lumbar nerve root compression associated with intradiscal gas formation and its migration are reported.

OBJECTIVES

To establish the pathogenic mechanism by which gas is formed in the spinal canal.

SUMMARY OF BACKGROUND DATA

Few such cases have been reported of patients with clinical symptoms of lumbar radiculopathy resulting from gas in the spinal canal.

METHODS

Surgery with needle aspiration of the gas was performed in all cases.

RESULTS

The presence of the gas was detected in the extradural space in one patient and within the nerve sheath in two patients. After surgery, all patients recovered well, and there were no obvious remnant neurologic abnormalities. One year later, all patients were completely free of symptoms.

CONCLUSIONS

Surgery with needle aspiration of the gas resulted in clinical improvement in all cases, confirming that intraspinal gas is an important cause of lumbar radiculopathy. The composition of the gas in one patient was analyzed by gas chromatography, which revealed an overwhelming preponderance of nitrogen. A relationship between a gas-containing pseudocyst in the spinal canal and a degenerated intervertebral disc was identified, a key finding for understanding the precise nature of this disorder. Intradiscal gas formation and its outward migration as a sequel of intervertebral disc degeneration also has been addressed in this report.

A cadaveric study on the stability of lumbar segment after partial laminotomy and facetectomy with intact posterior ligaments

This study aimed to biomechanically investigate a change in the stability of decompressed segments in the degenerative lumbar spine. Cyclic loading tests to the cadaveric spinal unit were conducted in compressive and bending directions with a stepwise resection of the posterior elements such as wide fenestration (partial laminotomy), unilateral and bilateral facetectomy with the intact supra- and interspinous ligaments and spinous process. Flexion stability did not decrease significantly, and may reflect the fact that the aforementioned ligamentous structures were preserved throughout the resection process. After wide fenestration, the loss of compression stiffness amounted to only half that of bilateral facetectomy, and extension stiffness dropped to this same level. Lateral bending stiffness was maintained until unilateral facetectomy was performed. We recommend restricted decompression surgeries for a single-level central stenosis in the degenerative lumbar spine.

[An operative case of cholesterol granuloma of the petrous apex]

A 59-year-old man presented with a rare cholesterol granuloma of the petrous apex manifesting as headache, left facial dysesthesia, diplopia, left hearing impairment, and left tinnitus. Neurological examination revealed dysesthesia of territory in all divisions of the left trigeminal nerve, left incomplete abducens nerve palsy, left mixed hearing impairment, and left tinnitus. Plain CT scan showed a smoothly marginated mass involving the left petrous apex. The mass was isodense with the brain parenchyma and not enhanced by contrast medium. The mass appeared heterogeneously slightly hyperintense on the T1-weighted MR image and homogeneously hyperintense on the T2-weighted MR image except for the peripheral portion. The mass was not enhanced after intravenous gadolinium DTPA administration. Surgery via a petrosal approach totally removed the mass in the intracranial, extradural space. Histological examination showed typical features of cholesterol granuloma, with cholesterin clefts, hemosiderin deposits, and erythrocytes in non-specific granulation tissue. Cholesterol granuloma most commonly occurs in the middle ear cavity, and rarely in the petrous apex. The characteristic hyperintense appearance of cholesterol granuloma on T1- and T2-weighted MR images is very useful for differentiation from other lesions of the petrous apex and the cerebellopontine angle such as cholesteatoma, mucocele, chordoma, and meningioma. Solid cholesterol granuloma of the petrous apex should be treated by total removal via craniotomy, not by drainage which is commonly performed by otorhinologists.

Selecting a surgical method for thoracic myelopathy caused by ossification of the posterior longitudinal ligament

STUDY DESIGN

The authors classified typical distributional patterns of ossification of the posterior longitudinal ligament of the thoracic spine in 1) central part of S-curve, 2) just above apical vertebra, and 3) combined with ossification of ligamentum flavum below apical vertebra. The results of the surgical methods selected according to the authors' classification were compared with those of previous reports.

OBJECTIVES

To establish the criteria for selecting an appropriate surgical method for ossification of the posterior longitudinal ligament of the thoracic spine.

SUMMARY OF BACKGROUND DATA

Poor surgical results for ossification of the posterior longitudinal ligament of "middle or lower thoracic spine" have been reported, but the unsuccessful location and curve has not been strictly defined.

METHODS

The authors studied postsurgical results in 26 cases of thoracic myelopathy caused by ossification of the posterior longitudinal ligament. They also investigated radiographs of 111 cases, including 85 patients under observation, and examined the relationships between thoracic spine alignment and ossification of the posterior longitudinal ligament distribution.

RESULTS

Twenty-three patients treated with methods conforming to the authors' criteria achieved satisfactory recovery in walking ability except for one patient. The results of the other three patients who underwent surgery with nonconforming methods were uneven.

CONCLUSION

Posterior decompression, as well as anterior decompression, is effective in the first pattern in the cervicothoracic region. In case of the second pattern, the responsible ossification of the posterior longitudinal ligament always lies one or two levels above the apical vertebra and should be removed by anterior approach, regardless of the extent of kyphosis. Transthoracic anterior decompression surgery is considered the best method for most patients under the second and third patterns.

[A case of mycotic ICA petrous portion aneurysm treated with endovascular surgery]

A case is reported of mycotic aneurysm at the petrous portion of the internal carotid artery (ICA) treated with an endovascular procedure. A sixty-seven-year-old male who had suffered from chronic otitis media bilaterally for the last five years showed a sudden onset of massive left otorrhagia. Cerebral angiogram at the eighth day of otorrhagia disclosed a big aneurysm at the petrous portion of the left ICA. The aneurysm was round in shape but its wall was irregular. The angiogram also showed that a stenotic finding of the left ICA just at the proximal portion of the aneurysm and the neck of the aneurysm was not broad. Bone window computed tomography showed a destroyed petrous bone around the left ICA. The results of the Matas test and the Allcock test told us that left ICA occlusion should not be selected as a treatment. We decided that endovascular surgery could be applied as the treatment of this pathology. An endovascular procedure was performed for this pathology one month after the otorrhagia. The aneurysm was successfully embolized using platinum coils beside a part of the neck without occlusion of the parent artery. The patient's postoperative course was not eventful. We concluded that endovascular surgery might be the first choice for the treatment of an ICA petrous portion mycotic aneurysm.

The natural history of herniated nucleus pulposus with radiculopathy

STUDY DESIGN

The present study retrospectively investigated the morphologic changes that occurred during conservative treatment of patients with unilateral leg pain resulting from herniated nucleus pulposus without significant lumbar canal stenosis.

OBJECTIVES

The results were correlated with clinical outcomes and extruding forms to determine which type of herniated nucleus pulposus had the greatest capacity for spontaneous regression and how rapidly such regression might occur.

SUMMARY OF BACKGROUND DATA

The study population consisted of 77 patients with radiculopathy.

METHODS

All patients complained primarily of unilateral leg pain, and 94% had positive tension signs. Additionally, 32% exhibited muscle weakness corresponding to the symptomatic nerve root. All patients were studied more than twice using magnetic resonance imaging during conservative therapy at a mean interval of 150 days. Morphologic changes on magnetic resonance imaging fell into four categories, with herniated nucleus pulposus classified into three types using T1-weighted sagittal views. Each patient was reexamined on the same scanner; 53 patients were examined twice, and 24 patients were examined more than three times.

RESULTS

Morphologic changes, with the exception of 13 false-negative cases, basically corresponded to clinical outcome. In half of the cases that showed some improvement at follow-up evaluation, improvement of clinical findings were seen before those observed on magnetic resonance imaging. Migrating herniated nucleus pulposus frequently presented an obvious decrease in size, and even disappearance in seven cases. The further the herniated nucleus pulposus migrated, the more decrease in size could be observed. The cases apparently corresponding to "protrusion" showed little or no change on follow-up magnetic resonance imaging. Regarding the mechanism of herniated nucleus pulposus disappearance, exposure to the vascular supply undoubtedly took a part, although many factors were suspected to have some influence.

CONCLUSION

Morphologic changes on magnetic resonance imaging mainly corresponded to clinical outcomes but tended to lag behind improvement of leg pain. Disappearance of herniate nucleus pulposus was seen frequently in the cases of migrating disc herniation, and it was presumed that exposure to the vascular supply had a lot to do with this phenomenon.

[A case of multiple cerebral mycotic aneurysms treated with endovascular surgery]

A case of multiple mycotic cerebral aneurysms successfully treated with endovascular surgery is reported. A nine-year-old boy who has suffered from hypertrophic obstructive cardiomyopathy and active infectious endocarditis in the mitral valve developed sudden consciousness disturbance and convulsion. Computerized tomography revealed subarachnoid hemorrhage with subcortical hematoma in the left parietal lobe. Angiography demonstrated four aneurysms at the distal part of the middle cerebral artery on both sides. Since his physical status had been deteriorating, it was difficult to undergo a usual surgical operation. Therefore, endovascular surgery was performed. The catheter was super-selectively advanced to the parent artery of the left posterior parietal artery aneurysm which seemed to be the hemorrhagic source, and the embolization was performed using platinum coils and liquid embolization material. Angiography after embolization showed that the aneurysms had been successfully occupied by the materials while the aneurysm of the right anterior parietal artery had not responded antibiotic therapy. Therefore the second embolization was carried out to the parent artery of the aneurysm of the right anterior parietal artery one month later. The patient had no neurological deficit after embolization and no aneurysms have been detected by the follow-up angiogram after the second embolization. An endovascular approach might be an alternative useful treatment for cases in which the patient has, deteriorated so much that it is considered difficult to perform open craniotomy under general anesthesia.

[Primary malignant T-cell-rich B-cell lymphoma of the central nervous system: a case report]

An autopsy case of primary intracranial T-cell-rich B-cell lymphoma in a 69-year-old female is presented. The patient was admitted with a diagnosis of a brain tumor in July 1993 and a month long history of mental deterioration, motor weakness of the right arm and leg, and a tendency toward somnolence. Neurological examination revealed disturbance of consciousness, right hemiparesis, and papilloedema. However, her general physical examination was unremarkable. A CT scan and MR imaging revealed an irregular enhanced mass lesion at the paraventricular deep white matter in the bilateral parieto-occipital lobe. The patient was treated with surgical biopsy of the tumor followed by combined radiotherapy (a total of 50 Gy) and chemotherapy. Following repetitive episodes of remission and exacerbation, the patient expired about seven months after the onset of symptoms. Histopathological diagnosis of the tumor was malignant lymphoma (diffuse medium-sized cell type). In the immunohistochemical study, most of the lymphoma cells had T-cell markers, such as UCHL1. Some of the lymphoma cells were L26-positive. Neither glial fibrillary acidic protein nor neuron specific enolase were reactive with the lymphoma cells. At post-mortem examination, the specimens disclosed diffuse infiltration of medium-sized lymphoma cells. By contrast, most of the lymphoma cells were shown to be positive by the analysis of L26. None of the lymphoma cells exhibited the presence of UCHL1. These immunohistochemical evaluations conform to the criteria of T-cell-rich B-cell lymphoma.

Three-dimensional-MRI of neurovascular compression in patients with hemifacial spasm

We prospectively studied 30 patients to assess the usefulness of three-dimensional (3D) contrast-enhanced MRI in patients with hemifacial spasm. In all patients neurovascular compression of the facial nerve could be detected. Microvascular decompression was performed in 14, and vascular compression of the root exit zone of the facial nerve and the offending artery were exactly as predicted by MRI in all but 2. We also retrospectively studied whether the symptomatic side could be defined only by enhanced 3D MRI in 55 randomised individuals (30 with and 25 without hemifacial spasm). All symptomatic sides were correctly identified, and the false-positive rate was 13.8%.

Down's syndrome associated with intracranial germinoma and testicular embryonal carcinoma

In patients with Down's syndrome, the frequency of leukemia is significantly greater than normally would be expected. However, cancers other than leukemia have been reported to occur rarely. We present a case of Down's syndrome associated with intracranial germinoma and testicular embryonal carcinoma. Currently, no case of double primary carcinomas in Down's syndrome has been reported to the authors' knowledge.

[A case of dissecting aneurysm associated with mixed connective tissue disease]

A 41 year-old-female with mixed connective tissue disease (MCTD) associated with dissecting aneurysm (DA) of the right posterior cerebral artery is reported. This case satisfied the diagnostic criteria for MCTD, and cerebral angiography revealed the double-lumen sign and pooling of the contrast medium. Thus it was possible to make a definite diagnosis of both MCTD and DA. Fragility of the arterial wall due to the primary disease, MCTD, appeared to have played a role in the occurrence of dissection and the subarachnoid hemorrhage.

Long-term results of microvascular decompression for trigeminal neuralgia with reference to probability of recurrence

Sixty-one patients with trigeminal neuralgia who underwent microvascular decompression were analysed. Vascular compression of the trigeminal nerve root was found in all cases. The recurrence rate of pain in this series was 18% with an average follow-up of 80 months (range: 13 to 126 months). Ten patients developed recurrence of their trigeminal neuralgia during follow-up. Fifteen factors, including the clinical and operative findings in the pain-free patients versus the 10 patients with recurrence were analysed. Only the patients with venous compression singly or in combination with arteries were significantly related to recurrence. There was no relationship between recurrence and the duration of symptoms or the degree of compression. Based on vascular compression as the sole cause of TN, the results and interesting findings can not be explained. With reference to the hypothesis that vascular compression is only one of at least two causative factors for the development of trigeminal neuralgia, it is suggested that the intrinsic lesion in trigeminal neuralgia may be responsible for late recurrence.

[Estimation of malignancy using SPECT with 201Tl chloride in astrocytic tumors]

This study was designated to estimate the usefulness of SPECT with 201Tl chloride (Tl-SPECT) for the determination of the malignancy in astrocytic tumors. The subjects consisted of 39 astrocytic tumors in supra-tentorial regions. Tl-SPECT undertaken ten minutes to obtain an early image and four hours to obtain a delayed image, after intravenous injection of 74MBq 201Tl chloride (Tl). Tl index (L/N) was defined as the RI count ratio in the tumor lesion (L) to that in the normal parenchyma (N). Histological classification was determined by the WHO grading, and the results showed one case at Grade I, 11 cases at Grade II, 23 cases at Grade III and 4 cases at Grade IV. The proliferating activity was determined by the labeling index using the monoclonal antibody of proliferating cell nuclear antigen (PCNA). In both of the early and delayed images, Tl index was significantly higher (p < 0.01) in high grade astrocytomas compared with low grade tumors. There was a close correlation between the Tl index and the proliferating activity. The relationship between the Tl index and prognosis indicated that the high Tl index was corresponded to the poor prognosis. These results showed that the Tl index is useful to determine the malignancy of astrocytic tumors.

Hearing preservation and improvement of auditory brainstem response findings after acoustic neuroma surgery

Among 9 patients with acoustic neuroma who underwent tumor removal by the middle cranial fossa approach during the past 5 years, 6 were selected for hearing preservation surgery which was successful in 5 cases (83.3%). For the prediction of success in hearing-preservation, factors related to hearing preservation, including preoperative findings of neurotological examination, were analyzed. Postoperative hearing threshold correlated significantly with wave V latency and I-V interpeak latency of preoperative auditory brainstem response (ABR) and the SP/AP ratio of preoperative electrocochleogram and postoperative facial palsy. The size of tumors and preoperative results of speech audiometry did not correlate with hearing results. Postoperative ABR findings were normalized within the observation period from 5 days to 10 months in 3 hearing-preserved patients. Possible mechanisms for improvement of ABR findings after the removal of acoustic neuroma are discussed.

[Sequential changes in SPECT using 201T1 chloride during the treatment of intracranial gliomas]

The authors followed up the change in SPECT using 201Tl chloride (Tl-SPECT) according to the course of treatment of intracranial gliomas and analyzed the difference in Tl-SPECT between the stable and progressive groups. The subjects were 26 series of supratentorial gliomas subjected to Tl-SPECT before and after the treatment (radio-therapy and chemotherapy). They were put on Tl-SPECT after 10 minutes (early image) and 4 hours (delayed) following 74 MBq of 201Tl chloride intravenous injection. Besides, RI count ratio (L/N) in the tumor lesion (L) and contralateral parenchyma (N) was measured. The patients were divided into stable and progressive groups judging from the therapeutic effects, the change in L/N ratio between before and after the treatment was analyzed. The stable group showed a significant post-treatment decrease in L/N ratio compared with a significant post-treatment increase therein for the progressive group. This result suggested Tl-SPECT to change according to the course of treatment and to be applicable to the judgement of the therapeutic effect on gliomas.

[Correlation between clinical symptoms and draining pathways in dural arteriovenous malformation of the cavernous region]

The clinical picture of dural arteriovenous malformations cannot be explained on the basis of degree of arteriovenous shunting in many cases. In this study, therefore we focused on the relation between clinical symptoms and draining pathways. Eighteen patients with dural arteriovenous malformation in cavernous region were studied before treatment. All patients underwent examination for their clinical symptoms, opthalmological examination and angiography on admission. Angiograms were used to determine the degree of arteriovenous shunting and the direction of draining pathway. The relationship between severity and shunt volume was inexplicable in many cases. However, close correlations appeared to exist between ocular hypertension and drainage pathways toward the orbit, between cranial nerve signs and drainage pathways toward the posterior fossa, and between headache and drainage pathways toward the cortical veins.

[Correlation between sequential changes in angiographical findings and clinical deteriorations during management for dural AVM of the cavernous region]

The authors treated five patients with dural arteriovenous malformation of the cavernous region (DAVM) by cervical compression procedure as the initial treatment. In four of five patients clinical symptoms were aggravated during that period. The period between the beginning of cervical compression and the deterioration of clinical symptoms ranged from 11 to 20 days. In three of four patients, the angiography examined at the time of deteriorations confirmed the same amount of A-V shunt flow and otherwise the remarkable decrease of the draining pathway compared to the findings of the angiogram performed before the management. The angiography examined at the time of the remission of the symptoms showed the increase of the draining pathway in two patients and the resolution of the DAVM in another. These findings indicate that clinical courses of the DAVM and the amount of the draining pathway correlate to each other and that cervical compression procedure may occlude the important draining pathway of the DAVM.

[Correlation between the analgesic effect by thalamic relay nucleus stimulation and somatosensory evoked potentials recorded from thalamus]

Electric stimulation of the thalamic sensory relay nucleus (Vc) has an analgesic effect on deafferentation pain, however, the analgesic effect differs from patient to patient. Electrode position and state of the substrate stimulated are considered important factors influencing the analgesic effect. In order to determine the best position for the stimulating electrodes, we recorded somatosensory evoked potentials (SEPs) from stimulating electrodes implanted in the Vc and compared thalamic SEPs with the analgesic effect of Vc stimulation. The subjects were thirteen patients with deafferentation pain, four patients with thalamic lesions, seven patients with suprathalamic lesions and two patients with infrathalamic lesions. We inserted the electrode array into the Vc stereotactically, and fixed it so that stimulation-induced paresthesia would cover the painful frea. The electrode array consisted of the four contact points of four electrodes spaced at 2 mm intervals within 10 mm from the tip. Using bipolar combinations of the four electrodes (twelve combinations in all), we stimulated the Vc for about half an hour with each combination. We then rated the degree (%) of analgesia as 100% when pain disappeared and 0% when there was no change. Thalamic SEPs elicited after stimulation of the contralateral median nerve were recorded from all four contact points simultaneously. The latencies, amplitudes and recorded positions of large early positive components (P1) followed by large negative components (N1) with latencies between 10 and 20 msec were then analyzed and compared with the best electrode combination for optimal pain relief and with the degree of analgesia.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracranial germinoma and Down's syndrome--case report

A germinoma in the basal ganglia developed in a 9-year-old boy with Down's syndrome, presenting as left hemiparesis. An initial computed tomographic (CT) scan demonstrated no notable abnormalities, but serial CT scans followed the entire course of tumor growth. Subtotal removal and irradiation achieved tumor remission. This is the first case reported of intracranial germinoma associated with Down's syndrome.

Long-term roentgenographic and functional changes in patients who were treated with wide fenestration for central lumbar stenosis

Thirty-four patients who had central stenosis of the lumbar spine were treated with wide fenestration, a procedure in which only the medial parts of the inferior facets and the adjoining ligamentum flavum were removed. The patients were followed for an average of five and one-half years (range, four and one-half years to seven years and ten months). Wide fenestration successfully relieved the symptoms. The new bone that was laid down in the operatively treated segments did not reproduce the symptoms of spinal stenosis; instead, it appeared to stabilize those segments.

[Neurophysiological study on hemifacial spasm--the abnormality and origin of the electromyographic response to stimulation of the facial nerve]

Electromyographic responses (MD-OC) of the orbicularis oculi muscle to stimulation of ipsilateral marginal mandibular branch of the facial nerve were recorded in 20 patients with hemifacial spasm, pre-, post-operatively and during operations to relieve it by microvascular decompression, and the abnormal features and origin of the MD-OC were investigated. On the affected side, the MD-OC were recorded in pre- and during operative state, and disappeared with disappearance of hemifacial spasm after microvascular decompression, while no response was recorded in pre-, during and post-operative state on the healthy side. In 17 patients, the MD-OC was recorded continuously during operation. In all cases except for one case in whom the MD-OC was recorded even the end of operation, the MD-OC disappeared on several stage of procedure from dural opening through vascular mobilization. The compound nerve action potential (MD-VII) to stimulation of the marginal mandibular branch was recorded from the facial nerve near its root entry zone after exposure of the intracranial portion. There were two patterns in the records, i.e., one group consisting of early component and the other consisting of early and late component. The MD-VII was only consisted of the early component in 12 cases in whom the MD-OC have already disappeared, and was consisted of the early and late component in 5 cases in whom the MD-OC still recorded. And in 2 cases of the later, the late component disappeared simultaneously with disappearance of the MD-OC during vascular mobilization.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intra-arterial chemotherapy of malignant glioma after osmotic blood-brain barrier disruption]

Reversible transient osmotic blood-brain barrier disruption was used to increase drug delivery to the brain. The authors treated 10 cases of malignant gliomas with intra-arterial chemotherapy after osmotic blood-brain barrier disruption. Ten patients received intra-arterial anticancer drugs (5-FU, ACNU, IFN-beta) after intra-arterial infusion of 20% mannitol to open the blood-brain barrier at the tumor site. Clinical responses in 9 evaluable cases were 1 Complete Response, 3 Partial Responses, 5 No Change and no Progressive Disease in CT examination. Response rate was 44.4% (4/9). The most untoward effect of this method was myelosuppression. Platelet and leukocyte count diminished below 20,000 and 2,000, respectively in 3 cases, and 2 out of these 3 cases died of severe infection. The other complications were eye pain during mannitol infusion in all cases, when the selective catheterization of the internal carotid artery failed to pass the origin of the ophthalmic artery. Decreased activity was seen in 70%, nausea and vomiting in 50%, swelling of external decompression area in 33%, increased neurological deficit in 20%, but all these side effects were transient. This method was considered an effective treatment for malignant gliomas.

Bromocriptine-induced morphological changes in cultured growth hormone-producing pituitary adenoma cells

Tumor tissues obtained from two patients with growth hormone-producing pituitary adenomas were cultured and treated with bromocriptine, then examined for morphological changes. Untreated tumor cells (controls) were morphologically well preserved and in terms of growth hormone secretion. Tumor cells exposed to bromocriptine for 7 days contained many vacuoles, which, after 14 days of exposure, grew larger and more numerous. These vacuoles appeared to be extensions of endoplasmic reticulum: some were connected to rough or smooth endoplasmic reticulum or, occasionally, to Golgi apparatus, and there were ribosomes on their surfaces. Bromocriptine apparently has cytocidal effects on growth hormone-producing pituitary adenoma in vitro.

[Responsiveness of brain tumors to chemotherapeutic agents in the subrenal capsule assay]

The 6-day subrenal capsule assay was used to determine chemotherapeutic sensitivities of brain tumors. Twenty-nine brain tumors were obtained at the time of surgical resection. A minced tumor fragment (1-mm cube) was implanted under the renal capsule of 5- to 8- week-old normal female ddY mice. Each fragment was measured at two diameters using ocular micrometer unit (10 omu = 1.0 mm). The animals were randomized, usually 5 to 7 per group, and treated with anticancer drugs on day 1 through 5. On day 6, the mice were killed. The kidney was exteriorized and the tumor was again measured. The change in tumor size was obtained for each animal by ratio of the final tumor size/the initial tumor size. Sensitivities of tumors to anticancer agents were determined by comparing differences in mean values of the change in tumor size between control and treated group. Twenty-seven out of 29 specimens (93%) were submitted to evaluable assay. The response rate of 11 malignant gliomas (grade 3 and 4) was 44% and that to anticancer drugs tested were as follow: 5-FU 78%, ACNU and CPA 50%, VCR 40%, CDDP 36%. The response rate of 3 medulloblastomas was 36%: MTX 67%, CPA 50%, ACNU and CDDP 33%. That of two low-grade gliomas (grade 2) was 29%, while that of 4 malignant brain tumors (2 metastasis, chordoma, malignant fibrous histiocytoma) was 60%. Four neurinomas and 3 meningiomas were not sensitive to Tamoxifen and none were determined for estrogen receptor. In histological analysis, the transplanted tumor retained similar characteristics to the original tumor in the cases of neurinomas, meningiomas and some gliomas. Lymphocytic infiltration was observed in many cases. In the cases of metastasis (adenocarcinomas), considerable mesenchymation and lymphocytic infiltration was observed, tumor cells were reduced in number with poor preservation. Clinical response in 9 cases treated with sensitive drugs were 1 complete response, 2 partial response, 5 stable and 1 progressive disease in CT examination. The subrenal capsule assay is therefore considered to be very useful for determining suitable chemotherapeutic agents for brain tumors.

[Monitoring of the spinal cord function using evoked spinal cord potentials]

Monitoring of the spinal cord function by evoked spinal cord potentials (ESP) has come to be used widely with the establishment of a safe technique using an epidural electrode and the great improvement in medical electronic devices. According to other investigations ESP has been recorded through an electrode placed in the posterior epidural space, it is well known that residual ESP can be actually recorded after transection of the posterior half of the spinal cord and that ESP shows no change after a small transection of the anterior column. If ESP originating from the anterior half of the spinal cord is recorded, it is very useful for monitoring during anterior decompression surgery for myelopathy such as ossification of the posterior longitudinal ligament and cervical spondylosis. The purpose of this report is to analyse ESP originating from the anterior half of the spinal cord experimentally and further investigate the ESP monitoring clinically. Sixty cats were used in this study. ESP recording principally consisted of stimulation to the spinal cord at the level of thoracic or lumbar region and recording of ESP with a monopolar electrode placed in the cervical epidural space. Changes in the ESP after transection and compression of the spinal cord were analysed. Anterior vertebrectomy and laminectomy at C2 and C6 were performed for the purpose of placing an electrode correctly and facilitating transection or compression of the spinal cord. Recording electrodes were placed on both the anterior and posterior surfaces of the dura mater at C2. As the result of this study, it is apparent that there exists the ESP originating from the anterior half of the spinal cord. Such ESPs are more accurately recorded through an anterior placed electrode rather than through that placed posteriorly.

Dynamics of contrast enhancement in delayed computed tomography of brain tumors: tissue-blood ratio and differential diagnosis

Thirty-one patients with brain tumors were studied by delayed computed tomographic (CT) scanning performed one and two hours after intravenous administration of contrast medium. Dynamics of contrast enhancement in the lesion were analyzed quantitatively and qualitatively by calculating the tissue-blood ratio (TBR) at each scan, and are expressed as relative TBR (R-TBR). The R-TBRs obtained two hours after the first contrast-enhanced scan were found to be most useful in diagnosis, and were classified into three groups: less than 1.5 (Class I), 1.5 to 3.0 (Class II), and more than 3.0 (Class III). In the glioma group, seven of eight anaplastic gliomas were Class III and all of three anaplastic astrocytomas were Class II. All of seven meningiomas were Class I. Four of five pituitary adenomas were Class II. Three of four neurinomas were Class III. This method is potentially useful in differential diagnosis of some brain tumors.