[Clinicopathological studies of three cases of cerebral aneurysms associated with systemic lupus erythematosus]

We report three cases of ruptured cerebral aneurysms associated with systemic lupus erythematosus (SLE). A 52-year-old woman (case 1) with a fifteen-year history of systemic lupus erythematosus suddenly lost consciousness. She was admitted in a state of deep coma. A computed tomography (CT) scan revealed acute hydrocephalus and diffuse subarachnoid hemorrhage in the basal, interhemispheric and bilateral Sylvian cisterns. Fifteen years prior to this admission, cerebral angiograms demonstrated no cerebral aneurysm. She underwent ventricular drainage immediately. Postoperatively, her condition did not improve, and she died on the 18th day. During the autopsy, two saccular cerebral aneurysms were found: one aneurysm was at the right middle cerebral artery bifurcation, and another one was on the anterior communicating artery, which had disruption of the internal elastic lamina and medial smooth muscle, and infiltration of inflammatory cells. In the major cerebral arteries, for example the bilateral internal carotid arteries, disruption or dissection of the internal elastic lamina, intimal fibrosis and transmural infiltration of inflammatory cells were observed. The second patient, a 36-year-old woman with a six-year history of SLE, was admitted to our hospital with sudden severe headache. A CT scan showed subarachnoid hemorrhage, and cerebral angiograms disclosed saccular cerebral aneurysms on the anterior communicating artery and the left superior cerebellar artery, and a fusiform one on the left posterior cerebral artery. Surgery was not recommended because of her multiple medical problems. Her consciousness improved gradually over 2 months. She was transferred to the department of internal medicine for treatment of renal failure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Esophageal motility and gastric emptying in PSS patients, correlation with symptoms]

Progressive systemic sclerosis (PSS) commonly involves the esophagus. Dysphagia and heartburn are the most common esophageal symptoms. In this study we evaluated the relationship between esophageal symptoms and esophago-gastric motility. On esophageal manometry, loss of peristalsis, peristaltic contraction amplitude of distal esophagus less than 30 mmHg and decreased LES pressure were critical for esophageal symptoms. The degree of symptoms correlated to esophageal dysmotility. The gastric emptying in PSS patients was delayed, but there was no significant difference in gastric emptying between the patients with and without reflux esophagitis. Esophageal dysmotility is considered to be much responsible for the reflux esophagitis in PSS patients than gastric emptying.

[Diaphragmatic electromyography (DEMG) in achalasia patients]

LES pressure increase following diaphragmatic contraction as a pinch-cock action acts as one of the barrier mechanism for gastroesophageal reflux. In achalasia patients, incomplete LES relaxation following wet swallow is one of the characteristic manometric findings, along with loss of peristalsis. On the other hand, it has been reported that swallowing effort or esophageal distention have no effect on the increase of LES pressure induced by diaphragmatic contraction, which condition is similar to achalasia. Therefore, to evaluate that whether diaphragmatic contraction is involved in the cause of achalasia, we recorded diaphragmatic electromyography (DEMG) using bipolar electrodes in 12 achalasia patients and 4 normal subjects. The phasic DEMG amplitude was 80-90 microV in normal subjects and achalasia patients. LES pressure and DEMG amplitude increased during both straight leg raising (SLR) and abdominal distention (AD), both of the maneuver induce diaphragmatic contraction, in normal subjects and achalasia patients similarly. From the data obtained with this equipment, we conclude that diaphragmatic involvement is not likely as a pathogenesis of LES dysfunction in achalasia patients.

[Intramedullary hemangiopericytoma of the spinal cord; case report and review of the literature]

Hemangiopericytoma is a rare tumor deriving from capillaries and pericytes. Although it is a well established entity clinically and histologically, its occurrence in the central nervous system adhering to the meninges has been controversial. We described a case of a 39-year-old man with intramedullary hemangiopericytoma. To the best of our knowledge, no previous case of hemangiopericytoma in this location has been reported. We reviewed differential diagnosis of spinal hemangiopericytoma based on neuroradiological points, and clinical findings of the 14 primary cases reported in the literature. The nosological problem of hemangiopericytoma was also discussed.

[Percutaneous recording of gastric electrical activity (electrogastrography): its technique and analysis]

In 1922, Alvarez made some electrical recordings from cutaneous electrodes, but the method has not been widely adopted. It has been caused by the technical difficulties in recording, and in extracting consistent information from the recording. Therefore in an effort to improve the ability to routinely obtain a recording of the gastric electrical activity, using cutaneous electrodes (electrogastrography, EGG), we have investigated different electrodes placement and bipolar recording techniques. We studied 10 healthy asymptomatic volunteers. Frequency and power product have been used to help interpret the potential change. We found significant frequency component at approximately 3 cycle/min. Recordings from the upper part of epigastrium were better than those from the lower part of epigastrium. This suggests that these recordings are taken from electrical activity of the stomach. We found the good placement of cutaneous electrodes and good recording techniques.

[Cerebral ischemia (1)--Reversibility of ischemic lesion and CT findings]

Two hundred and twenty-one patients with cerebral cerebral ischemic attack in the middle cerebral artery territory were investigated. Those patients manifested several clinical types, TIA: 31, stroke with full recovery: 50, minor completed stroke: 54 and major completed stroke: 86 cases. CT classification was made 3 weeks after the ischemic attack based on the characteristic arterial topography. We discussed in this paper what kind of ischemic lesion had greater possibility of recovery from ischemic lesion had greater possibility of recovery from ischemia focusing on the retrospective study of clinical symptoms, CT classification and angiographic findings. We also referred to the other factors influencing the reversibility of an ischemia such as lacunae and PVH (periventricular hypodensity). The extent of and LDA on CT scan closely correlated with clinical symptoms, CT classification and angiographic findings. We also referred to the other factors influencing the reversibility of an ischemia such as lacunae and PVH (periventricular hypodensity). The extent of an LDA on CT scan closely correlated with clinical types (Table 2). The reversibility of type I was excellent, however aged patients over 70 with PVH and ventricular dilatation developed permanent neurological impairment associated with dementia. The reversibility of a small infarction in the basal ganglia (type II) depended mainly on the involvement of the internal capsule. Infarction involving a cortex (type IV and type V) invariably resulted in permanent neurological deficits except for the rare cases with involvement of silent areas. CT classification of type III, so called demarcation zone infarction, developed various clinical types, and showed transient functional disturbance of the cortex without an infarction i the cortico-subcortical region.(ABSTRACT TRUNCATED AT 250 WORDS)

[Studies on the muscarine receptors in rat gastric smooth muscle]

It has been reported that the two types of muscarinic receptors, "M1" and "M2", exist in the opossum lower esophageal sphincter. The presence of these muscarinic receptor subtypes had been confirmed with the discovery of the M1 selective antagonist, pirenzepine. But little is known about muscarinic receptor subtypes in gastric smooth muscle. The aim of this study was to identify the muscarinic receptor subtypes on the gastric smooth muscle responsible for the contraction of rat gastric muscle strip. Also, we examined the mechanism of the action of aclatonium napadisilate on rat gastric smooth muscle in vitro. The stimulation of M2 receptor caused the contraction of the gastric smooth muscle. McN-A-343, selective M1 agonist, caused weak contraction of the gastric smooth muscle, and this response was not affected by the selective M1 antagonist, pirenzepine. Aclatonium napadisilate stimulated M2 receptor and caused the gastric smooth muscle contraction. We conclude that the contraction of the gastric smooth muscle is caused by the stimulation of the M2 receptor and this reaction was not affected by tetrodotoxin, suggesting the M2 receptor is located directly on the gastric smooth muscle. The weak contraction of the gastric smooth muscle caused by McN-A-343 was not affected by the selective M1 antagonist, pirenzepine, suggesting that McN-A-343 may not be a pure M1 selective agonist. The action of aclatonium napadisilate is supposed to stimulate the M2 receptor.

[The effect of cisapride on intestinal transit]

Cisapride is known to accelerate gastrointestinal motility in various diseases with gastrointestinal motor abnormalities, and in normal subjects. In this study, we developed a new method to evaluate intestinal transit by radio-opaque markers, and evaluated the effect of oral doses of cisapride on intestinal transit in 6 normal subjects. Twenty markers were ingested with breakfast, and abdominal X-ray pictures were taken at 6, 24, 48 and 72 hours later, markers on the films were scored according to estimated their location. Geometric mean of the markers and half-dose transit-time (HT) at selected points of the colon were calculated. Cisapride 7.5 mg, 15 mg per day or placebo, were given in random order, in double blind fashion. Cisapride accelerated intestinal transit at every point calculated. HT at anus was shortened to 23.3 +/- 10.2 hours (mean +/- SD) (p less than 0.05) with cisapride 15 mg/day from 42.3 +/- 16.9 hours with placebo. Geometric means at 24-hour were 3.7 +/- 1.4 with placebo, 5.3 +/- 0.9 (p less than 0.05) with cisapride 7.5 mg/day, and 5.1 +/- 1.5 with cisapride 15 mg/day. No serious side effects were noted. Our new method to evaluate intestinal transit using radio-opaque markers is easy to perform, and is able to quantify the state of transit. Cisapride accelerated intestinal transit without diarrhea. This effect of cisapride on intestinal transit may be useful in patients with constipation.

[Effect of cisapride on delayed gastric emptying in diabetic patients]

Delayed gastric emptying is supposed to affect glycemic control in diabetic patients by relative over dosing of insulin to blood glucose level due to delayed absorption of nutrients. Therefore, treatment of delayed gastric emptying is important in diabetic patients. Cisapride, a potent gastrokinetic agents, has been reported to activate the motility from stomach to colon. We evaluated the effect of acute oral administration of cisapride in seven diabetic patients (aged 46-62) with delayed gastric emptying. All patients complicated with autonomic neuropathy. Ten mg of cisapride was administered orally 30 minutes before breakfast and lunch on the day of study. Gastric emptying study was done using 99mTc-tin colloid labeled omelet meal served with 2 slices of toast and 200 ml of milk. With cisapride, the retention rate at time of 150 minutes decreased from 76 +/- 10% to 47 +/- 13% (mean +/- SD) (p less than 0.001) and starting index shortened from 86 +/- 28 minutes to 38 +/- 27 minutes (p less than 0.05). Gastric emptying speed became faster from 0.31 +/- 0.16%/min to 0.43 +/- 0.12%/min (0.2 greater than p greater than 0.1). Blood glucose level before meal decreased from 117 +/- 27 mg/dl (mean +/- SE) to 74 +/- 7 mg/dl (n.s.), and difference between basal and maximal blood glucose level became larger from 46 +/- 27 mg/dl to 84 +/- 30 mg/dl (n.s.). We conclude that acute oral administration of cisapride has significant effect in improving delayed emptying of solid meal in diabetic patients.

Management of acute aortic dissections with a cylinder-type balloon catheter to close the entry

Despite recent advances in medical treatment, an acute aortic dissection is still now often fatal because of the seriousness of its condition. The currently available therapies include blocking the progress of dissection with intensive drug therapy, a process leading to the chronic stage. However, the dissection often proceeds rapidly and may result in death. Various surgical procedures have been attempted so far, but they produce highly invasive stress and high risks. Accordingly, we designed a cylinder-type balloon catheter and developed a new closing procedure, wherein a balloon catheter is introduced and inflated at the site with an intimal tear to maintain the blood flow to the distal vessels and also to close the entry. With this procedure, the complaints will be relieved or disappear, the progress of the dissection can be stopped, and the blood flow can be restored to the reduced and collapsed true lumen. When the blood in the pseudolumen becomes coagulated and organized, the balloon is removed. If this catheter is introduced from the femoral artery (similar to an intra-aortic balloon pumping method), the invasive stress will be further reduced. This method appears to be the most useful for DeBakey type III dissections. We are now intensively studying the safe and effective application of this balloon catheter under various clinical conditions.

[Cerebral arteriovenous malformations. 2. A study of cerebral hemodynamics]

Regional cerebral blood flow (rCBF) in 16 patients with cerebral AVM was measured using 133-Xe inhalation cerebrograph, and in 3 patients rCBF was measured using stable xenon enhanced CT. Neurological status and angiographical findings were studied in the connection with rCBF measurement. RCBF in almost patients with hemorrhagic episodes was low in the frontal area (frontal depression). The larger the size of nidus is, the higher the shunt flow through nidus is, therefore, there were no significant difference of mean rCBF between the affected and non-affected hemisphere independently of the size of nidus. But in the area adjacent to AVM nidus, particularly the nidus over 20 cm3 of volume, surrounding ischemic focus was noticed. And it was thought that brain swelling due to the normal perfusion pressure break through may occur when the nidus over 20 cm3 was removed. The reduction of rCBF of the non-affected cerebral hemisphere was noticed in the cases with nearly medical seated AVM and the rCBF reduction of the non-affected or affected hemisphere was noticed in the cases with posterior fossa AVM. There was similarity between the results concerning the hemodynamic status obtained by 133-Xe inhalation cerebrograph and stable xenon enhanced CT. But 133-Xe inhalation cerebrograph was less useful for estimation of cerebral hemodynamics than the stable xenon enhanced CT, because overestimation of rCBF was noticed in 133-Xe inhalation cerebrograph.

[A case of sudden gross hematuria caused by an iliac artery-ureteral fistula]

A 51-year-old male patient, who had been treated for nonspecific angitis with pulselessness in the upper extremities, was found to have stenosis of the left common iliac artery. Patch grafting was performed for the stenotic lesion of the artery. Sixteen months after the operation, the patient developed a sudden massive hematuria for which he was immediately admitted. He required blood transfusions and bed rest. Pyelography and arteriography revealed almost complete impairment of the left kidney function. During subsequent left retrograde ureterography , the patient again developed massive hematuria and fell in shock. The ureterogram revealed left hydronephrosis and the adhesive left ureter to the site of the patch graft. Extraluminal outflow of contrast medium into the artery was also noted. These findings were considered to indicate the hematuria being an extravasation of blood from an arterio-ureteral fistula formed in the patch graft region. An emergency operation was performed. Contamination was avoided by construction of the femoro-femoral arterial bypass graft to the left lower extremity, prior to the radical removal of the potentially infected fistula and left kidney. The surgical procedures have saved the patient and his lower extremities.

[Glucagon-producing carcinoid of the rectum--report of a case]

A 22-year-old male who had been receiving insulin therapy to treat uncontrollable hyperglycemia, was diagnosed to have a carcinoid in the lower rectum. The excised tumor was 1.5 cm in diameter, and showed a yellowish-white cut surface. It did not invade into the proper muscle. Numerous glucagon immunoreactive cells were found. The tumor cells contained many rounded neurosecretory granules. After tumor excision, the patient's hyperglycemia did not return in the absence of insulin administration. We suggest that the tumor may have secreted glucagon which may have acted as an antagonist against insulin in the circulation.