[HAC-titanium as an implant for interbody fusion in spinal canal stenosis of the cervical spine. Six-year clinical trial]

A total of 102 patients were operated on in 134 levels because of an isolated spondylotic cervical stenosis in 6 years. A titanium implant coated with hydroxyapatite ceramic (HAC) was inserted. The average age of the patients was 53 years. The final clinical and radiological follow-up was performed after 15 months. The functional outcome was classified as good to excellent (Odoms's score) in 83.8% of the patients. Implant-related complications requiring revision surgery included two dislocated dowels and one vertebral collapse in a bisegmental operation. After 6 weeks beginning of bony growth around the implant was seen in 38% of all inserted titanium cages on roentgenograms. A complete solid bony incorporation was shown in 91.2% of the fused segments after 6 months and in 96% after 12 months or at follow-up, respectively. These results illustrate the efficacy of the easy to handle HAC titanium implant, demonstrating that this technique achieves good clinical outcome with the same complication rate as comparable techniques.

[A case of thoracic vertebral tuberculosis associated with pulmonary sarcoidosis]

A 56-year-old woman was admitted to our hospital, on October 10, 1999 because of tingling numbness of the Th3 area and paraparesis. Her medical history included the diagnosis of pulmonary sarcoidosis which had responded to steroid therapy. On radiographic examination, a Th2 compression fracture and gadolinium enhanced areas were shown in MRI. We diagnosed vertebral sarcoidosis and restarted steroid therapy. Next day, she had no paresis and she was discharged after 20 days. However, the patient returned to our hospital with recurrence of the same pain and paraparesis on January 1, 2000, and spinal fusion of the Th2-3 was performed by a transpleural anterolateral approach using a block of iliac bone as a graft. Histology and cultural studies of tissue revealed tuberculosis. There is a diagnostic dilemma, "sarcoidosis or tuberculosis?", but it is necessary to be aware of this at the time of the initial diagnosis.

Pathological mechanism and three-dimensional structure of cerebral dissecting aneurysms

OBJECT

The goal of this study was to investigate the pathological mechanism and precise three-dimensional (3D) structure of cerebral dissecting aneurysms in association with their clinical course.

METHODS

Nine aneurysm specimens were excised from eight patients. Of the nine aneurysms, seven arose from the vertebral artery, one from the anterior cerebral artery, and one from the superior cerebellar artery. Eight aneurysms were accompanied with subarachnoid hemorrhage (SAH) and one with infarction. Seven aneurysms were obtained at autopsy and two were obtained during surgery (trapping and bypass). All nine aneurysms were sectioned into serial axial slices measuring 5 to 10 microm in thickness. Taking each slice as an element, we reconstructed the 3D structure of the aneurysm. The true lumen communicated with a pseudolumen through the disrupted portion of the internal elastic lamina (IEL) in all nine aneurysms. The ruptured portion was located just above the disrupted IEL. Two aneurysms had an exit back into the true lumen. but the other seven had no such exit.

CONCLUSIONS

The primary mechanism by which a cerebral dissecting aneurysm is created is by the sudden disruption of the IEL. The plane of dissection extends through the media. The majority of aneurysms have one entrance into the pseudolumen (entry-only type). This type is associated with an unstable clinical course. Some cerebral dissecting aneurysms have both an entrance and exit (entry-exit type). This type of aneurysm occasionally contains a constant flow of blood through the pseudolumen and is clinically more stable than entry-only aneurysms.

Trauma sites and clinical features associated with acute hyperextension spinal cord injury without bone damage--relationship between trauma site and severity

To elucidate whether a relationship exists between the site of trauma and severity of acute hyperextension spinal cord injury without bone damage, we examined the clinical features of 25 male and 10 female patients aged 13 to 88 years. None of the patients had vertebral damage such as fracture and dislocation. The site of impact was classified as the buccal, forehead, or mandibular region. The neurological findings were assessed according to Frankel's classification at admission and at follow up after 3 months or more to assess outcome. Eleven patients suffered trauma in the buccal region, one patient in Frankel's grade B, three in grade C, and seven in grade D at admission. All 11 of these patients showed an improvement of one grade or more to an outcome of C in one patient, D in one, and E in nine. Trauma occurred at the forehead region in 18 patients, four in grade B, 10 in grade C, and four in grade D. Improvement was seen at follow up by one grade or more to C in one patient, D in 10, and E in seven. Trauma occurred at the mandibular region in six patients, four in grade B and two in grade C. Four of these patients showed improvement of one grade or more to grade B in one, grade C in four, and grade E in one. Overall, seven patients had poor outcomes, five of whom suffered trauma to the mandibular region, indicating that impact to the mandibular region tends to have an unfavorable clinical outcome. Our findings indicate that the site of trauma greatly influences the severity of hyperextension spinal cord injury.

Hyperbaric oxygen (HBO) therapy for acute traumatic cervical spinal cord injury

STUDY DESIGN

A retrospective study of spinal cord injury (SCI) treated with and without hyperbaric oxygen (HBO) therapy.

OBJECTIVES

To report on the use of HBO in spinal cord injury.

SETTING

Neurosurgical Unit, Tokyo, Japan.

METHODS

Thirty-four cases of hyperextension spinal cord injury without bone damage and previous history of surgical intervention were divided into two groups, with (HBO) or without (non-HBO) therapy. The neurological findings at admission and their outcomes were evaluated by means of Neurological Cervical Spine Scale (NCSS)1 and the average improvement rates in individual groups were compared.

RESULTS

The improvement rate ranged from 100% to 27.3% with the mean value of 75. 2% in the HBO group, while these values were 100%, 25.0% and 65.1% respectively in the non HBO group.

CONCLUSION

In the HBO group, the improvement rate indicated effectiveness in acute traumatic cervical spinal cord injury.

[An autopsy case of pericallosal lipoma with mental retardation]

The patient was a 69-year-old male who had visited our psychological department due to mental retardation. Pericallosal lipoma was indicated by MRI taken during treatment. On December 30, 1998, the patient fell from steps and struck his forehead hard, and then limb palsy occurred. He was emergently brought to our hospital. Under the suspected diagnosis of traumatic cervical spinal cord injury, preventive therapy was performed to observe the clinical course in which paralysis gradually improved. On January 22, 1999, however, he died of cardiopulmonary arrest due to sudden suffocation. In general, the connection of choroid plexus lipoma and pericallosal lipoma is bilateral in most cases. In our patients, MRI suggested that a connection with cerebral ventricles through choroidal fissure existed with no right and left difference, however, autopsy findings revealed that the lipoma existed along the left cerebral arch with obvious connection only with the left choroid plexus. The present case seemed to be a very rare case.

Effect of glutathione-modulating compounds on platinum compounds-induced cytotoxicity in human glioma cell lines

The relation between the effect of glutathione(GSH)-modulating compounds and platinum compounds (Cisplatin, Nedaplatin)-induced cytotoxicity was investigated. Pretreatment of human glioblastoma (T98G, U87MG) and glioma (KG1C) cell lines with L-buthionine-[S,R]-sulfoximine, which decrease the intracellular GSH concentration, remarkably increased their sensitivity against platinum compounds, whereas pretreatment with N-acetyl-L-cysteine, which increase the intracellular GSH concentration, only marginally protected the cells from the cytotoxic effect of platinum compounds. The results suggest that platinum compounds-induced cytotoxicity can be modified by GSH-modulating compounds in glioblastoma and glioma cell lines.

Spinal epidural varices

A 16-year-old male experienced a sudden attack of back pain while walking through the corridor of school which required emergent hospitalization. Except for the back pain, no neurological symptoms were noted. Magnetic resonance (MR) imaging indicated an angiopathy-like flow void in the epidural region at Th 3-5 which seemed to explain the patient's back pain. Thoracic laminectomy at Th 3-5 and resection of the affected site were performed. Pathologically, the resected lesion only had a dilated normal vein and no findings indicating vascular deformity. The patient's outcome was good and no relapse of pain has occurred for about 2 years since the operation. Although some authors have reported vascular deformity with spinal epidural hemorrhage or varices with lumbar hernia of the intervertebral disc, there is no report concerning spinal epidural varices with pain only. The present case seemed to be a rare event and is reported here.

[A case of sacral meningeal cyst with Marfan syndrome]

A rare case of sacral meningeal cyst Marfan syndrome is reported. A 40-year-old male who had a past history of Marfan syndrome was admitted to Tokyo Metropolitan Ebara Hospital due to sensory disturbance in the right S1-2 nerve root area on October 1998. On admission, neurological deficits were sensory disturbance and decrease right Achilles reflex. Plain sacral X-ray was normal. Magnetic resonance imaging revealed a cystic mass in the intrasacral space. MR myelography showed the cyst followed the thecal sac. Signal intensity of the cystic mass was the same as the cerebrospinal fluid. In the prone position, laminectomy of the sacrum was carried out. The neck of the meningeal cyst was ligated with the help of an aneurysmal needle. The patient's sensory disturbance disappeared postoperatively. As MRI becomes more frequently used in Marfan syndrome, it is important to keep the presence of such an entity in mind. MR myelography made it easy to diagnose the meningeal cyst.

[A case of neuroaxis endodermal cyst]

The patient was a 69-year-old male. During examination of possible deafness, a cystic mass was found in the left frontal lobe, which required surgical intervention. Though the mass adhered strongly to the dura mater macroscopically, the boundary between the mass and arachnoid was clear, having a meningioma-like appearance. The pathological diagnosis was epithelial cyst consisting of layered cubic to cylindrical epithelium. It is essential to perform an electronmicroscopic or immunohistological examination for knowing the origin of an epithelial cyst in the neuroaxis, that is, of ectodermal, endodermal, or mesenchymal origin. However, the diagnosis of heterotopic endodermal cyst was established in this patient because the continuity with ependyma cells or choroid plexus was absent without the so-called ectodermogenic tissue such as glia and nerve cells.

Establishment and characterization of human immature teratoma cell line (TES-1)

A new human immature teratoma cell line, TES-1, was established from a surgical specimen from a 12-year old male with third ventricular immature teratoma. TES-1 shows polygonal morphology rich in neurites, and proliferated as adherent monolayer, with an approximate population doubling time of 48 hours. Electron microscopic analysis revealed the presence of swollen rough endoplasmic reticulum, and prominent lipid droplets, lysosomes and microfilaments. The chromosome numbers were between 41 and 160 (mode 78), including abnormal karyotypes 1p-, 5q-, 12p+ and 17p+ (G-band analysis). Hetero-transplantation of TES-1 into BALB/c nude mice produced no visible tumors. Multipotential differentiation was not induced in TES-1 monolayer culture, but significant neuron specific enolase activity was expressed in both extracellular (by RIA method) and intracellular fractions (by immunohistochemical method), suggesting the differentiation toward neurocytes. This cell line provides a useful in vitro model for the pathophysiological analysis of immature teratoma.

Endonuclease activity and hydrogen peroxide-induced cytotoxicity in human glioblastoma and glioma cell lines

Hydrogen peroxide (H2O2) induced internucleosomal DNA cleavage in human myelogenous leukemic cell lines (HL-60, ML-1, THP-1, U-937), but not in human glioblastoma (T98G, U87MG) and glioma (KG1C) cell lines. However, H2O2 produced apoptotic cells, characterized by cell shrinkage, nuclear fragmentation and chromatin condensation in glioblastoma and glioma cell lines. Autodigestion experiments revealed that the major endonucleases, present in all leukemic, glioblastoma and glioma cell lines, were divalent cation-independent endonuclease(s). The endonudease(s) present in the lysates of all these cells were activated at acidic, but not at neutral pH. The results suggest that the endonuclease activity might be differently regulated between leukemic and glioma cell lines.

Levodopa effective parkinsonism associated with aqueductal stenosis: a case report and review of the literature

A case of aqueductal stenosis (AS) associated with marked parkinsonism is described. A ventriculoperitoneal (V-P) shunt was performed in an 18-year-old female because of hydrocephalus associated with non-neoplastic aqueductal stenosis. The patient developed acute parkinsonism with Parinaud's sign after the shunt revision. She had a marked response to levodopa and the parkinsonism improved. Subsequently, levodopa therapy was gradually discontinued without any manifestation of parkinsonism. The pathophysiology of this type of parkinsonism probably involved presynaptic dopaminergic dysfunction. However, the etiology of this complication has not been confirmed.

[High uptake on 11C methionine PET scan in the pituitary gland of a patient with cerebral glioma after surgical abortion]

Positron emission tomography (PET) with various tracers provides physiologic and biochemical information of living organs. Since radiologic examinations are usually avoided in pregnant women, mainly because of the radiation risk to the fetus, little is known about the effect of pregnancy on cerebral blood flow and metabolism. This paper reports findings of a 11C methionine PET scan of the pituitary gland in a woman after an abortion. The patient was a 31-year-old woman who suffered a seizure in the 9th week of her second pregnancy. On admission, computed tomography showed an abnormal mass lesion in the right frontal lobe, and a brain tumor was suspected. The patient and her family asked that that pregnancy be terminated. Seven days after a surgical abortion, methionine PET was performed. The scan showed high methionine uptake in the pituitary gland as well as in the right frontal lobe tumor. We suspected that another tumor was present in the pituitary gland. The right frontal tumor was partially resected, and pathologic examination of the resected specimen showed an astrocytoma (grade 2). After the operation, the patient received 50 Gy irradiation and chemotherapy. Two months after the operation, we performed a second methionine PET scan, which showed high uptake in the residual right frontal tumor but not in the pituitary gland. Results of other radiologic studies of the pituitary gland were normal. These findings suggest that the transport of 11C methionine into the pituitary gland may increase during pregnancy. Moreover, the pituitary gland of pregnancy should be a part of the differential diagnosis of pituitary adenomas in PET scanning. The change in physiologic uptake by the female pituitary gland should be taken into account in the diagnosis of pituitary adenoma with methionine PET.

[A case of hypertrophic spinal pachymeningitis]

A 79-year-old woman was admitted to our hospital complaining of gait disturbance. At the time of admission, she had incomplete monoparesis of the left lower extremity, with a sensory level of T6. MR images showed a thickened dura at the C6-T4 vertebral levels. The thickened dura showed low intensities on T1- and T2-weighted images, and was homogeneously enhanced by Gd-DTPA. Hypertrophic spinal pachymeningitis (HSP) was suspected, and laminectomy was performed from T2 to T3. The thickened dura was found and partially resected. Microscopically, the diagnosis was HSP. Steroid therapy was initiated after surgery. Postoperatively, the patient's physical status and radiographic images improved. The etiology of HSP is not clear in most cases. It is difficult to diagnose radiographically, although MR imaging can help differentiate it from other disorders. T1- and T2-weighted images of HSP show low intensities, and the T1-weighted image is homogeneously enhanced by Gd-DTPA. Treatment is early decompressive surgery with possible excision of the involved dura. Steroid therapy was effective in our case.

Combined treatment of a dural arteriovenous malformation of the lateral sinus using transarterial and direct lateral sinus embolisation

An 80-year-old man presented with a dural arteriovenous malformation (DAVM) involving the left lateral sinus. A carotid angiogram showed the lateral sinus to be occluded proximally and distally, with unusual retrograde venous outflow from the residual sinus to the cortical veins, including a dilated vein of Labbé. Single photon emission computed tomography showed reduced left frontal and temporal cerebral blood flow. We concluded that the risk of bleeding from the DAVM was high and that the patient needed to be treated immediately. However, his age made surgical removal of the DAVM hazardous and we therefore chose to treat him by transarterial and direct lateral sinus embolisation via a burr hole.

[A case of venous angioma complicated by unruptured aneurysm with TIA as the initial manifestation]

Venous angioma is a relatively rare vascular malformation of the brain. It is usually asymptomatic and may be an incidental finding at autopsy or on cerebral angiography. We report a very rare case in which TIA-like attack occurred as the initial manifestation. A 59-year-old woman was hospitalized because of a TIA-like attack about 5 months after left putaminal bleeding. Detailed examination allowed us to make a diagnosis of subcortical venous angioma of the left parietal lobe and multiple cerebral aneurysms. The cerebral aneurysms were treated surgically. Since the angioma was localized in an eloquent area, radiotherapy was chosen first. Angioma giving rise to TIAs is very rare. The ischemia may have been caused by transient venous thrombosis or a steal phenomenon due to a decrease in blood circulation in the left cerebrum caused by the putaminal bleeding.

Serotonergic neurons in the brainstem modulate animal hypnosis

We previously found that the center of animal hypnosis production in the rabbit is located around the locus ceruleus and brachium conjunctivum (LC-BC) of the brainstem. The involvement of serotonergic neurons in this area of animal hypnosis was investigated by microinjection of serotonin into these regions. The duration of animal hypnosis (DAH) induced by inversion was diminished to about 65% of the controls by serotonin microinjection into the LC-BC and microinjection of methysergide prolonged the DAH to 3.2 times that of the controls. Flexor muscle contraction (CFM) of the upper extremities induced by electrical stimulation of the motor cortex was enhanced by serotonin. In normal rabbits, hard pressure on the ear base or the lumbar paravertebral area reduced CFM and this effect was partially antagonized by serotonin microinjected into the LC-BC. The results suggest that serotonergic neurons in the LC-BC modulate animal hypnosis.

Activation of the satiety center by auricular acupuncture point stimulation

Stimulation of the rat inner auricular regions that correspond to the human pylorus, lung, trachea, stomach, esophagus, endocrine, and heart acupuncture points evoked potentials in the hypothalamic ventromedial nucleus (HVM), the satiety center. Needle implantation into any of these points reduced the body weight to its initial 290 g after the rat had gained about 410 g in 20 days, and significantly reduced initial 450-g body weights (p less than 0.01, Student's t test) in 14 days. Stimulation of other acupuncture points did not evoke HVM potentials and did not reduce body weight. After the HVM was lesioned, body weight increased and acupuncture point needling had no effect on body weight. Needling of the auricular acupuncture points evoked no potentials in the lateral hypothalamus (LHA), the feeding center, and had almost no influence on weight reduction induced by LHA lesion.

Positive feedback action of pituitary beta-endorphin on acupuncture analgesia afferent pathway

Potentials in the final sector of the afferent pathway from the acupuncture point (AP) were enhanced by intraperitoneal 0.5 mg/kg morphine without changing the threshold of AP stimulation and greatly decreased by hypophysectomy. The decreased potentials were restored to the control level by morphine (0.5 mg/kg, IP). Potentials evoked in the final sector of the afferent pathway from the nonacupuncture point (NAP) by NAP stimulation after lesion of the analgesia inhibitory system were greatly enhanced by corticotropin (ACTH) (0.25 mg/kg, IP) and greatly decreased by hypophysectomy. Diminished potentials were restored to the control level by ACTH (0.25 mg/kg, IP). Both morphine (0.5 mg/kg, IP) and ACTH (0.25 mg/kg, IP) produced analgesia, but morphine did not affect acupuncture analgesia (AA) and ACTH did not affect nonacupuncture point stimulation-produced analgesia (NAA). All analgesia, that due to 0.5 mg/kg morphine or 0.25 mg/kg ACTH, AA, and NAA were abolished by hypophysectomy. The abolished AA and NAA were restored by 0.5 mg/kg morphine and 0.25 mg/kg ACTH, respectively. Hence, beta-E and ACTH liberated from the pituitary gland by stimulation of an AP and NAP may act as positive feedback on the AA and NAA afferent pathways, respectively.