Decreased perfusion in myocardial region of normal donor artery secondary to collateral development. Stress 201Tl myocardial emission CT performed in patients with single vessel exertional angina having collaterals

Thirty-one patients suffering from single vessel exertional angina with collaterals (Group A) were evaluated by stress 201T1 myocardial emission CT (Tl-SPECT) with 16 controls of severely stenotic single vessel exertional angina without collaterals (Group B). Group A included 21 patients (68%) who showed an extensive perfusion defect in double artery myocardial regions, including the normal donor artery myocardial region (DMR). However, there were no such cases in Group B, giving a significant difference between these 2 groups (p less than 0.001). Four patients in Group A, having a perfusion defect both in DMR and in the collateral dependent myocardial region (CMR) underwent a successful percutaneous transluminal coronary angioplasty (PTCA) with disappearance of collaterals. Tl-SPECT findings after PTCA showed no perfusion defect either in CMR or in DMR. This has been explained on the basis that the coronary collaterals stole blood and produced perfusion defect in DMR.

Usefulness of reinjection image for evaluating viable myocardium in the infarcted zone on exercise thallium-201 SPECT

Reinjection images were obtained in 23 patients with myocardial infarction by the additional injection of 37 MBq of thallium-201 after obtaining 4 hour delayed images on exercise thallium-201 SPECT (TSPECT). A redistribution index (RI) was derived of the changes in perfusion defects between immediate and 4 hour delayed images as well as immediate and reinjection images on polar bull's eye maps. The RI of reinjection images (46 +/- 27%) was significantly greater than that of 4 hour delayed images (26 +/- 26%) in patients with myocardial infarction (p less than 0.01). Significant redistribution after reinjection occurred in 4 of 9 patients (44%) without significant redistribution on 4 hour delayed images. Improvement in redistribution on reinjection images correlated significantly to the small extent of coronary artery disease and collateral development. The appearance of redistribution from 4 hour delayed imaging to reinjection imaging also might reflect the function of collateral development in the resting state in patients without significant redistribution on 4 hour delayed images. It has been demonstrated that underestimated viable myocardium on 4 hour delayed images in the infarcted zone can be better assessed on reinjection images. This reinjection technique is recommended in patients with no or partial redistribution on 4 hour delayed images.

Transcoronary chemical ablation of atrioventricular node for the treatment of paroxysmal supraventricular tachycardia--a case report

We applied transcoronary chemical ablation of the atrioventricular (AV) node to a patient with uncontrollable paroxysmal supraventricular tachycardia (PSVT). Through an angioplasty dilatation catheter. 99% ethanol at a dose of 1.0 ml was selectively infused into the AV nodal artery. Complete AV block with junctional escape rhythm occurred. Two weeks later, the treadmill exercise test was performed according to a modified Bruce protocol. The patient tolerated for 12 min, and the heart rate increased to 85 beats/min. His bundle electrocardiogram showed that the AV block resulted from atrio-Hisian block. Neither atrial nor ventricular extrastimulus could induce the tachycardia. It appeared that chemical ablation was a good method for controlling medically resistant PSVT. Elevation of serum creatine kinase was observed when ethanol overflowed during the ablation procedure. Occlusion of branches of the AV artery and mild hypokinesis in the inferobasal wall of the left ventricle were seen.

[Inflammatory granulomas extending from the sphenoid sinus to the cavernous sinus: report of three cases]

We treated three cases of inflammatory granulomas extending from the sphenoid sinus to the cavernous sinus. Case 1 was that of a 36-year-old male with diplopia and right ptosis. Case 2 was that of a 40-year-old male with frontal headache. Case 3 was that of a 70-year-old female with left impaired vision and frontal headache. In the first case, MRI demonstrated a mass lesion extending from the right half of the sphenoid sinus to the cavernous sinus and retropharyngeal space. In the second case the granuloma extended from the right cavernous sinus to the right retroorbital space. In the last case, MRI demonstrated diffuse Gd-DTPA enhancement of the left cavernous sinus and the left half of the sphenoid sinus. In all cases an operation was performed using the sublabial rhinoseptal approach, and the tumor in the sphenoid sinus was removed. Histological examination revealed an inflammatory granuloma in all 3 cases. In the first case the clinical symptoms improved following administration of glucocorticoids. In the second case the mass in the cavernous sinus decreased in size postoperatively. In the last case, the clinical symptoms gradually improved with administration of antibiotics after surgery. Granuloma of the cavernous sinus is difficult to diagnose, but when a similar pathological lesion coexists in the sphenoid sinus, a definitive diagnosis can be easily made via the sublabial rhinoseptal approach.

Persistent primitive hypoglossal artery associated with arteriovenous malformation--case report

A case of persistent primitive hypoglossal artery (PPHA) associated with arteriovenous malformation (AVM) is reported. A 46-year-old male suddenly developed severe headache followed by transient unconsciousness and was admitted to our hospital 2 hours later. A computed tomographic scan showed subarachnoid hemorrhage. Angiograms revealed an AVM in the left cerebellar hemisphere and an ipsilateral PPHA. The AVM was completely removed and he was discharged 1 month after surgery without neurological deficit. Only three cases of PPHA associated with intracranial AVM have been reported in the literature. One patient died of rebleeding from the AVM before surgery, and another was conservatively treated because the AVM was too large for resection. The remaining one was surgically treated only by ligation of the feeding arteries. Ours is the first case treated by total removal of the AVM. Since these four cases, including ours, account for 3.0% of 134 cases of PPHA reported, PPHA associated with AVM is considered rare.

[Effects of intravenous aprindine on hemodynamics in patients with cardiac dysfunction and its pharmacodynamics in patients with premature ventricular contractions]

The effects of aprindine, 100 mg iv, on hemodynamics, and the relationship between its inhibitory effect on PVC and its levels in the blood were determined in patients with diminished cardiac function. PVC was inhibited in 7 of 13 patients (54%), compared with a 50% inhibition rate in controls. The levels of aprindine in the blood after intravenous administration, rapidly decreased from 1.78 +/- 1.09 micrograms/ml immediately after administration, to 0.80 +/- 0.25 micrograms/ml after 15 min, to 0.65 +/- 0.23 micrograms/ml after 30 min and to 0.56 +/- 0.19 micrograms/ml after 1 hour. The duration of blood levels of 0.55 +/- 0.35 micrograms/ml, which are the levels presumed to be effective, was one hour after administration. The mean elimination half-life of aprindine was 18.9 +/- 8.4 hours. Aprindine produced relatively little effect on hemodynamics in patients with moderate to severe heart failure, but when its effects in individual cases were studied, it was found that aprindine elicited such changes as reduction in cardiac index, stroke volume index and stroke work index, and elevation in pulmonary arterial diastolic pressure. These findings suggest that care should be exercised in aprindine therapy in patients with diminished cardiac function. At least there should be monitoring of blood pressure and heart rate at appropriate times after intravenous administration.

[Radiation therapy of carcinoma of the hypopharynx and recurrence in the epipharynx and mesopharynx]

The role that radiation therapy plays in the prophylaxis of an epi-and mesopharyngeal recurrence of a hypopharyngeal cancer remains undefined. Because of this 48 patients with a hypopharyngeal cancer, who had undergone radiation therapy from 1975 through 1987 at Chiba University Hospital, have been analyzed retrospectively. The 5-year-survival was 17% and an epi- or a mesopharyngeal recurrence was found in 8 patients. A radiation dose of more than 1350 ret seemed to prevent a recurrence in these regions, although it must be further studied as to whether an increase of the radiation field to include the epipharynx can be effectively improved the recurrence-free survival rate.

Primary squamous cell carcinoma of the parotid gland: a case report with electron microscopic findings

Primary squamous cell carcinoma of the parotid gland is a rare tumor. Histological and ultrastructural features of a primary squamous cell carcinoma arising in the right parotid gland is presented. Light microscopically the tumor consisted of poorly differentiated squamous cell nests. PAS reaction was negative. Ultrastructurally the tumor cells were oval or spindle shaped and the cytoplasmic processes were frequently found. The majority of the tumor cells contained numerous intermediate filaments in their cytoplasm. No secretory granule was found. The desmosomes were well developed. It is known that mucoepidermoid carcinoma may be often misdiagnosed as squamous cell carcinoma. These findings can enable us to distinguish primary squamous cell carcinoma from mucoepidermoid carcinoma of the parotid gland.

Radiation therapy of the nasopharyngeal cancer and its prognostic factors

39 patients with the regional nasopharyngeal cancer (NPC) underwent radiation therapy from 1975 through 1984 in the Department of Radiology, Chiba University Hospital. A retrospective study was carried out to find out prognostic factors of these NPC patients. Radiation therapy was performed under megavoltage condition. 31 patients were given more than 50 Gy. 41% of the whole had T4 extension and 69% had lymph node metastasis. The pathological slides were reviewed and classified by the proposal of Shanmugaratnam. Advanced N-stage and the absence of the lymphocytic infiltration tended to affect the survival unfavorably, whereas the prognostic significance of histology, especially of keratinizing squamous cell carcinoma remained unclear. T4 lesion often recurred even with high dose radiation therapy. To improve the local control rate in NPC, wide field irradiation from the base of skull to the lower neck seemed necessary as well as the dosage greater than 66 Gy.

[Salivary gland cancer]

Till 1985, UICC had not developed the TNM-classification system of salivary gland cancer because of insufficiency of the number of cases. In this study, influences of various parameters such as age, sex, histological type, mobility of the tumors and facial nerve involvement were analyzed in a total of 354 cases of parotid gland cancer obtained by nationwide research. Furthermore, UICC classification system made in 1985 was assessed by application to these 354 cases.

Determination of left ventricular volumes with use of DSA density values

A computer program was developed to obtain left ventricular volumes from the density values of DSA. The highest density value along the horizontal pixel line over the left ventricle in 30 degrees RAO was considered to correspond to the greatest width on the same level of 60 degrees LAO. The left ventricular volume was obtained by converting the density values into the width and integrating these values. This method estimated experimental balloon volumes with considerable accuracy. Clinical evaluation revealed good correlation between DSA and conventional cine left ventriculography.

[On the time of cardiac aneurysm formation following acute myocardial infarction]

It has been said that ventricular aneurysm is formed in the relatively late stage after the onset of acute myocardial infarction. We examined the time of its formation using digital subtraction angiography (DSA) performed immediately after infarction and at various intervals thereafter. We also examined correlations between aneurysm formation and the degree of rest after infarction, blood pressures, sites of infarction and coronary angiographic findings. The subjects consisted of 35 hospitalized patients with acute myocardial infarction. They were examined by DSA immediately, and one week and one month after their admissions. DSA was performed in the 30 degree right anterior oblique projection, and cardiac aneurysms were diagnosed by the presence of regional protrusion or of dyskinesis of the left ventricular wall on left ventriculography. The results were as follows: Cardiac aneurysms were noted in eight men and four women. The mean age was 69.2 +/- 8.1 years. Infarctions were located in the anteroseptal region (nine patients), in the broad anterior wall (two patients) and in the inferior wall (one patient). The average onset-to-admission interval was 5.6 hours in the aneurysm group, and eight hours in the aneurysm-free group. Cardiac aneurysms were demonstrated by DSA immediately after hospital admission in all 12 patients in the aneurysm group and the size did not increase appreciably with time. The peak CPK was significantly higher in the aneurysm group (3,163) than in the aneurysm-free group (1,655), but there was no group-related difference in risk factors, hypertension, the duration of rest after infarction, or coronary angiographic manifestations. Cardiac aneurysm has been considered as a late complication of myocardial infarction. Many investigators have reported that its formation begins one to four weeks after the onset of infarction with gradual protrusion. In the present study, however, the formation of aneurysms was complete at very early stages after the onset of the myocardial infarction and often encountered in patients with relatively extensive infarction.

A proposal of TNM classification system for cancer of the salivary gland--comprehensive retrospective study

Until recently, there has not been a sufficient number of cases of salivary gland cancer to permit the development of a clinically useful TNM classification system. A comprehensive retrospective study of 354 patients with cancer of the parotid gland from 46 institutions in Japan was carried out at the request of the Japanese Committee on TNM Classification (JJC), and we propose JJC T-categories for parotid gland cancer. The characteristic of this proposal involves T-categories determined according to tumor size. Fixed tumors or tumors with facial nerve involvement were classified as T4 regardless of tumor size. In 1983, the AJC proposal for a TNM classification system of salivary gland cancers was tentatively approved at a AJC/UICC joint meeting. In comparison with the AJC classification, our proposal seems to be better in terms of simplicity and the balanced distribution in T-categories of parotid gland cancers.

Feasibility of ventricular function analysis by digital subtraction angiography

Continuous or cine mode of digital subtraction angiography (DSA) following intravenous injection of contrast media was evaluated in regard to feasibility of obtaining physiologic data in cardiac abnormalities. Computer programs for cardiac function analysis including stroke volume, ejection fraction and display of left ventricular wall motion in end-diastole and end-systole have been developed with use of automatic contour plotting and densitometry for depth information. Experiments with contrast-filled balloons demonstrated good correlation between the true volumes and the calculated volumes. Clinical study also demonstrated good correlation between the values obtained from conventional left ventriculography and DSA.

The clinical feature of pre-hospital phase of acute myocardial infarction--the advantages and limitations of the MCCU

For purposes of evaluating the clinical features in the prehospital phase of acute myocardial infarction, 22 patients presenting prehospital syncope and patients presenting in-hospital re-attack were chiefly studied. Cardiac or ventricular standstill, acute mechanical failure, ventricular fibrillation, serious block, bradycardia-hypotension syndrome, cardiogenic shock, cardiac failure and cardiac rupture may be cited as the complications likely to occur in the early phase of the onset of acute myocardial infarction. Among these complications, cardiac or ventricular standstill results from overactivity of the vagus nerve, and acute mechanical failure is a result of drastically decreased cardiac output due to extensive infarction. There is no report of either complication, and both may be considered to be the fatal complications occurring almost simultaneously with the onset of acute myocardial infarction. The time intervals from the onset of symptoms to hospital admission were perspectively analyzed on 72 patients transported by the MCCU and 139 by ordinary ambulance. The interval from the onset of symptoms to medical help and that from the examination by personal physician to the call for ambulance were the greatest of all time factors, while the interval for emergency transport of the patient was short. There was no significant difference in the interval to hospital admission between the patients transported by the MCCU and those by ordinary ambulance. However, the in-transit death rate was 1/72 patients transported by the MCCU and 8/139 by ordinary ambulance: in other words, this death rate tended to be high in the latter. Twenty-two normal volunteers were studied for changes in heart rate, blood pressure and double product with the speed of transport. The transport at a low speed caused less changes in these parameters than that at a high speed.