[Some considerations on surgical approaches to the anterior communicating artery aneurysms--radiological study of 122 cases]

We studied the operative approaches to anterior communicating artery aneurysms by means of reviewing preoperative angiogram and operation records. During the past 5 years, 117 patients with anterior communicating artery aneurysms were operated on in our hospital. Among these, we examined 112 cases of which preoperative angiogram and operation records were satisfactory for this study. We checked the next points on the preoperative angiograms. Neck of aneurysm-planum sphenoidal distance. Direction of the anterior communicating artery. It means which A2 is anterior to the other A2 in the lateral view of angiogram. Size of aneurysm. We checked the next points on the operation records. Operative approach and the side of craniotomy. When the pterional approach was taken, the rectal gyrus was aspirated or not. This analysis derived these two conclusions as below. 1. In the literature, as the operative approach to anterior communicating artery aneurysm, the pterional approach has a lot of advantages. For example, the pterional approach was accomplished without extensive frontal lobe retraction, without mobilization of the temporal lobe, without sacrificing the olfactory tract, and so on. Moreover, in early stage after onset of SAH, it is possible to remove the subarachnoid blood extensively without obvious brain damage by the pterional approach. In this study, we paid attention to the correlation between the neck-planum sphenoidal distance and the fact of aspiration of the rectal gyrus in the pterional approach. The result is that the higher aneurysmal neck was, the more frequently the rectal gyrus was aspirated. So, if the neck-planum sphenoidal distance is under 12 mm, which includes the majority of the cases (94% of cases), we think the pterional approach is the best approach for anterior communicating artery aneurysm.(ABSTRACT TRUNCATED AT 250 WORDS)

[Use of real-time ultrasonography in neurosurgical operations]

The authors' experience with the application of real-time ultrasonography during 29 and after 3 neurosurgical operations is reported. Intraoperative sonography was performed in 29 cases. The neurosurgical operations include aneurysm surgery in 13 cases, removal of intracerebral hematoma in 11 cases, neoplasm surgery in 2 cases, and so on. Moreover, sonographic examination through bone defect was performed in 3 cases after decompression craniectomy. The instrument used was an ATL (Advanced Technology Laboratories, Bellevue, WA, USA) mechanical sector scanner of which scanhead contained transducers of three frequencies: 3, 5 and 7.5 MHz. The scanhead was wrapped with a sterile rubber bag after acoustic coupling gel had been applied to the head's tip. Then the scanhead was placed on the dura and ultrasonic examination was performed. The result was that the lesion was clearly identified and localized in all cases except for three cases of mild subarachnoid hemorrhage. In addition, in the two cases of needle aspiration of cyst or hematoma, the needle was easily identified and needle aspiration was performed safely and accurately. Moreover, during aneurysm surgery, aneurysm itself was detected in two cases by the real-time ultrasonic imaging. Especially, in the case with large aneurysm of the left middle cerebral artery, the findings about the aneurysmal wall, that is to say, which part is thick and which part is thin, could be obtained. Prior to the operation of aneurysm, cerebral angiogram and computerized tomographic scan are always examined thoroughly, but information about aneurysmal wall can be rarely obtained by them.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative use of real time ultrasonography applied to aneurysm surgery

The intraoperative application of real time ultrasonography during 13 neurosurgical operations for intracranial aneurysms is reported. In 2 cases, the aneurysms themselves could be detected clearly by real time ultrasonic imaging. In the case of a large aneurysm, information about the nature of the aneurysmal wall was obtained. Other lesions coexisting with the aneurysm (namely, intracerebral hematoma, massive subarachnoid hemorrhage, and hydrocephalus) could be recognized clearly. Real time intraoperative ultrasonography is considered to be useful in aneurysm surgery.

Relationship between contrast enhancement on computed tomography and cerebral vasospasm in patients with subarachnoid hemorrhage

To elucidate the relationship between abnormal enhancement of the cisterns on computed tomography and cerebral vasospasm, we performed a systematic and prospective study in 60 patients with ruptured cerebral aneurysms. There is a significant relationship between the findings of contrast-enhanced computed tomography (CECT) within Day 3 of rupture and cerebral vasospasm. Among 37 patients undergoing CECT between Day 0 and Day 3, 17 (46%) showed prominent increases in density in the region around the circle of Willis and its branches. In 13 of 17 cases (76%), severe vasospasm with motor paralysis occurred. In the remaining 4 cases (24%) with only slight or no cerebral vasospasm, the hematoma in the subarachnoid space was removed surgically by Day 3. In 19 of 20 cases without remarkable CECT, no severe cerebral vasospasm with motor paralysis occurred. There is no significant relationship between the CECT findings after Day 3 and cerebral vasospasm. The results indicate that the prominent increase in density in the region of the circle of Willis and its branches often observed on CECT within Day 3 of subarachnoid hemorrhage is useful for prediction of the occurrence of cerebral vasospasm and also provide information on the pathogenesis of cerebral vasospasm.

CT and arteriographic comparison of patients with transient ischemic attacks--correlation with small infarction of basal ganglia

Fifty patients presenting clinically with TIAs were examined angiographically. Twenty one patients (42%) had no abnormality. Twenty patients (40%) had stenosis or occlusion in the MCA, ACA or intracranial carotid, whereas 11 (22%) had involvement of their extracranial internal carotid artery. Seven of the 28 CTs performed showed basal ganglia infarcts. This suggests that the cause for the TIA was an infarct in the vascular territory of a lenticulostriate artery.

[Dynamic pathophysiology of cerebral infarction and revascularization. III. Changes of regional cerebral blood flow]

Thirty-eight patients with occlusive cerebrovascular disease were followed with regional cerebral blood flow (rCBF) measurement, angiography and computerized tomography (CT) to know the time course of rCBF in cerebral infarction. The rCBF study was carried out by the 133Xe intracarotid injection method with 16 scintillation detectors. They were allocated to two groups according to the findings on angiograms; 15 patients having any change of occlusive lesion (the group of no-recanalization ) and 23 patients showing reopening of occluded vessels (the group of recanalization). A mass sign and an extent of cerebral infarction were observed on CT. In the group of no-recanalization, a mean value of rCBF (mean rCBF) in acute stage was well correlated to the severity of ischemic stroke. In minor completed strokes the average mean rCBF was 35.8 +/- 3.7 ml/100g/min, which is significantly higher than that in major strokes and progressing strokes of 24.8 +/- 3.9 ml/100 g/min (p less than 0.001). Sequential change of mean rCBF was not prominent in the group of no-recanalization. However, rCBF change was conspicuous in the group of recanalization. In acute stage of recanalization, rCBF were markedly affected by the presence of mass sign (cerebral edema) on CT. When CT showed midline shift of structure, mean rCBF was markedly reduced, and when without midline shift, focal hyperemic areas were sometimes observed in the revascularized area. Thus, the inhomogeneity of rCBF was characteristic in cases with recanalization. The focal hyperemia usually disappeared within one week in cases of minor stroke and lasted until 2 or 3 weeks in cases of major stroke. In chronic stage, mean rCBF decreased, and there was no significant difference of averaged rCBF between two groups. Those findings suggests that the main factor influenced on the sequential change of rCBF is reopening of occluded vessels. Regional CBF may depends both on the degree of cerebral edema and the extent of vasoparesis after revascularization. In chronic stage CBF value is not always dependent to the presence of occlusive lesion but might be reflected in the total brain function.

[Dynamic pathophysiology of cerebral infarction and revascularization. I. Ischemic cerebral edema]

A natural history of ischemic cerebral edema was analyzed in 100 patients with occlusive cerebrovascular diseases admitted within one week of onset, with serial computed tomography (CT) and angiograms. Cerebral edema was defined as a low-density area with mass sign on CT. A total of 446 studies of CT were performed. In 40 patients with major completed stroke admitted 24 hours of onset, a total of 73 studies of CT were taken within 48 hours of onset, and a timing of appearance of cerebral edema was analyzed. Patients were allocated to two groups according to the findings on angiograms; 68 patients who showed occlusive lesions on sequential angiograms (the group of no-recanalization), and 32 patients who showed reopening of occluded vessels on the first or sequential angiograms (the group of no-recanalization). In the group of no-recanalization a low-density area gradually appeared between 6 and 24 hours of onset A. mass sign reached its peak on the 3rd day with a peak incidence of 56%, and midline shift was present in 30% of the cases. It was resolved within 2 weeks in most cases. In the group of recanalization, a low density area appeared after 4 hours and rapidly increase after 6 hours. All patients had a low-density area at 12 hours of onset. A mass sign progressed until the 6th day with a peak incidence of 82%, and midline shift was present in 50% of the cases. The duration of mass sign was longer than that in the group of no-recanalization. These results suggest that the permissible duration of ischemia is considered to be within 6 hours of onset in profound ischemia. After 6 hours, ischemic tissue damage may not be reversible by the revascularization, even if CT shows no change during ischemia. An abrupt revascularization may not contribute to the recovery of brain damage, but accelerate the ischemic cerebral edema.

Prevention of vasospasm by early operation with removal of subarachnoid blood

Sixty-four patients who were operated on within 4 days after acute subarachnoid hemorrhage are included in this study. All patients underwent preoperative computed tomographic (CT) scanning, and the amount and distribution of subarachnoid blood clot were noted. Operation was carried out by the frontobasal lateral approach, and the subarachnoid clot was removed by microsurgical suction-irrigation after clipping of the aneurysm. Immediate postoperative CT scanning was performed to evaluate the completeness of the subarachnoid blood clot removal. The presence or absence of postoperative vasospasm was determined with angiography performed between the 7th and 10th postoperative days. All patients were, of course, also evaluated for evidence of neurological deterioration. Approximately two-thirds of the patients in this series showed high density subarachnoid blood clot on the preoperative CT scan. The postoperative CT scans showed that it was possible to remove the majority of the blood clot except that located in the frontal interhemispheric fissure, the posterior part of the insular cistern on the approached side, and all of the insular cistern on the contralateral side. There was no spasm or only mild spasm in any site where the blood clot had been successfully removed. Delayed neurological deficits occurred only in those cases in which subarachnoid blood clot remained in the cisterns. These results suggest that it is possible to prevent intracranial arterial spasm and associated neurological deterioration by early operation and removal of clotted blood from the subarachnoid space.

Separation and purification of (Cd, Cu, Zn)-metallothionein in carp hepato-pancreas

1. Cd-binding protein was isolated from the hepato-pancreas of carp administered CdCl2 (2 mg/kg). 2. This protein had a high absorption at 254 nm derived from Cd-mercaptide binding, and a low absorption at 280 nm derived from the absence of aromatic amino acids; the authors recognized the presence of two types. 3. The amino acid composition of the proteins was determined. The contents of cysteine residues were 34.24% and 31.90% in MT-I and -II respectively. Tyrosine, phenylalanine, tryptophan, histidine, leucine and arginine residues were absent in both types.

Protection by metallothionein against cadmium toxicity

1. The protective effect against Cd toxicity of prior exposure to Cd or Zn solutions at low concentration was studied. 2. Carp were bred in tap water (A), 1 ppm Cd solution (B) and 5 ppm Zn solution (C) for 14 days and then transferred into 15 ppm Cd solution. The survival ratio of carp decreased in the order: (C):(B):(A). 3. Binding capacity of Cd to high molecular and metallothionein fractions in the cytoplasmic solutions of the hepato-pancreas was studied and the binding capacity to the metallothionein fraction was stronger than that to the high molecular fraction. The authors recognized that Zn in the metallothionein fraction is substituted by Cd.

Formation of metallothionein in fish

1. Carp were bred in Cd solution, and each organ was homogenized and centrifuged at 105,000 g. The Cd content of the supernatant was much more than that of the precipitate. 2. In examining the metal form in the supernatant, the induction of metallothionein (MT) was found in carp exposed to Cd and Zn solutions and the presence of metallothionein was found in fish captured in Nagara river and breeding ponds. 3. Cd content in the metallothionein fraction of hepato-pancreas increased at the early stages of exposure, but Cd in the metallothionein fraction of the other organs increased as time proceeded. 4. In the tap water group, metallothionein in hepato-pancreas and kidney contained Cu, and increased with the induction of metallothionein in hepato-pancreas due to Zn-exposure.

[Angiographic vasospasm and regional cerebral blood flow in the cases of ruptured aneurysm --Correlation between vasospasm in the middle cerebral artery and delayed ischemic hemiparesis (author's transl)]

It is well known that the vasospasm following rupture of aneurysm causes ischemic neurological symptoms. However, there are a few literatures which refer to the relationship between the severity of angiographic vasospasm and regional cerebral blood flow (rCBF) and ischemic neurological symptoms. To elucidate this problem, 41 patients with ruptured aneurysm were analysed by means of repeated cerebral angiography and rCBF study, and the following results were obtained. 1. Mean rCBF was reduced to its lowest level in the second week of hemorrhage and at this stage, the values of mean rCBF were well correlated with the severity of the angiographic vasospasm and with the development of delayed ischemic neurological symptoms. 2. The morphological feature of the angiographic vasospasm was a smooth narrowing of the vessels, and the delayed ischemic hemiparesis occurred when both M-1 and M-2 portions of the middle cerebral artery are narrowed more than half comparing the calibers as seen within 3 days of hemorrhage. 3. The average of mean rCBF in 15 patients with symptomatic spasm was 27.0 +/- 5.5 ml/100 g/min. and that in 11 patients with asymptomatic spasm was 40.8 +/- 8.8 ml/100 g/min. As a conclusion, the prognosis of the patients with angiographic vasospasm may be predicted through the value of rCBF and the severity of angiographic vasospasm in the second week of hemorrhage.

Value of computed tomography in the prediction of cerebral vasospasm after aneurysm rupture

The relationship between high density (HD) on computed tomographic (CT) scans (which indicates a collection of blood in the subarachnoid space) and cerebral vasospasm was studied in 177 patients with ruptured aneurysm. The development of cerebral vasospasm was confirmed at the high rate of 84.6% in 26 cases where HD was demonstrated on the CT scan within 4 days after subarachnoid hemorrhage (SAH). In 8 cases where HD was not found on the CT scan obtained within 4 days after SAH, no cerebral vasospasm was seen. However, no relationship was found between HD and the occurrence of cerebral vasospasm in cases in which CT was performed after the 5th day of disease. It is suggested that CT performed within 4 days after SAH may give important information for predicting cerebral vasospasm.

Intensified cancer themotherapy by induction of hepatic drug-metabolizing enzymes as a trial for the treatment for stomach cancer

Studies of an intensified chemotherapy of FT-207, combined with MMC, have been under way since April 1977 in the First Department of Surgery of Chiba University Hospital and five closely related hospitals. These studies were performed on 114 patients with curative stomach cancer. The 114 patients received intravenously 0.4 mg/kg and 0.2 mg/kg of MMC on the operation day and the next day, respectively, and then intravenously 800 mg of FT-207 daily from the 10th postoperative day until discharge, followed by oral administration of FT-207, 600 mg, for more than 1 year after discharge. The 114 patients were divided into two groups. Half of the patients received 100 mg of phenobarbital and 30 mg/kg of glutathione for the purpose of induction of hepatic drug-metabolizing enzymes (induction group). Significantly higher levels of serum 5-FU released from FT-207 were observed in the patients of the induction group when compared to those of the control group. However, there was no statistically significant difference in survivals at both 12 and 24 months after operation between both groups.